Perioperative Medication Regimens for Cataract Surgery

Evidence-based recommendations on anaesthesia, endophthalmitis prophylaxis, and inflammation control in the European Society of Cataract and Refractive Surgeons (ESCRS) Cataract Surgery Guidelines should promote high-quality care and reduce existing unwanted practice variations in perioperative medication protocols, according to Thomas Kohnen MD, PhD.

Summarising the guideline’s key recommendations on these topics, Professor Kohnen discussed some of the underlying evidence and shared some details about the regimens followed at the Department of Ophthalmology, Goethe University, Frankfurt, Germany.

Per the ESCRS Guidelines, topical anaesthesia appears to be the most commonly used technique for anaesthesia. If needed, surgeons can consider adding intracameral lidocaine to reduce pain. An intracameral antibiotic (e.g., cefuroxime 1 mg/0.1 mL) injected at the end of surgery is recommended to reduce the risk of endophthalmitis. Postoperatively, a combination of a topical nonsteroidal anti-inflammatory drug (NSAID) plus a corticosteroid is recommended to prevent inflammation and cystoid macular oedema (CME) after routine cataract surgery. However, a depot of triamcinolone should also be considered in patients with diabetic retinopathy, and intraocular pressure monitored postoperatively.

Prof Kohnen said povidone-iodine is used for antisepsis at his centre. It is applied three times—10 minutes before the start of surgery, after inserting the eyelid retractor, and at the end of the procedure—and left on for 40 seconds each time. Consistent with the ESCRS Guidelines recommendation, intracameral cefuroxime saline (1 mg/0.1 mL) is injected at the end of the procedure, and patients are prescribed a topical corticosteroid to use on a tapering schedule for 4 to 6 weeks, along with a topical NSAID for 6 weeks. A 1-week course of a topical antibiotic is prescribed only if an intraoperative complication occurs.

“We stopped routine postoperative use of a topical antibiotic five years ago and have not seen any increase in infectious complications,” Prof Kohnen said.

The recommendation for intracameral cefuroxime is based on results of the prospective, randomised ESCRS Endophthalmitis Study showing intracameral cefuroxime decreased the risk of postoperative endophthalmitis by approximately fivefold.¹ The preference for intracameral versus topical antibiotic treatment also reflects the need for antibiotic stewardship in the face of rising antimicrobial resistance and its benefits in reducing the burden and compliance issues accompanying topical drops. However, Prof Kohnen acknowledged that not all surgeons have access to a commercially available antibiotic approved for intracameral injection and compounded alternatives carry a risk of toxic anterior segment syndrome.

The recommended regimens for controlling inflammation and reducing the risk of CME are supported by findings of prospective, randomised ESCRS PREMED studies that compared different regimens in non-diabetic and diabetic patient cohorts.^2,3 The study enrolling non-diabetics found the incidence of CME within 6 weeks after surgery was significantly reduced among patients treated with topical bromfenac and dexamethasone compared to those receiving the NSAID or corticosteroid as monotherapy (1.9% versus 4.1% and 8.1%, respectively). In the diabetic cohort, a single subconjunctival injection of triamcinolone acetonide added to a topical NSAID/corticosteroid regimen effectively prevented the development of CME, Prof Kohnen said.

Prof Kohnen spoke at the 2025 ASCRS annual meeting in Los Angeles.

Thomas Kohnen MD, PhD, FEBO is professor and chair of the Department of Ophthalmology, Goethe University, Frankfurt, Germany. kohnen@em.uni-frankfurt.de

1. Barry P, Seal DV, Gettinby G, Lees F, Peterson M, Revie CW; ESCRS Endophthalmitis Study Group. J Cataract Refract Surg, 2006; 32(3): 407–410. Erratum in: J Cataract Refract Surg, 2006; 32(5): 709.

2. Wielders LHP, Schouten JSAG, Winkens B, et al; ESCRS PREMED Study Group. J Cataract Refract Surg, 2018; 44(4): 429–439. Erratum in: J Cataract Refract Surg, 2018 Sep; 44(9): 1166.

3. Wielders LHP, Schouten JSAG, Winkens B, et al; ESCRS PREMED study group. J Cataract Refract Surg, 2018; 44(7): 836–847.