For contact lens intolerance, extreme discomfort, consider punctal occlusion

Issue: May 1999

Many practitioners will say that a patient’s dry eye does not need to be a severe case to consider punctum plugs as a solution. However, a number of factors are taken into consideration when deciding whether or not to perform the procedure. If a patient is suffering from itching, burning or watering sensations or is experiencing increased contact lens intolerance, it may be time to broach the subject of punctal occlusion.

“Optometrists hear contact lens wearers complain about decreased wearing time a lot. That should send up a red flag,” said Albert Morier, OD, an instructor in clinical ophthalmology at Albany Medical College.

Often, patients who opt for punctal occlusion have also tried lubricating drops with limited or no success. Objective findings, such as a slit-lamp examination showing decreased tear meniscus and punctate epithelial keratitis, as well as objective tests, such as Schirmer’s or a Zone Quick phenol red thread test (Menicon, Clovis, Calif.) for aqueous deficiency, can also help in determining that punctal occlusion may be warranted. But the decision whether or not to insert punctum plugs lies in the hands of the patient as well as the practitioner.

Ease the patient’s anxiety

The optometrist can certainly recommend what he or she feels to be the right course of action, but, in the end, the patient makes the final decision. To make sure you and your patients are on the same wavelength, discuss the subject and come to a conclusion together, suggested Kathleen Foster Elliott, OD, in private family practice. “I give them all of the pros and cons, and then we decide together,” she said. “If they feel uncomfortable about it or are at all opposed to it, I let them know that it’s just one option.”

J. James Thimons, OD, executive director of TLC The Laser Center in Connecticut, said to address any fears or questions the patient may have about the procedure, no matter how unlikely it may seem, and be prepared with alternatives.

“In developing a relationship, the patient needs to feel very comfortable that the recommendation you’re making is something that benefits him or her,” he said. “Some individuals are greatly concerned about the implantation of silicone, no matter what the size. Obviously, silicone breast implant concerns have been raised, and they have been addressed in literature over time, but those initial concerns linger in the public’s mind. In those individuals who don’t want silicone, we can either continue to use tears or close the tear duct with a laser or cautery unit. So there is an alternative, but that’s a rarely used one.”

Dr. Morier suggested talking to a patient honestly and describing the procedure thoroughly to boost its acceptance rating with patients. “I did a survey over the Internet, and I received about 60 responses from practitioners,” he said. “I asked what percent of people balk at the procedure. About 50% said that they got a 10% to 50% acceptance rate, and the other 50% had a 90% or above acceptance rate. That tells me that doctors believe in the procedure, but they’re not explaining it carefully. This tells me that the doctors must believe in the procedure and get that message across to the patient.”

Sizing the puncta: Find the right fit

Practitioners can use the system of measuring that the manufacturer includes with the punctum plugs, or some are comfortable just judging the correct size by sight. “I mostly judge by sight now because I’ve been doing it for 5 years,” said Dr. Elliott, “but if there is a plug that I’m not sure of or if I want to use a different type, I do have all of the measuring devices at my disposal. If doctors are just starting out, I encourage them to use the gauging devices until they become more familiar with how each of them will react to the eye.”

Dr. Thimons said that he takes into consideration not only the apparent size of the puncta, but the age of the patient to gauge how snugly the plug may fit. “I manipulate the puncta slightly prior to the procedure to see how elastic the punctal ring is so I can get an idea of how tightly the unit’s going to fit,” he said. “In a younger patient, you typically end up with a slightly tighter ring, so you want to use a smaller unit that will fit well.”

Start with a collagen trial

A collagen trial is a good indicator of what size silicone plug to use, advised Dr. Morier. A bit of trial and error is involved, but the dissolvable plugs allow the patient to give the practitioner a feel for what size would best suit the patient’s needs. “You can easily put two or three plugs in a canal, and I often put two in,” he said. “So you can start with a .3, and then if it goes in too easily, go up to a .4. If it works well for 2 to 3 days, then use the punctal gauge system and choose the appropriate size.”

Whether or not to anesthetize, lubricate

Deciding to use a topical anesthetic or lubricant often depends on the personal preference of the doctor, as well as the emotional state of the patient about to undergo the procedure. “I seldom use a topical anesthetic unless the patient is extremely jumpy,” said Dr. Morier. “Most (95%) of the time, I don’t use anything. Some people may use a lubricant to make it go in smoother, but I find that that’s not necessary. I like it to be nearly dry in order to screw it in.”

Dr. Elliott said that she will often place a drop of anesthetic in the patient’s eyes prior to the procedure for comfort. Dr. Thimons will opt for a topical anesthetic unless he will be probing the area first, in which case he will use a lavage system. “I’ve found that most patients do not need more than a topical drop to decrease the sensitivity around the area,” he said. “One technique is to place a pledget soaked in anesthetic on the puncta and have the patient gently blow his or her nose, which pulls the tears and the material into the punctal area. For a really sensitive person, you can use something stronger, such as topical lidocaine.”

Dr. Thimons added that comfort levels during the procedure differ between age groups as well. “Younger patients are more sensitive to the placement of the silicone device,” he said. “Older patients don’t have quite the level of sensitivity; for them, it’s more finding the right plug size and making sure that it fits well. Comfort is not usually a big problem with them; they’re more tolerant.”

Inserting the plug

Because the manufacturer usually offers a plug gauging system and self-inserter for use with their plugs, most of the doctors agreed that additional tools are not usually necessary. Dr. Morier suggested that when inserting plugs into the upper puncta, inverting the lid so the punctum points out or upward helps make the process easier. “Use a swab, and invert the lid as if you were checking the tarsal plate for giant papillary conjunctivitis,” he said. “Inverting the lid makes it much stiffer.”

