Dry eye, plugs, DCR surgery

[Lisa2]

Hello,

I am hoping to find some information from others regarding dry eyes & my recent surgery.

I had Herrick plugs placed in my lower ducts for dry eyes. My Dr., at that time, said I was not a candidate for Restasis because he believed it was to be prescribed for those only with secondary dry eye, not as a primary problem. So he suggested punctal plugs.
Many months later I had constant tearing, flooding is more like it.

I ended up seeing an occuloplastic eye surgeon who tried 4 times to irrigate, then once with a wire probe over a 6 month period to fix the eye non-drainage problem. NO success.
He asked me if I had Herrick Plugs inserted, I said Yes.
I had a DCR surgery 2 weeks ago & now have new ducts through the side of my nose with silicone tubes.
I never knew of these RISKS of these specific plugs, or I would not have said Yes to placement.

Anybody else with a similar experience or information to share?

Thank you

[mary kenny badami]

Lisa2 --

Welcome to Dry Eye Talk! Might you further spell out DCR, and then explain or provide a link to what DCR surgery is? Other than your posts here, I don't recall ever hearing about it before.

(For dry eye problems, both before and after Lasik surgery, I did have plugs "buried" in both lower puncti, but I don't know if they were specifically Herricks or not. Subsequent docs haven't figured out whether the plugs are still there. At one time I did consider having cautery to close the pucti, but since the plugs weren't apparently working, I declined).

Nowadays I'm managing pretty well with drops . . . but if DCR were to be in my future or that of one of my acquaintances here, I'd like to hear more about it.

mary

[Lisa2]

definition of DCR for obstructed tear ducts

Hi Mary and others,

DCR is a surgical procedure done when there is a 100% tear duct block. The blockage can be caused from scarring from frequent infections, from unknown causes & from a 'thing' causing occlusion, like punctal plugs.
I had 4 irrigations & one wire probing in both eyes to fix the problem w/out any success. My right eye is over 75% blocked, my left eye 100% causing constant tearing, blurry vision.

The surgery took 2 hrs under general anesthetic & the occuloplastic surgeon has to create a new tear duct drainage system. DCR is where that system is created by drillling through the side of the nose into the sinuses. Silicone tubes through your tear ducts then through the side of your nose. The tubes are left in place for 6-12 months, then removed & hopefully that new system will work great. In my situation, it was & should always be, a last resort. I had dry eyes, had the plugs placed, but they migrated & one lodged in my lacrimal sac, had to be surgically removed & a new tear system made. Average time off work is a full week. The pain is not overwhelming at all, but you are swollen, bruised, tubes are irritating all the time, you have lots of nose sprays, eye drops/lubricants, etc. The stitches are taken out 1 week post-op. It's truly a last resort.
My complaint is my eye Dr. never said this was a RISK or I would never have had puntal plugs put in.

I found another person who posted about needing a DCR under 'Surgery'
Thank you, Lisa

Definition of Dacryocystorhinostomy

Dacryocystorhinostomy: The surgical creation of a passage between the lacrimal sac (tear sac) and the nasal cavity to permit the drainage of tears. Dacryocystorhinostomy may be done to remedy an obstructed nasolacrimal duct.

[Lisa2]

Links

www.oregoneyecenter.com/tearing.htm

http://www.eyemdlink.com/EyeProcedur...ProcedureID=32

http://www.oculoplastics.co.uk/dacry...y_overview.php
This last link provides photos.

I hope these links work.
Lisa

[Lucy]

Lisa, thanks for telling about your surgery. Many of the people reading this forum DO have problems with plugs being buried, causing scarring and just about any combination of the above. I think many of us just "leave things as they are." My bottom puncta(um) have been scarred shut for a long, long time. I do not know to what degree. One doctor I saw told me "well this is what you wanted, the ducts closed." Yeah, right.

I am going to check out the websites you posted. Your situation will possibly provide valuable info to someone reading this, or sometime in the future.

[Lisa2]

Hello, I thought I would clarify.
My personal feeling is to avoid this surgery at all costs. It's a last resort & only when the flooding effects your everyday life/job & only when the ducts are 100% blocked. The reason for that is just what you said, leave things as they, as long as they are working (even partially).

