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  • Rebecca Petris
    started a topic My SmartPlug 'situation'

    My SmartPlug 'situation'

    Yup. It happened to me too.

    Talk about ironic.

    For years I've been warning people not to get Medennium SmartPlugs (a thermoplastic intracanalicular plug to help retain tears on the eye surface).

    Nine months ago my left tear duct became completely blocked quite suddenly. Literally within hours, I went from normal (my normal, that is) to tears pouring down my cheek. In the ensuing weeks I went through cycles of raging canaliculitis, keratitis, other itises. Those things calmed down but still flare occasionally. The blockage continued. During the day my eye alternates between dripping and oozing, sometimes both. I can't wear my scleral lens in that eye. At night, it goes bone-dry, erosion-inducing dry, the kind that not even goggles helps, only tape and goop. Then as soon as I'm up in the morning, back to streaming. Sometimes it's bright red, other times looks normal except that I appear to always be crying. I styled my hair to hang over that eye a bit till I couldn't stand it anymore and cut some bangs. The inflammation makes computer work very painful so I often tape the eye down during work and I've become an adept at whipping that tape off really fast when the UPS guy walks in so I don't freak him out.

    Speaking of work, for 9 months I haven't been able to work full time because of the pain and vision. Disabled husband, me breadwinner, etc, so it's been stressful. I've been so fortunate to have my farm and offgrid tinyhouse project to keep me sane. When I hit a wall at work, I go home and work on my sheeps-wool insulation or garden or anything other than a computer screen.

    I visited various doctors those first few months. The blockage didn't respond to any treatment.

    Then I tried to 'background-noise' it the way I do eye stuff in general, hoping it would eventually go away, especially because I wasn't insured at the time and money's always tight.

    Then one day a couple of months ago while puzzling once again over the suddenness of it, it dawned on me.

    Way back in 2003, when I was living in London, my ophthalmologist put SmartPlugs in both my lowers. I was very dry. Other plugs were falling out. These ones were a new concept that expanded to fit after insertion. It seemed a reasonable thing to do. (Heh. So did LASIK, two years before.) What did I know. At the time I knew a lot less about dry eye products (what few of them there were back then) than about lasik vision complications which was my main problem. The bottom line was, I badly needed a way to get my eyes wet enough to tolerate gas perm lenses which were the only way I could see. I had no idea there were possible complications of these plugs, and even if I had known enough to research it, the product was brand new and there wasn't any literature about it.

    One of those plugs came out. I don't remember when or how. Maybe a year or so later? Probably a sneeze. I just have a vague memory of gazing at a tiny piece of mangled something and thinking, Gee, I wonder if that's one of those plugs?

    The other one, I *assumed*, eventually flushed through.

    Right? Wouldn't it? I mean, plugs don't stay in there forever. I literally forgot all about it. Years and years passed.

    Then a few months back it suddenly occurred to me. What if....? Naw. If I even mention it to the MD he'll probably think I'm nuts. It's been so long. Then I was emailing with an old RS complications buddy, who, sadly, after so many years of vision issues from RK, had to go through oculoplastic surgery for SmartPlug complications awhile back. His surgeon told him sometimes a plug may float around in the lacrimal sac for a long time doing no harm then migrate and get lodged somewhere where it starts causing problems.

    Bingo. That's me. After a 3 month wait (trying to pick up any cancellation I could but no luck) I saw the only oculoplastic surgeon on my insurance yesterday, and he concurred that that's almost certainly what's going on.

    So here I am, and don't know quite where I'm going with this. Doc does not want to cut me open to try to get it out because he doesn't know where it is. (One of my research points - there's got to be a way to figure out where it is, I want to know what that is and figure out how to talk my insurance into it.) Doesn't want to get as drastic as a DCR if it can be avoided. Doesn't want to do a stent, on what seems to me a rational basis (eg all my problems are from a foreign body lodged in there... why put another foreign body anywhere in there?). So, we're culturing my crud and waiting for my next canaliculitis flare-up to possibly help localize the thing, then talk again about what to do next.

    Meanwhile back at the ranch... I'm seeing the days get shorter and wondering how on earth I'm going to drive my daughter to evening activities this fall and winter, with my left eye always so inflamed that the incoming headlights on our county roads are quite blinding.

    Sigh.

    [/sob story]

    MY ADVICE TO ANYONE CONSIDERING PLUGS:

    1) Do not get durable intracanalicular plugs of any kind.
    I have been vocal in the past about SmartPlugs just because in the literature they seemed to have considerably more frequent and worse complications, but the fact is the problem is in the whole concept of intracanalicular plugs (that's any plug pushed all the way in - that doesn't have a little umbrella top sitting where it can be grabbed). It's not that they always cause complications. It's that when they do, the complications can be so bad and it's SO HARD to do anything about it without quite drastic surgeries, and even those don't necessarily work, which is another of the big concerns pointed out by the oculoplastic surgeons in the studies I've read. Once those plugs are in there, you can't see them, you don't know where they are, you can't reach in and grab them, and the available methods for removing them can cause serious harm by driving the plugs somewhere other than out the door.

