What is the preferred surgical approach for an adult patient with a cataract, comparing small incision cataract surgery (SICS) to phacoemulsification under topical anesthesia?

Phacoemulsification vs Small Incision Cataract Surgery Under Topical Anesthesia

Phacoemulsification is the preferred surgical approach for adult cataract patients in resource-adequate settings, as it produces superior uncorrected visual acuity, lower complication rates, and less surgically-induced astigmatism compared to small incision cataract surgery (SICS), though both techniques achieve excellent final corrected visual outcomes. 1

Primary Recommendation Based on Guidelines

The American Academy of Ophthalmology's 2022 Preferred Practice Pattern establishes phacoemulsification as the predominant method of cataract surgery in much of the world, performed as sutureless, small-incision surgery with foldable IOL implantation on an outpatient basis 1. This recommendation is based on randomized clinical trials demonstrating that phacoemulsification produces:

• Better uncorrected distance visual acuity (UDVA) compared to manual extracapsular cataract extraction (ECCE) and manual SICS 1
• Lower rates of surgical complications, including iris prolapse and posterior capsule rupture 1
• Superior astigmatism control due to smaller incisions, enabling both astigmatism management and specialty IOL implantation 1

Comparative Outcomes: Phacoemulsification vs SICS

Visual Acuity Results

Both techniques achieve comparable final corrected visual outcomes, but phacoemulsification demonstrates advantages in uncorrected vision:

• At 6 weeks post-surgery, UDVA of 20/60 or better was achieved in 87.6% of phacoemulsification patients versus 82.0% of SICS patients (not statistically significant) 2
• Final CDVA of 20/60 or better was nearly identical: 99.0% for phacoemulsification versus 98.2% for SICS 2
• In uveitic cataract patients, CDVA of 20/60 or better at 6 months was 90.9% for phacoemulsification versus 88.3% for SICS (not statistically significant) 3

Astigmatism Outcomes

Phacoemulsification produces significantly less surgically-induced astigmatism:

• Mean SIA: 0.86 ± 0.34 diopters for phacoemulsification versus 1.16 ± 0.28 diopters for SICS (P = 0.002) 3
• This difference is clinically meaningful for patients requiring optimal uncorrected vision and those receiving premium IOLs 1

Complication Rates

Complication rates are comparable between techniques in experienced hands:

• Posterior capsule rupture: 2.2% for phacoemulsification versus 1.4% for SICS (not statistically significant) 2
• In uveitic cataracts, rates of macular edema, persistent uveitis, and posterior capsule opacification were similar between groups 3
• First postoperative day corneal edema was actually lower with SICS (10.2%) compared to phacoemulsification (18.7%) in white cataracts 2

Surgical Efficiency

SICS is significantly faster:

• Mean surgical time: 8.8 ± 3.4 minutes for SICS versus 12.2 ± 4.6 minutes for phacoemulsification (P < 0.001) 2
• In uveitic cataracts: 10.8 ± 2.9 minutes for SICS versus 13.2 ± 2.6 minutes for phacoemulsification (P < 0.001) 3

Topical Anesthesia Considerations

Both techniques can be performed under topical anesthesia, though patient and surgeon satisfaction differs:

Patient Experience

• Topical anesthesia results in more patient-reported pain compared to peribulbar anesthesia during phacoemulsification 4
• Satisfaction with pain mitigation was statistically significantly greater with peribulbar anesthesia (P = 0.001) 4
• However, topical anesthesia is safe and effective for routine phacoemulsification, with mean pain scores of 0.36 ± 0.8 5

Surgeon Satisfaction

• Surgeons reported greater satisfaction with peribulbar anesthesia compared to topical anesthesia (RR = 1.4,95% CI: 1.34-1.63) 4
• Topical anesthesia does not compromise surgical safety when supplemented with analgesic medications 4

Complication Profile

• Day 1 postoperative complications were significantly greater with topical anesthesia (RR = 1.36,95% CI: 1.17-1.58) 4
• Anesthesia-related complications were more common with peribulbar blocks 4
• Topical anesthesia is safe for patients with glaucoma, with similar complication rates to non-glaucoma patients 5

Clinical Decision Algorithm

Choose Phacoemulsification When:

1. Resources and equipment are available (phacoemulsification machine, foldable IOLs) 1
2. Patient desires optimal uncorrected vision or requires premium/toric IOLs 1
3. Minimizing astigmatism is critical for refractive outcomes 3
4. Patient has pre-existing corneal astigmatism requiring management 1

Consider SICS When:

1. High surgical volume settings where efficiency is paramount (e.g., eye camps) 3
2. Limited access to phacoemulsification technology or in economically disadvantaged regions 1, 3
3. Dense white cataracts where both techniques perform equally well 2
4. Cost-effectiveness is a primary concern 1

Anesthesia Selection:

1. Topical anesthesia is appropriate for cooperative patients undergoing routine phacoemulsification, but counsel patients about potential for more intraoperative discomfort 4, 5
2. Supplement topical anesthesia with analgesics to improve patient comfort 4
3. Consider peribulbar anesthesia for anxious patients, complex cases, or when surgeon preference dictates 4

Important Caveats

• The guideline notes that sutureless ECCE with IOL implantation performed very well compared to phacoemulsification in one randomized trial, suggesting technique quality matters more than technique type in some contexts 1
• SICS remains popular in economically disadvantaged countries due to cost-effectiveness 1
• Both techniques require experienced surgeons to achieve optimal outcomes 3, 2
• Patient selection and preoperative counseling about expected visual outcomes and anesthesia experience are critical regardless of technique chosen 1, 6