Cautery and no difference.

[Matt0029]

I had cautery 4 days ago. The day after my eye was maybe a bit more moist, but very sore. Then my eye has gone back to as bad as before is it possible /likely the cautery hasn't sealed up correctly?

[Milo007]

Punctal occlusion doesn't work in the long term since the lacrimal gland down regulates their secretions in response to the decreased neural feedback of the corneal nerves initially after cautery. Initially your ocular surface is flooded with tears following punctal occlusion so the friction between the tarsus and the cornea decreases dramatically. This results in decreased lacrimal secretions over time until the basal rate of lacrimal secretions is restored (which is already less than normal since the lacrimal glands are malfunctioning). So you come back to the same position after a few days or weeks of punctal occlusion.

Additionally if you have MGD or unaddressed inflammation then cautery can actually cause more accumulation of inflammatory mediators on the ocular surface decreasing the volume of secretions of both lacrimal and meibomian glands due to inflammation.

[Matt0029]

Thank you I think my problem is inflamation as after a long course of predesolne 0.5% my eyes were back to normal a flood of tears. Ikevris on its own isn't much help. At a total lost what to do

[Matt0029]

I think the duct is still open as u can see a hole still. Had it done 6 days ago

[Rebecca Petris]

Punctal occlusion doesn't work in the long term since the lacrimal gland down regulates their secretions in response to the decreased neural feedback of the corneal nerves initially after cautery...

I think that's a rather dogmatic statement. It contradicts the real life experience of a ton of patients I've known over the years as well as clinical experience of a ton of doctors.

Matt0029 What's your doctor saying? Have you spoke with them about it?

Doesn't always completely seal for sure, and a lot of people don't really know where they're at for awhile afterwards.

[Milo007]

Thank you I think my problem is inflamation as after a long course of predesolne 0.5% my eyes were back to normal a flood of tears. Ikevris on its own isn't much help. At a total lost what to do

Have you been using moisture chamber glasses?

I think moisture chambers would certainly help keep the inflammation down by reducing evaporation. Also if you can manage to get xiidra it would be of significant help (better than restasis but continue both). You must address inflammation and the source of it. Don't give up on restasis or xiidra as they work slowly. And don't abuse ocular steroids as they come with serious side effects.

How long have you been using the steroid?

[Milo007]

I think that's a rather dogmatic statement. It contradicts the real life experience of a ton of patients I've known over the years as well as clinical experience of a ton of doctors.

Well I read this somewhere on some medical journals. But definitely it's not applicable to everyone in general and there are patients who significantly benefit from it. Again I have come across some patients who felt great for the first few weeks or months but the effect weaned off with time. Could well have been the failure of the seal of the tear ducts!

[Matt0029]

I think that's a rather dogmatic statement. It contradicts the real life experience of a ton of patients I've known over the years as well as clinical experience of a ton of doctors.

Matt0029 What's your doctor saying? Have you spoke with them about it?

Doesn't always completely seal for sure, and a lot of people don't really know where they're at for awhile afterwards.

I haven't spoken to him yet have a follow up booked 2.5 weeks after the procedure. Which is on the 5th of February. So just under 2weeks time. Wondering whether I should really go back before. The duct had been cut before to try to remove a plug that was pushed too far in. So was a large puntum area that needed sealing. Can see a white scar bit but then a hole behind that. Like it hasn't scared the whole opening.

[Guest]

Punctal occlusion doesn't work in the long term since the lacrimal gland down regulates their secretions in response to the decreased neural feedback of the corneal nerves initially after cautery. Initially your ocular surface is flooded with tears following punctal occlusion so the friction between the tarsus and the cornea decreases dramatically. This results in decreased lacrimal secretions over time until the basal rate of lacrimal secretions is restored (which is already less than normal since the lacrimal glands are malfunctioning).

I get where you got this idea from, but it's overstating the case to say it doesn't work in the long term. I have all 4 puncta cauterized and can say with 100% certainty that cautery can indeed work long term.

