Phacoemulsification versus extracapsular cataract extraction:

where do we stand?
Suzann Pershinga and Abha Kumarb
a
b
Stanford University Medical Center, Stanford and
Santa 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

ß 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 ß 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,
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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
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