Eyedolatry: January 2012

A Closer Look at Punctal Plugs

Punctal plugs are a concept that sounds quite scary when presented to a patient for the first time, but could have a number of benefits for multiple ocular conditions. A new article by Review of Optometry features all of the unsung potential uses for plugs. For a treatment once thought out of date due to the advent of Restasis, more and more doctors are returning to plugs for helping their patients achieve relief from dry eye. Now we are finding new applications for this quick and painless procedure!

Properly inserted permanent plug

DRY EYE
We recently discussed punctal plugs and their benefits for patients with dry eye, and Dry Eye Syndrome is still the most popular use for these devices. Punctal plugs prevent rapid drainage of your own tears through your nasolacrimal tear duct, keeping a healthy layer of tear film on the eye for a longer time. I especially prefer plugs on patients where there is minimal to no meibomian gland dysfunction and:

Contact Lens Wearers with poor comfort due to dryness
filamentary keratitis from advanced dry eye
pre or post-op LASIK --- a healthy tear film will improve comfort and post-LASIK visual outcome!

Remember it is ok to use plugs AND Restasis! Restasis will help increase tear production, and plugs will just keep the tears on the eye longer. We just want to treat any inflammatory component before plugging the eye.

Pyogenic Granuloma with embedded plug

Why I use Dissolvable Plugs

Permanent plugs are perfectly healthy and can easily be removed in most cases. But sometimes permanent plugs can fall into the puncta and be lodged there. Now, in most cases the plug will either stay there harmlessly, offering continued relief from dryness. Sometimes, however the body can mount an inflammatory reaction to the embedded plug (this is called a pyogenic granuloma) and the plug may even have to be surgically removed. This is very rare, but already in my short career I have seen a buried plug (where it falls into the punctal opening and cannot be retrieved). Dissolvable plugs do have to be replaced more frequently, but there is NO risk involved, which makes things a lot easier when explaining an already intimidating procedure idea to the patient. For other OD's out there: buried plugs are a big risk when you have a patient who is a frequent eye rubber, or when you have a patient who has a very large puncta.

OTHER USES FOR PUNCTAL PLUGS

Sometimes when doctors prescribe an eye drop, they will recommend you closing your eyes or putting a finger over the nasal corner of your eye to prevent systemic absorption of the drop. This is called punctal occlusion, a procedure that reduces the amount of drug getting into your bloodstream and travelling to other areas of the body, as well as increases the amount of drug absorbed by your eye! The longer the drop is in contact with your ocular tissue, theoretically there should be a better therapeutic effect. A punctal plug would do the same thing that your finger would, and could be very effective in patients with:

Glaucoma, using topical eye drops to increase the contact time of the drop
bacterial corneal ulcers to increase the amount of antibiotic on the surface of the eye
corneal dystrophies or recurrent corneal erosion to keep the eye lubricated
history of herpetic infections to protect the eye from dryness or other ocular stressors that could reactivate the virus

THE FUTURE OF PUNCTAL PLUGS

For people using daily eye drops (sometimes four or five times a day!) for the treatment of glaucoma, less dosing is a great improvement to quality of life. There have been numerous studies reporting that the more drops required, compliance with dosage greatly decreases, which can directly result in further damage to the optic nerve and vision! A company called QLT has proposed using a punctal plug filled with Latanoprost (a glaucoma medication) that can be inserted just like any other plug and provide sustained release of medication. The patient would no longer need to remember to insert drops!! This could be an incredible new therapeutic option that could be incorporated into the treatment of other ocular conditions where regular dosing of drugs is needed. Imagine a punctal plug filled with Restasis! I'm sure someone is working on this as we speak.

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Waiting for Spring

90210 glasses 4:28 PM

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The Patient's Guide to Dry Eye Syndrome: Hormones and Dry Eye

dry eye syndrome 7:41 PM

Let's face the facts; women report dry eye symptoms more frequently than males in the same age group. In a study by the American Journal of Ophthalmology, 7.8% of women over 50 report dry eye, versus only 4% of polled men. The theoretical culprit?

