Dropless Cataract Surgery - Best Practices & Pitfalls to Avoid

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13 min read

Join Eric Donnenfeld, MD, and John Hovanesian, MD, to learn about the latest developments in drug delivery to optimize dropless cataract surgery.

In this episode of Interventional Mindset, Eric Donnenfeld, MD, and John Hovanesian, MD, discuss three ways drug delivery in cataract surgery can be optimized with new therapies and devices while offering clinical pearls for performing dropless cataract surgery.

Interventional Mindset is an educational series that gives eye physicians the needed knowledge, edge, and confidence in mastering new technology to grow their practices and provide the highest level of patient care. Our focus is to reduce frustrations associated with adopting new technology by building confidence in your skills to drive transformation.

Browse through our videos on a variety of topics within cataract and refractive surgery, glaucoma, and ocular surface disease to learn practical insights into adopting a variety of new surgical techniques and technology.

The shift to dropless cataract surgery via improved drug delivery

Taking control of your patient’s medications is the second most important factor to treatment success in cataract surgery after the actual procedure, began Dr. Donnenfeld. Dr. Hovanesian agreed, noting that, for patients, the procedure is only 5 to 10 minutes (wherein they are asleep), but the part that is most memorable to them is the before and after care—including the number of drops they take for the weeks following the procedure.
Topical treatments post-cataract surgery are full of pitfalls, with compliance being the foremost, as around 30 to 93% of patients fail to comply in some way with their drop regimen.1,2 This is largely due to physical limitations that may inhibit patients from adequately instilling a drop into the eye.
Further, a study by Vandenbroeck et al. demonstrated that almost 40% of patients struggle with nonadherence to eye drop treatments.3 There is nothing more frustrating than performing a perfect surgery and then having the patient’s visual results go awry due to compliance issues, emphasized Dr. Donnenfeld.
He then listed the 5 Cs for how optimized drug delivery can potentially improve cataract surgery:
  • Compliance: Patients are more likely to comply because more of the treatment is in the hands of the clinician.
  • Cornea: Topical drops have preservatives that can cause dry eye and toxicity.
  • Comfort: Similarly, drops can cause stinging, which may demotivate patients from continuing to use the drops.
  • Cost: Many of the post-operative drops are expensive, which creates financial barriers to patients receiving the care they need.
  • Cosmesis: Topical drops can cause red eye and irritation, which can impact the patient’s cosmesis, and it can be particularly difficult for patients who wear makeup as the drops can cause smearing.
Dr. Hovanesian added a sixth C, control, reiterating the importance of putting as much control of the treatment in the clinician’s hands to ensure a higher probability of successful treatment outcomes.

How drug delivery in cataract surgery can be improved

The doctors then switched to discussing the three areas where improved drug delivery in cataract surgery could optimize treatment outcomes via prevention of infection, reduced inflammation, and prevention of cystoid macular edema (CME).

1. Preventing infection after cataract surgery

While topical antibiotics have been the standard of care to prevent infection following cataract surgery for a long time, there is data that has demonstrated the benefit of injecting antibiotics directly into the eye, explained Dr. Hovanesian.
Intracameral antibiotics are starting to become more of a standard of care in the US, although roughly less than half of American surgeons use them during cataract surgery.4 The most common medication used for intracameral antibiotics is moxifloxacin, followed by cefuroxime and vancomycin. Of the three, moxifloxacin tends to have the broadest spectrum coverage, does not use preservatives, is widely available, and has low toxicity.4
Dr. Donnenfeld noted that he leverages intracameral antibiotics in all of his cataract surgery patients as his go-to, however, occasionally, he supplements this with topical antibiotics. Specifically, if he is performing fairly large limbal relaxing incisions (LRIs) or making incisions into the eye (i.e. larger clear corneal incisions, scleral tunnels with or without sutures), he prefers to coat the ocular surface with antibiotics as well.

