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23rd Annual Contact Lens Report Plug. For the right patient, it's great. Plug. For the right patient, it's great. by Albert Morier, O.D., Schenectady, N.Y. That doesn't say that I immediately insert plugs every time a contact lens wearer presents with
marginal dry eye symptoms. You always need to perform a careful differential diagnosis when a patient presents with marginal dryness. There is little rationale in
treating blepharitis or meibomianitis with punctal occlusion. First, I tell the patient to use lubricating drops if he or she has not tried them before.
Patients often respond that the drops only work for 20 minutes or so. I'll also tell the patient to use lid scrubs with blepharitis. However, I'll also perform Zone Quick and
Schirmer's tests to evaluate aqueous tear production. Punctal occlusion is the true answer for the marginal dry eye patient who has aqueous deficiency.
Punctal occlusion is a forgiving procedure. It is not sight-threatening. It does not pose the risk to corneal health that even disposable contact lens wear does. If you start out
with a collagen plug as a diagnostic trial, the plug dissolves anyway. If it's not the correct therapy, no harm done. Few procedures are as risk-free with so few side effects.
And, in contact lens wearers with confirmed aqueous deficiency, punctal occlusion does have long-term benefits. I've heard the arguments against the long-term efficacy
of punctal occlusion, but I disagree. Indeed, after one month patients who have had silicone plugs inserted in their lower puncta do notice a so-called drift in their effect.
This has been confirmed by a study conducted by Gerald Lowther, O.D.1 However, the same study shows that 80 percent of these patients also claimed a long-term benefit of punctal plugs.
Occasionally, I've had patients drift. In these cases I'll insert a superior plug as well, perhaps even a Flow-Control plug, and I'll keep many of these patients in contact
lenses. This also illustrates other benefits of punctal occlusion therapy: It is reversible, you can take a stepwise approach, and you have many options.
Anecdotally, I've seen a lot of evidence that confirms this. Just a few days ago I had a female patient in her mid-30s with inferior punctal plugs I'd inserted more than six
months ago come in and complain that she'd lost a plug. She pleaded with me to insert a new one. "Dr. Morier, I'm tired of one eye being comfortable and one eye not being comfortable," she told me.
I had another young woman who said she couldn't wear her contact lenses for more than four hours. There was no lid inflammation, no follicles or papillae indicating
allergies. After my work-up, I put temporary plugs in her lower puncta, then put her contact lenses back in. She could then wear her lenses for 12 hours the next day.
Again, I get this response when I carefully choose the patients who need punctal occlusion. I pay close attention to their subjective complaints—dry, scratchy, itchy
eyes and decreased wear time. And, I perform a careful differential diagnosis. There's a benefit for us practitioners, too. With the right person, punctal occlusion
decreases our (and our patient's) chair time. We're not subjecting them or ourselves to trying to fit a lot of different contact lenses. Should we try high-water or low-water,
nonionic or ionic? For many patients, this question simply goes away. For the right patients with marginal dry eye, punctal occlusion is a quick and
long-term fix. And, we're absolutely keeping them in contact lenses.
Dr. Morier lectures frequently on contact lenses and punctal occlusion. He is in private practice and an instructor in clinical ophthalmology at Albany (N.Y.) Medical College.
1. Slusser TG, Lowther GE. Effects of lacrimal drainage occlusion with nondissovable intracanalicular plugs on hydrogel contact lens wear. Optom Vis Sci 1998;75:330-338. Don't plug. Find the true cause. by Milton M. Hom, O.D., Azusa, Calif. Punctal occlusion can be effective when aqueous deficiency is the root cause of pathological, or
"bone," dry eye. However, this approach may not always be the answer for marginal dry eye symptoms. The true cause of marginal dry eye is often something other than tear film problems. The three
things I look for in marginally dry eyes are lid disease, lid disease and lid disease. I can't emphasize how important this is. In a 1990 study Jerry Paugh and I found that more than 40 percent of contact lens
patients with dry eye had meibomian gland dysfunction.1 Lid disease requires treatments such as lubricants, ointments, lid scrubs, sometimes temporarily
discontinuing contact lens wear, and prescribing oral tetracycline or doxycycline. Punctal occlusion will not resolve these problems, but there are doctors who will
reach for plugs before doing anything else. Resolving the lid disease is critical if the patient wants to continue wearing contact lenses (and that's usually the case).
Avoiding the "plug first" mentality improves your chances of properly treating the patient. You can't dismiss the other causes of marginal dry eye, either. Around this time of
year, allergies are a common cause of these symptoms. You can treat them with Patanol (olopatadine) one drop before lens insertion and after lens removal each
day, or with Livostin (levocabastine) (I prefer the former because of its dosing). I often prescribe non-preserved tears for less-severe cases.
Environmental causes also play a role in inducing marginal dry eye in contact lens patients. These problems usually have a dismal prognosis. Winter heating season
often equals contact lens-drying season. Altitude is another environmental cause. In such cases, if you can make the patient feel even 50 percent better, that's considered an outstanding success.
Punctal plugs do have their place, specifically for treating pathological dry eyes. Marginal dry eyes pose a different situation, particularly where contact lens patients
are concerned. One study shows that plugs do not resolve dryness in contact lens-intolerant patients after three months.2 Other studies show that plugs are
effective for short term, but don't look at the long-term effects.3 There may be a couple of explanations for this. The "closed-loop" theory, put forth by
Todd G. Slusser, O.D., Alan Tomlinson and Gerald Lowther, O.D., says that the eye may adjust its tear production after occlusion.4 In an eye that's aqueous-deficient, the
body's own feedback mechanism interprets that as the normal baseline. If you put a plug in that eye, this feedback system tells the lacrimal gland that it is overproducing tears, so it cuts back tear production.
There's also the "cesspool" theory put forth by Art Epstein, O.D. This holds that the eye is designed for a natural river of tears to flow from the lacrimal glands, over the
cornea and then drain into the puncta. If you plug the puncta, you are clogging the drains, so to speak. Tear preservation becomes tear stagnation. There is the
argument that says punctal occlusion does decrease the bacterial count on the eye, but this has only been proved in patients with pathological dry eye.
New technologies are on the horizon, such as Allergan's cyclosporine. This immunosuppressant agent is effective in stopping infiltration of the lacrimal gland. Its
role for helping contact lens patients with marginal dry eye remains to be seen. Fact is, there are many different reasons for marginal dry eyes in contact lens
patients. Before you reach for those plugs, ask yourself if they're really a cure or simply a quick—and temporary—fix.
Dr. Hom is author of Manual of Contact lens Prescribing and Fitting, Butterworth-Heinemann. 1. Hom MM, et al. prevalence of meibomian gland dysfunction. Optom Vis Sci; 1990:67-710. |
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Punctal occlusion is a safe and effective way of
treating marginal dry eye in contact lens patients. First, however, you must know what kind of dry eye you're dealing with. Punctal occlusion is not for every dry eye patient, but it can provide immediate
relief to at least one-quarter of the contact lens wearers I see with marginal dry eye symptoms in a typical week. What's more, plugs also provide a long-term solution and help to prevent these
patients from dropping out of contact lens wear.
If a contact lens patient with marginal dry eye comes into my practice, I don't think to plug him first. Instead, I undertake a diligent differential
diagnosis to get at the underlying cause of the dry eye symptoms. Otherwise, any therapy would be hit-and-miss.