A review of the complications of lacrimal occlusion with punctal and canalicular plugs

Surgical Procedures in the Treatment of Dry Eye Disease

Dry eye disease (DED) is a multifactorial disease affecting 5% to 50% in different populations. The most severe cases of DED are often caused by aqueous deficient dry eye disease (ADDE) due to lacrimal gland (LG) hypofunction. Many patients with severe ADDE do not experience adequate symptom relief from topical treatment, severely reducing their quality of life. The focus of this review is to describe the surgical interventions presently being used or investigated when topical treatment with eye drops is insufficient. The conventional surgical approach is to proceed to punctal occlusion or partial or total tarsorrhaphy. However, novel surgical procedures have been reported to have higher efficacy and patient satisfaction than conventional treatments. These procedures include amniotic membrane transplantation, transposition or transplantation of the salivary glands, and cell-based injections into the LG, each with strengths and weaknesses. Further development of these treatment modalities might prove pivotal in treating dry eye patients in the future.

A Simple Step-by-Step Guide to Permanent Punctal Occlusion with the Ophthalmic Burr and Suture Technique

The medical treatment of dry eye disease usually follows a step-wise approach to achieve clinical improvement, ranging from non-surgical interventions with intensive lubrication to permanent surgical punctal occlusion. While frequent lubrication is essential, the intense regime is often too burdensome and difficult to maintain at the required frequency. Punctal plugs are an invaluable alternative approach, but also have limitations, especially in conscious children, in whom inserting and re-inserting punctum plugs in clinic can be challenging. If a patient has permanent and severe dry eye disease and responded well to a trial of temporary punctal plugging, a permanent surgical solution should be considered next. Liu et al showed that a more successful, yet simple technique to achieve permanent occlusion is to combine de-epithelialising the punctum and ampulla with the immediate firm apposition of the de-epithelialised surface using a self-absorbable suture - with a success rate of 92% in a prospective study. This article demonstrates this technique step-by-step in an 8-year-old child with severe chronic dry eye disease following proton beam therapy for orbital rhabdomyosarcoma. She underwent this procedure with excellent results.

Effects of Punctal Occlusion on Ocular Itching and Conjunctival Redness Associated with Allergic Conjunctivitis

PURPOSE

Punctal occlusion using punctal plugs has been successfully used to treat the signs and symptoms of dry eye disease. However, the effects of punctal occlusion on the symptoms of allergic conjunctivitis (AC) have been less well documented. There is some concern among clinicians that punctal occlusion may make signs/symptoms of allergic conjunctivitis worse by trapping allergens on the eye. The objective of this post hoc analysis was to address this question and thus assess the effect of punctal occlusion alone on ocular itching and conjunctival redness associated with AC.

METHODS

This was a pooled post hoc analysis of three randomized, double-blind, placebo insert-controlled clinical trials in subjects with AC. Enrolled subjects were generally healthy adults with ocular allergies and a positive skin test reaction to perennial and/or seasonal allergens. The study used a modified version of the traditional conjunctival allergen challenge (CAC) model, which included multiple, repeated allergen challenges following placement of the intracanalicular insert. Subjects were rechallenged on Days 6, 7 and 8; Days 13, 14 and 15; and Days 26, 27 and 28.

RESULTS

The data set included 128 subjects that were administered placebo. Baseline mean (SD) ocular itching and conjunctival redness scores were 3.52 (0.44) and 2.97 (0.39), respectively. On post-insertion Days 7, 14 and 28, mean itching scores were 2.62, 2.26 and 1.91, respectively, representing 26%, 36% and 46% itching reductions, respectively (p < 0.001). On Days 7, 14 and 28, mean conjunctival redness scores were 1.98, 1.90, and 2.08, respectively, representing 33%, 36%, and 30% redness reductions, respectively (p < 0.001).

CONCLUSIONS

Based on this post hoc pooled analysis, punctal occlusion with a resorbable hydrogel intracanalicular insert did not worsen ocular itching or conjunctival redness in this patient population.

