September 2019

CATARACT

Pharmaceutical Focus
Simplifying surgery with Dexycu


by Maxine Lipner EyeWorld Senior Contributing Writer


A blunt cannula is used to deliver Dexycu into the
posterior chamber.
Source: John Hovanesian, MD

Sometimes Dexycu can inadvertently get into the
anterior chamber but still works and dissipates on
its own.
Source: Brandon Ayres, MD

 

While many patients who have undergone cataract and other intraocular surgery are asked to take a plethora of drops postoperatively, the newer approach of injecting the FDA-approved Dexycu (dexamethasone intraocular suspension 9%, EyePoint Pharmaceuticals) can simplify things for patients, according to John Hovanesian, MD.
“Dexycu is a sustained-delivery form of dexamethasone that is placed intracamerally in the posterior chamber of the eye, typically at the end of surgery,” Dr. Hovanesian said, adding that the body will slowly absorb the dexamethasone as it is continuously released over a 1-month period. It provides an anti-inflammatory effect comparable clinically to topical Pred Forte (prednisolone acetate, Allergan) taken 4 times a day, he said. Dexycu is used most commonly in conjunction with cataract surgery.

Injecting Dexycu

Dexycu is injected through a blunt cannula that’s placed behind the iris into the ciliary sulcus at the conclusion of the case. “It lays as a sphere or as a cohesive layer of this hydrophobic material,” he said, adding that since there can be a learning curve, viewing the technique beforehand can be helpful.
Brandon Ayres, MD, finds the 27-gauge cannula to inject the self-tapering dose of Dexycu is preferable to the larger 25-gauge cannula typically used. “When we started with the 25-gauge cannula what we think was going on was that the surface tension of the Dexycu was strong enough that when we tried to leave the depot injection behind the iris, it would follow the cannula,” he said, adding that this resulted in inadvertently getting more Dexycu in the anterior chamber. When he switched to the smaller 27-gauge cannula, however, it seemed easier to place the Dexycu where it belonged. “A second advantage to the smaller cannula is that we didn’t get as much leakage of the aqueous through the incision that the cannula was put into the eye with,” Dr. Ayres said.
In addition to using Dexycu for cataract surgery, Dr. Ayres uses it for IOL exchanges. It would also not be contraindicated for glaucoma surgery. However, some procedures that involve the use of air bubbles, such as DSEK and DMEK, might be very challenging, he said.
Dr. Hovanesian views Dexycu as potentially well-suited for all patients, but as a particularly important option for those with which practitioners have concerns about compliance issues, since this takes dosing out of their hands.

Giving a heads-up

Dr. Ayres finds that telling patients there is a medication likely to prevent them from needing some drops is a selling point. “Patients rapidly accept it and it makes my life, our office life, and the patient’s life easier,” Dr. Ayres said, adding that so far, he has only had to dose one patient with postoperative steroid drops, and that was a case where additional surgery occurred.
In Dr. Hovanesian’s experience, it is important to warn patients about the possibility that not all of the material will stay behind the iris. “Patients may see a tiny white pearl, but they should know if they do that it’s going to go away pretty quickly and it won’t leave any permanent mark,” he said. “For clinicians, they may also see it residing against the endothelium and they may temporarily see a little bit of corneal edema locally.” However, such corneal edema will clear, Dr. Hovanesian stressed. The Phase 3 study showed the decrease in endothelial cell density was not significantly different between the Dexycu and prednisolone groups.1
A more common concern with Dexycu is pressure spikes. But in the FDA trial there were no more incidences of steroid-induced pressure spikes with Dexycu beyond the 1-day mark when caused by retained viscoelastic. When steroids are released slowly, they seem less prone to causing pressure spikes, he said.
Dr. Ayres finds that any pressure spike can be effectively lowered with a glaucoma drop. He attributes issues he’s had to a learning curve. “When I initially used the Dexycu implant, I think we were getting too much medication in the eye,” he said. The result was some transient corneal edema. Now that they have gotten a better handle, however, he finds this is far less likely to occur.
Overall, Dr. Ayres is excited about Dexycu and other products such as Dextenza (dexamethasone ophthalmic insert 0.4 mg, Ocular Therapeutix) that can reduce confusion in the office. “I think we get the cost savings, less confusion, and effective medication in the eye, so it’s a win for both the patient and the surgeon,” he concluded.

About the doctors

Brandon Ayres, MD

Wills Eye Hospital
Philadelphia

John Hovanesian, MD
Stein Eye Institute
University of California,
Los Angeles

Reference

1. Donnenfeld ED, et al. Safety of IBI-10090 for inflammation associated with cataract surgery: Phase 3 multicenter study. J Cataract Refract Surg. 2018;44:1236–1246.

Relevant financial interests

Ayres
: None
Hovanesian: EyePoint
Pharmaceuticals, Ocular
Therapeutix, Omeros

Contact information
Ayres
: BAyres@oppdoctors.com
Hovanesian: jhovanesian@harvardeye.com

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