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http://www.ophmanagement.com/article.aspx?article=86437
Ophthalmology Management September 2005
excerpt:
Ophthalmology Management September 2005
excerpt:
"In the old days, I used punctal occlusion on day 1," Dr. Sheppard says. "In severe cases, I started with a collagen plug, followed by cauterization. For milder cases, I'd trial, and then insert a silicone plug."
Dr. Sheppard changed his approach as both the literature and his own experience revealed problems with early punctal occlusion.
"Now the paradigm has really changed because we know plugs can trap 'bad tears,'" he says. "Pflugfelder and colleagues1 have shown that punctal occlusion can worsen a Schirmer test score, and premature occlusion can harm the biofeedback loop to the ocular surface enervation."
Dr. Holland recalls, "In the old paradigm, we gave dry eye patients some artificial tears and occluded their puncta. The eyes looked moist, but they were still red and painful. The patient had more tears but often was not happy."
Dr. Donnenfeld uses a bathtub analogy to describe the situation. "If someone bathed in a tub, you'd drain the dirty water and refill it before the next bath. The same applies to punctal plugs," he says. "In an eye with inflammatory mediators like cytokines, interleukin and neutrophils, why would you want to insert a plug and keep these inflammatory cells on the ocular surface? With an anti-inflammatory approach, we fill the tub with fresh, new water. We treat the inflammation, and then we insert the plugs. This therapy improves not only the quantity of tears, but also the quality of the tear film on the ocular surface."
In this approach, physicians start by improving the quality of the tear film, eliminating the cytokines, down-regulating the T-cell activation on the ocular surface and improving goblet cell production and the mucin layer of the tear film by reducing ocular surface inflammation.
"If anti-inflammatory therapy doesn't work or it doesn't work completely — and that often happens in moderate and severe cases — then we follow with punctal occlusion 4 to 6 weeks after starting anti-inflammatory therapy." Dr. Sheppard says.
By prescribing an anti-inflammatory first, physicians have greater success with punctal occlusion. Dr. Holland points out, "The anti-inflammatory makes a big difference because we soothe a mediator of the pain and all the complications we might see."
Dr. Sheppard changed his approach as both the literature and his own experience revealed problems with early punctal occlusion.
"Now the paradigm has really changed because we know plugs can trap 'bad tears,'" he says. "Pflugfelder and colleagues1 have shown that punctal occlusion can worsen a Schirmer test score, and premature occlusion can harm the biofeedback loop to the ocular surface enervation."
Dr. Holland recalls, "In the old paradigm, we gave dry eye patients some artificial tears and occluded their puncta. The eyes looked moist, but they were still red and painful. The patient had more tears but often was not happy."
Dr. Donnenfeld uses a bathtub analogy to describe the situation. "If someone bathed in a tub, you'd drain the dirty water and refill it before the next bath. The same applies to punctal plugs," he says. "In an eye with inflammatory mediators like cytokines, interleukin and neutrophils, why would you want to insert a plug and keep these inflammatory cells on the ocular surface? With an anti-inflammatory approach, we fill the tub with fresh, new water. We treat the inflammation, and then we insert the plugs. This therapy improves not only the quantity of tears, but also the quality of the tear film on the ocular surface."
In this approach, physicians start by improving the quality of the tear film, eliminating the cytokines, down-regulating the T-cell activation on the ocular surface and improving goblet cell production and the mucin layer of the tear film by reducing ocular surface inflammation.
"If anti-inflammatory therapy doesn't work or it doesn't work completely — and that often happens in moderate and severe cases — then we follow with punctal occlusion 4 to 6 weeks after starting anti-inflammatory therapy." Dr. Sheppard says.
By prescribing an anti-inflammatory first, physicians have greater success with punctal occlusion. Dr. Holland points out, "The anti-inflammatory makes a big difference because we soothe a mediator of the pain and all the complications we might see."
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