My SmartPlug 'situation'

[Rebecca Petris]

I've felt sure all along it was lodged well down in the NLD so I wasn't too surprised... just disappointed. It would have been soooo nice to have this 'fixed' with an in-office procedure that only cost me a $15 copay as opposed to a hospital surgery.

Thanks for the tips about DCR. I might try pushing for a scan again... his objection was just that it will verify blockage but not locate the plug itself. He's not really crazy about DCR I think because he's concerned about the possibility of just not finding the darned thing. Plugs do weird things, and Smartplugs can also just fall apart in there. George do you have any opinion about general vs regional anaesthesia?

In case anyone reading this is facing the prospect of a canaliculotomy, probing etc, I thought I'd share a little about what it was like. I wish I'd been better prepared. I don't know why I didn't read up more about it - but then, it's not one of those procedures where googling it turns up a zillion forum and blog posts. When the assistant called me to schedule it, he make it sound like no big deal - for example I asked specifically whether it was going to affect my driving home and he didn't think so. Then when I showed up for surgery, the surgeon was surprised and concerned that I didn't have anybody with me. He knows I'm pretty eye-savvy so he may have assumed I knew more than I did about this.

Anyway, the whole process was maybe half an hour or so. Started with some numbing drops, was positioned leaning way back, then had several shots - and I've never had any problem with shots of any kind, but these ones seemed to take forever, burned like crazy and were very uncomfortable. Then when the real business got started... some of the probing and whatever else he was doing in there had me absolutely squirming in my chair. Being able to see a lot of long skinny sharp things heading in didn't help. We finished up with irrigating the upper canaliculus just confirming that the loop is clear... tried a few times but nothing in the NLD budged. The ophthalmic techs told me I did really well and shared stories of people who really fell apart during this kind of procedure but I must say I still felt like a complete wimp.

First 12 hours afterwards, pretty uncomfortable as anaesthetics wore off, and very oozy and drippy. (Taking steroid/antibiotic 4x daily for awhile.) 24 hours afterwards, I started to feel like I'd been punched. Edema and soreness all around the lower part of the orbit. Today (2nd day afterwards) about the same, just feels bruised so any movement of the eye is a little painful, plus cornea is very uncomfortable, taping eye shut today to get some work done. Otherwise doing fine and I'm sure it will all be back to normal fairly soon.

Thanks for the kind notes everybody... Tealeaf, no, the plug is apparently in a part of the duct that they can't reach with the type of surgery I just did, so I'll probably be moving on to a bigger surgery later in the year.

[DCRdryeye]

Darn!! sorry it didn't work out Rebecca, certainly wasn't expecting to hear that. And they still don't want to do a dacrocystogram? You can always have it done just for greater peace of mind and knowing where a possible block is. I had a dacrocystogram done "after" my DCR only when I found out about it. Let us know if you are going for a DCR. I'd request they drill the opening in the nasal bone as small as possible since you don't require an alternative tear drainage. Generally the hole is 10-12mm and it's large enough to feel an annoying gush of air, upon inhale, travel from your nose to the corner of your eye. Only a plug will remove such a feeling.

[tealeaf]

Rebecca,
Sorry to hear about the uncomfortable procedure. Keeping you in my prayers.

Are the plugs out?

[bunnyrabbit123]

Dear Rebecca,
I'm really sorry you're having to go thru this-Wish I could plunk my magic twanger and make it all go away!

[RFREITAS]

I am sorry Rebecca!

I have been praying for you. Wish all the best!

[Rebecca Petris]

Cut it open, probed, explored, irrigated. No joy. Probably need to go for the DCR after all.

I wish I had been better prepared for how uncomfortable that procedure would be.

[rant]I hate Medennium.[/rant]

[Rebecca Petris]

Thank you TeaLeaf... so kind

DCR and LM, fyi dr is insisting that dacryocystography of either kind will not localize the plug, only verify blockage. I haven't seen anything to the contrary online (not that I've looked very far yet). Going to try probing/canaliculotomy on Monday.

[tealeaf]

Yup. It happened to me too.

Talk about ironic.

For years I've been warning people not to get Medennium SmartPlugs (a thermoplastic intracanalicular plug to help retain tears on the eye surface).

Nine months ago my left tear duct became completely blocked quite suddenly. Literally within hours, I went from normal (my normal, that is) to tears pouring down my cheek. In the ensuing weeks I went through cycles of raging canaliculitis, keratitis, other itises. Those things calmed down but still flare occasionally. The blockage continued. During the day my eye alternates between dripping and oozing, sometimes both. I can't wear my scleral lens in that eye. At night, it goes bone-dry, erosion-inducing dry, the kind that not even goggles helps, only tape and goop. Then as soon as I'm up in the morning, back to streaming. Sometimes it's bright red, other times looks normal except that I appear to always be crying. I styled my hair to hang over that eye a bit till I couldn't stand it anymore and cut some bangs. The inflammation makes computer work very painful so I often tape the eye down during work and I've become an adept at whipping that tape off really fast when the UPS guy walks in so I don't freak him out.

