A short-term sustained-release insert can offset treatment burden

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It is common for surgeons to gain new ideas from other subspecialties or fields of medicine. Looking at innovative tools and their applications in different disease states can help us to think creatively about ways to benefit our patients in retina care.

As a partner and member of the medical executive committee for American Vision Partners, one of the nation’s largest eye care practices, I have had the opportunity to observe how valuable the 0.4-mg dexamethasone sustained-release intracanalicular insert (Dextenza; Ocular Therapeutix) has been for my cataract surgery colleagues. This sustained-release insert enhanced the patient experience and eliminated physician concerns about adherence to drop regimens. It also dramatically reduced the burden on the practice to triage phone calls from patients, caregivers, and pharmacies about costs, schedules, and formulary substitutions. “Dropless” surgery (or surgery with fewer drops) made great sense for cataract patients, and I immediately thought this tool would also benefit our patients in the retina world.

We already have sustained-release intraocular corticosteroid implants. I routinely use Ozurdex (AbbVie), Iluvien, and Yutiq (both Alimera Sciences) for retinal indications. However, these are designed for long-term (approximately 36 months) management of underlying inflammatory disease processes. By contrast, Dextenza lasts up to 30 days and is indicated for treating and controlling postoperative inflammation and pain. I see an intracanalicular dexamethasone insert playing a role in 2 types of retinal surgery at opposite ends of the complexity spectrum.

Complex surgeries

First and most obvious is as an adjunctive therapy in highly complex and inflammation-inducing surgeries, such as those in which we are dissecting the Tenon capsule (ie, suturing lenses), repairing or reattaching the retina, or providing extensive retinal laser. Suppose I am treating a patient who presents as diabetic, hypertensive, and vasculopathic and has preexisting macular edema (Figure 1). I am about to perform a procedure that will induce even more inflammation. In that case, there is a clear need to control inflammation postoperatively as much as possible. In such cases, I like to have the sustained-release insert in place to complement, rather than replace, topical steroid drops.

It can be placed during a single office visit before or after surgery or even on the operative day if desired. The insert provides continuous, controlled delivery of the preservative-free steroid directly to the eye, enhancing efficacy and minimizing steroid adverse effects. With this approach, my colleagues and I are seeing less inflammation. I have not seen any IOP spikes due to the insert, but I might be more cautious using it in a patient with glaucoma simply because I have less ability to titrate the amount of steroid.

The Dextenza insert provides an additional measure of safety should patients be nonadherent to instructions for postoperative drops. We have all seen patients at a postoperative appointment without having filled their prescription for prednisolone drops, either because they forgot or balked at the cost. Some patients have mixed up the bottles and accidentally stopped the prednisolone at 1 week and began tapering the antibiotic instead of the reverse as was instructed. In the past, I would expect to see robust inflammation when these mistakes occur. However, I haveseen several cases where a patient with the intracanalicular dexamethasone insert failed to use their steroid drops correctly and still had no postoperative edema or inflammatory cells because they had the adjunctive dexamethasone on board, as well.

Minor vitrectomy

At the other end of the spectrum, there is also the potential to use sustained-release dexamethasone for minor vitrectomies. I have started using Dextenza in the proportion of my retinal surgeries that are less invasive and performed in healthier eyes, such as an epiretinal membrane peel or less involved vitrectomy. For example, given the improvements in vitrectomy techniques and technology in the past 15 years, we are increasingly performing vitrectomy for symptomatic floaters in patients with good vision and no other pathology.

In these cases, I make three 0.5-mm transconjunctival, sutureless incisions. These incisions are much smaller than the 2.2- or 2.4-mm wounds created in “small incision” cataract surgery. Unlike our cataract surgery colleagues, we are not violating the lens capsule or releasing proinflammatory lenticular debris into the immune-privileged anterior chamber. Consequently, these minor retinal procedures are potentially even less inflammatory than cataract surgery and have as good or better a chance of being successfully performed in a dropless manner.

Doctors from Retina-Vitreous Surgeons of Central New York published a small, prospective, randomized phase 4 pilot study (the ADHERE trial; NCT04462523). They compared outcomes for patients who received an intracanalicular dexamethasone insert before surgery, day of surgery, or postoperative day 1 with those treated with standard topical prednisolone acetate 1% drops 4 times daily. All 4 groups had well-controlled postoperative pain and inflammation.¹

I have used a sustained-release insert without a topical steroid in about 20 patients undergoing simple vitrectomy surgery for floater removal. So far, I have seen no inflammation, no cystoid macular edema, and no inflammation at the slit lamp with this approach. Just as in cataract surgery, it significantly reduces the burden on patients of instilling drops, limits postoperative costs, and helps to control the volume of calls to the office.

First cases

For those who have never used the intracanalicular dexamethasone insert, I recommend beginning with complex patients who could benefit from its adjunctive anti-inflammatory effects before considering it for minor vitrectomy patients.

Although we all learned about the canalicular system in residency, most ophthalmologists outside of oculoplastics and pediatrics have little experience with it. I recommend a brief refresher course on canalicular anatomy and a little practice on using a punctal dilator and correctly positioning the device so the first insertion is successful. If multiple attempts are required, the insert can become hydrated prematurely, which makes it more difficult to place in the canaliculus. My technique, which could be helpful to beginners, is to “park” the surgical drying spear vertically between the conjunctival bulb of the globe and the canaliculus (Figure 2). After I dry it, I use a cellulose sponge spear to place the insert on the palpebral conjunctival side, underneath the canaliculus, which helps to prevent any fluid reaccumulation around the punctum.

As our management of retinal procedures continues to evolve, I believe that inflammation control with an intracanalicular dexamethasone implant can play an important role in complex and simple procedures. Controlled studies in larger populations are needed to validate our early perceptions of efficacy and safety. •

Jordan Graff, MD, FACS

is a retina and vitreous surgeon at Barnet Dulaney Perkins Eye Center in Phoenix, Arizona, and a surgeon and medical executive committee member for American Vision Partners. He is a consultant for Ocular Therapeutix.

E: JGraff@BDPEC.com

Reference

1. Ueberroth JA, Oellers PR, Brown J, Rosenberg KI, Breazzano MP. Intracanalicular dexamethasone insert after retinal surgery: the ADHERE trial. Ophthalmol Retina. 2023;7(9):831-833. doi:10.1016/j.oret.2023.06.011