French national diagnostic and care protocol for Sjögren's disease

Sjögren's disease (SD), also known as Sjögren's syndrome (SS) or Gougerot-Sjögren's syndrome in France, is a rare systemic autoimmune disease in its primary form and is characterised by tropism for the exocrine glandular epithelia, particularly the salivary and lacrimal glands. The lymphocytic infiltration of these epithelia will clinically translate into a dry syndrome which, associated with fatigue and pain, constitutes the symptom triad of the disease. In about one third of patients, SD is associated with systemic complications that can affect the joints, skin, lungs, kidneys, central or peripheral nervous system, and lymphoid organs with an increased risk of B-cell lymphoma. SD affects women more frequently than men (9/1). The peak frequency is around the age of 50. However, the disease can occur at any age, with paediatric forms occurring even though they remain rare. SD can occur alone or in association with other systemic autoimmune diseases. In its isolated or primary form, the prevalence of SD is estimated to be between 1 per 1000 and 1 per 10,000 inhabitants. The most recent classification criteria were developed in 2016 by EULAR and ACR. The course and prognosis of the disease are highly variable and depend on the presence of systemic involvement and the severity of the dryness of the eyes and mouth. The current approach is therefore to identify at an early stage those patients most at risk of systemic complications or lymphoma, who require close follow-up. On the other hand, regular monitoring of the ophthalmological damage and of the dental status should be ensured to reduce the consequences.

In situ formation of injectable organogels for punctal occlusion and sustained release of therapeutics: design, preparation, in vitro and in vivo evaluation

The treatment of dry eye mainly includes instillation of cyclosporine A (CsA) nanoemulsion or the use of punctal plugs. Therefore, in this study, a novel injectable in situ organogel plug was developed using CsA as a model drug, stearic acid, injectable soybean oil, and N-methyl-2-pyrrolidinone (NMP) (1.25:10:0.6, w/v/v) as gel materials, to provide a dual mechanism for dry eye treatment. The formulated CsA injectable in situ organogel (CsA-OG) was evaluated in terms of stability, in vitro release, rheology, ocular irritation, punctal occlusion tests, and ocular distribution assessment. In vivo ocular distribution investigations showed that CsA-OG achieved considerably higher C_max (1.94, 1.92 and 1.97-fold respectively) and AUC_0-72h in the cornea, conjunctiva, and sclera (2.49, 2.27 and 2.15-fold respectively) than ciclosporin eye drops (p < 0.05). In vitro model evaluation demonstrated significant decrease in flow flux to 52.78% at 2 min after CsA-OG injection. According to evaluation of the in vivo model, the organogel plug can completely block the lacrimal passages and greatly decrease the lacrimal drainage rate (p < 0.05). The above results suggest that these intracanalicular CsA-OG plugs can offer more extensive clinical applications than existing lacrimal drainage plugs and may act as a drug delivery system.

In Situ Forming Hydrogel as a Tracer and Degradable Lacrimal Plug for Dry Eye Treatment

Lacrimal plug is an effective and widely therapeutic strategy to treat dry eye. However, almost all commercialized plugs are fixed in a certain design and associated with many complications, such as spontaneous plug extrusion, epiphora, and granuloma and cannot be traced in the long-term. Herein, a simple in situ forming hydrogel is developed as a tracer and degradable lacrimal plug to achieve the best match with the irregular lacrimal passages. In this strategy, methacrylate-modified silk fibroin (SFMA) is served as a network, and a self-assembled indocyanine green fluorescence tracer nanoparticle (FTN) is embedded as an indicator to develop the hydrogel plug using visible photo-crosslinking. This SFMA/FTN hydrogel plug has excellent biocompatibility and biodegradability, which can be noninvasively monitored by near-infrared light. In vivo tests based on dry eye rabbits show that the SFMA/FTN hydrogel plug can completely block the lacrimal passages and greatly improve the various clinical indicators of dry eye. These results demonstrate that the SFMA/FTN hydrogel is suitable as an injectable and degradable lacrimal plug with a long-term tracking function. The work offers a new approach to the development of absorbable plugs for the treatment of dry eye.

Plug-related canaliculitis: a rare or underdiagnosed disease?

CLINICAL RELEVANCE

Conjunctivitis, chalazion and blepharitis are routinely managed by optometrists. However, it is especially important to consider the diagnosis of canaliculitis in patients with chronic or recurrent conditions.

BACKGROUND

This study aimed to report the clinical features, radiological findings and treatment outcomes in patients with plug-related canaliculitis.

METHODS

This retrospective study included patients with canaliculitis secondary to plug insertion between 2007 and 2020. All data regarding epidemiological characteristics, clinical presentation, isolated microorganisms, computed tomography imaging findings, treatment, and outcomes were analysed.

