Phacoemulsification Versus Manual Small Incision Cataract Surgery in Hard Nuclear Cataracts

Turkish Online Journal of Qualitative Inquiry (TOJQI)

Volume 12, Issue 3, June 2021:700- 705

Research Article

Phacoemulsification Versus Manual Small Incision Cataract Surgery in Hard Nuclear

Cataracts

Ragni Kumari1, Nitesh Pradhan2*, Sunil Kumar Gupta3, Gaurav Dubey4* , Aysworya Mohapatra5,
Jitendra Singh6 , Jamshed Ali7, Mrinal Ranjan Srivastava8 , Rajiv Janardhanan9

ABSTRACT

Objective: The aim of this study was to compare the clinical outcomes of phacoemulsification
with that of manual small incision cataract surgery (MSICS) in cases of hard nuclear cataract.
Methods: 160 of 160 patients with gradual painless diminution of vision, diagnosed as senile
nuclear cataract grade 4 or higher according to Lens Opacities Classification System III (brown
cataract), were studied. These eyes were divided randomly into two groups: group A included
80 eyes treated by phacoemulsification by the vertical chopping technique and group B included
80 eyes treated by MSICS by the viscoexpression technique. Results: One day postoperatively,
the corrected distance visual acuity was at least 6/18 in 42 (52.5%) patients in the SICS group
and in 18 (22.5%) patients in the phacoemulsification group. The difference was statistically
significant (P=0.01). A postoperative increase in intraocular pressure was recorded in 2 (2.5%)
case in the phacoemulsification group. On the first postoperative day, 22 (27.5%) cases in the
SICS group and 26 (32.5%) cases in the phacoemulsification group developed postoperative
iritis, with no statistically significant difference between both the groups. Conclusion: Both
phacoemulsification and SICS achieved comparable and excellent visual outcomes for
treatment of hard brown cataract, with lower complications rates and earlier postoperative
visual rehabilitation in small incision cataract surgery.
Keywords: cataract, manual small incision cataract surgery, phacoemulsification.
1
Ph. D. Scholar, Amity Institute of Public Health, Amity University, Noida.
2
Assistant Professor, Department of Ophthalmology, Maharishi Markandeshwar Institute of Medical Science and
Research, Mullana, Ambala.
3
Lecturer, Department of Optometry Era University, Lucknow.
4*
Optometry Faculty, Department of Optometry, Faculty of Paramedical Sciences, UPUMS, Saifai Etawah.
5
Internship In-charge, Laxmi Charitable Trust and Laxmi College of Optometry Panvel, Navi Mumbai.
6
Chief Optometrist, Indra Gandhi Eye Hospital and Research Centre, Gurugram, Haryana
7
Assistant Professor, Department of Optometry, College of Allied Health Sciences, IIMT University Meerut India
8
Assistant Professor, Department of Community Medicine, Dumka Medical College, Dumka.
9
Professor & Head, Amity Institute of Public Health, Amity University, Noida, U. P., India
*Corresponding Author, Gaurav Dubey Email Id: [email protected]

INTRODUCTION
The main objective in modern cataract surgery is to achieve a better unaided visual acuity with a
rapid postsurgical recovery and reduced intraoperative and postoperative complications.[1] Hard
brown cataract is a risk factor for intraoperative complications during phacoemulsification in the

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 Ragni Kumari1, Nitesh Pradhan2*, Sunil Kumar Gupta3, Gaurav Dubey4* , Aysworya Mohapatra5, Jitendra Singh6 ,
Jamshed Ali7, Mrinal Ranjan Srivastava8 , Rajiv Janardhanan9

hands of surgeons who deal with such cataract occasionally. It is still a challenge for experienced
surgeons. The chances of conversion into extracapsular cataract extraction (ECCE) are higher than
soft and medium-hard nuclei because of the damage to intraocular tissues produced by surgical
trauma during emulsification of hard and large nuclei. [2] Phacoemulsification has become the
routine procedure for cataract extraction in the developed countries, where rehabilitation of the
patient is fast, associated with good visual outcomes. It offers the advantages of faster and more
predictable wound healing, reduced discomfort to patients, fewer wound complications, and less
changes of postoperative astigmatism than conventional ECCE. [3] Modern ECCE surgery involves
removal of the lens fibers, which form the nucleus and cortex of the cataract, leaving the posterior
epithelial capsule to hold the new artificial intraocular lens (IOL) and keep the vitreous humor
away from the anterior chamber. Extracapsular techniques of cataract extraction surgery originally
involved manual nuclear expression. Phacoemulsification is a mechanically assisted extracapsular
technique of cataract extraction surgery. [4] Small incision cataract surgery (SICS) is characterized
by early wound stability, less postoperative inflammation, no suture-related complications, few
postoperative visits, and less damaging effect on the corneal endothelium. Moreover, SICS can be
performed in almost all types of cataract in contrast to phacoemulsification, where case selection
is extremely important for junior surgeons. [5] Studies on normal population to assess the response
of the endothelium to cataract surgery have shown a decrease in the endothelial density over a 3-
month period postoperatively with an increase in the coefficient of variation and decrease in the
percentage of hexagonal cells. [6] In developing countries such as India, where there is a cataract
backlog, SICS with IOL implantation promises to be a viable cost-effective alternative to
phacoemulsification. [7] In Egypt, SICS is less dependent on technology; hence, it is less expensive
and more appropriate for the treatment of advanced cataracts. [8] The aim of present study was to
compare the clinical outcomes of phacoemulsification with that of SICS in cases with hard nuclear
cataracts.

