Punctal plug long term effectiveness - Advice from professional and patients

[DontSMILE]

Dear all,

first a brief introduction of myself.
41 years - Italian

I had refractive surgery September 2017 (SMILE) with quite a few unpleasant side effects, such high order aberrations and induced dry eye.
The dry eye improved, but is far to be solved. I started using drops 12+ times per day, now I'm around 6-7, but still the dryness feeling and the correlated fluctuating vision, and the other symptoms you know so well are really a problem.
I have a decent TBUT (about 8 s) with a low schirmer (3 mm), last time I checked it, so mine should be classified as ADDE.

After being visited by several ophtalmologists finally I found one (big one) that with a very deep investigation went to the root cause of my bad vision quality (despite 25/20 + quantity), even without giving me a solution (I'm not considering further surgery and he himself advised me against it btw). I'd like to try RGP lenses to see the level of improvement I can get, but with the dry eye I'm experiencing I'm pretty sure I won't tolerate them.

I took the chance to ask him advice also on the dry eye, that is really bothering me, especially I asked him about punctual occlusion.

He advised me against punctual plugs for 2 reasons.

The first one is higher infections risk (and this is something I can understand)

The second, on which I'd like your advice (professionals and patients), is about the temporary effects that the plugs have in relieving symptoms.
I was told that there is an immediate improvement that tends to fade in time when the neural feedback gets used to the new situation, meaning that over a couple of years time the basal tears will further reduce, and removing the plugs the situation will be even worse than now.

Is this effect something you have had experience with or is documented in literature?


Thank you in advance

[deep_dry_eye]

I don't have much of an opinion except to continue to finding a super dry eye expert. I'm specifically interested in determining if you are inflammatory dry eye, or perhaps dry eye caused by nerve damage from the surgery.

Possible low risk treatment options include restasis, xiidra and Prokera. Prokera is very interesting, if your dry eyes were indeed caused by nerge damage from your surgery, Prokera might have a chance of healing you there. It's really low risk.

[Hokucat]

When I first got my lower plugs, I did get immediate relief. My eyes felt moist for a couple weeks, I thought plugs were THE solution. But then my eyes reverted back to how dry they were before, and continued to get drier. Whether the continued decline over the next several years was because the plugs caused my basal tears to further reduce, that I do not know, as besides severe aqueous deficiency, I also had severe MGD.

I've kept lower plugs in for over eight years. Aside from one falling out a few times, I've only had one or two infections which were pink eye, which I honestly think was more related to me having to touch my eyes all the time, because my eyes were so severely dry there were no tears to naturally clean and protect my eyes, and/or I got it from my school-aged kids where pink eye can be very contagious. I think if there's a chance plugs can help to some degree, it's worth a try since it's a very easy procedure to put in and take out if needed.

If the lowers by themselves are not enough, you can also try having the uppers plugged at the same time. Some people in this form have found that helped a lot. For me, having all four plugged gave my eyes a weird, uncomfortable feeling, so I have only kept the lowers.

Even though the effect of the lowers was short-lived, I think it still helps me at least a little, and here's why. Several months ago I noticed my left eye had felt drier for a few weeks. When I checked for the plug, yep, it was gone. When I had it replaced, my eye felt back to normal (my normal) again. So even if some of these things help some but not a lot, if you have several things that help a little, that can add up.

Besides the typical silicone plugs, there are also dissolvable plugs that last three months. When I saw my eye doctor to replace that last plug, she asked if I wanted to go with dissolvable plugs that get put in every three months instead of the silicone. I asked her why I would want to come every three months when I've only had to come a few times in the past eight years to replace the silicone ones, and she said some people just prefer dissolvable. But I think if you want to try plugs for uppers, lowers, or both at the same time temporarily, dissolvable is a good option. It's also a good option for those who have had problems with the silicone plugs slipping into their tear ducts, having trouble getting them out of there, and getting an infection or problem from that.

Am glad your dry eye problems has improved, that's at least going in the right direction. When you say you'd like to try RGP lenses, are you referring to scleral lenses? Sclerals have been used increasingly for dry eyes. I wear mines 12 hours a day, and it does help with comfort and daily functioning. Not everyone can tolerate them, but it's worth a try to go for a consult to try on a trial pair to see if you can wear them and if they help, otherwise you will never know. Given you still have a semi-decent TBUT, you might be able to tolerate them. Here's a good general description of sclerals, however there are several brands and fitters:

http://www.bostonsight.org/PROSE/PROSE-treatment/Conditions-PROSE-Treats/Dry-Eye-Syndrome

http://www.bostonsight.org/PROSE/PROSE-Treatment/Conditions-PROSE-Treats/Post-LASIK

BTW, your screen name is very clever and appropriate!

