Eye Drops After Cataract Surgery

Dr. Gary Foster – Fort Collins & Loveland, CO

eye drops after cataract surgery northern colorado

Eye Drops After Cataract Surgery

I prescribe several eye drops after cataract surgery. These drops protect against infection, decrease inflammation, and keep you comfortable.

Antibiotic Medication

Antibiotic treaments are routinely administered after cataract surgery for the first few weeks.  They are intended to help decrease the chance of infection…inside the eye.

Interestingly, there are no studies showing that antibiotic eye drops decrease the infection rate.

This is because the chance of getting an infection inside your eye following cataract surgery are very low, about one out of every 1,500 people nations wide.  In my hands, it has been even rarer.

You would have to create a study with hundreds of thousands of patients in it with half getting antibiotics and half not getting antibiotics to prove a difference.

That study has never been done because you can’t find enough eye surgeons or patients willing to go without antibiotic medication.

Branded vs. Generic Antibiotic Medication

The good news is that after an antibiotic eye drop has been out for a long time it goes generic and is cheap to purchase.  The bad news is that after an antibiotic eye drop has been out for a long time, the bacteria get used to them.

The bacteria become resistant to the antibiotic so that the drugs don’t work as well anymore. Alas, the better medications cost more.  I would not recommend cutting a corner here. The latest generation medications are Besevance (fastest kill curve), Vigamox (no preservative and best eye penetration), and Zymaxid.  These are my favorite eye drops after cataract surgery.

Anti-inflammatory Medication

We want the immune system to react to your cataract surgery to help heal the incisions and prevent infection, but we don’t want the eye to over do it.  When the immune system detects an insult, like surgery, it releases chemicals that cause swelling and others that can be toxic to the gentle structures of the eye.  We want just the right amount of inflammation following your procedure.  Eye Drops after cataract surgery help fine-tune the response level from your immune system.

Cystoid Macular Edema (CME)

Anti-inflammatory medication allow us to moderate and control the level of inflammation.  This decreases the chance a complication called CME that occurs if inflammation and swelling reach the delicate center of your retina called the macula.

Eye Drops after Cataract Surgery, Cataract Surgeon Fort Collins

NSAID Eye Drops for Cataract Surgery

Steroidal Anti-Inflammatory Treatments

Cortisone is a steroidal anti-inflammatory.  A number of different steroidal eye drops have been developed that work better than cortisone. They can raise the eye pressure in about 10% of patients that use them longer term so I like to stop these treatments at two to three weeks.

Generic steroidal topical treatments are available and work pretty well in the post cataract setting but their potency has been less predicable than the branded newer medications like Durezol that don’t need to be used as many times per day.

Non-steroidal Anti-Inflammatory Eye Drops (NSAIDs)

Ibuprophen is an example of a NSAID.  Several different NSAID drops are available.  NSAIDs decrease inflammation by a different pathway than the steroidal eye drops.  Studies have shown that the effects of using a NSAID and a steroidal anti-inflammatory are additive. This means that it is helpful to use both types of anti-inflammatory medications to decrease the chance of CME.

I would likely ask you to use NSAID once a day for six weeks after your cataract surgery. There are older generic and NSAID that work well, but they tend to sting more and you have to use them more times per day.  The new designer NSAIDS like Ilevro are comfortable for most and only have to be used once per day. It is important that you take you take your topical medications to help decrease the chances of infection and CME.

Cataract Eye Drops.  Cataracts Surgery Eye Drops.  Generic vs. Brand Name Eye Drops

Eye Drop Calendar to Help You Organize Your Drops

Eye Drop Calendar

We will provide you with an eye drop calendar to help remind you when it is time for your medication.  It shows a picture of the drops you will be using and then has check boxes for each drop you should take every day. As you mark these boxes after each dose, it will help you stay right on track of your eye drops after cataract surgery so that you can achieve the most brilliant vision possible after your procedure.

Glaucoma and Cataract

If you have glaucoma, you will need to continue your glaucoma drops along with your cataract drops.  Some patients without glaucoma will develop high pressure in their eyes during the healing phases.  If this happens, your eye doctor will prescribe some pressure lowering for cataract removal recovery that you will take while your eye heals from the cataract surgery.

Cataract Eye Drops

Cataract eye drops have become more expensive is the last year.  This comes from several factors.  There are hundreds of different drug benefit plans.  The drug companies have to make arrangements with each one of these plans to try to make the cost of their cataract eye drops affordable.  Each year these arrangement change, so one year the cataract eye drops could be reasonable with your plan while the next they could be completely unaffordable.  In some cases, the companies that own the branded cataract eye drops have also purchased the companies that make the generic cataract eye drops.  They have then raised the price on the generics to almost the same as the branded products.  Many of the companies have put out coupons to make the branded products reasonable, but many pharmacies will not accept the coupons if your have a Medicare part D plan, which often makes the drug more expensive if you have the insurance than if you didn’t and could use the coupons.  I know that all sounds like a bad dream, only because it is.

If I can provide any other information about eye drops after cataract surgery, please schedule a time to meet with me or send me a note.

Comments

  1. Can we give this article to your patients???

  2. Dieter W Klaas MD says:

    Dear Gary
    Thanks for the very informative article, indeed I discuss the topic like you with my patients and hope you agree that I will translate it in German an put it on our website http://www.augen.de
    Greetings from Friedberg/Augsburg city of Mozart

  3. Pui yin says:

    My ophthalmologist wanted me to start prolensa three days before surgery. Isn’t that going to make my eyes bleed more during surgery I ready have some bleeding problems please let me know thank you

    • Great question.