Speaking of work, for 9 months I haven't been able to work full time because of the pain and vision. Disabled husband, me breadwinner, etc, so it's been stressful. I've been so fortunate to have my farm and offgrid tinyhouse project to keep me sane. When I hit a wall at work, I go home and work on my sheeps-wool insulation or garden or anything other than a computer screen.

I visited various doctors those first few months. The blockage didn't respond to any treatment.

Then I tried to 'background-noise' it the way I do eye stuff in general, hoping it would eventually go away, especially because I wasn't insured at the time and money's always tight.

Then one day a couple of months ago while puzzling once again over the suddenness of it, it dawned on me.

Way back in 2003, when I was living in London, my ophthalmologist put SmartPlugs in both my lowers. I was very dry. Other plugs were falling out. These ones were a new concept that expanded to fit after insertion. It seemed a reasonable thing to do. (Heh. So did LASIK, two years before.) What did I know. At the time I knew a lot less about dry eye products (what few of them there were back then) than about lasik vision complications which was my main problem. The bottom line was, I badly needed a way to get my eyes wet enough to tolerate gas perm lenses which were the only way I could see. I had no idea there were possible complications of these plugs, and even if I had known enough to research it, the product was brand new and there wasn't any literature about it.

One of those plugs came out. I don't remember when or how. Maybe a year or so later? Probably a sneeze. I just have a vague memory of gazing at a tiny piece of mangled something and thinking, Gee, I wonder if that's one of those plugs?

The other one, I *assumed*, eventually flushed through.

Right? Wouldn't it? I mean, plugs don't stay in there forever. I literally forgot all about it. Years and years passed.

Then a few months back it suddenly occurred to me. What if....? Naw. If I even mention it to the MD he'll probably think I'm nuts. It's been so long. Then I was emailing with an old RS complications buddy, who, sadly, after so many years of vision issues from RK, had to go through oculoplastic surgery for SmartPlug complications awhile back. His surgeon told him sometimes a plug may float around in the lacrimal sac for a long time doing no harm then migrate and get lodged somewhere where it starts causing problems.

Bingo. That's me. After a 3 month wait (trying to pick up any cancellation I could but no luck) I saw the only oculoplastic surgeon on my insurance yesterday, and he concurred that that's almost certainly what's going on.

So here I am, and don't know quite where I'm going with this. Doc does not want to cut me open to try to get it out because he doesn't know where it is. (One of my research points - there's got to be a way to figure out where it is, I want to know what that is and figure out how to talk my insurance into it.) Doesn't want to get as drastic as a DCR if it can be avoided. Doesn't want to do a stent, on what seems to me a rational basis (eg all my problems are from a foreign body lodged in there... why put another foreign body anywhere in there?). So, we're culturing my crud and waiting for my next canaliculitis flare-up to possibly help localize the thing, then talk again about what to do next.

Meanwhile back at the ranch... I'm seeing the days get shorter and wondering how on earth I'm going to drive my daughter to evening activities this fall and winter, with my left eye always so inflamed that the incoming headlights on our county roads are quite blinding.

Sigh.

[/sob story]

MY ADVICE TO ANYONE CONSIDERING PLUGS:

1) Do not get durable intracanalicular plugs of any kind.
I have been vocal in the past about SmartPlugs just because in the literature they seemed to have considerably more frequent and worse complications, but the fact is the problem is in the whole concept of intracanalicular plugs (that's any plug pushed all the way in - that doesn't have a little umbrella top sitting where it can be grabbed). It's not that they always cause complications. It's that when they do, the complications can be so bad and it's SO HARD to do anything about it without quite drastic surgeries, and even those don't necessarily work, which is another of the big concerns pointed out by the oculoplastic surgeons in the studies I've read. Once those plugs are in there, you can't see them, you don't know where they are, you can't reach in and grab them, and the available methods for removing them can cause serious harm by driving the plugs somewhere other than out the door.

2) Do not get any kind of plugs without informed consent.
Placement of plugs is, in insurance and medical terms, a surgical procedure. I am horrified at the stories I hear of people having these things placed in their eyes without even being told much less having a detailed discussion about the pros and cons and opportunity to research on one's own. ALL PLUGS can cause complications, yes, even the external 'punctal' plugs - which, it's true, CAN fall in rather than out and cause harm, especially if not sized right. Dissolvable intracanaliculars will at least not be there forever, but they're still a foreign body in your canaliculus while they last, and can cause canaliculitis. Have a look at plug manufacturers' websites. They provide informed consent forms, just like laser surgery centers give you before laser surgery. The doctors have an ethical obligation to provide you with this form and answer your questions, and you have a right to be informed before you get plugs. Do not consent to getting any kind of plugs without this. You have reason to question the medical ethics of any doctor who does not take this seriously!

