Eyeworld

70 | EYEWORLD | FALL 2024 C ORNEA Relevant disclosures Donnenfeld: Nordic Pharma, Ocular Therapeutix Massaro-Giordano: Alcon, Dompe, Tarsus Pharmaceuticals White: Nordic Pharma Contact Donnenfeld: ericdonnenfeld@gmail.com Massaro-Giordano: mina@pennmedicine.upenn.edu White: dwhite2@skyvisioncenters.com punctum and has the advantage of no external exposure. This option is usually very comfort- able, he said, but the downside is that it dis- solves over time, becoming less effective, and it does not conform to the canaliculus. But it's comfortable and effective, and the average plug lasts for a couple months. There are also more permanent plugs made of silicone or acrylic. This is an external plug that fits into the punctum with a cap on top, and it should stay in place indefinitely. It provides a longer duration of punctal occlusion, but the external cap is sometimes irritating, and there is often fluorescein staining on the adjacent con- junctiva. Additionally, biofilm or bacteria often build up with this approach, potentially leading to infection. Permanent punctal occlusion is an option for patients with very dry eyes, Dr. Donnenfeld said. "You can cauterize the punctum with a handheld cautery, and that will cause a closure of the punctum, which tends to be permanent and comfortable." There's a fourth option that includes a med- ication, he said. This is Dextenza (dexametha- sone ophthalmic insert, 0.4 mg, Ocular Thera- peutix), which is commonly used in the context of cataract surgery. Dextenza provides the dual benefit of punctal occlusion and steroid elution that lasts about a month. A new product in the space A newly approved option in the punctal occlu- sion space is Lacrifill (Nordic Pharma), a cross- linked hyaluronic acid. "Lacrifill is an exciting new technology that I think, in many cases, will replace traditional punctal occlusion because it has some significant advantages," Dr. Donnen- feld said. It's crosslinked hyaluronic acid that is inserted into the inferior punctum and will wrap around to superior punctum, so you can get both puncta, he said, adding that this option is comfortable, lasts for 6 months, and can be irri- gated out at any time. "Whereas a collagen plug sits in the punctum and fluid can leak around the edge, this conforms to the anatomy of the canalicular structure [and] provides a more efficient and effective punctal occlusion." Dr. Donnenfeld said trials have shown that patients who got Lacrifill compared to a con- ventional plug had higher Schirmer's scores. He started using the product in his practice in June 2024 and said it's nice that one vial is enough to fill both puncta. "It's comfortable and fast, and I think it provides a better way of occluding the punctum," he said. Dr. White also touted the benefits of the newly approved Lacrifill. This type of option has been used for 10–15 years as a dermal filler for cosmetic and reconstructive purposes. "We know that it's inert in the vast majority of cases, and the beauty is we're not putting it under anything. We're putting it into an open canal," he said. Lacrifill offers many of the benefits of punctal occlusion, such as reduced outflow and therefore an increased amount of the patient's natural tears. "We know from the FDA trial that it's going to stay there at least 6 months," Dr. White said, adding that there's an option to flush it out if the patient is having issues with excess tearing. When deciding which patients are best for Lacrifill, Dr. White said it comes down to the type of dry eye disease. In the simplest of terms, there are two different types of dryness, he said. Aqueous deficient dry eye occurs when the patient has symptoms from dryness because they don't have enough tears. The other type is evaporative dry eye, where tears don't work well enough (a quality problem, not a quantity problem). Those patients who have evaporative dry eye, who don't have a secondary decrease in tear volume, probably don't need any sort of punctal occlusion, Dr. White said. The patients who have aqueous deficient dry eye are good candidates. Dr. White also thinks Lacrifill will make it easier to treat dryness in the perioperative period between cataract and refractive surgery. As part of the perioperative treatment, patients could have Lacrifill put in before they have their final measurements. "If they have dryness, even if we get good measurements, I think we'll start to see in the premium space physicians putting Lacrifill in because we make the eye dryer when we do surgery. If you put Lacrifill in prior to surgery, you can mitigate those effects," he said. Dr. Massaro-Giordano said she's excited about Lacrifill, particularly its ability to mold to the patient's unique anatomy. You don't have to worry about it being too big or small or falling out, she said, and it helps with increased tear levels for at least 6 months. "I think this is wel- come in the dry eye world. … [It's] novel and needed in our armamentarium," she said, espe- cially for those who have failed with plugs. continued from page 68

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