EyeWorld Asia-Pacific June 2021 Issue

GLAUCOMA 52 EWAP JUNE 2021 Visanee Tantisevi, MD Associate Professor, Department of Ophthalmology, Faculty of Medicine Chulalongkorn University 1873, Rama 4 Rd, Patumwan, Bangkok, Thailand tvisanee@gmail.com ASIA-PACIFIC PERSPECTIVES O ptions to reduce the number of therapeutic drops used after cataract surgery in glaucoma patients to mitigate the misuse of postoperative anti-glaucoma and anti-inflammatory agents were suggested. Introducing sustained-release drugs at the end of surgery is highlighted. As is, dexamethasone is the choice. It can be formulated as an intra-canalicular insert that gradually releases the active ingredient over 30 days (Dextenza, Ocular Therapeutics) or as an intracameral sphere (Dexycu, EyePoint Phamaceuticals) for 21-day release. A study of immediate intracameral dexamethasone showed its effectiveness in reducing AC cells and flare at day 1. 1 Since dexamethasone has a rapid turnover in aqueous plus single application, continued topical steroid is mandatory. For that reason, the novel delivery system is developed to fill the gap. Dexycu was FDA-approved for treating postoperative inflammation in 2018, the same year Dextenza was FDA-approved for pain treatment after cataract surgery, but additional approval for treatment of ocular inflammation following ophthalmic surgery was announced in 2019. RCTs comparing intra-canicular dexamethasone vs. vehicle insert in post-cataract surgery patients reported statistically significantly higher proportion of patients with absence of AC cells and flare at day 14 and absence of pain at day 8 in the treatments than in the controls (p < 0.001). Adverse events such as aggravated IOP were also shown but discussed as rather related to surgical procedure. 2 A three arms of the RCT comparing two doses (342 µg and 517 µg) of intracameral dexamethasone with placebo (5 µl) for their effect on clearing of AC cells at day 8 post cataract surgery revealed significantly greater percentage of patients achieving the endpoint in both dexamethasone groups, 2/3, than in the control, 1/4. (p<0.05). It also disclosed that this relationship was carried until day 30. During follow-up, IOP greater than 10 mmHg were also observed, 29% in 517 µg group, 21% in 342 µg group and 13% in the placebo. Unfortunately, the incidents were not detailed or explored. 3 The above data makes the sustained-release dexamethasone a promising alternative to months-long postoperative topical steroid, particularly for anterior segment surgeries, for example, glaucoma filtering or combination of cataract and glaucoma procedures, in which IOP rise should not be a challenge. Their longer anti-inflammatory effect allows the reduction in the number of postoperative eye drops used, resolving confusion and taming the ocular surface. However, the studies had been primarily in post-cataract surgeries. Further research in other ophthalmic surgeries and in other ethnic groups are warranted. Moreover, the price itself may be a concern. References 1. Güngör SG, et al. Comparison of intracameral dexamethasone and intracameral triamcinolone acetonide injection at the end of phacoemulsification surgery. Indian J Ophthalmol . August 2014;62(8):861–864. doi: 10.4103/0301-4738.141045 2. Donnenfeld E, Holland E. Dexamethasone Intracameral Drug-Delivery Suspension for Inflammation Associated with Cataract Surgery: A Randomized, Placebo-Controlled, Phase III Trial. Ophthalmology . 2018 Jun;125(6):799-806. doi: 10.1016/j.ophtha.2017.12.029. Epub 2018 Feb 13. Erratum in: Ophthalmology . 2018 Oct;125(10):1664. PMID: 29397189. 3. Tyson SL, et al.; Dextenza Study Group. Multicenter randomized phase 3 study of a sustained-release intracanalicular dexamethasone insert for treatment of ocular inflammation and pain after cataract surgery. J Cataract Refract Surg . 2019 Feb;45(2):204–212. doi: 10.1016/j.jcrs.2018.09.023. Epub 2018 Oct 24. Erratum in: J Cataract Refract Surg . 2019 Jun;45(6):895. PMID: 30367938. Editors’ note: Dr. Visanee Tantisevi declared no relevant financial interests. antibiotic is out of pocket, but he said it is usually around US$20. Dr. Radcliffe and Dr. Herndon said they haven’t seen contraindications for patients receiving Dextenza or Dexycu. Even the concern of a steroid response in glaucoma patients with these options is minimal. Dr. Herndon said most steroid responses occur after 4–5 weeks. Both Dextenza and Dexycu last up to 30 days and taper over time, and neither have had steroid response issues with the products they use. “I fi nd with Tri-Moxi [triamcinolone acetonide/ moxifloxacin, ImprimisRx], Dexycu, and Dextenza, I can get most of my patients to have surgery without any eye drops, and that is a huge relief for my colleagues who are seeing them postoperatively and for my office staff who don’t have to put in many prescriptions the day after a big surgery day,” Dr. Radcliffe said. Dr. Radcliffe said that any surgeons who would like to discuss “in-the-bag” or intravitreal Dexycu techniques can contact him. EWAP Reference 1. Robin A, Covert D. Does adjunctive glaucoma therapy affect adherence to the initial primary therapy? Ophthalmology . 2005;112:863–868. Editors’ note: Dr. Herndon is Professor of Ophthalmology, Duke University School of Medicine, Durham, North Carolina, and has relevant interests with Ocular Therapeutix. Dr. Radcliffe is Associate Clinical Professor, New York Eye and Ear Infirmary of Mount Sinai, New York, and has relevant interests with Alcon, EyePoint Pharmaceuticals, Glaukos, and Ocular Therapeutix.