    2) Do not get any kind of plugs without informed consent.
    Placement of plugs is, in insurance and medical terms, a surgical procedure. I am horrified at the stories I hear of people having these things placed in their eyes without even being told much less having a detailed discussion about the pros and cons and opportunity to research on one's own. ALL PLUGS can cause complications, yes, even the external 'punctal' plugs - which, it's true, CAN fall in rather than out and cause harm, especially if not sized right. Dissolvable intracanaliculars will at least not be there forever, but they're still a foreign body in your canaliculus while they last, and can cause canaliculitis. Have a look at plug manufacturers' websites. They provide informed consent forms, just like laser surgery centers give you before laser surgery. The doctors have an ethical obligation to provide you with this form and answer your questions, and you have a right to be informed before you get plugs. Do not consent to getting any kind of plugs without this. You have reason to question the medical ethics of any doctor who does not take this seriously!

    If you have any doubts about what I'm saying, all you have to do is chat with an oculoplastic surgeon. They're the ones that really know. They all deal with people like me regularly. Ask THEM what plugs they think are safest.

    EDIT: One last note. I want to apologize to anyone I may have ever encouraged to get the removable type of plugs (true 'punctal' plugs) without duly cautioning them about possible complications. Rare complications are still complications.

  • Amanda
    replied
    Resolved?

    Originally posted by Rebecca Petris View Post
    Hmmm the link didn't seem to work?

    My eye's kind of tanked the last several days... heading back to Seattle to see the doc this afternoon... with all the goop oozing out I'm guessing the canaliculitis is raging again.
    Hi Rebecca,

    Has your situation been resolved? If so, how?

    Leave a comment:


  • Rebecca Petris
    replied
    Hmmm the link didn't seem to work?

    My eye's kind of tanked the last several days... heading back to Seattle to see the doc this afternoon... with all the goop oozing out I'm guessing the canaliculitis is raging again.

    Leave a comment:


  • RFREITAS
    replied
    Today I found this at my doctor blog:

    http://www.alvaro-sa.com/2014/01/dac...r-externa.HTML

    Hope you are doing well!

    Leave a comment:


  • Rebecca Petris
    replied
    Originally posted by cristinalatina View Post
    How is your lovely daughter? Is she 11-12 now? I want to ask about her by name but will not for privacy reasons!
    Oops missed that bit! She is doing wonderfully, thanks... You're right on, she will be 12 on Saturday... and she is almost as tall as me now! If you're on Facebook come find me!

    Leave a comment:


  • Rebecca Petris
    replied
    Originally posted by cristinalatina View Post
    What? They're not supposed to irrigate? I don't understand that, how are they going to get the plug out otherwise?
    Check out this abstract. (Also more references in my blog post about SmartPlugs a couple years back here.) In many cases, surgery is required. That's why the SmartPlug study group basically called for a moratorium on the product. Hm, 8 years ago? Has it happened? No.

    Hugs my friend, and apologies for hijacking the thread with personal details...
    Right back at you! No apologies necessary just so great to 'see' you!

    Leave a comment:


  • cristinalatina
    replied
    What? They're not supposed to irrigate? I don't understand that, how are they going to get the plug out otherwise?

    Originally posted by Rebecca Petris View Post

    Congrats on your little boy!!! I'm so happy for you. How fun to be in N. Ireland! That's a big move! I'm actually American, just lived abroad a lot - I must have been in England still when I first got to know you here? But yes, I loved the NHS, especially post-natal care... My goodness, they sent a midwife out to my house to check on me every day for something like two weeks. Then I come to the US where few subjects are as toxic as social medicine I had an emergency appendectomy last year at a time when I didn't happen to have insurance. $40,000 for about a day and a half. I'll be paying that one off forever.
    They still do that! I gave birth with midwives at the hospital and walked out with baby, not having paid a quid. Then the midwife was over for a couple weeks to check on baby's weight, breastfeeding, my stitches etc. And then health visitor took over. I haven't paid anything for health care except for dental coverage and optometrist. Even my eye drops are free!!I'm happy to have had my baby here. I was helped to deliver naturally without drugs. They were very patient and helped me do the unthinkable.

    Yes, I think when we met many moons ago you were still living here. Even though many are complaining about waiting times etc. I will forever be grateful for the NHS.

