Original Article

Meta‑analysis to Compare the Safety and Efficacy

of Manual Small Incision Cataract Surgery and
Phacoemulsification
Parikshit Gogate1,2,3, Jyoti Jaggernath B. Optom1,4, Swapna Deshpande5, Kovin Naidoo1,4

ABSTRACT Access this article online

Website:
Purpose: A systematic review and meta‑analysis comparing the safety, efficacy, and expenses www.meajo.org
related to phacoemulsification versus manual small incision cataract surgery (SICS). DOI:
Methods: PubMed, Cochrane, and Scopus databases were searched with key words 10.4103/0974-9233.159763
manual SICS 6/18 and 6/60; astigmatism and endothelial cell loss postoperatively,
Quick Response Code:
intra‑ and post‑operative complications, phacoemulsification, and comparison of SICS and
phacoemulsification. Non‑English language manuscripts and manuscripts not indexed in the
three databases were also search for comparison of SICS with phacoemulsification. Data were
compared between techniques for postoperative uncorrected and corrected distance visual
acuity (UCVA and best corrected visual acuity [BCVA], respectively) better than 6/9, surgical
cost and duration of surgery. The Oxford cataract treatment and evaluation team scores were
used for grading intraoperative and postoperative complications, uncorrected near vision.
Result: This review analyzed, 11 comparative studies documenting 76,838 eyes that had
undergone cataract surgery considered for analysis. UCVA of 6/18 UCVA and 6/18 BCVA were
comparable between techniques (P = 0.373 and P = 0.567, respectively). BCVA of 6/9 was
comparable between techniques (P = 0.685). UCVA of 6/60 and 6/60 BCVA aided and unaided
vision were comparable (P = 0.126 and P = 0.317, respectively). There was no statistical
difference in: Endothelial cell loss during surgery  (P  =  0.298), intraoperative  (P  =  0.964)
complications, and postoperative complications (P = 0.362). The phacoemulsification group
had statistically significantly less astigmatism  (P  =  0.005) and more eyes with UCVA
of 6/9  (P  =  0.040). UCVA at near was statistically significantly better with SICS due to
astigmatism and safer during the learning phase (P = 0.003). The average time for SICS was
lower than phacoemulsification and cost <½ of phacoemulsification.
Conclusion: The outcome of this meta‑analysis indicated there is no difference between
phacoemulsification and SICS for BCVA and UCVA of 6/18 and 6/60. Endothelial cell loss and
intraoperative and postoperative complications were similar between procedures. SICS resulted
in statistically greater astigmatism and UCVA of 6/9 or worse, however, near UCVA was better.

Key words: Astigmatism, Manual Small Incision Cataract Surgery, Meta‑Analysis,

Phacoemulsification, Vision Outcome

INTRODUCTION economical technique of cataract surgery remains debatable.1,2 Over

the past decade, manual small incision cataract surgery (SICS) has

C ataract remains the leading cause of avoidable blindness

worldwide.1 However, the safest, most effective, and
become an established surgical alternative to phacoemulsification.
Phacoemulsification is the preferred technique in the developed

African Vision Research Institute, Durban, South Africa, 2Dr. Gogate’s Eye Clinic, 3Department of Ophthalmology, Padmashri D. Y.
1

Patil Medical College, Pimpri, 5Independent Biostatistician, Pune, Maharashtra, India, 4Brien Holden Vision Institute, Sydney, Australia
Corresponding Author: Dr. Parikshit Gogate, Dr. Gogate’s Eye Clinic, K‑102, Kumar Garima, Tadiwala Road, Pune ‑ 411 001, Maharashtra, India.
E-mail: parikshitgogate@hotmail.com

