Dropless cataract surgery (DCS) describes the complete provision of anti-inflammatory and antibiotic prophylaxis intraoperatively. This eliminates the need for postoperative eyedrops to be self-administered by the patient and thus is also known as ‘dropless after cataract surgery’ (DACS) (n.b. this does not include other eyedrop treatment the patient may need for other conditions, e.g. dry eye disease or glaucoma).
Mechanisms of achieving DCS include intraoperative depot injections or, less commonly, novel drug eluting intracameral (IC) or intracanalicular implants [1]. The most common depot method is a periocular steroid injection, e.g. subconjunctival (SC) triamcinolone acetonide (TA), paired with the standard pre-prepared IC antibiotic injection, e.g. cefuroxime.
Why are we talking about this now?
There is a growing opinion that DCS will soon become standard practice for routine cataract surgery, and for good reason. Several studies and meta-analyses have shown non-inferiority of DCS compared with topical treatment. Notable recent examples include the European Society of Cataract and Refractive Surgeons (ESCRS)-led EPICAT trial in Europe [2] and the work of Shorstein, et al. in the US [3]. Closer to home, independent private cataract providers such as Optegra and SpaMedica have recently piloted DCS in the UK with positive patient feedback, though peer-review reporting of clinical results are awaited [4-5]. Perhaps even more compelling than these are the attractive practical and financial benefits of DCS to both the patient and the healthcare provider.
Furthermore, the United Kingdom and Ireland Society of Cataract and Refractive Surgeons (UKISCRS) recently published the results of a 2025 survey of their membership, which identified positive attitudes towards adopting DCS (67% either would consider dropless (52%) or were already practising it (15%) [6].
What does the evidence say about steroids?
High-quality evidence, including a large meta-analysis published in April 2025, make it clear that a steroid depot is safe and efficacious for prophylaxis of postoperative inflammation, cystoid macular oedema and infection, with minimal risk of additional complications such as intraocular pressure (IOP) spikes [1].
The overall dose of TA appears to influence the effectiveness of cycstoid macular oedem (CMO) prevention, and the concentration (10mg/ml or 40mg/ml) impacts the effectiveness of iritis prophylaxis. Both dose and concentration appear to impact the risk of IOP rise. And 10mg/ml TA confers lower rates of postoperative CMO, equivalent risk of inflammation, and the same or lower rates of IOP spikes than topical treatment [7]. Higher concentration 40mg/ml TA has superior efficacy in preventing postoperative iritis compared to standard topical treatment and the lower 10mg/ml concentration. However, it may increase the relative risk of IOP spikes by 1.5–2x (although no difference has been found with 40mg/ml in the early results of the EPICAT trial) [1-3,7].
What does the evidence say about antibiotics?
ESCRS published its landmark trial proving the efficacy of IC antibiotics in 2007 [9]. Since then, several prospective and retrospective meta-analyses spanning several decades have consistently shown that the addition of topical antibiotics offers no benefit over IC injection of cefuroxime or moxifloxacin alone [1,10].
The benefits to patients?
Dropless cataract surgery has a myriad of potential benefits from the patient’s perspective. Adherence to eyedrop regimes in treatment-naïve patients is often very poor. One study found that as few as 7% of patients adhere to their eyedrop regimen as instructed [11]. Patients undergoing cataract surgery are often elderly, with cognitive problems, manual dexterity issues and joint pain. Prescription of self-administered eyedrops exacerbates these issues or even adds to existing carer burden. Up to 60% of eyedrop-naïve patients cause dropper abrasions during administration [12]. Dropper contamination, infection, corneal surface toxicity and antibiotic resistance are other underreported but important issues that can be mitigated by the adoption of DCS [3].
Table 1: Notable recent international and national examples.
The benefits to healthcare providers?
Dropless cataract surgery has clear financial and environmental benefits for the healthcare provider. At University Hospitals Dorset NHS Foundation Trust, UK, in 2025, a standard postoperative regime of g. chloramphenicol QDS for 1–2 weeks and g. dexamethasone 0.1% QDS for four weeks cost £6.00 and £5.40 respectively, totalling £11.40. This does not include the additional supply required if patients ran out of their eyedrops before the end of the course, nor the additional cost for patients who required preservative free formulations.
In contrast, the lowest cost steroid option for DCS (0.4ml depot of SC TA 10mg/ml) costs £0.32 per patient. Given that IC cefuroxime is already being used as the standard of care (in addition to postoperative eyedrops), moving to DCS at this hospital would amount to a saving of £11.08 per patient, or over £35k per year.
Dropless cataract surgery also helps to significantly reduce the carbon footprint of cataract surgery. Using a top-down approach to estimate greenhouse gas emissions, based on DEFRA conversion factors, the carbon saving of switching to DCS amounts to roughly 7kg of carbon per patient, or 21.9 tonnes per year [13].
