Getting plugs - what to expect?

[Tridnod]

Well, it seems like i don't have blepharitis after all.
Atleast that is what my doc is telling me. He said that my tearfilm looks fine but i'm just not producing enough tears.

He asked me if i wanted plugs inserted and thougt that this would be good for me.
Now, what can i expect from the plugs when it comes to improving my dry eye problem? I know that there are som issues finding the right plug etc.
If the reason for my dry eye problem really is lack of tears and not the composition of the tear film then it seems that there would be a significant improvement. As said before i have moderate dry eyes and im hoping that finding the right plugs/combination up and lower, will be the issue from now on and not my dry eyes.

[np1981]

There are other threads here that go into more detail. My personal experiance is with "permanent" silicone plugs with the cap. The cap seems to cause problems for some people and they opt for internal plugs. For me the cap doesnt cause me any problems (I have 4 plugs) and it lets me see if they are still present. For me, having plugs significantly increased the moisture in my eyes.

[mspirk]

Silicone plugs

I'm satisfied with my four silicone plugs. The downside is the frequent overflow of tears, but I can put up with that as compared to the extreme dryness that occurs when I don't have them in.

[kitty]

When I did a trial of all four punctum plugged with temporary plugs, I noticed an immediate improvement in my DES. I had much more moisture in my eyes. As soon as those plugs dissolved, I was back to square one. I then had only the lowers plugged with silicone Herrick plugs (intracanalicular). I have noticed no improvement with just the two. I will probably know tomorrow if I will go for having the uppers plugged as well. I have had a few episodes of tear overflow with just the two lowers plugged, but I think it was caused by some little erosions and some allergy problems I had been having. It has only happened a few times and has lasted only a few days each time. It is just something to consider as you contemplate your options. My suggestion would be to start with a trial of temporary plugs, then try just two, then go to four if necessary. Doing all four at once may be too much.

[Rebecca Petris]

Has anyone here on the board ever had just the uppers plugged?

It seems to me that I remember some favorable reports about upper vs. lower plugging - may date back to the SurgicalEyes boards though.

[indrep]

There used to be a theory that 60% of tears were removed by the lowers and 40% by the uppers. This is no longer thought to be the case and since the lowers are easier to occlude they are the default location for plugging.

[np1981]

So how much do they think drains out the uppers?

[indrep]

The prevailing thought is 50/50 from the upper and lower puncta.

[kitty]

I cannot find the source right now, but if memory serves me correctly (and it may not), I believe it was Dr. Herrick who was the big advocate for plugging the uppers first, then the lowers. I will do some searching and see if I can find the source.

[np1981]

I wonder if the amount of tears drained through the upper punctum also increases when the lowers are plugged. That is, more going through the uppers than would normally do so when there are lower plugs in place, compared with no plugs at all. I'm still confused why plugging all 4 puntum made such a difference compared with just the lower two. My eyes were never moist with just two lower plugs only.

[indrep]

Kitty,
You are correct about Dr. Herrick being a proponent of uppers first. I think this was also back when everyone thought the uppers had less tear volume removal. Now that we know its a 50/50 ratio everybody does the easy lowers first.

np1981,
Lets assume you have 1 ounce of tears. .5 ounce will drain from the upper punctum and .5 will drain from the lower punctum. Understand that the tear outflow is controlled by the peristolic motion of the intracanalicular muscles. Similar to your esophagus, No matter how much food or beverage you put in your mouth only so much is going to be pushed down by your esophagus.

So we have a patient whose tears are evaporating too fast or he doesn't make much tear. The goal is to keep as much of that natural tear on the eye as long as we can. We plug the lower punctum, we now have stopped half the available tear from leaving the eye. For many people this brings comfort and there is no need to plug the upper punctum, for others this helps but there is still some discomfort. So now you can plug the upper punctum. This hopefully brings the great majority of patients some comfort. Unfortunately DES is not so simple a disease. Usually by this time many people have electrolyte imbalance, inflammation of corneal tissues, lid margins, etc. bringing these back under control is the mission of many in ophthalmology.

Also doing only one punctum per eye first is a conservative approach.

I hope this helps.

[SusieD]

The doctor who put mine in said that plugging the lowers does not reduce tear drainage by 50% because the upper ones kind of 'compensate' for this.

[Danny_]

Maybe Tridnod will be a guinny pig for us. I'd try having the uppers only plugged except that I am terrified of DES and as annoying as my overflow problems are, there are a million times better than what I had before. It is interesting though that having the lowers pluged had no effect whatsoever virtually for me but having the uppers plugged had a huge effect (granted that it was because all four were plugged). But, I never did try just having the uppers plugged. It would be great if I could find a balance.

[Tridnod]

Thanks for all the replies and sorry for late post.

Well, altough it would have been interesting only plugging the upper once, my doc wanna do the lower first with my left eye (problem eye) to begin with. I guess that is the normal ruitine.
If the lower plugs won't be enough we will go for the upper aswell. If that will do the trick i will try with only upper once and see what happends.
Just praying that plug is the answer, or else im back to square one again.

Just another question, can the doc determine if it really is lack of tears only by doing the tear break-up time test? He never did schirmers. I asked him if i he was certain that the reason was lack of tears and he said yes and that the tear composition was fine.

[kitty]

My doc has never done a Schirmers. He uses the flouresceine dye. With that he can see the volume of the tear lake and can look for dry spots on the cornea. As far as a tear lake goes, mine is "very scant", barely there. This is the same dye that is used for the TBUT. During that test, the doc can see how much splash there is and can determine from that if it is an aqueous difficient problem or not. From what I have heard and read, there are many conflicting opinions about the validity of the Schirmers and much depends on whether it is done with or without anesthetic. I hope I got all of this right, if not someone please correct me!