Time is right for intraocular delivery of steroid after cataract surgery
Patients have fewer medications to deal with, and surgeons are assured that the full course of postoperative corticosteroid has been delivered.
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Controlling inflammation after cataract surgery is of paramount importance, and this is just as much the case for routine low-risk surgeries as it is for complicated or high-risk procedures. Patients today have high expectations of cataract surgery, and providing potent, immediate inflammation control postoperatively is essential to ensuring a positive experience.
Having an anti-inflammatory medication on board at the time of surgery and at the site of the surgical insult serves to block the cascade of molecular events that lead to inflammation and resulting tissue damage. Without adequate prevention and control of inflammation after cataract surgery, negative outcomes such as corneal edema, cystoid macular edema and persistent/recalcitrant uveitis are possible.
Conventional topical eye drops
Topical eye drops are the most common way to deliver anti-inflammatory treatment after cataract surgery. However, topical drops are associated with a host of physical and logistical barriers that reduce the likelihood of medication reaching the site of inflammation. For instance, the volume of tear fluid on the ocular surface, the rapidity of tear drainage and the tight junctions of the corneal epithelium substantially limit the amount of drug penetration.
Whether and how patients use their eye drops is also an important challenge. In most cases, patients need to administer multiple eye drops postoperatively, each with its own schedule and instructions for use, which patients may easily confuse or forget. Also, due to insurer preferences or cost concerns, patients may receive generic eye drops at the pharmacy, which may be less effective or require alternative dosing and administration instructions (eg, the need to shake before use). All of these factors can limit a surgeon’s ability to ensure adequate postoperative inflammation control and the quality of patient outcomes.
Intraocular steroids: Dexycu
Thus, ophthalmic surgeons look with great interest to Dexycu (dexamethasone intraocular suspension 9%, EyePoint Pharmaceuticals), the first corticosteroid FDA approved for intraocular administration. Because the medication is delivered by the surgeon directly at the site of surgical trauma, issues of ocular surface penetration and patient administration of eye drops are eliminated.
Dexamethasone is administered continuously at a tapered release rate through the early postoperative period. Patients who are known to have an elevated IOP response to steroids may be prescribed a weaker steroid or a nonsteroidal medication; however, in clinical studies of Dexycu, IOP elevations were transient and easily controlled with topical IOP-lowering medications.
Developing administration technique
There is a brief learning curve to the procedure, which involves depositing a droplet of dexamethasone behind the iris via a cannula. Some surgeons may use the main surgical wound to place the drug; I favor paracentesis because it tends to immediately self-seal and prevents aqueous from leaking. Regardless of technique, maintaining adequate anterior chamber volume and pressure is important because the medication may be more likely to move out from under the iris border when pressure is too low.
In my experience, the drug is best administered by going as far back into the ciliary sulcus as is safely possible and then, in one continuous motion, spreading the medicine along the back wall of the sulcus. Once the dexamethasone is applied, I immediately rapidly withdraw the syringe and the cannula to help maintain normal IOP and further help the bead of dexamethasone remain behind the iris. If necessary, surgical wounds should be rehydrated gently to avoid causing turbulence in the anterior chamber, which could dislodge the droplet.
In my experience, if drug migrates into the anterior chamber, the patient typically experiences no adverse effects. If the droplet adheres to the IOL implant near the visual axis, there may be a brief reduction in visual acuity until the droplet dissolves.
Outcomes and patient experience
I have used Dexycu in 25 patients, for whom visual acuity was 20/20 or 20/25 at the week 1 visit, and none have had an IOP increase. In cases in which the drug adhered to the lens implant, the issue resolved within a few days, and at the 1-week visit, their eyes were quiet, vision was 20/20, and patients were happy.
When counseling patients, I tell them that, until this point, three different medicines were needed after surgery, but with placement of the intraocular steroid, only two are needed.
After surgery, if there is a small aliquot of dexamethasone visible beyond the boundary of the iris border, I tell patients that the small white pearl they may see when looking in the mirror is the medicine I placed in the eye at the end of surgery and that it will remain there, working 24 hours a day, until it ultimately disappears over the next few weeks. Patients typically receive this information well.
Conclusions
As our technology and surgical techniques have evolved so much in recent years, expectations among surgeons and patients are for a rapid return to normal daily function and activities after cataract surgery. The opportunity to place a medication directly into the eye at the end of surgery, at the site from which inflammation arises, is important for patients, who have fewer medications to deal with, and for surgeons, who can be assured that a patient’s full course of postoperative corticosteroid has been delivered before they leave the operating room. Dexycu is an exciting addition to our armamentarium, and I strongly encourage other ocular surgeons to try it.
- References:
- Donnenfeld E, et al. Ophthalmology. 2018;doi:10.1016/j.ophtha.2017.12.029.
- Donnenfeld ED, et al. J Cataract Refract Surg. 2018;doi:10.1016/j.jcrs.2018.07.015.
- Ghate D, et al. Expert Opin Drug Deliv. 2006;doi:10.1517/17425247.3.2.275.
- Olson RJ, et al. Ophthalmology. 2017;doi:10.1016/j.ophtha.2016.09.027.
- For more information:
- Steven M. Silverstein, MD, FACS, can be reached at Silverstein Eye Centers, 4240 Blue Ridge Blvd., Suite 1000, Kansas City, MO 64133; email: ssilverstein@silversteineyecenters.com.
Disclosure: Silverstein reports he is a consultant and lecturer for EyePoint.
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