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 Table of Contents    
Year : 2023  |  Volume : 16  |  Issue : 1  |  Page : 51-54  

Visual outcome and complications of small-incision cataract surgery

1 Sagarmatha Choudhary Eys Hospital, Lahan, Nepal; Department of Ophthalmology, Government Medical College, Surat, India
2 Sagarmatha Choudhary Eys Hospital, Lahan, Nepal
3 Department of Ophthalmology, Government Medical College, Surat, India

Date of Submission04-Jun-2021
Date of Decision24-Jun-2022
Date of Acceptance26-Aug-2022
Date of Web Publication21-Feb-2023

Correspondence Address:
Rupak Kumar Jha
Department of Ophthalmology, Government Medical College, Surat

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ojo.ojo_172_21

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BACKGROUND AND OBJECTIVES: Small-incision cataract surgery (SICS) is a commonly performed procedure in developing countries. It does not require expensive machines and can be safely done in high-volume centers also yielding good visual outcomes in the majority of patients. The objective of our study was to assess visual outcomes after SICS conducted at a tertiary care center in South Gujarat and also assessment of various complications responsible for poor visual outcomes.
MATERIALS AND METHODS: Three hundred and fifteen cataract patients were included in the study. An assessment of intraoperative and postoperative complications was done. Postoperative visual acuity assessment was done and compared with preoperative visual acuity of the patient and factors responsible for poor visual outcomes were assessed. A follow-up examination was done on days 1, 3, 7, 14, and 30.
RESULTS: The mean age group of patients was 59.3 years. Females were slightly more (53.3%) in number as compared to males. The most common surgical complication encountered were striate keratopathy (6.35%), followed by iris damage (5.71%), posterior capsular rent (PCR) with vitreous loss (3.14%), hypotony (0.63%), intraocular lens decentration (0.63%), surgery-induced astigmatism (0.63%), choroidal detachment (0.32%), endophthalmitis (0.32%), and hyphema (0.32%). About 95.87% of patients had vision better than 6/18. Complications associated with poor visual outcome (<6/18) were PCR, endophthalmitis, choroidal detachment, and surgical-induced astigmatism.
CONCLUSIONS: Although SICS can have a significant chance of complications, good visual outcomes can be attained in the majority of patients.

Keywords: Cataract, small-incision cataract surgery, posterior capsular rent

How to cite this article:
Jha RK, Priya B, Solu TM, Patel I. Visual outcome and complications of small-incision cataract surgery. Oman J Ophthalmol 2023;16:51-4

How to cite this URL:
Jha RK, Priya B, Solu TM, Patel I. Visual outcome and complications of small-incision cataract surgery. Oman J Ophthalmol [serial online] 2023 [cited 2023 Mar 26];16:51-4. Available from: https://www.ojoonline.org/text.asp?2023/16/1/51/370035

   Introduction Top

Population-based studies and meta-analysis have shown that cataract accounts for 47.8%–51% of global blindness.[1],[2],[3],[4],[5],[6],[7] India has 9 million people living with blindness, one of the highest worldwide. Several studies have shown that unoperated cases of cataracts are the most common cause of blindness.[8],[9],[10] Cataract is defined as a loss of transparency of the crystalline lens. Cataracts can occur due to various causes such as increasing age, trauma, smoking, alcohol, and radiation. It can be associated with systemic diseases such as diabetes, ocular diseases (uveitis, glaucoma, and myopia), or metabolic diseases. Increasing age is one of the major factors for the development of cataract. There is an increase in the ratio of insoluble to soluble protein with age which causes fluctuations in the refractive index of the lens, scattering of light, and cataract formation.[11] In India, it is expected that the population of more than 60 years will rise from 8.2% in 2011 to 10.7% in 2021.[12] As the aging population will increase, so will the number of people at risk of developing cataracts. Initially, by the National Programme for Control of Blindness, cataract surgeries were carried out in mobile camps that have gradually shifted to permanent set up of operation theaters at district hospitals and medical colleges.

