You’re not alone in juggling long-term methotrexate with a planned cataract operation. Plenty of people do this safely every year. Cataract surgery is typically a short, low-trauma, day-case procedure with tiny incisions and very high success rates. Methotrexate does change the way your immune system behaves, but it doesn’t automatically mean you must stop the drug or that you’re destined for complications. The key is planning.
This article walks you through how methotrexate works, what it means for eye surgery, when it’s continued or paused, how to prepare, and what to watch for afterward. I’ll keep jargon light and give you practical checklists you can take to your pre-op visit.
Why methotrexate and cataract surgery feels like a tricky combo
Cataracts creep up on vision—glare, blur, foggy contrast, haloes around lights—until you notice daily things feel harder. Surgery replaces the cloudy natural lens with a clear artificial one through a micro-incision, usually with topical anaesthetic and no sutures. Healing relies on your body’s ability to keep bacteria in check and settle inflammation.
Methotrexate (MTX), meanwhile, is a cornerstone treatment for many autoimmune conditions—rheumatoid arthritis, psoriasis and psoriatic arthritis, inflammatory bowel disease, certain uveitis syndromes, and more. It calms an immune system that’s been overreacting. Understandably, you might worry that “calming” could also blunt your ability to heal or fight infection. That’s the tension we’re going to unpack.
A plain-English refresher on methotrexate
- What it is: A disease-modifying antirheumatic drug (DMARD). At the low weekly doses used in autoimmune disease, it reduces inappropriate inflammation rather than “wiping out” your immunity.
- How it works: It nudges folate-dependent pathways and immune cell activity, lowering signals that drive chronic inflammation.
- How it’s taken: Typically once weekly, orally or by subcutaneous injection, often with folic acid supplementation on non-MTX days to reduce side effects.
- Why it matters for surgery: It can slightly increase susceptibility to infection and may affect cell turnover. But the real-world impact depends on dose, your other medicines (e.g., steroids, biologics), kidney function, and how active your autoimmune disease is.
Cataract surgery in brief (and why it usually heals quickly)
Modern cataract surgery uses a tiny self-sealing incision at the edge of the cornea. Ultrasound (phacoemulsification) or femtosecond laser assists in removing the cloudy lens; an intraocular lens (IOL) is inserted. The incision is so small that stitches are rarely needed. The eye is drenched in antiseptic (povidone-iodine) before surgery and usually receives a dose of antibiotic into the front chamber at the end, alongside meticulous sterile technique. Post-op drops (often antibiotic for a short course and steroid for a few weeks) keep infection risks low and inflammation settled.
Because the surgical footprint is small, healing is typically swift, even in people with long-term conditions—provided the eye surface is healthy and the immune system, while modulated, isn’t profoundly suppressed.
The two big questions: infection and healing
1) Infection risk
Methotrexate modestly affects immune responsiveness, but cataract surgery already has robust infection prevention built in. Your individual risk depends more on the overall picture:
- Concomitant medicines (e.g., oral steroids, biologics, or multiple DMARDs).
- Poorly controlled diabetes, smoking, or skin/eyelid conditions (blepharitis).
- A history of recurrent infections or very low white cell counts.
- Kidney impairment (affects methotrexate clearance).
When these are managed sensibly, the absolute risk of a serious post-op eye infection remains very low.
2) Wound and tissue healing
Cataract wounds are micro-incisions that self-seal. Delayed healing is uncommon even in immunomodulated patients. The rare healing problems the eye world worries about (like corneal melts) are far more tied to severe ocular surface disease, uncontrolled inflammation, or certain topical medicines in high-risk corneas—not to routine methotrexate use by itself. If your surface is dry or inflamed, we fix that first.
Should you stop methotrexate before cataract surgery?
Here’s the honest, patient-centred answer: often not—but the decision is individual.
Factors your team weighs
- Autoimmune disease control: A flare can hurt outcomes more than theoretical infection risk. Uncontrolled systemic inflammation can make the eye grumpier after surgery.
- Dose and schedule: Low-to-moderate weekly doses for autoimmunity behave differently from high-dose oncology regimens. This guide is about the former.
- Other immunosuppressants: If you’re on combination therapy (e.g., methotrexate + biologic + steroids), your overall immune suppression is higher.
- Bloods and kidneys: Abnormal liver enzymes, low white cells, or reduced kidney function nudge clinicians toward caution.
- History of infections: Frequent infections may prompt a tailored plan.
The spirit of modern practice
For minor, clean procedures like cataract surgery, many teams continue methotrexate to avoid autoimmune flares, especially if you’re stable. That said, your rheumatologist’s view matters. If anyone suggests a pause, it’s usually brief (e.g., skipping the dose just before and/or just after surgery), and only when the benefits outweigh the risk of a flare. The call should be multidisciplinary—eye surgeon + rheumatologist + you.