Hormones

As women go through menopause, androgen levels appear to drop, causing a range of side effects. In the ocular world, the result is a significant reduction in the production and secretion of tears. We need tears constantly to keep the eye lubricated; these baseline tears are necessary for clear vision and comfort. Reflex and emotional tearing are a different etiology, and are not the type of tearing we are discussing. Menopause isn't the only time imbalanced hormones wreck havoc on the eye in women; we can also see significant dryness and vision changes during pregnancy!

Treatment Options
If artificial tears and gel drops aren't offering enough relief, there are some more aggressive options to try. When I prescribe tears for this population, sometimes an artificial tear with supplemental natural tear components like growth factors can be more beneficial than the standard OTC brands. Viva drops are my favorite tear drop when I am trying to supplement missing components of natural tears.

In this patient population I also really like Restasis. It tends to perform well in post-menopausal women, and I know some doctors that prescribe it strictly for this population. Restasis increases tear production by reducing inflammatory mediators that cause poor tear film performance. Remember, Restasis is a twice a day; every day drop, and sometimes it can take as long as 3-6 months to get relief. Sometimes when initiating Restasis it is a good idea to pulse with a stronger anti-inflammatory like Lotemax until Restasis has time to get into the system. Patients are less likely to give up if they see some relief!

Restasis comes in individual vials. To save money, I always recommending uncapping a vial for your AM dose, then putting the cap back on and storing upright in a clean environment for the rest of the day. That same vial can be used again for your PM dose. This will save you a ton on copays!0

A less common treatment involves direct hormone supplementation. In this 2003 study, Dr. Connor of SCO fame offers testosterone cream as an effective option. He recommends applying 3% Testosterone Cream twice daily to the eyelids. No insertion into the eye itself is necessary. Interestingly, estrogen supplementation is not found to be effective. The extra testosterone helps to counteract the androgen deficit found post-menopause. After just two weeks of treatment, he reported 50% of patients had improved signs and symptoms. I haven't prescribed this myself, but in the future if a patient is willing to try, I might have some case studies to report of my own.

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Office Essentials for the New OD

bulletin board project 11:52 PM

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Spring 2012 Glasses Sneak Peak

color blocking glasses 7:32 PM

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Everything You Need to Know About Punctal Plugs

dissolvable plugs 4:50 PM

We've been talking a lot about Dry Eye Syndrome and its causes and treatments, so I thought it was about time to address punctal plugs! When my patients can't get relief from their dryness symptoms with artificial tear drops, I always suggest we try either Restasis or punctal plugs as our next option. Restasis is a prescription drop that improves production of the patient's own tears. There are some drawbacks however.
Restasis is:

expensive; most insurances have high copays
time consuming; it is dosed twice a day every single day, potentially forever
takes time to work; in some cases it can be as long as 3 to 6 months before the drop reaches optimum performance

Punctal plugs are another option when Restasis isn't the appropriate direction due to the above complications. Punctal plugs are small collagen or silicone cylinders, typically less than 1 mm in width and around 3 mm in length, that are inserted into the puncta of the eyelid. The puncta is the drainage opening of the eyelid, where tears drain down into the nasolacrimal duct. If we "plug" the puncta, tears are collected onto the eye for a longer period of time. If your tears are staying on the eye longer, you will be experiencing much less dryness.

Not everyone is a candidate for punctal plugs. If you have blepharitis/meibomian gland dysfunction/ocular rosacea symptoms that are greatly flared up, plugs will keep the inflammatory mediators on the surface of your eye which results in more redness and irritation. We have to treat this inflammation first before plugs would be a good option.

I preferably insert dissolvable collagen plugs into the lower puncta of each eye. Some doctors may also insert plugs into the upper puncta in cases of severe dryness, but this is much less common. Dissolvable plugs are placed all the way into the puncta, so they are not visible when you look in the mirror. They typically last 3 months (and as long as 6 months) before being completely dissolved. That means that they would need to be replaced on a regular basis to offer continue relief. The benefits of dissolvable plugs is that there is very little infection or inflammation risk.

Collagen plugs insert fully into the puncta and are not visible to the patient. I use Eaglevision Durasert plugs most frequently of this type.

Silicone permanent plugs are also available and offer longer term relief. They typically sit on top of the puncta so that they could be removed with tweezers if needed. While these plugs are permanent, if you have an eye infection it is best to remove them and then have a new plug inserted when the infection is cleared. They can also fall out (especially if you are rubbing your eyelids quite a bit), or fall down into the tear duct. If these plugs fall down inside of your tear duct, they aren't dissolvable so they will always be there. If they need to be removed, they can be either irrigated or surgically removed. Because of this risk, I tend to insert dissolvable plugs more frequently.