If you have any doubts about what I'm saying, all you have to do is chat with an oculoplastic surgeon. They're the ones that really know. They all deal with people like me regularly. Ask THEM what plugs they think are safest.

EDIT: One last note. I want to apologize to anyone I may have ever encouraged to get the removable type of plugs (true 'punctal' plugs) without duly cautioning them about possible complications. Rare complications are still complications.

Rebecca,
My heart goes out to you. When I read your post yesterday, I told my husband you are indeed a strong lady. I am so so sorry that you are going through this. Keeping you in my prayer for you - strength for you and God to work out a smooth way for you to drive your daughter this Fall/Winter.

[Rebecca Petris]

LM - got results - It's only mild staph - I really didn't think it would be anything important as I'm not in one of my really icky flare-ups - doc offered to rx antibiotic if i was really keen on it but I'm not. Currently emailing about probing versus cutting open and asking about ct and mr dacryocystography. Trying to be gentle... not all doctors love control freak patients

LaDiva, thanks You know, I think it's really to your dr's credit that he is paying enough attention to the literature to stop fitting Herricks! Too many of them either never read anything outside their primary interest, or drink too much manufacturer koolaid. I remember a few years back when I went down to LA to one of the OC dry eye support groups, there was a speaker who was a very prominent local corneal specialist. This guy talked about how they can just put more smartplugs in if they aren't working or you aren't sure they're still there. He'd put three or four pairs in some people (shudder). He did NOT get invited back.

[littlemermaid]

We used a fluoroquinolone for an infected tear duct to cover more options - let's hope you find out what the gunk is soon.

[LaDiva]

First, I am very sorry to hear you are going through this Rebecca. Second, I just discovered why my eye doctor told me he is no longer using the kind of plugs he put in my upper eyes and why he said he would need to remove them surgically if they ever need taking out. They are Herrick plugs, and when I googled this after reading your post, I discovered they are intracanalicular plugs. I think it is time to change eye doctors again. I ASSUMED he would be knowledgable enough not use these plugs. Wow. Wrong again. Hope you are feeling better soon.

[Rebecca Petris]

He's certainly not pushing for DCR (though I am not currently against it if all else fails - but still need the plug out of there). We talked a bit about probing, he had some concerns but we *might* pursue that. I will look into dacrocystogram - thanks.

[DCRdryeye]

Hi Rebecca, are you able to get a macrodacrocystogram to locate where the plug is hiding? It’s most likely lodged in the naso-lacrimal duct. Simply probing it through could ‘push’ it out and into your nose for elimination. I’ve found oculoplastic surgeons are reluctant to ‘probe’ an occluded naso-lacrimal duct and rather push a DCR operation. There’s really no harm in trying to push it out, it’s the most non-invasive procedure and worth a try. Probing has a low efficacy rate only when the naso-lacrimal duct is occluded due to inflammation and scar tissue. However with a foreign body lodged in it, there’s no damage to the lining of the naso-lacrimal duct, so the higher your chances of success.

[Rebecca Petris]

Yup. It happened to me too.

Talk about ironic.

For years I've been warning people not to get Medennium SmartPlugs (a thermoplastic intracanalicular plug to help retain tears on the eye surface).

Nine months ago my left tear duct became completely blocked quite suddenly. Literally within hours, I went from normal (my normal, that is) to tears pouring down my cheek. In the ensuing weeks I went through cycles of raging canaliculitis, keratitis, other itises. Those things calmed down but still flare occasionally. The blockage continued. During the day my eye alternates between dripping and oozing, sometimes both. I can't wear my scleral lens in that eye. At night, it goes bone-dry, erosion-inducing dry, the kind that not even goggles helps, only tape and goop. Then as soon as I'm up in the morning, back to streaming. Sometimes it's bright red, other times looks normal except that I appear to always be crying. I styled my hair to hang over that eye a bit till I couldn't stand it anymore and cut some bangs. The inflammation makes computer work very painful so I often tape the eye down during work and I've become an adept at whipping that tape off really fast when the UPS guy walks in so I don't freak him out.

Speaking of work, for 9 months I haven't been able to work full time because of the pain and vision. Disabled husband, me breadwinner, etc, so it's been stressful. I've been so fortunate to have my farm and offgrid tinyhouse project to keep me sane. When I hit a wall at work, I go home and work on my sheeps-wool insulation or garden or anything other than a computer screen.

I visited various doctors those first few months. The blockage didn't respond to any treatment.