      It is very uncommon to have bleeding inside the eye during cataract surgery. For this reason, I no longer have my patients stop taking aspirin, motrin, or Coumadin. The white part of they eye can have small hemorrhages develop (sub conjunctival hemorrhages) when it is touched during the surgery, but these are outside the eye and generally inconsequential. The topical Prolensa or Ilevro NSAIDs are even less likely to cause bleeding than the oral blood thinners.

      The benefits of using the Prolensa or Ilevro prior to surgery include the following: 1. Less discomfort during surgery, 2. Less IV anesthesia needed, 3. Shorter surgery, 4. Better dilation, which makes the surgery easier for the surgeon, 5. Less discomfort after surgery, 6. Less red eye after surgery, and 7. Lower chances of retinal swelling.

      In short, the benefits outweigh the risks of bleeding for this particular surgery for most patients given the fact that clinically significant healing is so rare.

      You mentioned that you have some increased risks for bleeding. It is important that you discuss the specific nature and severity of your issues with your surgeon to make sure that the NSAID drops are a good choice in your particular surgery. It is possible to skip the NSAIDs and rely on the steroidal anti-inflammatory drops since they don’t increase bleeding times.

      God Bless with your upcoming surgery.
      Gary Foster

  4. Gretchen C. says:

    My eye doctor put me on Durezol in April 2012–1 drop in both eyes twice daily–and has continually renewed the prescription to date–April 10, 2014, and I’ve seen him twice since April 2012. He did not tell me that Durezol was a “steroidal anti-inflammatory”, and he’s never told me that it could raise the pressure in my eyes if used “longer term”, or that there is a generic version. Durezol is fairly expensive, but you say that Durezol doesn’t have to be used as many times per day as the generics. Considering he has me using Durezol twice a day, how many times per day do you think I would I have to use the generic? He said I already have glaucoma, but I don’t know how much glaucoma I have, but I have noticed lately that I can’t see out of the inner half of my left eye–I can’t see my nose and my depth perception has diminished terribly. I called his office and he told his PA to renew the Durezol prescription, and schedule an appointment for August 2014. Do you prefer one generic over another? and what is “longer term” to you? Also, what happens if the pressure in my eye increases? Will he increase the number of times I have to use Durezol daily? Because it’s tedious now at 2x daily, but I’ll continue to do it, as long as he says. Thank you for the information here on your site, it’s informative and pretty easy to see/read after I increased the font size on my computer screen.
    Genuinely,
    Gretchen C.

    • Gretchen:

      I will review four concepts.
      1. Steroid responder vs. not a steroid responder.
      Around 10% of patients respond to steroid use with an increase in intraocular pressure. The other 90% can use steroid drops or pills without changes in intraocular pressure.

      2. Glaucoma vs. Inflammatory Glaucoma
      Most have normal glaucoma. A patient with glaucoma could be a steroid responder or not. If a glaucoma patient is a steroid responder, then the steroid drop would raise the eye pressure even further and extra glaucoma drops would be needed to keep to lower the pressure to normal.

      If a patient is not a steroid responder, the steroidal eye drop would not alter the intraocular pressure.

      Inflammatory glaucoma is a different kind of glaucoma.

      3. Chronic Iritis vs. Inflammatory Glaucoma
      Chronic inflammation in the eye is called iritis. A patient can have normal glaucoma with high eye pressure and also happen to have iritis. The glaucoma would be treated with glaucoma eye drops and the iritis with steroid eye drops. Such a patient could be a steroid responder or not as previously discussed.

      Inflammatory glaucoma is a special kind glaucoma where the inflammation itself causes the eye pressure to rise. The inflammation causes the glaucoma. Steroid eye drops decrease the inflammation and the eye pressure in these patients.

      4. Branded vs. Generic Steroid Eye Drops
      Steroidal eye drops vary in their potency. Durezol is a strong steroid so it doesn’t need to be used as many times per day. Pred forte is another common steroid. Twice a day with durezol would be about equivalent to 4-5 times a day with pred forte. Pred forte has a generic, which would save money.

      Pred forte is a suspension so you have to shake it up well or all the medicine is at the bottom of the bottle. In addition, the effective strength of generic pred forte seems to vary from one manufacturer to another. If I am worried about the inflammation, I insist on brand name steroids. If the inflammation is mild and long standing, I do not mind the generic.

      I hope this helps
      Gary Foster

  5. David Hahn says:

    How about using oral antibiotic? If agreeable to oral, then what kind ?

    I had cataract removal and standard IOL two days ago. Is astigmatism or Diplopoda common after (standard ) IOL? When does it disappear ? How soon should I report to eye surgeon?

    Does the laser assisted cataract surgery reduce post op Diplopoda
    and Astigmatism ? Also help removing fragments of the cataracted lens?

    • David
      We prefer topical eye drops to oral antibiotics because we can reach higher concentrations without high levels of antibiotic in the rest of your body. Having said that, oral antibiotics could be used. Depending on the antibiotic your surgeon prefers for eye drops, often there is an oral agent in the same drug category.
      Some patients have astigmatism in their cornea but are fortunate enough to have a counterbalancing and correcting amount of astigmatism in the lens inside their eye. When the cataract lens is removed, if the laser is not used to decrease the corneal astigmatism or if a toric IOL is not placed, then there is nothing correcting the astigmatism. This could cause some diplopia in that eye. Glasses, contact lenses, or laser eye surgery could reduce the astigmatism. An eye doctor would be able to help you decide if the diplopia is caused by astigmatism or because the eyes are not pointing the same direction.
      The laser does help in breaking the cataract into small pieces so it is easer to remove.
      God Bless with your recovery
      Gary Foster

  6. gloria agbor says:

    my mother had cataract surgry 2 months ago, but unfortunately up till this month her vision is still cloundy. the doctor said there are infection in the eye the cataract was removed and the other eye that has not being operated on, pls what eye drop can she use to help clear the vision

    • Gloria:
      There are a number of potential causes of blurry vision after cataract surgery. Some of the causes are due to eye problems that existed prior to cataract surgery that limit how much the vision can be correct by the procedure. For example, if a patient has macular degeneration or corneal scaring and a cataract, removing the cataract will correct the part of visual blurring caused by the cataract, but not the parts caused by the macular degeneration or corneal scarring.

