EyeWorld Asia-Pacific June 2021 Issue

GLAUCOMA EWAP JUNE 2021 51 Jayant Iyer, MD Consultant, Clinical Assistant Professor Singapore National Eye Centre 11 Third Hospital Avenue, Singapore 168751 medjayant@gmail.com ASIA-PACIFIC PERSPECTIVES A recent Cochrane review revealed with “high certainty” that intraoperative intracameral injection of cefuroxime in addition to administration of antibiotic eyedrops postoperatively reduces the risk of endophthalmitis following cataract surgery. 1 As such, many centers worldwide prescribe topical antibiotics following cataract surgery in addition to prescribing topical steroids to control surgery-related ocular inflammation. These medications are typically prescribed over a 1-month duration following the surgery. There are however many challenges in eyedrop use following cataract surgery. They include (1) potential confusion with preexisting eyedrop regime especially in glaucoma patients, (2) complexity of postoperative eyedrop regime, (3) eyedrop-related ocular surface toxicity, (4) inconvenience of use, (5) improper eyedrop instillation technique, and (6) non-compliance. As such, the rationale for exploring a “drop-free” approach during the postoperative period following cataract surgery is sound. Currently, strategies offering a drop-free postoperative recovery period include intracameral injection of antibiotics such as cefuroxime or moxifloxacin, along with use of periocular dexamethasone via an intracanalicular implant, Dextenza, or intracameral or intravitreal injection of Dexycu. This strategy would alleviate many of the potential problems faced by some patients in using eyedrops following cataract surgery. There would be reduced burden on the patient postoperatively to apply the eyedrops correctly and compliantly. There would also be no eyedrop-related ocular surface toxicity. A study evaluating Dextenza found it to be well tolerated and convenient for patients. 2 Studies evaluating Dextenza and Dexycu also found them to have good efficacy in controlling postoperative ocular inflammation. 3 There are some potential drawbacks in using an intracameral or intravitreal injection of Dexycu. Any migration of the suspension to the visual axis could result in temporary vision disturbance due to the opaque nature of the dexamethasone suspension. In addition, there is a possibility of steroid response in patients injected with Dexycu. In patients on postoperative eyedrops, the steroid medication could be reduced to a lower potency formulation in the event of steroid response. Unlike Dexycu, the intracanalicular Dextenza could be easily removed in the event of steroid response. In addition, intracanalicular Dextenza also offers the surgeon the flexibility of choosing to use it pre-, intra- or postoperatively. There is however a possibility of extrusion of the intracanalicular insert device over the postoperative course. In summary, drop-free cataract surgery is a distinct reality and a step in the right direction. I look forward to being able to offer this option to my patients in the near future. References 1.Gower EW, et al. Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery. Cochrane Database Syst Rev . 2017 Feb 13;2(2):CD006364. 2.Gira JP, et al. Evaluating the patient experience after implantation of a 0.4 mg sustained release dexamethasone intracanalicular insert (Dextenza): results of a qualitative survey. Patient Prefer Adherence . 2017; 11:487–494. 3.Assil KK, et al. Dropless cataract surgery: modernizing perioperative medical therapy to improve outcomes and patient satisfaction. Curr Opin Ophthalmol . 2021 Jan;32 Suppl 1:S1-S12. Editors’ note: Dr. Iyer declared no relevant financial interests. Intravitreal Dexycu being delivered via pars plana injection in a patient receiving a PanOptix IOL (Alcon). Source: Nathan Radcliffe, MD Dexycu (dexamethasone intraocular suspension, EyePoint Pharmaceuticals) is injected into the iridociliary sulcus forming a sphere of dexamethasone. When using an intracameral antibiotic, Dr. Radcliffe said the wounds need to be especially tight and well-sealed because the volume injected into the vitreous can cause a high positive pressure situation. There can also be temporary visual issues with the opaque solution. Dr. Radcliffe said some surgeons have had trouble with the placement of Dexycu, the sphere getting into the anterior chamber. As such, he said he’s placed it into the periphery of the capsular bag or in the vitreous. He has also injected a little under the conjunctiva for additional surface anti- inflammatory therapy. He noted that these injection approaches are considered off-label, though the drug is approved for after eye surgery. Dr. Radcliffe said he’s found Dextenza and Dexycu helpful in cataract surgery plus MIGS cases, but he’s also found it useful in traditional glaucoma surgeries. Dr. Herndon also said he has used Dextenza with trabeculectomy procedures but still prescribes a prednisolone acetate drop. “I’m hesitant to make [trabeculectomies] dropless because the inflammatory reaction is so much more potent in those patients,” Dr. Herndon said. From an ocular surface standpoint, Dr. Herndon said taking away steroid and nonsteroidal drops that have preservatives in them is beneficial to glaucoma patients who could be particularly sensitive on the ocular surface. Reimbursement for these is a regional issue. Dr. Herndon said his staff preoperatively confirms patients who would be approved for Dextenza. He’s found good coverage for Medicare patients coming to Duke University for surgery. Dr. Radcliffe said if done on-label, the reimbursement landscape works for Dextenza and Dexycu. An intracameral