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Recent studies have espoused the benefits of preoperative and intraoperative antibiotic eye drops for cataract surgery, yet none have proven the need for eyedrops following surgery. I am going to challenge the hypothesis by suggesting that eyedrops are no longer necessary during or following today's new microincision cataract procedure. Is one antibiotic or antiinflammatory eyedrop really better than the other? With today's new microincision procedures, do we really need these drops at all?

A recent survey from a national panel published in the Review of Ophthalmology, provides insight into the eyedrop habits of our colleagues. It showed that preoperatively, most surgeons are using topical povidone iodine and 64% are using a topical antibiotic prior to surgery. One third are using anti-inflammatory drops during surgery, antibiotics in the irrigation solution in about 22%, and in about a third of the cases, surgeons are using subconjunctival antibiotic injections at the end of the surgery. For postoperative anti-inflammatory control, 60% of surgeons are using Prednisolone Acetate or Diclofenac eyedrops following surgery. Yet none have proven that any of this is actually necessary!

Eyedrops may be more effective if used before surgery. Is there any benefit to the patient by using eyedrops following surgery? My studies show that it is what you do during the surgery that counts, not what you put in after the surgery. Eyedrops are necessary preoperatively to dilate the pupil. With topical anesthesia they are needed to anesthetize the eye. We need drops such as povidone iodine prior to surgery to prep and to sterilize the eye. Eyedrops are not necessary during surgery or following surgery. It is not necessary to irrigate the eye. Irrigation of the eye obscures the surgeon’s view, irritates the cornea, disrupts the corneal surface and requires an assistant to keep a constant vigilance to keep the cornea wet. Instead of constant irrigation with balanced salt solution (BSS) surgeons might want to adopt my approach. Consider substituting one drop of 2.5% hydroxypropylmethylcellulose, (HPMC), instead of irrigation during surgery. One drop of HPMC applied only once at the start of the case, after the incision is made, provides 1.5x magnification, coats and protects the cornea and frees up your scrub assistant to do more important things. A good source of HPMC is Goniosol (Cibavision), which we fill into syringes using sterile technique at the start of the morning's surgery. Goniosol is the thickest and most viscous and works the best. Ocucoat (Baush and Lomb) works well, but it’s a little bit less viscous at 2% and costs more. Xylocaine jelly (Astra) is superb because in addition to being 2% HPMC it also has Xylocaine (Lidocaine hydrochloride) so there is anesthetic effect as well. Other sources, such as artificial tears eye drops usually are not viscous enough to be effective.

I did a prospective evaluation of microincision cataract surgery with and without drops to see if using eyedrops makes any difference. I divided 322 eyes of 169 patients into two groups. Group 1 received BSS irrigation and a postoperative antibiotic/steroid eyedrop combination for two weeks. Group 2 received one drop of HPMC at the start of the case and a single 0.1cc subconjunctival injection of antibiotic (cefazolin/betamethasone) at the end of surgery. These patients did not use any postoperative eye drops. The patients were seen at one day, one week, one month and at three months. We recorded their visual acuity, their level of inflammation at the slit lamp, and graded their corneal clarity on each of the postoperative visits.

There were no statistically significant differences between the two groups that received postoperative eye drops and the group that did not. In the HPMC Group 2, corneal clarity, as measured at the slit lamp, were superior and the eyes were clearer. Group 1 with drops, tended to have a bit more SPK than Group 2 without drops. Visual acuity, lack of inflammation and infection were essentially the same whether they had drops or not.

This study supports the hypothesis that eyedrops are not necessary during and following microincision clear cornea cataract surgery. There was no statistically significant advantage in using eyedrops for reducing inflammation, infection or in improving visual outcome. Furthermore, patients do not like the inconvenience, the cost and the discomfort that hypertonic instillations into the conjunctival sac four times a day can cause. I contend therefore, that it is indeed what you do during the surgery that counts and not what you put in after the surgery that matters. Maybe the time has come for all of us to reconsider and change our routine. Patients no longer need eyedrops postoperatively.

Dr. Kershner is Clinical Professor of Ophthalmology at the University of Utah College of Medicine, Moran Eye Center, Salt Lake City, Utah, Director of the Orange Grove Center for Corrective Eye Surgery in Tucson, Arizona and a board member of the American College of Eye Surgeons. Dr. Kershner has no financial or proprietary interest in any of the instruments or techniques described.