      Other causes of blurry vision after cataract are due to normal healing. For example, it is normal to have mild corneal swelling or dry eye for the first few weeks after cataract surgery. The anti-inflammatory drops help speed this healing process. Some patients have more profound corneal swelling due to other corneal problems. If this does not clear on its own, then other corneal procedures could be considered to relieve the swelling.

      Many patients require a change in their glasses prescription to obtain their clearest vision after cataract surgery.

      Some patients develop swelling in their macular (center part of the retina) after cataract surgery. The swelling is treated with anti-inflammatory drops or shots.

      You describe an “infection.” It would be helpful to have your eye doctor be more specific on what is meant by that term. An infection inside the eye is a medical emergency treated with antibiotic injections into the eye. An infection of the cornea is called a corneal ulcer. These are usually treated with strong antibiotic drops taken frequently both day and night. An infection of the conjunctiva is called conjunctivitis and is commonly referred to as “pink eye.” These are commonly treated with low frequency antibiotic eye drops.
      God Bless,
      Gary Foster

  7. M.Almoufti says:

    Dear Dr
    I had cataract surgery two years ago . Do i have to use any type of eye drops as a long term protection for the new lense and the eye ? Thanks

  8. Paul Appenzeller says:

    Dr. Foster,

    I have had several relatively mild reactions to steroids. I had used Group 1 topical steroids for various skin applications successfully for many years when suddenly every time they are used I got a ‘funny’ feeling in my throat. This has caused me to steer clear of them. I have also had a bad experience with Prednisone pills. Additionally, I got a nasty rash below my ear when taking an Otic Solution, and had to switch to a more expensive and different type, although that may have been from something other than steroids.

    Yesterday, I visited an ophthalmologist on a pre- cataract surgery exam (scheduled in two weeks.)
    The subject of steroids came up quickly as I had spoken to my regular eye doctor about it a few days prior, and the two of them had discussed that conversation. This doctor stated at the outset that if
    I didn’t want to use steroids, I would have to find another doctor to perform the surgeries, since he would not do the surgery without them. He uses a time-release steroid injected directly into the eye,
    and no longer uses drops.

    Although I have used this doctor several times before, and always found him to be pleasant and open,
    he really dug his heels in on this subject, and, frankly, made me feel uncomfortable. He is a pretty well known, state of the art doc. He claims that none of the steroid would get into my bloodstream from this injection, and clearly does not believe that my reactions have a medical basis.

    I. of course, am very concerned that this medicine placed in my eye might cause a serious reaction.
    Worse, once it’s in there, it isn’t coming out and could cause weeks or longer of complications.
    Frankly, I don’t know what to think or do about all this. Your perspective would be very much appreciated.

    Thanks,
    Paul A

    • Paul,
      There is not enough detail in your description of troubles with steroid to determine if your issues while using steroids have been from the steroid or some other cause. Having said that, most patients do fine without steroid if they are faithful in the use of a NSAID anti-inflammatory eye drop. You could choose another eye doctor that would accept your desire to avoid the steroid and only start it if inflammation became an issue. In addition, a topical steroid would allow you to stop the drug with a quicker washout of effect if problems resulted while the long lasting injectable would follow its long course as you suggested.
      God Bless
      Gary Foster

  9. Betsy Hale says:

    I have had cataract surgery on both eyes during the past two months. My surgeon was as flabbergasted as I was at the cost of the three eye drops he prescribed. He told me that instead of the $250.00 they cost, before “Obamacare” the three together were less than $50.00. What gives???

    • Betsy: Insurance and its coverage of specific drops changes almost weekly in the current environment. It is wise to check the price of the various drops at several different pharmacies as they vary considerably from one store to another. Often, the antibiotic is cheaper at one pharmacy while the anti-inflammatories at another.
      I hope this helps. We have tried to not have any substitutions with our patients so we can know which drops they are actually on when they call us with questions. With the wild prices occurring at the pharmacies, we are re-thinking our position.
      God Bless,
      Gary Foster

      • Betsy Hale says:

        Thanks so much for your reply. All three eye drops were generic; I did check all the pharmacies in our area (they were very close in price to the original store); and my vision is so precious to me that the cost is really negligible. I do realize that other people are not as fortunate as myself, and don’t have money to spare. Just wondering why the great cost leap? I chose not to have prescription insurance coverage because I will almost always opt to use natural healing rather than prescription drugs. My surgeon indicated that most probably no one else bothers considering the costs of the eye drops since most folks have prescription insurance and just count on their insurance to cover the cost. This doctor plans to investigate the leap in cost in cooperation with his colleagues (other doctors, pharmacists, etc.) Thanks again for your reply.

        • Betsy:
          Some of the generic drops have become expensive because of consolidation. For example, generic pred forte drops used to be very inexpensive but now there are only two companies that make it and those two companies are owned by the same two large pharmaceuticals that own the branded medicines, hence the price of the generic is almost the same as the expensive branded options. The price of drugs does vary from one pharmacy to another and each insurance plan has its preferred drugs which cost much less for patients depending on the deals they have made with the manufactures. For example brand A might be priced well at one store because they have made a good deal with the manufacturer and made it their preferred drug while brand B would be expensive. Across town a different drug store chain might have a great price for B and a high price for A because they have make B their preferred drug and have a great volume price with the manufacturer.
          Alas, it is hard to find a cost effective way to protect your eyes around cataract surgery.
          God Bless,
          Gary Foster

  10. Jimmy Goyu says:

    Dear Dr. Foster.
    I am 76 years old and my eye doctor advises me to have cataract surgery asap. But I am taking Duodart for BPH.. My doctor wanted me to stop Duodart for one week prior to surgery. My Urologist advises me to take Xatral instead of Duodart for one week before surgery. Thanks for your advice. Best regards!

