Reported Tetracaine Allergy in Cataract Surgery: A Phenotype-Based Framework for Preoperative Decision-Making

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Abstract
Reported tetracaine allergy, particularly in the absence of supporting medical documentation or a confirmed allergy diagnosis, represents a common challenge during the preoperative assessment of patients undergoing cataract surgery. In such cases, clinical decisions often rely primarily on patient history, which may be incomplete, inaccurate, or unreliable, resulting in considerable diagnostic uncertainty. A narrative review of the literature was conducted to examine the clinical relevance of reported tetracaine allergy in perioperative management of cataract surgery. Based on critical appraisal and synthesis of the available evidence, a phenotype-based framework comprising three clinical presentation phenotypes was developed, accompanied by a structured algorithm to support preoperative decision-making. The proposed framework classifies patients into three clinically relevant phenotypes: the irritative phenotype, the suspected hypersensitivity phenotype, and the clinical uncertainty phenotype. This classification provides a structured approach to interpreting reported tetracaine allergy and forms the basis of a practical algorithm for phenotype-guided preoperative management. The phenotype-based framework is intended to support, rather than replace, clinical judgment in the preoperative evaluation of patients with reported tetracaine allergy. By providing a structured approach to decision-making when diagnostic information is limited or uncertain, the framework may improve the consistency and transparency of perioperative management. Although conceptual, the proposed framework highlights the importance of obtaining reliable clinical information in patients reporting tetracaine allergy. Further methodological studies, including prospective validation, are required before the framework can be recommended for routine clinical practice.

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