October 2019

REFRACTIVE

Pharmaceutical Focus
Plugging cataract patients into Dextenza use


by Maxine Lipner EyeWorld Senior Contributing Writer


The Dextenza plug is placed into the tear duct, usually at the time of cataract surgery.
Source: John Berdahl, MD

 

The FDA-approved drug-eluting punctal plug Dextenza (dexamethasone, Ocular Therapeutix) is now being used by cataract practitioners hoping to alleviate some of the postoperative drop burden for patients, according to John Berdahl, MD. What can physicians expect when including this in their patients’ cataract regimens?

Implanting Dextenza

Dr. Berdahl said that the FDA indication for Dextenza is to lower pain and inflammation associated with cataract surgery. There are several advantages to using it over postoperative drops alone, he pointed out.
The plug itself works in a straightforward manner. “It’s a hydrogel polymer implant that goes into the canaliculus either at the time of cataract surgery or in the office, and it elutes dexamethasone over the following 4 to 6 weeks,” he said. “It delivers dexamethasone and patients don’t have to take steroid eye drops,” Dr. Berdahl said, adding that it auto-tapers itself so patients get the benefits of a punctal plug and better lubrication of the eye after cataract surgery. It also helps circumvent dependence on patient compliance.
David Stephens, MD, views Dextenza as particularly helpful for patients who are at risk for more inflammation than normal, such as someone with uveitis or ocular surface disease for whom the physician would like to alleviate the drop burden.
Dr. Stephens implants Dextenza in the operating room at the time of cataract surgery, just as he would with a normal punctal plug. “Following the surgery, we take the drape down and I evert the eyelid with a cotton tip and we perform punctal dilation,” Dr. Stephens said. Then the surface of the eye and the punctum is dried thoroughly and the plug inserted with forceps into the lower punctum.
He explains to patients beforehand that he will be putting a medicated plug into the tear duct at the time of the cataract procedure. He alerts them that they might feel a little pressure because the eye is numb but the eyelids are not. When inserting the plug, Dr. Stephens stressed the need to keep it dry. Dextenza swells immediately when it comes in contact with water, which would make it difficult to insert.

Postoperative expectations

Dr. Stephens found that patient responses to the drug eluting plug have been promising. “We do an injection of antibiotic and steroid at the time of cataract surgery and we have them on a combination drop of prednisolone, gatifloxacin, and bromfenac once a day for 2 weeks,” he said, adding that so far results have been good.
Dr. Berdahl agreed that those already on a steroid antibiotic combination in conjunction with Dextenza won’t need much else. The FDA study1 showed that at day 14 approximately 52% of patients had the absence of anterior cell flare compared with 31% in the placebo group.
While there can be some complications, these are limited. With the plug in the eye, patients’ tears don’t drain as rapidly as they would otherwise. “In an older population, we like those extra tears around in the healing period with cataract surgery,” Dr. Berdahl said. One possibility to watch out for is difficulty getting the plug in all of the way, in which case you might have to trim this postoperatively, Dr. Berdahl noted.
Dr. Stephens pointed out that rebound inflammation can sometimes be an issue. However, this has only occurred in one of his cases so far and it responded well to topical steroids. “The main thing is telling patients that if they have some inflammation afterward, we might have to give drops for a little bit longer,” he said.
Another side effect could be increased IOP. “This happened in 6% of eyes in the FDA trial,” Dr. Stephens said. “So far we have avoided using this in patients who we were worried about having an IOP spike such as those with glaucoma.” If such a spike were to occur, the pressure would be treated with topical medication until the plug dissolves at about 1 month or until the pressure goes down, he noted.
When it comes to the addition of topical steroids postoperatively, Dr. Stephens has found only 1 out of 30 to 40 patients has needed it.
Dr. Berdahl said that Dextenza is a forerunner. “Dextenza is one of the early products to do ocular drug delivery,” he said. “If we can get it right, we’ll improve results and we’ll make it so we’re less dependent on patient compliance for good outcomes.”

About the doctors

John Berdahl, MD
Vance Thompson Vison
Sioux Falls, South Dakota

David Stephens, MD
Tyson Eye
Fort Myers, Florida

Reference

1.Tyson SL, et al. Multicenter randomized phase 3 study of a sustained-release intracanalicular dexamethasone insert for treatment of ocular inflammation and pain after cataract surgery. J Cataract Refract Surg. 2019;45:204–212.

Relevant financial interests

Berdahl: None
Stephens: Ocular Therapeutix

Contact information

Berdahl: john.berdahl@vancethompsonvision.com
Stephens: david.stephens@tysoneye.com

Plugging cataract patients into Dextenza use Plugging cataract patients into Dextenza use
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