Phacoemulsification Versus Manual Small Incision Cataract Surgery: An Umbrella Review of Systematic Reviews

Phacoemulsification and manual small incision cataract surgery (MSICS) are two widely practised techniques for cataract surgery worldwide. However, their comparative efficacy in terms of postoperative visual acuity (VA) remains debated. This paper is an umbrella review for this topic, which synthesises evidence from systematic reviews and meta-analyses directly comparing VA outcomes between the two techniques. PubMed, Cochrane, Web of Science, and the Excerpta Medica database (Embase) were searched, with 712 results remaining after de-duplication. After screening, six papers underwent full-text review, leaving four systematic reviews/meta-analyses for final inclusion. Inclusion criteria were English-language systematic reviews directly comparing postoperative VA between phacoemulsification and MSICS in adults undergoing cataract surgery. Data extraction focused on uncorrected and best-corrected VA (BCVA) at early (≤1 week), intermediate (six to eight weeks), and late (≥6 months) time points. Methodological quality was assessed using A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2). The four included reviews ranged from six to 11 primary studies each, with total sample sizes ranging from 1315 to 76,838 eyes. They were published in the years 2013 and 2015. Across reviews, no statistically significant differences were consistently found in BCVA at any time point. Two reviews reported small early advantages for phacoemulsification in uncorrected VA (UCVA, odds ratios (ORs) of 1.40 and relative risk (RR) of 0.90 for achieving ≥6/9 or ≥6/18, respectively), but these differences were not maintained at later follow-up. Complication profiles were broadly similar. AMSTAR 2 ratings indicated high confidence in the Cochrane review, moderate confidence in two reviews, and low-to-moderate confidence in one review. Evidence from conducted systematic reviews suggests that phacoemulsification and MSICS yield similar postoperative VA outcomes. As such, the choice of technique may be guided more by resource availability, surgeon expertise, and patient-specific considerations.