362 Middle East African Journal of Ophthalmology, Volume 22, Number 3, July - September 2015
 Gogate, et al.: Meta‑analysis comparing Phaco with Manual SICS
world and tertiary centers of developing countries.3‑8 Numerous
randomized controlled clinical trials (RCTs) have proved both
techniques are safe and effective for rehabilitating the vision
of cataract patients.9‑14 The advantage of both techniques are
sutureless, require small incisions, and result in faster visual
rehabilitation. Phacoemulsification requires a much smaller
incision (3.2 mm) than SICS but the incision size dependent on
the type of phacoemulsification machine being used. An ultrasonic
probe is used to emulsify the cataractous crystalline lens, and
the debris is aspirated with high vacuum. In manual SICS, the
entire crystalline lens is removed through a self‑sealing scleral
tunnel incision (5–7 mm) and a rigid polymethyl methacrylate
intraocular lens implanted. A meta‑analysis published last
year reported mostly comparable results with both techniques
with phacoemulsification providing better uncorrected visual
acuity (UCVA) due to lower astigmatism.15 The results were
drawn from the six RCTs, which were selected using the Jaded
composite scale.16 Although, the study discussed postoperative
UCVA and best‑corrected visual acuity (BCVA), astigmatism
and complications, it did not comprehensively evaluate the
complications (during and after surgery), learning curves and
surgeon time for SICS and phacoemulsification.
The significant backlog of individuals who are blind due to
cataract awaiting surgery has resulted in cataract being the leading
cause of avoidable blindness globally, including in Africa.1 The
reasons for this backlog include lack of access to eye care and lack
of resources, specially trained surgeons, to deliver cataract surgery
safely, and reliably. We performed a meta‑analysis comparing
SICS with phacoemulsification using a wider publication base,
with an emphasis on safety, learning curves, and resource inputs
to get a more holistic view of the two techniques. Comparisons
were performed with the safety, reliability, effectiveness, and
affordability of the two surgical techniques.
METHODS
This meta‑analysis compared phacoemulsification and SICS.
Ethics Board Approval was not required because the study
involved a review of published manuscripts, each of which
had Research Ethics Board Approval. PubMed, Cochrane,
and Scopus databases were searched using the keywords
manual SICS and phacoemulsification. Non‑English language
manuscripts and literature were not indexed that compared
SICS to phacoemulsification were also reviewed.
Individual data from each study was grouped for the following
objectives.
• Uncorrected and BCVA at 6/18 cut‑off (<6/18 vs. ≥6/18)
• Uncorrected and BCVA at 6/9 cut‑off (<6/9 vs. ≥6/9)
• Uncorrected visual acuity 6/60 cut‑off (<6/60 vs. ≥6/60)
• Astigmatism
Middle East African Journal of Ophthalmology, Volume 22, Number 3, July - September 2015 363
• Intraoperative complications
• Postoperative complications
• Endothelial cell loss
• Duration of surgery
• Cost of surgery
• Postoperative UCVA at near.
The cut‑off of 6/9 vision was selected because it is the standard
acuity required for a driver’s license in most developed countries.
World Health Organization (WHO) standards classify 6/18 and
better vision as normal vision, and 6/60 is considered a severe
visual impairment (economic blindness). The legal norm for
blindness in the United States and India is 6/60  (<6/60 in
the better eye with available correction). We analyzed UCVA
because many patients may not have spectacles or cannot afford
a pair of spectacles. Only astigmatism was considered because
the postoperative refractive spherical error was addressed by
A‑scan biometry and proper intraocular lens implantation. The
postoperative cylinder depended on the size, site, and type of
incision, which differed in the two techniques. The subjective
refractive correction was considered for astigmatism.
The Oxford Cataract Treatment and Evaluation Team (OCTET)
grading was used to compare the intraoperative and
postoperative complications depending on their severity.17 The
frequency of complications was graded for each technique.
The severity of complications was graded, and their effects on
final visual acuity were compared. Endothelial cell loss, though
not always obvious during surgery, has the ability to affect
corneal transparency in the long‑term. Endothelial cell loss was
compared for both techniques. Intraoperative complications
such as posterior capsular rent, vitreous loss, zonular dialysis,
and iridodialysis were compared between groups. Postoperative
complications were compared between techniques included
endophthalmitis, retinal detachment, posterior capsular
opacification, postoperative corneal edema that has the
potential for corneal decompensation. The complication scores
were compared including and excluding high volume settings
separately. The duration of each type of surgery and the cost
for surgery were compared. This was because surgeon time was
a factor in the cost of high volume Asian and African practices
where surgeons are scarce. The learning curves were compared
between techniques as new surgeons would need to be trained
for helping eliminate the cataract backlog.
Statistical analyses were performed using STATA (version  10;
StataCorp, College Station, Texas, USA). Randomized control
trials or parallel arms (one with phacoemulsification and one
SICS) design studies were included in the meta‑analysis. Primary
outcomes were presented either as binary or continuous variables.
Binary data (BCVA and UCVA related) were based on standard
cut‑offs as explained previously. For binary variables, a pooled odds
ratio (OR) with 95% confidence interval (CI) were calculated. For
 Gogate, et al.: Meta‑analysis comparing Phaco with Manual SICS

