Inserting Dextenza in Eyelids with Small Puncta

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3 min read

In this episode from Interventional Mindset, Dr. Singh reviews pearls for inserting Dextenza in the eyelids of patients with small puncta.

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.

Interventional Mindset is an educational series that gives eye physicians the needed knowledge, edge, and confidence in mastering new technology to grow their practices and provide the highest level of patient care. Our focus is to reduce frustrations associated with adopting new technology by building confidence in your skills to drive transformation.

Browse through our videos on a variety of topics within cataract and refractive surgery, glaucoma, and ocular surface disease to learn practical insights into adopting a variety of new surgical techniques and technology.

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.


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.
I. Paul Singh, MD
About I. Paul Singh, MD

Dr. I. Paul Singh, MD, is a glaucoma specialist. He completed his residency at Cook County Hospital – Division of Ophthalmology, completed his internship at Michael Reese Hospital – Department of Medicine, and completed his fellowship in Glaucoma at Duke University. Dr. Singh is actively involved in clinical research and has presented his research at national meetings and universities and published papers in many ophthalmology journals.

Dr. Singh was the first ophthalmologist in Wisconsin to implant the iStent, a device designed to treat glaucoma. He also pioneered the use of in-office lasers to remove visually significant floaters. Recently, he was instrumental in bringing laser assisted cataract surgery to the area. He enjoys giving lectures and teaching seminars around the globe to help other doctors adopt these and other newer technologies and techniques.

I. Paul Singh, MD
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