Are 4 plugs healthy?

[cristinalatina]

Hello all,

I need advice on whether plugging all 4 puncta would be a good idea.

I have moderate Lasik-induced dry eye, which is tolerable with DEZ drops, lower plugs (Smartplugs-everything else escaped in a matter of days) and hot compresses.

I don't have any tear overflow with the lower plugs, and I can tell that they're still in I'd like to limit the constant use of drops, etc and tolerate better the dry climate in the office and the windy outdoors.

I'm not a big fan of Panoptx, etc so I'm considering plugging the upper punctae as well, with the Smartplugs (OD says it's a viable option). However, I'm concerned about infections, etc-would 4 plugs retain bacteria in the eye and make them impossible to be flushed out? In other words, is it healthy or to be saved for really desperate cases???

Any ideas would be very much appreciated!

[kitty]

I have not read anywhere that 4 punctum plugged increase the risk for eye infections. The puctum are just drainage tubes. If they are plugged, the tears (whether natural or artifical) will slosh out the sides of the eyes as overflow. I have all four puncta plugged, and occasionally slosh quite well.

[cristinalatina]

Kitty,

I am dreaming of really wet eyes, tear overflow, tears sloshing wonderfully around my eyeballs...ahhh...

However, I've read many times that plugging all 4 "might" keep debris and "bad tears" on your cornea, if not bacteria (I don't have a more sophisticated way to put it). That's why I'm reluctant. But if it's safe, then I'd love to have wet eyes again...

[np1981]

I have had all 4 plugged since June. The main advice I was given was to use a saline rinse before and after bed to clean out debris etc. So far I havn't had a problem with it, and am looking to get the lower 2 cauterised.

[neil0502]

I have no idea (and I'm quadra-cauterized), but ... here's a Pflugfelder paper that sheds some important light:

1) http://www.ncbi.nlm.nih.gov/entrez/q...=pubmed_docsum

[emphasis added]

The effect of punctal occlusion on tear production, tear clearance, and ocular surface sensation in normal subjects.

* Yen MT,
* Pflugfelder SC,
* Feuer WJ.

Ocular Surface and Tear Center, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, Florida, USA

PURPOSE: To evaluate the effect of temporary punctal occlusion on tear production, tear clearance, and ocular surface sensation in normal subjects. METHODS: Noncomparative interventional case series. Punctal occlusion with silicone punctal plugs was performed on nine normal subjects without complaints of ocular irritation and no known history of ocular surface disease. The lower punctum of both eyes was occluded in five subjects. The upper and lower puncta of only one eye were occluded in four subjects. Corneal and conjunctival sensations were measured with the Cochet-Bonnet anesthesiometer. Tear fluorescein clearance was evaluated with a CytoFluor II fluorophotometer by measuring the fluorescein concentration in minimally stimulated tear samples collected from the inferior tear meniscus 15 minutes after instillation of fluorescein. Schirmer test was performed without anesthesia. The tests were performed at days 0, 1, 3, 7, and 14 to 17 after punctal occlusion. Relationships were analyzed with linear regressions, and a quadratic term was used to model a return to preocclusion levels. Paired t test was used to study the change in tear fluorescein concentration. RESULTS: In subjects who had the lower puncta of both eyes occluded, conjunctival sensation decreased in both eyes (right eye, P =.008; left eye, P =.003), but there was no change in corneal sensation. Their tear fluorescein clearance did not show a significant change from baseline (P =.90). However, a decrease in Schirmer test scores approached statistical significance (P =.056). In subjects with both puncta of only one eye occluded, we noted a decrease in corneal sensation (occluded eye, P =.042; nonoccluded eye, P =.036), conjunctival sensation (occluded, P =.001; nonoccluded, P =.060), and Schirmer scores (occluded, P =.022; nonoccluded, P =.011). Linear regression did not show a significant change in tear fluorescein clearance for either eye (occluded, P =.28; nonoccluded, P =.44). However, paired t test showed a significant worsening of tear clearance in the occluded eye from day 0 to day 3 (P =.001) followed by a subsequent improvement in tear clearance from day 3 to the end of the study period (P =.045). Paired t test did not reveal any significant changes in tear clearance in the nonoccluded eye. The quadratic term of the linear regression model demonstrated an increase toward preocclusion levels that approached statistical significance for corneal sensation (occluded, P =.053; nonoccluded, P =.099). It was statistically significant for conjunctival sensation (occluded, P =.001; nonoccluded, P =.045) and Schirmer scores (occluded, P =.047; nonoccluded, P =.044). CONCLUSIONS: Temporary punctal occlusion in normal subjects decreases tear production and ocular surface sensation. Our findings suggest that in addition to blocking tear drainage, punctal occlusion may affect the ocular surface/lacrimal gland interaction. These effects were more pronounced in subjects with both upper and lower puncta occluded. In normal subjects, there appears to be an autoregulatory mechanism to return tear production, tear clearance, and ocular surface sensation to preocclusion levels 14 to 17 days after punctal occlusion.
--
2) http://www.revoptom.com/HANDBOOK/March_2004/sec3_3.htm

