Eyeworld

68 | EYEWORLD | FALL 2024 C ORNEA STRIKE! by Ellen Stodola Editorial Co-Director About the physicians Eric Donnenfeld, MD Ophthalmic Consultants of Long Island Garden City, New York Mina Massaro-Giordano, MD Professor of Clinical Ophthalmology Scheie Eye Institute University of Pennsylvania Philadelphia, Pennsylvania Darrell White, MD SkyVision Centers Westlake, Ohio P unctal occlusion remains an important resource for dry eye patients. Several physicians discussed how they use it in practice, available options, and a new product in this space. Punctal occlusion is fundamental for dry eye and has been for decades, said Darrell White, MD. "If you have a patient who has a low tear film, you can increase the amount of tears on the surface of the eye by doing some- thing to maintain the tears' contact time longer by reducing outflow. … We've used a number of different types of plugs." Mina Massaro-Giordano, MD, agreed that punctal occlusion plays a role in dry eye man- agement. While she said that it's important to get the inflammation under control before moving forward, she added that "there's always going to be some degree of inflammation." She tries to get inflammation under the best control she can before putting a plug in because once you do that, the tears are lubricating and on the surface for a longer period of time. You don't want inflamed tears bathing the eye, she said. The important thing to decipher is what makes a good candidate. Dr. Massaro-Giordano checks all four puncta. "If they've had chronic inflammation of the lid, their punctum opening is tiny to begin with, you might not be able to put a plug in," she said. "If there is a gaping hole, the tears they make are going to be sucked down that drain, and it makes sense to put a plug in, but if it's too small, it might not make sense." It's also important to look at the archi- tecture of the lid, as well as the patient's history to see if plugs have been tried in the past. "I usually start with the lower punctum, maybe one eye over the other, to see if they notice a difference," she said. Sometimes you put a plug in and they tear too much. There's a lot of trial and error that goes into placing plugs because you also have to choose the right type of plug. There are plugs that will block the punctum completely, but sometimes that will cause too much tearing. In this case, Dr. Massaro-Giordano will choose a plug that has a small hole in it. There are also permanent and temporary options. In the past, physicians would reserve plugs for patients who had tear insufficiency dry eye or autoimmune conditions, Dr. Massaro-Gior- dano said, but they can be helpful for many patients. In addition to dry eye, punctal occlu- sion can work for other ocular conditions like neurotrophic keratitis, for those who just had a refractive procedure where the nerves are temporarily cut, for patients who have recur- rent erosion, or for pregnant patients when you want less systemic absorption of a medication. Eric Donnenfeld, MD, called punctal oc- clusion one of the fundamental options for dry eye management. He added that treating the inflammation first is important in these pa- tients before using punctal occlusion as a way of improving the volume of tears available to the patient. It is an effective and cost-effective therapy. "[There's] very little downside to doing the procedure, and I think there's an enormous benefit. I think this is underutilized by a lot of clinicians," he said. There are different punctal occlusion op- tions available. You can use a collagen punctal plug, an indwelling plug that goes into the Punctal occlusion: a valuable resource for dry eye patients continued on page 70 Lacrifill is crosslinked hyaluronic acid that is inserted into the inferior punctum and wraps around to superior punctum. Source: Eric Donnenfeld, MD

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