Dr. Thimons said that no matter what materials or process you may use, making sure that everything is sterile at the time of insertion is of utmost importance. “The infectious risk can be minimized to zero in short order by using a sterile technique, so you can wash your hands thoroughly or wear gloves,” he advised. “The instrumentation and plugs are sterile, and it’s very important that they be kept that way throughout the procedure. It’s not appropriate to take the unit out and place it on a surface while you’re doing other things, because it could be inoculated with local flora. With those minor precautions, it’s a very safe and easily accomplished procedure.”

After-care for punctum plugs

After the plugs have been inserted, there are certain points to keep in mind to help the patient adjust to them and ensure that the plugs remain in place for a long time. Dr. Thimons advises patients to slowly decrease their current use of wetting agents, with the end result typically a cessation of the drops altogether. “I don’t usually have them go cold turkey because I don’t think that the plugs have an instantaneous effect,” he said. “It takes several days for the tear quality and balance to reach a point of equilibrium, so I have them continue the wetting agents. Over a week or so, I’ll have them slow those down appreciably and see when they begin to experience symptoms.”

The doctor should also advise the patient to take care when rubbing his or her eyes, Dr. Elliott said, for fierce rubbing will often force the plug out of the puncta. “I tell them not to briskly rub the corner of their eyes because they could dislodge the plug or damage the eye,” she noted. “Especially for female patients who wear make-up, I instruct them how to properly clean around the area so as not to extricate the plug.”

Under normal circumstances, however, most plugs will stay where they belong, Dr. Morier said. He said that while, in his experience, they do fall out about 25% of the time — usually occurring within the first month of wear — a patient can expect the plugs to last months or even years. “Usually, when people ask how long the plugs will last, I’ll tell them that when someone digs up their graves 200 years from now to put in a parking lot for a mall, they’ll open up the casket and all that’s going to be left are two little plugs. They get the point,” he explained.

Addressing punctal irritation

Often, when a patient complains of irritation the first days following the procedure, an ill-fitting punctum plug is the culprit. After checking the lid apposition and examining the area surrounding the conjunctiva for irritation by using a fluorescein stain or rose bengal, Dr. Thimons said to then investigate the plug itself. “The next issue is to look at the actual plug and see if it’s too tight or too large,” he said, “because patients will frequently confuse irritation from the plug with an eye irritation. If, in fact, it is due to an oversized plug, I’ll take it out, wait a couple of weeks and insert a smaller one.”

Dr. Elliott said that she informs her patients that they may feel some irritation initially, but the sensation should go away in a relatively short period of time. Dr. Morier explains to his patients the difference between a normal reaction to having plugs inserted and an abnormal one. “I tell my patients that there are three ways that they can feel this plug,” he said. “One is not at all. Two is that they can feel it when they think about it, the same way you might feel a contact lens when it’s first in and you’re very aware of it. But number three is different: if that corner becomes red or irritated that same day, we have to remove it. It shouldn’t distract you if you’re watching television or hurt you.” If it does, Dr. Morier said, he chooses a different type of plug or a smaller size or refers the patient for punctal cautery.

Removal easier than insertion

If plug removal is necessary, due to either an ill-fitting plug or excessive lacrimation, the simple procedure is often faster and easier than the insertion, Dr. Thimons said. After placing the patient under the slit lamp, a number of instruments, such as jewelers’ forceps, can be useful in their removal. “The key to removal is simply to lift the edge of the flap slightly and grasp beneath the edge,” he said. “I then place my finger on the base of the lid right below the punctum itself so that the lid doesn’t tug up when you pull. I try to give a little twist to it, because if you just lift vertically, a suctioning effect occurs. If you have a gentle, lateral massage, it’s relatively simple to have the plug disengage from the punctal margin.”

Dr. Thimons said that if a new plug is needed, he will typically wait a week or two until the eye returns to its normal state. A topical antibiotic or antibiotic steroid may also be used if there is local inflammation around the margin, he noted.

Long-lasting benefits

Although some patients may need to continue using drops after punctal occlusion has been performed, it is much less frequently, and patients should save money in the long run, Dr. Thimons said. “Using a multidose system two or three times a day vs. an unpreserved solution six or eight times a day rapidly offsets the cost of punctal occlusion,” he said. “A lot of people think that it’s an expensive technique, but, in fact, the expense is primarily driven as a one-time cost vs. chronic costs of using unpreserved solutions, which are excellent, but are not inexpensive over the long run. I think these plugs are a magnificent alternative to anything that we currently have.”

Dr. Elliott is pleased with the vast selection of punctum plugs from which to choose to help resolve a problem that affects a large number of people. “Dry eye syndrome is probably one of the most underdiagnosed conditions of the eye, and a lot of patients go from doctor to doctor, trying a different drop each time, without going to the root of the problem, which is lack of tears,” she said. “So, I’m very excited about the new technology in the area of punctum plugs, which will give us more options for our patients.”

For Your Information:

Albert Morier, OD, is an instructor in clinical ophthalmology at Albany Medical College, Albany, NY, 12208; (518) 355-0956; fax: (518) 355-1208; e-mail: amorier1@nycap.rr.com. Dr. Morier has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

Kathleen Foster Elliott, OD, may be reached at PO Box 719, Bristow, OK 74010; (918) 367-2020; fax: (918) 367-9542; e-mail: IDoctors@aol.com. Dr. Elliott has no direct financial interest in the products mentioned in this article, nor is she a paid consultant for any companies mentioned.

J. James Thimons, OD, is the executive director of TLC The Laser Center Connecticut and the medical director of a referral, secondary and tertiary level practice. He can be reached at Ophthalmic Consultants of Connecticut, 165 Stella Lane, Fairfield, CT 06432; (203) 255-6196; fax: (203) 265-1467. Dr. Thimons has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.