Aim:To compare the visual outcomes and postoperative complications between Manual Small Incision Cataract Surgery (MSICS) and Phacoemulsification in patients undergoing cataract surgery at a tertiary care center.Material and Methods:This prospective, comparative observational study was conducted in the Department of Ophthalmology at Nalanda Medical College and Hospital, Patna, from October 2023 to September 2024. A total of 100 patients aged 50 years and above with visually significant senile cataract were enrolled and randomly divided into two groups: Group A (MSICS) and Group B (Phacoemulsification), with 50 patients each. Preoperative and postoperative visual acuity (UDVA and BCVA) were assessed at Day 1, Week 1, and 1 Month using LogMAR conversions. Complications were recorded and statistical comparisons were made using t-tests and Chi-square tests (p< 0.05).Results:Baseline demographics and preoperative visual acuities were comparable between the two groups (p> 0.05). Postoperatively, the Phacoemulsification group showed significantly better mean UDVA at Day 1 (0.32 vs. 0.43), Week 1 (0.21 vs. 0.29), and 1 Month (0.12 vs. 0.19), all p< 0.001. Similarly, BCVA at 1 Month was significantly better in the Phaco group (0.07 vs. 0.11, p< 0.001). At 1 Month, 86% of Phaco patients achieved 6/6 to 6/9 UDVA, compared to 64% in the MSICS group (p = 0.01). Postoperative complications were fewer in the Phacoemulsification group, with 88% having uneventful recovery versus 64% in MSICS (p = 0.006).Conclusion:Phacoemulsification resulted in superior uncorrected and best corrected visual outcomes with fewer complications and faster recovery when compared to MSICS. Despite this, MSICS remains a safe and effective alternative, particularly in resource-limited settings.