the continuous outcomes, the standardized mean difference (SMD) of one study,23 the surgeons in all others studies were fully trained,
with 95% CI was calculated. Statistical heterogeneity was tested experienced cataract surgeons. The total sample size was 76,838
using the Chi‑square and I2 statistic. To accommodate the diversity for the complications data from 11 studies. After excluding the
that each study is contributing, or treatment effects that individual Haripriya et al. and Khanna et al. studies, the other 9 studies had
studies are estimating; the results using random effects modeling a total sample size of 1768 cataract surgeries.
are presented. A random‑effects meta‑analysis was performed using
DerSimonian‑Laird method.18 Intraoperative and postoperative Comparison of best corrected visual acuity at the
complication data were analyzed by taking weighted estimates for 6/18 cut‑off using phacoemulsification versus the
analysis by assigning OCTET score to each of the complication as small incision cataract surgery technique
its weigh, where data was not available (for certain visual acuity Figure 1a presents the comparison of BCVA <6/18, relatively
cut‑offs or details such as endothelial cell loss or astigmatism), those poor or borderline and poor outcomes with phacoemulsification
studies were excluded from the meta‑analysis of that particular versus SICS.
outcome measure. Surgery time and cost data were obtained from
a review manuscript.19 Seven publications included BCVA data on 1229 eyes reported
the proportion of patients with BCVA <6/18 versus BCVA of
RESULTS 6/18 or better postoperatively (around 6 weeks + 2 weeks).
Heterogeneity among study resulted was detected to be
The literature search resulted in 84 studies, which fulfilled (I2 = 0.0%). Analysis of these data revealed that the difference in
the inclusion criteria. One study each involved comparison of
the proportion of participants with BCVA  6/18 postoperatively
phacoemulsification and SICS with conventional extracapsular
between the phacoemulsification and SICS groups was not
cataract surgery. Totally, 38 articles were published in PubMed
indexed journals, 30 in other indexed journals, 2 in local journals significant (OR: 0.73 95% CI: 0.34–1.82) (P = 0.989).
while one was published in the proceedings of the All India
Comparison of uncorrected visual acuity at 6/18
Ophthalmology Society’s Annual Conference.20 Eleven studies
cut‑off
involved a direct comparison between phacoemulsification and
SICS. Of these, six were randomized control trials,9‑14 and three Figure  1b presents the comparison of UCVA  <6/18 versus
others were direct comparison, one with near vision data, the second UCVA >6/18, relatively poor or borderline and poor outcomes
comparing subluxated cataracts while the third compared immature with phacoemulsification versus SICS.
cataract surgery with both techniques.20‑22 A study by Khanna
et al. compared the safety and efficacy of both techniques during Five publications included UCVA data on 1082 eyes and reported
their learning curves in a large residency and fellowship training the proportion of patients with UCVA <6/18 versus UCVA of
program.23 It had a large sample size and variety of complications 6/18 or better postoperatively (around 6 weeks + 2 weeks).
and dominated the forest plots comparing intraoperative and Heterogeneity among studies was estimated to be (I2 = 53.10%).
postoperative complications. Hence, it was not included in the Analysis of the data revealed that the difference in the proportion
meta‑analysis but discussed in parallel, especially in view of safety of participants with UCVA  <6/18 postoperatively between
and complications. A study by Haripriya et al. compared SICS and techniques was not statistically significant (OR: 0.81; 95% CI:
phacoemulsification in a high volume setting.24 With the exception 0.51–1.29; I2 = 53.1%, P = 0.373) [Figure 1b].

Events, Events, %
Events, Events, %

STUDY_ID YEAR AUTHOR OR (95% CI) Treatment

Phaco Control
SICS Weight
ID YEAR AUTHOR OR (95% CI) Treatment Control Weight

5 2005 Gogate, PM 1.01 (0.20, 5.07) 3/185 3/187 27.27

5 2005 Gogate, PM 0.57 (0.35, 0.93) 35/185 54/187 27.17
9 2005 George, R 0.29 (0.01, 7.25) 0/60 1/53 6.84

2 2007 Ruit, S 1.00 (0.06, 16.41) 1/54 1/54 9.07 2 2007 Ruit, S 1.39 (0.45, 4.32) 8/54 6/54 11.57

1 2010 Venkatesh, R 0.51 (0.05, 5.74) 1/113 2/117 12.18 3 2009 Singh, SK 1.64 (0.85, 3.18) 30/93 20/89 21.58

4 2010 Kulkarni, N 2.02 (0.18, 22.65) 2/100 1/100 12.16

1 2010 Venkatesh, R 0.65 (0.31, 1.34) 14/113 21/117 19.59
6 2010 Gogate, PM 0.52 (0.05, 5.88) 1/71 2/75 12.09
4 2010 Kulkarni, N 0.55 (0.27, 1.13) 16/100 23/90 20.08
7 2012 Goel, R 0.64 (0.10, 4.15) 2/30 3/30 20.39
Overall (I-squared = 53.1%, p = 0.074) 0.81 (0.51, 1.29) 103/545 124/537 100.00
Overall (I-squared = 0.0%, p = 0.969) 0.78 (0.34, 1.82) 10/613 13/616 100.00

NOTE: Weights are from random effects analysis NOTE: Weights are from random effects analysis

.0115 1 86.7 .231 1 4.32

a Phaco Technique SICS Technique

b
Phaco Technique SICS Technique

Figure 1: (a) Comparison of best corrected visual acuity at 6/18 cutoff using Phaco vs. SICS Meta Analysis based on data from 7 studies; Event is BCVA < 6/18, OR: odds
ratio, OR of Phaco over SICS. (b) Comparison of Unaided corrected visual acuity at 6/18 cutoff using Phaco vs. SICS Meta Analysis based on data from 5 studies; Event is
UCVA < 6/18, OR: odds ratio, OR of Phaco over SICS

