A touchy situation

[Jade9923]

I have a touchy situation and I’m asking all you wonderful folks for your advice. I posted to Dr. Latkany regarding an intracanalicular plug (Oasis form fit) that is stuck inside one of my punctums. My regular doctor was on vacation and I saw another Doctor who did try to irrigate it out. She met with resistance and didn’t want to try any further. My normal doctor of 14 years who is a saint to me and who is the doctor that finally was able to help with my dry eyes is saying that there is no need to take this plug out because I won’t get an infection from this kind of a plug. A asked her about it at two separate visits. At one point she said I will probably swallow it eventually. She said if it were a regular silicone plug stuck inside that would need to come out.

From everything I have read and from the response from Dr. Latkany, the consensus seems to be just the opposite of what my doctor is saying. All other sources say these plugs should be irrigated or taken out if they are stuck inside. I don’t know how to handle this with my Doctor. She is a highly regarded Ophthalmologist and surgeon I have tremendous respect for her…she has been a life saver for me.

I’m asking for advice about how to handle this with her. I don’t want to insult her certainly but it seems like this thing should come out of me. I also have the issue of what to do with this punctum in general. I can’t seem to find a plug big enough for it and I’m quite uncomfortable with the resulting dryness.

Any help you can offer would be appreciated…I have enclosed my post to Dr. L and his response below. Thank you!

At a loss of what to do...

Dear Dr. Latkany,

I have dry eyes caused by MGD diagnosed over 14 years ago and have had much success with lid scrubs and all 4 punctums plugged. I have been on Restatis and Omega 3’s for about 5 months.

About 6 months ago, the upper punctum plug in my right eye that had been in place for over 10 years fell out. (the other 3 plugs are still in place) My doctor put in an Oasis Form Fit Intracanalicular Plug (made of hydrogel material that expands into a soft, pliable, gelatinous material when it contacts tear film.) The Oasis plug worked great for about 4 months in terms of being comfortable and having enough tears in that eye and then my eye became very dry. My doctor said the plug is most likely not occluding 100 percent anymore and put a silicone type plug in over the Oasis plug which is inside.

Since then that plug fell out and we tried several others that also fell out or were uncomfortable…(my punctums are very large and now, they only make plugs to about 1.1mm which doesn’t seem to be big enough for me)

The strange part is that I have been without a plug in this upper eye other than the Oasis that is somewhere inside for a few months and my eye has been comfortable in terms of tears for several weeks and then became dry again and then comfortable again and now currently dry for the last two weeks. I’m not sure why it is so inconsistent at this point. I was thinking that perhaps the Restasis/Omega’s were maybe starting to work, however it doesn’t make sense that it would fluctuate like that. I also thought that perhaps the Oasis is moving around in there causing this. The dry periods are very very uncomfortable for me.

At this point I really am not willing to put up with the dry periods as it is very painful and hard for me to function. I am at a loss of what to do. I am worried about this Oasis plug that is somewhere inside. At my request, she tried to irrigate it out but couldn’t... she met resistance so it is still there. She said she is not at all worried about this type of plug being inside me and that it would not cause an infection. (She said silicone plugs can if lost inside)

At this point I see my options as:
• Searching for another larger silicone plug to try again to put in over the Oasis
• Putting in another Oasis in on top of the one that is in there since it did work well for awhile (but then I would probably end up with 2 Oasis plugs locked inside me).
• Cauterize that punctum but doing that with the Oasis plug inside me is scary.

Can you comment on the options I’ve listed and suggest any others you would have. Also, could comment about this Oasis plug that is stuck inside me and your thoughts about how worrisome that is. And finally, would you ever consider cauterizing that upper punctum with this Oasis plug inside me.

Thank you so much.
Jade
____________
Robert Latkany MD
Jade,

Note to every member on this site. I am not a huge fan of form fit plugs and the smart plug. How would you like a plug placed inside your eyelid that is very difficult for me to see, usually never stays there,
unsure if it is working or not, and is not that uncommon to cause an infection? There are groups of doctors who have published papers on the downsides of these plugs.

This is rarely the case for standard plugs. Ideally you want to remove the form fit plug. If this is not possible you should not cauterize above it. This is an uncomfortable situation and I can only suggest what you should do if you actually came to see for an examination and were my patient. I deal with this situation regularly and very often solve the problem.

Dr L
__________________
Robert Latkany, M.D.

[kitty]

From what I have read, and seen posted here and on other web sites, there are as many differing opinions regarding the management of DES, drops, plugs, steroids, etc. as there are people who have this affliction. If it were me, I would trust my gut. If you want the plug removed, tell your doctor so. You do not have to give a reason other than you are not comfortable not knowing where it is and what may or may not happen to it if it is left in place. If your doctor cannot do it, ask for a referral. It is your body, your eyes and your plugs. Do what makes you feel most comfortable based upon the information you have. Good luck to you!

[calli66]

off topic...

Reminds me of the time I jambed 2/3 of a wooden toothpick into the bottom of my foot. The other 1/3 broke off and the swelling obscured the hole. Two doctors at the urgent care clinic insisted there wasn't anything there, because THEY couldn't see it or feel by probe. They even took an x-ray (to see a toothpick?) They insinuated that I was imagining things.

