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Punctal occlusion remains an integral component of dry eye management
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![Michael D. DePaolis, OD, FAAO [photo]](/~/media/shared-images/michael-d-depaolis-od-faao.jpg)
Whether we’re talking about a favorite sports team or the political climate of our country, the pendulum of change is always swinging. We witness this phenomenon every day of our lives, both personally and professionally. In our professional lives this is perhaps best exemplified in managing the dry eye patient.
Every one of us appreciates dry eye as a formidable entity. It’s fairly common, accounts for a great deal of patient complaints and is a tricky condition to diagnose and manage. In fact, managing the dry eye patient often requires a “juggling act.” We juggle a variety of therapeutic endeavors, including environmental risk factors, dietary and lifestyle considerations, oral supplementation, eyelid hygiene, lubricating drops, anti-inflammatory agents and punctal occlusion. For sure, the dry eye management pendulum continues to swing. This is especially true for punctal occlusion.
Punctal occlusion: A simple solution
Punctal occlusion emerged as a viable dry eye management strategy some years ago for good reason. The concept was simple and logical. Conserve what precious few tears were available in an effort to bathe the ocular surface. It made perfect sense and, for many dry eye patients, it worked well.
However, a strange and unanticipated phenomenon ensued. Over time it became clear that punctal occlusion was not a panacea for every dry eye patient. In certain cases, punctal occlusion provided little symptomatic relief and no improvement in ocular surface appearance. In addition, on rare occasions, the procedure actually seemed to exacerbate symptoms. Combined with the occasional complication – plug extrusion, epiphora, dacryocystitis and pyogenic granuloma – punctal occlusion began to fall out of favor. Therefore, the pendulum of sentiment began to swing again.
Tear deficient vs. inflammatory dry eye
Fortunately, time has yielded a greater understanding of the dry eye state and the fact that not all patients are the same. Various etiologies and differing pathophysiology necessitate different treatment hierarchies.
Certain patients are truly tear deficient and warrant a more aggressive use of punctal occlusion. Other dry eyes conditions are inflammatory in nature, in which case punctal occlusion assumes more of a supportive role. Simply put, we’re more inclined to prescribe punctal occlusion for the post-LASIK patient while less likely to do so in the meibomianitis patient. And, so, the pendulum has swung. Again.
A multitude of punctal plug options
For certain, punctal occlusion will always be an integral component of managing dry eye. Today we are fortunate to have a multitude of punctal plug options. Various sizes, shapes, materials and designs provide us with exceptional results. Of equal importance is the fact that widespread use has given way to a more intelligent case-by-case application, further enhancing clinical outcomes.
Perhaps the punctal occlusion pendulum has finally come to a position of balance. Moreover, while this is good news for clinicians, it is even better news for our patients.