Intraoperative Use Of A Topical Anesthetic Gel Versus Balanced Salt Solution During Cataract Surgery: Effects On Corneal Structure And Ocular Surface

During cataract surgery, topical anesthesia is routinely achieved through the instillation of preoperative topical anesthetic eye drops, while different agents may be applied to the corneal surface during the procedure to support lubrication and protection. The impact of these intraoperative strategies on corneal integrity and postoperative ocular surface recovery remains an area of clinical interest. 

This study aimed to compare the intraoperative and postoperative effects of applying a topical anesthetic gel (Ophtesic, Horus Pharma) on the corneal surface versus the use of balanced salt solution (BSS) during cataract surgery.

Monocentric, observational, prospective study.

Patients undergoing standardized phacoemulsification surgery at the Eye Clinic of Careggi University Hospital in Florence, Italy, were enrolled between February and June 2025. Individuals with comparable clinical characteristics were included. Inclusion and exclusion criteria were defined.

This longitudinal, observational prospective study included 24 eyes of 24 patients undergoing phacoemulsification who received either a topical anesthetic gel (n = 15) applied to the corneal surface intraoperatively or standard BSS irrigation (n = 9). Central corneal thickness (CCT) and epithelial thickness were measured preoperatively and at postoperative days 1, 5, and 15 using anterior segment optical coherence tomography (AS-OCT). Basal epithelial cell (BEC) density, using in vivo confocal microscopy (IVCM), OSDI score, non-invasive breakup time (NI-BUT), and Schirmer test I values were assessed preoperatively and at postoperative days 5 and 15. Patient and surgeon satisfaction were evaluated using a Likert-like verbal rating scale.

Both groups showed increased CCT and epithelial thickness at day 1 postoperatively. In the gel group, CCT returned to baseline by day 15 (p=0.361), and epithelial thickness normalized by day 5 (p=0.066). In the BSS group, CCT remained elevated at day 15 (p<0.05), and epithelial thickness decreased significantly at day 5 (p<0.05) before returning to baseline. BEC density normalized at day 15 in the gel group (p=0.107) but remained significantly altered in the BSS group (p<0.05). NI-BUT returned to baseline by day 15 in the gel group (p=0.484), while tear production measured by Schirmer I test normalized earlier, at day 5 (p=0.492). In the BSS group, both NI-BUT and Schirmer I values showed delayed recovery. 

Our prospective study demonstrates that the intraoperative application of ophthalmic lidocaine hydrochloride gel 20 mg/g (Ophtesic, Horus Pharma) provides effective corneal protection during phacoemulsification. Compared with repeated BSS irrigation, the gel significantly reduced mechanical and inflammatory stress on the ocular surface, as reflected by faster normalization of epithelial thickness, CCT, and basal epithelial cell density. These microstructural benefits were accompanied by accelerated recovery of tear film stability and aqueous tear production, as well as earlier resolution of subjective dry eye symptoms.