Drop-Free Approaches for Cataract Surgery

Neal H. Shorstein; William G. Myers


Curr Opin Ophthalmol. 2020;31(1):67-73. 

In This Article

The Trouble with Drops

Incorrect technique of patient-administered eyedrops may be as high as 93%.[6] Table 1 lists potential risks of eyedrops. Corneal and conjunctival abrasions were observed in 68% of elderly study patients resulting from instillation of drops.[7] The potential for wound gape and efflux of fluid into the eye following pressure on the eye has been reported.[8] The result of these effects may be to increase the risk of endophthalmitis from the very treatment meant to diminish risk.

Iris Dilation

Dilation with topical cyclopentolate alone in the preoperative area of the surgical suite requires 90 minutes for maximal binding to receptors.[9] This may impact throughput efficiency. With the approval by the US FDA in 2007 of tamulosin, surgeons soon became aware of a trend of poor pharmacologic iris dilation and intraoperative lack of tone. Topical dilation drops were relatively ineffective for this 'intraoperative floppy iris syndrome' or IFIS.[10]


There are no studies to date showing level I evidence of the effectiveness of topical antibiotics in reducing endophthalmitis.[11] Intraocular penetration of drops is variable and poor, achieving only relatively low concentrations in the anterior chamber.[12] Although a large retrospective study showed that topical fluoroquinolones and polymyxin/trimethoprim antibiotic drops reduce the risk of endophthalmitis,[13] 5% of patients never filled their eyedrop prescription and were twice as likely to develop endophthalmitis.


Topical corticosteroids have been the mainstay of cataract surgeons for the prevention of postoperative inflammation and pain for decades. Prednisolone acetate is not as potent per weight of a corticosteroid as dexamethasone, but it has a longer duration of action because of its suspension preparation.[14] The literature is replete with comparison studies of corticosteroid and nonsteroidal antiinflammatory agents (NSAID). There is general agreement that a combination of NSAID and steroid suppress inflammation in the early postoperative period better than steroid alone.[15,16] Nevertheless, there have been no large, prospective studies showing any benefit to visual acuity with the addition of NSAID at three months or more following surgery.[17] The number of cataract surgery patient eyes needed to treat with NSAID to prevent one case of CME has been calculated at between 238 and 320.[18,19]

The costs of topical drops, which may be hundreds of dollars,[20] should be weighed against the benefit of the treatment, particularly when injectable steroids offer less expensive, equivalent prevention.