Plugs & quality of tears

[SusieD]

Hi all

I just have a quick question re: punctal plugs (I know you're probably sick of talking about them!)

I am due to have the silicone plugs in shortly but I am a little confused.

I have read many of the posts in the plugs archive and am a bit scared now! I think I would prefer the ones that you can see - just so I know whether or not they have fallen out. The thing is, if it is the quality of your tears that is the problem then surely the plugs wont help much. How do you know if it is a quality problem and more importantly how the heck do you begin to address that?

My schrimers suggest I am aqueous deficient - however I have no problems crying, or producing reflex tears - does this mean plugs will not help me?

Many thanks.

[Gaye]

Quality and Quantity of Tears

Hi Sara,

I can cry just fine (sad movies, baby and puppy commercials, you name it) with no quantity problem and still have dry eyes. Usually I feel worse after crying and need to apply drops as those tears wash away my quality tears. So for me, quantity doesn't have much to do with quality.

[Rebecca Petris]

But if you had a quantiy problem would crying then be compromised?

Not necessarily. Emotional tears are like reflex tears in terms of the different composition, aren't they? You certainly can have little to no basal tear production at all, but still have reflex tears. I was just speaking with a doctor on Friday about a case like that. I think you can find this out by careful performance of both anaesthetized and unanaesthetized Schirmer. The patient in question had a score of 0 on the anaesthetized Schirmer and a low score (but not zero) on the unanaesthetized one.

[kitty]

As I understand it, a quality problem means you have an isufficient amount of one or more tear components- water, oil and mucin. Plugs simply help you retain what tears you do have. They help keep all of the tear components from draining, so you do retain some of each of the tear components. The reflex tears are primarily water, that is why they do not soothe a dry eye. I suggest you click on the following link and read the Dry Eye FAQ. There are other links as well that you may find of interest. I have aqueous deficient dry eye, and a tear quality problem. Not only do I not make enough tears, but my Goblet cells are not producing enough mucin. My eye doctor plans to treat the inflammation with Restasis. If my eyes don't produce tears with that, then he will insert the plugs. Plugs also keep you from having to use drops quite so often, though you will still need them.
Dry Eye FAQ

[kitty]

Hi kitty what indicates (test or something else) that you dont have enough mucin? and what may have caused the a mucin problem. What i have read is : it can be caused by Abnormalities in the mucin layer of the PCTF often occur as a result of loss of the goblet cells of the conjunctival epithelium.

Caused by Infections and trauma resulting in corneal scars and ulcerations can damage the microvilli, causing permanent dry spots. Damage to the corneal surface can also result from exposure to certain drugs, including many types of general anesthesia. I havent had this (apart from medication), but i have no signs of anything apparently.

My eye doctor told me that in addition to the sandy/gritty feeling that I have, the combination of my symptoms of stringy discharge, reflex tearing and constant burning indicates that the goblet cells have either been severely damaged or destroyed by inflammation. It is the goblet cells that produce Mucin. In advanced cases of dry eye, the inflammation can cause destruction of the goblet cells. In less advanced cases, goblet cell function can be restored by reducing the inflammation. He also did a flouresceine stain which revealed a very low tear lake, which confirmed the aqueous deficient part. My eye Dr. had the diagnosis before he did the stain. Its based on symptoms and clinical findings with the slit lamp more than anything. Hope I got all of this straight. If not, I'm sure someone more knowledgeable than I could clarify. I'm kind of new to all of this.

[Rebecca Petris]

I think goblet cells can also be damaged/destroyed by auto-immune diseases and limbal stem cell deficiency. - And (some theorize) by LASIK.

Personally I tend to associate mucin deficiency with patients who have unexplained and very high levels of pain, i.e. where aqueous production is at least acceptable and where meibomian gland disease is under control.

[kitty]

In my case, it is more than likely caused by hormonal changes and too many years of contact lens wear, along with maybe an underlying autoimmune disorder that has not shown it's dirty little head as yet! Dry Eye in and of itself, when not caused by Lasik, is viewed as an autoimmune disease in many circles, especially when there is no other underlying autoimmune disease like rheumatoid arthritis or sjogrens. For many people, no specific cause will be found. I can sure relate with what Rebecca said, about the unexplained and high levels of pain with mucin deficiency! I wanted to strangle my eye doctor of 15 years when he looked at me with sad eyes and said "I have no quick fix for your pain" and "you may have to live with it".

[kitty]

If you have rosecea, you may very well have ocular rosecea which could be causing or contributing to your dry eye symptoms. There are specific treatments for that. What kind of eye doctor are you seeing? Have you seen an ophthalmologist? I was under the impression that rosecea is a type of auto immune disorder. I am on Restasis to try to reduce the inflammation. I'm not sure I understand the rest of your questions, re the test? My doc put flouresceine dye in my eye. That apparently causes the real tear film to show up. He said mine was "very low". I have never heard of limb cell deficiency.

[sazy123]

I have thought that it could be occular rocesea, but the rocesea is not that bad. I wasnt aware of any treatments for it other than just those for dry eye.

Im not seeing anyone currently becuase i have seen 3 doctors but they only saw me once, they didnt want to see me again because theres nothing they can do for me. I already had plugs, tried steroids and thats all they can do. I dont have a regular eye doctor.

Sorry what i mean by the test is, what makes them think you have mucin deficiency? just the symptoms. or is there any thing that shows up in tests to make them think that? in a flouresceine dye test, one doc said i had a few dry stops in the tear film but not that bad again. I just cant figure out why i have such bad dry eye symptoms if i have no clinical signs of it. the only sign i have is 6 sec TBUT, which i know is bad. So i know i have an evaporative problem, but i dont know where its coming from like MGD or mucin deficiency. coz i dont have signs of MGD apparently. All i can think is that the docs dont know much about dry eye in UK and arn't diagnosing me properly.

And if the mucin cells were damaged, then surely the symptoms would just occur sudenly. I already knew i had abit of a problem, because i couldnt tolerate contacts a year before the bad dry eye was triggered by anti depressants. So i assumed i had a lower tear pool. I should probally get a propper diagnosis from someone!

[kitty]

Needs help in the U.K.!

As you will find by reading posts in other threads, good dry eye treatment is hard to find in the UK. I will defer to others in the UK to try to assist you. The only test I had was flourescein dye, done only to test the tear volume (he was too busy that day and my eyes were too hot to tolerate much else). The rest of the diagnosis was based on my clinical exam and symptom complaints. Like I said before, my eye doctor said that the constancy and severity of my symptoms were consistent with failure of the goblet cells to produce mucin. If you have not seen an ophthalmologist (eye MD), I would suggest you do so. I'm hoping that others in the UK reading this can give you some guideance. I see my eye doctor tomorrow and will let you know if I learn anything more. I know that I had a tendency towards dryness from the time I started wearing contacts. It was over the last year or so, when I switched brands of contact lenses and began experiencing menopausal symptoms that my contact lens intolerance really increased. I stopped wearing them entirely about 6 months before I was diagnosed.