Giving patients oral diazepam before they undergo cataract surgery, instead of running an intravenous (IV) drip with sedatives, can provide adequate, complication-free sedation, a single-center study of more than 800 consecutive cases has found. Patients said they preferred the pill to the IV, according to the researchers, who presented the findings at the American Academy of Ophthalmology (AAO) 2025 Annual Meeting.

Previous studies of oral sedation for cataract surgery have come from academic and hospital settings. The new work is the first to report on oral sedation for the procedures in an office setting, said Brad Feldman, MD, cataract surgeon at Philadelphia Eye Associates and Wills Eye Hospital, both in Philadelphia, who helped conduct the analysis.

“Oral sedation for office-based cataract surgery works very well,” Feldman told Medscape Medical News. “It’s very safe, very effective, cost-efficient, well tolerated by the patients and surprisingly easy for the surgeon.”

The study enrolled the first 804 consecutive patients who had cataract surgery in medical group’s office, instead of a hospital or ambulatory surgery center, from February 2024 to September 2025.

Oral Sedation Protocol and Operation

Patients received either 5 mg or 10 mg of diazepam. About 10% of patients required additional sedation of a combination midazolam, ketamine, and ondansetron as a disintegrating tablet placed under the tongue. The average time from when the patients arrived until discharge was 84 minutes, and the only complication was one case of vitreous prolapse, the researchers reported.

Feldman said that the actual operation, which involves removing the cataractous lens from the anterior chamber of the eye and placing a prosthetic intraocular lens in the now-empty posterior chamber, takes an average of around 10 minutes. “There isn’t a need for high doses of sedation,” he said.

“One of the problems with IV sedation is the risk of oversedation,” Feldman said. “What I found when we give patients low-dose sedation with either 5 mg diazepam or 10 mg is that we don’t end up over-sedating patients.”

Over-sedated patients can become disoriented during surgery, and some can potentially harm themselves, he said. Oral sedation removes that risk.

Oral sedation has other advantages, Feldman said. Without the need for an IV, patients do not have to change out of their clothes and into a hospital gown to accommodate the line. They can also drink fluids and eat lightly before surgery, avoiding the fast required with IV sedation, he said.

Oral sedation also gives the cataract surgeon more control over making sure patients are appropriately sedated before surgery rather than delegating that responsibility to an anesthesiologist.

“When we do oral sedation ahead of surgery, we give the patient a pill by mouth and we let them sit down as their eye dilates, which takes about 30 minutes for both,” he said. “We get to evaluate their level of sedation before we bring them to the operating room and if they’re not properly sedated, we can wait or give more medication, which helps us prevent having patients who are under- or over-sedated.”

The process improves efficiency, Feldman noted. “Cataract surgeons in particular like to be efficient in the operating room and don’t want to sit and wait several minutes for the IV medications to kick in,” he said.

Potential Cost Savings

The potential cost savings by not having an anesthesiologist or nurse anesthetist run the IV sedation go beyond insurance carriers, Feldman added. “It’s getting harder and harder to afford having MD anesthesiologists in surgery centers because of the amount they’re asking to be paid — not just the amount they’re getting paid by insurance, but on top of that they are typically demanding contracts that guarantee additional payments from the surgery center,” he said.

Another advantage of diazepam is the cost, Feldman said: less than $1 per patient.

Feldman acknowledged “bias” in the study population, which included patients the investigators thought would do well with surgery. “There are still patients that need to have IV sedation,” he said. “These patients were selected out ahead of time.” Patients with severe chronic obstructive pulmonary disease, severe congestive heart failure, and other active cardiovascular diseases are still thought to require IV sedation, he said.

“Patients prefer this generally,” Feldman said of oral sedation. “At least our patients have expressed their preference for it over the ambulatory surgery center.”

The group of four surgeons is continuing to track outcomes and now has performed more than 1200 cases in the office.

The study sheds some new light on the use of oral sedation for cataract surgery, according to Nick Mamalis, MD, director of ocular pathology at the John A. Moran Eye Center, University of Utah in Salt Lake City.

“The nice thing about this study is that it shows in the proper patient group who does not have any significant systemic disease, and who would maybe require having an anesthesiologist there and IV access, that using the oral sedation and doing the surgery can be done safely,” Mamalis said.

But the study leaves unanswered whether patients with some systemic disease are not suitable for oral sedation, he said. “That’s what we don’t know because I’m at a tertiary care hospital, we tend to see more elderly, sicker type patients,” he said. “Those patients definitely need at least a nurse anesthetist and IV access, because there have been issues where you have to control systemic issues such as blood pressure and heart rate.”

Feldman reported consulting for Alcon and Tomey Corp. Mamalis reported having financial relationships with Adaptilens, AkkoLens, Alcon, Alta Vision, Carl Zeiss Meditec, Cristalens Industrie, Hoya Corp., Iota, Long Bridge Medical, OcuMetrics, Perfect Lens, Rayner, SpyGlass Pharma, and Stabilens. 

Richard Mark Kirkner is a medical journalist based in Philadelphia.