Cataract Surgery Postoperative Care
Clinical Snapshot
Cataract extraction with intraocular lens implantation is one of the most frequently performed elective surgical procedures, and most patients are discharged the same day to be followed by their surgeon at scheduled visits while day-to-day questions and a complex postoperative drop regimen fall to a community pharmacist or primary care practitioner in between.[1] The postoperative period centers on 3 pharmacologic goals: prevent infection (bacterial endophthalmitis), control inflammation and prevent cystoid macular edema (CME), and support comfort and healing while the eye recovers. Achieving this typically means a multi-week regimen of a topical antibiotic, a topical corticosteroid on a defined taper, and often a topical NSAID — 3 different bottles, 3 different schedules, and sometimes 3 different tapering timelines in the same patient. Without a slit lamp, tonometer, or indirect ophthalmoscope, a community pharmacist or primary care practitioner cannot definitively diagnose a postoperative complication; the role in this setting is early recognition of red flags that need urgent ophthalmology referral, plus adherence support for a regimen that is genuinely easy to get wrong.
Recognize the Condition
The expected normal postoperative course
A comfortable eye is the expectation after cataract surgery — at worst, a mild foreign-body sensation is normal. Postoperative inflammation from the surgery itself is most prominent in the first 48 hours, while infection (endophthalmitis) most commonly develops between days 3 and 7, though it can occur at any point afterward.
Some findings are expected and, on their own, do not indicate a problem: transient blurred vision right after instilling a drop, mild grittiness, and dysphotopsia — glare or a shadow in the peripheral vision from the edge of the intraocular lens — which is common in the first days to weeks after implantation and typically settles as the brain adapts. Confrontation visual field testing (finger counting in the periphery) should be normal in a patient with dysphotopsia; if it is not, or the shadow is progressive rather than stable, this is no longer routine dysphotopsia and needs assessment. A pinhole used to retest visual acuity can separate a genuine reduction in vision from an uncorrected refractive error.
Itching as the predominant symptom points toward an allergic reaction to one of the topical medications, or dry eye, rather than infection or inflammation, and it usually resolves with a change in drop formulation rather than a referral.
Risk Factors
Risk factors for postoperative endophthalmitis
- Posterior capsule rupture or vitreous loss during surgery.
- Prolonged or complicated surgical time.
- Clear corneal incision technique, compared with a scleral tunnel incision.
- Diabetes mellitus or other immunosuppression.
- Pre-existing blepharitis or lid margin disease.
- Inadequate perioperative reduction of eyelid and periocular skin flora.
- Silicone oil use or a combined intraocular procedure.
- A postoperative wound leak.
Risk factors for cystoid macular edema
- Diabetic retinopathy.
- A personal history of uveitis, or CME in the fellow eye.
- Epiretinal membrane or other pre-existing macular pathology.
- Complicated surgery — posterior capsule rupture or vitreous loss.
- Concurrent use of a topical prostaglandin analogue for glaucoma.
- Poor adherence to the prescribed topical NSAID/corticosteroid course.
Risk factors for a postoperative intraocular pressure spike
- Pre-existing glaucoma or ocular hypertension.
- Pseudoexfoliation syndrome.
- Retained viscoelastic material at the end of surgery.
- A known steroid responder — a prior significant IOP rise with corticosteroid use.
- Complex surgery involving a small pupil or iris manipulation.
Red Flags & Refer
Any of the following after cataract surgery should be treated as a possible ophthalmic emergency needing same-day assessment by the operating surgeon or the nearest ophthalmology/emergency eye service — do not simply reassure the patient or advise them to continue their drops and wait for the scheduled visit.
- Significant or worsening eye pain — the postoperative eye should be comfortable, at worst a mild foreign-body sensation; genuine pain, especially with headache, nausea, vomiting, or feeling generally unwell, is not expected and needs urgent evaluation.
- Redness together with a decline in vision, especially with pain, in the days after surgery — this combination is the classic presentation of bacterial endophthalmitis, a true sight-threatening emergency most common between postoperative days 3 and 7, though it can occur at any time.
- Vision that is significantly worse than the day before, or worse than immediately after surgery, rather than gradually improving as expected.
