Had Punctal Cautery

[willwork4tears]

I thought I'd start a new thread since my Smart-Plug thread morphed into a cautery thread. Maybe this will make the topic more visible for those interested in cautery.

I had my surgery on Tuesday, September 28. My opth cauterized both lower puncta. I'll leave updates as things go along in case other people are considering the procedure and are wondering how it's going.

Here's the first post copied from the Smart Plug thread:

Well friends, here's the update!

Since I decided against the SmartPlugs, I had punctal cautery instead. My surgery was yesterday AM (performed under propofol sedation). I'm back at work the next day and in no pain or discomfort. I feel about 95-99% normal. The only issue I'm having is a little foreign body sensation if I look to the side and then blink. If I look straight ahead and blink it feels normal.

The puncta are flat and white. They kind of look like tiny white second degree burns. There's no raised blister or obvious signs of swelling.

And the good news is my eyes feel moister already!

[willwork4tears]

day 3 post-cautery

Foreign body sensation is decreasing. But now my eyes feel a little irritated and the puncta are starting to itch a little. This is very similar to the itchy sensation you get when a cut is healing.

1. The surface area of the white part is decreasing indicating healing. No swelling, pain or discharge.

2. I do have more tears. Surprisingly I have visible moistness to my eyes and you can see a little layer of moisture at the eyelid margin! Can't remember the last time my eyes looked like that without it being the result of reflex tearing.

3. Stinging/burning/reflex tearing is definitely decreasing. Sandpaper/gritty feeling is also decreasing.

4. Not experiencing a flood of tears (bummer). Definitely not overtearing or "spilling".

5. On a scale of 1-10 (1 feeling perfectly normal, 10 feeling like there's 150 grit sandpaper tucked under my eye lid). I used to be a 7-8, now I'm oscillating between a 3-6.

6. My eyes are still bloodshot and look like I've been participating in dubious activities (I don't.) Maybe that will improve with time.

[dave25]

It's great to hear that you are feeling better! Keep us updated on your progress.

[bvendig]

cautery

hi!

i have 4 punctal plugs but am still pretty dry. i was wondering if you had also had 4 plugs before trying cautery and if so, was there a difference in how much it helped???

thanks!!
betty

[willwork4tears]

Thanks Dave!

It's great to hear that you are feeling better! Keep us updated on your progress.

Hi Betty,
I was never quadra-plugged. I had 2 lower plugs previously. I couldn't tolerate the silicone "umbrella" type b/c I have inward-turning puncta and they rubbed on my eyes. I had great success with the collagen plugs, but I wanted something more permanent so I didn't have to get collagen plugs put in every two months. (Mine only lasted about 8-9 weeks). I feel about the same post-cautery as I felt with the 2 collagen plugs. So far, it's pretty comparable, but hopefully more permanent.

I know others on here have complained that their plugs leak. So it's possible that you may feel better with cautery than with plugs. Check out my older Smart Plug post. Jenny2008 posted a reply where she describes being quadra-plugged and having a combination of silicone and Smart Plugs in her lower puncta. Double plugging like that may be something to consider.

i have 4 punctal plugs but am still pretty dry. i was wondering if you had also had 4 plugs before trying cautery and if so, was there a difference in how much it helped???

[hirentherock]

I had cautery on 24th sept.

And it has worked like magic for me.Eyes keeping moist now.My schimer test scale has risen from 7-8 to 13-15.
The most soothing symptoms r
1-Reduced photo phobia.
2-moists eyes.
3-No wake up time severe dryness like before.
4-reduced pain.
5-I used to have infection in 1 eye...with heavy discharge...antibiotics didnt work...was to take FML...thought to give a try to cautery before FML..now almost all discharge has disappeared due to natural epithelium's immunity strengthened.

Im very hapy...i wud say its like a magic to me...I guess cautery opens up in abt 6-8 months time.I wudnt mind having this done every 8 months.It costs less here in India...My optho took 2000Rs(abt 40$).

[jenny2008]

it opens up every 6-8 months? huh? i thought it was more rare for it to open back up??? willworkfortears--what did your doc say as it seems you go to a good doc? just curious!!!

and btw.. yes i had the smart plugs-have one now in my upper right puncta-it is enough for my right eye -plus my puncta in the right eye also turned inward so i couldn't tolerate umbrella plugs in the upper puncta....

i tried smart plugs in my lower puncta but it seems like the umbrella keep more tears in so i ended up getting plugs put in over the top of the smart plugs.. also, my right lower puncta grew shut on it's own and is still shut! yeah!

