Background: Cataract remains a leading cause of preventable blindness, especially in rural populations with limited access to advanced eye care services. Manual Small Incision Cataract Surgery (MSICS) and Phacoemulsification are two widely practiced surgical techniques for cataract removal, each offering distinct advantages in different resource settings. Aim: To compare the visual outcomes, complication rates, and patient satisfaction between MSICS and Phacoemulsification in patients with age-related cataract residing in rural areas. Material and Methods: This prospective, comparative observational study was conducted in the Department of Ophthalmology at a tertiary care center serving rural populations. A total of 100 patients with senile cataract were enrolled and randomly allocated into two groups: Group A (MSICS, n=50) and Group B (Phacoemulsification, n=50). Standardized surgical protocols were followed, and patients were evaluated at day 1, week 1, and 6 weeks postoperatively for uncorrected and best corrected visual acuity (UCVA and BCVA), complications, and satisfaction scores. Statistical analysis was performed using SPSS version 26.0 with p< 0.05 considered significant. Results: The baseline demographic and clinical profiles were comparable between both groups (p> 0.05). On day 1 and week 1, UCVA was significantly better in the Phaco group (0.52 ± 0.19 and 0.34 ± 0.14 LogMAR) than in the MSICS group (0.68 ± 0.21 and 0.45 ± 0.18 LogMAR), with p< 0.001. At 6 weeks, BCVA remained superior in the Phaco group (0.18 ± 0.07) compared to MSICS (0.22 ± 0.09, p = 0.03). A greater proportion of Phaco patients achieved BCVA ≥6/9 (78.00% vs. 64.00%). Complication rates were low in both groups, though minor issues like iris prolapse and corneal edema were slightly more frequent in MSICS. Patient satisfaction was higher in the Phaco group (mean score 4.64 ± 0.49 vs. 4.36 ± 0.58, p = 0.02). Conclusion: Both MSICS and Phacoemulsification are effective techniques for cataract surgery in rural populations. While Phacoemulsification offers superior early visual outcomes and higher satisfaction, MSICS remains a practical, cost-effective option, especially in settings with limited infrastructure.