Eyeworld

SEPTEMBER 2019 | EYEWORLD | 39 C PHARMACEUTICAL FOCUS Contact information Ayres: BAyres@oppdoctors.com Hovanesian: jhovanesian@harvardeye.com About the doctors Brandon Ayres, MD Wills Eye Hospital Philadelphia John Hovanesian, MD Stein Eye Institute University of California, Los Angeles Reference 1. Donnenfeld ED, et al. Safety of IBI-10090 for inflamma- tion associated with cataract surgery: Phase 3 multicenter study. J Cataract Refract Surg. 2018;44:1236–1246. Relevant financial interests Ayres: None Hovanesian: EyePoint Pharmaceuticals, Ocular Therapeutix, Omeros times a day, he said. Dexycu is used most com- monly in conjunction with cataract surgery. Injecting Dexycu Dexycu is injected through a blunt cannula that's placed behind the iris into the ciliary sul- cus at the conclusion of the case. "It lays as a sphere or as a cohesive layer of this hydropho- bic material," he said, adding that since there can be a learning curve, viewing the technique beforehand can be helpful. Brandon Ayres, MD, finds the 27-gauge cannula to inject the self-tapering dose of Dexycu is preferable to the larger 25-gauge can- nula typically used. "When we started with the 25-gauge cannula what we think was going on was that the surface tension of the Dexycu was strong enough that when we tried to leave the depot injection behind the iris, it would follow the cannula," he said, adding that this resulted in inadvertently getting more Dexycu in the anterior chamber. When he switched to the smaller 27-gauge cannula, however, it seemed easier to place the Dexycu where it belonged. "A second advantage to the smaller cannula is that we didn't get as much leakage of the aque- ous through the incision that the cannula was put into the eye with," Dr. Ayres said. In addition to using Dexycu for cataract surgery, Dr. Ayres uses it for IOL exchanges. It would also not be contraindicated for glaucoma surgery. However, some procedures that involve the use of air bubbles, such as DSEK and DMEK, might be very challenging, he said. Dr. Hovanesian views Dexycu as potential- ly well-suited for all patients, but as a particular- ly important option for those with which practi- tioners have concerns about compliance issues, since this takes dosing out of their hands. Giving a heads-up Dr. Ayres finds that telling patients there is a medication likely to prevent them from needing some drops is a selling point. "Patients rapidly accept it and it makes my life, our office life, and the patient's life easier," Dr. Ayres said, adding that so far, he has only had to dose one patient with postoperative steroid drops, and that was a case where additional surgery occurred. In Dr. Hovanesian's experience, it is im- portant to warn patients about the possibility that not all of the material will stay behind the iris. "Patients may see a tiny white pearl, but they should know if they do that it's going to go away pretty quickly and it won't leave any permanent mark," he said. "For clinicians, they may also see it residing against the endotheli- um and they may temporarily see a little bit of corneal edema locally." However, such corneal edema will clear, Dr. Hovanesian stressed. The Phase 3 study showed the decrease in endothe- lial cell density was not significantly different between the Dexycu and prednisolone groups. 1 A more common concern with Dexycu is pressure spikes. But in the FDA trial there were no more incidences of steroid-induced pressure spikes with Dexycu beyond the 1-day mark when caused by retained viscoelastic. When ste- roids are released slowly, they seem less prone to causing pressure spikes, he said. Dr. Ayres finds that any pressure spike can be effectively lowered with a glaucoma drop. He attributes issues he's had to a learning curve. "When I initially used the Dexycu implant, I think we were getting too much medication in the eye," he said. The result was some transient corneal edema. Now that they have gotten a better handle, however, he finds this is far less likely to occur. Overall, Dr. Ayres is excited about Dexycu and other products such as Dextenza (dexa- methasone ophthalmic insert 0.4 mg, Ocular Therapeutix) that can reduce confusion in the office. "I think we get the cost savings, less con- fusion, and effective medication in the eye, so it's a win for both the patient and the surgeon," he concluded. A blunt cannula is used to deliver Dexycu into the posterior chamber. Source: John Hovanesian, MD Sometimes Dexycu can inadvertently get into the anterior chamber but still works and dissipates on its own. Source: Brandon Ayres, MD

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