I'm a nurse, so there my eye was dripping into a sterile field. I was wiping my eye constantly. I had one eye dripping & the other sticky dry all the time. There is also a risk for lacrimal sac or general eye infections because of this complete blockage. It's better to have the surg. before it gets infected, but I did not want this surgery, absolutely did not. I was frustrated this happened & that I had to go through general anesthetic, recovery & permanant eye changes all because I had puntal plugs put in. The specific plugs are Herrick plugs & I am told by the eye surgeons they are trying to get them off the market.
I read on another community board called www.eyetowncenter.com
of many other patients who have experienced the same issues after plugs migrating. Personally, I would always say to go with Restasis rather than plugs because the risks are far fewer & it's not invasive, cannot lead to surgery.

Thank you

[kitty]

Where are the published articles?

Lisa2, I too am a nurse, so I think you will relate to what I am about to say. To add a bit more credence to what I am about to say, I also work as a medical malpractice claims adjuster. I can speak from both sides when it comes to determining liability and damages. In all fairness, and to avoid having a lot of people panic by reading this thread, I feel a few things should be said.

I would like you to provide references to some published articles about recent incidents of complications from the Herrick plugs. I reviewed the posts at the message board link that you provided. I know one reference was to an incident that occurred, I believe, back in 1992, which generated several published articles. Another was a 3rd party, stating what he had heard about some survey responses. The last one about the 9 patients did not specifically say that they needed the surgery that you did.

I recently had the Herrick's placed in my two lower punctum, and am waiting to have them placed in my upper punctum. I did a lot of research online before consenting to the procedure. I ran across the article regarding the early complications and the need for surgery like what you had. I also noted that I could find nothing in the literature since, as far as new cases go. There is a difference between published studies/articles and hearsay.

Prior to having my plugs placed, I went to the lacrimedics website and reviewed the consent forms that physicians can download and use with their patients. I read the forms, and I signed one at my doctor's office after having full opportunity to discuss my concerns with my doctor. He said he could insert the 6 month plug if I was not comfortable with the permanent ones. He has the permanent Herrick's himself, and has used them pretty much exclusively since they came out, without a significant number of complications.

Visit the lacrimedics web site and go to the physician information link. In there you will find consent forms (under practice aids) and a link to articles. The article has an excellent discussion about canalicular obstruction.

Herrick Plug consent form (Practice Aids, forms, request for treatment)

Obstruction Article

Bottom line is this. There are risks to any surgical procedure. The doctor and patient need to work together as a team to determine the risk vs. benefit. It is up to the doctor to provide informed consent (risks and benefits). It is up to the patient to be a responsible healthcare consumer, to ask questions and do some digging before jumping in. As a nurse, I tend to go overboard doing my part.

While I am sorry that you had to go through what you did, the complication that you had is uncommon, but a known risk of the procedure. In all fairness, your concerns should be directed to the eye doctor who inserted the plugs and the informed consent procedure that he/she uses. That does appear to be your main concern. However, the way in which the message is delivered sent my mind in the direction of a problem with the Herrick plugs, and how they should be taken off the market. I just don't find evidence to support that suggestion and I don't think that most people who have Herrick plugs need to panic.

[Lisa2]

WOW, you did go overboard & into a panic.
There was no way in which my personal situation was intended to do such a thing.

One of the posts on the site you looked at said,
"I am having a problem with the herrick plugs and am not sure if my message went through to you. Irrigation did not work. Surgery is suggested!"

I certainly have spoken with my eye Dr. who placed them, as you suggested.
He is not using them anymore, per his statement.

I was sharing my own situation & information. I am not talking about published articles on plugs leading to DCR's.

[Rebecca Petris]

Hi Lisa and welcome to Dry Eye Talk!

I see the plug debates are alive and kicking here and interestingly it closely parallels the the LASIK debates: Those who truly experience the benefits don't want the ones with complications to convey the impression that the risk of complications is so high no one should do it. Those who experience serious complications of which they were not warned don't want anyone to suffer what they have suffered. Both are right, really.

