Phacoemulsification vs small-incision manual cataract surgery: an expert trial.

r T b k t S a i a m c A m i r i h N THIS ISSUE, RESULTS FROM A RANDOMIZED, CONtrolled trial (RCT) are published in which two techniques for cataract extraction are compared.1 The uestion of whether manual sutureless small-incision exracapsular cataract surgery (SICS) is as effective and safe s phacoemulsification is addressed. This may seem to be a fruitless enquiry because it is ssumed by most that phacoemulsification is the gold tandard for treatment of cataract worldwide. Remarkably, his standard was established without a single RCT comaring the new technique to established extracapsular urgery being published. When publication was sought for British Medical Research Council (MRC) trial comparng phacoemulsification to extracapsular extraction, peer eviewers initially recommended rejection because they egarded the case already made that phacoemulsification as safer and more effective. But it was, in fact, an mportant trial (and the study was eventually published) ecause it showed that despite the additional costs associted with the technology, phacoemulsification resulted in onger-term savings as a result of more rapid rehabilitation nd fewer postoperative visits.2 But this was only relevant to affluent health systems. For oorer countries, the capital and consumable costs of hacoemulsification remain a major issue. Cost is one of he most important barriers to cataract surgery, and it is in he poorer parts of the world where the huge backlog of voidable cataract blindness exists. Pioneers of cataract echniques in India and Nepal soon found a way of educing the incision size and eliminating the need for utures in manual or nonmechanized techniques. This onstituted the specific disadvantage of the traditional xtracapsular technique: the need to have the sutures emoved at three months, and the degree of postoperative stigmatism. Variations of the small-incision manual techique have rapidly developed, and last year, the first trials omparing phacoemulsification with SICS and SICS with xtracapsular surgery were published.3–5 These trials as-