    • Jimmy:
      Doudart is a drug that can cause the iris inside your eye to become more flaccid. This makes the iris floppy during cataract surgery. About every tenth patient I operate on has been on a drug like this so it is common to face this extra challenge. Once a patient takes a drug from this category, there are lifelong effects on the iris. I do not personally feel that stopping the drug makes any difference as the effects have already occurred once a patient uses the drug. As such, I do not have my patients stop the drug since they need it for other reasons. I realize that not all surgeons feel this way and many have their patients take a holiday from the drug around cataract surgery. Your surgeon has reasons for his/her recommendation and it is important to make sure you and your surgeon are both on the same page about any recommendations made for your surgery.
      God Bless,
      Gary Foster

  11. Dear Dr. Foster,
    I currently get Avastin shots every 4 weeks to combat macular edema/swelling caused by radiation retinopathy from treatment of choroid melanoma. I recently had cataract surgery, and was taking Durezol until I discovered that my eye pressure had increased significantly. I called my doctor to ask what I should do, but he never got back to me, so I stopped using the Durezol before the end of my prescription (I had 1 week of 1 drop per day left). Since then, my macular swelling has increased, where before it was stable. Could this be caused by suddenly stopping the steroid? I am now reading in a number of places that one should not stop steroid use suddenly, but I can’t find a list of consequences anywhere. Thank you for your help!
    Sincerely, Mimi

    • Mimi: About 10% of patients are steroid responders, meaning that their eye pressure goes up while on steroids. The stronger the steroid, the more likely this is to happen. Durezol is one of the stronger steroids available and is the one I most commonly prescribe. If the pressure is high, I usually either stop the steroid or put my patients on a weaker steroid like Lotemax that has less potential to elevate pressure. I make this decision based on the amount of remaining inflammation. In addition, I always also start pressure lowering drops to prevent optic nerve damage. Once the steroid effect washes out, the pressure lowering drops are stopped. Sometimes this takes several months. I have my patients use a non-steroidal anti-inflammatory drop unless they have an allergy to NSAIDS. These help prevent macular edema and do not have the potential of elevating intraocular pressure like the steroidal drops. The macular edema you have is most likely from the cataract surgery. It is possible that the cessation of Durezol allowed this to happen, but it is also likely that you had to stop the drops because of the IOP. It isn’t clear how much these steps where directed by an eye doctor from your post. It is also possible that the increased edema has nothing to do with the drops or the surgery but represents a worsening of your blood flow from the radiation retinopathy. The advice of your retinal specialist would be important to help you manage the pressure and swelling given the more complicated nature of your eyes.
      God Bless,
      Gary Foster

      • Thank you very much for your reply. Luckily the swelling has gone down, so I think you were right that it was from the cataract surgery. I appreciate your time; this was helpful to me.

  12. Nelson Champine says:

    I had my cataract surgery pre-op consult today, and it seems I have some choices.
    Anti-inflammatory; ILEVRO or PROLENSA
    Antibiotic; BESIVANCE or OFLOXACIN
    No other health problems and all seem to be covered by my insurance, BCBS.
    Would you recommend one over the other, or any preferences due to good/bad outcomes?
    Thank you.

    • Nelson: I am equally impressed with Ilevro and Prolensa. Besivance has much much better coverage than ofloxacin for most bacteria. Ofloxacin was a great drug when it first came out, but resistance has grown over the years so many bacteria are no longer affected by it.
      God Bless,
      Gary Foster

      • Nelson Champine says:

        Thank you Doctor.
        I visited my pharmacist and he said the main reason for the multiple choices is insurance coverage.
        I will certainly try to opt for the Besivance. Thanks for the valuable information.

  13. John Holbrook says:

    Hello, I had cataract surgery in both eyes and have past history of detached retina-left-1997 and right 2013-14 (5 surgeries total). I did my one month follow up today and there is still a “pocket of inflammation” in my right eye. So, my surgeon wants me to use prednisolone 2x/day for 6 months. Although, I’m not pressure responsive to it, I am concerned about the long term effects of using it (such as glaucoma). Since November, I’ve used it (other than 2 months off). Would prolensa be an alternative? Do you have any thoughts on my using prednisolone long term in such a manner ( curious if you’ve taken a similar approach). Thank you.

    • John: Sorry you are having so much trouble with your eyes. Prolensa in a non-steroidal anti inflammatory while prednisolone is a steroid. They affect the inflammation pathway at different points to decrease swelling. They each have their own set of potential complications. In some cases either one would do the job, in others one would excel the other for various reasons, while in others, both are needed in an additive fashion for satisfactory results. If the prednisolone is not raising your pressure after being on it for a while, then glaucoma is not much of a risk, especially if your doctor checks your pressure at regular intervals. Even if the pressure does rise, it would eventually go back down if the steroid was stopped. You could consider getting a second opinion from the retinal surgeon that helped you with your retina detachment surgeries since they are the experts on pockets of inflammation in the back of the eye. There have been occations when longer term steroids is the best solution.
      God Bless,
      Gary Foster

      • John Holbrook says:

        Thank you so much for responding. Actually, my outcome is remarkable. I had silicone in my right eye to hold the retina in place from January thru April. As a result, a cataract developed (as you would expect) and it was removed in June with an IOL. I see 20/40 uncorrected with it and I had the left cataract removed in July with a toric IOL and see 20/15 uncorrected. I wear transitionals for intermediate and reading but cannot complained. As one cataract surgeon who evaluated my eyes back in my stated “I’m a walking miracle” after all my retina issues. Thankfully, God put me in the hands of the most experienced retina surgeon in the world in Memphis (after 3 unsuccessful surgeries). My cataracts were done by a great surgeon in Cincinnati so I’m very fortunate. My biggest concern was the length of time I’ve been on the prednisolone but my pressure (at it’s highest) was 23 and that was with my eye full of silicone! During the cataract treatments it ranged from 14-17. I can’t thank you enough for replying and I’m sure your patients are fortunate to have you treat them. I will stay the course with it and I see my retina surgeon in October. God Bless You!

        • John: Who was your retina surgeon and who removed your cataract, if you don’t mind?
          Gary

          • John Holbrook says:

            Dr Steve Charles is my retina surgeon and Dr Michael Snyder was my cataract surgeon. I don’t mind sharing, because I hold them both in the highest regard. Take Care.

          • John Holbrook says:

            This is unrelated to the topic, but has to do with my vision result mentioned above. I have gone from being right eye dominant to left eye dominant. This is a huge/ tough adjustment and affects me especially in golf, basketball, reading, etc. If you’ve dealt with this issue or have written about it, I would appreciate you pointing me in that direction. Again, sorry for asking on this part of your blog. God Bless You!

  14. My husband has glaucoma and heart disease. He recently had cataract surgery with Toric lenses in both eyes on (Sept. 4th left eye and Sept.18th Right eye.). He also had an ECP procedure at the same time. His left eye lens rotated 5-10% out of focus so he needs to have another surgery to correct the problem. This corrective surgery will be on Thursday 10-9-14. This, also, means another month of drops. He will start Vigamox on Tuesday 3x a day and continue with Nevanac 3x and Prednisolone 3x – then after surgery he will need to take drops tapered off until mid November.
    My concern is with the long term side effects of the NSAID on his heart and the corticosteroid on his his existing Glaucoma which he has control so far with Combigan and Latanoporst. Is Two and a half months on these drops putting him at risk for irregular heart beat and increased IOP? Your opinion is greatly appreciated. Concerned, Joani

    • Joaini: I am glad your husband has a surgeon committed to achieving a good result with his toric lens You will need to get specific drug advice from your cardiologist. Many cardiologists ask their patient to take aspirin to protect agains heart attacks. Aspirin is an NSAID. The Nevanac is in that same family of drugs so generally would not be opposed by heart doctors. The corticosteroide, prednisone, will raise the pressure in patients that are steroid responders. About 10% of patients are steroid responders while the other 90% do not have pressure elevations with the steroids. If your husband was a steroid responder, he would have most likely had elevated pressure with the first surgery. If he did not, he is probably not a steroid responders, though it would be wise to still monitor his pressure closely given his glaucoma.
      God Bless,
      Gary Foster

  15. Frances turner says:

    question : my husband had Cataract surgery Oct 31 he has been using drops .. Is it possible that these drops could cause a serious rash on the side of his nose.. The same Side as the eye surgery??

    • Fances:
      An allergy to one of the medicines could definitely cause a rash on that side of the face. It is also possible that it is a reaction to the tape from the surgical drape or the eye patch.
      God Bless,
      Gary Foster

  16. Dear Dr. Foster,

    Your Web site is very useful; it’s probably the best that any eye doctor maintains. And you even respond to queries!

    I have a question: You mention that you prescribe antibiotic eye drops for the first few weeks after cataract surgery. I read that prolonged use of any particular type of antibiotic eye drops can lead to the growth of non-susceptible organisms, like fungi.

    Would you suggest that I change the type of eye drops after the first week? For example, if I use Zymaxid in the first week, should I switch to, say, Vigamox in the second week to prevent the growth of non-susceptible organisms?

    • B.
      Interesting question. The treatment time of one or two weeks is short enough that I don’t change the antibiotics in that time frame. By the third day most have a completely sealed wound so the antibiotics are of decreasing value from that point on. I wouldn’t fault you for the plan you propose, but I don’t feel it would be worth the extra expense or hassle.
      God Bless,
      Gary Foster

  17. Betts Jeffries says:

    Dr. Foster
    Thank you so much for this blog. I have read your info and comments and feel I am getting more from this than from my regular surgeon.
    I was scheduled for cataract surgery on my left eye tomorrow. My doc prescribed Vigamox 4x a day/2 day prior and Prednisolone 4x a day for 2 weeks after. I was to be told the day of surgery whether or not to continue the Vigamox (another thing I like about your system…you seem to tell people IN ADVANCE).
    I have many allergies, including sulfa, penicillin, Advil/Motrin, demerol, morphine, latex, among others. I assume that that was taken into account when choosing the Vigamox (at $50, I hope so!).
    The first time I used the Vigamox, I developed a small headache and my vision, already blurred from the cataract, seemed to become worse. This increased with each subsequent dose until after the 3rd drop, I had a raging headache and clearly worsening vision. I called my surgeon’s office and they told me not to take the final drop of the day and they would call me back the next day (one day prior to the surgery) with additional instructions.
    I waited until 10am the next day (the day before the surgery), still with a massive headache and the decreased vision, and decided to cancel the procedure. I figured if they stopped the drops and switched me to something else, I wasn’t getting all the doses…and if they didn’t, I wouldn’t have taken them anyway because of this headache.
    It is now 24 hours since the last drop and my head is killing me. I read the side effects and blog comments on Vigamox and they are all over the map (some scary stuff, which I guess is typical of patient reporting so decided not to panic).
    I am now waiting for the office to call me back and reschedule with new instructions.
    Have you heard of this reaction with Vigamox (bad headache continuing 24 hours later and the visual changes)?
    I assume I wasn’t prescribed a post op NSAID because of my Advil/Motrin allergy?
    What would you recommend as an alternative to the Vigamox with my allergies?
    And you probably can’t answer this, but can you mention any great cataract surgeons (warm and fuzzy type as well as highly proficient) in the Columbus Ohio area (smile).
    Thanks for a great blog. Glad I found it.