- Sudden new or markedly worsening flashes of light, floaters, or a curtain/shadow in the visual field — these suggest a retinal tear or detachment rather than routine postoperative dysphotopsia.
- Any trauma to the operated eye during the early postoperative period.
- Swollen or red eyelids or conjunctiva, a hazy cornea, a white layer (hypopyon) in the anterior chamber, or a poor or absent red reflex on direct ophthalmoscopy.
- A flat or poorly formed anterior chamber, or a wound that appears to be leaking fluid.
- Photophobia (light sensitivity with pain or glare) beyond what is expected from routine postoperative pupil dilation.
Assessment & Diagnosis
Differentiating causes of a postoperative concern
Several distinct problems can all present as "the eye doesn't feel right" after cataract surgery — telling them apart, or recognizing that this cannot be done without a slit lamp and tonometer, is the central assessment skill in this setting.
| Feature | Normal postoperative course | Endophthalmitis | Inflammation/uveitis flare | Elevated IOP | Cystoid macular edema |
|---|---|---|---|---|---|
| Typical onset | Improves day by day from surgery | Days 3-7 postoperatively, but can occur at any time | First 48 hours most common; can recur if a corticosteroid is tapered too quickly | Hours to days postoperatively (retained viscoelastic) or weeks in (steroid response) | 4-6 weeks postoperatively, sometimes later |
| Pain | None to a mild foreign-body sensation | Significant, often with headache or nausea | Mild-to-moderate photophobia and ache | Ache, sometimes headache if pressure is high | None — painless |
| Vision | Gradually improving | Rapidly declining | Mildly blurred, fluctuates with inflammation | Usually preserved unless pressure is very high | Painless, gradual central blurring |
| Redness | Mild, resolving | Marked, often with lid swelling | Present, circumcorneal | Usually minimal | Usually minimal |
| Key distinguishing finding | Confrontation visual fields normal; no red flags | Hypopyon, poor red reflex, hazy cornea — a true emergency | Responds to corticosteroid; no hypopyon | Elevated pressure on tonometry; needs a slit lamp/tonometer to confirm | Needs a dilated exam or OCT to confirm; suspect if vision plateaus or declines around 1 month |
| Action | Reassure; continue the regimen | Refer immediately — same-day ophthalmology emergency | Refer for a slit lamp exam; the corticosteroid taper likely needs to be extended, not stopped | Refer for a pressure check; may need temporary IOP-lowering therapy | Refer for a dilated exam/OCT; the NSAID course likely needs to be extended |
History
- Characterize the pain — the postoperative eye should be comfortable, at worst a mild foreign-body sensation; more intense pain suggests elevated IOP, increased inflammation, or infection.
- Ask about any trauma to the eye since surgery, which needs reassessment with a slit lamp regardless of how minor it seems.
- Ask about a change in vision — worsening, darkening, loss of detail, or peripheral visual loss — any significant change could indicate infection, hemorrhage, retinal detachment, or other acute intraocular pathology.
- Ask about visual phenomena — flashing lights, dark shadows, or floaters. Worsening floaters need reassessment to rule out infection, retinal tear/detachment, or uveitis; new, mild dysphotopsia (glare or a peripheral shadow) in the early weeks after lens implantation is usually not concerning provided confrontation visual fields are normal.
- Ask specifically about itching as the predominant symptom, which suggests an allergic reaction to a topical medication or dry eye rather than infection.
- Review the ocular medication regimen in detail — reinforce correct technique, clarify any confusion about which drop is which, and involve a family member if the patient is having trouble managing multiple bottles.
- Confirm the patient has a scheduled follow-up visit with the surgeon and knows when it is.
Examination — requires ophthalmology-level equipment
A visual acuity chart, slit lamp, tonometer, and indirect ophthalmoscope are needed to properly examine a postoperative cataract patient; a community pharmacist or primary care practitioner without these tools cannot reliably rule out the differentials above and should not attempt to. When these tools are available, key findings include: lid or conjunctival swelling (suggests drug allergy or infection); pupil reactivity, which should be normal unless a mydriatic was used; photophobia, which can indicate anterior uveitis or corneal haze from infection, inflammation, or elevated IOP; corneal clarity, which should be free of clouding or infiltrates; and a clear red reflex on ophthalmoscopy, whose absence suggests vitreous clouding, inflammation, or infection.
