April 2020

GLAUCOMA

Using Dextenza and Dexycu outside of cataract surgery


by Liz Hillman Editorial Co-Director


Dextenza placement

Dexycu placement
Source (all): Inder Paul Singh, MD

 

Dexycu (dexamethasone intraocular suspension, EyePoint Pharmaceuticals) and Dextenza (dexamethasone ophthalmic insert, Ocular Therapeutix) both received FDA approval in 2019. While they are both approved for the treatment of postoperative inflammation, they are most thought of in association with cataract surgery. Of note, both products are not contraindicated in glaucoma but contain a label warning that prolonged use of steroids can be associated with elevated IOP and that IOP should be monitored in patients using steroids. Inder Paul Singh, MD, and Nathan Radcliffe, MD, shared how they’ve been using these products to calm inflammation in a variety of procedures.
“A very simplistic way to look at it is wherever you use a steroid, you could use these products,” Dr. Singh said.
Dexycu and Dextenza can reduce or eliminate the need for topical steroid drops, Dr. Singh said.
Because Dexycu is an injection, Dr. Singh and Dr. Radcliffe said they use it for intraocular surgeries, such as tube shunt surgery, IOL exchange, standalone and combined MIGS procedures, and pupilloplasty, to name a few.
“One thing people worry about is does Dexycu clog the stent; it does not,” Dr. Radcliffe said, referencing stenting procedures for glaucoma. “I would say you could think of Dexycu for any intraocular surgery you’re doing.”
Dr. Singh said Dexycu is advantageous because you don’t have to worry about absorption into the eye. He said people with significant risk factors for inflammation, such as epiretinal membrane, CME, diabetic retinopathy, rheumatoid arthritis, autoimmune conditions, or past uveitis, could benefit. One of the negatives of Dexycu is you can’t remove it if a negative response occurs.
Removability, however, is one of Dextenza’s advantages. Dr. Singh said he uses Dextenza for canaloplasty, goniotomy, subconjunctival surgery with the XEN Gel Stent (Allergan) or tube shunts, and pterygium surgery. He has found a significant benefit for the ocular surface preoperatively before taking measurements for cataract surgery and for optimizing the ocular surface before subconjunctival surgery. Dr. Radcliffe also said Dextenza makes sense for conjunctival surgeries, pterygium, and glaucoma tube shunt surgeries.
Dr. Singh mentioned a study that looked at use of Dextenza before XEN surgery; there is a J code that allows Dextenza to be placed in the office. Anecdotally, he said the outcomes thus far are no different than those on topical steroids every few hours during the first week. He uses loteprednol twice a day along with Dextenza for subconjunctival surgery, which he said improves patient compliance due to the reduced dosing regimen of the steroid drops they do have to take.
For glaucoma procedures where doctors might watch for an IOP spike after steroid use, Dr. Singh cited Phase 3 clinical trial data for Dextenza that showed there was no significant steroid response.
Taking a step back, Dr. Singh said that for glaucoma, cataract surgery, and managing dry eye, patient satisfaction has become more important than ever before. To this end, reducing the drop burden is a major factor in achieving high patient satisfaction. Dr. Singh discussed a nonpublished in-office study where patients 3 months post-cataract surgery who were happy with outcomes were asked what the most difficult part of the surgical process was.
“It was drops,” he said. “The whole paradigm shift is toward earlier intervention, number one, but number two is maintaining a high patient satisfaction at the same time.”
For procedures like endocyclophotocoagulation or micropulse, Dr. Radcliffe said Dexycu or Dextenza might not provide enough anti-inflammatory action, requiring a topical backup. Similarly, for pterygium surgery, Dr. Radcliffe said you need to monitor to make sure the patient doesn’t need additional anti-inflammatory action.
“But the good news is you can dose it two, three, four times a day, instead of every hour,” he said.
Some patients might not tolerate drops well. Dr. Singh described a patient who developed significant keratitis for 8 months from the preservatives in the drops used after cataract surgery in her first eye. After her second cataract surgery, she received Dextenza without any other anti-inflammatory medications, and she ended up with an uneventful postoperative course.
“What’s also nice about Dextenza is it conforms to the size of the canaliculus and punctum, functioning as a kind of punctal plug,” Dr. Singh said. This is another benefit; helping the ocular surface post-surgery can assist in speed of visual recovery.
Dr. Radcliffe said that for glaucoma patients who are already taking drops to reduce IOP, use of one of these products after a procedure can reduce the drop burden and increase compliance.

About the doctors

Nathan Radcliffe, MD

Associate clinical professor
New York Eye and Ear Infirmary
New York, New York

Inder Paul Singh, MD
The Eye Centers of
Racine & Kenosha
Racine and Kenosha, Wisconsin

Relevant disclosures

Radcliffe
: EyePoint Pharmaceuticals, Ocular Therapeutix
Singh: Allergan, Bausch + Lomb, Kala Pharmaceuticals, EyePoint Pharmaceuticals

Contact

Radcliffe: drradcliffe@gmail.com
Singh: ipsingh@amazingeye.com

Using Dextenza and Dexycu outside of cataract surgery Using Dextenza and Dexycu outside of cataract surgery
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