I went for it....

[Danny_]

Danny,
I am glad that plugs are working for you.

Please know there is a huge difference in cauterizing a punctum and inserting plugs which are reversible. Once you cautrize tissue it is damaged forever. Punctal occlussion with silicone exposed top plugs can be reversed with no tissue damage. This assumes they were inserted correctly. Some peoples DES will go away if they stop using a medication that is causing the DES. Even some Rheumatoid patients will have a reversal if it is Juvenile RA. Permanent tissue alteration is a serious decision.

Agreed but PERMANENT punctal plugs, while not as bad as cautery, cause exactly the same problem if the patients symptoms improve becasue they CANNOT be removed so patients can end up with an overflow that is very difficult to solve.

[Danny_]

Danny, thank you for sharing your experience with the plugs. I noticed when I had all four plugged with the test plugs, I thought I was more comfortable for a couple of days until they dissolved. At present, I am only producing a scant amount of tears. The purpose of plugs for me is to keep every drop of moisture in my eyes that I can. My doctor has recommended that if Restasis is not for me, I should try the 6 month dissolving plugs for my upper puncta. After that, we will decide whether or not to go with "permanent" plugs. My eye doctor has the same kind of plugs that I do. He had one easily removed through irrigation.

While I appreciate your insight, and do not mean to offend, I am comfortable with my physician's treatment plan and recommendations at this time.

That's fine. Its your eyes and this is a complicated disease so punctal plugs won't work for everyone (and if your doctor has the same problem you do, that's great because he is going to know all about it) but all I was saying is that punctal plugs should be tried IMHO before anything else because they are the best potential solution out there (at least that I have found) and offer the possibility of a permanent (or as permanent as you can get) solution to this problem. My physican told me the permanent ones were not possible to remove so I would be very slow to get them myself but it sounds like you are in safe hands since your doctor also suffers from the same disease that we do.

[indrep]

Danny, There is no such thing as a permanent punctum plug. Sorry. The closest thing to a permanent plug would be the Herrick Intracanalicular plug or the Medinium Smart Plug. And the only reason I say that is they are silicone or Acrylic and you can never be absolutely sure they were irrigated through the lacrimal sac. Trust me I've been at this Dry Eye and plug thing for 19 years.

[neil0502]

Punctal plugs can make a big difference for people with aqueous-deficiency dry eye (not enough tears).

From my understanding, though, if you plug somebody with evaporative dry eye (enough tears, in an absolute sense, but because of a deficiency in either the mucin or lipid layer, they evaporate too quickly), you may further dilute the mixture and actually worsen their condition.

This is why optometry and ophthalmology are now trying to standardize the testing and treatment protocols for DES--so that "one size fits all" isn't the first-line treatment anymore....

[Rebecca Petris]

There is no such thing as a permanent punctum plug. Sorry. The closest thing to a permanent plug would be the Herrick Intracanalicular plug or the Medinium Smart Plug.

Quite. This is apparent in the literature as well. There was a recently published study about the SmartPlug which was fairly positive in general but the authors expressed the complaint that they did not know how long they were lasting.

Indrep, I appreciate the input about cautery. I have always thought of it as a reasonable option in those cases where there has been longstanding evidence of a permanent need for occlusion, but I agree there's risks in 'encouraging' it. And doing all four at once sure sounds unnecessarily risky in any case.

Reason I asked is, I know plenty of people with epiphora after quadraplugging or even with lowers only, but the only post cautery complaints I have personally ever happened to come across are the opposite - failure to fully occlude, or the puncti re-opening later - so I'd be really interested to hear about any 'real live' cautery downsides.

[neil0502]

I might be right in that camp, Rebecca.

Last time (a week ago) I got the fluorescein treatment, a half-hour afterward, I was blowing ... uh ... fluorescein out my nose. Theoretically, it should only have gotten in my nose if there was drainage via my "cauterized" puncta.

I had already left the doc's office, so ... I'll leave it 'til next time to verify whether they're all closed x 4.

