What else is new? - A new numbing drop (& how it can help with things like Maskin Probing) and a new “implantable” steroid!
Dextenza is a new implantable steroid. Responding to the question of using Dextenza for relief of dry eye flares – Dextenza is a dissolvable, punctal plug-like device that releases Dexamethasone (a powerful steroid) for up to 30 days before fully dissolving. It has been approved for use in recovery from eye surgeries and for severe eye allergies, but a recent study suggests it may be useful in treating dry eye disease.
Steroids are anti-inflammatory medications that come in differing degrees of strength and are generally coupled with preservatives in drop and ointment forms. The strongest (like Dexamethasone) are capable of shutting down the natural defenses (which are often involved in dry eye issues) – so this can explain the rationale for using them in dry eye, allergy and post-surgical inflammation. I posted on steroids (and anti-inflammation) here: https://www.eyethera.com/blog/segment-10-b-when-we-are-at-war-with-ourselves
As far Dextenza in this setting, all the steroid-related pros and cons relate. The benefit of this device is the slow, continual release, the lack of preservatives, and the fact that it takes daily drops off the table (certainly a convenience factor). The unique negatives include:
- Price (much more expensive than the drops – and since this is considered an “off-label use” it may not be covered by insurance). Check with your provider about cost.
- The “one size fits all” means some that have very small or very large openings to their tear duct may not be a candidate. Certainly, if the puncti (openings to the tear ducts) have been cauterized shut, then it won’t be possible to use it. It also comes in but one strength, so if a little less or a little more would be better, then it might under or over treat.
- It is designed to drop below sight into the tear duct. This leaves the question of whether it might pass directly to the nose (where it won’t help the eye) – and though the company has assured me this is not common (it is designed to swell and “stick” in the tear duct passage near the lid margin), once it “drops in” there is no way to know with certainty where it may land.
- The duration (up to 30 days) is longer than most flares might need (most seem to do OK weaned over 2 weeks, but some do need longer) – and when it comes to strong steroids, less is often better. Eysuvis was approved for dry eye flares because it is a very dilute form of Loteprednol (a weaker steroid to begin with) – so this is more my usual “go-to.” This is a link to the dry eye drug study: https://www.ophthalmologytimes.com/view/ocular-therapeutix-announces-topline-results-for-phase-2-clinical-trial-of-otx-ded-for-short-term-treatment-of-dry-eye-disease?fbclid=IwAR1ZRI5QsteFgQAC07YfAmerlYOcqYNFvAdMDcn06VFQHzJSEURGq-TAzDk and it is no surprise that, according to the study report: “The most common ocular adverse events for subjects treated with OTX-DED (Dextenza insert) were epiphora (lacrimation increase) (8.1%) and elevated intraocular pressure (IOP) (3.6%).” Epiphora is tearing (commonly reported as flowing down the cheek) and this would be a common side effect of a punctal plug (blocking the tears from flowing down the natural tear duct pathway to the nose) where elevated eye pressure can eventually lead to nerve damage called Glaucoma – see my blog on punctal plugs and “Toxic Soup,” here: https://www.eyethera.com/blog/what-about-punctal-plugs-or-why-not-dam-up-those-damn-tears and https://www.eyethera.com/blog/when-tears-dont-drain-properly-you-get-toxic-soup-and-the-toxic-soup-syndrome
My added concern is that when a “toxic soup” situation exists, this will cause an apparent dry eye flare. Adding a steroid into the toxic soup may quite the eye, but does not relieve the obstruction causing the toxic soup. Rather, it may add further obstruction to it. It also may knock out the immune system’s ability to defend against germs that may brew in this soup, so I don’t see Dextenza as a particularly good fit for many - but may be a specialty-specific tool to help select patients. As always, check with your dry eye specialist to see if you may qualify for its use.
Responding to a question of Maskin style probing without using topical anesthetics or IPL (due to extreme sensitivities to preservatives in most drops, gels and sensitivities to all forms of heat - including IPL, as is common among many with Rosacea-related dry eye) – I posted the following:
I've posted on a lot of dry eye care but your question is a new one (I have yet to have any patient ask to forego all topical anesthetics, but do routinely offer small injections of numbing medication to add a deeper level of numbing as probing can otherwise be relatively painful) - and the short answer to tolerating the numbing vs tolerating the treatments (without the numbing) - is that it almost always is necessary to do some numbing with drops or gels prior to Maskin Probing (or any number of other dry eye treatments). We do have a new, preservative free gel (IHEEZO) more commonly used for cataract surgery (it offers a deep level of topical anesthesia without the irritating preservatives found in most other topical anesthetics), so this might help in cases like yours. In my Maskin protocol (a bit different from each doctor), I start with putting metal eye shields in each eye (sometimes over a bandage contact lens for patients with your complaints), which could be uncomfortable without some numbing, followed by IPL over the lids (to soften some oils and "wake up" some glands). I follow this with a strong scuffing of the lid margins (to remove any gummy/waxy "plaque" and then probe serially using a high powered operating microscope, as deep as the MGs will let me (trying for 4mm i upper and lower lids). I follow this with removing the metal shields, applying a plastic shield and then heating with Radio Frequency to "melt" any residual waxy oils and then expressing all of the probed glands while they are optimally "hot." This attempts to purge any "bad" oils and leave room for better oils to come along. I have patients apply a combination antibiotic and steroid eye drop on a tapering schedule to prevent germs from getting a foothold in the probed glands and preventing scar tissue from recurring in the probed areas, so the glands can continue to do their best (& hopefully regenerate to their fullest potential). Sticking to this protocol has helped most of my patients to achieve the highest level outcome - based on a decade of doing the probing along various other protocols and using a variety of other tools. I find some basic "homework" (taking good Omega oils, doing good lid hygiene and, when appropriate, some home-based heated eyelid crunches to help turn over oils) along with a series of IPL and heated expressions, can often help enough (when caught early) to prevent the need for the probing - and when probing is required, to help "wake-up" and support the glands, so that probing can better succeed. Following this, the same ongoing homework and some degree of maintenance treatments (customized to the patient's needs) is typically needed. Check out my blog at eyethera.com for more on my typical "homework" and to see me perform some of these peripheral treatments. An earlier post on Maskin probing can be found here: https://www.eyethera.com/blog/why-do-expensive-dry-eye-treatments-fail-and-what-is-maskin-probing
I hope this helps!
To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:
(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020
(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463