Permanent plugs: I find that the Parasol plugs are very easy to insert and remove. Oasis is also a very nice brand.

The Procedure:

On the day of your punctal plug insertion, expect the procedure to be surprisingly fast and easy! Almost all of my patients are apprehensive at first, and then are surprised when I am finished that the procedure was already over. Your doctor may first insert a drop to numb your eye, just to make you more comfortable during the procedure. In the microscope, they will first use a device called a "dilator" to open your puncta to ease the insertion process. Then it is time for the plugs to be inserted. Temporary plugs have to be inserted further into the puncta so they may take a little longer to put in place compared to the permanent plugs that sit on top of the lid margin. Usually everything is finished in less than 10 minutes. The first day you may experience mild discomfort around the inner corner of your eyes, but symptoms should be no worse than that. Marked pain or discharge should not occur. Just make sure not to rub your eyes too much because the plugs can come dislodged! After a day or two at most, you shouldn't even be able to feel that something is there!

When Should Plugs Start Working?

This depends on how dry your eyes were prior to plug installation. You have to give your eye time to heal -- and dry eye can be ongoing for years before some patients seek treatment, so we are trying to reverse years of damage. On average, I expect patients to be feeling significant improvement if plugs are going to be effective treatment in 1 month, but it could be much faster for milder cases. I have had patients note improvement as quickly as within a week!

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The Patient's Guide to Dry Eye Syndrome: Lacrimal Gland Insufficiency

dry eye syndrome 9:18 PM

We have covered the Meibomian glands of the eyelid quite in depth now, and how clogged glands are often the culprit for dry eyes. Remember, those Meibomian glands secrete the oily surface layer of the tear film, that locks the tears onto the eye and prevents evaporation. There is another gland located higher up in your eye lid area, tucked just under the brow bone, that is responsible for the actual "watery" component of tear production. The lacrimal gland is responsible for the "aqueous" middle layer of the tears. This gland is responsible for emotional and reflex tearing, as well as producing the aqueous layer of regular tear film. So just because you cry easily, doesn't mean you don't have dry eyes.

The lacrimal gland is usually not the problem when someone has Dry Eye Syndrome; Meibomian gland issues are much more common. But when the lacrimal gland is not functioning properly the type of dryness that results is usually very severe. These people are using artificial tear drops every hour or two, lubricating gels at night, and sometimes even need specialized "moisture goggles" to help protect their eyes from drying out. The lacrimal gland can be damaged in conditions like sarcoidosis and Sjogren's Syndrome. The latter condition involves extreme dryness of both the eyes and mouth. Sjogren's has an auto-immune component, so patients with conditions like lupus, rheumatoid arthritis, and other auto-immune disorders are much more likely to experience dryness from reduced lacrimal gland function. The culprits are inflammatory mediators released by the body's own cells that disrupt normal functioning of the lacrimal gland.

The Tranquileyes moisture goggles. These sometimes come with a gel bead packet that can be heated and used to treat Meibomian Gland clogging at the same time!

Restasis is also another great option for these patients. Restasis is still a relatively new pharmaceutical in the grand scheme of things, so there is much debate on what types of dry eye the drop is and isn't effective for. The theory behind Restasis is that it is a potent anti-inflammatory agent (cyclosporine to be precise) that helps block the chemical mediators causing inflammation of the lacrimal gland, and increase your own tear production. Restasis is dosed twice daily, every single day, and can take as long as 3 to 6 months to become fully effective. Most patients begin seeing some relief within 1 month. This drop is quite a big time commitment, and involves an expensive copay on most medical insurances, but in some cases it is the best option for relief.

Restasis comes in individual vials. To save on copays, I always recommend recapping the vials, storing in a nice clean environment with the vial upright if possible, and then using the same vial again for your nighttime dose.

Other experimental treatments for severe Dry Eye resulting from lacrimal gland insufficiency include using testosterone cream (to help balance androgen levels; I will discuss this more when we discuss hormonal causes of dry eye) and autologous serum tear drops. These drops are comprised of your own blood that is centrifuged and prepared into a dosable tear drop that retains your own chemical mediators and growth factors that are always found in natural tears but not found in pharmaceutically manufactured tears. Needless to say, I have never prescribed this yet for patients but there is some interesting literature out there!

