As with any ophthalmic condition, the choice of which cataract procedure to employ must primarily be based upon clinical outcomes. However, given the status of cataract surgery as the most frequent, and therefore largest, overall procedural expenditure, the cost to the healthcare system should be considered as well. In their article in this issue of the BJO (p 822), Minassian and co-authors give us a definitive answer. This is a well designed prospective study in which eight experienced surgeons each performed equal numbers of phacoemulsification (Phako) and standard large incision extracapsular (ECCE) procedures; 500 patients were enrolled. Measured outcomes included uncorrected and best corrected visual acuity, astigmatism, intraoperative and postoperative complications, and cost.

A very important feature of this prospective study makes it unique in the cataract literature. The patients operated on by each surgeon were randomised between the two different procedures. This was necessary in order to avoid two potential and significant biases that would otherwise affect retrospective or non-randomised comparisons. Firstly, those surgeons primarily performing standard ECCE in recent years have tended to do a lower volume of surgery.1 Secondly, when surgeons regularly perform both procedures they tend to utilise standard …