What if you’re on methotrexate and a biologic?
Combination therapy is common. Biologics differ (TNF-alpha inhibitors, IL-17/23 blockers, JAK inhibitors—though not biologics strictly speaking, they’re potent). Practices vary: some clinicians time surgery mid-cycle or miss one dose around the procedure to lower infection risk while keeping disease control. Methotrexate may be continued, with the biologic being the drug that’s briefly adjusted. Again, it’s individualised; your team will steer you.
The special case of oral steroids
If you also take a long-term steroid (e.g., prednisolone), infection risk and slower healing inch upward with higher doses. Cataract surgery still goes smoothly for most people on maintenance steroids, but:
- Your surgeon may be extra-watchful for infection.
- You’ll usually receive anti-inflammatory drops post-op for longer.
- If you’re on a dose that risks adrenal suppression, anaesthetists sometimes plan peri-operative steroid cover (eye lists are short and low-stress, but they’ll still think it through).
Alright — here’s the rest of the article in exactly the same wording as before, just with the excessive bold removed from the paragraphs.
Drug interactions to have on your radar
Methotrexate’s clearance and toxicity can be affected by other medicines. Around the time of surgery:
- Trimethoprim-sulfamethoxazole (co-trimoxazole) can raise methotrexate toxicity—flag this if anyone suggests it for an infection.
- Some penicillins, NSAIDs at high dose, and PPIs can interact in susceptible people; context and kidney function matter.
- Folic acid is typically continued (not on MTX day), including through surgery.
Always bring an up-to-date medication list to your pre-op visit. If a new antibiotic is needed for any reason, your team will choose one that plays nicely with MTX.
Pre-operative checklist you can take to clinic
Print or save this and tick things off:
- I know my exact MTX dose, day of the week, and route (tablet/injection).
- I take folic acid on: ________ (days).
- Other immune drugs I’m on: __________________________.
- Rheumatologist or prescribing GP is aware of my surgery date.
- Latest blood tests (FBC, LFTs, U&Es) are recent and available.
- My kidney function is stable.
- I’ve told the team about any past infections or wound issues.
- I’ve optimised my eyelids and lashes (blepharitis care if needed).
- My ocular surface (dry eye) is treated and comfortable.
- I know which eye drops I’ll need and when to start.
- I have transport and someone to help the first 24 hours.
Optimising the ocular surface (this matters more than you think)
Autoimmune conditions often come with dry eye or blepharitis, and some medicines can nudge dryness along. A gritty, inflamed surface is a double-whammy: it increases discomfort and can slightly raise infection and inflammation risks after surgery. Sensible steps:
- Lid hygiene (warm compresses and gentle cleaning) for 1–2 weeks pre-op if your team recommends it.
- Lubricants (preservative-free) to get the cornea happy before surgery.
- Treat allergies or rosacea-related lid disease if present.
- If your rheumatology disease has ocular involvement (e.g., uveitis, Sjögren’s), tell your surgeon—timing surgery when the eye is “quiet” matters.
Anaesthesia and the day of surgery on methotrexate
Most cataract operations use topical anaesthetic drops with or without a small local block. You’re awake, comfortable, and home the same day. Methotrexate doesn’t usually change the anaesthetic plan:
- No fasting beyond instructions from the hospital (often light food allowed—follow your letter).
- Keep taking your other routine medicines unless told otherwise.
- Bring your drops and drug list.
- Don’t wear eye make-up on the day.
Intra-operative infection prevention: what your team does
It’s reassuring to know how belt-and-braces cataract surgery already is:
- Antisepsis with povidone-iodine on the eye surface and lashes.
- Sterile draping that isolates the lashes and lids.
- Intracameral antibiotic at the end of the case in many centres.
- Tiny, self-sealing wounds that limit bacterial access.
Your methotrexate is a consideration, but it’s not the main player here—technique and protocols are.
Post-operative drops and methotrexate: how they work together
You’ll typically be given:
- A short course of antibiotic drops (varies by centre).
- A tapering course of steroid drops to settle inflammation.
Both are compatible with methotrexate. Two tips:
- Stick to the schedule—don’t tail off early unless instructed.
- If drops sting or blur for long, ask about preservative-free options.
If you use topical NSAID drops, follow your surgeon’s plan closely—great at controlling cystoid macular oedema risk in some patients, but if your cornea is compromised or your surface is fragile, your surgeon may tailor or avoid these.
What to watch for after surgery (and what’s normal)
Normal in the first few days: mild grittiness, light sensitivity, slight redness, vision gradually clearing, haloes that fade as the cornea settles.
Call urgently if you notice:
- Increasing pain (not just scratchiness).