When testing is not indicated
A patient with mild, improving symptoms and no red flags does not need urgent same-day ophthalmology assessment — reassurance, a review of correct drop technique, and confirmation of the scheduled follow-up visit is appropriate. Any red flag from the callout above bypasses this and goes straight to urgent referral rather than a watch-and-wait approach, since the tools needed to safely rule out infection or a retinal problem are not available outside an eye care setting.
Treatment Targets
- Control inflammation.
- Prevent infection (endophthalmitis).
- Maintain eye comfort.
- Promote early visual rehabilitation.
- Detect intraocular infection at its earliest stage.
- Detect postoperative uveitis or intraocular pressure elevation early.
- Detect other abnormalities in the postoperative course — retinal detachment, iris prolapse, a wound leak, a flat anterior chamber, excessive corneal edema, or intraocular hemorrhage.
Choose Initial Treatment
Antibiotic prophylaxis
1st line a topical fourth-generation fluoroquinolone such as moxifloxacin 0.5% QID, started immediately after surgery rather than waiting for the first postoperative day, and continued for about 7-10 days.
Alternative a fixed antibiotic/corticosteroid combination (for example, tobramycin/dexamethasone) — some surgeons prefer this for ease of use, which can improve adherence to a multi-bottle regimen.
Special situation some surgeons additionally give intracameral antibiotic (commonly moxifloxacin or cefuroxime) injected into the anterior chamber at the end of surgery. Current evidence supports this as an effective, and in some studies more effective, prophylactic strategy than topical antibiotic alone, with growing evidence that topical antibiotic adds little additional benefit once intracameral antibiotic has been given.[2][3]
Avoid intracameral vancomycin — it has been associated with hemorrhagic occlusive retinal vasculitis (HORV), a rare but potentially devastating vision-threatening complication, and is no longer favoured for routine prophylaxis.[4]
Corticosteroid and NSAID selection
1st line corticosteroid prednisolone acetate 1%, or another topical corticosteroid, started the day after surgery and tapered over about 3-4 weeks — continue longer if there is evidence of cystoid macular edema.
Add a topical NSAID in patients at elevated CME risk (diabetes, prior uveitis or fellow-eye CME, complicated surgery) and consider it routinely in all patients — a Cochrane review found low-quality evidence that topical NSAIDs, alone or combined with a corticosteroid, may control inflammation and prevent CME more effectively than a corticosteroid alone.[5]
Special situation — higher CME risk continue the NSAID for the full postoperative course rather than a short course, and coordinate with the surgeon on extending therapy further if early signs of CME appear.
Regimen track
Standard track topical antibiotic, topical corticosteroid taper, and (in most current protocols) a topical NSAID, all self-administered by the patient — the default approach for most patients and surgeons.
Simplified/dropless track intracameral or sustained-release corticosteroid delivery that replaces or substantially reduces the self-administered topical corticosteroid taper, usually paired with intracameral antibiotic — a reasonable alternative, particularly for a patient with dexterity, cognitive, or access barriers to reliably self-administering multiple drops, where it is available and the surgeon uses it.[6]
Non-Pharmacologic Treatment
- Continue other systemic medications, including antiplatelets and anticoagulants, on the day of surgery and afterward unless the surgeon specifically advises otherwise.
- For diabetes: insulin and insulin secretagogues (sulfonylureas, meglitinides) may need a modified or held dose the day before or day of surgery because of hypoglycemia risk in the perioperative fasting state; metformin is often held the day before and day of surgery because of lactic acidosis risk — confirm any changes with the prescriber before surgery, and increase glucose monitoring frequency if doses are adjusted.
- Use a protective eye shield at night for the first week, or as directed, to prevent inadvertent rubbing or pressure on the eye during sleep.
- Avoid rubbing the operated eye.
- Avoid swimming, hot tubs, and dusty or dirty environments for the period the surgeon specifies.
