Phacoemulsification versus extracapsular cataract extraction:

where do we stand?
Suzann Pershinga and Abha Kumarb
a
Stanford University Medical Center, Stanford and
bSanta Clara Valley Medical Center, San Jose,
California, USA
Correspondence to Abha Kumar, Valley
Specialty Center, 751 South Bascom Avenue,
3rd floor, San Jose, CA 95128, USA
Tel: +1 408 885 7980; fax: +1 408 885 5849;
e-mail: abha.kumar@hhs.co.santa-clara.ca.us
Current Opinion in Ophthalmology 2011,
22:37–42
Purpose of review
Cataract surgery at present is divisible into two general techniques: manual
extracapsular cataract extraction and phacoemulsification – with ECCE further
separated into the traditional form and small-incision cataract surgery. This review
will discuss updates in surgical techniques, outcome comparisons, cost analysis,
and the continued role of extracapsular cataract extraction in Western countries.
Recent findings
Surgical techniques for manual extracapsular cataract extraction have undergone
much refinement, with numerous descriptions of techniques in a recent literature.
Studies that have emerged in the last several years allow us to compare surgical
results between different techniques and suggest that there is little difference in
final outcome when each surgery is done well. Overall cost–effectiveness and
suitability of each technique vary based on location and facilities.
Summary
Manual extracapsular cataract extraction (especially small-incision versions)
occupies an important place in modern cataract surgery, and, while not a
replacement for phacoemulsification in Western countries, should be part of a
cataract surgeon’s overall skill set.

Keywords
manual extracapsular cataract extraction, manual sutureless cataract surgery,
phacoemulsification, resident training/education, small-incision cataract surgery

Curr Opin Ophthalmol 22:37–42

2010 Wolters Kluwer Health | Lippincott Williams &
Wilkins 1040-8738

manual ECCE (often called small-incision cataract

Introduction
Over the past several decades, cataract surgery has split
into phacoemulsification and manual extracapsular catar-
act extraction (ECCE) – the former predominating in
industrialized countries and the latter in developing
countries. It has been questioned whether planned man-ual
ECCE has a continued role in modern cataract surgery in
Western countries, and especially whether it should
continue to be taught in residency training. Central to the
debate is the relative effectiveness of each operation.
A series of trials published over the past several years
allow us to compare outcomes. They will be discussed,
along with advancements in surgical technique, relative
cost–effectiveness, and roles in resident education.
Background and techniques
For purposes of this review, we will make distinction
between classic manual ECCE and newer small-incision
1040-8738 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
surgery or SICS).
There is wide variation in technique for classic manual
ECCE; however, it generally involves a 9–13-mm shelved
incision, typically a ‘smile’ running parallel to the limbus,
and usually from a superior approach. The incision is
followed by an anterior capsulotomy (continu-ous
curvilinear capsulorhexis or can-opener capsulot-omy),
lens expression (posterior pressure or assisted delivery),
and cortical cleanup (manual Simcoe cannula or other
device). After IOL insertion, the wound is closed with
multiple sutures – yielding a variable amount of
astigmatism.
Descriptions of small incision, often sutureless, manual ECCE
surfaced in the literature in the early 1990s [1–4]. We saw the
adoption of smaller linear or ‘frown’-shaped incisions [5,6],
prolapse of the lens nucleus into the anterior chamber before
removal, and sutureless yet watertight wound closure. At
present, these surgeries can be routinely performed in 4–5 min
in experienced hands [7].
DOI:10.1097/ICU.0b013e3283414fb3

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 38 Cataract surgery and lens implantation
The past year in particular has seen numerous publi-cations
of surgical refinements: intraocular nuclear seg-mentation
[8] – in the capsular bag (Akahoshi prechop [9]), anterior
chamber (between instruments or with a snare) [10–14], or
scleral pocket [15]; nucleus removal via irrigating vectis
[16] or curved ‘fish-hook’ cystotome [7], via
viscoexpression [17] (possibly aided with a sheets glide
[18]), or sandwiched between two instruments [12,19,20]
and other techniques such as use of an anterior chamber
maintainer [8,21].
