Focus on the Cataract Patient’s Experience

After cataract surgery, patients are commonly prescribed a regimen of topical ocular therapeutics including antibacterials, steroidals, and NSAIDs. Multiple studies have shown that patients exhibit limited compliance with medication protocols, even when the repercussions of noncompliance include significant morbidity.^1,2

Cataract surgery requires patients to follow a complex topical drop regimen, tasking health care workers with explaining the regimen to patients who then often struggle with adherence.^1,2 Further complexity ensues because patients are responsible for continuing the use of ocular medications that were prescribed before their cataract surgery. In addition, they may be given additional medications and instructions, aside from the standard protocol, if complications such as corneal edema or IOP rise occur postoperatively.

EASING THE TREATMENT BURDEN

One option for decreasing the burden of topical drop regimens is to use a sustained delivery approach for the administration of postoperative medications such as the dexamethasone 0.4 mg ophthalmic insert (Dextenza, Ocular Therapeutix). This intracanalicular insert elutes a sustained and tapered dose of the steroid dexamethasone for 30 days after insertion.³ The insert resorbs 90 days after placement. It can be positioned within the canaliculi preoperatively, intraoperatively, or postoperatively, according to the preference of the surgeon. Other options include the use of compounded steroid injections, combination drops, and the single-dose, sustained-release dexamethasone intraocular suspension 9% (Dexycu, EyePoint Pharmaceuticals), approved for the treatment of cataract postoperative inflammation (see Intraocular Suspension Aims to Improve Patient Compliance and Outcomes).

This article recounts our experience with the dexamethasone intracanalicular insert. To avoid using the brand name repeatedly, we hereafter refer to it as the insert.

POSITIVE FEEDBACK

When given the choice between the insert and topical therapy, nearly all of our patients have opted for the insert. The first patients we treated with the insert were patients who had already undergone cataract surgery in one eye and had received topical therapy after surgery. We offered these patients the choice between using topical therapy or the insert after the second eye surgery. This allowed us to make subjective and objective comparisons throughout the postoperative period. Patients were evaluated at standard postoperative visits of 1 day, 1 week, and 1 month.

Participants in phase 3 clinical trials involving the insert reported decreased pain and inflammation and needed rescue topical steroid therapy intervention with the insert less frequently when compared with a placebo vehicle.^4,5

So far, our patients who have received the insert have given positive feedback on their experiences. Additionally, they have communicated a preference for the insert relative to topical therapy. In clinic, we have noted that the degree of postoperative intraocular inflammation and resolution has been comparable between patients treated with the insert and those treated with a topical steroid.

None of our patients have experienced severe complications to date, although one patient did note the awareness of a congealed yellow substance at the caruncle. Upon slit-lamp evaluation, we concluded that the substance resulted from the breakdown of the insert. This was akin to the clumping of prednisone acetate 1% topical drops that can occur on the ocular surface after application if patients fail to shake the suspension sufficiently.

The time frame for the placement of the insert is flexible, distinguishing this treatment from other treatments intended to simplify postoperative topical regimens, such as intracameral injection and intraocular suspension. Ophthalmic surgeons usually place the insert immediately after completion of cataract surgery, with the patient still in the OR.

Before placing the insert, the punctum is dilated and dried with a Weck-cel surgical sponge (BVI). The insert is removed from its holder using toothless Bishop forceps and is positioned through the punctum and into the canaliculi. The insert begins eluting dexamethasone onto the ocular surface as contact is made between the insert and the patient’s tears. Absorption of the tears also causes the insert to decrease in length and widen, which secures it in place within the canaliculi (Figure 1).

The insert will reside in this location for the next 90 days and will disperse dexamethasone onto the ocular surface in a tapered fashion for the first 30 days. For a video depiction of the application of the insert with commentary visit bit.ly/1021MODSkor.

OPTOMETRIC POSTOPERATIVE CARE

Cataract surgery postoperative visits are largely the same for patients who have received the intracanalicular insert as for those using a topical steroid. The day 1, week 1, and month 1 assessments should include patient history, UCVA, pinhole acuity, refraction (depending on corneal clarity), IOP measurement, and slit-lamp examination.

Additionally, for patients who have received the insert, the lower lid is everted to allow evaluation of the inferior punctal and canalicular region to confirm that the insert is in place. The insert contains fluorescein, which improves visualization under cobalt blue light. Visualization can be further accentuated by using a yellow Wratten filter in conjunction with the blue light setting on the slit-lamp (Figure 2). With these lighting conditions, appropriate placement of the insert can be confirmed, giving the doctor confidence that the patient is receiving steroidal treatment.

The most frequently noted complications for patients with the insert are anterior chamber inflammation including iritis and iridocyclitis (10%), IOP increase (6%), visual acuity reduction (2%), cystoid macular edema (1%), corneal edema (1%), eye pain (1%), conjunctival hyperemia (1%), and headache (1%).⁶ In the great majority of instances, reactions were noted within 2 days of surgery and were attributed to the surgery rather than the insert.⁷

The risks of complications associated with the use of corticosteroids on the ocular surface remain the same for insert placement and topical therapy alike. Should such complications arise, removal of the insert may be necessary. Fortunately, the insert can be easily removed either proximally with manual expression or distally with saline irrigation.⁶ As with other steroidal therapeutics, the insert is contraindicated for patients who have corneal, conjunctival, or canalicular infections, and it should be cautiously used in patients with glaucoma, ocular hypertension, or a history of steroid-induced IOP elevation.⁶

COMPLIANCE ENSURED

Along with the insert, we have continued to prescribe topical antibacterial and nonsteroidal antiinflammatory drops for patients after cataract surgery. Nevertheless, time spent educating the patient on the use and schedule of their postoperative eye drop medications is greatly decreased with the dexamethasone insert. Furthermore, the insert mitigates compliance issues. So long as the insert remains in place, compliance with the steroid portion of the postoperative regimen is ensured.