And anecdotally, I can tell anyone reading this that when my eyes are doing well, they OVERFLOW with tears dripping down my face and it feels amazing compared to the alternative, which is bone dry... this absolutely glorious, drippy state of affairs NEVER happened pre-cautery. :-)

So my eyes definitely did NOT decrease tear production to nullify the effects of cautery.

For me, cautery has been absolutely fantastic and almost 10 years later I'm still extremely glad I did it (case in point: the past couple of days my eyes have been dripping, which feels so awesome on my ocular surface!).

Additionally, the DEWS report consistently suggests punctal plugs and/or cautery because it's a known fact that they can help increase the amount of tears on the ocular surface and provide significant symptomatic relief.

I'm definitely not suggesting everyone will be happy with punctal occlusion, but for many people, it's a great solution.

So you come back to the same position after a few days or weeks of punctal occlusion.

Not necessarily... For one thing, it can happen because the puncta can reopen, not necessarily because tear production has decreased.

For example, pre-cautery, the puncta looks like a tiny black dot on the lid. Post-cautery, after the swelling goes down, you can often still see a tiny black dot on the lid.

So the question becomes, is the dot there because the exterior is unsealed, but deeper in the puncta it's burned shut? Or is the puncta, in fact, still open even inside?

You can't tell just by looking at it, nor can the doctor (any doctor I've spoken to about this who is familiar with the cautery procedure will agree.)

The doc can test by - for lack of a better way to put it - shooting saline through the puncta to see if the patient can feel it running down the back of the throat. However that procedure may in itself cause a sealed puncta to open. Additionally, if the puncta is only partially unsealed, the amount of liquid getting through to the back of the throat via the puncta may be too little for the patient to detect it. However, this tiny opening may still be enough to make the patient's eyes feel too dry... and then if you seal that tiny opening (for example, by re-doing the cautery), it can be enough to provide the patient with significant relief.

If I'd ever seen a study claiming that "you come back to the same position after a few days or weeks of punctal occlusion" my strong suspicion is that for many of the study participants, the result was due to the puncta re-opening.

Anyhow, if one experienced relief during the initial healing period post-cautery, and then things dried up again... if one can still see the puncta opening, then I think it's well worth considering a re-do of the cautery in case it re-opened.

Additionally if you have MGD or unaddressed inflammation then cautery can actually cause more accumulation of inflammatory mediators on the ocular surface decreasing the volume of secretions of both lacrimal and meibomian glands due to inflammation.

But if one pre-treats to decrease inflammation prior to undergoing cautery, one can experience a net benefit, which is what happened with me (and many other patients). Furthermore, one can decrease any accumulation of inflammatory mediators by frequent application of eye drops to flush away such things (assuming one's own tear production isn't doing the trick).

[Guest]

I had cautery 4 days ago. The day after my eye was maybe a bit more moist, but very sore. Then my eye has gone back to as bad as before is it possible /likely the cautery hasn't sealed up correctly?

It's possible that your eyes unsealed as they healed and the swelling reduced. And the doctor can't always tell for sure if there's any passage left to drain tears.

If I were you, I'd ask them to redo it once everything heals and settles down. My approach was to say something like "I know there's no guarantee this will work, but can you re-do it in case it's open again... it felt great for a while after you did it, and then when the swelling went down, my eyes were back to the way they were before which makes me think there is still an opening there for tears to drain." I think the fact that I was not putting any pressure on the doc to guarantee success made them more comfortable giving it another go... it was kind of a "we're in this together" kind of thing.. "let's see what happens"... "no pressure".

Out of 4 puncta, only one of mine stayed sealed on the first try... the rest required a few attempts. By the time we were done, you could no longer even see a dot to represent where the puncta once was... it's just a smooth surface now.

And on the bright side, I always found the healing for the first attempt to be the most annoying... subsequent re-do's were much easier since the tissue was no longer as sensitive... I'm assuming the initial cautery deadened some pain-sensing nerves (in the lid) in the vicinity of the puncta.

[Matt0029]

Have you been using moisture chamber glasses?

I think moisture chambers would certainly help keep the inflammation down by reducing evaporation. Also if you can manage to get xiidra it would be of significant help (better than restasis but continue both). You must address inflammation and the source of it. Don't give up on restasis or xiidra as they work slowly. And don't abuse ocular steroids as they come with serious side effects.