RESULTS

A total of 20 plug-related canaliculitis from 19 patients (18.3%) among all 109 cases of canaliculitis were identified. All patients with plug-related canaliculitis were females with a past history of lacrimal plug insertion for dry eye (mean age: 58.2 years). Most patients were initially treated as conjunctivitis with the mean time lapse to a diagnosis of 5.2 months. The average time from plug insertion to onset of symptoms was 5.1 years. Eighteen patients underwent canaliculotomy, and one patient received lacrimal irrigation. Plugs were identified in 18 cases, with SmartPlug in 13 cases (72%), followed by EaglePlugTM (two cases), Herrick Lacrimal Plug (two cases), and migrated FCI Painless Plug (1 case). Cultures of discharge, concretions, and/or infected plugs mostly revealed Pseudomonas aeruginosa (42%). Orbital computed tomography in four cases with SmartPlug revealed central radiolucency with surrounding soft-tissue enhancement. No recurrent canaliculitis was observed throughout a mean follow-up period of 13.7 months. No patient needed re-plugging after canaliculotomy and plug removal, with only one required additional lubricants for recurrent dry eye.

CONCLUSION

Plug-related canaliculitis is often underdiagnosed due to late onset and similar symptoms to common ocular diseases. Awareness of plug insertion history as well as meticulous removal of the plug, concretion and/or granulation tissue is important for early diagnosis and to ensure a good outcome.

Botulinum Toxin A Injection for the Treatment of Intractable Dry Eye Disease

Background and Objectives: To evaluate the clinical efficacy of periocular botulinum toxin A (BTA) injection in patients with intractable dry eye disease (DED). Materials and Methods: Medical records of patients with intractable DED who underwent periocular BTA injection from December 2019 to March 2020 were reviewed retrospectively. Patients were injected with 2.5 units of BTA in the medial part of the lower eyelids. The clinical data collected included age, sex, ocular surface disease index (OSDI) score, tear film break up time (TBUT), Schirmer test results, tear osmolarity (I-PEN), and tear meniscus height (TMH) measured by anterior segment optical coherence tomography. All subjective and objective data were collected before treatment and at 1 month after treatment. Results: Twenty-eight consecutive patients were eligible for chart review and analysis. Significant improvements in OSDI, tear osmolarity, and TMH were observed at 1 month after periorbital BTA injection. At the baseline and 1-month follow-up examinations, OSDI scores were 62.22 ± 21.30 and 47.98 ± 17.23, respectively (p < 0.001). TMH increased significantly after treatment (82.25 ± 40.50 at baseline vs. 138.02 ± 66.62 1-month after treatment; p < 0.001). Tear osmolarity using I-PEN showed a significant decrease after treatment (320.82 ± 24.66 at baseline vs. 302.75 ± 22.33 at 1 month after treatment; p < 0.001). No significant differences were found in TBUT or Schirmer test results before and after BTA injection. Conclusions: BTA injection into the medial part of the eyelid improves dry eye symptoms, the amount of tear retention, and tear osmolarity. Based on the objective parameters of the tear condition, this study supports the idea of BTA use as a potential treatment option for patients with intractable DED.

Oculoplastic aspects of ocular surface disease and their management

The normal structure and function of the eyelids, eyelashes, conjunctival fornices, and lacrimal system are essential for the health of the ocular surface, and abnormalities of these structures accompany many cases of ocular surface disease. We describe the role of oculoplastic intervention in the context of ocular surface disease, focusing on blink disorders, lagophthalmos, entropion, lid scarring and keratinization, trichiasis, and punctal and lacrimal sac disease.

[Inflammatory granuloma after intracanalicular punctal plug migration (a clinical case)]

At present, installation of punctal plugs (tear duct occluders) draws attention of ophthalmologists, but this method of treating dry eye syndrome (DES) is not without complications. Considering the rise of DES occurrence - the tendency anticipated to continue - as well as expansion of indications for installation of tear duct occluders, their usage can be expected to rise. The article describes a relatively rare clinical case that involved intracanalicular migration of silicone punctal plug. A female patient of 36 years old sought medical help in Research Institute of Eye Diseases (Moscow) to treat a lump in the area of lower lacrimal punctum in the left eye that was growing in size; the lump had appeared around 2 months prior to the visit. Patient's medical history read that around 2 years ago she had a silicone occluder installed in the lower lacrimal punctum of the left eye. On examination, in the area of lower lacrimal punctum, a body with a nutrient vascular pedicle deriving from lower lacrimal duct could be found. The occluder was absent in the opening of the lacrimal punctum. A revision of lower tear duct cavity was performed to remove its contents. The body filling tear duct opening was removed with forceps. Substance was then sent for histological examination. Tear duct was scraped out, the silicone occluder removed and sent to laboratory for scanning electron microscopy. The patient had no complaints 6 months after the procedure. CONCLUSION: The study showed that the forming body was granuloma resulting from aseptic inflammation. Surface of the silicone occluder in retention of lacrimal pathways remained unchanged. Described surgical tactic is suitable for treating patients with intracanalicular punctal plug migration.

