Punctal Occlusion for the Dry Eye

[Punctal and canalicular plugs: Indications, efficacy and safety (French translation of the article)]

Lacrimal occlusion with punctal or canalicular plugs have been used to treat dry eye disease for more than 40 years. Indeed, punctal plugs constitute a safe and effective tool to retain the natural tear film and prolong the effect of tear substitutes. A wide variety of plugs is available, differing in their design, location (punctal versus canalicular) and their resorbability. There indications have increasingly broadened, and they are now one of the treatment options for numerous ocular surface diseases. Current research focuses on using punctal plugs for extended delivery of drugs to the ocular surface. This review addresses physiology of lacrimal drainage, available models of punctal plugs, their indications, practical details of prescribing and placing punctal and canalicular plugs, and possible complications.

Punctal and canalicular plugs: Indications, efficacy and safety

Lacrimal occlusion with punctal or canalicular plugs have been used to treat dry eye disease for more than 40 years. Indeed, punctal plugs constitute a safe and effective tool to retain the natural tear film and prolong the effect of tear substitutes. A wide variety of plugs is available, differing in their design, location (punctal versus canalicular) and their resorbability. There indications have increasingly broadened, and they are now one of the treatment options for numerous ocular surface diseases. Current research focuses on using punctal plugs for extended delivery of drugs to the ocular surface. This review addresses physiology of lacrimal drainage, available models of punctal plugs, their indications, practical details of prescribing and placing punctal and canalicular plugs, and possible complications.

A Pragmatic Approach to the Management of Dry Eye Disease: Evidence into Practice

Dry eye disease (DED) is a highly prevalent chronic ocular disorder that can lead to significant discomfort and visual disturbance. It is a potentially debilitating condition that can have significant negative impact on quality of life. A diverse range of management options exists for DED, including tear supplement products, anti-inflammatory agents, immunomodulators, punctal occlusive devices, and environmental modifiers. Although the availability of a variety of treatment approaches provides clinical flexibility and can enable individualized care, it can also complicate clinical management decisions and lead to variability in the nature of the clinical care provided to patients. By considering two dry eye case scenarios, this review evaluates the currently available evidence relating to DED therapy to describe a pragmatic clinical approach to best-practice management of dry eye patients.

Ocular involvement in chronic graft-versus-host disease: therapeutic approaches to complicated courses

Chronic graft-versus-host disease (cGvHD) is a major concomitant phenomenon in recipients of allogeneic hematopoietic stem cell transplantations, affecting multiple organ systems including the eye. Ocular structures, such as lacrimal gland, conjunctiva, and eyelids with meibomian glands, are frequently involved with clinical features ranging from dry eyes and common inflammatory conjunctival disease to severe complications like corneal ulcerations or even perforations. We present 2 patients with complicated courses of ocular cGvHD. In both cases, keratoconjunctivitis sicca refractory to systemic immunosuppressive therapy and to conventional topical treatment resulted in progressive binocular corneal melting and finally repeated perforations. According to our 2 cases and to the current pathophysiological understanding, we discuss possible strategies for the treatment and prevention of ocular cGvHD complications.

Surgical punctal occlusion with a high heat-energy releasing cautery device for severe dry eye with recurrent punctal plug extrusion

PURPOSE

To report the rate of recanalization and the efficacy of punctal occlusion surgery with a high heat-energy-releasing cautery device in patients with severe dry eye disease and recurrent punctal plug extrusion.

DESIGN

Prospective, interventional case series.

METHODS

Seventy puncta from 44 eyes of 28 dry eye patients underwent punctal occlusion with thermal cautery. All patients had a history of recurrent punctal plug extrusion. A high heat-energy-releasing thermal cautery device (Optemp II V; Alcon Japan) was used for punctal occlusion surgery. Symptom scores, best-corrected visual acuity, fluorescein staining score, rose bengal staining score, tear film break-up time, and Schirmer test values were compared before and 3 months after the surgery. Rate of punctal recanalization also was examined.

RESULTS

Three months after surgical cauterization, symptom score decreased from 3.9 ± 0.23 to 0.56 ± 0.84 (P < .0001). Logarithm of the minimal angle of resolution best-corrected visual acuity improved from 0.11 ± 0.30 to 0.013 ± 0.22 (P = .003). Fluorescein staining score, rose bengal staining score, tear film break-up time, and the Schirmer test value also improved significantly after the surgery. Only 1 of 70 puncta recanalized after thermal cauterization (1.4%).

CONCLUSIONS

Punctal occlusion with the high heat-energy-releasing cautery device not only was associated with a low recanalization rate, but also with improvements in ocular surface wetness and better visual acuity.

