Topical eye drops have been a cornerstone of cataract surgery care for decades. Standard regimens typically involve several weeks of topical antibiotics, corticosteroids, and often non-steroidal anti-inflammatory drugs (NSAIDs). Some ophthalmologists still recommend topical antibiotics and NSAIDs to also be taken preoperatively for at least a few days. This approach places a significant burden on patients, carers, and healthcare systems. Increasing evidence now supports an alternative strategy – dropless cataract surgery (DCS) – in which medications are administered intraoperatively, eliminating or markedly reducing the need for postoperative drops.
Dropless cataract surgery is no longer a niche concept. The recent UKISCRS (United Kingdom & Ireland Society of Cataract & Refractive Surgeons) Recommendations of Practice for Dropless Cataract Surgery (2026) provide the first consensus framework for its use in routine uncomplicated cataract surgery cases. This article explores the problems inherent in postoperative drop regimens, the rationale and evidence supporting dropless approaches, and the practical recommendations for contemporary cataract practice.
The problem with postoperative eye drops
Poor adherence and incorrect administration
Non-compliance with postoperative drops is widespreadElderly patients – who constitute most cataract surgery recipients – often struggle with dexterity, tremor, arthritis, poor vision, or cognitive impairment. Studies consistently demonstrate incorrect instillation technique, missed doses, contamination of bottle tips, and premature cessation of treatment. Even highly motivated patients frequently fail to adhere completely to prescribed regimens. From a clinical perspective, this introduces variability into postoperative inflammation control and infection prophylaxis, undermining the predictability of surgical outcomes and sometimes prolonging postoperative care due the consequences of poor or non-compliance.
Polypharmacy and ocular surface toxicity
Many cataract patients already use chronic topical medications, particularly for glaucoma or ocular surface disease. Adding multiple postoperative drops increases preservative exposure, exacerbates dry eye disease, may worsen ocular surface inflammation, and can simply cause confusion to the patient. The cumulative toxicity of preservatives such as benzalkonium chloride is increasingly recognized as a contributor to postoperative discomfort and delayed visual rehabilitation.
Cost, sustainability, and health system burden
Topical drops carry significant financial costs, particularly when prescribed routinely after uncomplicated surgery. At a population level, this represents a substantial and ongoing expenditure for health services. In addition, the environmental impact of single-use plastic bottles, packaging, and transport is increasingly difficult to justify in the context of sustainable healthcare. The UKISCRS document highlights reduced cost and carbon footprint as key advantages of a dropless approach.
What is dropless cataract surgery?
Dropless cataract surgery proposes replacing postoperative topical medications with the intraoperative delivery of antibiotics and anti-inflammatory agents, administered by the surgeon at the end of surgery. Most contemporary regimens include:
Intracameral antibiotics for endophthalmitis prophylaxis
Subconjunctival depot corticosteroids for postoperative inflammation control
Optional intracameral NSAIDs, typically reserved for higher-risk cases
The UKISCRS recommendations focus specifically on avoiding postoperative drops, rather than preoperative dilation or analgesia strategies, providing a pragmatic and immediately applicable framework.
(The UKISCRS guidelines are available here: )
Evidence supporting dropless cataract surgery
Endophthalmitis prophylaxis
The evidence base supporting intracameral antibiotics is robust. Large studies, including the landmark ESCRS trial, demonstrate a significant reduction in postoperative endophthalmitis with intracameral cefuroxime. Importantly, multiple national registry studies show no additional benefit from postoperative topical antibiotics when intracameral antibiotics are used. Several large UK providers have already ceased routine postoperative antibiotic drops without observing increased endophthalmitis rates, reinforcing the real-world safety of this approach.
Inflammation and cystoid macular edema (CME)
Subconjunctival corticosteroids have been shown to be non-inferior – and potentially superior – to topical steroids in controlling postoperative inflammation and preventing CME. Recent high-quality studies demonstrate comparable rates of inflammation control and similar incidences of steroid-related intraocular pressure rise when appropriate dosing is used. Emerging data, including preliminary results from the ESCRS EPICAT trial, suggest that periocular steroid depots may offer enhanced protection against CME, particularly when combined with intracameral NSAIDs in selected cases.