Studies supporting the use of intracameral moxifloxacin

Most American surgeons have gravitated toward intracameral moxifloxacin, observed Drs. Hovanesian and Donnenfeld, and findings from studies have illustrated that rates of endophthalmitis are very low. For example, one study measured the rates of posterior capsule rupture (PCR) and post-operative endophthalmitis (POE) in 10 Aravind Eye hospitals in India, showing that with intracameral moxifloxacin, the rate of POE was 2 per 10,000.5
Additionally, a study by Shorstein et al. found intracameral moxifloxacin could be used successfully without topical drops.6 They demonstrated that adopting intracameral antibiotic injection correlated with a decline in the rate of POE, and a lower infection rate was reported with intracameral injection alone.
Of note, in Europe, topical antibiotic prophylaxis has almost completely disappeared. Intraocular delivery of antibiotics has become universal practice in Sweden, is deemed the standard of care in France and Denmark, and is recommended by national societies in several countries.2

2. Anti-inflammatory treatments in cataract surgery

Similar to topical antibiotics, prednisone acetate was the standard of care for anti-inflammatory treatments. Now a commonly used drug delivery system for steroidal anti-inflammatory medication is a preservative-free intracanalicular insert that can be placed in the punctum at the time of surgery, called Dextenza (dexamethasone ophthalmic insert 0.4mg, Ocular Therapeutix).
Dextenza is FDA-approved with an indication for both 1) the treatment of ocular inflammation and pain following ophthalmic surgery and 2) ocular itching associated with allergic conjunctivitis.7 The process is similar to inserting a temporary collagen punctal plug, as it is made of hydrogel material that dissolves and releases the dexamethasone in a tapered dose in the punctum for up to 30 days.
Over time, Dextenza resorbs and exits the nasolacrimal system without the need for surgical intervention. With its low-dose steroid formula, it may help to treat post-operative dry eye by acting as a punctal plug that bathes the cornea with topical dexamethasone to possibly prevent a heightened inflammatory response.

Subconjunctival triamcinolone acetonide

However, Dextenza can be expensive for patients when insurance coverage is challenged or denied, so a potential alternative could be subconjunctival triamcinolone acetonide, mentioned Dr. Donnenfeld. For doctors with patients who might not be a good fit for a canalicular insert, subconjunctival triamcinolone is a straightforward and inexpensive alternative.
The second report from the PREvention of Macular EDema after cataract surgery (PREMED) study from the European Society of Cataract and Refractive Surgeons (ESCRS) found that perioperative 40mg subconjunctival triamcinolone acetonide could dramatically reduce the risk of CME in diabetic patients undergoing cataract surgery.8
In fact, patients who received a subconjunctival injection of triamcinolone acetonide towards the end of cataract surgery had both a lower macular thickness and macular volume at 6 and 12 weeks post-operatively.
Consequently, for all of his diabetic patients, Dr. Donnenfeld recommends subconjunctival triamcinolone acetonide. While the recommended dose is 40mg, for a routine cataract surgery, Dr. Donnenfeld prefers to use around 10mg of triamcinolone.
Dr. Hovanesian added that both of these alternatives provide tapering doses, and the taper for topical therapies is only as good as the patient’s adherence to follow the drop regimen and the ability of the vial to provide a consistently tapering dose, which is not always possible with a suspension formulation, such as in prednisone acetate.

3. Preventing CME after cataract surgery

The first report from the PREMED study compared the efficacy of topical corticosteroids (dexamethasone 0.1%), non-steroidal anti-inflammatory drugs (NSAIDs, bromfenac 0.09%), and a combination of both following cataract surgery to prevent the occurrence of CME in nondiabetic patients.9 The findings demonstrated that bromfenac 0.09% twice daily for 2 weeks was more effective than dexamethasone 0.1% four times daily with one drop less per day every following week.
Dr. Donnenfeld explained that in the past, doctors relied on ketorolac tromethamine 0.4% ophthalmic solution QID, with patient reports of irritation and burning upon instillation of the drops. However, topical bromfenac has become a helpful alternative and can be used once a day, which he finds to be similarly effective.

