1. Extracapsular cataract surgery (ECCE) compared with manual small

    Dear Editor

    We read with keen interest the article by Gogate et al. on extracapsular cataract surgery (ECCE) compared with manual small incision cataract surgery(MSICS) in community eye care setting.[1]

    We fully endorse their views that MSICS should be the choice for effective rehabilitation of the cataract patients. They have rightly pointed out that the conventional (ECCE) with posterior chamber intraocular lens implantation (PCIOL) is becoming less frequent as phacoemulsification has gained popularity worldwide. Further, they have made the scenario of MSICS more realistic for the developing countries to effectively manage the large backlog of cataract blindness which is still a burning problem in India. MSICS is a good quality alternative to both ECCE and Phaco as it is safe, quick, cost effective and produces less astigmatism and unlike phacoemulsification it does not have a long learning curve . However, we would like to comment on some areas of concern.

    The authors have recommended either straight or frown incision. In our opinion, frown incision would be preferable as it induces lesser astigmatism and prevents sliding between the roof and floor of the tunnel as happens in straight incision.

    Capsulorrhexis is a good method of capsulotomy, but it is not a must for MSICS as for phaco. One can perform MSICS safely with linear capsulotomy which provides additional advantages: the anterior capsular flap prevents rubbing of the hard nucleus to the corneal endothelium, allows aspiration in the bag, ensures in the bag placement of the IOL and almost behaves like capsulorrhexis at end.

    The authors have also commented that mature and hypermature cataracts are more prevalent in India and the hardness of the nucleus has a direct correlation with both intra and postoperative complications. Therefore, it would have been better if the patients would have been grouped as per the maturity of the cataract.

    It is mentioned that though the posterior capsular rent is a major problem in their study especially in hypermature cataracts and with hard nuclei, incidence of vitreous loss is minimal in MSICS due to the self sealing wound which helps to maintain the anterior chamber. In our opinion the size of the incision is an important factor in causation of posterior capsular rent besides the hardness of the nucleus. They have kept the incision size constant between 6.5 and 7.5 mm. Hard nucleus requires a larger incision than the conventional size for its easy delivery. Further, in hyper mature cataract with calcification dragging of entire lens capsule is possible during nucleus delivery. Therefore, a good hydro dissection and adequate quantity of viscoelastic injection in the bag both infront and behind the nucleus is mandatory to ensure nuclear separation and thus preventing dragging of entire capsule. Further, with all types of cataract, full nuclear rotation is mandetory.

    The authors have mentioned about the two major advantages of this method in terms of time and money which should have been elaborated.

    Finally, the authors are to be congratulated for their effort to popularise MSICS which is a boon not only for the community setting but for the centres/ hospitals with limited resources.


    (1) Gogate PM ,Deshpande M, Wormald RP, Deshpande R, Kulkarni SR. Extracapsular cataract surgery compared with manual small incision cataract surgery(MSICS) in community eye care setting. Br J Ophthalmol 2003;87:667-672 .

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