364 Middle East African Journal of Ophthalmology, Volume 22, Number 3, July - September 2015
 Gogate, et al.: Meta‑analysis comparing Phaco with Manual SICS

Comparison of 6/9 best corrected visual acuity data on UCVA <6/60 for 1777 eyes and reported the proportion
Figure  2a presents the comparison of BCVA  >6/9 with of patients with BCVA <6/60 versus BCVA of 6/60 or better
phacoemulsification versus SICS. Three publications reported postoperatively (around 6 weeks + 2 weeks). Khanna et al. study
the proportion of patients with BCVA  >6/9 versus BCVA were included in this analysis. The difference in BCVA <6/60
of <6/9 postoperatively (6  weeks  +  2  weeks). Random postoperatively between techniques was not statistically
effect modeling was used and analysis of these data indicated significant (OR: 0.61; 95% CI: 0.33–1.19; P = 0.126) [Figure 3a].
no statistical difference in the proportion of participants Figure 3b compares aided visual acuity <6/60, a poor outcome
with postoperative UCVA  <6/9 between techniques with phacoemulsification versus SICS. There was no statistical
(OR: 0.81; 95% CI: 0.3–2.22; P = 0.685) [Figure 2a]. difference between techniques (OR: 2.19; 95% CI, 0.46–10.38;
P = 0.314) [Figure 3b].
Comparison of uncorrected visual acuity <6/9
Figure  2b compares UCVA  <6/9 between techniques. Comparison of astigmatism with both techniques
Three publications reported the proportion of patients Figure 4 compares postoperative astigmatism after
with UCVA >6/9 vs. UCVA  <6/9 postoperatively phacoemulsification versus SICS. Seven studies evaluated 1303 eyes,
(6 weeks + 2 weeks). Random effect modeling was used and data comparing surgically induced astigmatism after phacoemulsification
analysis indicated that there was a statistically significant difference and SICS. Phacoemulsification had statistically significantly lower
between the proportion of participants with postoperative than SICS (SMD = −0.614; 95% CI: −1.05, −0.18; P = 0.005).
UCVA >6/9 was (OR: 0.71; 95% CI: 0.51–0.98; P = 0.04) The smaller incision size in phacoemulsification led to significantly
[Figure 2b]. lower astigmatism than SICS.

Comparison of best corrected visual acuity and Comparison of complications with both techniques
uncorrected visual acuity at 6/60 cut‑off Khanna et  al. compared outcomes while learning both
Figure  3a compares BCVA  <6/60, a poor outcome with techniques. Haripriya et al. presented data from a high volume,
phacoemulsification versus SICS. Two publications presented high‑quality cataract surgery practice. Hence, the intraoperative

Events, Events, % Events, Events, %

ID YEAR AUTHOR OR (95% CI) Treatment Control Weight ID YEAR AUTHOR OR (95% CI) Phaco
Treatment SICS
Control Weight

5 2005 Gogate, PM 1.69 (0.99, 2.88) 41/185 27/187 41.51 5 2005 Gogate, PM 0.83 (0.54, 1.28) 117/185 126/187 50.45

2 2007 Ruit, S 0.55 (0.12, 2.43) 3/48 5/46 23.08 2 2007 Ruit, S 0.41 (0.18, 0.95) 22/48 31/46 14.71

1 2010 Venkatesh, R 0.45 (0.19, 1.03) 9/113 19/117 35.41 1 2010 Venkatesh, R 0.71 (0.42, 1.20) 62/113 74/117 34.84

Overall (I-squared = 74.1%, p = 0.021) 0.81 (0.30, 2.22) 53/346 51/350 100.00 Overall (I-squared = 8.8%, p = 0.334) 0.71 (0.51, 0.98) 201/346 231/350 100.00

NOTE: Weights are from random effects analysis NOTE: Weights are from random effects analysis

.123 1 8.14 .177 1 5.65

Phaco Technique SICS Technique Phaco Technique SICS Technique
a b
Figure 2: (a) Comparison of best corrected visual acuity at 6/9 cutoff using Phaco vs. SICS. (b) Comparison of unaided corrected visual acuity at 6/9 cutoff using Phaco vs. SICS

Events, Events, % Events, Events, %

ID YEAR AUTHOR OR (95% CI) Treatment Control Weight

STUDY_ID YEAR AUTHOR OR (95% CI) Treatment
Phaco SICS Weight
Control

5 2005 Gogate, PM 3.05 (0.12, 75.32) 1/185 0/187 21.41

5 2005 Gogate, PM 3.05 (0.12, 75.32) 1/185 0/187 3.82
3 2009 Singh, SK 6.07 (0.72, 51.46) 6/93 1/89 43.27

8 2012 Khanna, RC 0.57 (0.31, 1.08) 16/507 28/522 96.18

1 2010 Venkatesh, R 0.51 (0.05, 5.74) 1/113 2/117 35.32

Overall (I-squared = 0.3%, p = 0.317) 0.61 (0.33, 1.15) 17/692 28/709 100.00
Overall (I-squared = 13.7%, p = 0.314) 2.19 (0.46, 10.38) 8/391 3/393 100.00

