Cataract surgery has become one of the most predictable procedures we perform. The operation itself is efficient, refined, and reproducible. And yet, despite all of that control in theatre, we continue to rely on one of the least reliable variables in medicine: the patient’s ability to use postoperative drops.

In my own practice, this has become increasingly difficult to ignore. We ask patients – often elderly, sometimes frail, occasionally cognitively impaired – to manage multiple bottles, follow tapering regimens, and administer drops accurately several times a day. Unsurprisingly, many struggle with this postoperative regimen. Studies have shown that the majority of patients do not instill drops correctly, even when carefully instructed (1).

So the question naturally arises: if we can control almost every aspect of cataract surgery, why do we relinquish control at the very moment it matters most?

That question is at the heart of dropless cataract surgery.

Rethinking postoperative care

For me, dropless cataract surgery is not about eliminating drops for the sake of it. It is about improving reliability.

If treatment can be delivered at the time of surgery – accurately, consistently, and without relying on patient adherence – then we remove a significant source of variability. This is particularly relevant in modern high-volume cataract practice, where consistency of outcomes matters as much as surgical precision.

While the term “dropless” has been used to describe a range of techniques, the approach I have found most practical – and increasingly adopted – is straightforward: Intracameral antibiotics combined with a subconjunctival depot of triamcinolone.

This is not a radical departure from conventional practice. It is a refinement of it.

The technique in practice

At the end of routine phacoemulsification, once the intraocular lens is in place and the wounds are secure, I administer intracameral antibiotic prophylaxis as standard (2).

I then inject a small volume of triamcinolone into the inferior subconjunctival space.

The depot is visible as a white bleb and gradually resorbs over the following weeks. It provides sustained anti-inflammatory cover during the period when postoperative inflammation is most active.

What appeals to me about this approach is its simplicity. It does not require additional intraocular manipulation. It does not depend on zonular access. It adds very little time to the procedure. And, importantly, it is easy to reproduce across cases.

In a busy cataract list, that matters.

Why this approach works

There are more complex ways to achieve dropless surgery – transzonular injections, intravitreal combinations, sustained-release implants – but in my experience, simplicity often wins.

The subconjunctival approach strikes a balance. It allows us to reduce or eliminate steroid drops while avoiding the potential risks and technical demands of intraocular steroid delivery.

It also preserves flexibility. If a patient needs additional treatment, drops can still be introduced postoperatively. We are not locked into a single pathway.

In that sense, I do not see this as an “all-or-nothing” approach. It is a tool – one that can be tailored to a specific patient.

What the evidence shows

The literature supporting subconjunctival triamcinolone continues to grow, and importantly, it reflects real-world practice.

Lindholm and colleagues demonstrated in a prospective controlled study that subconjunctival triamcinolone provided effective control of postoperative inflammation and macular oedema, with outcomes comparable to topical steroid regimens (3).

More recently, Shorstein et al. analyzed nearly 70,000 eyes and found that injection-based regimens were associated with similar or lower rates of macular oedema and postoperative inflammation compared with topical therapy (4). What is particularly useful from that study is the insight into dosing – lower concentration preparations appear to offer a more favourable safety profile.

Earlier randomized work by Negi et al. also supports the use of periocular steroid depot, showing comparable efficacy to topical steroids following uncomplicated phacoemulsification (5).

Taken together, the data suggest that this approach is not simply convenient – it is clinically sound.

Patient selection remains key

Despite its advantages, dropless cataract surgery is not suitable for every patient.

I find it particularly useful in:

• Patients with poor dexterity

• Those who struggle with compliance

• Individuals living alone

• Patients with ocular surface disease

However, I remain cautious in:

• Known steroid responders

• Patients with glaucoma or ocular hypertension

• Eyes at higher risk of cystoid macular oedema

In these cases, I will often modify the approach – either by reducing reliance on depot steroid or supplementing with topical therapy.

Dropless surgery, in my view, works best when it is selective rather than routine.

Risks and limitations

The main limitation of any depot steroid is its persistence.

Unlike drops, it cannot be simply stopped. Steroid-induced intraocular pressure rise is therefore the most important consideration.

Wu et al. reported higher rates of steroid response in dropless cataract surgery using subconjunctival triamcinolone, particularly in patients with pre-existing glaucoma (6). While most cases can be managed, the risk is real and must be considered during patient selection.

Patients should also be counselled about the visible depot. The white subconjunctival bleb can be surprising if not explained in advance, but is otherwise benign and self-limiting.

Other dropless approaches

Other techniques remain part of the discussion.

Transzonular, intravitreal and sub-tenons injections can eliminate drops entirely, but they introduce intraocular variables that I do not feel are necessary in routine cases.

Sustained-release implants offer elegant pharmacology, but access and cost remain limiting factors.

For me, the subconjunctival approach offers the best balance between effectiveness, safety, and practicality.

Follow-up and mindset

Follow-up does not change dramatically, but the mindset does.

When we adopt a dropless approach, we take ownership of postoperative pharmacology. We are no longer relying on the patient to deliver treatment – we have already done so.

This makes careful monitoring of intraocular pressure and inflammatory response even more important, particularly in the early postoperative period.

Conclusion

Dropless cataract surgery is not about removing drops – it is about removing uncertainty.

Subconjunctival triamcinolone, combined with intracameral antibiotics, offers a simple and effective way to improve consistency in postoperative care. It reduces reliance on patient adherence, simplifies recovery, and aligns postoperative treatment more closely with surgical control.

It is not a universal solution. But, when used thoughtfully, it represents a meaningful step forward in modern cataract surgery.