    I hope you'll find relief soon and that you'll keep us posted! With 4 smart plugs in and a love of makeup I don't consider myself a statistical improbability!

    How is your lovely daughter? Is she 11-12 now? I want to ask about her by name but will not for privacy reasons!

    Hugs my friend, and apologies for hijacking the thread with personal details...
    Last edited by cristinalatina; 15-Sep-2014, 18:15.

    Leave a comment:


  • Rebecca Petris
    replied
    Statistically it's very unlikely that yours will ever go wrong but just in case, if you ever get canaliculitis, please, don't let them irrigate... at least, not without research and a second opinion. There's actually some medical documentation on the harm that can come from irrigating this particular type because they can break or be driven unwanted places.

    I had a few attempts at irrigation early in the year (my blockage first started last December) but at the time, I had no idea a plug might be the problem - I had these plugs put in so long ago I'd forgotten all about them and it never occurred to me till this summer that something so old might be there. If I had realized in time, I wouldn't have had the irrigations. I don't believe they actually did any harm, but everything about these plugs is guesswork - for all I know, an irrigation might have pushed it from the canaliculus all the way into the NLD.

    Congrats on your little boy!!! I'm so happy for you. How fun to be in N. Ireland! That's a big move! I'm actually American, just lived abroad a lot - I must have been in England still when I first got to know you here? But yes, I loved the NHS, especially post-natal care... My goodness, they sent a midwife out to my house to check on me every day for something like two weeks. Then I come to the US where few subjects are as toxic as social medicine I had an emergency appendectomy last year at a time when I didn't happen to have insurance. $40,000 for about a day and a half. I'll be paying that one off forever.

    Leave a comment:


  • cristinalatina
    replied
    My dear Rebecca, of course now I realise that your issue is being able to wear the lens. I thought at first you were concerned about worsening dry eye.

    After reading about Smartplug complications at first I had contacted the optometrist who put them in, who said that in case of an infection I'd need antibiotics and irrigation, but most likely not surgery. I wonder whether you were one of the unlucky few, or whether its just a matter of time.

    By the way, just wanted to let you know that my husband and I moved from Greece to Northern Ireland, where I had my wee boy (16 months old now!) I am grateful for the NHS. You might wait forever to be seen, but cost is never an issue. I remember you are British, would you not consider "medical tourism" if you plan to come see your family?

    Leave a comment:


  • Rebecca Petris
    replied
    Hey CL! great to see you!!!

    Originally posted by cristinalatina View Post
    I didn't understand why the canaliculotomy was not enough and DCR was suggested? Just because the foreign object wasn't found?
    Yeah. Basically canaliculotomy verified that nothing is in the canaliculi or the lacrimal sac. You can't get at the nasolacrimal duct though with canaliculotomy, have to go in through the bone (DCR) hence that really is the only approach to take *if* we think there may be a plug in the NLD. Certainly possible it's not there either. Plugs do strange things and wind up in strange places.

    What is your prognosis? Is lacrimal function compromised after those procedures in any way long term?
    I don't think what I just had done will hurt anything. I'm back to status quo at this point. I don't really know about the DCR... I have a lot of reading to do. Without any research I'd expect that I can't mess around in there too much without affecting something adversely - never having believed in free lunch. However, frankly I'm not too daunted by risks to the tear function... this is my better eye and if it ends up like my worse eye, it won't kill me. (Though I need to look into what DCRDryEye just mentioned about obicularis muscle... stuff affecting the lids for example would concern me) Since I have dry eyes, we don't need to bypass the NLD because frankly a duct blocked by scar tissue isn't going to bother me... wouldn't have to bother with cautery LOL... My real problem is the infections/canaliculitis which are not a good thing in general but in my case are keeping me out of a lens in that eye. If I could just *do nothing* right now, I absolutely would. Drippy eye won't kill me but constant infection pain and poor vision, harder to visualize tolerating that long term. So my only real non-financial concern about surgery thus far is, is the !#$ plug actually there in the NLD to be found. I *think* it is, but won't know till they lay it open. And if it ain't, well, that's another bridge for another day.

    Leave a comment:


  • cristinalatina
    replied
    Rebecca, I am very sorry to hear of your situation as a Smart plug owner myself (I have 4, good God, were of little help but are still there threatening to cause problems!)

    I didn't understand why the canaliculotomy was not enough and DCR was suggested? Just because the foreign object wasn't found?

    Hope your problem gets resolved soon. What is your prognosis? Is lacrimal function compromised after those procedures in any way long term?

    Hugs my dear friend x
    Last edited by cristinalatina; 13-Sep-2014, 16:53.

