Manual Small Incision Cataract Surgery (MSICS) is a type of extracapsular cataract extraction (ECCE) surgery. It is predominantly used in developing countries due to low costs. MSICS carries the following advantages over ECCE and phacoemulsification (when the surgeon makes use of an ultrasonic device to break up the cloudy lens and remove it):

  • No need for sutures as the wound heals by itself
  • A shorter time for the operation since the procedure can be done in 6 minutes
  • Less need for technology
  • Less expensive because of low-cost implant lens and low cost of equipment and disposables

The rates of outcomes and complications between MSICS and Phacoemulsification and ECCE are similar as far as posterior chamber intraocular lens (IOL) placement is concerned.

MSICS combines the techniques of phacoemulsification and ECCE. It is the preferred technique for developing countries due to harder cataracts.

Cataracts occur when the lens is clouded. The lens focuses light on the retina. The retina is tissue that lines the back of the eye and is responsible for clear, sharp vision. The lens can change shape, also known as accommodation leading to cataract formation.

Most cataracts develop due to age although some are present at birth or develop in childhood.  Due to age, the protein fibers thicken. They  then clump together and cause opacity in the lens. Cataracts may affect both eyes but the speed of progression in each eye varies.


The goal of MSICS is to restore vision in the eye of a cataract patient. Because of significant low costs, MSICS aims at rapid patient mobilization so that many more people can be prevented from blindness. The surgical procedure generally aims for early visual rehabilitation and minimal induced astigmatism.

Preparation & expectation before Surgery

The patient will undergo an eye examination prior to the surgery. The eye care professional will conduct an ultrasound analysis to check that the retina is fine.

The patient will go through a preoperative physical examination to rule out diseases that might complicate the ICCE procedure.

The doctor will prescribe antibiotic eye drops or an ointment a day to the surgical procedure.


The following take place in an MSICS operation:

  • An ophthalmic assistant injects a peribulbar anesthetic and preps the patient with iodine-based antiseptics. Drapes are laid over the patient.
  • The surgeon inserts a lid speculum on the eyelid to keep them open and injects viscoelastic material to protect the corneal endothelium.
  • The surgeon uses a fornix-based conjunctival flap to expose the sclera. He/she creates a sclerocorneal tunnel and a tissue plane before making a triangular capsulotomy using a needle. The surgeon uses a blade to open the inner parts of the sclerocorneal tunnel to help engage the nucleus at the time of removal.
  • If the cataract is less mature, the surgeon injects anterior chamber irrigation fluid into the lens to separate the nucleus from other components of the lens.
  • To remove the nucleus, the surgeon can use toothed forceps or an irrigation vectis.
  • The surgeon will then remove cortical material and inject air into the anterior chamber.
  • The IOL is inserted followed by the removal of the air that was previously injected into the eye. The air is replaced with irrigation fluid.
  • The surgeon presses on the globe to ensure there is no leakage leading to self-healing of the wound.
  • An injection of steroids and antibiotics will be administered.
  • The surgeon closes the lids and applies a standard dressing on the wound.


After care, recovery, results

MSICS is successful in 99% of cataract cases. Most of the patients register excellent visual outcomes following MSICS surgery.
However, the procedure requires a larger incision than phacoemulsification or ECCE. This means the wound may take longer to heal.
The patient is required to use eye drops for a week or two to reduce swelling, prevent infection and manage pain. The eye drops must be used exactly as prescribed.

The patient should wear eyeglasses during the day and a protective shield at night following surgery. They should also avoid rubbing the eye or situations where something can bump the eye.

Frequent check-ups are necessary beginning with a day after the procedure. The surgeon will then check the patient weekly for several weeks.

Risks & complications

  • The incision may leak or rupture
  • There may be an infection in the external eye
  • Corneal edema or the swelling of the cornea
  • The IOL may move from its position or dislocate
  • There may be an increase in intraocular pressure
  • Uveitis may result. It is inflammation that affects eye tissue including the iris
  • Hyphema, which is the presence of blood inside the anterior chamber of the eye, can occur
  • Retinal tear or detachment when a layer of tissue in the retina pulls away from its normal position
  • Cystoid macular edema which causes cyst-like fluids to form in the macula, obstructing vision