Purpose: To determine whether eyes undergoing manual small incision cataract surgery (MSICS) have better uncorrected distance visual acuity (UCDVA) and lower postoperative astigmatism with a horizontal stitch compared to phacoemulsification and MSICS without this suture. Methods: Participants with uncomplicated cataract were offered phacoemulsification or MSICS. Those who opted for MSICS were randomly assigned to get the horizontal stitch at the end of the cataract surgery. The primary outcome measure was the UCDVA between three groups. Results: Seventy–five eyes of 75 patients were recruited, 25 in each group. At 6 weeks, 56% eyes in MSICS with horizontal stitch and 52% in phacoemulsification group had UCDVA of 6/6 compared to only 16% in MSICS group. The spherical equivalent for the MSICS group (–0.78 ± 0.76D) was significantly higher than MSICS with horizontal stitch (0.32 ± 0.30) and phacoemulsification (–0.28 ± 0.21) (p<0.05 for both), though there was no difference between the latter two groups. Conclusion: Adding a horizontal stitch to MSICS significantly improves uncorrected vision and reduces postoperative astigmatism and visual results are comparable to phacoemulsification.