NOTE: Weights are from random effects analysis NOTE: Weights are from random effects analysis

.0133 1 75.3 .0133 1 75.3

Phaco Technique SICS Technique Phaco Technique SICS Technique
a b
Figure 3: (a) Comparison of best corrected visual acuity at 6/60 cutoff using Phaco vs. SICS. (b) Comparison of unaided corrected visual acuity at 6/60 cutoff using Phaco
vs. SICS

Middle East African Journal of Ophthalmology, Volume 22, Number 3, July - September 2015 365
 Gogate, et al.: Meta‑analysis comparing Phaco with Manual SICS

and postoperative complications were analyzed separately, with Comparison of postoperative complications with
and without these two manuscripts. both techniques
Figure 6 compares postoperative complications excluding Khanna
Comparison of intraoperative complications with et al.23 study and Haripriya et al.24 study. Using the OCTET scores,
each technique there was no difference between the two techniques (P = 0.362).
Figure 5 compares of intraoperative complications
excluding Khanna et al. 3 study and Haripriya et al. 24 study. Comparison of endothelial cell loss with both
Six studies that compared intraoperative complication techniques
for a total of 1220 eyes were reviewed. There was no Figure 7 compares the change in endothelial cell count after
difference in intraoperative complications between each phacoemulsification and SICS. Two studies compared
techniques (P > 0.05). endothelial cell loss after phacoemulsification and SICS each
were similarly weighted in the meta‑analysis. The odds ratio was
OR 1.00 (−0.29, 2.90). One study13 reported higher loss with
N, mean N, mean %

STUDY_ID YEAR AUTHOR SMD (95% CI) (SD); Treatment (SD); Control Weight
phacoemulsification and the other study reported no difference,
even though sodium hyaluronate and acrylic foldable lenses were
4

7
2005

2005
Gogate, PM

George, R
-0.10 (-0.30, 0.10)

-0.16 (-0.53, 0.21)

185, 1.1 (.9)

60, 1.38 (.77)

187, 1.2 (1.1)

53, 1.5 (.77)

15.13

14.04
used for phacoemulsification and methylcellulose, and PMMA
2 2009 Singh, SK 0.03 (-0.27, 0.32) 93, .11 (.74) 89, .09 (.82) 14.62 lenses were implanted for patients undergoing SICS in both
1

3
2010

2010
Venkatesh, R

Kulkarni, N
-1.30 (-1.59, -1.02)

-1.12 (-1.42, -0.82)

113, .8 (.24)

100, .6 (.5)
117, 1.2 (.36)

100, 1.16 (.5)

14.66

14.57
studies.
5 2010 Gogate, PM -0.86 (-1.20, -0.52) 71, .48 (.3) 75, .95 (.7) 14.28

6 2012 Goel, R -0.81 (-1.34, -0.28) 30, .58 (.43) 30, .95 (.48) 12.70 Comparison of duration of surgery
Overall (I-squared = 92.8%, p = 0.000)

with estimated predictive interval

-0.61 (-1.05, -0.18)

. (-2.16, 0.93)
652 651 100.00
The average duration of surgery of each technique is presented
NOTE: Weights are from random effects analysis
in Table 1.
-1.59 0 1.59
Phaco Technique SICS Technique
A meta‑analysis could not be performed as the published
Figure 4: Astigmatism using Phaco vs. SICS technique manuscripts did not report standard deviations for each surgery.

N, mean N, mean % N, mean %

STUDY_ID YEAR AUTHOR SMD (95% CI) (SD); Treatment N, mean (SD); Control Weight
STUDY_ID YEAR AUTHOR SMD (95% CI) (SD); Treatment (SD); Control Weight

5 2005 Gogate, PM -0.95 (-1.16, -0.74) 199, .116 (.034) 201, .149 (.0369) 16.67
5 2005 Gogate, PM -0.95 (-1.16, -0.74) 199, .116 (.034) 201, .149 (.0369) 20.32
3 2009 Singh, SK 0.99 (0.68, 1.30) 93, .0538 (.0386) 89, .0225 (.0223) 16.67
3 2009 Singh, SK 0.99 (0.68, 1.30) 93, .0538 (.0386) 89, .0225 (.0223) 20.14
1 2010 Venkatesh, R 1.37 (1.10, 1.64) 133, .0677 (.0342) 137, .0292 (.0205) 16.67
1 2010 Venkatesh, R 1.37 (1.10, 1.64) 133, .0677 (.0342) 137, .0292 (.0205) 20.22
6 2010 Gogate, PM 0.43 (0.15, 0.71) 100, .13 (.0485) 100, .11 (.0451) 16.67
6 2010 Gogate, PM 0.43 (0.15, 0.71) 100, .13 (.0485) 100, .11 (.0451) 20.19
7 2012 Goel, R -2.06 (-2.69, -1.43) 30, .4 (.146) 30, .733 (.176) 16.64