Then I tried to 'background-noise' it the way I do eye stuff in general, hoping it would eventually go away, especially because I wasn't insured at the time and money's always tight.

Then one day a couple of months ago while puzzling once again over the suddenness of it, it dawned on me.

Way back in 2003, when I was living in London, my ophthalmologist put SmartPlugs in both my lowers. I was very dry. Other plugs were falling out. These ones were a new concept that expanded to fit after insertion. It seemed a reasonable thing to do. (Heh. So did LASIK, two years before.) What did I know. At the time I knew a lot less about dry eye products (what few of them there were back then) than about lasik vision complications which was my main problem. The bottom line was, I badly needed a way to get my eyes wet enough to tolerate gas perm lenses which were the only way I could see. I had no idea there were possible complications of these plugs, and even if I had known enough to research it, the product was brand new and there wasn't any literature about it.

One of those plugs came out. I don't remember when or how. Maybe a year or so later? Probably a sneeze. I just have a vague memory of gazing at a tiny piece of mangled something and thinking, Gee, I wonder if that's one of those plugs?

The other one, I *assumed*, eventually flushed through.

Right? Wouldn't it? I mean, plugs don't stay in there forever. I literally forgot all about it. Years and years passed.

Then a few months back it suddenly occurred to me. What if....? Naw. If I even mention it to the MD he'll probably think I'm nuts. It's been so long. Then I was emailing with an old RS complications buddy, who, sadly, after so many years of vision issues from RK, had to go through oculoplastic surgery for SmartPlug complications awhile back. His surgeon told him sometimes a plug may float around in the lacrimal sac for a long time doing no harm then migrate and get lodged somewhere where it starts causing problems.

Bingo. That's me. After a 3 month wait (trying to pick up any cancellation I could but no luck) I saw the only oculoplastic surgeon on my insurance yesterday, and he concurred that that's almost certainly what's going on.

So here I am, and don't know quite where I'm going with this. Doc does not want to cut me open to try to get it out because he doesn't know where it is. (One of my research points - there's got to be a way to figure out where it is, I want to know what that is and figure out how to talk my insurance into it.) Doesn't want to get as drastic as a DCR if it can be avoided. Doesn't want to do a stent, on what seems to me a rational basis (eg all my problems are from a foreign body lodged in there... why put another foreign body anywhere in there?). So, we're culturing my crud and waiting for my next canaliculitis flare-up to possibly help localize the thing, then talk again about what to do next.

Meanwhile back at the ranch... I'm seeing the days get shorter and wondering how on earth I'm going to drive my daughter to evening activities this fall and winter, with my left eye always so inflamed that the incoming headlights on our county roads are quite blinding.

Sigh.

[/sob story]

MY ADVICE TO ANYONE CONSIDERING PLUGS:

1) Do not get durable intracanalicular plugs of any kind.
I have been vocal in the past about SmartPlugs just because in the literature they seemed to have considerably more frequent and worse complications, but the fact is the problem is in the whole concept of intracanalicular plugs (that's any plug pushed all the way in - that doesn't have a little umbrella top sitting where it can be grabbed). It's not that they always cause complications. It's that when they do, the complications can be so bad and it's SO HARD to do anything about it without quite drastic surgeries, and even those don't necessarily work, which is another of the big concerns pointed out by the oculoplastic surgeons in the studies I've read. Once those plugs are in there, you can't see them, you don't know where they are, you can't reach in and grab them, and the available methods for removing them can cause serious harm by driving the plugs somewhere other than out the door.

2) Do not get any kind of plugs without informed consent.
Placement of plugs is, in insurance and medical terms, a surgical procedure. I am horrified at the stories I hear of people having these things placed in their eyes without even being told much less having a detailed discussion about the pros and cons and opportunity to research on one's own. ALL PLUGS can cause complications, yes, even the external 'punctal' plugs - which, it's true, CAN fall in rather than out and cause harm, especially if not sized right. Dissolvable intracanaliculars will at least not be there forever, but they're still a foreign body in your canaliculus while they last, and can cause canaliculitis. Have a look at plug manufacturers' websites. They provide informed consent forms, just like laser surgery centers give you before laser surgery. The doctors have an ethical obligation to provide you with this form and answer your questions, and you have a right to be informed before you get plugs. Do not consent to getting any kind of plugs without this. You have reason to question the medical ethics of any doctor who does not take this seriously!

If you have any doubts about what I'm saying, all you have to do is chat with an oculoplastic surgeon. They're the ones that really know. They all deal with people like me regularly. Ask THEM what plugs they think are safest.

EDIT: One last note. I want to apologize to anyone I may have ever encouraged to get the removable type of plugs (true 'punctal' plugs) without duly cautioning them about possible complications. Rare complications are still complications.