I think Kitty makes valid points, generally speaking. There is always risk here that two or three categorical condemnations of a certain treatment or product may be taken wrong by readers. This bulletin board almost by definition is going to attract a disproportionate number of "exceptional" patients: those for whom traditional treatments really have not been too helpful. Thus if one were to judge exclusively from certain posts when a lot of us are having bad eye days, one might conclude that artificial tears are glorified water, Restasis is glorified hydrochloric acid, plugs are tools of torture, and so on. That's not because those things are bad in themselves, it's because it's the people for whom these treatments don't work that go hunting on the internet for more & better solutions. I would guess though that most readers know enough to put the individual posts in context.

And I think Lisa's story is important and needs to be heard. In my opinion no one should have an intracanalicular plug inserted without being fully informed of the potential risks AND THE ALTERNATIVES, including other types of plug materials, other plug designs, punctal cautery, and other dry eye treatments.

[indrep]

The design of the Herrick plug may have more to do with the issues that have been caused by the use of it than punctal occlussion with intracanlicular plugs. The plug is shaped like a golf tee. The sharppoint going in first. Some suggest this could damage tissue when being inserted. Other suggestions of where problems originate are that patients rub their eyes and force the sharp end into the tissue. Either way tissue is damaged and scar tissue grows and that all leads to uncomfortable issues.

If you can't tolerate silicone plugs there are other intracanlicular plugs. Medinium Smart Plug is an Acrylic material that shrinks in length and expands in diameter. They have been used for about 3 years. OASIS Medical makes a hydrogel Form Fit plug. When hydrated it expands in length and diameter to conform to the patients anatomy. It is also 90% water when hydrated and has no sharp edges.

Keep in mind that cauterization of the punctum has had rates of opening back up in up to 50% of patients. Also if your condition improves for what ever reason a cauterized punctum is damaged and would require the DCR surgery.

[neil0502]

Keep in mind that cauterization of the punctum has had rates of opening back up in up to 50% of patients. Also if your condition improves for what ever reason a cauterized punctum is damaged and would require the DCR surgery.

Thanks for your input. You always add value to this site with your posts.

It's my understanding, though, that the DCR surgery is a rare, last-resort option for the re-opening of cauterized puncta, no?

http://www.slackbooks.com/excerpts/67514/67514.asp

If the patient experiences significant epiphora after any of the aforementioned thermal punctal occlusion methods, the obstruction may be reversed in some cases by using a punctal dilator to probe and dilate the punctal opening and the proximal canaliculus.9 If this fails, more invasive methods, such as passage of a pigtail probe, incision of the eyelid margin medial to the punctum with marsupialization of the canaliculus, or (in extremely rare instances) a full dacryocystorhinostomy, may become necessary.

BTW: I'm fairly sure that "marsupialization" means "to make a kangaroo out of...."

[SusieD]

Ive had the Oasis form fit - wouldnt do it again. To be fair Ive had no problems like those listed above, being a soft gel-like material it is unlikely to cause any damage to surrounding tissue. In my experience, it just didnt help at all - not like the silicone ones that sit outside the punctum. I dont think they're in place anymore anyway.

What was strange is that the doctor that put them in called and asked Oasis how long these plugs were effective and they replied 'around 12 weeks' I was then informed they would have to be syringed out before new ones could be put in. I couldnt see the point to that - they're still in there but just not effective - but they dont dissolve? An awful lot of messing around and expense if you had to go through that every 12 weeks!

Yet, the Oasis medical website says it is a 'permanent' plug. Maybe they should get their story straight.

Sorry - I've got off topic abit here - should have put it in plug forum.

[Rebecca Petris]

Sorry - I've got off topic abit here - should have put it in plug forum.

Just FYI, I regularly go through the Open Forum and "file" threads in the topical archives to make searching/browsing easier. If they are interesting and fit in more than one subject heading I make copies. So don't worry about where you post.

[Rebecca Petris]

BTW: I'm fairly sure that "marsupialization" means "to make a kangaroo out of...."

LOL!

Online medical dictionary says... "Surgical alteration of a cyst or similar enclosed cavity by making an incision and suturing the flaps to the adjacent tissue, creating a pouch." Bleeech, in any case.

[indrep]

Neil,
Yes that would be a last resort to reopen the puncta.

SusieD
Oasis has the 12 week plug, Extended Duration plug, which is their version of a 90 day temporary. The Form Fit plug is a "permanent" Hydrogel plug that does not dissolve. The Form Fit plug could have come out if the punctum was dilated prior to insertion, but this would have happened within the first 10-20 minutes after implanting.