EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/176967
September 2013 EW CORNEA 65 Device focus Treating moderate to severe dry eye by Michelle Dalton EyeWorld Contributing Writer In most cases, once tears and topical cyclosporine have failed, punctal plugs may provide some relief F or patients in whom artificial tears or topical cyclosporine fail to provide relief from dry eyes, punctal plugs may be a viable adjunctive treatment option. These devices, when used properly and in the right type of patient, can offer relief, but experts say there are downsides to using these, too. On the upside, they can safely retain tears on the ocular surface and help extend the duration of artificial tears, but they may aggravate the problems associated with dry eye in the presence of inflammation. Some types of plugs are rather difficult to remove and can cause inflammation themselves, particularly in the nasolacrimal area, said Audrey TalleyRostov, MD, Northwest Eye Surgeons, Seattle, and other plugs can fall out or require frequent replacement. "Intracanalicular plugs have a huge increased risk for infection, including that they can become occluded," she said. Many patients with chronic dry eye have an unstable tear film. Once you have re-established the integrity of the tear film, the next goal is to retain the tears in the eyes for a longer duration using punctal occlusion, said Alice T. Epitropoulos, MD, clinical assistant professor, The Ohio State University Wexner Medical Center, and in private practice, The Eye Center of Columbus. "If this is done prematurely, patients tend to be more uncomfortable because they still have inflammatory mediators in the tear film," she said. Because dry eye is a chronic, progressive disease, Dr. Epitropoulos prefers to use "semi-permanent" or long-term use plugs. "I rarely use collagen plugs because they don't last very long, they are not cost effective, and I don't want to inconvenience patients to have to come back after their temporary plugs dissolve for a longer-term solution," she said. For those patients who have difficulty tolerating the "semi-permanent" plugs, they can easily be removed. Some published studies and anecdotal reports suggest plug retention can be upward of 90% when sized and placed properly, although most of the published literature reports much lower and widely different retention rates. And, of course, because these are placed by eyecare practitioners and not by the patient, compliance is not usually an issue. Dr. Epitropoulos also avoids using intracanalicular plugs, noting that while they work in a large majority of patients, in cases where the plug gets "stuck," the potential for dacryocystitis or "permanent damage to the tear duct system requiring major reconstructive surgery to the tear duct" overrides any potential benefit they might provide, she said. Differentiating between the varieties Before deciding on a punctal plug treatment, Dr. Talley-Rostov said it helps to have patients assessed with the Ocular Surface Disease Index "because it helps patients to think about dry eye and how their dry eye is impacting their life," she said. Dr. Talley-Rostov said attempting to determine the underlying etiology of the dry eye by quantifying the symptoms and time of day when they are at their worst can help tailor treatments, including punctal plugs. "Once the quality of tear film has been evaluated and stabilized, punctal plugs can be placed into the puncta," Dr. Epitropoulos added. "There are a variety of plugs that we can use when other treatments have been inadequate." Dr. Talley-Rostov said the Preferred Practice Patterns recommends starting dry eye patients on an artificial tears regimen, moving to topical cyclosporine 0.05%, and then to punctal plugs for the moderate-tosevere dry eye patient. She does not use (nor recommends) temporary plugs, mainly because the time it takes for these plugs to dissolve varies from patient to patient, "so it's very difficult to assess if the plug made a difference for the patient," she said. "I prefer the non-dissolvable—also called permanent—plugs; I place them in the lower puncta and only on very rare occasions would I need to insert them in the upper puncta as well." ABCs continued from page 64 those that are currently closest to nature's own. Considering preservatives There's also the looming preservative question: Can vanishing preservatives work, or must these drops be preservative free? Dr. Lemp noted that the vanishing preservatives are designed to be gentler than traditional benzalkonium chloride (BAK). "You put them in the eye and the drop comes in contact with a different PH (on the surface); they then dissociate and lose some of their toxic properties," he said. Some drops with vanishing preservatives include Refresh Tears and GenTeal (Novartis, Basel, Switzerland). However, Dr. Coroneo's preference is to go preservative free. "Vanishing means that it is still there when it hits the eye," he said. Dr. Pflugfelder agreed. "I just don't know that those vanishing preservative won't have any toxicity," he said. For patients using more than four drops a day, he recommends preservative-free tears. Overall, Dr. Pflugfelder marvels at the options. "The artificial tear landscape is just so much vaster than it used to be," he said. "There are a lot of great preparations out there, and they still remain a big part of the dry eye treatment." EW Editors' note: Dr. Coroneo has financial interests with Transcend Medical (Menlo Park, Calif.), Eagle Vision (Memphis, Tenn.), and Dutch Ophthalmic USA (Exeter, N.H.). Dr. Lemp has financial interests with Bausch + Lomb, Merck (Whitehouse Station, N.J.), Novagali Pharma (Evry, France), Santen Pharmaceutical (Osaka, Japan), and TearLab (San Diego). Dr. Pflugfelder has financial interests with Allergan and Bausch + Lomb. Contact information Coroneo: Coroneom@gmail.com Lemp: malemp@lempdc.com Pflugfelder: stevenp@bcm.tmc.edu Patients with more severe dry eye may benefit from upper puncta placement in addition to lower puncta, she said. Dr. Epitropoulos said the "temporary, or trial, plugs are usually made of collagen and last from a few days to a few weeks. For the most part, punctal occlusion is considered in patients with chronic dry eye, so we're looking for a more permanent solution. Plugs made from silicone are designed to remain in the puncta over the long term, however one of the disadvantages of punctal plugs is that they can and do fall out, especially if a patient rubs the eye or lid too vigorously." To truly occlude the puncta on a long-term basis, surgeons often need to cauterize the area to close the tear duct, Dr. Epitropoulos said, so the moniker of a "permanent" punctal plug may be misleading to patients. "Punctal plugs can fall out or be rubbed out; when that happens usually increasing the size can alleviate the issue," Dr. Talley-Rostov said. "You don't want the plug to be too large, because then it becomes difficult to extract when necessary. Evaluating the anatomy to ensure patients aren't rubbing their eyes is helpful." Sjogren's patients Although most dry eye patients do not have a systemic component, patients with Sjogren's often complain of severe dry eye (and dry mouth). "I am much more aggressive in using plugs earlier in patients with Sjogren's since they don't tend to respond as much with topical cyclosporine 0.05%, and many times they are incapacitated by their dry eye condition," Dr. Epitropoulos said, but added she still prescribes topical cyclosporine 0.05% and aggressively treats blepharitis "to improve the quality of the tear film before plugging." Dr. Talley-Rostov will consider plugs in Sjogren's patients, but also advises considering cautery. "If the patient presents with Sjogren's, I'm likely to go to plugs sooner than with the typical woman in her 40s or 50s who does a lot of near work and needs dry eye management," Dr. Talley-Rostov said. "All dry eye patients need education—they need to know that while continued on page 66