The aim of this study was to investigate the outcomes of sutureless, manual small-incision cataract surgery (SICS) in rural sub-Saharan Africa using standard intraocular lenses (IOLs). In order to assess the quality of surgery, we prospectively evaluated the visual outcomes of 1455 consecutive cataract operations performed in 2006 in patients ≥40 years at Nkhoma Eye Hospital, Malawi. All operations used standard 22-dioptre IOLs without pre-operative biometry. Outcomes were categorised according to the World Health Organization criteria, and causes of a poor outcome were recorded. Mean age of patients was 71.5 ± 9.5 years, and 53 % were female. Pre-operatively, 64 % of eyes had a visual acuity (VA) <6/60, and 41.3 % of eyes were blind (VA < 3/60). Without correction (uncorrected VA), nearly eighty percent (78.7 %) achieved a 'good' outcome (VA 6/6-6/18), 19.8 % were 'borderline' (VA < 6/18-6/60), and 1.5 % had a poor (VA < 6/60) outcome. With pinhole-correction, the proportion of good outcomes increased to 89.4 %, and poor outcomes decreased to 0.9 %. Poor outcomes were most commonly due to ocular co-morbidities (54.5 %) and refractive error (36.4 %). Older age and pre-operative blindness were strongly associated with borderline or poor visual outcomes. The most common surgical complication was posterior capsule tear (without vitreous loss). In a rural African environment, using standard IOL power plus SICS can lead to a high proportion of good outcomes and a low frequency of surgical complications. A comparative study is required to determine if any additional benefit in visual outcomes can be gained by the addition of biometry.