My husband told them straight away, that we weren't leaving until they removed the toothpick. I was in too much pain to speak. The doctors just didn't want to deal with it----but--they HAD to. Man, was that thing painful.

The Lost Plug: As Kitty said, "It is your body."

C66

[Julie1]

I don't think I would let a doctor cauterize me with a plug still in the punctum. I am would be way too afraid of any infections. I would definitely do what your gut is telling you to do. They are your eyes and you will have to live with your eyes for the rest of your life.

[cristinalatina]

Dear Jade,

if I were you, I would simply say that "I personally don't feel comfortable with the plug in there. Even though I consider your opinion most valid, I would appreciate your help in getting more peace of mind."

Nice, subtle, emphasizes the "I" factor, won't offend, and a good doctor will help you feel better about the issue (which in your case is not an academic point of debate, but an actual problem.)

Hope it works out well for you!

[Rebecca Petris]

Touchy situation indeed! I feel for you on this Jade... and here's my 2 cents FWIW. You know me... mouth size in inverse proportion to my credentials

IMy regular doctor was on vacation and I saw another Doctor who did try to irrigate it out. She met with resistance and didn’t want to try any further... My normal doctor of 14 years... is saying that there is no need

Why?

I really don't know much about removing plugs. But it seems to me there are a few reasons for them to not want to do it and you need to know which one(s) apply here.
1) if they feel the risk is greater than the benefit. In that case I'd want more information about any risk involved. I thought that one of the selling points of the Oasis is that it's supposed to just break up when irrigated, as opposed to breaking off and going somewhere unwanted which is one of the concerns with silicone intracanaliculars.
2) if they just feel it's unnecessary and that there's no point putting you through the cost and discomfort. That's a good thing, they're being conservative for you, but at the end of the day it's your body.
3) lack of experience with this specific situation (not meant as a criticism - it's a relatively new plug - and reluctance to do this for this reason also amounts to being protective of you). Why was there resistance during the irrigation and what does it mean? Have either of these doctors ever irrigated an Oasis plug? might be some questions to explore.

In any case, removal boils down to a risk/reward equation. Placing and removing plugs are both considered minor surgery and as such, informed consent ought to be part of the process. In fact some of the plug manufacturers provide an informed consent template for doctors to use.

From everything I have read and from the response from Dr. Latkany, the consensus seems to be just the opposite of what my doctor is saying. All other sources say these plugs should be irrigated or taken out if they are stuck inside.

I posted in the Q&A forum asking for a clarification from Dr. Latkany about his opinion of the Oasis specifically as I'm curious about this.

But it seems fairly straightforward to me. Setting aside the opinions of the various doctors, physically and emotionally you're clearly not comfortable with this plug in there.... if it were me, out it would come unless the doctor gave me a compelling argument for the risks involved in trying to remove it. No way would I do any more plugging or cautery with a plug in there no matter what type of plug (that's simply my personal bias). You're already clearly being considerate of your doctor as a professional and so you're 90% of the way there... maybe just need a little more communication to get at her real issues and a little firmness about your needs.

[indrep]

Jade,
The OASIS Form Fit plug is 90% water when hydrated. I have seen demonstrations of the plug in silicone tubing and suspended in water. The product elongates and shreds when irrigated. As for infections, I am unaware of any infections being reported on the OASIS Form Fit, however there have been reports regarding other intracanlicular plugs. The material used in the three types of intracanalicular plugs is different in each one. I would be reluctant to try another silicone plug without knowing what the obstruction was in the lacrimal system. I have also seen the Form Fit when moisture is removed and the plug shrinks back to what appears to be less than .2mm in diameter.

[Rebecca Petris]

Jade,

I just re-read your post to DrL. If I understand right you've had 2 silicone plugs in that punctum (1 before the Oasis, and 1 after). Am I understanding right that both were punctal, not intracanalicular? And, did you actually see the whole plug both times when it came out? I know this is farfetched but I'm just wondering if there's any possibility a piece or all of one of those plugs is in there somewhere.

[indrep]

Rebecca, I think you may be on to something. A 1.1 punctal size could easiliy have had a silicone plug migrate in. If there was a silicone plug in the canaliculus and a Form Fit was inserted it is possible the Form Fit did not get inserted deep enough and may indeed not be in place. It is very important that the Form Fit be inserted properly and ideally the punctal ring will not have been dilated.

[Jade9923]

Thank you all for your thoughtful comments. Rebecca and Indrep, I am certain that both the silicone plugs were removed. The doctor removed one and I removed the other.

Rebecca, I appreciate your insight in further sorting this out for me. You really have pinpointed the real issues here in terms of the reluctance to take this plug out. Thank you so much for that. That will really help me talk to my doctor about this issue. I will also be very interested in Dr. L's response to your follow up question.

Indrep, your insights are interesting too. The Oasis does seem to differ in composition to the other intracannular plugs. It never ceases to amaze me at how much knowledge you all have.

I have made an appointment with my doctor and I will let you all know how it goes.

Thank you all again for your insights and advice. What a great place this is!

[Julie1]

Hi Jade,

I was just thinking about your situation the other day and was wondering how you resolved it. I hope that your appointment with your doctor went well and that you were able to solve the problem. Please let us know sometime what you ended up doing.

Thanks,
Julie