Dextenza helps simplify medication regimen

Before the insert is placed, it is important to ensure adequate dilatation if the punctum appears small and to dry the punctal area.

Issue: April 10, 2019

ByJohn P. Berdahl, MD

Advances in cataract surgery have reached reasonably great heights and continue to rise in sophistication from both the technological side and the surgical techniques arena. This amalgamation of technology with ophthalmic surgery translates into better quality of vision for our patients, with a faster visual recovery and quicker return to normal activities. Parallel to surgical advances, medical therapeutics have also advanced to provide better wound healing and prevent intraocular infection and endophthalmitis, while controlling inflammation that may potentially compromise corneal endothelial function, contribute to increased IOP and result in macular edema.

To provide a therapeutic safety net after cataract surgery, ophthalmic surgeons have stepped up the number of medications from two to three, namely, a topical corticosteroid, an NSAID agent and an antibiotic drop, often started 3 days or less before surgery and continued until about 4 weeks postoperatively.

It has been well documented that as the number of eye medications increases, patient compliance decreases. While the antibiotic drop is often stopped about 1 week after cataract surgery, the corticosteroid and the NSAID are used for about 4 weeks. With the new Dextenza intracanalicular insert, patients can eliminate the use of corticosteroid eye drops, thus partially overcoming the compliance hurdle and providing an overall positive experience with modern-day cataract surgery.

In this column, Dr. Berdahl describes the technique of inserting Dextenza in the intracanalicular site.

Thomas “TJ” John, MD
OSN Surgical Maneuvers Editor

The vigorous topical therapy regimen required after cataract surgery is widely acknowledged to be the biggest negative in what is otherwise a straightforward and elegant procedure. Many patients struggle with the complex drop protocol, with one study determining 92.5% of patients had compliance issues. However, the steroid regimen especially, including the need to taper the administration, is vital to the healing process.

One solution, recently approved by the FDA in November 2018, is Dextenza (Ocular Therapeutix). This noninvasive, preservative-free, intracanalicular insert is placed into the punctum. The hydrogel insert taper-releases 0.4 mg of dexamethasone over a 4-week period, ensuring compliance and providing convenience and peace of mind for doctor and patient alike. Once the drug is completely dispensed, the insert is reabsorbed and exits the nasolacrimal system, requiring no further intervention by the ophthalmologist. While there is no need for removal, if desired, saline irrigation or manual expression can be performed to easily remove the insert if necessary. Another clever feature of this device is that it is impregnated with fluorescein, allowing visualization under blue light at the slight lamp, especially with the yellow filter.

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The process of placing this insert is similar to implanting traditional intracanalicular plugs, with some nuances. The most notable difference is perhaps that this procedure is primarily performed in the operating room while most physicians are accustomed to placing punctal plugs in the clinic. However, while the approach may feel slightly different, supine vs. seated, it is well within the skill set of any comprehensive ophthalmologist to perform a routine insertion.

Figure 1. Dilate (when necessary) and dry. — **Figure 1**. Dilate (when necessary) and dry.

Surgical maneuvers

Similar to the process of placing punctum plugs, good exposure and a comfortable approach to the punctum are essential. There is variability among punctums. Some point more nasally, some more vertically, some more temporally; yet, as the intracanalicular insert can be placed from either a temporal approach or a superior approach, it should not necessitate an adjustment of the surgical chair location.

Figure 2. Get a comfortable angle for insertion. — **Figure 2.** Get a comfortable angle for insertion.

Once you know your passive insertion, the next step is to evaluate whether or not dilatation of the punctum is necessary. Dimensions of the non-hydrated Dextenza are approximately 0.5 mm in diameter and 3 mm in length. Dextenza will swell and conform to the size of the lacrimal canaliculus upon contact with moisture, so it is important to ensure adequate dilatation in cases in which the punctum appears small enough to require it.

Figure 3. Insert. — **Figure 3.** Insert.

With this insert, it is also critical to dry the punctal area before insertion, which is different from your typical punctum plugs. As previously mentioned, once this insert is exposed to moisture, it becomes softer and expands. When you are ready to place the insert, ensure the punctal area is dry, confirm you have a good approach and then put the eyelid on stretch. This is especially important because oftentimes this procedure will be performed in conjunction with cataract surgery in an older population that in general may have lids that are somewhat more lax than in younger patients. Place the lower eyelid on stretch by using the thumb of the non-insertion hand to gather redundant lower eyelid tissue and pull toward the lateral canthus.

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Then, using blunt (non-toothed) forceps, place the intracanalicular insert. Pay attention to how the punctum presents itself. It is important to understand and envision the canalicular anatomy as the insert is placed. When you place the insert, approach perpendicular to the punctum until you feel resistance and then drop the back of your hand and move nasally to insert it into the transverse portion of the canaliculi. Once the insert is in place, tap the back of it to advance it further into the puncta if necessary because Dextenza should be placed just below the punctal opening. Then, the procedure is complete.

Figure 4. Tap the back of the insert to ensure placement. — **Figure 4.** Tap the back of the insert to ensure placement.

This is a straightforward and efficient procedure with the exciting potential to ensure patients receive the necessary postop steroid treatment without the confusion and inconvenience of a complex drop regimen.

References:

An JA, et al. J Cataract Refract Surg. 2014;doi:10.1016/j.jcrs.2014.02.037.

Gira JP, et al. Patient Prefer Adherence. 2017;doi:10.2147/PPA.S126283.

Mehari T, et al. BMC Ophthalmol. 2016;doi:10.1186/s12886-016-0316-z.

Sleath B, et al. Health Educ Res. 2015;doi:10.1093/her/cyv034.

Torkildsen G, et al. J Ocul Pharmacol Ther. 2017;doi:10.1089/jop.2016.0154.

For more information:

John P. Berdahl, MD, can be reached at Vance Thompson Vision, 3101 W. 57th St., Sioux Falls, SD 57108; email: john.berdahl@vancethompsonvision.com.

Edited by Thomas “TJ” John, MD, a clinical associate professor at Loyola University at Chicago and in private practice in Oak Brook, Tinley Park and Oak Lawn, Ill. He can be reached at email: tjcornea@gmail.com.

Disclosures: Berdahl reports relevant financial disclosures with Ocular Therapeutix and Imprimis. John reports no relevant financial disclosures.