Some individuals have actually cautioned against occlusion therapy in many cases, citing the new inflammatory theories of dry eye; they suggest that the use of punctal plugs actually creates a "cesspool" of cytokines and promotes, rather than alleviates, damage to the ocular surface
--
Based on this, I think I'd recommend people consider four PLUGS, but be very hesitant before going forward with full CAUTERY. Just my opinion....
--
Keywords: cautery puncta punctal occlusion cauterization plugs

[YGB]

I think the plug debate comes down to each individual understanding why they have dry eye and what would work best.

If you have MGD that worsens with inflammation, then having 4 plugs may not be optimal since the inflammatory agents do get trapped in the eye. However, if the inflammation is not too bad or the dry eye is symptomatically helped by 4 plugs with only slight to no additional inflammation, then 4 plugs sound good.

I may try 4 plugs again in the future. Currently I only have one plug. My inflammation has decreased since removing 3 plugs but I've also been on restasis and diligently doing compresses, supplements, etc.. Now that the inflammation is less, perhaps trying the plugs may be worth it with the hopes of having more comfort in the day. As one MD put it, you can always have them pulled out if it doesn't work but the counter-point could be that your messing with your tear balance and process by doing so.

In summary, in my opinion, if inflammation of lids, etc. is not a big issue for an individual's DES, then plugs seem to make more sense than if inflammation is a big issue. Good luck!

http://www.dryeyezone.com/talk/showthread.php?t=2205

[cristinalatina]

np1981,

that's a great idea! I'm not fond of saline, but I could use Nutratear and put in 3-4 drops just to rinse the eye.

Neil, while the study sounds discouraging, my understanding is that the tear production initially declined and then returned to pre-occlusion levels, therefore-no improvement and stable, actually not worse (I really hope I'm making sense ) My experience with the lowers is an increased tear meniscus (before I had none...) I haven't had a Schirmers, but I'll bet it will be (artificially?) elevated. However, symptoms persist, as I still have SPK and discomfort.

YaGottaBelieve, I am currently using Restasis, not sure about the benefits as I don't have the guts to quit for a while just to find out. I don't know how the "inflammatory component" can possibly be diagnosed (maybe only after a Restasis treatment? ) I think we're all doomed to trial-and-error treatment modes to eventually find out what the diagnosis should have been!

[neil0502]

Neil, while the study sounds discouraging, my understanding is that the tear production initially declined and then returned to pre-occlusion levels, therefore-no improvement and stable, actually not worse

Wellllll, I dunno. I just dunno.

A case could be made that--if occlusion is NOT going to alter the level of tears in the eyes in the long run, then some might want to err to the conservative regarding that "cesspool effect" (what a delicious name, huh?).

Only slightly off-topic: this whole "autoregulatory mechanism" has ME reluctant to make drops a part of my life. I'm really using my custom-compounded hyaluronic acid drops two or three times a day. Nothing else.

Everybody will have to make these decisions by themselves, certainly, but ... it's POSSIBLE that the neural feedback mechanism will view regular instillation of artificial tears the same way it views increased tear presence as a result of occlusion .... and reduce the production of tears.

No real information to back that, but ... there IS some logic there.

[YGB]

Neil - at this point, I am subscribing to a similary theory as you. However, instead of hyaluronic acid drops two or three times a day I am using Nature's Tears mist as needed. I have been almost exclusively using Nature's Tears the last few weeks instead of drops (except Restasis 2x/day). Nature's Tears is really just water (tissue grade) and sprays in a mist so it does not create the "flood" effect of drops that I think can affect "autoregulatory mechanism". However, I will say that it can put a dent in your budget if you solely use these one ounce cans since each can costs about $6.50 online if you get the 3 packs (I suggest you become an annual online member for $5 for a 10% discount on all purchases if you try something like this).