7 2012 Goel, R -2.06 (-2.69, -1.43) 30, .4 (.146) 30, .733 (.176) 19.13
11 2012 Haripriya, A 10.47 (10.41, 10.52) 20438, .0177 (.00136) 53603, .00854 (.00058) 16.68

Overall (I-squared = 98.5%, p = 0.000) -0.02 (-1.10, 1.05) 555 557 100.00
Overall (I-squared = 100.0%, p = 0.000) 1.71 (-3.98, 7.39) 20993 54160 100.00

with estimated predictive interval . (-4.25, 4.20) with estimated predictive interval . (-19.59, 23.01)

NOTE: Weights are from random effects analysis NOTE: Weights are from random effects analysis

-2.69 0 2.69 -10.5 0 10.5

Phaco Technique SICS Technique Phaco Technique SICS Technique
a b

N, mean %

STUDY_ID YEAR AUTHOR SMD (95% CI) (SD); Treatment N, mean (SD); Control Weight

5 2005 Gogate, PM -0.95 (-1.16, -0.74) 199, .116 (.034) 201, .149 (.0369) 14.29

3 2009 Singh, SK 0.99 (0.68, 1.30) 93, .0538 (.0386) 89, .0225 (.0223) 14.29

1 2010 Venkatesh, R 1.37 (1.10, 1.64) 133, .0677 (.0342) 137, .0292 (.0205) 14.29

6 2010 Gogate, PM 0.43 (0.15, 0.71) 100, .13 (.0485) 100, .11 (.0451) 14.29

7 2012 Goel, R -2.06 (-2.69, -1.43) 30, .4 (.146) 30, .733 (.176) 14.27

8 2012 Khanna, RC -3.77 (-3.98, -3.57) 507, .12 (.0217) 522, .215 (.0278) 14.29

11 2012 Haripriya, A 10.47 (10.41, 10.52) 20438, .0177 (.00136) 53603, .00854 (.00058) 14.29

Overall (I-squared = 100.0%, p = 0.000) 0.93 (-4.86, 6.71) 21500 54682 100.00

with estimated predictive interval . (-20.54, 22.39)

NOTE: Weights are from random effects analysis

-10.5 0 10.5
Phaco Technique SICS Technique
c
Figure 5: (a) Intra-operative complications excluding studies with learning curves and high volume surgery using Phaco vs. SICS technique. (b) Intra-operative complications
including high volume setting. (c) Intra-operative complications including studies with learning curves and high volume surgery using Phaco vs. SICS technique

366 Middle East African Journal of Ophthalmology, Volume 22, Number 3, July - September 2015
 Gogate, et al.: Meta‑analysis comparing Phaco with Manual SICS

N, mean N, mean % N, mean %

STUDY_ID YEAR AUTHOR SMD (95% CI) (SD); Treatment N, mean (SD); Control Weight
STUDY_ID YEAR AUTHOR SMD (95% CI) (SD); Treatment (SD); Control Weight

Phaco SICS

5 2005 Gogate, PM 1.86 (1.63, 2.10) 199, .221 (.0453) 201, .144 (.0369) 20.08
5 2005 Gogate, PM 1.86 (1.63, 2.10) 199, .221 (.0453) 201, .144 (.0369) 25.13

2 2007
1 2010
2 2007 Ruit, S -1.80 (-2.25, -1.35) 54, .259 (.0914) 54, .444 (.113) 19.73
Ruit, S -1.80 (-2.25, -1.35) 54, .259 (.0914) 54, .444 (.113) 24.80
1 2010 Venkatesh, R 2.85 (2.51, 3.19) 133, .376 (.0678) 137, .204 (.0518) 19.94
Venkatesh, R 2.85 (2.51, 3.19) 133, .376 (.0678) 137, .204 (.0518) 24.99
6 2010 Gogate, PM 0.16 (-0.12, 0.43) 100, .23 (.0654) 100, .22 (.063) 20.03

6 2010 Gogate, PM 0.16 (-0.12, 0.43) 100, .23 (.0654) 100, .22 (.063) 25.08
11 2012 Haripriya, A 2.62 (2.60, 2.65) 20438, .00205 (.00055) 53603, .00112 (.00025) 20.22

Overall (I-squared = 99.1%, p = 0.000) 0.77 (-0.89, 2.44) 486 492 100.00
Overall (I-squared = 99.4%, p = 0.000) 1.15 (-0.12, 2.42) 20924 54095 100.00

with estimated predictive interval . (-7.36, 8.91)

with estimated predictive interval . (-3.89, 6.19)

NOTE: Weights are from random effects analysis NOTE: Weights are from random effects analysis