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  • DCRdryeye
    replied
    Rebecca, yes I agree External DCR has a reputation for having a higher success rate (92%) compared to Endoscopic DCR (about 86%). However, there are biases. Firstly, external DCR has been around for a lot longer (about a century, in fact) and thus has a longer history. Endoscopic DCR is the new kid on the block without the history to compare. Quite a few ophthalmologists don’t have the skills to perform endoscopic DCR and if a patient requests it, they require an otorhinolaryngologists to assist during surgery. So they have a personal investment in recommending external DCR.

    For current figures found on the internet, difference in success rate is only very minimal, about 6% difference. When you weigh that up against the side effect profile, you’ll find the benefit to risk ratio leans in favour of Endoscopic DCR.

    External DCR requires removal of bone in two locations (side of nose and in the nasal cavity), whilst Endoscopic DCR only creates one hole. It’s great you don’t mind an unsightly scar near your eye, but the real problem is post surgical complications where the wound isn’t healing. I’ve received numerous emails from External DCR complications where a bony ridge on the nose is not healing and it’s now difficult to wear glasses due to pain. This will be a problem for those needing to wear moisture chamber glasses.

    I find it frightening that External DCR cuts part of the orbicularis muscle which is responsible for the pump mechanism for the excretion of tears (see paragraph below).
    The success rates between External and Endoscopic DCR are questionable. A study finds Endoscopic DCR to be more successful: http://www.aaojournal.org/article/S0...05)00460-4/pdf

    An extract from, “Endoscopic nasal dacryocystorhinostomy: results and advantages over the external approach”...

    The choice of indication between external or endoscopic approach depends on the service where the patient is being seen, because normally external access is performed by Ophthalmologists whereas endoscopic access is preferred by Otorhinolaryngologists. The advantages of endoscopic DCR are quite a few compared to external approach:

    Absence of external scars, maintenance of a lachrymal pump system through the orbicularis muscle (which is sectioned in the external approach), less bleeding, in addition to being easier in revision procedures, because the lachrymal sac is already exposed owing to the previous osteotomy. The possibility of performing repairs in the same surgical time for the association with nasal pathologies or those that are prone to recurrence (septal deformity, rhinosinusitis or synechiae of previous surgeries, patients with history or predisposition to formation of keloids), emphasize the endonasal indication. Endonasal approach may be preferred also in cases of acute dachryocystitis resistant to antibiotics.


    Reference: http://www.ncbi.nlm.nih.gov/pubmed/16446941
    Last edited by DCRdryeye; 13-Sep-2014, 00:18.

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  • Rebecca Petris
    replied
    F/G - great to see you - almost missed your post! Thanks! Will look into the plantain leaves...

    Leave a comment:


  • Rebecca Petris
    replied
    I had quite a good informed consent (written and verbal) from the surgeon before we started the canaliculotomy so no real complaints there - to be honest I just fault myself for not researching a bit more first.... we'll certainly be having some long conversations before heading to a DCR.

    But re external versus endoscopic: What is your specific objection to the external approach? I haven't talked to the surgeon about it at all yet but I have read over and over in articles I've come across that external DCR has better overall clinical results than endoscopic. Had a long talk with another surgeon friend who was quite adamant about superior clinical results from external too. I don't care too much about aesthetic aspects - I already have a scar on that side of my nose and am not planning to apply for any modeling jobs....

    Appreciate all the thoughts on anaesthetic. Purely from a comfort standpoint I'd rather do general but at the end of the day I want to go with whatever's got the best clinical results. I have lots of time so I'll be doing plenty more reading

    Leave a comment:


  • DCRdryeye
    replied
    Rebecca, regarding the possible DCR you may require. Firstly, insist on the least invasive “Endoscopic DCR”, please don’t let them do an “External DCR”. With regards to general or local anaesthetic, it depends if you don’t mind hearing them “drill” through bone. It’s a procedure that takes about an hour and you’d be very uncomfortable for that length of time. I’ve spoken to people whom have had it done with a local and all mention how painful it was. If you thought the local anaesthetic for your recent procedure was lengthy, imagine how much more you’d require for the more invasive DCR!!

    It also depends on the surgeon. They have their own preferences, whilst one may always do a DCR with a general, others will use a local. I highly recommend you insist on a general anaesthetic.

    It’s not surprising the assistant made the procedure sound like no big deal. The surgeon whom performed my DCR made it seem like a ‘scratch’ with nothing to be worried about other than ‘bruising’, ‘bleeding’ or a chance of it ‘failing’. Nothing else. He failed to list the other relevant complications which everyone having a DCR should be informed about. I hesitantly give you this link from my website with a comprehensive list of possible complications...

    http://www.blockedtearductsurgeryadult.com/?p=158

    Please don’t allow the list to detour you. It’s frightening but in all likelihood you won’t experience anything other than bruising and discomfort. It’s just our right to be fully informed.

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