- Avoid eye makeup on the operated eye until cleared by the surgeon.
- Avoid heavy lifting, straining, or bending at the waist in the first week, and avoid strenuous exercise until cleared.
- Driving: do not drive on the day of surgery, especially with a dilated pupil and blurred vision, and do not resume driving until vision meets the legal standard in both the operated and non-operated eye and the patient feels visually comfortable doing so.
- Dispose of any unused ophthalmic medication once the prescribed course is finished — these are limited-course products, and reusing a partly used bottle for a future, unrelated eye problem risks contamination or self-treating the wrong diagnosis.
Correct eye drop technique and sequencing when multiple drops are used
- Wash hands before each dose, and avoid letting the dropper tip touch the eye, eyelid, or any surface.
- When more than one eye drop is prescribed, separate the administration of each by at least 5 minutes — instilling drops too close together washes out the first drop before it can be absorbed.
- A practical order when the regimen includes a suspension (for example, prednisolone acetate) is to instill solutions before suspensions, since a suspension left on the ocular surface can slow absorption of a solution instilled afterward — confirm the specific order with the surgeon or pharmacist if uncertain.
- After instilling a drop, gently closing the eye for 30-60 seconds helps maximize ophthalmic absorption; for a medication where reducing systemic absorption matters, applying gentle pressure over the inner corner of the eye (nasolacrimal or punctal occlusion) for 30-60 seconds while keeping the eye closed reduces drainage of the drop into the nose and throat, where it can be absorbed systemically.
- Shake suspension formulations, such as prednisolone acetate, well before each use; solutions do not need shaking.
Special Populations
Pregnancy
Elective cataract surgery is uncommon in pregnancy and is typically deferred where possible, but urgent cases can occur. Topical ophthalmic antibiotics, corticosteroids, and NSAIDs are generally used with the same caution principles as other topical ophthalmic drugs in pregnancy — systemic absorption is low, but a topical NSAID should be used only when necessary given the known risks of oral NSAIDs later in pregnancy, and prolonged or high-dose topical corticosteroid use should be avoided where a reasonable alternative exists. Any decision to proceed with surgery and its drug regimen during pregnancy should directly involve the surgeon and the patient's obstetric provider.
Breastfeeding
Systemic absorption from topical ophthalmic antibiotics, corticosteroids, and NSAIDs is low, and standard postoperative regimens are generally considered compatible with breastfeeding; oral acetaminophen for postoperative analgesia is also compatible.
Pediatrics
Pediatric cataract surgery carries considerations beyond this chapter's adult-focused scope — amblyopia risk from visual deprivation, more pronounced postoperative inflammation, and a higher rate of steroid-induced IOP elevation than in adults — and is managed by pediatric ophthalmology with individualized dosing and monitoring.
Renal and hepatic impairment
Topical ophthalmic drops have minimal systemic absorption and generally do not require renal or hepatic dose adjustment. If oral acetazolamide is used for a severe pressure spike, check renal function given the risk of metabolic acidosis and electrolyte disturbance; if oral ciprofloxacin is used, for example after a ruptured lens capsule, renal dose adjustment applies as it would for any systemic use.
Standard-risk vs. higher-risk patients
Standard-risk patients
Uncomplicated surgery, no diabetic retinopathy, no history of uveitis or fellow-eye CME, and no pre-existing macular pathology — the standard antibiotic course, corticosteroid taper, and NSAID course described above are usually sufficient.
Higher-risk patients
Diabetic retinopathy, a personal history of uveitis or CME in the fellow eye, epiretinal membrane or other macular pathology, or complicated surgery (posterior capsule rupture, vitreous loss) — these patients benefit from an extended topical NSAID course, often continued beyond the standard 3-4 weeks, and a more gradual corticosteroid taper, with closer monitoring for CME and a lower threshold for ophthalmology follow-up if vision plateaus instead of improving.
