Background and aims: Midazolam and dexmedetomidine have been routinely used for intravenous sedation in ophthalmic surgeries. Dexmedetomidine is an alpha-2 agonist that provides sedation and analgesia without respiratory depression. It has also been shown to reduce intraocular pressure (IOP) in ophthalmic surgeries done under regional anesthesia. Midazolam has been used alone or in combination with opioids or propofol with variable results. This study aimed to compare the efficacy of single low-doses of midazolam and dexmedetomidine for reducing blood pressure (BP) in patients undergoing ophthalmic surgeries under local anesthesia. Methods: In a prospective blinded study, 50 patients undergoing cataract surgery under local anesthesia whose on table BP was >150/90 mm Hg were randomly divided to receive either dexmedetomidine 0.4 μg/kg or midazolam 20 μg/kg single dose. Reduction in BP, heart rate (HR), sedation level, decrease in IOP, and any delay in discharge were assessed. Results: There was a significant drop in HR after 10 minutes in the dexmedetomidine group compared to the midazolam group (p < 0.05). Systolic BP (SBP), diastolic BP (DBP), and mean arterial pressure (MAP) were comparable in both groups. But eight patients in the midazolam group required a second dose of the study drug for the control of BP, which was clinically significant. Also, patients who received dexmedetomidine had a significant fall in IOP compared to those who received midazolam (p < 0.00001). The sedation score was 2 in all patients and there was no delay in discharge from the recovery room. Conclusion: Small single dose of dexmedetomidine of 0.4 μg/kg in patients undergoing short duration cataract surgery under regional anesthesia, provides adequate control of BP without causing undue sedation, respiratory depression, and without any delay in discharge compared to 20 μg/kg midazolam.