Sir,

I read with interest the article by Hennig et al1 describing the outcomes of high-volume phacoemulsification in Nepal. Although patients’ expectations of cataract surgery will undoubtedly increase in future, it is important to remember that more than 18 million people in developing nations are blinded by cataracts, with the number increasing each year.

Studies have shown that the percentage of patients with good visual outcomes with phacoemulsification is comparable to that of manual small-incision cataract surgery (MSICS).2, 3 The reported cost for consumables performing phacoemulsification with a rigid intraocular lens (IOL) was US$0.50 more than MSICS.1 However, this cost differential can become quite significant when the total volume of cases is considered. For the 8955 phacoemulsification surgeries performed in this series, an additional $4477.50 could have been saved with MSICS, which can be used for consumables for more than 1000 additional patients. In addition, the authors rightly point out that this cost does not take into account the cost of the phaco machine and its maintenance. In contrast, MSICS is considerably less dependent on expensive equipment and costs less in consumables.2, 3, 4

It would be interesting to know the density of the cataracts, whether sutures were required to close the 5 mm phaco wound, and the resultant astigmatism. It has been shown that MSICS causes less postoperative oedema,2, 3 which may be quite significant in phacoemulsification, depending on the density of the nucleus. The majority of patients in underserved areas of developing countries usually present only when the cataracts are quite advanced. One potential advantage of phacoemulsification may be the slightly lower amount of surgically induced astigmatism3, 5 but a 5 mm wound may cause more astigmatism than with a foldable IOL.

In summary, I feel that there are many factors that should be considered when using phacoemulsification in a high-volume setting in developing regions, and a prospective comparative study would go a long way to answering these questions. Nevertheless, I congratulate the authors on their results and commend them for their good work in Nepal and India.