Wound construction is very important to the surgical
outcome. Wounds begin in the sclera and, due to their
width, are longer than traditional phacoincisions –
extending 1–2 mm into clear cornea, with sides wider
internally than externally [22]. Length ranges from 5– 8
mm (depending on nuclear size/density, to allow easy lens
removal) [23 ], and a frown shape provides the best relative
astigmatic neutrality. Optimal incision depth is
approximately 0.3 mm (1/2–2/3 scleral thickness), to avoid
button-holing or premature ocular entry [12]. Incision
location may also be varied (more posterior [23 ], temporal
versus superior [24,25]) to lessen post-operative
astigmatism.
Traditionally, ECCE was done under retrobulbar or
peribulbar anesthetic block; however, sub-Tenon’s blocks
are reported to yield equal anesthesia with improved
patient comfort [26]. And, SICS was reported successful in
India under topical anesthesia with intra-cameral lidocaine,
with patients experiencing minimal to no pain [27]. Of
course, pain tolerance and patient expectations likely
contribute – it is doubtful that topical anesthesia is
adequate for all patients.
Outcomes: small-incision cataract surgery
and phacoemulsification both yield good
results
As both phacoemulsification and SICS improved, relative
safety and efficacy was appropriately questioned. The
literature in the past year shows that SICS yields good
results. In 14 393 cases performed over 1 year at a hospital
in India, 87% had a best corrected visual acuity (BCVA) at
least 20/60 at 6 weeks [28 ]. A smaller series of 55 eyes
over 3 years at a teaching hospital in the United Kingdom
found that 65% achieved a BCVA at least 20/40, with only
one case of vitreous loss [29 ]. But what is the evidence
that advances in SICS resulted in an improvement over
traditional ECCE, and how does this compare to
phacoemulsification?
One of the earliest comparative studies looked at manual
ECCE (9–13 mm incisions) versus phacoemulsification
(3.2 mm incisions, widened to 6.7 mm for IOL insertion).
Results were comparable between the two groups,
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Key points
Manual small incision cataract surgery may yield
results comparable with phacoemulsification.
Lower postoperative astigmatism is seen with
temporal scleral incisions for small-incision cataract
surgery (SICS; versus superior incisions).
Some reports suggest that endophthalmitis rates,
while low, may be higher with SICS than with
phacoemulsification. We suspect that this differ-ence
would not be seen in a comparison of sutured SICS
with phacoemulsification – something that should be
studied.
Skill in manual extracapsular cataract surgery is
valuable for a cataract surgeon to possess, and we
believe it remains an important component of
resident education.
excepting astigmatism [mean of 1 diopter (D) with pha-
coemulsification, and 3.3 D with manual ECCE] [30]. A
subsequent 476-patient study comparing modern small-
incision phacoemulsification with traditional manual
ECCE was performed in Britain in 2001 [31]. Phacoe-
mulsification produced better acuity with fewer compli-
cations and was concluded to be more cost-effective (faster
rehabilitation and fewer visits).
Later publications compared SICS to manual ECCE. In
2003 studies, from Ghana (232 eyes) [32] and India (741
eyes) [33], respectively, the techniques were comparable.
SICS, however, yielded better uncorrected acuity [33],
faster rehabilitation, and less iritis [32]. BCVA was at least
20/60 in 90% of SICS patients [32,33], and there was no
significant difference in complications between the two
groups [33].
As skill increased, excellent results were reported from
SICS by experienced surgeons. With 500 consecutive
surgeries in Nepal [7], uncorrected visual acuity was at
least 20/60 in 70% of eyes at 6 weeks and 65% of eyes at 1
year (decline attributed to slight increase in astigma-tism).
BCVA was at least 20/60 in 95–96% of eyes at both 6
weeks and 1 year. There was only one case of posterior
capsule rupture.
