Background: Both cataract surgery and anesthesia techniques are rapidly evolving to become more patient friendly. However, comparison of topical anesthesia (TA) and peribulbar anesthesia (PA) for phacoemulsification and cataract surgery is limited. We evaluated the clinical outcomes and patient and surgeon satisfaction between anesthetic techniques. Materials and Methods: This randomized clinical trial was conducted between January and June 2012. Patients were randomly assigned to TA and PA groups for surgery. Visual acuity at 4 weeks postoperatively, status of the cornea and the wound and intraoperative complications were compared between groups at day 1, and 1 and 4 weeks after surgery. Patients and the surgeon completed a close-ended questionnaire on satisfaction with analgesia and comfort. The relative risk (RR) with 95% confidence intervals (CI) was calculated. Result: There were 500 patients in each group. There were no significant differences between groups preoperatively. Complications at 1-day postoperatively were significantly greater in the TA group (RR = 1.36, 95% CI: 1.17-1.58). Satisfaction with the mitigation of pain was statistically significantly greater in the PA group compared to the TA group (χ2 = 10.9, df = 3, P = 0.001). Surgeons were more satisfied with PA compared to TA (RR = 1.4, 95% CI: 1.34-1.63). There were more anesthesia-related complications in the PA group compared to the TA group. Conclusions: Patients who underwent surgery with topical anesthetic experienced lower complications by more pain compared to patients who underwent PA. Topical anesthetic supplemented with analgesic medications could help the patient and surgeon during cataract surgery.