[willwork4tears]

I have never read/heard that punctal cautery opens up every 6-8 months. Maybe you had a different type of procedure??? Did your doctor use an argon laser or thermal (heat) cautery? I had the thermal type. There's also a procedure that's similar to cautery called canalicular ligation. That's where they cut out the canal that the punctum drains to and suture it shut. This technique is supposed to be a little easier to reverse than cautery (if you need reversal due to overtearing) My doctor said that punctal cautery is permanent about 90% of the time.

I'll attach a link to a research article that describes failure rates in these various types of surgery. These authors suggest that failure rates for thermal cautery is as high as 50%. However, they also go on to say that failure is much lower if the doctor cauterizes aggressively. Here is an excerpt.

When permanent occlusion is desired, the choices are thermal injury to the lacrimal punctum either with cautery, diathermy or laser, or by incisional surgery. To have success with one of the thermal injury techniques, it is important to destroy the lacrimal punctum and the canaliculus, otherwise recanalization may occur resulting in failure of the procedure. Failure rates with superficial thermal cautery have been reported as high as 50% and with laser occlusion as high as 86%. However, with more aggressive thermal cautery of the punctum and canaliculus, the recanalization rate is significantly reduced. In the absence of recanalization, the scar tissue created by the thermal injury will certainly block tear drainage; however, it may also result in eyelid distortion, and can make any attempt to reopen the system difficult in patients who develop subsequent tearing.


The article they reference about the aggressive thermal cautery says: One month after cauterization, the puncta that received deep cauterization were significantly more likely to have remained closed than those that received superficial cauterization (P less than .01).

So I guess if you're going to have cautery done, the success rate is higher if your doctor performs deep cautery and not just superficial cautery. This is how my doctor did my surgery. He cauterized inside the canal and then cauterized again on the surface.

http://dl.dropbox.com/u/4805513/cana...20ligation.pdf

it opens up every 6-8 months? huh? i thought it was more rare for it to open back up??? willworkfortears--what did your doc say as it seems you go to a good doc? just curious!!!

[jenny2008]

wow. thanks for this explaination!! both my docs have told me they hesitate to let me get cautery cause it is permament!! I think too the chance of it reopening is minimal.. just like any procedure that is done there is always a tiny risk of something..no biggie.. I am hoping to get it done on my lower left puncta -it is just now my new doc has only seen me 2 x and wants to get to know me first.. my older doc is now just teaching and researching...etc..

everybody have a great weekend.. )) Glad you're healing nicely Willwork4tears.

[spmcc]

RE: puncta opening after cautery

My ophthalmologist has cauterized my two lower puncta 3 times. The last time was one month ago and the right has already opened.

My optometrist also has dry eyes and he says he gets cautery every year because they open back up every year.

I don't think my ophthalmologist is doing a "superficial" cautery... I think he's going down into the canaliculi. But I still think they have the tendency to open... just my experience.

Good luck. I hope your puncta get the message the first time!

[djb]

In the past 10 years, been cauterized multiple times in the uppers and lowers. Only one is closed and three are partially closed right now. Cautery isn't a sure thing....the body's healing process is amazing....maybe if you build up enough scar tissue in time, it will close permanently.

[willwork4tears]

hirentherock, spmcc & djb: Thanks for posting your experiences. Both ophthalmologists I saw said cautery was effective in 90% of patients, so I didn't realize people were getting cauterized multiple times unsuccessfully. I hope I don't need to have it done once a year. We'll see what happens.

[spmcc]

RE: cautery

I was surprised to read that you had propofol prior to cautery. I've only had local injections... definitely the worst part of the procedure. Maybe your doctor does an extra good job since you're out and not just numbed? I'll ask my doctor... esp since I'll be having the procedure repeated...

[hirentherock]

I also had local injection on both eyes before they started surgery.
While surgery i cud hear the electric sparks sound being made in my duct to close them.So it must be a thermal one..
I had cautery before 2 years...it opened in abt 8-10 months...then i had it just before a few days.And im happy about it!

[hirentherock]

@jenny2008... cheaper surgery cost does not mean doctor is bad...I meant to inform all of you that any medical surgery is cheaper in India compared to other countries.