The first trial comparing modern SICS with phacoemul-
sification randomized 400 eyes to each technique [34]. At 1
week, 68% of phacoemulsification eyes and 61% of SICS
eyes had uncorrected visual acuity (UCVA) at least 20/60.
At 6 weeks, 81% of phacoemulsification eyes and 71% of
SICS eyes were at least 6/18 uncorrected. Ninety-eight
percent of patients in both groups had a BCVA at least
20/60. The average astigmatism was similar between the
two groups (1.1 and 1.2 D, respectively) but the mode
higher for the SICS group (1.5 D, as opposed to 0.5 D).
This situation may have been due to incision location
 Phaco vs manual extracapsular cataract surgery Pershing and Kumar 39
(unspecified in the article), because temporal incisions
generally yield less astigmatism and more long-term
stability [35].
One of the criticisms of these analyses was that the
surgeons may not have been equally skilled in both
techniques (phacoemulsification and SICS) [36]. A study
was therefore created following expertise-based trial design
[37]. One hundred and eight consecutive eyes were
randomized to phacoemulsification or SICS. All surgeries
were performed in Nepal by an expert in that technique.
The investigators concluded that each tech-nique achieved
reasonable outcomes with few compli-cations, SICS
having the advantages of lower cost and less technology
dependence. At 6 months, 89% of SICS eyes and 85% of
phacoemulsification eyes had UCVA at least 20/60. BCVA
was at least 20/60 in 98% of each. SICS induced less
immediate postoperative corneal edema than
phacoemulsification – a small difference, returning to
baseline in both groups by 3 weeks [38 ].
Posterior capsule compromise
Out of 400 randomized eyes, rates of posterior capsule
rupture were 6% with SICS and 3.5% with phacoemulsi-
fication [34]. This difference (not statistically significant)
may have been partly due to the use of can-opener
capsulotomies (versus the more stable continuous curvi-
linear capsulorhexis). Other studies of eyes undergoing
SICS – with continuous curvilinear capsulorhexis – yielded
rates of 0–2% [29 ,38 ,39 ,40].
A review of all cases of posterior capsule rupture over 2
years at one hospital in India (127 cases total) found
similar rates of posterior capsule rupture or vitreous loss
between phacoemulsification (47% of cases) and
traditional ECCE (53% of cases). The final anatomic and
visual outcomes of each group were comparable [41].
Endophthalmitis
A 2009 publication reviewed all cataract surgeries (mostly
sutureless) performed in an 18-month period at Aravind
Eye Hospital. Thirty-eight of 42 426 total cases (0.09%)
developed endophthalmitis within the first 3 months
postoperatively – a rate of 0.11% in SICS cases and 0.03%
in phacoemulsification [42 ]. The three-fold to four-fold
difference (statistically significant) between techniques
may be due to SICs cases being sutureless, without
intraoperative antibiotics.
Retrospective reviews from Saudi Arabia [43] and Aus-
tralia [44] (29 509 and 95 653 patients, respectively) found
higher endophthalmitis rates with phacoemulsification than
traditional manual ECCE: 0.16% ECCE versus 0.19%
phaco (Australia), and 0.049% ECCE versus 0.085% phaco
(Saudi Arabia). And clear corneal incisions have three-fold
to six-fold greater endophthalmitis risk
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
than scleral tunnel incisions [45–49]. Because there is little
difference between scleral tunnel and SICS incisions – save
for size – and SICS incisions are shorter than traditional
ECCE, it stands to reason that sutured SICS with
intracameral and subconjunctival antibiotics would have
equal or lesser risk of endophthalmitis than
phacoemulsification. There are unfortunately no direct
comparisons in the literature of phacoemulsification versus
sutured SICS; this aspect is something that should be
studied.
Iritis
With the greater iris trauma experienced in manual surgery,
it is unsurprising that there is more anterior segment
inflammation. One week after SICS cases with dense
lenses, 6% of eyes had mild iritis and 3% had moderate
iritis [39 ,40].
