What is the recommended postoperative medication regimen and follow‑up schedule for an otherwise healthy adult after uncomplicated phacoemulsification with foldable intra‑ocular lens (IOL) implantation for age‑related cataract?

Postoperative Medication Regimen and Follow-Up After Uncomplicated Phacoemulsification

For an otherwise healthy adult after uncomplicated phacoemulsification with foldable IOL implantation, use a topical antibiotic (moxifloxacin 0.5% three times daily for 7 days) combined with a topical corticosteroid (prednisolone acetate 1% four times daily, tapered over 3-5 weeks), strongly prioritizing preservative-free formulations, with follow-up on the day of surgery (4-6 hours postoperatively) and at 1 week, 1 month, and 3 months. 1

Medication Regimen

Topical Antibiotic

• Moxifloxacin 0.5% three times daily for 7 days starting immediately postoperatively 1
• Preservative-free formulations are strongly preferred to minimize ocular surface toxicity 1

Topical Corticosteroid

• Prednisolone acetate 1% (or loteprednol as alternative) with the following taper schedule: 1
  • Week 1: Four times daily
  • Weeks 2-3: Two to four times daily
  • Weeks 4-5: Two times daily
  • Total duration: 3-5 weeks 1

Optional NSAID Therapy

• Ketorolac 0.45% (preservative-free) four times daily for the first 2 weeks postoperatively can be added to manage inflammation and reduce pain 1, 2
• The FDA-approved dosing for ketorolac is one drop four times daily beginning 24 hours after surgery and continuing through the first 2 weeks 2
• Ketorolac 0.5% and diclofenac 0.1% are equally effective for controlling postoperative inflammation 3

Critical Consideration: Preservative-Free Formulations

• High-risk patients must use preservative-free drops, including those with: 1
  • History of dry eye disease
  • Current use of multiple topical medications
  • History of cataract surgery-induced dry eye
  • Contact lens use
  • Diabetes
• Using preserved drops in these patients significantly increases risk of ocular surface toxicity and dry eye exacerbation 1

Postoperative Follow-Up Schedule

Same-Day Review (4-6 Hours Postoperatively)

• This visit is essential and cannot be safely eliminated 4, 5, 6
• Check for IOP elevation (18.4% of non-glaucoma patients and 46.4% of glaucoma patients develop IOP >28 mm Hg at 3-7 hours) 4
• Evaluate for wound leak, iris prolapse, and patient comfort 5
• IOP spikes >40 mm Hg occur in 3.6% of non-glaucoma patients and 18.8% of glaucoma patients, requiring immediate intervention 4
• Potentially sight-threatening complications, though infrequent (1.53% IOP elevation requiring treatment, 0.26% iris prolapse), justify this early review 5

Week 1-2 Visit

• Assess for infection, inflammation, and corneal abrasions (2.81% incidence) 1, 5
• Monitor IOP (should normalize by this point) 4
• Evaluate visual acuity and ocular surface status 1

1-Month Visit

• Check visual acuity, refraction, and IOP 1
• Assess for dry eye disease development or exacerbation 1
• Evaluate for ocular surface damage from topical medications 1

2-3 Month Visit

• Final assessment of visual acuity and refractive outcome 1
• Monitor for posterior capsular opacification 1
• Confirm IOP stability, especially if corticosteroids were used 1

Common Pitfalls to Avoid

Medication-Related Pitfalls

• Never use preserved drops in high-risk patients – this significantly increases ocular surface toxicity 1
• Do not undertaper corticosteroids – inadequate duration increases inflammation risk, but monitor IOP closely as prolonged use causes significant IOP elevation in a substantial proportion of patients 1
• Avoid inadequate dry eye management – cataract surgery can cause or exacerbate dry eye disease, requiring more aggressive therapy than preoperative management 1

Follow-Up Pitfalls

• Do not eliminate the same-day postoperative visit – IOP spikes occur frequently (18.4% in healthy patients) and can be sight-threatening if untreated 4, 5
• Do not discharge glaucoma patients without same-day IOP check – 46.4% develop significant IOP elevation requiring intervention 4
• Do not assume moderate IOP spikes (<40 mm Hg) always require treatment – they decline spontaneously if not associated with corneal edema or patient discomfort, but patients with compromised optic discs must be carefully evaluated 6

Special Considerations

• Patients with preexisting glaucoma require more intensive IOP monitoring, with 56.5% requiring IOP intervention on the day of surgery 4
• Close IOP monitoring is essential with any corticosteroid regimen 1
• All topical medications can be safely administered together, including antibiotics, beta blockers, carbonic anhydrase inhibitors, cycloplegics, and mydriatics 2