Romanian Journal of Ophthalmology, Volume 63, Issue 1, January-March 2019.

pp:61-67

GENERAL ARTICLE

Central corneal thickness changes following manual small

incision cataract surgery versus phacoemulsification
for white cataract
Kongsap Pipat
Department of Ophthalmology, Prapokklao Hospital, Thailand

Correspondence to: Pipat Kongsap, MD,

Department of Ophthalmology, Prapokklao Hospital, Meuang, Chanthuri 22000, Thailand,
Phone: 663-9319666 ext 1450, or 666-3539—8795, Fax: 663-932-4861,
E-mail: pkongsap@gmail.com

Accepted: January 25th, 2019

Abstract
Aim: To assess the central corneal thickness (CCT) and endothelial cell loss after manual
small-incision cataract surgery and phacoemulsification in patients with white cataract.
Material and methods: This is a comparative, prospective, non-randomized study on 42
patients with white cataract, who underwent cataract surgery. The patients were divided
into manual small-incision cataract surgery (21 eyes, MSICS group) and
phacoemulsification cataract surgery group (21 eyes, phaco group). The endothelial cell
density (ECD), central cornea thickness (CCT), and corrected distance visual acuity
(CDVA) were evaluated at 1 day, 1 week, 4 weeks, and 3 months postoperatively. The
results of 20 cases of nuclear sclerosis grade II-III (LOCS III) who underwent
phacoemulsification by the same surgeon were also compared. Propensity scoring was
used to adjust for confounding by selection bias.
Results: The CCT increased after surgery in both groups. The thickness was greater in
the phaco group on first day postoperatively (73 µ increase in MSICS group and 138 µ in
phaco group, p=0.008) and it returned to preoperative levels 1 month postoperatively.
The endothelial cell loss was lower in the MSICS group at 3 months postoperatively
(11.8% in MSICS group and 15.8% in phaco group, p=0.111). The CDVA was not different
in both groups at 1 week and 4 weeks postoperatively (p>0.05).
Conclusions: Manual small-incision cataract surgery for white cataract provided
less central corneal thickness changes compared to conventional phacoemulsification.
Keywords: manual small incision cataract surgery, white cataract, phacoemulsification,
central corneal thickness, endothelial cell loss
Abbreviations: CCT = central corneal thickness; ECD = endothelial cell density; CDVA =
corrected distance visual acuity; APT = absolute phacoemulsification time; EPT =
effective phacoemulsification time; MSICS = Manual small-incision cataract surgery in
white cataract; Phaco II = Phacoemulsification in white cataract; Phaco I =
phacoemulsification in NS 2 + Cataract; Phaco = Phacoemulsification in white cataract;
APACRS = Asia-Pacific Association of Cataract and Refractive Surgeons

Introduction recover from the disease. Phacoemulsification

provides better visual outcomes and risks fewer
Cataract is one of the most common causes complications than ECCE [8-11]. However,
of blindness on all continents [1-7]. Various surgery is difficult on a cataract that has become
surgical treatments are available to help patients hypermature and cloudy (a white cataract) and

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Romanian Journal of Ophthalmology 2019; 63(1): 61-67

is likely to cause postoperative complications, approved by the ethics committees of

such as posterior capsule rupture [12-13] or Prapokklao Hospital.
corneal edema [13,14]. A comparative study of Population: Cataract patients who
manual small-incision cataract surgery (MSICS) underwent surgery in the ophthalmology
and phacoemulsification in 108 cataract patients division of Prapokklao Hospital between May
found a 9-micron increase in corneal thickness in 2016 and March 2017.
patients receiving MSICS and a 70-micron Participants: White cataract patients who
increase in corneal thickness in patients received treatment by means of manual small
receiving phacoemulsification [15]. However, incision cataract surgery or phacoemulsification
there are no published studies comparing these (Fig. 1), selected based on the following
two methods for white cataract surgery. inclusion and exclusion criteria:
The objective of this study was to compare
central corneal thickness and endothelial cell Inclusion criteria
loss resulting from hypermature cataract  White cataract patients with no zonular
surgery using MSICS versus phacoemulsification. dialysis.
Exclusion criteria
 Cataract patients with concurrent diseases,
Material and Methods such as glaucoma, retinal detachment, or
The research design used in this study was diabetic retinopathy.
a non-randomized clinical trial. The study was  Cataract patients with a cataract attributed
to an accident.

