Questions on my Diagnosis/Treatment (Plugs)

[DryEyeEric]

Hi all,
This is my first post here. I just have a few questions regarding my recent Dry Eye diagnosis and treatment. For some background information, I've suffered from dry eye for around 3 years now. I've done a lot of research on DES and have tried to self-treat myself, trying all the basics like drops (spent lots of $$ trying different brands/types), supplements, lid scrubs, hot compresses etc. Nothing provided much relief. About a year ago I went to my regular optometrist to try to get a good disgnosis and treatment. He wasn't helpful at all for whatever reason. No tests were done, he basically looked at my eyes and said "Yeah, theyre really dry" and then got me to buy a supplement and asked if I wanted a prescription for Restasis (Which I declined). Fast forward a year, I finally got fed up again with my eyes as they were having a significant impact on my career, social life, mental health etc. Did a lot of searching on Google and finally found one ophtamologist in my city that apparently has a special interest in Dry Eye. Set up an appointment and saw him. They did a Tear Lab Test, my scores were around 305 and 310 (although I had A LOT of reflex tearing so I'm not sure how accurate that test was). TBUT test was around 10 seconds according to him. He said my meibomian glands were fine. Basically the diagnosis was that I just lacked tears (Aqueous layer). It's a mystery to me why this has happened to me, as I am in generally good health and in my mid twenties. Anyway, I agreed to have punctal plugs inserted. My lower tear ducts were plugged with "Odyssey Extend" plugs. These are intracanilicular plugs that last around 3 months. The first day and a half my eyes felt a lot better, but then the effect wore off and I was back to how I was. A week later at my follow-up appt. I asked if I could have my uppers plugged as well. Same type of plugs were used, except he had to use the smallest size to get them in. Later that day my eyes felt great, they felt and looked very moist. Almost to the point of overflow but not quite. However once again, about a day and a half later the effect wore off a little. Now, my eyes have definitely improved but I feel like they could still be better. I am curious as to why the effect of the punctal plugs degraded so soon?? Is it possible that my eyes have adjusted to them? Or maybe the plugs migrated too far back and are now not blocking up the tear canal as well as they could be? My instincts tell me it is the latter, and one reason I believe this is because when I try to use drops, they still do not stay in my eyes very long (they never did before my plugs, which is why I stopped using drops.) What are your thoughts on this? And how should I explain this to my doctor? I have a followup appointment this Friday. Thanks.

[farmgirl]

I have had both dissolvable plugs and permanent umbrella type plugs. I had the dissolvable ones to see if plugs would help,they did. I will say that the permanent ones plug much better than the dissolvable ones and I think, like you that they did not block the canal as well. I know this because at times I could taste the restasis in the back of my throat. After the 3 months you may want to try more permanent ones although it is generally agreed upon on this forum that the intracanilicular ones can possibly give you problems in the future so I recommend you stick with the removable umbrella type.

Having said all that I am not 'cured' and still have problems but I will say that the plugs have been a Godsend and I will probably always have them. i did have the uppers cauterized as I didn't like the feeling that the uppers were 'scratching' my eyeballs, the lowers are plugged. Hope this helps...cheers....F/G

[DryEyeEric]

farmgirl, can I ask what brand of umbrella plugs you have? I would definitely like to try the more permanent plugs and/or cauterization, the only problem is this particular office ONLY uses intracanilicular plugs. The doctor told me he doesn't like the other types because they usually irritate the eyes. He insisted that if the plugs worked I should just come in every 3 months to have them replaced with the odyssey extend. Should I just start calling random eye doctors and asking what type of plugs they use? I'm not really sure what to do next. I feel plugs are the best method of treatment for my type of DES, but these extend plugs are too expensive and not as effective as others.

Also, about the safety concern with intracanicular plugs, I see that many people have complained about the Smart Plugs. Does this safety concern also apply to the absorbable 3-month plugs like I have? Or only permanent ones? Thanks.

[Rebecca Petris]

Smart Plugs have very serious well documented complications that result in the need for surgeries (and even then aren't always fixable). That's a unique ball of wax and I don't know of any other plug type with the same issues though there are of course risks with any plugs... In general though the most serious risks all have to do with a non-dissolving piece of something lodged way back where no one can remove it without surgery.

Paying for new plugs every 3 months, youch. If it were me, and if my doctor were not willing to consider other plug options for me, I would be looking round for someone who works with multiple types of plugs... To find someone with more options, yes you could call around (but don't even bother calling anyone who is not really "into" dry eye... but do consider both optometrists and corneal specialist ophthalmologists). You might also call a couple of plug manufacturers in case they can help.

[farmgirl]

I am sorry I don't know what type I have or had. I cold possibly call my Dr office tomorrow and find out though. Bottoms don't seem to be an issue, it is the uppers that seem to cause problems. I am sure a lot depends on the shape of the eye as there are probably many on this forum who seem to tolerate the uppers as well as the lowers. Unfortunately I am one of the ones for whom uppers was an issue.

I defer to Rebecca for advice on what to do now. You just have to call around and find someone who is more flexible. Perhaps if you can find the name of a plug that you would like to try they may special order it in for you at your current Dr. office though. I will see what I can do tomorrow....cheers...F/G

[indrep]

Eric, It is not uncommon today to see patients in their 20s with dry eye issues. Usually these people have been wearing contacts since their early teen years. Understand that the plugs seem to be working in that water is now visible on your ocular surface. So the irritation now could be coming from the damaged epithelial cells of your cornea. It takes a minimum of 90 days for the epithelial cells to heal. Longer if the damage is deeper than one layer of cells. The most important question is the osmolarity number dropping. As long as that number is elevated it slows the healing process of the cells. What I am saying is retaining more water is just the first step in finding the personalized therapy that benefits your specific condition.

As for the doc only wanting to use 90 day plugs, he could have had a bad experience with the Smart Plugs and doesn't want to live through that again. It could be profit motivated, get paid every 3 months, it could be he is uncomfortable (skill level) inserting long term plugs, as he stated. I would call other eye care providers and ask specifically if they use silicone long term plugs. There are many types of silicone plugs and may take more than one attempt to find the one that is most comfortable for your anatomy.