Patient experience and equity of care
By removing reliance on patient-administered drops, dropless surgery standardizes postoperative treatment delivery. This improves equity of care, particularly for patients with physical or cognitive limitations, and reduces dependence on carers or community nursing support. Improved patient satisfaction and reduced postoperative confusion are consistently reported benefits.
Addressing common concerns
Despite growing evidence, some surgeons remain cautious. Key concerns include subconjunctival hemorrhage, steroid response, and perceived risk of postoperative inflammation. The UKISCRS guidance addresses these directly, emphasizing careful patient selection and clear exclusion criteria, such as patients who are known steroid responders, those who have uncontrolled glaucoma, and eyes with significant retinal comorbidity. Importantly, dropless cataract surgery is not presented as a one-size-fits-all solution, but rather as a default strategy for routine, uncomplicated cases, with topical therapy reserved for higher-risk patients.
Summary of UKISCRS recommendations
The UKISCRS recommends that, following routine uncomplicated cataract surgery:
Intracameral antibiotic prophylaxis should be administered in all cases (cefuroxime of moxifloxacin, as per local guidance).
Subconjunctival triamcinolone (typically 2–4 mg) may be used to control postoperative inflammation, recognizing its off-label status.
Postoperative topical antibiotics should not be prescribed routinely, unless additional risk factors are present.
Patients should receive clear postoperative safety advice and timely follow-up, typically within four weeks.
These recommendations align with sustainability initiatives from the Royal College of Ophthalmologists and reflect evolving best practice in high-volume cataract surgery.
Conclusion
Dropless cataract surgery represents a logical evolution in postoperative care – one that aligns evidence-based medicine with patient-centered practice, sustainability, and health system efficiency. The growing body of data demonstrates that, in appropriately selected patients, dropless regimens deliver outcomes equivalent to traditional drop-based protocols while addressing many of their inherent shortcomings.
The UKISCRS Recommendations provide timely, practical guidance for surgeons wishing to adopt dropless strategies safely and responsibly. As regulatory frameworks and licensed formulations continue to evolve, dropless cataract surgery is well positioned to become the new standard of care for routine phacoemulsification.
Dropless cataract surgery is no longer a niche concept. The recent UKISCRS (United Kingdom & Ireland Society of Cataract & Refractive Surgeons) Recommendations of Practice for Dropless Cataract Surgery (2026) provide the first consensus framework for its use in routine uncomplicated cataract surgery cases. This article explores the problems inherent in postoperative drop regimens, the rationale and evidence supporting dropless approaches, and the practical recommendations for contemporary cataract practice.
The problem with postoperative eye drops
Poor adherence and incorrect administration
Non-compliance with postoperative drops is widespreadElderly patients – who constitute most cataract surgery recipients – often struggle with dexterity, tremor, arthritis, poor vision, or cognitive impairment. Studies consistently demonstrate incorrect instillation technique, missed doses, contamination of bottle tips, and premature cessation of treatment. Even highly motivated patients frequently fail to adhere completely to prescribed regimens. From a clinical perspective, this introduces variability into postoperative inflammation control and infection prophylaxis, undermining the predictability of surgical outcomes and sometimes prolonging postoperative care due the consequences of poor or non-compliance.
Polypharmacy and ocular surface toxicity
Many cataract patients already use chronic topical medications, particularly for glaucoma or ocular surface disease. Adding multiple postoperative drops increases preservative exposure, exacerbates dry eye disease, may worsen ocular surface inflammation, and can simply cause confusion to the patient. The cumulative toxicity of preservatives such as benzalkonium chloride is increasingly recognized as a contributor to postoperative discomfort and delayed visual rehabilitation.
Cost, sustainability, and health system burden
Topical drops carry significant financial costs, particularly when prescribed routinely after uncomplicated surgery. At a population level, this represents a substantial and ongoing expenditure for health services. In addition, the environmental impact of single-use plastic bottles, packaging, and transport is increasingly difficult to justify in the context of sustainable healthcare. The UKISCRS document highlights reduced cost and carbon footprint as key advantages of a dropless approach.
