Manual small incision cataract surgery: An ergonomic solution to tackle cataract backlog and challenging situations

Cataract surgery is still the most common surgery performed worldwide. It has evolved tremendously in terms of incision, from 12 mm to 1.8 mm, in terms of capsulotomy from envelope type to automated capsulorhexis, and from rigid intraocular lens to foldable intraocular lenses. Manual small incision cataract surgery (MSICS) remains a valuable technique, particularly in rural and underserved areas, due to its cost-effectiveness and simplicity. Its low logistics and favorable outcomes are particularly useful for managing the cataract backlog in developing countries. This review highlights the history and evolution of MSICS, and the reasons for the advent and popularity of this technique, especially in developing countries. It reviews the various recent modifications of the technique, for example, from a superior incision approach to temporal incision to customized MSICS, 2 mm MSICS, and astigmatism-correcting MSICS. It provides an overview of its applicability in complicated scenarios (viz., small pupil, compromised cornea, pseudoexfoliation, subluxated cataract, etc.). It briefly reviews the clinical trials on MSICS and its comparison with phacoemulsification. Finally, the review emphasizes why every ophthalmic surgeon must know MSICS, its relevance in postgraduate teaching, and the role of MSICS simulators for the same. Overall, the review presents a comprehensive picture of the present status of this technique in the surgical armamentarium of ophthalmology.