- Worsening vision after an initial improvement.
- Marked redness, pulsing ache, or thick discharge.
- New floaters or flashes (retina symptoms).
- Fever or feeling systemically unwell.
There’s no prize for “toughing it out” on methotrexate—ring the number in your post-op pack and be seen early. If there’s an infection brewing, fast treatment saves sight.
Timing considerations: which week is best if you do make an adjustment?
If your team decides to time surgery around your weekly methotrexate dose (many don’t need to), a common-sense approach is:
- Operate mid-week relative to your MTX day, so you’re not immediately at a peak level or immediately due a dose.
- If skipping one dose has been agreed, schedule surgery in that “gap”.
- Restart as advised once the surface looks good—often within a week or two.
Remember: this is a team decision, not a rule you should implement alone.
High-dose methotrexate (oncology) is different
If you’re receiving high-dose methotrexate as part of cancer treatment, your care pathway is specialised. Cataract surgery is rarely urgent in that context and is usually scheduled away from intensive chemotherapy cycles, with haematology/oncology sign-off. This article focuses on low weekly doses for autoimmune disease.
Folate, diet, and recovery
- Keep taking folic acid as prescribed (not on the methotrexate day).
- Hydration helps general well-being and drug clearance.
- Aim for a balanced diet; there’s no special “cataract-healing” diet, but protein and vitamins support tissue repair.
- Alcohol: follow your existing methotrexate advice and any peri-operative guidance you’re given.
Vision targets, IOL choice, and autoimmune nuances
Methotrexate itself doesn’t limit your choice of intraocular lens. What does influence it?
- The health of your macula (e.g., in long-standing inflammatory disease).
- The stability of your ocular surface (multifocal lenses are less forgiving of dryness).
- Any uveitis history (surgeons tailor anti-inflammatory cover and IOL type).
Expect a conversation about what you want to see without glasses (distance, near, or a blend) and how that fits your daily life.
Travel, work, and exercise after surgery on methotrexate
- Work: Many people are comfortable returning within a few days for desk roles; give physical or dusty jobs a week or so.
- Exercise: Gentle activity is fine quickly; avoid swimming and very heavy lifting until your team clears you.
- Travel: If flying, it’s wise to wait until your first post-op check confirms all is well (and be able to access care if needed).
Vaccinations and timing
If you’re due a vaccine, plan it away from the immediate peri-operative period so you can tell apart side-effects from any eye concerns, and follow your rheumatology vaccine guidance (especially for live vaccines). Methotrexate policies differ slightly between specialties; your GP/rheumatology team will advise.
Reducing risk in simple, practical ways
- Wash hands before any eye drop goes in.
- Don’t touch the dropper tip to lashes.
- Sleep on the non-operated side for a few nights if comfortable.
- Use the provided eye shield as advised.
- Keep pets and dust away from the eye for the first few days.
When methotrexate is a plus: the uveitis angle
If your cataract relates to uveitis, being on methotrexate may actually be protective against post-op inflammation and cystoid macular oedema when the disease is well controlled. Surgeons often aim for a quiet period (e.g., 3 months without flare) before operating, and your existing immune therapy can help maintain that stability.
Putting it all together: the bottom line
- Cataract surgery is low-trauma, highly standardised, and usually heals fast—even on methotrexate.
- Many patients continue methotrexate; occasionally a dose is timed or skipped after joint decision-making to balance infection risk against flare risk.
- Your overall immune burden (other drugs, steroid dose), bloods, kidneys, and ocular surface matter more than methotrexate in isolation.
- Preparation, clean technique, and post-op vigilance keep risks low.
- If anything feels off after surgery, don’t wait—call.
FAQ: 10 common questions, straight answers
Do I have to stop methotrexate before cataract surgery?
Not necessarily. For many people on low-to-moderate weekly doses, methotrexate is continued to avoid an autoimmune flare, which can complicate recovery. The decision is personalised: your surgeon and rheumatologist will weigh your disease control, other immune-active medicines, kidney function, and infection history. If they advise a pause, it’s usually brief and timed around the operation.
Will methotrexate make an eye infection after surgery more likely?
Methotrexate modestly dampens immune responses, but cataract surgery has strong infection-prevention steps—antisepsis, sterile draping, tiny self-sealing wounds, and often an antibiotic placed inside the eye. Your absolute risk remains very low when other factors (like diabetes, lid hygiene, and steroid dose) are well controlled. Good drop hygiene at home is your part of the partnership.
Could healing be slower because I’m on methotrexate?
Healing after cataract surgery mostly reflects the tiny incision and the health of the cornea and tear film. In routine methotrexate use, delayed wound healing is uncommon. The eye world worries more about severe ocular surface disease or uncontrolled inflammation than methotrexate per se. That’s why pre-op surface optimisation matters.