What is dropless cataract surgery?
Dropless cataract surgery proposes replacing postoperative topical medications with the intraoperative delivery of antibiotics and anti-inflammatory agents, administered by the surgeon at the end of surgery. Most contemporary regimens include:
Intracameral antibiotics for endophthalmitis prophylaxis
Subconjunctival depot corticosteroids for postoperative inflammation control
Optional intracameral NSAIDs, typically reserved for higher-risk cases
The UKISCRS recommendations focus specifically on avoiding postoperative drops, rather than preoperative dilation or analgesia strategies, providing a pragmatic and immediately applicable framework.
(The UKISCRS guidelines are available here: )
Evidence supporting dropless cataract surgery
Endophthalmitis prophylaxis
The evidence base supporting intracameral antibiotics is robust. Large studies, including the landmark ESCRS trial, demonstrate a significant reduction in postoperative endophthalmitis with intracameral cefuroxime. Importantly, multiple national registry studies show no additional benefit from postoperative topical antibiotics when intracameral antibiotics are used. Several large UK providers have already ceased routine postoperative antibiotic drops without observing increased endophthalmitis rates, reinforcing the real-world safety of this approach.
Inflammation and cystoid macular edema (CME)
Subconjunctival corticosteroids have been shown to be non-inferior – and potentially superior – to topical steroids in controlling postoperative inflammation and preventing CME. Recent high-quality studies demonstrate comparable rates of inflammation control and similar incidences of steroid-related intraocular pressure rise when appropriate dosing is used. Emerging data, including preliminary results from the ESCRS EPICAT trial, suggest that periocular steroid depots may offer enhanced protection against CME, particularly when combined with intracameral NSAIDs in selected cases.
Patient experience and equity of care
By removing reliance on patient-administered drops, dropless surgery standardizes postoperative treatment delivery. This improves equity of care, particularly for patients with physical or cognitive limitations, and reduces dependence on carers or community nursing support. Improved patient satisfaction and reduced postoperative confusion are consistently reported benefits.
Addressing common concerns
Despite growing evidence, some surgeons remain cautious. Key concerns include subconjunctival hemorrhage, steroid response, and perceived risk of postoperative inflammation. The UKISCRS guidance addresses these directly, emphasizing careful patient selection and clear exclusion criteria, such as patients who are known steroid responders, those who have uncontrolled glaucoma, and eyes with significant retinal comorbidity. Importantly, dropless cataract surgery is not presented as a one-size-fits-all solution, but rather as a default strategy for routine, uncomplicated cases, with topical therapy reserved for higher-risk patients.
Summary of UKISCRS recommendations
The UKISCRS recommends that, following routine uncomplicated cataract surgery:
Intracameral antibiotic prophylaxis should be administered in all cases (cefuroxime of moxifloxacin, as per local guidance).
Subconjunctival triamcinolone (typically 2–4 mg) may be used to control postoperative inflammation, recognizing its off-label status.
Postoperative topical antibiotics should not be prescribed routinely, unless additional risk factors are present.
Patients should receive clear postoperative safety advice and timely follow-up, typically within four weeks.
These recommendations align with sustainability initiatives from the Royal College of Ophthalmologists and reflect evolving best practice in high-volume cataract surgery.
Conclusion
Dropless cataract surgery represents a logical evolution in postoperative care – one that aligns evidence-based medicine with patient-centered practice, sustainability, and health system efficiency. The growing body of data demonstrates that, in appropriately selected patients, dropless regimens deliver outcomes equivalent to traditional drop-based protocols while addressing many of their inherent shortcomings.
The UKISCRS Recommendations provide timely, practical guidance for surgeons wishing to adopt dropless strategies safely and responsibly. As regulatory frameworks and licensed formulations continue to evolve, dropless cataract surgery is well positioned to become the new standard of care for routine phacoemulsification.
