Transitioning to Dropless Cataract Surgery

Clinical Report: Transitioning to Dropless Cataract Surgery

Overview

At the 2026 American Academy of Ophthalmology meeting, clinicians described a dropless cataract-surgery approach using intraoperative intracameral moxifloxacin and subconjunctival triamcinolone to address infection prophylaxis and postoperative inflammation. In a retrospective cohort of approximately 69,800 eyes, high-dose Kenalog 10 mg/mL (approximately 4 mg) was associated with lower odds of postoperative macular edema than topical prednisolone acetate, with similar odds of glaucoma events and rebound iritis; Kenalog 40 mg/mL groups had higher odds of glaucoma events.

Background

Postoperative topical regimens commonly require patients to administer antibiotic, steroid, and NSAID drops, which can be difficult, particularly for older patients. The speakers identified challenges with self-administration, including potential injury and contamination of the surgical wound. Their reported study evaluated subconjunctival triamcinolone as inflammation prophylaxis after phacoemulsification in patients treated at Kaiser Permanente Northern California from 2018 through 2021. The discussion also addressed reducing medication-related packaging and supply-chain demands through intraoperative drug delivery.

Data Highlights

Study feature or comparison	Reported finding
Design and population	Retrospective comparative-effectiveness cohort; approximately 69,800 eyes at Kaiser Permanente Northern California, 2018–2021.
Exposure groups	Topical prednisolone acetate (PA), with or without NSAID, and subconjunctival triamcinolone acetonide (Kenalog) at 10 mg/mL or 40 mg/mL, in low-dose (1.0–3.0 mg) or high-dose (3.1–5.0 mg) groups.
Outcomes assessed	Postoperative macular edema and iritis were used to assess effectiveness; glaucoma events were used to assess steroid safety.
Kenalog 10 mg/mL, high dose (~4 mg), versus topical PA	36% lower odds of postoperative macular edema; similar odds of glaucoma events and rebound iritis.
PA with NSAID versus PA alone	Reported as comparable; the authors concluded that Kenalog 10 mg/mL injection alone was sufficient for inflammation control in their analysis.
Kenalog 40 mg/mL groups	Statistically significantly higher odds of a glaucoma event.
Practice pattern described by the speakers	Kenalog brand 10 mg/mL, 0.4 mL (4 mg), injected 6–8 mm inferior to the inferior corneal limbus.

Key Findings

The study was a retrospective comparative-effectiveness cohort of approximately 69,800 eyes, excluding patients with prior surgeries or chronic conditions such as uveitis, according to the article.
Compared with topical prednisolone acetate, high-dose subconjunctival Kenalog 10 mg/mL (approximately 4 mg) was associated with 36% lower odds of postoperative macular edema and similar odds of glaucoma events and rebound iritis.
Prednisolone acetate with an NSAID was reported as comparable to prednisolone acetate alone; the study authors stated that Kenalog 10 mg/mL injection alone was sufficient for inflammation control.
Kenalog 40 mg/mL groups had statistically significantly higher odds of glaucoma events.
The speakers described a practice pattern of injecting 0.4 mL (4 mg) of Kenalog brand 10 mg/mL 6–8 mm inferior to the inferior corneal limbus, and cautioned about patients younger than 65 years, those with glaucoma or ocular hypertension, ocular herpetic infection, or axial length greater than 29 mm because of increased risk of intraocular pressure spikes with steroid treatment.
Dr. Stuart described potential sustainability advantages of fewer eye-drop bottles, cartons, leaflets, and single-use packaging, as well as a leaner supply chain.

Clinical Implications

The speakers recommended considering subconjunctival Kenalog 10 mg/mL, rather than 40 mg/mL, as an intraoperative inflammation-prophylaxis approach alongside intracameral antibiotic prophylaxis, while exercising caution in the risk groups they identified. The reported findings are from a retrospective cohort and the article specifies that the data concern brand-name Kenalog; the speakers noted that brands may differ in particle shape, size, and pharmacodynamics.

Conclusion

The article presents intraoperative intracameral moxifloxacin and subconjunctival triamcinolone as a dropless alternative to postoperative eye-drop regimens. In the reported cohort, outcomes differed by triamcinolone concentration, with the authors favoring Kenalog 10 mg/mL and reporting increased glaucoma-event odds in the 40 mg/mL groups.