    • Betts:
      Headaches with Vigamox are not common, but I have had a couple of patients develop headaches while on the drop. If you get headaches from time to time anyway, it could be unrelated to the drops and more related to the stress of surgery and going without food in preparation. Zymaxid is a drop from the same family as Vigamox and a common alternative. Tobramycin and Polytrim are other alternative drops that could be considered.
      I don’t know the Columbus area well, although I was born at Wright Patterson.
      God Bless,
      Gary Foster

      • Betts Jeffries says:

        Thank you for your reply. I’m still waiting for the doc to get back with me on an alternative.

        Actually, headaches are quit rare for me, which is why this one made me think it had to be from the drops. Perhaps there was another source. I hated to waste the drops, a $50 for that tiny bottle.

        Hopefully, the alternative will be better. Thanks

  18. Dear Dr. Foster,

    Thanks for great informative article. Information about Durezol,Ilevro .
    We are worried about usage of Megabrom(non-steroidal bromfenac) twice a day for 4 weeks and usage of Pred-forte for 6 weeks.

    Post cataract surgery our eye doctor has suggested pred forte (steroidal) dosage for 6 weeks as follows
    4 times a day for first 3 weeks,3 times a day for 4th week,2 times a day for 5th week,1 time for 6th week
    My worry is 4 times a day pred forte (prednisolone acetate) for first 3 weeks is quite high. Some risks are associated with pred forte for pro long use like increase in eye pressure-glucoma, posterior subcapsular cataract formation and delayed wound healing. Patient is one eyed and we are worried about risk involved with pred-forte.

    Megabrom (non steroidal) is given 2 times a day for 4 weeks. Is this dose high? Are any risks like internal bleeding/cornea-retina injury associated with this? Normal dosage is 2 week.

    First two weeks we gave drops as per above schedule. Third we week we reduced 1 drop. Third week out of fear giving pred forte 3 times a day, megabrom once a day. After 3 weeks once doctor tests – if he continues same drops is it okay to suggest Durezol, Ilevro (which have less side effects)? Does changing drops in 4th weeks cause any problems?

    Zymer is given 4 times a day for 1 week.( we have already stopped)

    Kindly advise.

    Thanks

    • Ramesh:
      There are risks involved with using any medicine or eye drop, but there are also risks involved in not using them. The practice of medicine involves the careful balance of the risks of treating and the risks of not treating. Your eye doctor takes all of these factors into account when he/she writes the prescriptions. As a general rule, it is advisable to carefully follow the regimen prescribed and to avoid changes without the counsel of your doctor. There may be specific reasons why a doctor chooses his/her standard drug regimen and whey he/she alters it for the needs of a specific patient.
      The main risk with the steroid is that it raises the eye pressure in a small percentage of patients. The majority of patients do not have their pressure rise with the steroid. At your postoperative visits, your doctor checks the pressure to make sure this is not happening. The risk with the NASAID (megabrom) is that on rare occasions, the cornea reacts poorly to the drug. This is rare and your doctor would notice corneal problems at the post operative visits if it where developing.
      The main risk of not using the drugs is the development of macular edema. Most patients do not develop macular edema even if they don’t use any drops after surgery, but studies have shown that fewer patient develop the edema if they are on the drops so we put all patients on the drops to help prevent the problem in a few that otherwise would have been harmed.
      God Bless,
      Gary Foster

      • Thanks Dr.Foster for all answers. In-spite of taking drops (pred-forte,megabrom) patient experiences prickling/stinging sensation and hazziness/dullness in vision. Her sight is 6/9. Here doctor has given lubricant drop (genteal eye drops(Hypromellose (0.3%)) which forms water molecule inside eyes. Is this okay to use considering fact that after cataract surgery water should not enter operated eyes?
        Regards

  19. Dr.Foster – for distance sight glasses power was 0.25. Earlier she had no power for distance sight (6/9). My guess is IOL measurement was done immediately after dilation (during examination). Is it true that aspherical IOLs like Alcon IQ introduce an additional 0.25D post cataract (due to dilation and IOL measurement)?
    Thanks

  20. Kay Walker says:

    Dear Doctor: Love your blog. Betts is lucky. I’m scheduled for cataract surgery next week. I called the pharmacy about the post-op drops. They gave me a price of $201 fir the Nevanec, $114.39 for the Prednisolone, and $9.91 for the Ofloxacin!! Are there any other options out there? I realize my eyes are precious, but I feel that the drug companies are just taking advantage of us elderly since we have so little choice. I have no insurance so what else can I do? I do know that I’m not going to have this surgery until I have explored all possibilities

    • Kay
      Ilevro is a different form of Nevenac. Usually it costs more, but with your plan it may actually cost less. It’s worth trying. I like the drug Prolensa about the same as Ilevro so you could check on the price of that also. Generic Ketolorac may cost less than the branded Ilevro and Prolensa. It works about the same but you have to take it more times per day and it stings quite a bit more.

