05 December 2025
What is drop-free cataract surgery?
Patients undergoing cataract surgery are normally prescribed steroid and antibiotic eye drops to use afterwards – sometimes combined into a single drop. These drops are crucial to reduce inflammation and prevent infection. However, some patients may struggle with administering drops, or experience adverse reactions to the medication or preservatives, with compliance becoming an issue.
Over time, evidence has shifted our practice. We now know that routine antibiotic drops are unnecessary, as an antibiotic injection is administered during surgery. The focus of drop-free cataract surgery is on managing inflammation. It sees a depot steroid injection administered under the conjunctiva at the end of surgery. In the UK this is commonly triamcinolone.
Newmedica performs drop-free cataract surgery, if clinically appropriate, with decisions tailored to each patient
Who benefits most?
Patients who may have difficulties using drops post-operatively will benefit from drop-free cataract surgery. This may include patients with learning disabilities, those undergoing surgery under general anaesthesia who cannot instil drops, individuals with dementia, or those with challenges adhering to a drop regimen.
Typically, the decision to offer a steroid injection is made on a case-by-case basis. After assessing a patient’s ability to manage drops and discussing the available options, the approach is tailored to their needs.
Balancing the risks and benefits
Like any surgical intervention, drop-free cataract surgery should be based on careful weighing of risks and benefits. Patients with existing glaucoma, a family history of the condition, or those who are myopic may be at higher risk of a steroid-induced pressure response and a need for closer monitoring.
Unfortunately, there is a lack of robust evidence to guide best practice on who should receive additional monitoring. Most available studies are retrospective, and more quality, methodologically-sound trials are needed. At Newmedica, we also run glaucoma clinics, so monitoring is part of our approach.
The potential pitfalls and risks
While the convenience of depot steroid injections is clear, they are not without risk. A primary concern is the potential for raised intraocular pressure and glaucoma – a particular problem for those predisposed to these conditions.
Around 5–10% of people given steroids will experience a rise in eye pressure. With eye drops, this is relatively easy to manage, as stopping the drops usually resolves the issue. However, a depot injection cannot be reversed easily; the only option is to attempt to wash out the steroid, and this is not always effective. The spike in eye pressure typically occurs between one and four weeks after surgery but can happen later. Evidence suggests that if we’re going to give steroids, we need to monitor more closely to pick up a pressure spike that the patient wouldn’t realise is there.
Glaucoma is the hidden danger.
Given that as many as 10% of the population could be steroid responders and very rarely know, there needs to be a considered approach before using drop-free surgery widely.
Advice for optometrists and eye care professionals
Newmedica performs drop-free cataract surgery, if clinically appropriate, with decisions tailored to each patient. My advice to colleagues in optometry, and other eye health professionals, is to be aware of the risks and benefits. Inform patients of them. We can perform drop-free cataract surgery if it’s appropriate, but they may need closer monitoring. They need to be warned about the risk of glaucoma. Drop-free cataract surgery will be appropriate for some, but we need more evidence before offering it to everyone. If it’s appropriate, we’ll do it, but it might not be for all.