-3.19 0 3.19 -3.19 0 3.19

favours Phaco favours SICS favours Phaco favours SICS

a b

N, mean %

STUDY_ID YEAR AUTHOR SMD (95% CI) (SD); Treatment N, mean (SD); Control Weight

5 2005 Gogate, PM 1.86 (1.63, 2.10) 199, .221 (.0453) 201, .144 (.0369) 16.72

2 2007 Ruit, S -1.80 (-2.25, -1.35) 54, .259 (.0914) 54, .444 (.113) 16.34

1 2010 Venkatesh, R 2.85 (2.51, 3.19) 133, .376 (.0678) 137, .204 (.0518) 16.57

6 2010 Gogate, PM 0.16 (-0.12, 0.43) 100, .23 (.0654) 100, .22 (.063) 16.67

8 2012 Khanna, RC 1.04 (0.91, 1.17) 522, .0421 (.0111) 507, .0316 (.00921) 16.83

11 2012 Haripriya, A 2.62 (2.60, 2.65) 20438, .00205 (.00055) 53603, .00112 (.00025) 16.87

Overall (I-squared = 99.6%, p = 0.000) 1.13 (0.11, 2.15) 21446 54602 100.00

with estimated predictive interval . (-2.68, 4.94)

NOTE: Weights are from random effects analysis

-3.19 0 3.19
favours Phaco favours SICS

c
Figure 6: (a) Post-operative complications excluding studies with learning curves and high volume surgery using Phaco vs. SICS technique. (b) Post-operative complications
including high volume settings but excluding studies with learning curves. (c) Post-operative complications including studies with learning curves and high volume surgery

Cost comparison
N, mean N, mean %
The cost of each technique is present in Table 2. The details are
STUDY_ID YEAR AUTHOR SMD (95% CI) (SD); Treatment

Phaco
(SD); Control

SICS
Weight
presented from a review article.19,25‑28

Postoperative uncorrected near visual acuity

9 2005 George, R 1.98 (1.52, 2.43) 60, 136 (10.3) 53, 115 (11) 49.65

6 2010 Gogate, PM 0.05 (-0.28, 0.37) 71, 474 (387) 75, 456 (392) 50.35

Overall (I-squared = 97.8%, p = 0.000) 1.00 (-0.89, 2.90) 131 128 100.00
One prospective comparative study found the 35% of SICS
Inestimable predictive distribution with <3 studies . ( - , - )
patients had UCVA at near better than N9 compared to 3% of
phacoemulsification patients, when the A‑scan and IOL power
NOTE: Weights are from random effects analysis
was calculated for emmetropia at a distance.20 Near UCVA
between N 9 and <N 18 was reported in 46% of SICS patients
-2.9 0 2.9
Phaco Technique SICS Technique

Figure 7: Endothelial cell count loss using Phaco vs. SICS technique and 16% of phacoemulsification patients. Near UCVA of N 18
or better was reported in 81% of SICS patients and 19% of
Table 1: Average duration of phacoemulsification and manual phaco patients.20 Against‑the‑rule myopic astigmatism helped
small incision cataract surgery more patients achieve better UCVA at near after SICS.
Author Journal, year Phacoemulsification SICS
Venkatesh et al. 12 JCRS 2010 8.8 12.2 DISCUSSION
Ruit et al.11 AJO 2007 15.5 9.0
Singh et al.22 NJO 2009 7.0 5.4
The meta‑analysis revealed no differences between
Kulkarni et al.20 AIOC proceedings 2010 15.0 7.0
Gogate et al.25 Ophthalmol 2005 15.0a 7.0 phacoemulsification and SICS for BCVA and UCVA at the
SICS: Manual small incision cataract surgery, JCRS: Journal of Cataract and
6/18 and 6/60 cut‑offs and at the BCVA 6/9 cut‑off. There was a
Refractive Surgery, AJO: American Journal of Ophthalmology, NJO: Nepal Journal small difference favoring phacoemulsification for the 6/9 UCVA
of Ophthalmology, AIOC: All India Ophthalmology Conference proceedings
cut‑off (P = 0.04). There were differences between techniques
in endothelial cell loss and intraoperative and postoperative
All except one of the five publications report much lower average complications scores. However, SICS was safer for beginning
time for SICS than phacoemulsification.19,25 surgeons (P = 0.03 for postoperative complications).