      For the steroid, I usually use Durezol instead of Prednisolone. Both work, but you have to really shake the Prednisolone since it is a susupension or all the medicine is at the bottom of the bottle. Some Medicare patients can use coupons for their Durezol that you could get from your eye doctor. It depends on the pharmacy and your drug insurance plane on whether they will let you use the coupon which would lower the Durezol price to 35.00.
      God Bless,
      Gary Foster

  21. Kay+Walker says:

    I’m scheduled to undergo cataract surgery but have postponed it due to health issue; however, after reading your posts I realize that I might not have to pay the $325 for post surgery eyedrops they prescribed. I checked on GoodRx website, I found generics and have come up with about a third of the cost. Thank you for keeping us informed. Now if I can just get my doctor to prescribe it. I’m apprehensive about this surgery as I developed endophthalmitis in my other eye a year ago requiring a vitrectomy. I now experience pain in that eye on a daily basis, and dread a repeat performance! My eye surgeon tells me that if I don’t have the other eye done, I could possibly lose the sight in it if the lens becomes thick and hardened and difficult to remove. What does an elderly patient do?

    • Kay and Walker
      The current branded generic problems are problematic. There are big differences between some of the antibiotics. Given the problems you had with the first eye it would not be wise to cut corners with antibiotic on the second eye. Your surgeon will be able to help with this decision. For example, Bessivance is a top end antibiotic that has coupons available for 35 dollars that work for more than half of Medicare patients. That may be a good avenue for getting a good antibiotic at a fair price.
      God Bless,
      Gary Foster

  22. Dr. Foster:

    I have pseudoexfoliation in one eye and have been using maximum dosages of drops to reduce IOP. I have been on them long enough to check efficacy. Lowest IOP achieved was 30. Subsequently I had SLT laser treatment which brought it down to 17. Because of the efficacy and safety as well as convenience, it seems logical to prefer laser treatment as the primary therapy. If the IOP increases over time, how frequently would you recommend repeat SLT since the drops don’t work?
    I am not certain whether I actually have signficant glaucoma yet. Two perimetry studies done a year and a half apart showed no changes. By the way, I just had cataract surgery on that eye and am hoping that may reduce presssure some. In this scenario at this time, it seems that a trabeculectomy procedure at this time would not be warranted.

    Your thoughts?

    • Phil:
      You will need to get specific guidance from your eye doctor, but you have described correct principles. SLT can be repeated if your visual fields begin to progress. Fortunately, yours are not. I usually place a migs device (iStent is the only one currently FDA approved) at the time of cataract surgery to father lower pressure in glaucoma patients. Currently there isn’t a Medicare code for placing one of those after cataract surgery, which is ridiculous enough that at some point I would think that the government would correct this and it would also become an option for you if SLT weren’t enough at some future time. A trabeculectomy is a great procedure when needed, but high enough risk that we exhaust other options first.
      God Bless,
      Gary Foster

  23. Virginia Teeney says:

    This is such a great question and answer site..Thank you so much…I just had cataract Surgery last week..the right eye was Jan 8 and my left jan 22 ..the question is my first batch of Prolenza, Benevance and Prednisolone Acetate Ophthalmic Suspension cost me 169 dollars. The second fill for my left eye was $369.00 . I could not believe it..and I had 2 coupons..my drugist said that because I had Medicare part 2 for drugs the coupons were no good..I tried to bring my subscription back after I realized I really could not afford this and my first batch was still good..could I stop taking the 3 after what length of time? my doctor gave me a chart for 28 days not including pre surgery.
    thank you again for your wonderful help

    • Virginia:
      You will need to check with your specific doctor on the length of time to use the drops. Based on how it has gone with the first eye and the results of your postoperative exams, it may be possible to stops some of them a bit earlier.

      There is considerable confusion among pharmacies on who can and cannot use the coupons. I am not an expert on this, but often you will find a pharmacy that will honor them if you check with several in your town.
      God Bless,
      Gary Foster

  24. Hi Dr. Foster. I had my second cataract surgery Thursday and when the doc took the patch off Friday I got dizzy and nauseous as the eyes don’t work together at all. He kept saying the surgery was perfect and didn’t want to address my concerns, which is unlike him. He said that it just needs to heal. Meanwhile, I’ve been wearing the patch most of the time because if I don’t I feel really nauseous and am afraid of falling (I’m also disabled). But first, could wearing the patch all the time be interfering with my eyes trying to coordinate again, and second, how long does this healing/working together process usually take? Thank you.

    • Elaine:
      The level of trouble you describe would usually only occur if the prescription for near/far sightedness or astigmatism was now quite different between the two eyes or if you now had double vision. Double vision could come from the two eyes not pointing the same direction or from astigmatism. If these symptoms are persisting, then you may want to schedule a sooner appointment with your surgeon.
      God Bless,
      Gary Foster

  25. Hi,
    A quick ?. I recently (well 2 days ago) had cataract surgery in southern Europe. The surgery was actually amazing, and the surgeon is brilliant. Yesterday, on the follow-up exam, the dr. gave me Predniftalmina in cream form. I used it last night, but this morning my vision seems a bit more blurry , although it is early yet. Is it possible this cream can enter the new lens via the incision, or am I worrying over nothing? Thanks in advance for any response.