Monitoring & Follow-Up
Follow the surgeon's specific visit schedule — typically postoperative day 1, about 1 week, and about 4 weeks, with additional visits if a higher-risk feature or complication is present. At every pharmacy contact, including a refill or a phone call, confirm the patient is applying each drop correctly and on schedule, with adequate spacing between different drops, and reinforce that the corticosteroid taper must be completed and never stopped abruptly. Ask specifically about pain, redness, and the trend in vision (better, the same, or worse) at every contact — a red-flag answer should trigger the same urgent-referral pathway described above rather than being deferred to the next scheduled visit. Confirm intraocular pressure has been checked if a corticosteroid course is being extended, since steroid-induced IOP elevation can develop silently over weeks. In a higher-risk patient, confirm that a dilated macular assessment or OCT has been arranged if the NSAID/corticosteroid course is being extended for suspected CME.
Common Errors to Avoid
- Stopping the corticosteroid taper abruptly, or as soon as the eye feels comfortable, instead of completing the prescribed taper — this risks rebound inflammation.
- Instilling multiple eye drops back to back without at least 5 minutes of spacing, which washes out the first drop before it is absorbed.
- Mistaking normal early dysphotopsia (glare or a peripheral shadow) for a medication problem and stopping a needed drop, or conversely dismissing a genuinely progressive visual field defect as routine dysphotopsia.
- Managing reported eye pain with reassurance and analgesics instead of recognizing it as a potential red flag — significant postoperative pain is not expected and should prompt referral, not just acetaminophen.
- Discontinuing a patient's antiplatelet or anticoagulant around cataract surgery without confirming this was actually directed by the surgeon — these are usually continued.
- Missing the need to adjust diabetic medications, particularly metformin and insulin secretagogues, around the day of surgery because of the perioperative fasting state.
- Reusing a partly finished ophthalmic bottle left over from this surgery for a new, unrelated eye complaint later — these are limited-course products, and reuse risks contamination.
- Assuming a fourth-generation topical fluoroquinolone alone fully prevents endophthalmitis and downplaying red-flag symptoms because a topical antibiotic is already being used.
Clinical Decision Algorithm
Drug Tables
How to use this table: doses are adult doses and require patient-specific confirmation. A null link means no distinct monograph for that specific ophthalmic formulation exists yet in the Pharmasist Drug Database — where a monograph for the same molecule in a different formulation (oral, injectable) exists, it is deliberately not linked here to avoid misrepresenting the product. Select any linked drug name to open its complete Pharmasist Drug Database page.
Some surgeons additionally give an antibiotic by intracameral injection into the anterior chamber at the end of surgery (commonly moxifloxacin or cefuroxime, compounded or specially prepared for this route) rather than relying on topical drops alone — this is a one-time intraoperative step performed by the surgical team, not a postoperative self-administered medication, so it does not appear as its own row below.
Antibacterials — perioperative prophylaxis
A fourth-generation fluoroquinolone (moxifloxacin, besifloxacin) is the most commonly used topical choice; gatifloxacin and ofloxacin remain effective alternatives but are less commonly prescribed than moxifloxacin in current practice.
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Moxifloxacin 0.5% (ophthalmic) | Dosing: 1 drop in the affected eye 4 times daily for 7-10 days, started immediately after surgery | Blurred vision, local irritation or discomfort | Minimal systemic absorption; no clinically significant systemic interactions established | Fourth-generation fluoroquinolone with improved gram-positive coverage; preservative-free formulation; the most widely used topical prophylactic agent. |
| Besifloxacin 0.6% (ophthalmic) | Dosing: 1 drop 3 times daily for 7-10 days | Blurred vision, eye irritation/pain, itching, discharge | Minimal systemic absorption | Fourth-generation fluoroquinolone; suspension formulation. |