METHODOLOGY
Eighty eyes of 160 patients were chosen from the outpatient clinic of the Department of
Ophthalmology Era University,
Lucknow. These patients had gradual painless diminution of vision, diagnosed as senile nuclear
cataract grade 4 or higher according to Lens Opacities Classification System III (brown cataract).
[9]
The eyes were divided randomly into two groups: group A included 80 eyes treated by
phacoemulsification by the vertical chopping technique and group B included 80 eyes treated by
MSICS by the viscoexpression technique. Exclusion criteria: Patients younger than 50 years,
with dislocated and subluxated lenses, corneal diseases (congenital anomalies, degeneration,
dystrophies, peripheral thinning, and conditions with a low endothelial count), ocular
inflammations such as scleritis, patients with chronic open-angle glaucoma, poorly dilated pupils,
a history of previous intraocular surgeries. Preoperative examination: The history obtained
from the patients included name, age, sex, history of any medical disease, especially diabetes and
hypertension, and a history of any previous operation (ocular or systemic). A careful
ophthalmologic examination was performed for each case in the form of measurement of distance
visual acuity, slit-lamp examination for assessment of the cornea, anterior chamber depth,
regularity of the pupil, nuclear hardness, measurement of intraocular pressure using a Schiotz
tonometer, and measurement of keratometric readings. After pupillary dilatation, nuclear grading
was performed according to Lens Opacities Classification System III. A-scan to measure the

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 Phacoemulsification Versus Manual Small Incision Cataract Surgery in Hard Nuclear Cataracts

axial length and keratometry to measure the corneal refractive power were performed for IOL
power calculation using the SRK II formula [P=A1−BL−CK, where P is the implant power for
emmetropia, L is the axial length (mm), K is the average keratometry, and A, B, and C are
constants] and B-scan ultrasonography was performed to evaluate the posterior segment if it was
could not be visualized properly because of the dense cataract. Pupillary dilatation was performed
by topical administration of phenylephrine hydrochloride 2.5% eye drops and cyclopentolate
hydrochloride 1% eye drops. Both operative procedures were performed under local anesthesia
by the ophthalmologist. Surface anesthetic, lignocaine 2% eye drops and sensocain 0.7%, was
administered once just before the operation. Surgical techniques: Group A included 80 eyes
treated by phacoemulsification by the vertical chopping technique. Group B included 80 eyes
treated by MSICS by the viscoexpression technique. The conjunctiva was closed by cauterization
at the end of surgery. Follow up: Patients were examined on the first postoperative day, and after
1, 2, 4, and 8 weeks. Statistical analysis: SPSS 23.0 was used. The independent-samples t-test
and χ2 were used. The test was considered significant if P is less than 0.05, highly significant if
P is less than 0.01, and not significant if P is more than 0.05.

RESULTS
160 patients undergoing cataract surgery were included in this study. Patients were divided into
two groups: group A
included those patients who underwent phacoemulsification and group B included those patients
who underwent MICS
(Table 1). Intraoperative complications in both groups were recorded. There was no
intraoperative complication between both groups.