Ocular Drug Delivery

Although the eye is an accessible organ for direct drug application, ocular drug delivery remains a major challenge due to multiple barriers within the eye. Key barriers include static barriers imposed by the cornea, conjunctiva, and retinal pigment epithelium and dynamic barriers including tear turnover and blood and lymphatic clearance mechanisms. Systemic administration by oral and parenteral routes is limited by static blood-tissue barriers that include epithelial and endothelial layers, in addition to rapid vascular clearance mechanisms. Together, the static and dynamic barriers limit the rate and extent of drug delivery to the eye. Thus, there is an ongoing need to identify novel delivery systems and approaches to enhance and sustain ocular drug delivery. This chapter summarizes current and recent experimental approaches for drug delivery to the anterior and posterior segments of the eye.

Reflections on Dry Eye Syndrome Treatment: Therapeutic Role of Blood Products

Dry eye syndrome (DES) is a multifactorial, frequent, pathology characterized by deficient tear production or increased evaporation of tears and associated with ocular surface alteration and inflammation. It mostly affects, but not exclusively, older individuals and leads to varying degrees of discomfort and decreased quality of life. Although the typical treatments of DES rely on using artificial tears, polyunsaturated fatty acids, integrin antagonists, anti-inflammatory agents, or on performing punctal occlusion, recently, standardized blood-derived serum eye drops (SED) are generating much interest as a new physiological treatment option. The scientific rationale in using SED for treating or releasing the symptoms of DES is thought to lie in its composition in multiple factors that resembles that of tears and contributes to the healing and protection of the ocular surface. This manuscript seeks to provide relevant background information on the management of DES, and on the increasing role that various types of SED or platelet lysates, from autologous or allogeneic origins, are playing in the improved therapeutic management of this pathology. The increasing role played by blood establishments in producing better-standardized SED is also addressed.

Review: The Lacrimal Gland and Its Role in Dry Eye

The human tear film is a 3-layered coating of the surface of the eye and a loss, or reduction, in any layer of this film may result in a syndrome of blurry vision and burning pain of the eyes known as dry eye. The lacrimal gland and accessory glands provide multiple components to the tear film, most notably the aqueous. Dysfunction of these glands results in the loss of aqueous and other products required in ocular surface maintenance and health resulting in dry eye and the potential for significant surface pathology. In this paper, we have reviewed products of the lacrimal gland, diseases known to affect the gland, and historical and emerging dry eye therapies targeting lacrimal gland dysfunction.

Clinical features, microbiological profiles and treatment outcome of lacrimal plug-related canaliculitis compared with those of primary canaliculitis

AIMS

To compare the clinical features and treatment outcome between lacrimal plug-related canaliculitis and primary canaliculitis.

METHODS

Patients with plug-related canaliculitis and primary canaliculitis between 2007 and 2014 in a medical centre were collected. Charts were reviewed for clinical features, microbiological profiles, time lapse between plug insertion and symptom onset, type of plug and outcomes.

RESULTS

Of 76 eligible cases collected, 13 were plug-related canaliculitis and 63 were primary canaliculitis. The most common presenting symptom was discharge in both groups (85% and 79%, respectively). The average time interval from plug insertion to symptoms onset was 5.5 years. Most canaliculitis developed in women, especially for plug-related canaliculitis, when compared with primary canaliculitis (100% vs 65.1%; p=0.015). The most common isolated microorganism was Pseudomonas aeruginosa in plug-related canaliculitis (46%) and Streptococcus in primary canaliculitis (28%), respectively. Isolation of Pseudomonas was significantly higher in plug-related canaliculitis than in primary canaliculitis (46% vs 12%; p=0.029). Most plug-related canaliculitis resolved after removal of plugs by canaliculotomy (12 cases, 93%). Most identified plug was SmartPlug (seven cases), followed by EaglePlug (two cases) and Herrick Lacrimal Plug (two cases). There was no recurrence in patients with plug-related canaliculitis, however, recurrence developed in seven patients (11%) with primary canaliculitis.