| Gatifloxacin 0.3% (ophthalmic) | Dosing: 1 drop 4 times daily for 7-10 days | Local irritation or discomfort; generally well tolerated | Minimal systemic absorption | Fourth-generation fluoroquinolone; less commonly used today than moxifloxacin. |
| Ofloxacin 0.3% (ophthalmic) | Dosing: 1 drop 4 times daily for 7-10 days | Local irritation or discomfort; generally well tolerated | Minimal systemic absorption | Third-generation fluoroquinolone with a broad-spectrum profile. |
| Ciprofloxacin 0.3% (ophthalmic) | Dosing: 1 drop 2-4 times daily for 7-10 days | Formation of a white crystalline precipitate on a corneal defect after administration | Minimal systemic absorption | Third-generation fluoroquinolone. If the lens capsule is ruptured during surgery, oral ciprofloxacin (linked below) is used instead of, or in addition to, the topical drop to achieve adequate intraocular penetration. |
| Ciprofloxacin, oral | Dosing: 500 mg PO every 12 hours for 7-10 days | Abdominal pain, headache, dizziness, photosensitivity, tendon toxicity, rare pseudomembranous colitis | Chelation with polyvalent cations (calcium, iron, magnesium, antacids); CYP1A2 interactions, for example theophylline | Reserved for the specific scenario of a ruptured lens capsule during cataract surgery, to achieve adequate intraocular antibiotic penetration. |
| Tobramycin 0.3% (ophthalmic) | Dosing: 1 drop 2-4 times daily for 7-10 days | Extended use may cause conjunctivitis or epitheliopathy | Minimal systemic absorption | Aminoglycoside; commonly used, and the concentrations achieved with topical dosing provide broader effective coverage than in vitro susceptibility testing alone would suggest. |
| Dexamethasone / tobramycin (fixed combination) | Dosing: 1-2 drops 4-6 times daily for 7-10 days | Elevated intraocular pressure; the anti-inflammatory effect can mask signs of infection | Minimal systemic absorption | Combines antibiotic and corticosteroid in a single bottle; some surgeons prefer this for ease of use, though it removes the ability to taper the antibiotic and corticosteroid independently. |
| Dexamethasone / neomycin / polymyxin B (fixed combination) | Dosing: 1-2 drops 4-6 times daily for 7-10 days | Elevated intraocular pressure; the anti-inflammatory effect can mask signs of infection; the neomycin component can cause contact allergy | Minimal systemic absorption | Alternative fixed antibiotic/corticosteroid combination. |
Glaucoma / intraocular pressure medications
Used short-term for a postoperative pressure spike. A patient already using a topical prostaglandin analogue or other glaucoma medication for pre-existing glaucoma should generally continue that regimen through the perioperative period unless the surgeon advises otherwise.
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Apraclonidine 1.0% | Dosing: 1 drop twice daily, used as long as pressure remains elevated | Ocular hyperemia and burning; dry mouth, tachycardia, hypotension, tremor systemically | Avoid with an MAO inhibitor; caution with tricyclic antidepressants | Potent short-term control of a postoperative pressure spike; avoid in significant cardiovascular disease given alpha-adrenergic effects. |
| Brimonidine 0.2% or 0.15% | 0.2%: 1 drop twice daily 0.15%: 1 drop 3 times daily | Ocular hyperemia and burning; dry mouth, tachycardia, hypotension, tremor systemically | Avoid with an MAO inhibitor; caution with tricyclic antidepressants | Similar efficacy to apraclonidine for a postoperative pressure spike. |
| Betaxolol 0.25% | Dosing: 1 drop twice daily, used as long as pressure remains elevated | Local stinging, dry eye; relatively beta-1-selective but systemic beta-blockade is still possible | Additive bradycardia with a systemic beta-blocker, diltiazem, or verapamil | Use caution in asthma/COPD or significant cardiac conduction disease despite relative selectivity. |
| Timolol 0.5% (or gel-forming 0.5%) | Solution: 1 drop twice daily Gel-forming solution: 1 drop once daily in the morning; shake before use | Local stinging, dry eye; non-selective beta-blockade can precipitate bronchospasm or worsen bradycardia/heart block | Additive bradycardia with a systemic beta-blocker, diltiazem, or verapamil | Avoid in asthma, COPD, or significant bradycardia/heart block; counsel on punctal occlusion to reduce systemic absorption. |
| Brinzolamide 1% | Dosing: 1 drop twice daily | Stinging; bitter, sour, or unusual taste; conjunctivitis and blepharitis not uncommon | Minimal systemic absorption; caution with a sulfonamide-sensitivity history | Topical carbonic anhydrase inhibitor. |
