Expert panel shares pearls on punctal occlusion

NEW YORK – A trio of clinicians recommended the use of punctal occlusion, with specific caveats depending on preoperative use and the type of ocular surface disease the patient is experiencing.

Paul M. Karpecki, OD, FAAO, Marc R. Bloomenstein, OD, and Jack Schaeffer, OD, spoke here at Vision Expo East during the Ocular Surface Disease and Wellness Symposium, which Primary Care Optometry News co-sponsored.

Karpecki encourages the use of punctal occlusion for dry eye, but only if the patient does not have allergies, inflammation or meibomian gland dysfunction.

Schaeffer noted that he will not perform punctal occlusion until he has treated a patient at least 8 weeks.

Marc R. Bloomenstein

Paul M. Karpecki

However, Karpecki said he would immediately choose punctal occlusion in preoperative LASIK patients or in patients with neurotrophic dry eye caused by diabetes or herpes simplex or zoster.

“When you plug those, you get a great response,” he said.

Bloomenstein said he immediately performs punctal occlusion on all patients scheduled for the AcuFocus Kamra corneal inlay.

“Patients are seeing through a small central aspect, and any mild edema will affect the visual quality,” he said.

Karpecki and Schaeffer recommended shorter-term occlusion with the Extend, a 90-day plug by Beaver-Visitec, or Comfortear Lacrisolve, a 180-day plug by Paragon Bio-Teck.

“They don’t fall out, they’re easy to insert and they don’t rub against the surface,” Karpecki said.

Schaeffer said disposable plugs are his initial solution.

“If these shorter-duration plugs work well, then I would move onto the 6-month plug,” he said. “I would want a new plug every 6 months for myself.”

He noted that if patients are still symptomatic after 6 months, he may try something more permanent.

The clinicians also shared pearls on ways to easily diagnose dry eye.

Jack Schaeffer

“When you’re conducting an eye exam and a patient can’t decide if one or two is better, have them blink and ask if it changed their vision,” Schaeffer said. “If they answer ‘yes,’ you just diagnosed dry eye.”

He also said “patients can diagnose themselves” by filling out a dry eye work-up sheet.

Bloomenstein added: “My staff knows if they can’t get a good reading on a topography without using artificial tears, I need to evaluate that patient for dry eye.”

According to Karpecki, some patients with normal osmolarity but dry eye symptoms may have alignment issues and should be evaluated for that.

The panel also had some tips on other types of treatment for dry eye.

Patients often complain of burning when using Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan), Schaeffer said, so he starts treatment with Lotemax (loteprednol etabonate, Bausch + Lomb) first.

“I check pressures and perform pachymetry,” he said. “I put them on it for a week and then see them back in a week to 10 days. I tell them to start on Restasis after a week. You rarely get burning, and you get that quick bump from the Lotemax.”

Schaeffer and Bloomenstein also referred to a study that showed that a 5-day course of azithromycin was equivalent to using doxycycline for 1 month for dry eye (Kashkouli, et al.) – by Nancy Hemphill, ELS, FAAO

Reference:

Kashkouli MB, et al. 2014; doi:10.1136/bjophthalmol-2014-305410.

Schaeffer J, et al. Ocular surface disease: Developing a strategy for diagnosis and treatment of OSD. Presented at: Vision Expo East. April 14-17; New York.

Disclosures: Bloomenstein is on the speakers’ panel for Abbott Medical Optics, Alcon, Allergan, Bausch + Lomb, Better Vision Institute, BlephEx, Bruder, Macular Health and TearLab. Karpecki receives consulting fees from AcuFocus, Aerie Pharmaceuticals, Anthem, AMO, Alcon Labs, Allergan, Akorn, Bausch + Lomb/Valeant, BioTissue, Bruder Healthcare, Cambium Pharmaceuticals, Eyemaginations, Essilor, Eyes4Lives, Eye Solutions, Focus Laboratories, iCare USA, Johnson & Johnson Vision Care, OcuSoft, Freedom Meditech, Konan Medical, MacuLogix, Beaver-Visitech, Ocular Therapeutix, Reichert, Shire Pharmaceuticals, Regeneron, RySurg, Science Based Health, SightRisk, TearLab, TearScience, TLC Vision, Topcon and Vmax. He is on the speakers’ bureau for Glaukos and Oculus; has conducted research for Akorn, Allergan, Bausch + Lomb, Eleven Biotherapeutics, Fera Pharmaceuticals, Rigel Pharma and Shire; and has an ownership interest in Bruder HealthCare and TearLab. Schaeffer is a consultant for Alcon, Allergan, Bausch + Lomb, CooperVision, Essilor and Vistakon.