CONCLUSIONS

In comparison with primary canaliculitis, plug-related canaliculitis appear to be more prevalent in women and show a different microbiological profile. Retrieval of infected plug by canaliculotomy and adequate antibiotics can achieve a good outcome. Long-term follow-up is required because canaliculitis may develop several years after plug insertion.

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.

Bilateral simultaneous pyogenic granuloma after perforated punctal plug insertion

A 44-year-old woman with recurrent attacks of bilateral adenoviral keratoconjunctivitis infections presented with excessive tearing of 5 months' duration. Slit-lamp examination showed bilateral punctal stenosis. Tearing improved for 2 months after insertion of perforated silicone punctal plugs, after which she had a bilateral foreign-body sensation due to pyogenic granuloma pushing through the lumen of the silicone plugs. The foreign-body sensation improved after removing the plugs and a short course of topical steroid-antibiotic eye drops.

Biofilms in infections of the eye

The ability to form biofilms in a variety of environments is a common trait of bacteria, and may represent one of the earliest defenses against predation. Biofilms are multicellular communities usually held together by a polymeric matrix, ranging from capsular material to cell lysate. In a structure that imposes diffusion limits, environmental microgradients arise to which individual bacteria adapt their physiologies, resulting in the gamut of physiological diversity. Additionally, the proximity of cells within the biofilm creates the opportunity for coordinated behaviors through cell–cell communication using diffusible signals, the most well documented being quorum sensing. Biofilms form on abiotic or biotic surfaces, and because of that are associated with a large proportion of human infections. Biofilm formation imposes a limitation on the uses and design of ocular devices, such as intraocular lenses, posterior contact lenses, scleral buckles, conjunctival plugs, lacrimal intubation devices and orbital implants. In the absence of abiotic materials, biofilms have been observed on the capsule, and in the corneal stroma. As the evidence for the involvement of microbial biofilms in many ocular infections has become compelling, developing new strategies to prevent their formation or to eradicate them at the site of infection, has become a priority.

Punctal plug: a medical device to treat dry eye syndrome and for sustained drug delivery to the eye

Punctal plugs (PPs) are miniature medical implants that were initially developed for the treatment of dry eyes. Since their introduction in 1975, many PPs made from different materials and designs have been developed. PPs, albeit generally successful, suffer from drawbacks such as epiphora and suppurative canaliculitis. To overcome these issues intelligent designs of PPs were proposed (e.g. SmartPLUG™ and Form Fit™). PPs are also gaining interest among pharmaceutical scientists for sustaining drug delivery to the eye. This review aims to provide an overview of PPs for dry eye treatment and drug delivery to treat a range of ocular diseases. It also discusses current challenges in using PPs for ocular diseases.

An evidence-based analysis of Australian optometrists' dry eye practices

PURPOSE

The aims of this study were to investigate the clinical practices of Australian optometrists as related to the diagnosis, quantification, and management of dry eye and to assess whether these are consistent with research evidence and current guidelines.

METHODS

An online survey was distributed to registered optometrists (n = 654). Respondents provided information regarding their preferred diagnostic procedures and management strategies for dry eye, practice modality, year of commencing practice, and whether they possessed an interest in dry eye.

RESULTS

Respondents (n = 144) used multiple procedures for diagnosis. Recording patient symptoms ranked as the most important, most valuable, and most commonly used technique. The main objective tests were fluorescein-assisted tear breakup time, corneal fluorescein staining, and meibomian gland evaluation. Optometrists with an interest in dry eye more frequently used lissamine green, phenol red test, interference fringes, and tear osmolarity than nonspecialist practitioners. Dry eye treatment varied with severity. The mainstay of therapy was nonpreserved lubricants and eyelid hygiene; more practitioners recommended topical corticosteroids, systemic omega-3 fatty acid supplementation and increased dietary intake of omega-3 fatty acids for moderate and severe disease, respectively. The primary sources of information used to guide practitioners' management were derived from continuing education conferences.

CONCLUSIONS

This study indicates that although Australian optometrists use subjective and objective diagnostic tests and stratify treatment based on dry eye severity, there is a lack of uniformity regarding diagnostic testing, infrequent use of standardized grading scales, and significant variability in clinical care. These findings highlight the potential to improve the translation of dry eye research evidence and evidence-based guidelines into Australian optometric practice.