(Originally Published in The Business News)
GREEN BAY – A new kind of dropless cataract surgery has made its way to Green Bay – with BayCare Clinic Eye Specialists being the first in the area to offer it.
Alexander Foster, refractive cataract surgeon with BayCare Clinic Eye Specialists, did his first cataract surgery using the Dextenza insert in March.
The procedure, Foster said, is a hydrogel steroid insert added during surgery that can treat post-surgery pain and inflammation without eye drops.
“Basically, our eyelids have little tiny tear troughs in them,” he said. “At the end of cataract surgery when it comes time to place the Dextenza, we use a little tiny dilator and put a little insert in one of the two tear ducts.”
Foster said it then sits there and slowly delivers steroids to the outside of the eye for four weeks – which is slowly absorbed.
According to Ocular Therapeutix, the company behind Dextenza, the insert is about three millimeters in length by about 0.55 millimeters (which, for reference, is smaller than a sesame seed).
“It’s nice because patients don’t have to give themselves drops,” Foster said. “It can be removed if it needs to be, and it’s something that is well tolerated.”
The FDA approved Dextenza in November 2018, and it has been used in some other communities in Wisconsin but never before in Green Bay – until now.
Foster said Medicare and its supplements cover Dextenza, and it has opened dropless cataract surgery to more patients than would otherwise be able to get it.
What is a cataract?
Cataracts, Foster said, are the normal eye lens slowly starting to break down.
“The human lens is a dense piece of protein, and as we age, that protein slowly starts to break apart,” he said.
Foster said the lens gets spots and little areas in which water can enter and cause it to swell – which can eventually lead to blurry vision.
“Our lens, when we are young, is flexible, and we can focus on anything at the tip of our nose out to infinity,” he said. “As we age, that lens stops being as flexible. It starts to get hard, and eventually, we won’t be able to focus as near anymore.”
Foster said some patients with cataracts may also see halos and starbursts with nighttime driving.
“Nighttime glare will start to occur,” he said. “Patients commonly come with that as their main complaint.”
In some cases, Foster said eye doctors see signs of cataracts in patients who are in their 40s, but most of the time, people don’t become symptomatic until about the age of 65.
In fact, he said more than 50% of people by the age of 65 will have a symptomatic cataract.
According to the Mayo Clinic, factors increasing the risk of cataracts, include diabetes, too much exposure to sunlight over a long period, smoking, obesity, family history of cataracts, high blood pressure, previous eye injury or inflammation, previous eye surgery, prolonged use of corticosteroids and drinking excessive amounts of alcohol.
Ditch the drops
Foster said BayCare was already offering a dropless method of cataract surgery before Dextenza came along.
He said for the last 18 months – pre-Dextenza – BayCare has used a technique whereby a tiny amount of antibiotic is placed inside the eye and a tiny amount of steroid is injected outside of the eye, in the conjunctiva, at the time of surgery.
Though the method was well tolerated by many, Foster said in some cases, it caused minor bleeding or a small white spot on the eye – therefore, not all doctors were comfortable using it.
So, Foster said when he heard about the Dextenza steroid insert, he thought it would be great for BayCare.
“I said, ‘this is the perfect bridge to help those docs who want to offer a dropless but don’t want to do it by injecting a steroid’,” he said. “Now, I have two ways of offering dropless to my patients.”
Foster said inserting the medicine at the time of surgery is also more cost-effective and less time-consuming for patients and the healthcare system overall.
He said patients don’t have to run to the pharmacy to pick up refills; doctors don’t have to worry about patients following eyedrop timetables; and pharmacists don’t have to fill prescriptions.
According to GoodRx Health, a person might spend anywhere from $45 to $200 on drops, depending on how much and what kind of drops are prescribed, where one gets them and how long they’re prescribed.
“It’s a clear win-win for everyone,” Foster said.
Time for a new lens
Foster said he uses the visual of an M&M to help illustrate the lens replacement process.
“We have to go in and access that M&M and remove the milky chocolate inside of that candy capsule, and then we place our own plastic lens inside our capsule, where the old lens you were born with used to reside,” he said. “It's an acrylic piece of plastic we place inside the eye.”
Foster said patients get their choice of three types of lenses: near, far and a combo.
And like with glasses, he said, there’s single-vision and multifocal lenses.
“It comes down to having a conversation with your ophthalmologist and trying to figure out what is important to you and what type of vision you want afterward,” he said.
Drops: What’s the big deal?
When it comes to preparing for typical, non-dropless cataract surgery and post-op care, Foster said patients have had to use three kinds of eye drops.
Foster said patients would take two kinds three days before the surgery, with additional drops needed after the surgery at different times in a certain sequence.
Sometimes, he said, for up to six weeks.
“After their surgery, they will complete all three of those drops, and they take two of those drops for a full month out afterward and the last drop they will take for two weeks,” he said.
Foster said several factors – including tremors, poor hand-eye coordination and memory problems – can also make the eye drops administration process complicated.
“That includes missing an eye, giving too little of it, contaminating the tip of the applicator, not washing their hands before touching their eyes,” he said. “If you’ve never given yourself an eyedrop before, it’s not easy. And the cost of these eyedrops is not insignificant.”
The drops, Foster said, are important to help with healing, reduce inflammation or pain caused by the sterile eye scrub used in surgery and prevent infection that could arise from bacteria entering the tiny incision made during surgery.
Foster said surgeons' techniques “continue to be perfected – we’ve come a long way.”
“The instruments we use are minimally invasive, and we use a machine that can provide real-time feedback for the best intraocular lens for our patients at the time of their surgeries,” he said.
Technology, new formulas and even artificial intelligence (AI), Foster said, are helping doctors to help their patients make the best decision on the right lens for them.
“It’s a tremendous time to be a cataract surgeon,” he said.