48 cases of white cataract patients

Excluded (n=6)
- Severe glaucoma/ retinal disease (2)
- No consent given (4)

42 cases divided
into 2 groups

21 cases were allotted to 21 cases were allotted to

MSICS PHACO

21 individuals 21 individuals
included in analyses included in analyses
-pachymetry -pachymetry
-cell count -cell count

Fig. 1 Flow diagram of study design

Sample size calculation cataract hardness (nuclear sclerosis 2+) showed

A comparison by Jain [15] of MSICS versus an average corneal thickness of 541 ± 39
phacoemulsification in patients with moderate microns in patients who had undergone MSICS

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and 581 ± 60 microns in patients who had Observation and assessment

undergone phacoemulsification at a significant The following patient data were collected:
level of 0.05 (two-ways) and a statistical power age, gender, visual acuity, corneal thickness,
of 80%. The samples were derived from 20 endothelial cell count, and intraoperative and
cataract patients in each group. The present postoperative complications. Data were collected
research similarly examined standards of using the following parameters and techniques:
cataract surgery (nuclear sclerosis 2+)  Data on phacoemulsification were
performed by the same surgeon on 20 patients, collected using the parameters of
using these patients as a control group to ultrasound power, absolute
evaluate surgical performance. phacoemulsification time (APT), and
effective phacoemulsification time
Sampling methods (EPT);
Voluntary patients participating in the  Surgery time measured the amount of
program received an explanation from a time from the beginning of the surgery
physician and signed a consent form to until the removal of the speculum;
participate in the program. The patients  Corneal thickness was measured using
underwent cataract surgery by means of manual a pachymeter (micron) on the 1st, 7th
small incision cataract surgery or day and 1 month after surgery;
phacoemulsification alternately without  Endothelial cell loss was measured
randomization (Fig. 1). The doctors collected using a specular microscope 1 month
patient and surgery details, such as age, gender, and 3 months prior to the day of
cataract hardness, and preoperative eyesight surgery;
level, which were permitted to vary among  Complications included posterior
patients in either group. A propensity score was capsule rupture, vitreous loss,
used to estimate the likelihood or the probability hyphema, iritis, lens drop, increased
of being assigned to each treatment arm. IOP, corneal edema, etc.

Surgical methods Data Analysis

 Patients in both groups received an Data analysis was conducted using a
anesthetic (retrobulbar anesthesia). statistical program. A p-value less than 0.05
MSICS was performed using the indicated statistical significance. Corneal
modified Blumenthal technique. A thickness and endothelial cell loss were
scleral tunnel incision was made, compared using a t-test and visual acuity and
capsulorhexis was performed, and complications were compared using the Fisher
viscoelastic material was injected into Exact test.
the anterior chamber. The lens was
extracted and an intraocular lens was
implanted in the capsular bag. Results
 Phacoemulsification was performed
using Stellaris (Bausch & Lomb). A clear The study included 42 participants, 21 of
corneal incision was made and whom underwent MSICS and 21 phaco. The
capsulorhexis was performed. The lens average age of the patients was 68 years
was emulsified and then replaced with (ranging from 40–83 years). Fifteen patients
an intraocular lens. were males (35.7%). Patients’ general data, such
as age, gender, and preoperative visual acuity
Postoperative care were not significantly different (Table 1).
Both groups of patients received the same
postoperative care according to existing
standards. After surgery, they received Dexoph
eye drops and returned for follow-up checks
after 1 day, 7 days, 1 month, and 3 months.

