To plug or not?

[MikeM]

OK, I am seeing my doc soon and am probably going to ask him to install a second plug (flow controller) in my upper left eye tear duct, in addition to the lower one already inserted.

Here is what I've done to no avail:

Restasis (6 months)
Serum tears (3 months)
Moisture goggles at night
Heat treatments
Fish oil
Increased hydration
Eyeglass Rx which corrects dryness-induced astigmatism

None of these things work and I have good vision (20/20 with/without Rx) less than 50% of time. With the onset of winter in CO I've noticed a sudden worsening of symptoms. I've had both ducts blocked before and the welling up of tears was a very unpleasant side effect. But, with only 1 day in 4 being managable vision-wise I'm inclined to try again. Should I ask for a dissolvable plug first to try it?

Thoughts?

[MaryVa61]

For me, the dissolvable plug was good. But I turned out to only need upper plugs when my dry eye problem was at it's peak, while we explored whether chemical allergies were going on and got a handle on that problem. I was lucky that I wasn't allergic to the soft plugs themselves!

I first had solid upper plugs, but gravity kept pulling them out just slightly and they'd irritate then. The corneal specialist, who'd put them in, removed them and then used the goo-type that dissolves. He said it was a common problem with gravity and blinking, and people with a certain angle of the ducts, to have a problem with keeping the solid uppers in.

If I had the chance to do it all over again though, I'd skip the uppers altogether and just use the lowers if needed.

[Ahmed]

MikeM,


I personally find flow controllers have very little effect. If it were me, I would fit something like a softplug, this can be removed later if required. Im just a little concerned about the vision, do you use any ocular lubricants?

Ahmed.

[MikeM]

Hi Ahmed,

Yes, I do use a lubricant but only at night, either Muro 128 or Genteal PM. My best vision is usually in the AM. I'm using serum tears 4 times/day. I found that Refresh Plus and Sustain really did nothing at all.

Out of frustration I had a flow controller installed today. I've been keeping a detailed vision log and have a follow up in 2 weeks. I can feel the heaviness of tear build-up and will have to assess how this goes. I don't think it is a long term solution but since I have strabismus my good eye can"t compensate. I'm 7 mos post LASIK and feel the shape of my cornea is such that my tears just can't coat it effectively. Not really sure where to go from here. I think the surgery was successful since I see 20/15 when vision is good, but those days are now few and far between.

[Ahmed]

MikeM,

What I find slightly confusion is that ocular lubricants dont appear to help, do you know your refraction is?

[Rebecca Petris]

MikeM:

Have you had corneal topography and/or wavefront aberrometry taken to determine whether there are surface shaping issues that could explain or at least be contributing to your vision issues? I know a lot of people with the vision fluctuation etc that you describe after a laser surgery without any clinically significant dry eye going on. Do find out your refraction too as Ahmed says or if not on file make sure they do a careful refraction at your next visit.

[Rebecca Petris]

OOPS. I meant to post this in Thanasis' thread and misplaced it... just noticed.

[Ahmed]

Rebecca,

I was thinking more along the lines that MikeM maybe a little longsighted. If that was the case, he would see fine when fresh, but as the day wore on, or if he stared to long at a near object his vision would be worse. This would also give a dull ache, that many patients think is dryness.

That could explain his variable vision, if he had an ectasia type of issue, that generally would give fairly consistent (poor) vision.

regards,

Ahmed.

[Rebecca Petris]

Yes I understand, makes good sense.

The reason I mention topography, etc. is that I have often over the years seen people here or on D'Eyealogues who eventually learned that their vision quality (not refraction) issues including diurnal fluctuations were due to higher order aberrations, irregular astigmatism etc - and dry eye (whether or not present) turned out to be the red herring as regards the vision. (In these situation patient goes round the bend trying to find the ideal dry eye treatment - seems to make sense to them because immediately after instilling drops their vision clears, ergo, dry eye is the problem right? Maybe but not always. After all there are a ton of people with dry eye whose vision is not noticeably affected at all.) So if someone here reports persistent vision problems after Lasik, prk etc, after eliminating 'normal' refractive error, I always tend to suggest they get topography and aberrometry.

[Ahmed]

Sure, in my experience most people who think they have DES, do not have it, Im not saying they dont have a problem, its just not dryness, and I suspect that is true for some people on this site as well.

regards,

Ahmed.

[MikeM]

I think you all bring up some interesting points. I am wearing an Rx (R +.25, -1.00; L +.25, -1.25) which matches the autorefraction although the axis that corrects my astigmatism does not match the auto-refraction measurements. My right eye is generally stable and my left eye varies. I've been examined when I'm having a very bad day and no refraction helps in those cases. OD claims that he sees dry patches right in the field of vision of the left eye.

I too am wondering if something else isn't happening since there is no correlation between what I do and how I see on a given day. I can do heat treatment, moisture goggles, be well hydrated and stay inside and see horrible followed by a 5 mile run the next day in Colorado wind and see fine. Is there latency...i.e, do conditions today lag and create effects tomorrow? I don't have much pain, stinging, or burning very often like so many people describe as symptoms here. Since I got the other plug inserted I have had a some good days, including today and what I call the "blink syndrome": blink once and see clear, blink again in see fuzzy. When my left eye is tearing heavy I do see 20/20 or better. Why do my eyes gush tears one day and feel dry the next?

One test will be Florida next week, will be in Sarasota for 6 days. In Sept I went to San Antonio and it was humid. By the time I drove from the airport to my hotel, changed and went to dinner I no longer needed my Rx and was seeing fantastic. The next 2 days were fantastic. I flew back to Denver and by the time I got to Colorado Springs I needed my Rx and vision had deteriorated again. Humidity seemed to help unless it was coincidence or change in altitude. I am still trying to arrange for a second opinion with the sole goal of checking for other problems.

Another option is to simply stop doing drops, ointment at night, heat treatment, moisture goggles before bed etc. and see what happens. A bit scary but if there is no effect then...well...perhaps something else is happening. An Air Force corneal surgeon that I talked to told me healing in my case is 9-12 mos given the +6.00 -2.75 pre-op Rx in each eye. His quote: "You are 7 mos into a 1 year tunnel and there is no light behind you and none out front. Your eyes will take a year to return to stability and pre-op tear production." Yet another opinion...

[Ahmed]

If blinking varies the vision, then its almost aways a surface issue.

I always advise 2 weeks of no drops/gels etc, then a review, then I would set that as my "baseline", then advise therapy from there.

A supprising number of patients report 2 weeks of no drops have helped, and they then go on with minimal drop usage.

I suspect in your case, the cornea is dry, causing areas which are "rough" and causing the vision to be affected, just as if you are looking through scrathed glasses, then a few blinks, and the tears fill those "rough" areas, and then the vision is good again. Consistent use of the correct drops should allow a better measurement of your refraction and more stable vision.

[indrep]

My experience with performing corneal topography on patients with ocular surface dryness is the refraction, especially cylinder(astigmatism), was it varied at least daily. I only took daily measurements. Most times it was by a diopter or more. This can impact the crispness of vision.
I don't know how this might be relevant to this particular issue other than a compromised ocular surface changes looking for nutrition and relief by swelling in dry areas to find tear film.

[buntbean]

I was SO freaked out when they wanted to put plugs in my eyes. The thought terrified me. Truth is, it's no big deal. I've had them put in and taken out several times. I've even taken them out myself. They say they can irritate for a few days but there is no harm in trying. It's something that can be undone easily.

I had problems with every plug they tried. They were actually scratching the surface, which they completely denied could happen when I called...changed their story when they saw me. Apparently, I have a slight turning in of my lower lids.