Clinical Scorecard: Transitioning to Dropless Cataract Surgery

At a Glance

Key Highlights

• In a retrospective cohort of approximately 69,800 eyes, Kenalog 10 mg/mL at a high dose of 3.1–5.0 mg was associated with 36% 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 statistically significantly higher odds of glaucoma events.
• The article describes reduced medication packaging and waste as sustainability advantages of dropless surgery.

Guideline-Based Recommendations

Diagnosis

• The article reports postoperative macular edema, iritis, and glaucoma events as study outcomes; it does not provide diagnostic criteria.

Management

• The Kaiser Permanente practice pattern described recommends brand-name Kenalog 10 mg/mL, not 40 mg/mL, with 0.4 mL (4 mg) injected subconjunctivally 6–8 mm inferior to the inferior corneal limbus.
• The article reports that Kenalog 10 mg/mL injection alone was sufficient for inflammation control in the study; adding an NSAID to topical prednisolone acetate was comparable to prednisolone alone.
• Intracameral antibiotic is described as standard-of-care infection prophylaxis. The Optegra comparison used intracameral cefuroxime in both pathways.

Monitoring & Follow-up

• The studies assessed postoperative macular edema, iritis, glaucoma events, and intraocular pressure outcomes.
• The article reports increased risk of intraocular pressure spikes with steroid treatment in patients younger than 65 years, with glaucoma or ocular hypertension history, ocular herpetic infection, or axial length greater than 29 mm.

Risks

• Kenalog 40 mg/mL groups had statistically significantly higher odds of glaucoma events in the Kaiser Permanente study.
• The article identifies increased risk of intraocular pressure spikes with steroid treatment in patients younger than 65 years, those with glaucoma or ocular hypertension history, ocular herpetic infection, or axial length greater than 29 mm.
• The article states that its data are specific to brand-name Kenalog because brands differ in particle shape and size and may have different pharmacodynamics.

Patient & Prescribing Data

The Kaiser Permanente retrospective cohort included approximately 69,800 eyes treated from 2018 through 2021; patients with prior surgery or chronic conditions such as uveitis were excluded. The article reports that the Optegra study included more than 15,000 patients; verify any procedure-count comparison against the full source.

The described dropless protocol used subconjunctival triamcinolone acetonide 0.4 mL of 10 mg/mL plus intracameral cefuroxime in the Optegra comparison. The comparison drop pathway used dexamethasone ophthalmic suspension 0.1% plus intracameral cefuroxime.

Clinical Best Practices

• Dr. Stuart emphasized that clinicians should follow published evidence when considering dropless cataract surgery.
• The reported Kaiser Permanente practice pattern specifies Kenalog 10 mg/mL rather than 40 mg/mL and a 4 mg subconjunctival dose.
• The article reports caution with steroid treatment in the patient groups identified as being at increased risk of intraocular pressure spikes.
• The article describes patient-administration challenges, including difficulty self-administering drops and risk of injury or wound contamination.

Related Resources & Content

• Article: Transitioning to Dropless Cataract Surgery