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Punctal plugs with cyclosporine most effective treatment for some with dry eye
Combining the two modalities gave patients in a study the greatest relief from dry eye symptoms.
The combination of cyclosporine and punctal plugs was most effective in relieving the signs and symptoms of dry eye, according to a study.
At Hawaiian Eye 2006, Calvin W. Roberts, MD, presented his study comparing Restasis (cyclosporine A, Allergan), punctal plugs and combination therapy to discern the most efficient modality for treating dry eye patients.
“In our hands, the combination of Restasis with plugs was most effective in terms of getting the eyes wet immediately and then, over time, improving their symptoms,” he said.
The study
“I like punctal plugs. I find that for some patients, they give really nice relief of symptoms,” Dr. Roberts said. “I also like to use cyclosporine.”
He added, “The question therefore becomes, How should I treat my patients? When do I use one modality? When do I use the other?”
To determine this, Dr. Roberts included in his study patients who had signs and symptoms of dry eye. Symptoms included scratchy or burning eyes, and signs included results of lissamine green staining. Patients had to find at least temporary relief in artificial tears.
Dr. Roberts said the patients were randomized to one of the three modalities: Restasis, punctal plugs or both. Patients were evaluated at baseline with lissamine green, Schirmer’s test and subjectively, based upon the number of times the patients used artificial tears. The patients underwent the same evaluations again at 1, 3 and 6 months after initiation of treatment.
“When we look at our Schirmer’s, what we found was that for the patients that were treated with plugs – either with plugs alone or plugs with Restasis – the tear production went up immediately,” Dr. Roberts said. “The patients who we started on Restasis took a while to catch up, but with Restasis alone at 6 months, we had as much tear production as we had with the plugs.”
Conversely, when the researchers looked at conjunctival staining with lissamine green, the patients with plugs showed little change within 6 months. Restasis and combination treatment greatly improved the conjunctival staining, he said. The data for frequency of artificial tear use showed similar results.
“The patients who started out with plugs initially got a nice improvement, but, over time, it was the patients with Restasis, and the combination patients even more, who got the best relief,” Dr. Roberts said.
Treatment choice
Dr. Roberts said he would treat a patient with mild dry eye, which he defined as symptoms and no signs, with a low viscosity tear, such as Soothe (Alimera Sciences). However, he said, “I’m aware of the fact that dry eye is a progressive disease.”
For patients who return or present with lissamine green staining, Dr. Roberts explained, his treatment begins with implantation of punctal plugs to retrieve symptoms and aid diagnosis.
“I put the punctal plugs in right away,” he said. “I find that punctal plugs are effective therapeutically to make my patients better, but, interestingly, are effective diagnostically.”
After implanting the punctal plugs, Dr. Roberts tracks patients to see if they improve. “All of us who use punctal plugs know that some people get better and some people don’t get better,” he said. Improvement or lack of improvement helps Dr. Roberts diagnose the patient’s specific problem.
“Why would it be that someone didn’t get better on punctal plugs?” he asked. “Probably, it would be that punctal plugs are trapping unhealthy tears.”
Dr. Roberts leaves an improved patient with punctal plugs and a viscous tear supplement. Those who do not improve, he said, are the best candidates for treatment with Restasis because they will see the most benefit.
“When patients don’t get better from punctal plugs, I take them out,” he said. “Eventually, if I’m getting a nice response from Restasis, I might even put the plugs back in once Restasis has restored normal, healthy tears.”
If a patient who responded to treatment with plugs returns months or years later with additional problems, Dr. Roberts said he will often put that patient on Restasis.
“These patients have a lot of confidence in me,” he said. “This regimen has worked nicely for me.”
For more information:
- Calvin W. Roberts, MD, can be reached at Weill Medical College of Cornell University, 1300 York Ave., Box 61, New York, NY 10021; 212-734-7788; fax: 212-734-4476; e-mail: RobertsMD1@aol.com. Dr. Roberts is a consultant for Allergan and has a financial interest in Alimera Sciences.
- Allergan, maker of Restasis, can be reached at P.O. Box 19534, Irvine, CA 92623; 714-246-4500; fax: 714-246-4971; Web site: www.allergan.com. Alimera Sciences, maker of Soothe, can be reached at 6120 Windward Parkway, Suite 290, Alpharetta, GA 30005; 678-990-5740; fax: 678-990-5744; Web site: www.alimerasciences.com.
- Katrina Altersitz is an OSN Staff Writer who covers all aspects of ophthalmology.