Phacoemulsification has transformed cataract surgery into a safe, effective, and minimally invasive procedure, becoming the global gold standard [1-3]. The recently published study titled ‘Long-Term Outcomes of Phacoemulsification Surgeries at ECWA Eye Hospital’ reports that 96.1% of eyes achieved a postoperative best-corrected visual acuity between 6/6 and 6/18 (20/20 to 20/60) at five-year follow-up, defined as successful outcome per the World Health Organization standards. Although the study did not include a formal comparator group, the findings reflect statistically consistent outcomes across age and gender subgroups, indicating robust long-term efficacy [3]. Key predictors of suboptimal outcomes identified include age, amblyopia, posterior capsular opacification (PCO), and macular edema.

This commentary builds on that study’s findings to explore broader implications for ophthalmic practice, including insights from global literature and innovations in surgical technique. It also proposes strategies that emerging centers can adopt to improve long-term surgical outcomes and patient satisfaction. These strategies have already been implemented by Ezioghene Eye Hospital in Delta State, Nigeria, to enhance surgical outcomes and patient satisfaction.

Strengths of the study

1. Comprehensive data collection: The study's longitudinal design, spanning five years, provides a robust dataset for evaluating long-term outcomes. This extended follow-up period ensures that postoperative complications and factors influencing visual recovery are thoroughly assessed. Similar studies have reported comprehensive data; for instance, Helayel et al. [4] conducted a 10-year retrospective study on phacoemulsification cataract surgeries complicated by retained lens fragments, identifying risk factors such as diabetes and dense nuclear sclerosis, and reporting that 73.4% of affected eyes retained their preoperative vision or experienced a one-line improvement. Additionally, Fong et al. [5] examined long-term outcomes of phacoemulsification cataract surgery performed by trainees and consultants, finding that 77–87% of patients operated on by trainees achieved best-corrected visual acuity of ≥6/12 at 12 months postoperatively.
2. High success rates: Phacoemulsification cataract surgery has consistently demonstrated high success rates globally, reinforcing its effectiveness as a preferred surgical technique [4,6,7]. These findings highlight the procedure’s reliability and transformative potential in improving cataract surgery outcomes, particularly in developing regions like Delta State, where Ezioghene Eye Hospital has applied these insights to improve patient care and surgical outcomes.
3. Focus on key predictors: By identifying specific factors like amblyopia, posterior capsule opacification, and macular edema as contributors to suboptimal outcomes, the study provides actionable insights for improving patient care. This focus on predictors enables clinicians to better anticipate and manage risks.

Recent advancements in phacoemulsification

Since the introduction of phacoemulsification by Charles Kelman in the 1960s, the procedure has undergone significant technological advancements [8]. Recent innovations include:

1. Femtosecond Laser-Assisted Cataract Surgery (FLACS): FLACS offers improved precision in capsulotomy and lens fragmentation, potentially reducing complications and enhancing visual outcomes [2]. While cost remains a barrier in resource-limited settings, its adoption in specialist centers like Ezioghene Eye Hospital could further improve outcomes.
2. Improved Intraocular Lens (IOL) Technology: Advances in IOL materials and designs, including multifocal and extended-depth-of-focus lenses, have expanded the possibilities for postoperative vision correction [9]. The incorporation of blue-light-blocking technology also protects against macular degeneration [10,11].
3. Real-Time Intraoperative Imaging: Technologies like optical coherence tomography (OCT) integrated into surgical microscopes allow real-time visualization, enhancing the accuracy of phacoemulsification [12,13].
4. These advancements underscore the importance of continuous investment in surgical training and technology to maximize the benefits of phacoemulsification.