Ancillary therapy and supportive care of chronic graft-versus-host disease: national institutes of health consensus development project on criteria for clinical trials in chronic Graft-versus-host disease: V. Ancillary Therapy and Supportive Care Working Group Report

The Ancillary Therapy and Supportive Care Working Group had 3 goals: (1) to establish guidelines for ancillary therapy and supportive care in chronic graft-versus-host disease (GVHD), including treatment for symptoms and recommendations for patient education, preventive measures, and appropriate follow-up; (2) to provide guidelines for the prevention and management of infections and other common complications of treatment for chronic GVHD; and (3) to highlight the areas with the greatest need for clinical research. The definition of "ancillary therapy and supportive care" embraces the most frequent immunosuppressive or anti-inflammatory interventions used with topical intent and any other interventions directed at organ-specific control of symptoms or complications resulting from GVHD and its therapy. Also included in the definition are educational, preventive, and psychosocial interventions with this same objective. Recommendations are organized according to the strength and quality of evidence supporting them and cover the most commonly involved organs, including the skin, mouth, female genital tract, eyes, gastrointestinal tract, and lungs. Recommendations are provided for prevention of infections, osteoporosis, and steroid myopathy and management of neurocognitive and psychosocial adverse effects related to chronic GVHD. Optimal care of patients with chronic GVHD often requires a multidisciplinary approach.

A Permanent and Reversible Procedure to Block Tear Drainage for the Treatment of Dry Eye

PURPOSE

To describe a technique of canalicular ligation and report observations on 59 consecutive surgeries.

METHODS

Retrospective, non-comparative case series of canalicular ligation by 3 surgeons over a 7-year period.

RESULTS

Fifty-nine eyelids of 29 patients (2 men and 27 women) underwent canalicular ligation for the treatment of severe dry eyes. Patient age ranged from 34 to 90 years. Average length of follow-up was 20 months. There were no complications. Ninety-one percent of patients noted an improvement in their symptoms. Two patients developed symptomatic epiphora more than 1 year postoperatively and both underwent successful reversal.

CONCLUSIONS

Canalicular ligation is an effective technique for punctal occlusion in patients with severe dry eyes. It combines surgical ease with excellent cosmetic outcomes.

Paradoxical increase of visual impairment with punctal occlusion in a patient with mild dry eye

We report a paradoxical increase in visual impairment after punctal plug placement despite improvement in corneal epithelial damage caused by mild dry eye. Ocular higher-order aberrations (HOAs) were measured sequentially with a wavefront sensor before and after punctal plug insertion in a patient with mild dry eye. Although postblink HOAs tend to increase in normal subjects or patients with dry eye, after treatment there was a maximum spike in HOAs for a few seconds that decreased gradually. Excessive retention of tear film by punctal occlusion may cause inferosuperior asymmetrical distribution in precorneal tear-film thickness, possibly leading to slower wavefront on the inferior cornea and increased coma-like aberrations. Increased visual impairment might occur paradoxically despite improvement in the corneal epithelial damage caused by dry eye.

The Economic Burden of Dry Eye

PURPOSE

To develop a conceptual framework for analyzing the economic burden of dry eye and a preliminary assessment of key factors that contribute to that burden.

METHODS

The MEDLINE database was searched from 1966 to May 2003 combining the term "dry eye" with various economic terms. In addition, individual interviews with a panel of clinicians were conducted to provide additional insight on resource use.

RESULTS

Direct resource utilization among dry eye sufferers includes healthcare professional visits, nonpharmacological therapies, pharmacological treatments, and surgical procedures, with the latter 2 categories being the major cost drivers. Complementary and alternative medicine (CAM) therapies are a newly recognized component of the dry eye economic burden. There is wide variation in patterns of diagnosis and treatment, but current therapies are not universally effective. Given the prevalence of the condition, indirect costs may be large. Utilization of pharmacological therapies, especially those other than tear replacements, the extent of CAM use, cost of complications of surgical procedures, and indirect costs are unknown. The natural history and probability that patients will transition between therapies, based on underlying disease severity, need to be elucidated.

CONCLUSIONS

Dry eye is a prevalent condition with the potential for a high economic burden; additional studies are needed to further characterize the economic impact.

Effects of lacrimal occlusion with collagen and silicone plugs on patients with conjunctivitis associated with dry eye

PURPOSE

To determine whether canalicular occlusion with collagen and silicone plugs reduces the severity of symptoms in patients with conjunctivitis secondary to dry eye.

