Comparison of the Outcomes of Manual Small Incision Cataract Surgery (MSICS) and Phacoemulsification (PHACO) in Ghana

Samuel Kyei1, Ebenezer Zaabaar1, Frank Assiamah1, Michael Agyemang Kwarteng2, Kofi Asiedu3

1.Department of Optometry and Vision Science, School of Allied Health Sciences, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana
2.Discipline of Optometry, University of KwaZulu-Natal, Durban, South Africa
3.Cosmopolitan Medical Center, Dzorwulu, Accra, Ghana

Correspondence to: Dr. Samuel Kyei; Email:

Received: 15th September 2020; Revised: 9th January 2021; Accepted: 3rd February 2021; Available online: 9th March 2021

Background: The growing middle-class population of Ghana has seen more people being employed in visually demanding occupations and hence there is an increased desire for quality post-cataract surgical visual outcomes. This study aimed at comparing the outcomes of manual small incision cataract surgery (MSICS) and phacoemulsification (PHACO) among Ghanaians. Methods: This was a retrospective cross-sectional study in which records of patients who underwent MSCIS or phacoemulsification by the same surgeon were reviewed. Results: Medical records of 248 eyes were reviewed, out of which 132 underwent PHACO and 116 had MSICS. A significant number of the PHACO group had good (6/6–6/18) uncorrected visual acuity (UCVA) compared to the MSICS group at 1–2 weeks follow-up (p = 0.003) and 4–6 weeks follow-up (p = 0.002). MSICS resulted in a higher total astigmatic change compared to PHACO (p < 0.001). The PHACO group had a higher number of postoperative complications compared with the MSICS group (p < 0.001). Postoperative borderline and poor uncorrected visual acuity were associated with age, total astigmatic change, and postoperative complications. Conclusion: The postoperative UCVA outcomes at 4–6 weeks’ follow-up indicates that PHACO resulted in noticeably less spectacle dependency when compared to MSICS.

Keywords: Cataract, postoperative visual acuity, postoperative complications, total astigmatic change

Ann Afr Surg. 2021 ; 18(3): 143-149

Conflicts of Interest: None
Funding: None

© 2021 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.

Despite efforts at tackling the menace of blindness due to cataract occurrence, it remains the leading cause of avoidable blindness worldwide, accounting for 51% of the global burden of blindness (1). In Ghana, cataracts are responsible for 54.8% of blindness nationwide (2). Cataract surgery has evolved from the earliest known method of couching to the recent approach of femtosecond laser-assisted cataract surgery (3).
Phacoemulsification (PHACO) is now the mainstay of cataract surgical extraction in the developed world and is the standard method of cataract extraction in regional centers in most developing countries (4), but manual small incision cataract surgery (MSICS) is the treatment modality that has gained popularity in Ghana.
However, the middle-class population of Ghana is growing (5, 6), and more people are now being employed in visually demanding occupations. There are now greater expectations concerning the quality of vision even among the retired. These visual demands associated with the changing economy of Ghana has ultimately led to patient dissatisfaction with late cataract extraction. Consequently, ophthalmology units in Ghana are gradually transitioning to PHACO, a technique that is ideally used for cataract removal at an early stage of its development.
Meanwhile, no survey has been conducted in Ghana to monitor the quality of this cataract surgical service or compare its outcomes to popular techniques that are already in place. This cataract surgery audit was, therefore, necessary to serve as an essential tool for monitoring the quality of cataract surgical services with PHACO and to determine whether the technique meets the high visual expectations of Ghanaians when compared with MSICS,  to lay a basis for the presumed excellent price–quality ratio of PHACO (7) and to ensure that a high standard of cataract surgery is maintained to achieve targets related to the World Health Organization (WHO) recommended postoperative visual outcomes (8).


Materials and methods
This was a retrospective cross-sectional study conducted in ophthalmology units where the same surgeon operated on all patients. The study covered a period of 5 years, from January 2014 to December 2018.To control confounding variables except for refractive errors, records of all cataract surgeries performed on patients with any associated comorbidities like coexisting glaucoma, corneal pathology, uveitis, and other known pathologies (i.e., diabetes, hypertension, etc.) that could impair visual potential were excluded. Besides, surgical records involving traumatic cataract, combined procedures (cataract with penetrating keratoplasty, trabeculectomy, or strabismus surgery), and secondary intraocular lens (IOL) implantation were excluded from the study to control the influence of external variables. As all these were ensured the visual defect was deemed to be attributable only to the cataract hence the same endpoint was expected in each technique.
Socio-demographic characteristics of patients, preoperative examination reports of patients, surgical details, and postoperative results were collated. Parameters studied included postoperative uncorrected visual acuity (UCVA) within 24 h of surgery, at 1–2 weeks’ follow-up and 4–6 weeks’ follow-up; total astigmatic change; postoperative best-corrected visual acuity (BCVA); intraoperative complications and number of postoperative complications.
Visual acuity was measured using Snellen’s visual acuity chart and refractive errors were determined objectively using a handheld auto refractometer and subjectively by the maximum plus to maximum visual acuity method at 6 m. Residual spherical refractive error was calculated by subtracting preoperative spherical power from postoperative spherical power; similarly, total astigmatic change was calculated by subtracting preoperative total cylinder power from postoperative total cylinder power. Visual acuities were categorized using the WHO guidelines on the outcome of cataract surgery: good (6/6–6/18), borderline (6/24–6/60), and poor (worse than 6/60) (8).
Data analysis was done using the Stat