I suppose that one could choose to just put water in a spray bottle for much less money but at this point, I am hoping that the "tissue grade water" will help the healing process and not have the chemicals that normal water has. Maybe using distilled water may be an option ... hmmmmm.

Just my 2 cents as we all attempt to manage a condition that requires our active and calculated management since MD's can only do but so much (and the reality is not much when it comes to DES).

[cristinalatina]

Unfortunately, I've had Lasik. I really, really doubt that I will ever be able to restore a normal "autoregulatory mechanism"- the microkeratome pass has taken that away from me. I believe that my only option would be ocular surface management. My "lacrimal feedback manager" has gone completely deaf!!!

[YGB]

I've had LASIK too (6+ months ago). The eye can heal post-LASIK (even for us slow pokes) so if I were you, I wouldn't give up on the hope of the eye circuits doing at least more reconnecting with time. I've read that it can take 18 months to 2 years post-LASIK some of the connections to regenerate. Of course, there are exceptions to the rule. Therefore, my thought is to be as smart as possible to try things that will jump start the healing process due to the damage caused by LASIK.

Again, the body has a natural tendency to heal and the eye is no exception. I think the biggest problem with the eye, specifically dry eye, is that most MD's have no clue as to what is needed to help us and then rather than helping they hurt the healing process, thus making us sometimes feel hopeless. That's why you have to be smart in trying new things and I think you must always hold out some hope that there will be an answer that will really make a difference.

Lucy's trying the Tea Tree shampoo for demodex and if nothing else, she will have really clean and soft, tea tree smelling eyelashes . But seriously, I think the Tea Tree treatments that I have been doing this last month have really helped and for some, if demodex is a root cause of their DES problem, then drops, restasis, compresses, etc. will not be the answer.

Just keep trying things, but to enhance the chance for success, the things we try need to be rational and sensible. As my grandpa used to say, even a blind squirrel can sometimes find a nut, but you can gather more nuts with your eyes open.

[Deb]

My experience is that after 4 months of 4 plugs, I had the upper 2 removed.
I did have more moisture in my eyes, but I looked like I was crying most of
the time. And sometimes tears would run out of the corners of my eyes,
at will.....it was like putting drops in my eyes, only the drops were administered on their own time table. It seems like every person's experience is different, depending on their bodies, but I would not have the upper's administered unless your symptoms grow more severe. I had no problems with infections, etc.

[kitty]

I have determined that my sloshing is due to reflex tearing. I seem to be comfortable enough with the four plugs that I forget to put in drops. Interesting, if I am sloshing and put in drops, the sloshing stops. I freaked out my poor dentist the other day. He put me back in the chair and then started asking me if I was ok, if he was hurting me. I denied both. He then said "but you have a tear rolling down your face!" He was so upset! Ha Ha Ha. I just told him I have an eye thing and to ignore it.

[cristinalatina]

YaGottaBelieve,

I indeed try to be hopeful, and I don't deny that as time goes by my eyes feel better, albeit they seem to improve very, very slowly. What I meant to say was that you can't possibly expect that a damaged lacrimal system can start taking care of itself with little help. If I deprive my eyes of moisture to make them start producing tears again, the experiment will (has) failed.

So I'm looking for ways to keep the eyes moist and comfortable. I agree that overdosing would be a bad idea, so I'm checking out this option (just the lower plugs have proven to be very satisfactory for me).

I don't mean to be a pessimist, but Lasik probably causes permanently drier eyes (not necessarily bone-dry, but certainly drier).

[YGB]

Christina - you make excellent points. My response was probably me trying to convince myself more than anyone else. The fact is that I am a realist and realize that LASIK does do quite a bit of nerve damage and for some folks more sensitive to this damage than others (i.e. you and I), we have to find a way to manage the dry eye process. Having said this, I am trying new things (as are you) and am hopeful that the right combination combined with more physical healing will lead to being able to live with dry eye in a better way than I have in the past. The body is as much of an art as it is a science and we just need to be as smart and diligent as we can (but not over-diligent since that can hurt). Good luck!