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Accommodative Insufficiency: A Guide for New ODs

accommodation 1:51 PM

Let me set the stage with a classic patient presentation.

10 year old patient complains of distance blur at school. When you ask a few more questions, they also state that sometimes when they are reading they have headaches or blurry vision. Sometimes they even tell you that their distance vision is blurry after they read (though it is rare for a young child to be this perceptive).

When vision is checked, acuity is typically 20/25 to 20/40 unaided. Usually worse at distance than near, but they read the 20/20 line really slowly up close. Their ending prescription is anywhere from +0.50 (low hyperopia or far sightedness) to -0.50 (low myopia or near sightedness), but the 20/20 line is still hard for them to read. Note: I know ODs out there know what I mean when I say myopia or hyperopia, but I am including the other terms for all other readers to the blog!

Kids and the phoropter: not exactly a match made in heaven. Best to not confuse things too much with subjective testing that is difficult to understand (like phorias or fused cross cylinder).

Then you switch to near testing. Depending on the patient, only certain tests yield good results. Cover test is normal (most kids don't do well with phorias and vergences!). You might be able to get a binocular fused cross cylinder on older children if you are lucky. The responses vary. My two best tests are NRA/PRA and near retinoscopy (such as MEM). Classic NRA/PRA readings are low usually on both plus and minus blur points. They typically do very poorly with PRA (the minus blur points). You can of course also do an accommodative facility test (with the +2.00/-2.00 flippers and a timer), but in the real world this test is very time consuming to perform in a routine exam.

Near Retinoscopy: I should do it more that I do -- lots of great information can be gleaned. But I don't have these cards in every exam room, so I typically rely on NRA/PRA results and then trialing loose lenses at near subjectively.

Then I like to demonstrate with loose lenses to the patient. Get them out of the phoropter as soon as possible! Let them hold a near card or reading material. Hold up a +0.75 lens and see their response. It is usually quite dramatic. Now sometimes the kid just wants glasses, so hold up a -0.75 or -1.00 and see what happens. If they are really having accommodative issues, they aren't going to like this at all. I will often show the patient what happens when they switch from near to distance with the lens to demonstrate that the glasses are only good for up close.

Prescription wise, I typically Rx +0.75 to +1.25 depending on the patient's distance prescription. The hardest part in all of this, of course, is telling the patient's parents why they need glasses. I always talk about Vision Therapy as an option too, but in my area, it is very expensive and of course not covered by insurances. I always explain that the glasses are for reading only (any near activity they are going to perform for longer than 10 minutes). A near activity I define as anything they are holding closer than arm's length. That means they are going to have to take the glasses on and off at school, but believe me this goes over much better than telling them they need bifocals. Here is my general discussion:

The focusing system of the eyes is made up of the eye muscles and a structure called the lens that the eye muscles control. When you do near work like reading, the eye muscles have to work to bring the image clear. Sometimes those eye muscles get tired, especially with so much near work at school like reading and math worksheets or tests. If you are straining those muscles up close, then they can get locked up in that position, so when you look across the room at the board, it will appear blurry too! The glasses I am prescribing are to relax how hard your eye muscles are having to work up close. Your child doesn't have bad vision, and doesn't need glasses all the time. They only need these glasses for near activities to reduce strain. In most cases, as the eyes continue to develop, they will no longer need these glasses over time. We will check the prescription and their need for near glasses every year at their annual exam.

I hope this helps. Telling a parent their child needs glasses is difficult in any situation, but when you tell them they need glasses for near when they have been complaining to mom and dad for months their distance vision is blurry, it is even harder. Most parents only know myopia (or near sightedness), so any other use of glasses seems strange. Again, especially when their child is coming home complaining of distance blur! I always like to tell parents that studies have shown myopia can be related to eyes being over-strained at near, so hopefully the use of these glasses can help with delaying myopia onset. If the parent is near sighted, they will appreciate any efforts to prevent their child from having a large myopic prescription. In a future post I will detail a patient's guide to accommodative dysfunction to hopefully make things easier for parents to understand!

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