March 2021

GLAUCOMA

Options to reduce postop cataract surgery drops for glaucoma patients


by Liz Hillman Editorial Co-Director

 

Dextenza
Source: Leon Herndon, MD

Intravitreal Dexycu being delivered via pars plana injection in a patient receiving a PanOptix IOL (Alcon)
Source: Nathan Radcliffe, MD

Studies have shown that the addition of a second glaucoma medication reduces adherence.1 With that in mind, it makes sense that adding postop cataract surgery drops to a patient’s existing glaucoma drop regimen could have the same effect. Newer steroid and NSAID options (and some off-label administration of antibiotics) that are delivered either via injection or intracanalicular insert can help avoid complicating a patient’s drop regimen that is already subject to non-compliance, instillation issues, potential for ocular surface agitation, and more.
When EyeWorld spoke with Leon Herndon, MD, he said he had a patient who came in recently for her cataract postop visit with a moxifloxacin bottle capped with a green Lumigan (bimatoprost, Allergan) top. “This happens,” he said. Nathan Radcliffe, MD, said “things fall apart” when you add a steroid, antibiotic, and NSAID onto a complicated glaucoma drop regimen.
“We see a lot of errors where instead of taking prednisolone four times a day, patients will take their glaucoma drop that’s usually once a day four times a day. This creates problems with healing, more inflammation on the eye,” he said.
In addition to the confusion adding new drops (even short-term ones) causes, Dr. Radcliffe pointed out that they can negate,
for a time, the glaucoma-related procedures that are often performed with cataract surgery to get patients off drops.
“It’s nice to be able to deliver on the promise to reduce drops by actually doing so, not just trading their glaucoma drops for anti-inflammatory drops,” he said.
Dr. Herndon said he has used Dextenza (dexamethasone ophthalmic insert, Ocular Therapeutix) for more than a year for combined cataract surgery/MIGS patients. He said he injects intracameral moxifloxacin and inserts the Dextenza intracanalicular implant, finding it has worked well with MIGS like iStent (Glaukos), Hydrus (Ivantis), and Kahook Dual Blade (New World Medical).
Dr. Radcliffe also said he’ll use intracameral moxifloxacin, off-label obtained by a compounding pharmacy, putting it in the anterior chamber. Dextenza, he said, is put into the lacrimal puncta; Dexycu (dexamethasone intraocular suspension, EyePoint Pharmaceuticals) is injected into the iridociliary sulcus forming a sphere of dexamethasone. When using an intracameral antibiotic, Dr. Radcliffe said the wounds need to be especially tight and well-sealed because the volume injected into the vitreous can cause a high positive pressure situation. There can also be temporary visual issues with the opaque solution.
Dr. Radcliffe said some surgeons have had trouble with the placement of Dexycu, the sphere getting into the anterior chamber. As such, he said he’s placed it into the periphery of the capsular bag or in the vitreous. He has also injected a little under the conjunctiva for additional surface anti-inflammatory therapy. He noted that these injection approaches are considered off-label, though the drug is approved for after eye surgery.
Dr. Radcliffe said he’s found Dextenza and Dexycu helpful in cataract surgery plus MIGS cases, but he’s also found it useful in traditional glaucoma surgeries. Dr. Herndon also said he has used Dextenza with trabeculectomy procedures but still prescribes a prednisolone acetate drop.
“I’m hesitant to make [trabeculectomies] dropless because the inflammatory reaction is so much more potent in those patients,” Dr. Herndon said.
From an ocular surface standpoint, Dr. Herndon said taking away steroid and nonsteroidal drops that have preservatives in them is beneficial to glaucoma patients who could be particularly sensitive on the ocular surface.
Reimbursement for these is a regional issue. Dr. Herndon said his staff preoperatively confirms patients who would be approved for Dextenza. He’s found good coverage for Medicare patients coming to Duke University for surgery. Dr. Radcliffe said if done on-label, the reimbursement landscape works for Dextenza and Dexycu. An intracameral antibiotic is out of pocket, but he said it is usually around $20.
Dr. Radcliffe and Dr. Herndon said they haven’t seen contraindications for patients receiving Dextenza or Dexycu. Even the concern of a steroid response in glaucoma patients with these options is minimal. Dr. Herndon said most steroid responses occur after 4–5 weeks. Both Dextenza and Dexycu last up to 30 days and taper over time, and neither have had steroid response issues with the products they use.
“I find with Tri-Moxi [triamcinolone acetonide/moxifloxacin, ImprimisRx], Dexycu, and Dextenza, I can get most of my patients to have surgery without any eye drops, and that is a huge relief for my colleagues who are seeing them postoperatively and for my office staff who don’t have to put in many prescriptions the day after a big surgery day,” Dr. Radcliffe said.
Dr. Radcliffe said that any surgeons who would like to discuss “in-the-bag” or intravitreal Dexycu techniques can contact him.

About the physicians

Leon Herndon, MD
Professor of Ophthalmology
Duke University School of Medicine
Durham, North Carolina

Nathan Radcliffe, MD
Associate Clinical Professor
New York Eye and Ear Infirmary of Mount Sinai
New York, New York

Reference

1. Robin A, Covert D. Does adjunctive glaucoma therapy affect adherence to the initial primary therapy? Ophthalmology. 2005;112:863–868.

Relevant disclosures

Herndon
: Ocular Therapeutix
Radcliffe: Alcon, EyePoint Pharmaceuticals, Glaukos, Ocular Therapeutix

Contact

Herndon
: leon.herndon@duke.edu
Radcliffe: drradcliffe@gmail.com

Options to reduce postop cataract surgery drops for glaucoma patients Options to reduce postop cataract surgery drops for glaucoma patients
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