A few weeks ago, I DID ask the corneal specialist that I had to see on an emergent basis (is that fun, or what?) what he saw and--with the thoroughness of ... well ... a doc dis-interested and rushed--he said they were fine.

Doubt it.

I have heard that incomplete occlusion/repeat performance are far from rare.

May have to go back to the oculoplastic guy for re-do, BUT ... only if the latest group thinks it's got an aqueous deficiency component.

[indrep]

Rebecca

You have the answer already.

If a person needs punctal occlussion, the solution is punctal occlussion. Back in the mid 90s several institutions who were in the transition from cautery to punctal plugs did a retrospective look at their cautery patients. The results were all over the board meaning that 30%-80% of the punctas had reopened to varying degrees. So if you need punctal occlussion you really only want to go once and have it done. Considering punctum plugs should be a painless quick procedure, cauterization has a little more of an "experience" that goes along with it. So some folks might not want the cautery again but their tissue is now "malformed" and plugs won't work.

Back to the point, imagine if all those people who had been cauterized had the same experience as those who get the epiphoria. How many surgeries would have been needed to reverse the situation? With plugs there are options. Also, the medical profession should first strive to"do no harm".

So the real life experience would be patients who have been cauterized might not be getting the most benefit from their punctal occlussion procedure. Where those who have epiphoria from plugs that can be reveresed have options.

[Danny_]

Indrep,

You say that you have been "at this for nineteen years". Are you a doctor?

[indrep]

No. I have been in the Plug industry since 1986. That was way back before any insurance company paid for punctal occlussion. Back before many docs even knew about plugs. Plugs were considered a last resort and there were no sizers to make sure what size was needed.

So much has changed over the 20 years and in the last five years more research has been started than in the previous 15. We are learning so much about tears and the ocular surface now and how they interact that the next two years will be very exciting. Docs will have more options for treatment and quantitative ways to measure success and improvement.

[SusieD]

IndreP

I am interested in this issue of 'watering down' tears even further (in patients with evaporative problems) with plugging.

Essentially I have both problems, aqueous and evaporative - although Im not sure how bad the evaporative problem is - the doctors have just said my tears break up quite quickly.

All I know is, when I had plugs in, particularly all four (temp) my eyes felt much more moist and comfortable and drop usage was reduced drastically. I'll take the comfort!!

Its got me thinking though - by plugging, even though it may make me feel better - am I likely to make it worse in the long term due to this 'watering down'?

I realise it is difficult for you to say, but I would really appreciate your comments on this issue. (Im supposed to be getting more plugs next week)

Many thanks

[indrep]

Susie,
When the aqueous(water) is reduced by evaporation then the osmoloarity increases. This causes the tear to become hypertonic (too salty) which is an elevation of tear film tonicity. This elevated tonicity dehydrates the cornea, in other words the tear film is sucking the moisture from your cornea. Recent research has confirmed earlier research that this elevated tonicity leads to subclinical inflammation on the eye surface. So assuming your current tear has the right electrolyte balance by increasing the amount of tear that stays on the eye you will decrease or lower the tonicity of your tears and start hydrating your cornea again. A hydrated cornea is a happy cornea.

This is a simple explanation, because other factors could come into play. Also, I am a big believer in plugging in stages. Do the lowers first, wait 3-4 weeks and then have the uppers if needed. Experience shows plugs can be very beneficial, also cleaning your lids after warm compresses will help increase your own lipid distribution. I say distribution because I am assuming your meibomian glands are functioning. My motto is "Hydrate, Clean and Nourish".

As for the drops you want to make sure your drops are hypotonic(lowers tonicity). If they are hypertonic (raises tonicity)then you are hurting more than helping.

I hope this helps.

[SusieD]

Thank you!

You are great to have around. I was planning on just the lowers first anyway. The drops I am using the most are Theratears (throughout the day) and a drop or two of celluvisc at night (just because its a bit thicker).

I think my glands are functional, they are not blocked or anything but perhaps Im not producing as much as I should.

Thanks again for the info.

[sazy123]

Indrep what drops are hypotonic and what drops are hypertonic ?