Procurement, regulatory and medicolegal issues
Despite the host of benefits, regulatory and procurement issues remain. Affordable TA products in the form of Kenalog and Adcortyl have both been discontinued. A more expensive product, Intracinol, is available at a cost of ~£80 per vial. A 1ml vial of 40mg/ml is dilutable to 4mls of 10mg/ml concentration, thus containing up to 10 individual doses at a cost of £8 per patient, negating most of the financial savings of switching to DACS in the NHS. Interestingly, qualitative evidence from the US suggests that many patients would be willing to pay more for dropless surgery [14], so these costs could be offset within the private sector.
Licensing is another issue. Intracinol is licensed for intraocular use for staining the vitreous. Periocular use for anti-inflammatory purposes would therefore technically constitute an off-label use, which patients should be informed of. An affordable 10mg/ml triamcinolone product licensed for both periocular and intraocular usage would be a significant step towards the widespread adoption of DCS in routine practice.
Figure 1: Example of a standard operating procedure for dropless cataract surgery.
Another barrier to UK surgeons embracing DCS is the fear of sticking one’s head above the proverbial parapet. National Institute for Health and Care Excellence (NICE) guidelines for cataract surgery, last updated in October 2017 [15], recommend surgeons to “offer” anti-inflammatory eyedrops for postoperative CMO prophylaxis (the term ‘offer’ equating to a strong recommendation of said practice [16]). Do NICE guidelines constitute a medicolegal basis for compulsory action? The short answer is no [17]. Be reassured by the words of the former chair of NICE, Sir Michael Rawlins: “there appears to be confusion about the circumstances in which it is obligatory for [doctors] to follow NICE guidance...the quick answer is ‘never’” [18].
Since Bolitho (1996) [19], the minimum standard of care is to be determined objectively and logically by the courts, not by a body of experienced professionals alone (Bolam, 1957) [20]. Thus, high-quality, recent evidence can carry more weight than an older, potentially outdated national guideline [21]. Applying this to DCS, with a strong clinical rationale and high-quality evidence of safety and efficacy, surgeons are extremely unlikely to be held liable for medical negligence should any issues arise [22].
Route, location and dose?
The work of Shorstein, et al. at Kaiser Permanente has provided much of the necessary work to guide the implementation of DCS in a high-volume cataract setting [3]. Subconjunctival administration of TA allows easy administration and visible precipitate can be excised if issues arise with IOP spikes, returning IOP to a physiological range [7,23]. Intracameral steroids have previously been tested but are unlikely to provide sufficient longevity to prevent postoperative inflammation, and intraocular use may increase the risk of toxicity [24].
The hypertensive effects of SC steroid can be minimised by administering the depot inferiorly, 6–8mm from the limbus, to minimise exposure to the trabecular meshwork [3]. As has been borne out in the evidence, the ideal option is 4mg of 10mg/ml TA (a volume of 0.4ml), which disperses over a wider area than would be achieved with a lower volume of higher concentration, and offers the same or superior prophylactic efficacy as topical steroid and NSAID, with the same or reduced risk of IOP spikes [7]. This will fully dissolve in 1–2 months, an ideal duration to cover postoperative inflammation.
Special patient groups
Patients with a history of inflammatory uveitis require additional consideration. The concentration of TA in the aqueous is higher with the 40mg/ml concentration [25]. A dose of 2–4mg 40mg/ml of TA is therefore highly effective for these cases, reducing the odds of iritis to 0.1–0.32x compared with using eyedrops, however requires monitoring due to a 1.5–2x relative risk of IOP spikes [7].
Some clinicians add topical NSAIDs for patients deemed to be at higher risk of developing postoperative CMO or uveitis (e.g. diabetes, epiretinal membrane, previous retinal vein occlusion with macular oedema). Risk should be assessed on a case-by-case basis and additional treatment prescribed as necessary, as would be done for non-dropless cases.
Young patients (<60) who also have higher axial lengths (>25mm) have a 40x relative risk of IOP spikes and DCS should be avoided [26]. Early follow-up should be considered for IOP monitoring for patients who are either young or have a higher axial length. Dropless cataract surgery should also be avoided for patients with glaucoma or optic neuropathy, due to the added difficulty in reversing an IOP steroid response in the injection group compared with stopping topical drops.
Applying the evidence to a UK public sector setting, an example of a standard operating procedure for DCS can be considered, as shown in Figure 1.
Conclusion
Dropless cataract surgery is equivalent or superior to topical treatment in both safety and efficacy in routine cases. There is a strong argument that all routine cataract surgery could be dropless, offering a host of practical and clinical benefits, at no extra cost to the patient or the UK taxpayer. The final results of the EPICAT trial are expected to be published imminently [2], the results of which are likely to support the elimination of topical drops and adopt DCS as the standard of care.
References
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[All links last accessed March 2026]
Declaration of competing interests: None declared.