    • Gabbie:
      We do not have that exact product in the U.S. It is unlikely that the cream would be the cause of your symptoms. A cream could enter the incision, though that would be rare. There are many potential causes of blurry vision. Some of these causes are concerning while others are not. It is wise to see your surgeon in the postop period if you are experiencing new symptoms just to be carful.
      God Bless,
      Gary Foster

  26. Elaine:
    Speaking generally, the stronger the steroid, the greater the risk of increased intraocular pressure and cataract formation (if you have not had them removed by cataract surgery already). If we are most worried about those complications then a weaker steroid would be lower risk. On the otherhand, the weaker the steroid, the greater the risk of ongoing inflammation. If we are most worried about the inflammation, then a stronger steroid could be the one with the lowest risk. In my opinion, the strongest steroid is durezol, then predforte (Prednisolone), then lotemax gel, then FML and the non gel lotemax, then Alrex.
    God Bless,
    Gary Foster

  27. Linfa Allen says:

    This is wonderful to be able to ask questions and actually get answer. Had catarac surgery in right eye. Have no problem with left but told I have catarac in left as well but no vision problem. Have been told I have closed angle glaucoma and these cataract surgeries will correct both eyes. Is that only way to help closed angle? Have been urged to do now or will go blind!!What? Having irritation beyond belief. Dont want to do other eye. Will I go blind soon? Such urgency but cant walk. shop continue my normal life because of stinging, depthnperception and one eye views things one inch different so I cant move around stable. I figured all this by observing. I had great surgeon but no education as to whats happening and hopefuylly I can wait a year or more vegore other eye bothers me. Will glasses helpe to even out this? Tied of being scared into instant surgery. Thanks for answers. This helps my outlook hust to get answers. There are none at my doc!!!

    • Linfa:
      There are two major types of glaucoma, open angle and closed angle. Open angle glaucoma is by the most common type and in these patients, the angle where fluid is supposed to leave the eye is open, but not enough fluid can leave the eye so the pressure rises. This is usually treated with drops.

      In closed angle glaucoma, the angle where fluid is supposed to leave the eye is closed off. This happens most commonly because these patients have shorter than normal eyes which makes them very far sighted. When they are young, the angle is narrow but open. As they age, their lens becomes thicker and thicker, pushing the iris forward, closing off the angle, and causing the eye pressure to rise. During cataract surgery, the big thick cataract lens is removed and a thin intraocular lens is place. This allows the iris to fall back to a more normal position and can allow the angle to reopen if it is not permanently scarred shut.

      The urgency of your surgery would depend on how high your eye pressure is and how much of your angle is closed. If most of it is closed or if it is extremly narrowed and would easily close off, then completing the surgery before the pressure goes sky high would be motivating for a sooner surgery date.

      If you are quite far sighted in the eye that hasn’t had surgery, but now are not far sighted in the eye that has had the cataract surgery, then it would make objects look bigger in one eye and smaller in the other. Glasses don’t help this problem and might even make it seem worse. Wearing a contact lens in the un-operated eye would make the image sizes almost the same and restore “balance.” If you are not a good candidate for a contact lens, then you may feel additional motivation to have the second cataract surgery sooner so the two eyes will again be in balance with similar image sizes.
      God Bless,
      Gary Foster

  28. Rosemarie Jax says:

    I had cataract surgery 4 days ago. Now the vision in that eye is like looking through wax paper. Will this get better? I think it is corneal edema?

    Also, I have been following the doctor’s orders and using the 3 types of drops – 3 times a day – Vigamox, Ilevro, Durezol. The information in the package inserts says this is too often – who is right – the doctor or the pharmaceutical companies?

    Bless you for helping…

    • Rosemarie:
      The most common cause of waxy vision in the first week after cataract surgery is corneal edema. If you ask your doctor or his/her assistants they will have noted that in the chart on your first post operative visit and they could let you know. If they are not confident of the reason for the vision, then a sooner postoperative visit could be warranted.

      The package inserts describe the dosing regimen that was used in the FDA trial for the medicines. Your doctor has developed a regimen that works for his/her style of surgery. For example, it is easier for patients to remember three drops three times per day. In addition, your surgeon may have specific reasons, based on your surgery for altering the dosing schedule. For example, above average inflammation or above average risk for CME might make a surgeon ask you to use the Ilevro more often.
      God Bless,
      Gary Foster

  29. alberto rivas says:

    If you would need cataracts surgery and you had astigmatism, a bit of macular degeneration, dry, and myopia, would you have it done with laser , in spite of the higher price , or you would have it done following the traditional method ?. Thank you for all your info. Pity I am not in USA but down here in Australia, a bit far away

    • Alberto:
      If the macular degeneration was mild so that I could anticipate good vision after cataract surgery I would prefer to have mine done with the laser method.
      God Bless,
      Gary Foster

  30. If I am not having problems with my eyes but doctor recommended cataract surgery, should I have it. Have always worn glasses. Now 73; had minor change in left eye.

    • Rose:
      As a general rule, there are two requirements for insurance to pay for cataract surgery: 1.0 Vision 20/50 or worse and 2. Visual problems from the cataract affecting your daily living. You are stating that your vision is not affecting your daily living, so by definition, it would not qualify for insurance to pay. If you want to pay cash, you could proceed, but why if you are not having any problems? There are several exceptions to what I am saying. Some have vision worse than what is required for a divers license, feel they see fine, and insist on still driving. These individuals need to proceed with cataract surgery or should forfeit their drivers license for the standards of public safety. In these individuals the cataracts have come on evenly between both eyes and so gradually that they do not realize how bad there vision has become.
      The other exceptions are rare conditions where the cataract is causing high eye pressure or eye inflammation so removing the cataract is a medical emergency to save the eye. Again, these conditions are quite rare and would have been carefully explained as such by your doctor if they existed.
      God Bless,
      Gary Foster

  31. Do I really have to take my contact out before using my pre op drops before my cat surgery? I don’t want to but that’s what the instructions say.

    • Wanda:
      Sorry for the inconvenience. We obtain more accurate measurement is you have removed your contact lenses for an appropriate amount of time to allow the corneas to return to a natural state. If the measurements have already been taken, then there are other considerations like will the drops stain the contact lenses and combined contact lens and steroid eye drop use may increase your chances for an infection.
      God Bless,
      Gary Foster

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