1. Phacoemulsification versus manual small-incision cataract surgery for white cataract
Rengaraj Venkatesh, MD, Colin S.H. Tan, MD, Sabyasachi Sengupta, DO, DNB,
Ravilla D. Ravindran, MD, Krishnan T. Krishnan, MD, David F. Chang, MD
J Cataract Refract Surg 2010; 36:1849–1854
R3 이재형 / AP.조양경

2. Purpose To compare the safety and efficacy of phacoemulsification and
manual small-incision cataract surgery (SICS) to treat white cataracts in southern India
Prospective randomized clinical trial

3. Introduction
white cataract : total white opacification of the crystalline lens that precludes visualization of the fundus as well as any red reflex
Phacoemulsification is difficult and more prone to complications in eyes with mature white cataract
Manual small-incision cataract surgery (SICS) has emerged as a cost-effective alternative to phacoemulsification in the developing world

4. PATIENTS AND METHODS

5. Surgical Technique Phacoemulsification Manual SICS
a temporal 3.0mm scleral tunnel incision and a separate clear corneal stab incision for the second instrument
trypan blue–assisted continuous curvilinear capsulorhexis
phacoemulsification : phaco-chop method
Manual SICS
6.5 to 7.0 mm superior frown-shaped sclerocorneal tunnel
trypan blue–assisted capsulorhexis
the nucleus was prolapsed from the capsular bag with a Sinskey hook or by hydrodissection injection & irrigating vectis
A single-piece rigid poly(methyl methacrylate) IOL with a 6.0 mm optic was implanted in the capsular bag
unsutured self-sealing wound

6. Patients and Methods Visual impairment : CDVA of 20/60
Total surgical time : from the initiation of the conjunctival peritomy to final conjunctival closure using cauterization

7. Results
Two hundred thirty of 270 patients (85.2%) completed the 6-week follow-up.
Phaco(n=133)
Manual SICS(n=137)
Op. time(min)
12.2 ± 4.6
8.8 ± 3.4
<0.001
PC rupture
3(2.2%)
2(1.4%)
0.681
Corneal edema at POD #1
25(18.7%)
14(10.2%)
0.047
Mean central corneal thickness at POD #1(µm)
596.5
574.3
0.032
SIA(diopters)
0.84 ± 0.24
1.2 ± 0.36
0.12

8. Results Visual acuity at POD #1 UDVA CDVA Visual acuity Phaco
Manual SICS
20/20 ~ 20/60
65 (48.9%)
70 (51.1%)
0.805
77 (57.9%)
113 (82.5%)
0.001

9. Results
the mean UDVA and CDVA

10. Discussion
phacoemulsification and manual small-incision ECCE were safe and effective for visual rehabilitation of cataract patients
the UDVA at 6 weeks was better in the phacoemulsification group
Gogate PM, Kulkarni SR, Krishnaiah S, Deshpande RD,Joshi SA, Palimkar A, Deshpande MD.
Safety and efficacy of phacoemulsification compared with manual small-incision cataract surgery by a randomized controlled clinical trial; six-week results.
Ophthalmology 2005; 112:869–874
rate of infectious endophthalmitis was lower after phacoemulsification than after manual SICS
Ravindran RD, Venkatesh R, Chang DF, Sengupta S, Gyatsho J, Talwar B.
The incidence of post-cataract endophthalmitis at an Aravind Eye Hospital; outcomes from more than consecutive cases using standardized sterilization and prophylaxis protocols.
J Cataract Refract Surg 2009; 35: 629–636

11. Discussion phacoemulsification
: a greater risk for posterior capsule rupture, endothelial cell loss, and incision complications in eyes with mature cataract
manual SICS
: potential to decrease the incidence intraoperative complications by eliminating the need for ultrasound and for nuclear fragmentation

12. Discussion UDVA better than 20/30 in phacoemulsification
: d/t higher SIA from the larger incision used in manual SICS
more corneal edema on the first postoperative day in phacoemulsification
: did not result in significant differences between the 2 groups in final visual outcomes
Both groups had low intraoperative complication rates
(capsulorhexis extension and posterior capsule rupture)

13. Discussion
unsuccessful fragmenting or emulsifying in phacoemulsification d/t extremely dense nuclei
-> convert to a larger incision manual ECCE in some circumstances
-> a scleral tunnel phacoemulsification incision can be enlarged to allow manual nuclear extraction
: routine use of scleral tunnel incisions
for phacoemulsification of mature cataracts

14. Conclusion
manual SICS to be a safe and effective alternative to phacoemulsification for advanced white cataract
no significant difference in complications or final CDVA outcomes
Significant advantages for the large number of mature white cataract cases in the developing world