treatment plan
Options for Treating Dry Eye
BY LEO SEMES, OD, FAAO

A 60-year-old, longtime clinic patient was told when she was 15 that she'd never be able to wear contact lenses because she had "dry eyes." Over the years she was treated with various tear supplements that followed the evolution from polyvinyl alcohol-based products to more sophisticated contemporary polymers.

As an almost last resort, we offered the option of reversible punctal occlusion. A two-week trial of collagen (0.4mm diameter) dissolvable plugs was the initial step. She appreciated a sub-
jective improvement, but no improvement in fluorescein staining or tear break-up time (TBUT).

Based on the clinical wisdom "treat symptoms, not findings," we decided to recommend reversible punctal occlusion with a 0.4mm silicone plug in the inferior punctum of each lid.

At the follow up, she said that the effect had worn off. Slit-lamp biomicroscopic inspection revealed the reason — both plugs were lost. She had corneal stippling that was heaviest inferiorly, and the TBUT was <3 seconds (same as at baseline).

At this point, we offered two options. The first was trying a larger size plug. This may allow better retention by the punctal ring. The other option was BionTears (Alcon) every one to two hours for two weeks. The patient chose the second option.

Two weeks later there was a marked reduction in corneal staining. The TBUT was unchanged, but she noted significant improvement in comfort.

We reduced the dosing and two weeks later, the symptoms were reduced and corneal staining was almost cleared.

Punctal Plug Types

Punctal plugs were introduced about 30 years ago with the aim of retaining tears for patients who have insufficient tear production. The logic was that tear retention would be more permanent than adding volume with "muco-mimetic" products. Since their introduction, variations have appeared including plugs whose head is visible at the punctal portal as well as the intracanalicular design of Herrick (Lacrimedics).

The advantage of reversible punctal occlusion appears to be obvious — reversibility as opposed to cautery, which was the procedure of choice prior to Freeman's innovation. If a patient suffered epiphora, then the plug was removed. Following its introduction into practice, reversible punctal occlusion has seen many iterations. Several manufacturers have morphed the plug shape. Sizing of punctal plugs came into practice years ago and remains an important parameter for appropriate long-term retention.

Another factor that relates to retention is age. In my experience, younger patients hold the plug better than do older ones whose punctal ring may have lost elasticity. In fact, one of the first patients in whom I implanted plugs continues to retain them more than 23 years later.

Intracanalicular implantation with the Herrick design has the advantage that no visible plug head appears on the lid surface. That is a double-edged sword — the patient has no sensation of the occluding element, but the clinician can't observe that it's in place. The index is when the patient remains symptom-free and the clinical signs remain in the normal range.

Other Options

Punctal occlusion with either strategy may be counterproductive when the patient suffers from ocular surface conditions that have an inflammatory component. For cases with an inflammatory component, introducing the immunomodulator cyclosporine (Restasis 0.5%, Allergan) is appropriate. You may ease its introduction with the concomitant use of a mild steroid applied topically.

More Treatment Opportunities

We now have an expanded armamentarium to treat dry eye/ocular surface disease. With at least one-third of patient visits including some dry eye complaint, we have an excellent opportunity to relieve this burden.

Dr. Semes is an associate professor at the University of Alabama at Birmingham School of Optometry.