Choices Matter in Postoperative Inflammation

Think of these four C’s: compliance, convenience, choice, and cost.

By Justin Schweitzer, OD, FAAO

As common and as safe as it may be, cataract surgery is not without potential risks. Complications have been reported to occur in about 5% of patients, and they can range from mild and transient to vision threatening.1 The two major complications requiring preventive strategies are infection and inflammation. Although approaches differ, most physicians use a perioperative regimen of topical fluoroquinolone antibiotics, corticosteroids, and NSAIDs to reduce the risk of infection and inflammation.


Patients have an increasing range of options for prevention of postoperative inflammation.

Uncontrolled inflammation carries the potential for decreased vision if conditions such as cystoid macular edema occur (Figure), and it is important to remember that such negative results affect the patient’s experience of cataract surgery. Inflammation can cause light sensitivity and pain, which can lead to a poor perception of the procedure and the surgeon.

Making sure patients are aware of the risk of inflammation and their options for preventing its occurrence are important elements of preoperative counseling for cataract patients. When discussing inflammation with patients, I like to think of the four C’s: compliance, convenience, choice, and cost.


A traditional postoperative cataract drop regimen that includes an antibiotic four times daily, a steroid four times daily, and an NSAID once or twice a day (thanks to newer agents with reduced dosing) can require a total of approximately 105 to 190 drops. The obvious problem with this approach is its lack of convenience, and we know that this adversely affects compliance.

Figure. Cystoid macular edema after cataract surgery.

Some physicians have incorporated intracameral injections administered during surgery to replace some or all of the postoperative drop regimen. The surgeon may then prescribe only an NSAID after surgery. Some surgeons go completely “dropless” in appropriate patients. These options improve convenience and lessen (or even remove) the obstacle of compliance.


Placing intracanalicular inserts through the punctum is another option for delivering medication to the eye after surgery. This approach provides convenience and compliance while at the same time maximizing safety: There is no injection, and side effects are minimal.

What Patients Have Said About the Intracanalicular Insert

As part of a phase 3 clinical trial program, 25 patients were interviewed about their experiences with the dexamethasone 0.4 mg intracanalicular insert (Dextenza, Ocular Therapeutix). The cross-sectional, qualitative evaluation involved individual interviews lasting approximately 45 minutes.1

Here is some of what patients reported:

• 92% reported the highest level of satisfaction grade with regard to overall product satisfaction.
• 100% of patients described the insert as comfortable.
• 96% described their overall experience with the insert as very or extremely convenient.
• 96% of participants rated their experience with the insert as very or extremely convenient compared with previous topical therapy.
• 88% of patients stated that if they were to undergo cataract surgery again, they would request the insert.
• 92% said they would recommend the insert.
• 84% said they would be willing to pay more for the insert than for drops.

1. Gira JP, Sampson R, Silverstein SS, et al. Evaluating the patient experience after implantation of a 0.4 mg sustained release dexamethasone intracanalicular insert (Dextenza): results of a qualitative survey. Patient Prefer Adherence. 2017;11:487-494.

An intracanalicular insert containing 0.4 mg dexamethasone (Dextenza, Ocular Therapeutix) is designed to deliver the drug to the ocular surface for up to 30 days. After that time, the insert resorbs and exits the nasolacrimal system.

This drug is undergoing clinical evaluation in the United States and has not received approval from the US Food and Drug Administration (FDA). Ocular Therapeutix has stated that it plans to resubmit its New Drug Application to the FDA pending resolution of issues raised by the regulatory agency.

Three phase 3 clinical trials evaluating the intracanalicular insert for the treatment of ocular pain and inflammation after ophthalmic surgery have been completed. A pooled analysis including data from the three trials showed that 79% of patients receiving the insert reported no pain at day 8 compared with 56.9% of patients receiving placebo.2


The relative cost of these options is a subject of current debate. It is not yet clear that performing an injection of drugs at the close of cataract surgery or inserting an intracanalicular device will be more cost effective than the use of postoperative drops.


Choices are important to patients undergoing cataract surgery. For prophylaxis against inflammation, some patients may prefer to have an intracameral injection, others will choose drops, and still others may choose an intracanalicular insert when one becomes available. The most important thing for practitioners is to make sure you have all of the C’s covered.

1. Cataract in the adult eye. Preferred Practice Pattern. San Francisco: American Academy of Ophthalmology; 2008.

2. Talamo JH, Tyson SL, Bafna S, et al. Dextenza (dexamethasone insert) 0.4 mg vs. placebo for the treatment of ocular pain after cataract surgery: results of three phase 3 studies. Paper presented at: Association for Research in Vision and Ophthalmology; May 6-11, 2017; Baltimore, MD.

Justin Schweitzer, OD, FAAO
• cornea, glaucoma, cataract and refractive surgery specialist, Vance Thompson Vision, Sioux Falls, S.D.
• financial disclosure: none