EyeWorld India December 2013 Issue

45 EWAP CORNEA December 2013 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 Talley-Rostov, MD , Northwest Eye Surgeons, Seattle, Wash., USA, 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, Ohio, USA, 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-to- severe 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.” 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 Continued on page 47