What about my weekly schedule—when should surgery fall relative to my MTX day?
If your team prefers timing, a mid-week slot relative to your MTX dose is a pragmatic choice, or you may skip one dose by prior agreement. Many centres don’t require any adjustment at all. Don’t change your schedule independently—agree the plan in clinic.
I take methotrexate plus a biologic—does that change things?
Combination therapy raises overall immune suppression. Some teams continue methotrexate but time or miss one biologic dose around surgery to tilt the balance toward safety without inviting a flare. It’s individualised; you’ll get a plan that fits your exact drug and dosing interval.
Are my post-op steroid drops safe with methotrexate?
Yes. Topical steroids act locally in the eye to control inflammation and are standard after cataract surgery. You’ll taper as advised. If your surface is very dry or sensitive, ask about preservative-free options. If topical NSAIDs are prescribed, your surgeon will consider your corneal health before and during use.
Which symptoms after surgery mean I should call straight away?
Increasing pain, worsening or fogging vision after an initial improvement, pronounced redness, thick discharge, or new floaters/flashes are the big red flags. Don’t wait overnight—contact the number in your post-op documents and be seen.
Do I need extra blood tests because I’m on methotrexate?
Your routine methotrexate monitoring (full blood count, liver and kidney tests) should be up to date before surgery. If results are abnormal—low white cells, deranged liver enzymes, or reduced kidney function—your team may adjust the plan or timing. Otherwise, no special extra tests are usually needed just because of cataract surgery.
Can I keep taking folic acid around the time of surgery?
Yes. Continue folic acid as prescribed (not on the methotrexate day). It doesn’t interfere with surgical healing and helps mitigate methotrexate side effects.
I’m worried about a disease flare if I stop methotrexate—what’s the real risk?
For many autoimmune conditions, even a brief pause can invite a flare, which may disturb your eye’s recovery and your general well-being. That’s a key reason many clinicians prefer to continue methotrexate for low-risk procedures like cataract surgery. If any pause is recommended, it will be short and carefully timed—with a plan to restart promptly.
A simple conversation script for your pre-op visit
- “I take methotrexate X mg once weekly on [day], with folic acid on [days].”
- “Other immune drugs I’m on: [list], including any steroids.”
- “My latest blood tests were [date] and were [okay/abnormal].”
- “I’ve had [no/few/recurrent] infections in the last year.”
- “What’s your view on continuing MTX for this cataract? If timing or pausing is better, what’s your preferred schedule?”
- “Any drop adjustments or extra precautions for me?”
- “Who should I call if I have pain, redness, or vision changes afterward?”
Final thoughts
For most people on weekly methotrexate, cataract surgery is straightforward, recovery is brisk, and vision improves quickly. The safest path is a joined-up plan between you, your cataract surgeon, and your rheumatology team—one that balances infection prevention with keeping your autoimmune condition calm. At London Cataract Centre, we make sure every patient’s surgical plan is tailored to their medical background, including medications like methotrexate. Get your surface comfortable beforehand, follow the drop schedule, and don’t hesitate to call if something feels wrong. With that approach, methotrexate is a consideration—not a barrier—to excellent outcomes.
References
- National Institute for Health and Care Excellence (NICE) (2017) Cataracts in adults: management (NICE guideline NG77). Available at: https://www.nice.org.uk/guidance/ng77/resources/cataracts-in-adults-management-pdf-1837639266757 (Accessed: 12 August 2025).
- UK Clinical Pharmacy Association (UKCPA) (2024) Methotrexate – Handbook of Perioperative Medicines. Available at: https://periop-handbook.ukclinicalpharmacy.org/drug/methotrexate/ (Accessed: 12 August 2025).
- Holroyd, C.R., Seth, R., Bukhari, M., Malaviya, A.P., Holmes, C., Loizou, C., Price, T., Thornhill, T., Akil, M., Dasgupta, B., & Ledingham, J.M. (2017) ‘The British Society for Rheumatology biologic DMARD safety guidelines in inflammatory arthritis’, Rheumatology (Oxford), 56(6), pp. 865–868. Available at: https://academic.oup.com/rheumatology/article/56/6/865/3053478 (Accessed: 12 August 2025).
- European Society of Cataract and Refractive Surgeons (ESCRS) (2018) ESCRS guideline for prevention and management of endophthalmitis. Available at: https://www.escrs.org/media/uljgvpn1/english_2018_updated.pdf (Accessed: 12 August 2025).
- Specialist Pharmacy Service (SPS) (2023) Managing interactions with methotrexate. Available at: https://www.sps.nhs.uk/articles/managing-interactions-with-methotrexate/ (Accessed: 12 August 2025).