Middle East African Journal of Ophthalmology, Volume 22, Number 3, July - September 2015 367
 Gogate, et al.: Meta‑analysis comparing Phaco with Manual SICS
Table 2: Cost comparison between the techniques
Country Study (year) (reference)
India Gogate et al.27
India Gogate et al.25
India Muralikrishnan et al.28
Nepal Ruit et al.11
SICS: Manual small incision cataract surgery, ECCE‑IOL: Extracapsular cataract extraction with implantation of the intraocular lens
The smaller incision size during phacoemulsification resulted
in statistically lower postoperative astigmatism. However, this
did not translate into a clinically significant difference in UCVA.
6/18 is considered to be normal vision by WHO for most tasks
and 6/9 is the international driving license standard in many
countries. Normal vision  (6/18) postoperatively  (UCVA and
BCVA) was reported in relatively equivalent numbers of SICS
and phacoemulsification patients. Similarly, almost equivalent
numbers of patients undergoing each technique achieved the
global standard for driver’s license vision (6/9). In terms of safety,
vision <6/60 was similar between techniques. This finding was
after considering manuscripts for white, hard cataracts, and
immature cataracts which were not a part of earlier meta‑analysis,
which was based solely on the RCTs. Hence, despite lower
postoperative astigmatism after phacoemulsification the UCVA of
these patients was not significantly better. Notably, the increased
astigmatism in SICS in one series from Miraj, India was responsible
for better UCVA compared to phacoemulsification.20 Although
the lack of postoperative astigmatism improved distance UCVA
in phacoemulsification patients, it was associated with impaired
UCVA at near.20 The unaided near vision was important even in
illiterate, rural communities for needlework, cooking and cleaning,
answering mobile phones and differentiating currency, and not
just for reading and writing. Hence, astigmatism is an issue in
differentiating the two techniques; it does not seem to have much
impact on functional vision.
There are some limitations of this study including the drawbacks of
the design of each individual study included in this meta‑analysis.
In addition, most studies had a short follow‑up (<4 months).
The longer follow‑up would lead to a decrease in astigmatism
but perhaps increased posterior capsular opacification. However,
to negate some of the drawbacks, we have considered all the
series comparing the two techniques, not just RTCs, to make
the meta‑analysis more wide ranging.
Comparison of complications using OCTET scores indicated
no difference in safety between techniques. SICS was also safer
during the learning phase for residents and trainees across two
large, reputed training programs in India.23,24 Some complications
such as nucleus drop was observed in phacoemulsification, while
iridodialysis was reported in SICS. Descemet’s detachment, a
not uncommon occurrence, was not discussed in any of the
series that were analyzed. The decrease in the endothelial cell
count was comparable between techniques. There was slightly
greater decrease associated with phacoemulsification despite the
368 Middle East African Journal of Ophthalmology, Volume 22, Number 3, July - September 2015
ECCE‑IOL Phacoemulsification SICS
US $15.82 US $15.68
‑ US $42.10 US $15.34
US $16.25 US $25.55 US $17.03
‑ US $70 US $15
use of high‑density viscoelastic devices. SICS had improved the
visual outcomes in a large community eye care center.29
Small incision cataract surgery was almost half the cost of
phacoemulsification with easier learning curves. The duration
of surgery was also lower. Hence, a surgeon using SICS would
more productive if there was a backlog of cataract patients.
The current meta‑analysis did indicate the similarity of results
between phacoemulsification and SICS even after considering
white, black, hard, and subluxated cataracts. A similar study
from China evaluated only RTCs. Some randomized trials
reported better UCVA in the phacoemulsification arm of the
study9 however, this meta‑analysis indicates that the difference
is not very significant. This outcome was similar to results from
a recent Cochrane review.30
The comparable results in UCVA and BCVA; intraoperative and
postoperative complications, endothelial cell loss make SICS an
equivalent technique to phacoemulsification. After considering the
saving in surgeon time, the easier and safer learning curves and the
cost of the procedure, SICS is the most suitable surgery for addressing
the backlog of cataract blindness in Africa. A study31 from South
Africa reported phacoemulsification was more effective. However,
the South African study31 reported 7% eyes with postoperative
visual acuity <6/60 as compared to the WHO standard of <5%.31
The South African study31 also reported astigmatism ranged up to
13 D and average astigmatism of one and half times greater than
the published literature. In addition, the surgeons are the South
African study31 used an 8 mm tunnel for SICS with suture unlike
the 5.5–6.5 mm in most series. In addition, 8% patients in the
phacoemulsification arm required conversion to SICS.31
The lesser duration of surgery and less need for equipment
in SICS means the surgeon would be more productive with a
higher turnover in communities where there is large backlog of
blindness and trained human resources are scarce, as in many
African countries. The more economical cost would mean that the
same budget could be used for a greater number of beneficiaries.
In a limited resource setting with large number of beneficiaries
awaiting cataract surgery/backlog of cataract blind, manual SICS
is the technique of choice over phacoemulsification, as in Africa.
In any publicly funded programs, it would give the most cost
effective results. Only when surgery is self‑paid would the small
advantage of phacoemulsification for UCVA at a distance be
justified. Even in developed countries, SICS can be appropriate
 Gogate, et al.: Meta‑analysis comparing Phaco with Manual SICS
for dense cataracts where the posterior capsule cannot be seen,
phacodonesis is very hard cataracts (as a high phaco power setting
is needed) and for inexperienced surgeons.32
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Cite this article as: Gogate P, Optom JB, Deshpande S, Naidoo K. Meta-
analysis to compare the safety and efficacy of manual small incision cataract
surgery and phacoemulsification. Middle East Afr J Ophthalmol 2015;22:362-9.
Source of Support: Nil, Conflict of Interest: None declared.
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