Every ophthalmologist deals with patient complaints of tearing and dry eye. In our ophthalmic plastic surgery practice, consultations for tearing problems are common, as well.
Though tearing and dry eye seem like converse problems, aqueous tear insufficiency and/or Meibomian Gland Dysfunction (MGD) are common causes of tearing. This is felt to be due to the two theoretical mechanisms of tear flow: basal tearing and reflex tearing. When the basal tear flow system (accessory lacrimal glands of Krause and Wolfring) fails, the lacrimal gland kicks in and provides an abundance of tears, if able. This results in a “rollercoastering” effect on tearing, with patients noticing episodes of tearing interspersed by dryness or no symptoms. When the meibomian glands are dysfunctional, even if tear production is normal, symptoms result from accelerated tear evaporation. In patients with severe dry eye/keratoconjuctivitis sicca (KCS), including patients with rheumatoid arthritis, lupus and Sjogren’s syndrome, even the lacrimal gland compensatory mechanisms fail and more significant corneal damage can occur.
Thinking about the inflammatory causes of KCS helps guide appropriate treatment.
Various proinflammatory cytokines (including interleukin 1 (IL-1), interleukin 6 (IL-6), interleukin 8 (IL-8), TNF-alpha and TGF-beta) are associated with this condition. Thus, treatment is aimed at reducing inflammation of the ocular surface and promoting tear flow. Artificial tear supplementation plays a role in treating the symptoms of KCS, as well as diluting and washing away inflammatory mediators. Topical corticosteroids short term (such as Lotemax®), and cyclosporine 0.05% (Restasis®) long term are important first line treatments for KCS.
Punctal occlusion may be an appropriate treatment for some patients, but I generally consider this a last resort. Occluding tear outflow can worsen the KCS condition as this obstruction causes inflammatory cytokines to remain on the ocular surface rather than exit through the lacrimal outflow system. Punctal plugs, especially intracanalicular plugs, are associated with canaliculitis, nasolacrimal duct obstruction, and other problems. We have surgically removed a number of intracanalicular plugs for these reasons and we therefore never insert them. When punctal occlusion is absolutely necessary, we recommend using traditional cap type plugs that can be seen on examination and removed if problematic.
The last issue to consider is KCS with concomitant nasolacrimal duct obstruction (NLDO). It has been suggested that NLDO “is good for” dry eye patients.
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This is a false assumption based on a lack of understanding of modern tear production theory. If punctal plugs are bad for dry eye patients then NLDO is even worse. Instead of occluding the punctae and keeping inflammatory mediators on the surface of the eye, NLDO allows a bag of these molecules, mucus and bacteria to have a home right next to the eye. First line treatment for dry eye in a patient with NLDO: DCR plus topical anti-inflammatory medication.
2 Comments
12:19 am
Jake Rastalson
Great Post, Dr. Black. Can you recommend a specific plug that you use when/if you must use one? In what specific sort of setting or situation have you found that punctal occlusion is absolutely necessary?
Jake
10:40 pm
Dr. Evan Black
Hi Jake
Severe KCS with near zero tear production (5 min basic secreter [schirmer type with topical anesthesia] readings of zero or 1mm) with keratitis +/- filaments, ulcer, etc., and/or failure of medical treatment are good reasons to plug, in my opinion.
Eagle Vision or FCI Ophththalmics both make nice plugs (Eagle Plug, snug plug, “ready set” plug). Any cap type plug is probably ok.
Hope that helps!