| Dorzolamide 2% | Dosing: 1 drop twice daily | Stinging; bitter, sour, or unusual taste; conjunctivitis and blepharitis not uncommon | Minimal systemic absorption; caution with a sulfonamide-sensitivity history | Topical carbonic anhydrase inhibitor; a preservative-free formulation is available for sensitive patients. |
| Acetazolamide, oral | Dosing: 250 mg PO up to 4 times daily, short-term | Paresthesias of the extremities, metabolic acidosis, hypokalemia, kidney stones, GI upset, rare aplastic anemia/Stevens-Johnson syndrome | Additive electrolyte disturbance with other diuretics; sulfonamide cross-sensitivity | Reserved for a severe pressure spike not controlled by topical agents alone, used short-term. |
| Methazolamide, oral | Dosing: 50-100 mg PO 2-3 times daily, short-term | Similar to acetazolamide, generally milder | Additive electrolyte disturbance with other diuretics; sulfonamide cross-sensitivity | Alternative oral carbonic anhydrase inhibitor for a severe pressure spike; no distinct Pharmasist Drug Database monograph at this time. |
| Bimatoprost 0.01% or 0.03% | Dosing: 1 drop once daily in the evening | Brown iris pigmentation, periocular skin darkening, eyelash growth; hyperemia common in the first month | Minimal systemic absorption | Not typically started fresh after cataract surgery — continue if the patient already used it for pre-existing glaucoma, unless the surgeon advises holding it. |
| Latanoprost 0.005% | Dosing: 1 drop once daily in the evening | Brown iris pigmentation, periocular skin darkening, eyelash growth; hyperemia common in the first month | Minimal systemic absorption | Continue if already part of the patient's pre-existing glaucoma regimen, unless the surgeon advises holding it. |
| Travoprost 0.004% | Dosing: 1 drop once daily in the evening | Brown iris pigmentation, periocular skin darkening, eyelash growth; hyperemia common in the first month | Minimal systemic absorption | Continue if already part of the patient's pre-existing glaucoma regimen, unless the surgeon advises holding it. |
Anti-inflammatory agents — corticosteroids
Started the day after surgery and tapered over about 3-4 weeks in a standard-risk patient; continued longer with evidence of cystoid macular edema.
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Prednisolone acetate 1% (ophthalmic) | Dosing: 1-2 drops 2-4 times daily for 3-4 weeks; longer with CME evidence | Elevated IOP; can mask signs of infection; posterior subcapsular cataract with prolonged use | Minimal systemic absorption | First-line topical corticosteroid after cataract surgery; shake well before use. |
| Difluprednate 0.05% (ophthalmic) | Dosing: 1 drop 4 times daily starting 24 hours after surgery, continued 2 weeks then tapered | Elevated IOP; can mask signs of infection; eye pain, photophobia, blurred vision | Minimal systemic absorption | More potent than prednisolone acetate; often dosed less frequently for equivalent effect. |
| Fluorometholone 0.1% (ophthalmic) | Dosing: 1-2 drops 2-4 times daily for 3-4 weeks; longer with CME evidence | Elevated IOP, less than with dexamethasone or prednisolone; can mask signs of infection | Minimal systemic absorption | Lower IOP-elevation risk than prednisolone acetate or dexamethasone but also less potent — a reasonable option in a known steroid responder. |
| Loteprednol etabonate 0.5% (ophthalmic) | Dosing: 1-2 drops 4 times daily for 3-4 weeks; longer with CME evidence | Elevated IOP, less than with dexamethasone or prednisolone; can mask signs of infection | Minimal systemic absorption | Lower IOP-elevation risk than prednisolone acetate or dexamethasone — a reasonable option in a known steroid responder. |
| Dexamethasone 0.1% (ophthalmic) | Dosing: 1-2 drops 4-6 times daily for 3-4 weeks; longer with CME evidence | Elevated IOP; can mask signs of infection | Minimal systemic absorption | Commonly used after eye surgery generally; no distinct ophthalmic-formulation monograph in the Pharmasist Drug Database at this time — a systemic (injectable) dexamethasone monograph exists but should not be substituted for this topical product. |
Anti-inflammatory agents — NSAIDs
Reduces the risk of cystoid macular edema without the IOP-elevation risk of a corticosteroid. Avoid all agents in this class in ASA/NSAID hypersensitivity or active asthma.
