Restasis Problem, Plugs, Autologous Drops

[calli66]

My dry eyes are due to Sjogren's Syndrome (auto-immune), and I just got 4 punctal plugs 2 weeks ago. At first it was OK, but I am still adjusting. I find that I can't use Restasis now that I have 4 plugs. I'm not sure if it's the cyclosporine in it that's causing the problem. Seems like the other ingredients in the drops are causing a mucous-producing response, and now my lids are coated and irritated (and the more I clean them off, the more irritated they get).

The drops and mucous collect in the inner corners of my eyes, and when I go to remove it, big long strings of mucous come out of my eyes. The TheraTear PF drops I'm trying do the same thing. My own tears (minimal, but there are a few) don't irritate, and don't cause all this mucous. I've stopped Restasis for the time being.

Alternatives to Restasis: Autologous serum drops? If these are made from my own blood, and it's full of auto-antibodies, how would that help my dry irritated eyes? I understand a bit of the mechanism behind Restasis---an immuno-suppressant--but it would seem counterproductive to put my own self-immune-activated serum into my eyes. Wouldn't that make them react more, not less?

Calli

[dianat]

I have one simple, non-scientific theory as to why autologous drops help me. I'm guessing there are beneficial things in the serum that acts on inflammation. I do they are also supposed to promote healing of the cornea, but I've never really had any real damaged corneas. I burned like crazy, but my corneas looked healthy and without dry spots.

So the best I could do was guess that the autologous drops were bringing down any inflammation that I might have had. My eye doc did confirm that it is a possibility.

If you find out anything on autologous serum drops in your quest for information, let us know.

[indrep]

The serum of the the blood is a hypotonic solution. What allows inflammation on the ocular surface is a hypertonic tear. A hypertonic tear film allows increased osmolarity of the tear film, this creates an environment on the ocular surface conducive to inflammation. So the serum is lowering the osmolarity of tear film reducing the environment for inflammation.

The mucous strings are a part of the dry eye disease.

I will write more later must go now.

[dianat]

...ahem. That's what I meant to say.

[calli66]

dianat--you crack me up.

Thanks Indrep--anxious to hear more about this....

Calli

[indrep]

In previous post I talked about hypertonic vs hypotonic and didn't mention what those terms mean. Hypertonic means there is more salt in the available aqueous than is normal. hypotonic means less salt than normal.

So the Serum works on returning our tear film to a normal or isotonic concentration. Restasis (cyclosporine) acts as antiinflammatory on the ocular surface. Unfortunately restasis only works on the secondary ocular surface inflammation that takes place from the original cause of dry eye disease. In the majority of cases of dry eye the lacrimal gland and meibomian glands have already atrophied to some degree and lost nerves required to stimulate secretion. So while reducing the inflammation is good it does not necessarily increase tear flow. Keep in mind Restasis is designed reduce inflammation of the lacrimal and meibomian gland ducts opening them so secretions can make it to the eye.

Now for serum. Some patients, my wife included, show improvement in their eyes when on antibiotics. No one really knows why but for some you can get relief. So serum is made in various concentrations. If you have noticed that when you take antibiotics your eyes feel better then the serum may help you. I would suggest trying because dry eye disease is so variable you never know what might be your secret combination of treatments.

I hope this helps.

[Toril]

Hello, Indrep!

...just one question... when you talk about antibiotics, do you mean oral antibiotics or antibiotic drops?

Greetings, Toril

[calli66]

Thanks Indrep-
I'm still trying to understand what mechanism is causing my varied response to being totally plugged. It's definitely not the plugs themselves, because I can't feel them at all--no rubbing or irritation in the duct. It's the "new" composition of my tears, I guess. I'm having such difficulty! If only it were as simple as having more quantity of tears as was the case in the first few days after insertion.

If I understand your post correctly, my own increased tear volume is making my eyes more hypertonic than they were before--which is leading to temporary inflammation, which produces increased mucous. Besides inflammation, the mucous and tears are irritating my eyes' inner corners where they collect and dry. This creates an external skin irritation, similar to what one would get with a runny nose from a cold--red, sensitive.

TheraTears is supposed to be hypotonic, so my reasoning says I should use it more often to control the salinity imbalance created by increased natural tears. I had been avoiding it because of the methylcellulose content which adds to the "gunk factor."

I think if I can get the inflammation under control, I may be able to use Restasis again, but my motivation is low because of the delayed burning problem.

So, autologous drops sound like something I could try---at least they would not have the typical methylcellulose-type ingredients in them, and they are prepared in a base of plain saline solution, which has never bothered me.

Calli

[indrep]

Calli,
The increased tear volume LOWERS osmolarity. The less tear volume you equals hyperosmolarity. So the more tear you have on the ocular surface the lower the osmolarity of the tears. This will take time to lower osmolarity to a normal level. Also the Restasis takes time to reduce inflammation. A good dose of topical steriods does the trick quick but does come with some side effects.

The mucous strings are a result of dry disease. When my wife was using TheraTears she would still occaisionally have the strands. She is now using a new drop that is not yet available to the public and has had greatly reduced instances of mucous strands.

Toril,
Oral antibiotics was what helped her, and she was taking them for unrelated problem to eyes. This has been noticed on three different occaisions but hard to get doc to put you antibiotics forever.

[Lucy]

Interesting stuff Indrep. While I am very low in tears, I never had any "strands or mucous." Since lasik almost 8 years ago, I stopped having anything in my eyes. While it's normal for folks to have "matter" in their eyes in the morning etc. I never have ANY. None. This was absolutely connected to the lasik chop. The dry eyes were also, but along the way, I now have a full case of Sjogrens to help things out.

My doc is trying me on Restasis again and having me use Lotemax for two weeks prior to starting the Restasis. When I start Restasis, I am to still use Lotemax twice daily for two weeks. Just wondering how this "new" way of taking Restasis has any merit.

Since I have no mucous EVER in either eye, I'm pretty sure I have no (what) mucin? Not that I want strands or anything, but how is it others seem to

After this next Restasis trial, I'm thinking of asking Dr. Butcher about autologous drops for my case.

Lucy

[indrep]

Lucy,
Allergan starting recommending Lotemax for two weeks then start Restasis and then in four weeks plug patients.
First the Lotemax is a corticosteroid and will knock the inflammation down quick. For many people this stops the burning and stinging of Restasis. Second the plugs help keep more tears on the eye and reduce the osmolarity of the tear film and ocular surface. This reduces the pro-inflammatory environment of the ocular surface. One study showed that 805 of people who were plugged and had two weeks of topical steroid (lotemax, etc.) showed Zero symptons and corneal staining at two months. Notice no mention of Restasis. But we don't know the severity of disease of the patients either.

Bottom line is Allergan is now telling physicians to use the topical steroid and plug patients to achieve maximum benefit of Restasis.

[calli66]

Thanks for the clarification, Indrep. I see that I understand things backwards sometimes, but I'm learning.

I will try my Lotemax drops again for a week and see if my eyes calm down.

Calli

[Lucy]

Re: Indrep's reply to me. I'm already plugged, cauterized or scarred shut on all 4. I now the doc didn't make this up on his drive home from work to "keep me at bay."
Lucy