DRY EYE PROBLEMS: CONTACT LENS WEAR,

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DRY EYE PROBLEMS CONTACT LENS WEAR, PUNCTAL
PLUGS AND OTHER TREATMENTS
GERALD E. LOWTHER, O.D., Ph.D. SCHOOL OF
OPTOMETRY INDIANA UNIVERSITY BLOOMINGTON, IN
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REVIEW OF DIAGNOSING DRY EYE
Biomicroscopy -lids injection, mucous staining
on lid margin
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REVIEW OF DIAGNOSING DRY EYE
Biomicroscopy -lids blepharitis, meibomianitis
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REVIEW OF DIAGNOSING DRY EYE
Biomicroscopy -lids meibomianitis
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REVIEW OF DIAGNOSING DRY EYE
Biomicroscopy Tear prism -thin tear prism and/or
scalloped edges
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REVIEW OF DIAGNOSING DRY EYE
Biomicroscopy -rose bengal, lissamine green or
fluorescein staining
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REVIEW OF DIAGNOSING DRY EYE
Tear film break-up time (BUT)-Less than 10
sec. may indicate a problem.
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DRYNESS SYMPTOMS WITH CONTACT LENS WEAR
A survey of 310 practitioners found that -18
to 30 of CL patients had dry eye problems -12
to 21 had reduced wearing time due
to dryness -6 to 9 discontinued wear due to
dryness (Orsborn Zantos, CL Spectrum,
1989)
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DRYNESS SYMPTOMS WITH CONTACT LENS WEAR
A survey of 214 hydrogel patients found 21 of
males and 26 of females had reduced wearing time
due to dryness symptoms. (Orsborn Robboy, J
Brit CL J. 1989)
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Treat lid problems first-blepharitis,
meibomianitis
-advantages to doing in office expression -hot
compresses followed by lid scrubs by
patient -medications in severe cases -oral
doxycycline 200 mg for 2 weeks, 100 mg for a
few months
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DRYNESS SYMPTOMS WITH CONTACT LENS WEAR
Numerous factors effect the dehydration of
hydrogel lenses Water content higher water
lenses lose more water Thickness Thin lenses
dehydrate more Humidity Lenses dehydrate more
in low humidity environments Temperature
less water at higher temperatures. -less water
in lens on eye than in solution (case)
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CORNEAL STAINING FROM DEHYDRATION THROUGH A THIN,
HIGH WATER LENS
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Consider using a humidifier and keeping patients
away from drafts
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SOLUTION SENSITIVITY
Recent studies by Pat Caroline indicate that
many hydrogel patients have staining and dryness
symptoms with preserved CL solutions. 50 to 73
had staining with ReNu after 1 month. The
hydrogel peroxide systems (AOSept and Clear Care)
caused the least problems. Of the preserved
solutions OptiFree was best.
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LUBRICATING SOLUTIONS
Low Viscosity Solutions -preservative free
solutions may be best but can be
expensive -some newer preservatives seem to cause
less problems. Moderate or high viscosity
solutions cause blurring of vision.
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PUNCTAL OCCLUSION
Should we do a trial with collagen
implants? Which permanent plug should be
used? Should we plug the lower puncta, upper or
both? How effective is punctal occlusion?
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ANATOMY OF THE LACRIMAL DRAINAGE SYSTEM
(Modified from Tanebaum McCord, 1991)
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COLLAGEN IMPLANTS
Rods of collagen-available in diameters of 0.2
mm to 0.6 mm and 1.5 to 3.0 mm long
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COLLAGEN IMPLANTS
Insert the plugs down into the punctum using
tweezers -some use 2 or 3 plugs
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COLLAGEN IMPLANTS
Effectiveness of collagen implants
In a double masked study with CL patients with
dryness symptoms, with 1 plug in each puncta of
one eye only, the patients did not notice a
difference between the two eyes.
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COLLAGEN IMPLANTS
Effectiveness of collagen implants Groves et al
found only 16.5 average decrease in out-flow
with one implant in each puncta. Sorensen et al
placed 2 collagen implants in both upper and
lower puncta of 26 patients. They found a
significant improvement of symptoms on day 5 but
no improvement in signs. Unterman et al found a
decrease in loss of fluorescein from the eye 24
hours after placing collagen plugs in both upper
and lower puncta
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COLLAGEN IMPLANTS
SUMMARY 1) multiple collagen implants must be
used. 2) not a highly reliable test indicating
if permanent occlusion will be successful
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SILICONE PERMANENT PLUGS
HERRICK LACRIMAL PLUGS (INCANALICULAR IMPLANTS)
Cone shaped silicone plugs inserted into the
canaliculus (available in 3 sizes 0.3, 0.5 and
0.7 mm diameters) Plugs not visible after
placement
Collagen implant
Herrick plug
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SILICONE PERMANENT PLUGS-HERRICK
Insertion Technique 1) apply local
anesthesia 2) dilate puncta only if necessary
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SILICONE PERMANENT PLUGS-HERRICK
Insertion Technique 3) start inserting plug
vertically, then rotate parallel to lid 4) push
plug into lateral canaliculus 5) pull wire
applicator out
Diagram from Lacrimedics, Inc.