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Table 1. Patient baseline characteristics

Patient MSICS Phaco II
characteristics (n= 21) (n=21)
n % n % p-value
Gender
Male 7 44.6 8 53.3
Female 14 48.2 13 51.8 0.747
Age (year)
Mean ± sd 62.3 ±4.0 68.6 ±1.9 0.083
Pre-op VA <6/ 21 100 21 100
60
Laterality (R) 11 47.8 12 52.2 1.000

Duration of Sx 13.2 ±0.6 16.5 ±2.3 0.086

(min)
Mean+-SD
Nuclear opacity
NS ≤ 3+ 16 72.6 13 61.9 0.202
NS 4+ 5 23.8 8 38.1

The data in Table 2 represent the absolute phacoemulsification time (APT) was
surgeon’s standard performance when 50.4 seconds and the effective
conducting phacoemulsification on cataract phacoemulsification time (EPT) was 12.2
patients with moderately hardened lenses. The seconds. By 1 day after the surgery, the cornea
surgeon spent 9.9 minutes performing the phaco thickened by an average of 67 microns, and after
surgery. The ultrasound power was 24.4%. The 3 months, endothelial cell loss averaged 8.4%.

Table 2. Comparative clinical outcomes of phacoemulsification in normal cataract and white cataract by the
same surgeon
Phaco I (N=20) Phaco (N=21) p-value
Mean age 68.4 ± 2.24 68.6 ± 1.93 0.94
Female sex, n (%) 7 (35.0) 13 (61.9) 0.085
Operation time (Min) 9.9 ± 0.36 16.5 ± 12.3 0.009
Mean US power 24.5 ± 0.94 30.1 ± 1.5 0.004
Mean APT(s) ± SD 50.4 ± 3.35 95.9 ± 13.6 0.006
Mean EPT(s) ± SD 12.2 ± 1.1 37.7 ± 5.7 0.0007
CCT Increase (µ) 67.4 ± 72.7 138.0 ± 103.1 0.018
Cell loss (%) 8.4 ± 8.1 15.8 ± 8.4 0.024
Postop VA > 6/ 18 19 (95%) 19 (90.5%) 1.00
Phaco I = phacoemulsification in NS 2 + Cataract;
Phaco = Phacoemulsification in white cataract.

Most MSICS and phaco patients had visual operation was at approximately 11.8% (Table 3,
acuity worse than 3/ 200 to HM. The group who Fig. 2).
underwent MSICS averaged 13.2 minutes for the
surgery. The first day after the surgery, the
cornea, initially 531 microns thick, rose to 603
microns (an average increase of 73 microns);
thickness returned to normal 1 month after the
surgery. Endothelial cell loss 3 months post

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Table 3. Clinical outcomes

Clinical outcomes MSICS Phaco
(n = 21) (n = )
X SD X SD p-value
CCT
PRE 531.6 40.1 544.2 45.0 0.342
1D 603.0 77.6 682.2 104.3 0.008
1 WK 537.5 46.4 562.5 42.0 0.076
1 mo 528.9 41.2 542.9 44.3 0.299

CELL
PRE
1 mo 2540.2 218.4 2486.6 218.5 0.495
3 mo 2314.9 215.3 2214.1 347.6 0.265
2239.4 232.5 2058.3 315.0 0.060
Cell loss (%)
11.8 6.4 15.8 8.4 0.111
MSICS = Manual small-incision cataract surgery in white cataract
Phaco II = Phacoemulsification in white cataract

(an average increase of 138 microns); thickness

returned to normal 1 month after the surgery.
Endothelial cell loss 3 months post operation
was about 15.8%.
The group who underwent phaco had
significantly higher corneal thickness than the
group who underwent MSICS (p< 0.008). Three
months after the surgery, however, MSICS
patients’ endothelial cell loss was 11.8%, while
phaco patients’ endothelial cell loss was 15.8%,
an insignificant difference (p< 0.111).
Regarding postoperative visual acuity, the
patients who underwent MSICS had visibility
higher than 6/ 18 at 71.4% and the patients who
Fig. 2 Central corneal thickness changes underwent phaco had visibility higher than 6/ 18
at 85.7% (p=0.454). Three months after the
surgery, the MSICS patients had visibility higher
For the group who underwent phaco, the than 6/ 18 at 90.5% and phaco patients had
operation time averaged 15.8 minutes. The visibility higher than 6/ 18 at 90.5% (p=1.000),
cornea was initially 544 microns thick. The first as shown in Table 4.
day after surgery, it increased to 682 microns