Challenges highlighted by the study

1. Age-related variability: Findings from the prospective cohort study that older patients experience less robust visual improvement align with existing literature [14,15]. Aging is associated with factors like compromised ocular structures and systemic comorbidities, which can limit surgical outcomes. Tailored preoperative counseling and customized surgical approaches for elderly patients are essential.
2. Impact of ocular comorbidities: Amblyopia, PCO, and macular edema collectively accounted for 60% of poor outcomes in the study [3]. These findings highlight the importance of addressing preexisting conditions and optimizing postoperative care to mitigate their impact.
3. Gender disparity: The male-to-female ratio in the study’s patient cohort suggests potential access disparities. Cultural and socioeconomic barriers may limit women’s access to cataract surgery [16,17], necessitating targeted outreach programs.
4. Long-term follow-up: Ensuring consistent follow-up in resource-limited settings poses logistical challenges. Innovative solutions, such as telemedicine and mobile clinics, could help maintain long-term patient engagement.

The findings from the ECWA Eye Hospital cohort, alongside broader literature, provide actionable insights and highlight areas requiring further investigation. In the following sections, we first outline the implications for clinical practice, emphasizing evidence-based strategies and standardized protocols that can be immediately implemented to enhance surgical outcomes. This is followed by an exploration of opportunities for future research, which identifies innovation-driven directions to advance the field, address current limitations, and personalize patient care through emerging technologies and therapeutic approaches.

1. Comprehensive preoperative assessment: Preoperative evaluation should include systemic health screening, detailed ocular history, and clear discussion of patient expectations. Diagnostic tools such as anterior segment optical coherence tomography (OCT) can enhance surgical planning and reduce intraoperative surprises.
2. Standardized postoperative care: Structured postoperative protocols are essential to detect and manage complications early, particularly posterior capsular opacification (PCO) and macular edema. Regular follow-up with visual acuity assessment and slit-lamp examination can improve long-term outcomes.
3. Bridging access gaps: To ensure equitable access to cataract surgery, especially for underserved populations such as women, community-based outreach, public education, and subsidized surgical initiatives should be expanded. Partnerships with NGOs and local healthcare programs have shown success in reducing surgical inequities [16,17].

Opportunities for future research

1. ­­ Exploring modifiable risk factors: There is a need for studies assessing how modifiable determinants like nutrition, glycemic control, and lifestyle affect surgical outcomes and recovery, especially in aging populations.
2. Personalized surgical algorithms: The integration of artificial intelligence and machine learning in surgical planning may help customize phacoemulsification based on patient-specific parameters such as corneal biomechanics, anterior segment morphology, and existing comorbidities [18,19].
3. Next-generation postoperative interventions: Research into drug-eluting intraocular lenses, anti-inflammatory biomaterials, and surface-modified IOLs offers promise in reducing common complications like inflammation and PCO [20].

Data from ECWA Eye Hospital have significant implications for global ophthalmology. It demonstrates that high success rates in phacoemulsification are achievable even in resource-constrained settings with skilled personnel and standardized protocols. Ezioghene Eye Hospital, Irri, Delta State and other similar settings can adopt these strategies to replicate similar success, ensuring equitable access to high-quality cataract surgery. Furthermore, the study underscores the importance of long-term follow-up and the need for tailored interventions to address age-related variability and comorbidities. By adopting innovations and fostering collaboration among stakeholders, ophthalmology centers can further improve outcomes and accessibility.

This commentary provides a critical synthesis of long-term outcomes in phacoemulsification surgery, with a particular focus on learnings from the ECWA Eye Hospital cohort and their broader relevance to ophthalmic practice. By integrating study findings with global innovations, we highlight practical strategies for improving visual outcomes, especially in under-resourced settings. The unique contribution of this commentary lies in bridging empirical evidence with forward-looking approaches, such as AI-driven surgical planning, advanced intraocular technologies, and policy-driven solutions to improve access. As phacoemulsification continues to evolve, sustained success will depend not only on surgical expertise but also on innovation, equitable care delivery, and long-term patient engagement.

All authors contributed equally, read and approved the final manuscript.

No funds, grants, or other support was received for this work.

There are no conflicts of interest.