While preservative-free artificial tears and topical allergy drops are the first treatments that tend to come to mind when thinking of ocular allergy management, punctal plugs, such as Dextenza (dexamethasone ophthalmic insert 0.4mg, Ocular Therapeutix), are of increasing interest to eyecare practitioners (ECPs).
This article will review pearls for inserting the Dextenza implant in patients with small puncta.
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What is Dextenza?
Dextenza is a preservative-free intracanalicular insert designed to deliver a tapered dose of steroid to the ocular surface for up to 30 days. Over time, Dextenza resorbs and exits the nasolacrimal system without the need for surgical intervention.
Eyelid positioning during Dextenza insertion
To start, clinicians should assess the patient’s punctum with a dilator to check for any abnormalities, such as a thin epithelial layer of fibrous tissue covering the punctum. For patients with covered puncta, Dr. Singh recommends gently breaking through this epithelial tissue with the dilator to get into the opening and access the canalicular system.
Initially, the clinician should hold the dilator perpendicular to the patient’s eye; however, after creating an opening in the punctum, Dr. Singh then turns the dilator horizontally toward the nasal bone, following the pathway of the canalicular system. Additionally, based on his surgical experience, Dr. Singh has observed that patients with small puncta often have a wide open canalicular system.
How to hold the eyelid during Dextenza insertion
After opening the punctum, Dr. Singh takes the Dextenza implant with fine insertion forceps and pulls the lower eyelid straight down (instead of temporally) with his left hand while inserting the Dextenza plug with his right hand. In the vertical direction, the implant goes in partially, and then a horizontal approach is taken once the punctal plug has been inserted vertically.
He then shifts his left hand to pull the lid temporally, and advances the implant horizontally, after which the Dextenza implant slides in easily. He noted in his video that although there is a small vertical portion of the lacrimal system, in reality, the majority of the canaliculus is horizontal, so shifting the direction of the implant from vertical to horizontal during insertion helps to position it quickly and comfortably.
Conclusion
Dextenza provides the opportunity for ocular allergy patients to take a short-term break from their preservative-free artificial tear and potentially allergy drop usage. Inserting the implant correctly is key to maximizing its impact; consequently, clinicians should ensure that they factor in eyelid positioning during the insertion process to facilitate implantation and prevent irritation.
