Dexamethasone Insert easy alternative for Treatment of Ocular Inflammation After Cataract/Cornea Surgery
Courtesy by Eugene B. McLaurin et al., American Journal of Ophthalmology
Adherence to treatment regimens after ocular surgery can be complicated by patient compliance and difficulty administering topical drops. It is particularly important to address ocular inflammation after surgical procedures such as cataract surgery and corneal transplantation to decrease the likelihood of anterior chamber inflammation, macular edema, and corneal edema/rejection. Surgical technique and postoperative treatments are both geared towards minimizing postoperative inflammation. Minimally invasive surgical techniques and technological advances have led to smaller surgical incisions, resulting in reduced trauma to ocular structures. Despite the novel advances to cataract surgery, postoperative inflammation remains ever-present.
The postoperative medication regimen is critical towards inhibiting the potentially destructive effects of the inflammatory cascade. Corticosteroids and non-steroidal anti-inflammatory drugs (NSAIDs) are the main tools in the ophthalmic surgeon's arsenal to combat non-infectious ocular inflammation, CME, and corneal graft rejection. An ocular side effect of corticosteroid use, regardless of the delivery mechanism is increased intraocular pressure (IOP) which can lead to optic neuropathy and steroid-induced glaucoma.
Topical administration of corticosteroids over a post-operative recovery period is the standard method for steroid delivery post cataract or corneal surgery, however long-term topical steroid use is not without its shortcomings. Topical steroids can reduce the immunological competence of the eye, as well as inhibit the corneal absorption of topical antibiotics, which can lead to opportunistic bacterial, viral, or fungal infections. Topical steroids have also been found to potentially delay corneal epithelial healing, particularly in the setting of a neurotrophic cornea. In addition, rebound ocular inflammation is always a risk following abrupt discontinuation or rapid tapering of topical steroids. The drawbacks of topical steroids extend beyond the realm of the eyeball itself; complex drop regimens give rise to increased costs and inconveniences to patients, leading to a reduction in patient drop compliance.
To help relieve patients of the burdens associated with the aforementioned corticosteroid delivery systems, authors Fram et al explored a sustained-release intracanalicular dexamethasone insert (Dextenza), which is placed in the punctum of the eye lid, and is designed to deliver preservative free dexamethasone to the ocular surface for up to thirty days. Dextenza has been shown to safely decrease ocular inflammation and pain post operatively and could provide a more consistent, reliable method for corticosteroid delivery to ocular structures. This strategy could simplify the complex drop regimens, potentially improving patient compliance, increasing both patient comfort and safety following surgery. The purpose of our study was to evaluate the safety and effectiveness of Dextenza as a corticosteroid delivery mechanism in combination with a shortened topical drop regimen following cataract or corneal surgery.
This retrospective case series contained 18 patients undergoing cataract surgery and 6 patients undergoing corneal surgery. All patients received the Dextenza intracanalicular insert. 6/18 of the patients in the cataract surgery arm were on the standard of care post-surgery topical steroid drop regimen, whereas 11/18 of the patients were on a reduced regimen. 1/18 of the patients was on a drop regimen that deviated from the aforementioned regimens. 2/6 of the patients in the corneal surgery arm were on the standard of care post-surgery topical steroid drop regimen, whereas 3/6 of the patients were on a reduced regimen. 1/6 of the patients were on a drop regimen that deviated from the aforementioned regimens.
The primary outcome measures are intraocular pressure (IOP) levels and anterior chamber inflammation levels across the post-operative recovery period. 1/18 of the patients in the cataract surgery arm and 1/6 of the patients in the corneal surgery arm experienced a clinically significant IOP spike greater than 10 millimeters of mercury (mmHg) above baseline IOP. No patient in either of the study groups had significant inflammation after 1 week post-surgery. 1/18 of the patients in the cataract surgery arm and 1/6 of the patients in the corneal surgery arm experienced a canalicular obstruction.
In summary, the Dextenza intracanalicular insert was found to be a safe and effective method for delivering corticosteroids to the ocular structures for inflammation management following cataract or corneal surgery, despite shortened treatment regimens in the immediate postoperative period. Future considerations that can be explored could involve the use of Dextenza without a topical steroid regimen, to elucidate if topical steroid use can be safely eliminated from a post-surgery treatment regimen instead of just reduced. The Dextenza insert ensures corticosteroid delivery to the ocular structures regardless of patient drop compliance and could bridge the gap between a surgeon's desired post-operative regimen, and the expectations of patients for a comfortable and safe regimen, in order to achieve the mutually desired outcome of a successful and uneventful surgery.
Source: Fram et al; Clinical Ophthalmology 2022:16
https://doi.org/10.2147/OPTH.S386702