How long have you been using the steroid?

About 3 months this time. Sortacort. I was on predesolne O. 5% about a year ago for 3 months when I started ikerivis my eyes were perfect after 3months on predesolne. Softacort helps but no were near like predesolne. I don't think can get xildra in the UK yet. So out of options to help stop the inflammation? Bar steriods?

[Milo007]

About 3 months this time. Sortacort. I was on predesolne O. 5% about a year ago for 3 months when I started ikerivis my eyes were perfect after 3months on predesolne. Softacort helps but no were near like predesolne. I don't think can get xildra in the UK yet. So out of options to help stop the inflammation? Bar steriods?

Well if steroids didn't have side effects probably it would have been the first choice of drugs to control inflammation.Steroids work wonders for me but I use them very cautiously (often for one or two days once or twice daily or at most for 3 days at a stretch - then I don't use them before a week). I have to be extra cautious with steroids because I have a family history of glaucoma and my IOP rises sharply in response to them.

For you or in general all I can say is that chronic steroid use must be monitored carefully (the IOP and close observation of the optic nerve) by a medical professional because it can cause some serious damage. Also different people respond differently to steroids like my IOP rises quickly with even two weeks of steroid use (loteprednol) whereas for someone it might not. So it all depends on your body's response to steroids. Steroids can cause glaucoma, corneal thinning, premature cataract, propensity towards ocular infections and rise of demodex population.

I don't think use of steroids for regular control of inflammation is a good idea until you know you are addressing the root cause of inflammation and you will need steroids to kill the inflammatory response of the body for a finite period.

Out of choices for anti inflammatories?

I don't think so!

There are other choices of safer anti inflammatories that can be used daily like heparin, chloroquine phosphate, restasis or xiidra(even though they are nothing compared to even the weakest steroid in controlling inflammation) . You need the find a doctor who can provide you with such innovative options. Finding a good doctor who can think out of the box is so important.

[Matt0029]

Thank you. I will have to look in to heparin and chloroquine not heard of these before.

[Matt0029]

It's possible that your eyes unsealed as they healed and the swelling reduced. And the doctor can't always tell for sure if there's any passage left to drain tears.

If I were you, I'd ask them to redo it once everything heals and settles down. My approach was to say something like "I know there's no guarantee this will work, but can you re-do it in case it's open again... it felt great for a while after you did it, and then when the swelling went down, my eyes were back to the way they were before which makes me think there is still an opening there for tears to drain." I think the fact that I was not putting any pressure on the doc to guarantee success made them more comfortable giving it another go... it was kind of a "we're in this together" kind of thing.. "let's see what happens"... "no pressure".

Out of 4 puncta, only one of mine stayed sealed on the first try... the rest required a few attempts. By the time we were done, you could no longer even see a dot to represent where the puncta once was... it's just a smooth surface now.

And on the bright side, I always found the healing for the first attempt to be the most annoying... subsequent re-do's were much easier since the tissue was no longer as sensitive... I'm assuming the initial cautery deadened some pain-sensing nerves (in the lid) in the vicinity of the puncta.

Did you have to pay for multiple cauterys for each puncta that didn't seal at the first attempt?

[Guest]

Did you have to pay for multiple cauterys for each puncta that didn't seal at the first attempt?

Good question!

For the puncta that was done in Canada, I didn't pay because any care you get an ophthalmologist is covered via out tax-funded healthcare system.

For the ones I had done in Penang (Malaysia), I don't remember if he charged me to do it again, to be honest.

Cautery is a tricky thing where technique hasn't been well studied as far as I can tell... I was told that in their training, they are basically taught to just "stick it in"... there's no specific like "put it in this deep for best results... this is how many seconds it takes at x temperature"... so I kind of feel like while the docs do their best, getting cautery right the first time is currently a bit of an art - with some luck thrown in (i.e. patient-specific factors in terms of how they heal etc.).

In any case, for me, the benefits of fully sealed puncta are well worth the time and trouble of getting it redone until the effects last... (provided one trusts one's doctor and one's doctor has steady hands hehe)