Vision impairment has detrimental effects; it reduces a person's ability to perform activities of daily living impairing his/her quality of life and mental health. Timely performed cataract surgery yields good results and ophthalmologists are trying their best to provide the best visual acuity to their patients. We have come a long way from couching techniques done hundreds of years ago to sophisticated methods like phacoemulsification. Different methods of cataract surgery include intracapsular cataract extraction (ICCE) and extracapsular cataract extraction (ECCE), conventional ECCE, small-incision cataract surgery (SICS), and phacoemulsification. In the developed world, phacoemulsification is a widely used technique, but the scenario in the developing world is a bit different. Gogate et al. did a meta-analysis and concluded that there is no difference between phacoemulsification and SICS for best-corrected distance visual acuity and uncorrected visual acuity of 6/18 and 6/60, respectively. SICS resulted in statistically greater astigmatism.[13] The objective of our study was to assess visual outcomes after SICS conducted at a tertiary care center in South Gujarat and also assessment of various complications responsible for poor visual outcomes.

   Materials and Methods Top

This was a prospective, longitudinal type of study conducted from August 2016 to October 2017 at a tertiary eye care center in South Gujarat. Ethical permission was taken from Human Research Ethics Committee at Tertiary Eye Care Center in South Gujarat in August 2016 (Ref. No.: MCS/STU/ETHICS/APPROVAL/16740). Three hundred and fifteen patients having age ranged from 21 to 95 years with visually significant cataract were included in this study. Exclusion criteria included patients having preexisting diseases such as diabetes mellitus, hypertension, ocular diseases such as glaucoma or iridocyclitis, nondilating pupil, or preoperative astigmatism (more than 2D). The nature and purpose of the study, its potential risks/benefits, expected duration, and other relevant details were well explained to participants. They also had been explained regarding their voluntary participation and they might withdraw anytime without giving any reason. Informed written consent was taken from each participant. This study adhered to the tenets of the Declaration of Helsinki. Preoperative visual acuity assessment was done with Snellens distance vision chart, and complete anterior and posterior segment examination was done. Intraocular lens (IOL) power was measured using manual keratometry and a scan contact machine. Intraocular pressure was measured with a Goldmann applanation tonometer. Routine blood and urine investigations were done and blood pressure was measured for every patient. The surgeries were performed under peribulbar anesthesia by experienced faculty and residents under the guidance of faculty. Intraoperative complications (tunnel-related complications, iris prolapse, and posterior capsular rent (PCR) with vitreous loss) were identified and managed immediately in a standard way. Postoperative visual acuity assessment and complete anterior and posterior segment examination were done on postoperative days 1, 3, 7, 14, and 30.

   Results Top

A total of 315 patients were included in the study, out of which 147 (46.67%) were males and 168 (53.33%) were females. The mean age of the study participants was 59.36 years. The median age was 60 years for both males and females in the study group. Thus, the two groups were comparable (P = 0.37). [Table 1] shows the age- and gender-wise distribution of study participants.
Table 1: Age- and gender-wise distribution of study participants

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In this study, out of 315 cataract patients, 230 (73.02%) had immature cataracts, whereas 85 (26.98%) had mature cataracts. There was no significant difference between the type of cataract and sex (P = 0.27). Participants were categorized according to the WHO criteria into four groups having visual acuity <3/60, 3/60–5/60, 6/60–6/18, and >6/18. Out of 315, 205 (65.08%) patients had preoperative vision <3/60, whereas only 5 (1.59%) had vision >6/18. Postoperatively, 302 (95.87%) achieved vision better than 6/18. The Spearman correlation between preoperative and postoperative (day 30) was found to be positive and significant at 0.05 level (correlation coefficient = 0.93, P = 0.050). [Table 2] shows the comparison of preoperative and postoperative visual acuity (day 30).
Table 2: Comparison of preoperative and postoperative visual acuity (day 30)

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The various intraoperative complications encountered were PCR with vitreous loss 10 (3.16%), choroidal detachment 1 (0.32%), and iris damage 18 (5.71%). Out of 10 cases, PCR-IOL was successfully implanted in the sulcus in five cases whereas the other five cases had to be left aphakic due to the larger size of PCR. Postoperative complications were striate keratopathy 20 (6.35%), wound leakage 2 (0.63%), hyphema 1 (0.32%), IOL decentration 2 (0.63%), and endophthalmitis 1 (0.32%). [Table 3] shows various intraoperative and postoperative complications and their frequency.
Table 3: Frequency of various intraoperative and postoperative surgical complications

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Complications associated with poor visual outcome (<6/18) were PCR with vitreous loss, endophthalmitis, choroidal detachment, and surgically induced astigmatism. [Table 4] shows various complications responsible for poor visual outcomes.
Table 4: Frequency of various surgical complications responsible for poor visual outcome

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   Discussion Top

SICS is a cost-effective and promising technique for cataract surgery, especially in low-resource countries. We have conducted this study to assess the visual outcome and also the intraoperative and postoperative complications associated with this technique.