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SILICONE PERMANENT PLUGS-HERRICK
Insertion Technique
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SILICONE PERMANENT PLUGS-HERRICK
Advantage of Herrick Intracanalicular
Plugs -Does not protrude from the puncta, thus
will not irritate the eye. -Is not visible
Disadvantage of Herrick Intracanalicular Plugs
-Not as easy to tell if it is in place (new
opaque plugs are easier to visualize) -Possible
infection
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SILICONE PERMANENT PLUGS-FREEMAN TYPE
Design -fits in punctum to plug opening -the cap
remains on the lid margin -cone shaped bottom
prevents plug from coming out -available from
several companies in slightly varying
designs -most are available in 3 or 4 sizes as
short as 1.3 mm to 3 mm
Plug shown in punctum
Plug on inserter
Diagram from Ciba
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SILICONE PERMANENT PLUGS-FREEMAN TYPE
Insertion of the plug 1. Apply topical
anesthetic 2. Dilate punctum if necessary-do not
over dilate 3. Pull lid away from eye, insert
plug until it pops into punctum 4. Release plug
from holder by pressing release on side of
holder. 5. The cap should be seated tight
against lid margin
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SILICONE PERMANENT PLUGS-FREEMAN TYPE
Plug in place
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SILICONE PERMANENT PLUGS-FREEMAN TYPE
Advantages of punctal plugs -plug is visible so
you know if it is in place -easily
removed Disadvantage of punctal plugs -cap can
cause irritation to conjunctiva and cornea -have
been reports of them pushed down into
canaliculus
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SILICONE PERMANENT PLUGS-EFFECTIVENESS
Effects of Lacrimal Drainage Occlusion with
Non-Dissolvable Intracanalicular Plugs on
Hydrogel Contact Lens Related Dry Eye (Slusser
Lowther)
Study effects of intracanalicular silicone plugs
in hydrogel lens wearers with dry
eyes Symptoms of dryness, lens awareness and
cloudy vision. Pre-lens tear film
stability. Hydrogel lens dehydration. Rose bengal
staining. Fluorescein staining. Study
effectiveness of concurrent use of rewetting
drops.
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SILICONE PERMANENT PLUGS-EFFECTIVENESS
Time line for study
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SILICONE PERMANENT PLUGS-EFFECTIVENESS
Change in dryness symptoms with plugs
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SILICONE PERMANENT PLUGS-EFFECTIVENESS
Number of patients improving over time-effect
decreased with time.
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SILICONE PERMANENT PLUGS-EFFECTIVENESS
Short term epiphora in 82 of patients. Positive
effects diminished with time in some patients
Approximately one third of the patients who
completed the study reported no noticeable
effect on dryness in either eye 4 weeks after
insertion (similar trends in other symptoms).
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SILICONE PERMANENT PLUGS-EFFECTIVENESS
In a group of 14 normal patients with punctal
plugs in both upper and lower puncta, Tomlinson
et al, found epiphoria for only the first few
days after plugging.
Basal tear production may be regulated by sensory
feedback system. If faulty the effect of the
plugs may be lost over time.
Faulty threshold level (i.e. dry eye not
recognized where wet eye would cause response
of decreased tear production)?
This and other studies have shown that there is
sensory control over tear production. This is
why many LASIK patients complain of dryness.
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SILICONE PERMANENT PLUGS
Adverse effects of silicone plugs -some
epiphoria with some patients first few
days -lost of plugs is common 20 to 40
lost -migration of plug down into canaliculus
can occur but is rare. May require surgical
removal.
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PLUG ONE OR BOTH PUNCTA?
Surgical reviews suggest repair of a single
damaged canaliculus is not needed as other one
will drain tears (Canavan Archer, 1979 Ortiz
Krausher, 1975 Sanders et al,
1978). Measurable impairment of drainage
occurred infrequently with experimental
monocanalicular occlusion (Lemp Weller, 1983
Meyer et al, 1990 Ogut et al, 1993). Both have
equal role in drainage as measured by Conduction
time (Jones et al, 1972). Dacryoscintigraphy
(Denffer et al, 1984). Fluorescein dye
disappearance (Ogut et al, 1993).
Most effective if both upper and lower are
plugged. Any epihoria usually disappears in a
few days.
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SUMMARY
Sequence of treatment 1. Environmental
modification 2. Treat any lid problems-blepharitis
and/or meibomianitis 3. Change solutions 4.
Thicker, low water content lenses usually best 5.
Add artificial tears 6. Punctal
occlusion Efficacy of collagen plugs
questionable Effect of plugs may diminish with
time due to adaptation (decrease in tearing due
to feedback system) Plugs increase the effect of
drops
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Thank You! IU School of Optometry, Bloomington,
Indiana.