This can only be treated with an operation, and the aim of this review was to assess two different surgical methods. The first, called manual small incision cataract surgery (MSICS) involves using instruments to remove the lens from the eye through a small incision. The second, phacoemulsification, involves using a high frequency ultrasound Objective: The aim of this study was to compare the clinical outcomes of phacoemulsification with that of manual small incision cataract surgery (MSICS) in cases of hard nuclear cataract. The incision is smaller for a soft cataract and larger for a dense, hard cataract. Usually, the incision is 6 to 7 mm long for a cortical cataract and 7 to 8 mm long for a hard cataract (such as 4+ nuclear sclerosis). The depth should be approximately 0.3 mm. Manual small-incision cataract surgery (SICS) has emerged as a cost-effective alternative to phacoemulsification in the developing world.4, 5 In a study by Ruit et al., 6 phacoemulsification and manual SICS gave excellent visual outcomes with few complications in a charity cataract surgical population in Nepal. In this randomized prospective Costs. In the developing world, the cost per case of providing phacoemulsification ranges from $25.55-$70, compared to $15-$17 for MSICS (Table 6 ). The wide variation in the cost of phacoemulsification relates to the varying case volumes, over which the fixed costs of expensive instrumentation are spread out. Additionally, there may be ethnic differences in anterior chamber and angle configurations that influence how much the angle will widen after phacoemulsification. Manual small-incision cataract surgery (MSICS) is a safe and cost-effective technique for tackling the huge backlog of cataract blindness in the developing world13, 14 and also in A large backlog of cataract blindness exists in the developing world, and cataract is still the most common cause of avoidable blindness. 1 An estimated 4 million people experience blinding cataract every year in India. 2 Nearly 4 million cataract surgeries are performed in India annually, but only a small proportion of these are performed on patients who are blind because of cataract. 3 MSICS technique, mostly used for complex cases (54.2%), reported a higher complication rate than the phacoemulsification technique (2.9% vs 1.4%, p < 0.001). However, the complication rates among the normal and complex cases were similar (2.3% vs 2.2%, p = 0.376). Objective: To compare the outcomes of manual small incision cataract surgery (MSICS) and phacoemulsification performed by ophthalmology trainees. Design: Retrospective cohort design. Setting: Tertiary eye care centre. Participants: A total of 1029 subjects underwent cataract surgeries with MSICS technique or phacoemulsification by trainees during one quarter (July-September 2007). PurposeTo evaluate a system that objectively assesses the risk of cataract surgery complications performed with phacoemulsification and manual small incision cataract surgery (MSICS) techniques Manual small incision extracapsular cataract surgery is significantly faster, less expensive and requires less technology than phacoemulsification, and may be the preferred technique for cataracts surgery in the developing world.