Monali Malvankar: Rethinking Cataract Care
Rethinking Cataract Surgery: Pragmatic Trial Examines Whether Epinephrine Is Still Necessary
By: Houda Houbeish
A pragmatic clinical trial being developed by researcher Dr. Monali Malvankar is challenging a long-standing practice in cataract surgery: the routine addition of epinephrine to the irrigation fluid used during the procedure.
Cataract surgery is one of the most frequently performed procedures in Canada and has evolved significantly over time. During surgery, surgeons use a balanced salt solution to irrigate the eye and maintain the surgical space. Depending on local practice, this solution may contain additives such as epinephrine, lidocaine, anesthetics, and ophthalmic viscoelastic devices (OVDs), all intended to support surgical stability and maintain pupil dilation.
Dr. Malvankar, a health data scientist and researcher participating in the Health Data Research Network Canada (HDRN Canada) pragmatic trials training program, is investigating whether epinephrine remains necessary in modern cataract surgery or whether it can be safely omitted without affecting patient outcomes.
Questioning the Routine Use of Epinephrine
In some operating rooms, epinephrine is routinely added to irrigation bags at the start of the day for all cataract procedures; in others, it is not. Regardless of the approach, surgeons can still request epinephrine during surgery or use specialized devices to maintain pupil dilation if needed.
The study asks an important question:
Can cataract surgery be performed just as safely without routinely adding epinephrine to irrigation fluid?
If the answer is yes, the implications could extend beyond the operating room. Eliminating the routine preparation of epinephrine-containing irrigation bags could reduce medication handling, simplify workflow, ease nursing workload, lower costs, and decrease unnecessary pharmaceutical and packaging waste.
Beyond examining clinical outcomes, the trial also explores the broader system-level effects of changing this practice. These include reducing the time and effort required to prepare operating rooms, minimizing the physical handling of medication vials, and improving efficiency in settings where cataract surgeries are performed in high volumes.
"The study is looking not only at patient outcomes but also at how we can make care more efficient," Malvankar explained, noting that even small changes in routine practice can have meaningful effects when applied across large numbers of procedures.
The patient population undergoing cataract surgery further highlights the relevance of the research. Many patients are older adults, often over the age of 65, and frequently live with chronic conditions such as diabetes and hypertension. Improvements in efficiency, safety, or workflow therefore have the potential to benefit a large and medically complex population.
The Value of Pragmatic Clinical Trials
For Dr. Malvankar, the project also demonstrates the value of pragmatic clinical trials in addressing practical questions that arise in routine healthcare settings. She emphasized the potential reach of the research, highlighting how findings from a relatively simple intervention could influence care across multiple jurisdictions.
"It's going to impact thousands of patients across Canada," she said.
More broadly, Malvankar described the project as an opportunity to learn and apply pragmatic trial methodology to real-world healthcare challenges. "I have learned a lot … it is a very useful program, especially for those who would like to see a scalable impact in healthcare," she said, adding that the skills gained through the program could be applied across other surgical specialties, including cornea and retina care.
As cataract surgery continues to advance, the study aims to help determine which long-standing practices remain essential and which may no longer be necessary. For Malvankar, answering that question could ultimately lead to a simpler, more efficient approach to care—one capable of benefiting thousands of patients across Canada's healthcare system.
** The HDRN Canada pragmatic trials training program is coordinated and hosted by the Schulich School of Medicine & Dentistry and is an initiative by Health Data Research Network (HDRN) Canada. It has been funded with $3.48 million from the Canadian Institutes of Health Research (CIHR). Read more.
You can also watch this video for a brief overview of Dr. Malvankar's work