Table 1 Patients’ data

Parameters Groups t-test P

PHACO SICS
Mean age (years) 63.1 65 0.885 0.634 (NS)
Sex (%)
Male 70 65 χ2=0.741 0.258 (NS)
Female 30 35
Preoperative IOP (mmHg) 14.6±2.1 14.8±1.9 0.5 0.620 (NS)
Preoperative CDVA (%)
6/60–3/60 67.5 62.5 χ2=0.741 0.258 (NS)
3/60–HM 32.5 37.5

A postoperative increase in the intraocular pressure was recorded in one (2.5%) case in the
phacoemulsification group. Postoperative iritis was observed on the first postoperative day in 22 (27.5%)
cases in the SICS group and 26 (32.5%) cases in the phacoemulsification group, a statistically
insignificant difference (P=0.258).
One day postoperatively, the corrected distance visual acuity was at least 6/18 in 42 (52.5%) patients
in the SICS group and 18 (22.5%) patients in the phacoemulsification group; the difference was
statistically significant (P=0.01, Table 2). Both groups had a comparable corrected distance visual

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 Ragni Kumari1, Nitesh Pradhan2*, Sunil Kumar Gupta3, Gaurav Dubey4* , Aysworya Mohapatra5, Jitendra Singh6 ,
Jamshed Ali7, Mrinal Ranjan Srivastava8 , Rajiv Janardhanan9

acuity of at least 6/18 2 months postoperatively (92.5% vs. 85%, P=0.36). In the present study,
uncorrected distance visual acuity of at least 6/18 2 months postoperatively was achieved in 85%
and 75% of the patients, respectively.
Table 2 Corrected distance visual acuity at the first day, first week, eighth week, and
uncorrected distance visual acuity at eighth week postoperatively in both groups

n (%)
Visual acuity
SICS PHACO
CDVA first day
≥6/18 9 (22.5) 21 (52.5)
<6/18 31 (77.5) 19 (47.5)
χ2 6.27
P value 0.001 (significant)
CDVA first week
≥6/18 24 (60) 32 (80)
<6/18 16 (40) 8 (20)
χ2 3.81
P value 0.05 (significant)
CDVA eighth week
≥6/18 34 (85) 37 (92.5)
<6/18 6 (15) 3 (7.5)
χ2 0.541
P value 0.36 (significant)
UDVA eighth week
≥6/18 30 (75) 34 (85)
<6/18 10 (25) 6 (15)
χ2 0.541
P value 0.39 (significant)

CDVA, corrected distance visual acuity;

MSICS, manual small incision cataract surgery;
PHACO, phacoemulsification;
UDVA, uncorrected distance visual acuity.
DISCUSSION
SICS is comparable to phacoemulsification for the rehabilitation of the patient with cataract. In the
present study, there was no intraoperative complications in both groups. Muhtaseb et al.[10] assessed
the risk factors for intraoperative recommended as an alternative to phacoemulsification
wherever the required equipment and experience are not available. A hard brown cataract is a well-
known risk factor for intraoperative complications during phacoemulsification. In the present
study, conversion to ECCE was recorded in 20% of phacoemulsification cases. Ali et al.[11] reported
a conversion rate in phacoemulsification cases of 1.67%, whereas Dada et al.[2] reported a

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 Phacoemulsification Versus Manual Small Incision Cataract Surgery in Hard Nuclear Cataracts

conversion rate in phacoemulsification cases of 3.7%. The reason for this higher rate of conversion
to ECCE was the nature of this hard brown cataract, which makes the nucleus management more
difficult and riskier.
In the present study, SICS yielded better successful visual results than phacoemulsification (i.e.,
≥6.18) in a larger proportion of patients 1 day postoperatively (52.5 vs. 22.5%, respectively). The
success rate correlated with the absence of severe corneal edema (5% vs. 25%, respectively).
Venkatesh et al.[12] showed that the SICS group had less corneal edema than the
phacoemulsification group on the first postoperative day in cases with white cataract. Previous
studies reported no significant difference in endothelial cell loss among conventional ECCE, SICS,
and phacoemulsification groups.[13] Gogate et al.[14] reported that both phacoemulsification and
small incision techniques were safe and effective for visual rehabilitation of cataract patients,
although phacoemulsification yields better uncorrected visual acuity in a larger population of
patients at 6 weeks. El-Sayed et al.[8] reported both phacoemulsification and MSICS achieved
excellent visual outcomes with low complication rates. SICS is less dependent on technology.
Hence, it is less expensive and more appropriate for the treatment of advanced cataracts prevalent
in the developing countries. Both SICS and phacoemulsification yielded excellent results in term
of anatomical and refractive. However, SICS appears to be more advantageous than
phacoemulsification in terms of speed, cost, and independence from technology, and appears to
more suitable for dense cataracts and mass surgery. [15]

CONCLUSION

Phacoemulsification and MSICS achieve comparable and excellent visual outcomes in dealing
with hard brown cataract, with lower complication rates and earlier postoperative visual
rehabilitation in SICS.
FINANCIAL SUPPORT AND SPONSORSHIP: Nil
CONFLICTS OF INTEREST: There are no conflicts of interest.

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Jamshed Ali7, Mrinal Ranjan Srivastava8 , Rajiv Janardhanan9

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