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Ketorolac 0.5% (ophthalmic) | Dosing: 1 drop 4 times daily for 3-4 weeks; longer with CME evidence | Mild-to-moderate burning on instillation; epitheliopathy and possible ulceration with prolonged, frequent use | Minimal systemic absorption | No distinct ophthalmic-formulation monograph in the Pharmasist Drug Database at this time — a systemic injectable ketorolac monograph exists but should not be substituted for this topical product. |
| Bromfenac 0.07% (ophthalmic) | Dosing: 1 drop once daily, started 1 day before surgery, continued through at least 2 weeks postoperatively; longer with CME evidence | Mild-to-moderate burning on instillation; epitheliopathy and possible ulceration with prolonged, frequent use; contains sodium sulfite | Minimal systemic absorption | Once-daily dosing may aid adherence; use caution in sulfite sensitivity. |
| Diclofenac 0.1% (ophthalmic) | Dosing: 1 drop 4 times daily for 3-4 weeks; longer with CME evidence | Mild-to-moderate burning on instillation; epitheliopathy and possible ulceration with prolonged, frequent use | Minimal systemic absorption | No distinct ophthalmic-formulation monograph in the Pharmasist Drug Database at this time — systemic (oral and topical-gel) diclofenac monographs exist but should not be substituted for this ophthalmic product. |
| Nepafenac 0.1% (ophthalmic) | Dosing: 1 drop 3 times daily for 3-4 weeks; longer with CME evidence | Mild-to-moderate burning on instillation; eyelid margin crusting, eye pain, punctate keratitis, dry eye | Minimal systemic absorption | Prodrug NSAID; shake well before using. |
| Nepafenac 0.3% (ophthalmic) | Dosing: 1 drop once daily, started 1 day before surgery, continued through at least 2 weeks postoperatively; longer with CME evidence | Mild-to-moderate burning on instillation; eyelid margin crusting, eye pain, punctate keratitis, dry eye | Minimal systemic absorption | Once-daily formulation may aid adherence; shake well before using. |
Dilators and cycloplegics
Used to keep the iris away from the intraocular lens implant during early healing and to improve comfort by reducing ciliary muscle spasm; less commonly needed with modern small-incision cataract surgery than with older techniques.
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Cyclopentolate 1% | Dosing: 1 drop 3 times daily for the first few weeks after surgery | Systemic anticholinergic effects (flushing, tachycardia, urinary retention) uncommon at ophthalmic doses | Minimal systemic absorption at typical doses | Less commonly needed with modern small-incision surgery. |
| Phenylephrine 2.5% (ophthalmic) | Dosing: 1 drop 3 times daily for the first few weeks after surgery | Tachycardia and hypertension, rare | Additive sympathomimetic effect with a systemic decongestant or stimulant | No distinct ophthalmic-formulation monograph in the Pharmasist Drug Database at this time — a systemic injectable phenylephrine monograph exists but should not be substituted for this topical product. |
| Tropicamide 0.5% or 1% | Dosing: 1 drop 3 times daily for the first few weeks after surgery | Systemic anticholinergic effects (flushing, tachycardia, urinary retention) uncommon at ophthalmic doses | Minimal systemic absorption at typical doses | Less commonly needed with modern small-incision surgery. |
Oral analgesia
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Acetaminophen | Dosing: 500 mg PO every 4-6 hours as needed | Hepatotoxicity in overdose or with chronic excessive use | Increased hepatotoxicity risk with chronic alcohol use | Significant postoperative pain is itself a red flag and should prompt reassessment, not just analgesia — see Red Flags & Refer. |
References
- Cataract in the Adult Eye Preferred Practice Pattern — Ophthalmology, American Academy of Ophthalmology Preferred Practice Pattern Cataract and Anterior Segment Panel (Miller KM, Oetting TA, Tweeten JP, et al.). Ophthalmology 2022;129(1):P1-P126
- Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors — Journal of Cataract & Refractive Surgery, Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons (ESCRS). J Cataract Refract Surg 2007;33(6):978-988
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