Endothelial cell loss
Postoperative endothelial cell loss does not appear to differ
among techniques. In the 2001 comparison of traditional
manual ECCE to phacoemulsification (476 eyes), mean
endothelial cell loss 1 year postoperatively was 224
cells/mm2 ( 9%) with traditional ECCE, and 259 cells/mm2
( 11%) with phacoemulsification [31].
In a later study, mean endothelial cell loss for 186 eyes at 6
weeks was found to be 4.7% with traditional ECCE, 4.21%
with SICS, and 5.41% with phacoemulsifica-tion [50]. This
year a 200-patient study showed an average loss of 474–
543 cells/mm2 after phacoemulsifica-tion and 456–505
cells/mm2 after SICS [51].
Macular edema
One might expect more cystoid macular edema (CME)
following manual extracapsular cataract extraction, due to
greater inflammation. A study this past year analyzed
macular appearance by clinical exam and OCT after
randomization to either SICS or phacoemulsification [52].
Although there was a greater subclinical increase in central
macular thickness on OCT after SICS (by 5– 9 mm),
significant CME was not seen in either group.
Astigmatism
One of the major weaknesses of manual extracapsular
surgery relative to phacoemulsification is greater surgic-
ally induced astigmatism. Average postoperative astig-
matism appears to range from 1.2 to 1.4 D with traditional
SICS [7,29 ,34,50] and to drift further with time (to around
2 D7), whereas the average is 0.7–1.1 D with
phacoemulsification [34,50] and 1.8 D with traditional
ECCE [50].
Various techniques have been developed to lessen astig-
matic effect – such as placing incisions more posteriorly,
and moving temporally (less against-the-rule drift
 40 Cataract surgery and lens implantation
with time) [23 ]. Mean astigmatism induced with SICS was
measured to be 1.28 D with superior incisions, 0.37 D with
temporal incisions, and 0.20 D with super-otemporal
incisions [25]. Another study showed 1.1 D with superior
incisions and 0.7 D with temporal incisions [39 ]. When
comparing phacoemulsification to temporal SICS, each in
expert hands, average postoperative astig-
matism was comparable – 0.7 and 0.88 D, respectively [38
].
Posterior capsule opacification
Rates of posterior capsule opacification (PCO) vary
between reports. In the trial of expert phacoemulsifica-tion
versus expert temporal SICS, PCO was seen more in the
SICS group – approximately 40% of SICS eyes versus
15% of phacoemulsification eyes having some PCO. This
may be partly from use of rounded-edge PMMA IOLs,
with a partially discontinuous capsulotomy, in the SICS
group [38 ].
Dense cataracts
SICS has been reported successful in patients with brown
or black [39 ] and white cataracts [40]. After 4–6 weeks,
77–78% had UCVA at least 20/60, and 97–99% had
BCVA at least 20/60.
Pseudoexfoliation/small pupil/phacodonesis
The rate of capsular compromise rises in cases with
pseudoexfoliation, weak zonules, small pupil, and/or
phacodonesis – regardless of technique used [53]. How-
ever, SICS may place added stress on zonules when
tumbling the nucleus into the anterior chamber, and small
pupils may hinder nucleus prolapse [54 ]. A study of 94
eyes – with pseudoexfoliation, small pupil, and
phacodonesis – randomly assigned each eye to phacoe-
mulsification (with iris hooks, capsule staining, capsule
tension ring, etc.) or extracapsular cataract extraction.
Zonular dialysis occurred in 2.1% of phaco cases and 32%
of ECCE cases, and posterior capsule rupture occurred in
4.2% of phaco cases and 17% of ECCE cases. BCVA was
better in the phacoemulsification group. How-ever, it is not
clear if the surgeons had greater experience with one of the
techniques [55].
