Follow the simple steps below, and click on the videos.
The Dextenza dexamethasone insert https://www.dextenza.com is one of the most innovative ocular and cataract surgery postoperative management products in many years. However, insertion of this extended-release dexamethasone
device/pharmaceutical into the puncta and canaliculus complex is occasionally tricky. The tiny Dextenza cylindrical-shaped device must be kept dry at all times to prevent it from swelling and impeding insertion into narrow puncta. In some lacrimal system anatomical variants the tail end of the Dextenza device may swell while trying to guide it into the canaliculus, thus preventing full insertion. To eliminate these Dextenza insertion issues, I have devised a simple, rapid and inexpensive method for inserting the Dextenza device without ever having to encounter swelling due to contact with tear fluid or BSS solution. Here are the steps for this technique:
1. Obtain a sterile, Becton Dickinson (BD) Insyte™ Autoguard™ Shielded 22 gauge IV Catheter *
2. Remove the plastic BD catheter from the sharp needle. Dispose of the needle.
3. Using a sharp scissor, cut the firm but flexible, soft, BD catheter near its hub. Dispose of the hub.
4. Under operating microscope observation, gently grasp the Dextenza Insert with a smooth, blunt forceps, such as a McPherson forceps.
5. Under operating microscope observation, insert the Dextnza cylinder into the cut end of the plastic BD catheter.
6. Using a 25-gauge BLUNT-tip-needle obturator **, push the Dextenza cylinder approximately half way into the BD catheter. Since the BD catheter is translucent, you can see exactly where the yellow, Dextenza cylinder is positioned within the BD catheter. The Dextenza cylinder sitting inside the plastic catheter is fully isolated from ocular surface tear fluid or BSS solution, remains dry at all times, and cannot swell or thicken. (DO NOT use a sharp needle to push the Dextenza cylinder inside the BD catheter, since the sharp needle may damage the plastic catheter, and/or impale, damage or cut the Dextenza cylinder).
7. For narrow punctal openings, first use a punctal dilator to enlarge the punctal orifice diameter. If the punctal opening is medium or large sized, punctal dilation is often unnecessary. In some puncta, the BD catheter, with the Dextenza cylinder within it, can be used as the punctal dilator since it has a tapered tip *.
8. Insert the tapered end of the BD catheter (which contains the Dextenza cylinder) about 2-3 mm. into the puncta, aiming it nasally towards the medial canthus.
9. Insert the BLUNT 25 gauge, blunt-needle obturator into the cut end of the BD catheter and push the Dextenza cylinder into the puncta and canaliculus so that it passes and fully exits the tapered opening of the BD catheter. (DO NOT use a sharp 25-gauge needle to push the Dextenza cylinder into the puncta and canaliculus since it may cut and damage the catheter, Dextenza cylinder, puncta and canaliculus).
10. Withdraw the BD plastic catheter from the puncta. The Dextenza cylinder will remain in the puncta-canaliculus complex.
* 1. The Dextenza cylinder is 0.55 mm. wide according to the manufacturer, Ocular Therapeutix https://www.dextenza.com/insertion-and-storage/
2. The BD Insyte™ Autoguard™ Shielded 22 gauge IV plastic catheter (BD, Reference #: 381423) has an internal diameter of 0.648 mm. throughout its entire length (manufacturer communication). This allows the Dextenza cylinder to move easily inside it, but it won’t spontaneously slide inside the BD catheter, unless you push it with the 25 gauge, blunt-needle obturator (0.515 mm. diameter) **.
3. The BD Insyte™ Autoguard™ Shielded 22 gauge IV plastic catheter has an external diameter of 0.876 mm. along most of its length, but tapers to about 0.750 mm. at its distal tip. This allows for easy insertion into most puncta, especially after punctal dilation. The tip of the BD plastic catheter is dull and relatively soft, so it cannot injure the puncta or canaliculus.
4. The BD Insyte™ Autoguard™ Shielded 22 gauge IV plastic catheter costs about $3.00 and is available in most hospital and ambulatory surgery centers, since it is used for inserting IVs in patients entering the operating room. It is available from most medical device distributors such as HenrySchein.com, where it is item code #: 1261683, (Becton Dickinson manufacturer’s code #: 381423)
** The autoclavable, stainless steel, blunt, 25 gauge needle obturators are manufactured by Pulpdent (product code #: PSN-25), https://www.pulpdent.com/products/pulpdent-pressure-syringe/ and cost about $30.00 for a dozen. They are available from medical distributor, HenrySchein.com, where it is item code #:384-7714, (manufacturer's Item #: PSN-25).
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