Drs. Radcliffe, Gupta, and Singh walk through surgical videos of them inserting Dexycu (dexamethasone intraocular suspension 9%, EyePoint Pharmaceuticals), Dextenza (dexamethasone ophthalmic insert 0.4mg, Ocular Therapeutix), and Durysta (bimatoprost intracameral implant 10mcg, Allergan, An AbbVie Company), respectively, while discussing surgical pearls based on their personal implantation techniques.
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Intravitreal Dexycu injection at the time of cataract surgery
To initiate the Dexycu placement, Dr. Radcliffe hydrates the main wounds, moves 3mm posterior to the limbus, and then injects Dexycu while visualizing the needle in the anterior vitreous. He added that during the injection, it is possible to see the dexamethasone bubble form in the vitreous.
Once the needle is withdrawn, the bubble settles inferiorly, which can reduce the potential for the patient to visualize Dexycu as a floater. Based on Dr. Radcliffe’s surgical experience post-operatively, he noted during slit lamp examination that Dexycu tends to stay in the peripheral vitreous until it is resorbed. Then, switching injection sites, Dr. Radcliffe injected additional Dexycu subconjunctivally, which tends to fully resorb after 1 week.
As antibiotic prophylaxis after cataract surgery is an integral part of Dr. Radcliffe’s surgical protocol, following cataract extraction and Dexycu placement, he builds an injection of intracameral moxifloxacin (using a 25 or 30G needle), along with subconjunctival ANCEF (cefazolin, GlaxoSmithKline) for a dropless cataract surgery.
Dextenza insertion with viscoelastic at the time of cataract surgery
Prior to inserting Dextenza, Dr. Gupta advised surgeons to make sure that the incisions are closed and the intracameral antibiotic has already been administered. Subsequently, she prefers to pull the drape away from the eye, gently pull the lid laterally, and dry the puncta to ensure the removal of any debris or residual mucus.
Next, with a dilator, Dr. Gupta approached the puncta with a horizontal and flat technique to dilate it, and she then adds viscoelastic to the puncta for lubrication. She mentioned that in her experience, the treatment outcome is not impacted by the brand of the viscoelastic (such as ProVisc [Alcon] or StableVisc [B+L]), as any cohesive viscoelastic will work. The key is to avoid adding too much viscoelastic to the puncta to prevent building too much pressure in the canalicular system.
Lastly, Dr. Gupta gently inserts the Dextenza into the puncta, sliding it in easily without excessive force.
Insertion of Durysta at the slit lamp
In the next video, Dr. Singh presented a slit lamp video of Durysta insertion, in which he uses a 20G needle loaded with Durysta, placing the needle anterior to the limbal vessels and parallel to the iris. He then pushes the needle into the anterior chamber about two bevel lengths, releases the implant, and withdraws. This marked the end of the procedure, as the implant will sink to the bottom (and out of view of the patient) with gravity.
Due to the fact that this can be a straightforward procedure, Dr. Singh highlighted that many patients perceive it to be similar to an intraocular pressure (IOP) check or eye exam, making the acceptance rate comparatively high. Further, the longevity of the medication is also generally not an issue for patients because the insertion is simple and relatively painless. Consequently, patients tend to be more open to the procedure since the bioerodible preservative-free implant can remain active for up to 4 to 6 months.
Conclusion
By employing the aforementioned surgical pearls for implanting Dexycu, Dextenza, and Durysta, surgeons will be able to maximize their effects with quick and proper placement with practice.
Disclaimer: Dexycu (dexamethasone ophthalmic suspension) 9% from EyePoint Pharmaceuticals is an injectable, single-dose, sustained-release medication indicated for the treatment of post-operative inflammation. Dextenza (dexamethasone ophthalmic insert) 0.4mg from Ocular Therapeutix is a preservative-free intracanalicular insert indicated for the treatment of post-operative inflammation and ocular allergy management. Durysta (bimatoprost intracameral implant) 10mcg from Allergan is a dissolvable preservative-free ocular implant indicated for the reduction of IOP in patients with open-angle glaucoma or ocular hypertension. The medical opinions and views expressed in this article are those of Preeya K. Gupta, MD, I. Paul Singh, MD, and Nathan Radcliffe, MD.