Cost
Cost analysis varies considerably by location, technique,
facilities, and method of analysis. Most studies from India
and Nepal report that SICS is costeffective, at US$10– 30
per surgery (varying by location and calculation methods)
[7,38 ,56–58]. ECCE, in comparison, ranged from US$15–
36 [56,58], and whereas cheapest to per-form, had the
highest total or societal cost. Phacoemulsi-fication ranged
from US$38–70 (an increase in cost partly from using
foldable IOLs instead of rigid PMMA) [38 ,56,57].
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
In Britain, by contrast, the total cost (including post-
operative visits, absence from work, etc.) was calculated to
be greater for traditional ECCE than for phaco (£367
versus £359 [31]). And this past year, a study from Brazil
indicated that, although direct costs of phaco were greater,
the societal costs were lower for working patients (US$342
versus US$587 for traditional ECCE [59]).
Planned manual ECCE/SICS in resident
education
The recent standard of US resident education involved
training in manual extracapsular techniques, followed by
gradual introduction to phacoemulsification. However,
trends have moved away from this, toward early intro-
duction to phacoemulsification – with emphasis on staged
surgical curricula [60,61], structured wet labs [62], and
surgical simulations [63] – leading, in many cases, to the
abandonment of teaching planned ECCE. In a survey of US
VA facilities published this year, only 26% of those
training ophthalmology residents taught manual ECCE
techniques [64 ]. A survey of 112 US residents graduating
in 2010 revealed that 25% had never per-formed a planned
ECCE, and more than 60% had per-formed less than 1–2
cases. More experience in planned ECCE correlated with
greater comfort level for future ECCE conversion from
phaco [65].
Unsurprisingly, the trend away from planned ECCE is
without apparent ill effect on phaco skills [66] – since,
short of basic microsurgical dexterity, phaco requires a
different skill set than manual ECCE. But how will the
newest generations of surgeons learn to comfortably
convert from phaco to manual ECCE when the need arises?
Such cases (we hope) will be seldom, but when they
happen, tension is inevitably high – and adapting on the
spot is not best for learning or patient outcomes.
Another reason to know the principles of manual surgery is
that there will come a time in every surgeon’s career when
technology fails. Imagine phacoemulsification machine
failure after constructing a capsulorhexis but before
entering the lens nucleus. If there is no backup machine
available, being able to convert to a small-incision manual
technique will allow the surgery to be completed without
incident – preferable to closing the eye until the machine
can be fixed (with the lens still in place and the capsule
violated), or enlarging the clear corneal wound to
accommodate the entire nucleus.
So what are the best cases for planned ECCE? We know
that dense cataracts can be safely managed via manual
techniques [39 ,40], and these cases are likely to have more
corneal edema from high phaco energy. They are,
furthermore, the cases identified by senior residents as
being most difficult to manage by phacoemulsification
 Phaco vs manual extracapsular cataract surgery Pershing and Kumar 41
[67]. With data showing comparable outcomes from
planned SICS, performing SICS ECCE on these is not
necessarily a compromise of patient care, and teaches
valuable skills to the resident.
Conclusion
SICS has advanced along with phacoemulsification over
the past decade and is now arguably an equally safe and
efficacious procedure. Surgically induced astigmatism is
the primary postoperative concern, but, with proper
attention to technique, results can be comparable to
phacoemulsification. Endophthalmitis rates are low, and
we believe that concern regarding endophthalmitis may be
alleviated via routine suturing of SICS wounds and
injection of subconjunctival/intracameral antibiotics
– a hypothesis that requires study.
SICS has been shown to be cost-effective in developing
countries, and although it may not be the best option for
more affluent/industrialized countries, the ability to
perform it capably is a valuable skill, especially for cases
requiring conversion from phacoemulsification. However,
it is important to highlight that neither tech-nique
(phacoemulsification or SICS/ECCE) is uniformly superior
for all cases and populations. By having both techniques at
his or her disposal, the accomplished surgeon is better
equipped to manage a wide variety of scenarios.
References and recommended reading
Papers of particular interest, published within the annual period of review,
have been highlighted as:
of special interest
of outstanding interest
Additional references related to this topic can also be found in the
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