Intracameral OMIDRIA for intra-operative mydriasis and CME prevention

Additional alternatives in the form of intracameral NSAIDs now exist as well. In particular, both Drs. Donnenfeld and Hovanesian recommended intracameral OMIDRIA (phenylepinephrine and ketorolac intraocular solution 1% / 0.3%, Rayner Surgical).
OMIDRIA is a sterile solution in which ketorolac is placed in a balanced salt solution (BSS) with phenylepinephrine to maintain mydriasis during surgery by preventing intra-operative miosis and potentially reducing post-operative pain.10 Currently, OMIDRIA is in an ongoing clinical trial to investigate whether intracameral OMIDRIA can deliver appropriate therapeutic levels of ketorolac into the vitreous to provide a sustained release of NSAIDs at the time of surgery.11
Dr. Donnenfeld highlighted a prospective study that he will present at ASCRS, comparing the levels of ketorolac in patients undergoing combined cataract surgery and vitrectomy (usually in patients with cataracts and epiretinal membranes), who were prescribed either topical ketorolac QID for 3 days or intracameral OMIDRIA. Initial analyses have indicated that trace levels of ketorolac are around five times higher with the use of OMIDRIA than with topical drops.12
These results support the clinical findings that patients who undergo cataract surgery with intracameral OMIDRIA have “white, quiet eyes with a lower risk of CME,” explained Dr. Donnenfeld.

Nepafenac and IOL attachment

Dr. Donnefeld mentioned an additional study published in the Journal of Cataract and Refractive Surgery (JCRS) on the safety and efficacy of a nepafenac punctal plug delivery system that resulted in significantly more pain-free patients, reduced inflammation, and better vision.13 Of note, the plug retention rate was 98% at Day 14 post-operatively.
Finally, Dr. Hovanesian brought up OcuRing (ketorolac ophthalmic implant, LayerBio), which is a bioerodible sustained-release ketorolac implant that can be applied to the haptic of an intraocular lens (IOL) during cataract surgery.14

Comparing drug delivery systems to a topical regimen after cataract surgery

Drs. Donnenfeld and Hovanesian recently published a paper together comparing three dropless drug delivery systems to conventional topical therapy in cataract surgery.15
Patients with bilateral cataracts were randomized to receive either intracanalicular dexamethasone insert (Dextenza), intracameral phenylephrine 1% / ketorolac 0.3% (OMIDRIA), and intracameral moxifloxacin 50μg in the study group while the control group consisted of topical moxifloxacin 0.5%, ketorolac 0.5%, and prednisolone acetate 1.0% QID.
They found that there was no CME in any of the 30 patients (60 eyes), and there were similar scoring of ocular inflammation and pain levels. However, what differentiated the two most significantly was both cost and patient preference. Nearly all of the patients greatly favored the dropless regimen (94.7%).15