Preoperatively, out of 315, 205 (65.08%) patients had visual acuity <3/60 and 5 (1.59%) had vision >6/18; after surgery, 302 (95.87%) patients achieved visual acuity >6/18. This shows that SICS has the capability of providing good vision to the majority of its patients. Chanchlani et al. conducted a study on 3000 patients and after 4 weeks, 89.5% had vision better than 6/24.[14] Another study done by Daniela Pulido et al.[20] found that 89.3% of patients had visual acuity between 6/6 and 6/18 after cataract surgery.[15] Our study shows that out of 315 patients who underwent cataract surgery, 10 (3.16%) patients had PCR with vitreous loss in which 5 (1.58%) were implanted with IOL but the remaining 5 (1.58%) were planned for secondary IOL due to inadequate ciliary sulcus support. Out of 10 surgeries having PCR, nine were performed by resident doctors. PCR is the most frequent complication encountered among learners in their initial phase. Most of these occur during irrigation and aspiration of cortical matter. The result was comparable with studies performed by Muhammed Tariq Khan et al.[19], Hashemi et al.[18] and Pulido et al.[20] found the frequency of PCR to be 3.3%, 2.86%, and 2.94%, respectively. Rathnakumar et al.[17] found the vitreous loss to be the most common intraoperative complication in their study 27 (11.5%).[18] The vitreous loss was due to posterior capsular rupture in 17 (8.5%) and zonular dialysis in 10 patients. The rate of PCR in their study was higher than our calculated rate of PCR. Tunnel-related complications leading to iris damage were found in 18 (5.71%) cases. In our study, iris damage is more as most of these surgeries are performed by resident doctors while they are still in their learning phase. This occurs mostly due to inadequate tunnels made in the cornea and also due to premature entry into the anterior chamber. Due to the inadequate size of the tunnel made nucleus can get stuck in the tunnel while delivery, leading to endothelial loss which causes striate keratopathy postoperatively. We found 20 (6.35%) striate keratopathy which was comparable to the study performed by Hosamani S et al. (6.7%), although iris damage in their study was lesser (0.48%). We found striate keratopathy to be the most common postoperative complication in our study. Hypotony was documented in 2 (0.63%) cases in which there was inadequate wound closure. Hyphema was found in 1 (0.32%) case which was due to direct trauma by the patient's own hand. However, it became clear in 3 days and the patient's visual outcome was good. In our study, 2 (0.63%) patients came across with IOL decentration which was due to improper implantation of IOL in the bag. However, the optic part of IOL remained in the field of vision so it did not affect the final visual outcome.

In the present study, 13 (4.13%) patient's vision was found <6/18 which includes complications such as PCR with subsequent aphakia, endophthalmitis, and choroidal detachment. Patients with aphakia were planned for secondary IOL implantation but were lost to follow-up. Cases of PCR with successful IOL implantation had a final visual outcome of 6/24. Surgically induced astigmatism was responsible for poor vision in two cases in which maximum visual acuity achieved was 6/24.

   Conclusions Top

Cataract surgery has evolved tremendously from couching in medieval times to ICCE, ECCE, and sophisticated techniques which have fewer complications and yield excellent results. SICS is a cost-effective technique which does not require expensive machines and can be performed in high-volume centers with good postoperative visual outcomes. Complications when managed under expert hands can still have good vision. However, a patient's noncompliance is a major issue that can affect the outcome.


The present study is a nonrandomized study and patients were selected according to inclusion criteria results cannot be generalized. As surgeries were performed by experienced surgeons and resident doctors (under guidance), the final outcome does not show uniformity.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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  [Table 1], [Table 2], [Table 3], [Table 4]


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