[DontSMILE]

Deep Dry Eye, Hokucat - thank you for the support, is really appreciated

Deep Dry Eye - Thank you for taking the time to read and reply to my post

My dry eye is definitively induced by the surgery - never had problems before. I'm now using Ialuvit drops (vitamin B and taurine, both known for neurotrophic effect) and a vitamin/antioxidant supplement for the same reason. I don't have corneal erosions, and the cornea looks clear. I will investigate what Prokera is and if it can be an option for me


Hokucat - I appreciate your input and the time you dedicated to give me comprehensive answer. This really make me feel good and less lonely.

Thanks for sharing your experience on punctal plugs. This to some extent seems to confirm the eye getting used to them and reducing tears accordingly, even if with a lot of other factors contributing is hard to tell.

If there's some professional in the forum with the experience of several patients and maybe some recorded trends on Schirmers etc. will be great if he can give his contribution on this point.

RGP (Rigid gas permeable) lens is not a scleral lens, but a corneal one. I want to try it only to see what kind of positive effect it can have on my poor vision quality. It should be able to remove most of the aberrations and tell me if aberrations are the only contributor to bad vision quality. Fitting is easier and quicker than sclerals, I'm pretty sure btw I will not tolerate them, but is part of the experimental path I'm planning.

Not ready for sclerals now - physically and emotionally.
If the trial with RGP fails in terms of comfort but demonstrate that I can solve aberrations problem, I will find the way of trying a pair of sclerals in the future.
In the case I'll maybe give a chance to laserfit, that at least on paper are designed to get rid of aberrations.
Living in Italy I'll need to go overseas for fitting - this is not major problem since a I travel quite a bit for job purpose - but is not something I'm planning to do shortly.

[Hokucat]

You’re welcome, DontSMILE. I had RGP lenses for years, and doctors think it’s possible all those years of wear could have contributed to my severe dry eye problem. As my dryness got worse, I could not bear to wear my RGPs anymore. I have several friends who developed dry eyes, although not to my degree of severity, who also had to stop wearing their RGPs and soft contacts. So likely you will not be able tolerate RGPs with dry eyes and it’s not usually recommended when one has dry eyes. But it will be a good sign if you find even trying on a trial pair of RGPs can correct your aberrations, because if it can, that means so can sclerals which are also RGPs.

I think LaserFit sclerals is a good option, especially if you’re coming all the way from Italy and paying for it yourself, you might as well come once to a doctor with an excellent reputation for doing custom fits. I would have gone there myself for sclerals, but went with PROSE because they have a good reputation, it was local, the fitter was excellent, I could easily wear their sclerals, and it cost me only a few hundred dollars since my insurance paid almost all of it.

Best of luck to you with sclerals if you end up going that route, and/or other options you pursue.

[farmgirl]

I know that there are some docs out there who do not want to put in plugs for various reasons. I am aqueous deficient with MGD thrown in for good measure and I can tell you that without all 4 of mine plugged (uppers are cauterized) my life would be unberable. I have been quadra plugged for about 6 years and unless something changes drastically I intend to remain that way.

[DontSMILE]

Hokucat

Yes, exactly - RGP will serve me as an indicator of possibility of getting rid of the vision problems, but won't be the solution.
I'm not in a rush anyway, so many things to stabilize, some emotional swings, away from home I'm on temporary assignment abroad..., don't want to throw too many thing up in the air at the same moment.
I appreciate your input and I'll post updates


Farmgirl

Thanks a lot for sharing your experience.
May I ask if your dry eye is from surgery?
Have you experienced the "effectiveness fading" phenomena with plugs?
I know is hard to tell, so many confounding factors on the single case... that's why if some professional with maybe tens or hundred of cases experience could join this discussion would be great
Is there anybody out there...?

[farmgirl]

Sjogrens syndrome. As regards 'fading' I will say that when the plugs were first inserted I had some over tearing the first day but no, they are pretty stable and I know that I will never be without them. I am actually cauterized on the uppers.

[DontSMILE]

farmgirl

thanks again for sharing. I'm really temped by the plugs, at least the dissolvable ones to try,
on the other hand I'm terrified of everything about my eyes

[quattroboy]

I've had dissolvable ones, silicon ones, which I kept rubbing out because I need to do my eye massages.

My doc has just put Smart Plugs in, "you can't rub these out", he said.

Don't know if that is true. However, Smart Plugs can be more problematic. Rebecca isn't a fan.

In terms of help, my better right eye seems ok, my left still bone dry. But it's only been a day.

BTW I'm 9 months post LASIK, so my dry eye is LASIK induced.