Both Drs. Donnenfeld and Hovanesian agreed that improved drug delivery is the future of cataract surgery, and interested surgeons can make the change today by either reducing the number of drops utilized after cataract surgery or fully switching to a dropless regimen.
With a range of options, such as intracameral moxifloxacin, Dextenza, intracameral OMIDRIA, nepafenac punctal plug, and more, there is a significant opportunity to take an interventional mindset by treating cataract surgery patients with either a low dose or no dose of topical drops to potentially improve treatment outcomes and overall patient care.
  1. Winfield AJ, Jessiman A, Esakowitz L. A study of the causes of non-compliance by patients prescribed eye drops. Br J Ophthalmol. 1990;74(8):477-480. doi:https://doi.org/10.1136/bjo.74.8.477
  2. Matossian C. Noncompliance with Prescribed Eyedrop Regimens Among Patients Undergoing Cataract Surgery—Prevalence, Consequences, and Solutions. US Ophthalmic Rev. 2020;13(1):18-22. doi:https://doi.org/10.17925/USOR.2020.13.1.18
  3. Vandenbroeck S, De Geest S, Fabienne D, et al. Prevalence and Correlates of Self-reported Nonadherence with Eye Drop Treatment The Belgian Compliance Study in Ophthalmology (BCSO). J Glaucoma. 2011;20(7):414-421. doi:https://doi.org/10.1097/ijg.0b013e3181f7b10e
  4. George NK, Stewart MW. The Routine Use of Intracameral Antibiotics to Prevent Endophthalmitis After Cataract Surgery: How Good is the Evidence? Ophthalmol Ther. 2018;7(2):233-245. doi:https://doi.org/10.1007%2Fs40123-018-0138-6
  5. Aravind H, Chang Df, Ravindran RD. Endophthalmitis reduction with intracameral moxifloxacin in eyes with and without surgical complications: Results from 2 million consecutive cataract surgeries. J Cataract Refract Surg. 2019;45(9):1266-1233. doi:https://doi.org/10.1016/j.jcrs.2019.04.018
  6. Shorstein NH, Winthrop KL, Herrinton LJ. Decreased postoperative endophthalmitis rate after institution of intracameral antibiotics in a Northern California eye department. J Cataract Refract Surg. 2013;39(1):8-14. doi:https://doi.org/10.1016/j.jcrs.2012.07.031
  7. Singh IP. Inserting Dextenza in Eyelids with Small Puncta. Eyes On Eyecare. Published November 22, 2020. Accessed February 14, 2024. https://eyesoneyecare.com/resources/inserting-dextenza-in-eyelids-with-small-puncta/.
  8. Wielders L, Schouten J, Winkens B, et al. Randomized controlled European multicenter trial of the prevention of cystoid macular edema after cataract surgery in diabetics: ESCRS PREMED Study Report 2. J Cataract Refract Surg. 2018;44(7):836-847. doi:https://doi.org/10.1016/j.jcrs.2018.05.015
  9. Wielders L, Schouten J, Winkens B, et al. European multicenter trial of the prevention of cystoid macular edema after cataract surgery in nondiabetics: ESCRS PREMED study report 1. J Cataract Refract Surg. 2018;44(4):429-439. doi:https://doi.org/10.1016/j.jcrs.2018.01.029
  10. OMIDRIA. Product Monograph. Rayner Surgical. Published 2022. Accessed February 14, 2024. https://www.omidriahcp.com/documents/36/OMIDRIA-Product-Monograph.pdf.
  11. Rondas L. Effectiveness of Periocular Drug Injection in CATaract Surgery (EPICAT). ClinicalTrials.gov identifier: NCT05158699. Updated December 15, 2021. Accessed February 14, 2024. https://clinicaltrials.gov/study/NCT05158699.
  12. Donnenfeld ED, Sigler E, Narain S, Rabinovitch D. Aqueous and vitreous ketorolac levels in planned cataract/PPV using intracameral phenylephrine 1.0%/ketorolac 0.3% vs topical ketorolac 0.4%. Paper presented at: American Society of Cataract and Refractive Surgery Annual Meeting. April 05-08, 2024; Boston, MA.
  13. Donnenfeld ED, Holland EJ, Solomon KD. Safety and efficacy of nepafenac punctal plug delivery system in controlling postoperative ocular pain and inflammation after cataract surgery. J Cataract Refract Surg. 2021;47(2):158-164. doi:https://doi.org/10.1097/j.jcrs.0000000000000414
  14. LayerBio. OcuRingTM. LayerBio. Accessed February 14, 2024. https://www.layerbio.com/ocuring.
  15. Donnenfeld ED, Hovanesian JA, Malik AG. A Randomized, Prospective, Observer-Masked Study Comparing Dropless Treatment Regimen Using Intracanalicular Dexamethasone Insert, Intracameral Ketorolac, and Intracameral Moxifloxacin versus Conventional Topical Therapy to Control Postoperative Pain and Inflammation in Cataract Surgery. Clin Ophthalmol. 2023;2023(17):2349-2356. doi:https://doi.org/10.2147/OPTH.S422502
Eric Donnenfeld, MD
About Eric Donnenfeld, MD

Eric Donnenfeld, MD is one of the ophthalmology industry's leading experts. With a career spanning over 20 years, he has helped to revolutionize the field. He is highly passionate about ophthalmology, his career, and helping his patients.

Eric Donnenfeld, MD
John Hovanesian, MD
About John Hovanesian, MD

John Hovanesian, MD is an eye surgeon in Orange County, California and a clinical faculty member at the UCLA Jules Stein Eye Institute. He founded MDbackline in 2012 to address needs of patients, doctors, and the health care industry. He does strategy consulting and research for over 20 health care companies and has published two textbooks and dozens of journal articles in his field.

John Hovanesian, MD
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