METHODS

This was a prospective, randomized, double-masked study conducted at a single center in Mexico, in which 61 patients with dry eye/conjunctivitis were assigned to progressive lacrimal occlusion with collagen and silicone plugs or a sham procedural group. Outcome variables included total and individual dry eye and conjunctivitis symptom scores, moisturizing agent usage, best-corrected visual acuity, ocular comfort level, visual performance, corneal/conjunctival fluorescein staining, and incidence of adverse events.

RESULTS

Total dry eye and conjunctival symptom scores were reduced by 43.7 and 33.7%, respectively 2 weeks after occlusion of all four lacrimal canaliculi with collagen plugs, increasing to 77.4 and 72.1% 2 weeks later following superior canalicular occlusion of both eyes with silicone plugs and inferior placement of collagen plugs. At the 8-week visit (4 weeks after silicone plug implantation of the inferior canaliculi of both eyes), the reduction in total dry eye and conjunctival symptom scores further increased to 94.2 and 93.0%, respectively, accompanied by a marked decline in each of the seven individual symptom scores (dryness, watery eyes, itching, burning, foreign body, fluctuating vision, and light sensitivity). In concert with these changes, moisturizing agent usage and corneal/conjunctival fluorescein staining decreased in a progressive fashion over the 8-week study period, and best-corrected visual acuity, ocular comfort, and visual performance improved in the absence of any treatment-related adverse events except for one case of epiphora. The response of patients to lacrimal occlusion can be sharply contrasted with the sham procedure group, which remained relatively unchanged from baseline at each of the study visits.

CONCLUSIONS

Progressive lacrimal occlusion with collagen and silicone plugs was of clinical benefit to patients with dry eye and conjunctivitis.

The effect of punctal occlusion on tear production, tear clearance, and ocular surface sensation in normal subjects

PURPOSE

To evaluate the effect of temporary punctal occlusion on tear production, tear clearance, and ocular surface sensation in normal subjects.

METHODS

Noncomparative interventional case series. Punctal occlusion with silicone punctal plugs was performed on nine normal subjects without complaints of ocular irritation and no known history of ocular surface disease. The lower punctum of both eyes was occluded in five subjects. The upper and lower puncta of only one eye were occluded in four subjects. Corneal and conjunctival sensations were measured with the Cochet-Bonnet anesthesiometer. Tear fluorescein clearance was evaluated with a CytoFluor II fluorophotometer by measuring the fluorescein concentration in minimally stimulated tear samples collected from the inferior tear meniscus 15 minutes after instillation of fluorescein. Schirmer test was performed without anesthesia. The tests were performed at days 0, 1, 3, 7, and 14 to 17 after punctal occlusion. Relationships were analyzed with linear regressions, and a quadratic term was used to model a return to preocclusion levels. Paired t test was used to study the change in tear fluorescein concentration.

RESULTS

In subjects who had the lower puncta of both eyes occluded, conjunctival sensation decreased in both eyes (right eye, P =.008; left eye, P =.003), but there was no change in corneal sensation. Their tear fluorescein clearance did not show a significant change from baseline (P =.90). However, a decrease in Schirmer test scores approached statistical significance (P =.056). In subjects with both puncta of only one eye occluded, we noted a decrease in corneal sensation (occluded eye, P =.042; nonoccluded eye, P =.036), conjunctival sensation (occluded, P =.001; nonoccluded, P =.060), and Schirmer scores (occluded, P =.022; nonoccluded, P =.011). Linear regression did not show a significant change in tear fluorescein clearance for either eye (occluded, P =.28; nonoccluded, P =.44). However, paired t test showed a significant worsening of tear clearance in the occluded eye from day 0 to day 3 (P =.001) followed by a subsequent improvement in tear clearance from day 3 to the end of the study period (P =.045). Paired t test did not reveal any significant changes in tear clearance in the nonoccluded eye. The quadratic term of the linear regression model demonstrated an increase toward preocclusion levels that approached statistical significance for corneal sensation (occluded, P =.053; nonoccluded, P =.099). It was statistically significant for conjunctival sensation (occluded, P =.001; nonoccluded, P =.045) and Schirmer scores (occluded, P =.047; nonoccluded, P =.044).

CONCLUSIONS

Temporary punctal occlusion in normal subjects decreases tear production and ocular surface sensation. Our findings suggest that in addition to blocking tear drainage, punctal occlusion may affect the ocular surface/lacrimal gland interaction. These effects were more pronounced in subjects with both upper and lower puncta occluded. In normal subjects, there appears to be an autoregulatory mechanism to return tear production, tear clearance, and ocular surface sensation to preocclusion levels 14 to 17 days after punctal occlusion.