We report the results of our initial 20 phacoemulsification cases performed using topical anesthesia. The preferred topical regimen consisted of preservative-free 0.75% bupivacaine. Intravenous sedation was provided primarily with fentanyl and midazolam. Phacoemulsification was performed through a scleral tunnel incision, and a one-piece poly(methyl methacrylate) or three-piece silicone intraocular lens was implanted. There were no complications with the anesthetic technique. One day postoperatively, 69% of patients with a desired refractive error within 0.75 diopters of emmetropia had an uncorrected visual acuity of 20/40 or better. At one month, all patients had a best corrected acuity of 20/30 or better, and 60%, 20/20 or better. Eighteen patients reported complete intraoperative comfort, and 17 reported complete postoperative comfort. Seven of the 10 patients who had had previous peribulbar anesthesia preferred topical. All 10 "first eye" patients said they would choose topical anesthesia for future surgery. With appropriate case selection, topical anesthesia for phacoemulsification surgery can be used with excellent intraoperative and postoperative results.