Study: Dropless Cataract Surgery Slashes Drug Costs

Medscape

20-05-2025

A regimen that spares patients recovering from cataract surgery the burden of using antibacterial and anti-inflammatory eye drops several times a day for weeks and instead uses an injection to administer those drugs immediately after the procedure is nearly as effective at preventing complications as the traditional drop regimen at a fraction of the cost, a study of both approaches found.
'Our study aims to underscore the benefits of the dropless cataract surgery approach as a promising alternative to the traditional drop regimen, particularly for populations where adherence to postoperative drops is challenging,' Yousef Yousef, a medical student at the University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, told Medscape Medical News. 'We hope our findings will encourage broader adoption of the dropless protocol by cataract surgeons, potentially establishing it as a new standard of care.'
Yousef Yousef
Yousef presented results from a retrospective chart review of 544 eyes that had cataract surgery at the Association for Research in Vision and Ophthalmology (ARVO) 2025 Annual Meeting in Salt Lake City.
Dropless vs Traditional Protocol
The traditional protocol, used in 265 study eyes, consisted of giving patients a prescription for drops of the anti-inflammatory corticosteroid prednisolone 1%, the antibiotic moxifloxacin 0.5%, and the nonsteroidal anti-inflammatory ketorolac 0.5% four times a day with a 4-week taper. The dropless protocol, assigned to 279 eyes, consisted of an intracameral injection of 0.2 mL of moxifloxacin 0.5% and a 10 mg/mL subconjunctival injection of the glucocorticoid triamcinolone (Kenalog) on completion of the operation.
The researchers found no significant differences in best-corrected visual acuity. Patients who had the dropless protocol had a higher incidence of cystoid macular edema — 5% vs 1% — Yousef said, but the incidence of ocular hypertension was not statistically significant between the two groups (2% vs 1%). A multivariate regression analysis showed the dropless protocol was not associated with increased risks for either complication, he added.
The dropless protocol has three key potential advantages over the traditional approach, Yousef said: Convenience for patients, improved drug bioavailability, and lower cost.
'The traditional drop protocol requires patients to administer three different medications four times daily over a 4-week tapering period,' he told Medscape Medical News . 'This regimen results in a total of 12 drops per day for one eye and 210 drops over the course of the taper.'
Poor drug bioavailability is a 'significant concern' with topical drops, Yousef said, because the epithelial membrane of the cornea can limit the ability of the drops from penetrating into the eye. 'Intracameral injection bypasses these barriers, delivering a more direct treatment,' he said.
A 2020 analysis of Medicare claims reported the average cost of medications for eye drops after cataract surgery was $228 per eye. 'Notably, 76.5% of this total cost was attributed to the use of brand-name medications,' Yousef said. 'In contrast, the dropless approach costs just $15.91 per eye when a single vial is used for approximately 10 cases.'
The new data are important because few randomized clinical trials have compared the dropless and traditional protocols for treating pain and inflammation and preventing infections after cataract surgery, according to Neal Shorstein, MD, a retired cataract surgeon with Kaiser Permanente in Northern California .
Neal Shorstein, MD
'There are an accumulating number of observational studies, so this adds to the retrospective, observational literature, and that's a good thing because different locations and practice environments add to the experience,' said Shorstein, an adviser to the Seva Foundation, a nonprofit group that develops eye care programs in underserved regions.
The doses of medication used in the dropless protocol in the analysis are higher than what others have reported. The 0.2 mL of intracameral moxifloxacin 0.5% is 'about the upper limits of what you want to inject of moxifloxacin.' The 0.5-mL dose of subconjunctival triamcinolone is, 'in my estimation, a good dose.'
The formulation of triamcinolone used has a large particle size, which 'matters a lot because the safety and effectiveness of triamcinolone depends on the particle size,' he said. Triesence, another formulation of triamcinolone used in some dropless protocols, has a smaller particle size, he said.
The entry point on the conjunctiva for the triamcinolone injection is another important factor, Shorstein added. 'Our findings show that 6-8 mm from the limbus is the optimal location,' he said.
The study was independently supported. Yousef and Shorstein reported having no relevant financial relationships.