Table 4. Postoperative visual acuity

Postoperative visual acuity MSICS Phaco
(n = 21) (n = 21)
n % n % p-value
Post VA 1 week
< 6/ 60 1 4.8 0 0 0.454
6/ 60-6/ 18 5 23.8 3 14.3
> 6/ 18 15 71.4 18 85.7

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Post VA 4 week
< 6/ 60 1 4.8 0 0 1.000
6/ 60-6/ 18 1 4.8 2 9.5
> 6/ 18 19 90.5 19 90.5

MSICS = Manual small-incision cataract surgery in white cataract

Phaco = Phacoemulsification in white cataract

An intraoperative complication that thickness (a 28 micron increase) and cell loss at

occurred was a dropped nucleus in one patient 6.32% in the MSICS group and a 10.4% increase
from the group who underwent phaco; there in corneal thickness (a 53 micron increase) and
were no occurrences of either posterior cell loss at 8.2% in the phaco group [15]. In
capsule rupture or dropped nucleus in the MSICS addition, the white cataract patients lost
group. endothelial cells at 11.8% and 15.8% post
operation in the MSICS group and the phaco
group, respectively. Cell losses were higher than
Discussion those found in other studies due to the different
White cataract can be treated by degrees of white cataract hardness, ranging from
extracapsular cataract extraction, manual small moderate to high at NS 4+ levels. In cases of very
incision cataract surgery, or phacoemulsification. hard cataracts, higher ultrasound energy is
The former surgery is currently not popular due necessary, which can also result in higher
to its large wound and long recovery time. As a corneal cell loss.
result, MSICS and phaco have become more The limitations in this study were: 1) The
popular. Capsulorhexis is a challenging lack of randomization in sampling could have led
component of conducting white cataract surgery. to bias in sample selections; however, according
However, with the development of a dyeing to the propensity score used for calculations,
capsule [16-19], capsulorhexis has become there were no differences between the sample
easier. The difficulty level of the process for groups; 2) The sample groups were small.
breaking the lens varies according to the In summary, the current study showed that
hardness of the lens. If the lens is very hard, such white cataract surgery using phacoemulsification
as in a brown cataract, a lot of energy is required, caused higher levels of corneal thickness and
and this can increase corneal thickness. endothelial cell loss than manual small incision
A comparative study of MSICS and cataract surgery.
phacoemulsification on 108 eyes found that
corneal thickness increased by 9 micrometers Acknowledgements
and 70 micrometers in the MSICS group and the The authors thank Jayanton Patumanond,
phaco group, respectively [20]. In the current MD, PhD, for assistance with statistical analyses
study, the researcher performed cataract surgery and www.onlineproofreadingservices.net for
on patients with normal lenses. This was useful editing the manuscript.
as a benchmark to compare surgical skills. The
operation time was 9.9 minutes and corneal Previous Presentation: Data from the analysis
thickness increased by 67 microns the first day were previously presented in part at the 31st
after surgery, indicating that the standard Asia-Pacific Association of Cataract and
performance was not different from that of a Refractive Surgeons (APACRS) Congress, 19-21
professional ophthalmologist [15]. After white July 2018 Chiang Mai, Thailand.
cataract surgery, the corneal thickness increased
by 67 microns and 138 microns in the MSICS
Conflict of interest
group and the phaco group, respectively. This
was a statistically significant difference None.
(p=0.008).
A comparative study of MSICS and Thai clinical trial registry:
phacoemulsification on moderately hard TCTR20161129002.
cataracts found a 5.33% increase in corneal

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extraction: A study in a district hospital in Malaysia.

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