Punctal plugs is an integral part of the dry eye treatment algorithm that optometrists should be ready to utilize when needed.
With so many designs to choose from, how do you go about selecting those punctal and intracanalicular plugs that are the easiest to insert, most comfortable for the patient, less likely to be extruded, less inclined to invite complications, and most clinically efficacious?
DRY EYE ALGORITHM
Before discussing the various puntcal plugs, which are typically reserved for patients who have not achieved success with previous therapies, it’s essential to review the dry eye treatment progression.
Artificial tears. “First line therapy in dry eye management typically includes artificial tears—preservative-free if used more than four times a day,” says Joseph P. Shovlin, OD, FAAO, senior optometrist at the Northeastern Eye Institute in Scranton, PA. Optom-etrists suggest giving artificial tears two weeks to work and have the patient return. If adequate relief is not found, move on to the next step.
Topical steroids. Often depending on its etiology, many cases of dry eye come with concomitant inflammation in the peri-canalicular area. Any time an inflammatory component accompanies dry eye, hold off on
|Distributed by OCuSOFT, Quintess has indentations in its dome to reduce foreign body sensation by trapping tears.|
punctal plugs until the inflammation is under control. Otherwise, infection may occur. If prescribing steroids, limit them to a short course of two to four weeks, and go with a relatively mild agent such as Bausch + Lomb’s Lotemax® (loteprednol).
Restasis. The immunomodulator in Allergan’s Restasis® (topical cyclosporin) has proven highly effective in relieving the inflammatory component of dry eye. It can be used in place of, or following, a steroid. “I would give a patient at least six weeks to three months (on Restasis) before I would say it isn’t working maximally,” asserts Alan G. Kabat, OD, FAAO, associate professor at Nova Southeastern University College of Optometry in Fort Lauderdale, FL. “That’s when if we’re not getting enough relief based on the patient or if we aren’t seeing any additional production of tears and tear volume is still low I would then consider punctal plugs.”
|The user-friendly Parasol Punctal Occluder from Odyssey Medical features an inserter with a push-button release.|
One popular punctal plug is Odyssey Medical, Inc.’s Parasol Punctal Occluder. Dr. Kabat says this is his “go-to” plug for almost all of his dry eye patients who require punctal occlusion. The Parasol plug comes in extra-small, small, medium, and large sizes, but according to the company the small and medium sizes should accommodate 95% of all patients. In fact, Dr. Kabat finds that the medium fits the vast majority of his patients. This makes insertion easy and retention reliable. And because Dr. Kabat can stock many units, he’s ready to treat patients when they visit rather than having to order one and have the patient return. “It’s (Parasol) comfortable, it does what I need it to do, it’s affordable, and it has a lot of different options for purchase,” avows Dr. Kabat. “It also has a really nice inserter with a push-button release,” he adds.
|OASIS Medical’s Flow Control plug maintains
a channel that allows
a continuous flow out.
Another option is OASIS Medical, Inc.’s Flow Control punctal plugs. “There’s a channel in the middle of the punctal plug which is preloaded on the stylus, and with the inserter you push the plug into the punctum and squeeze the handle to release the plug from the stylus.” Dr. Kabat says. “They’ve extended that channel all the way to the end and they’ve cut the tip off the plug. So there’s a hollow tube running through it.” This is a useful treatment for patients whose tears overflow because the punctum becomes flaccid and closes. This might happen in older patients or those who have suffered a stroke. The Flow Control plug, “maintains a channel that allows a continuous flow out because you’re kind of creating an artificial punctum,” adds Dr. Kabat. OASIS also offers the Form Fit intracanalicular plug, a hydrogel material that expands into a soft, pliable, gelatinous material when it come in contact with the tear film.
Andrew S. Gurwood, OD, FAAO, professor of clinical services at Salus
|CPT CODE FOR TEARLAB OSMOLARITY TEST The American Medical Association issued a new CPT code which applies to TearLab Corp.’s TearLab® Osmolarity test. The CPT code is: 83861; Microfluidic analysis utilizing an integrated collection and analysis device, tear osmolarity (for microfluidic tear osmolarity of both eyes, report 83861 twice). This code is listed under the Clinical Laboratory Fee Schedule by the Centers for Medicare and Medicaid Services. The TearLab Osmolarity System uses a lab-on-a-chip technology that requires less than 50nL of tear fluid in order to measure tear osmolarity. System can produce a sample-to-answer in less than 30 seconds.|
University Pennsylvania College of Optometry, favors Medennium Inc.’s aesthetically pleasing SmartPLUG®. Among its advantages, Dr. Gurwood says, are that it’s “quite thin when unhydrated; small puncta that are resistant to dilation can be easily blocked with a SmartPLUG; and they are also terrific for upper punctal occlusion.” Medennium also offers Xsorb™ temporary punctum plugs that last up to three months, so follow-up visits are kept to a minimum. Xsorb is a biode-gradable synthetic polymer which is a great alternative for patients who might be sensitive to animal products like collagen.
FCI Ophthalmics Inc. has the Ready-Set Punctum Plug with its slanted cap. The slanted design is meant to assure that the cap remains flush against the lid margin and will not irritate the eye. Dr. Kabat advises to make sure it’s inserted properly since it has one orientation—it isn’t symmetrical. “If you inadvertently insert it backwards, it won’t ride low against the lid, and it will stick up. And then you have to spin it around.”
FCI also offers its Snug Plugs, the one-size-fits-all silicone punctum plug. These plugs are packaged preloaded and stretched for easy insertion. Once released in punctum, the plug returns to its natural shape for snug fit and secure retention. No need to size the punctum or to stock multiple plug sizes. In addition, the company’s TearSaver plug features a tapered shaft design that anchors securely in the punctum for more comfort and less risk of rub-out.
With what is sometimes called a reservoir design, Quintess™ Punctal Occluders (distributed by OCuSOFT, Inc.) has indentations in its dome to reduce foreign body sensation by trapping tears, thus reducing surface tension and enhancing patient comfort.
Punctal plugs will likely remain an integral part of the dry eye treatment algorithm for some time to come. “Punctal plugs are just one of several options that can be employed to provide relief for those who suffer from dry eye,” Dr. Shovlin asserts. “Key issues include minimizing inflammation with topical steroids and managing complicating lid-related problems before inserting plugs. It’s important to use all options that are available to us today.”
Robert Murphy is a freelance writer with over 20 years’ experience writing for the optometric industry.
WHERE TO FIND IT:
Allergan • 800-347-4500 • allergan.com
Bausch + Lomb • 800-828-9030 • bausch.com
FCI Ophthalmics Inc. • 800-932-4202 • fci-ophthalmics.com
Medennium Inc. • 949-789-9000 • medennium.com
OASIS Medical, Inc. • 800-528-9786 • oasismedical.com
OCuSOFT, Inc. • 800-233-5469 • ocusoft.com
Odyssey Medical, Inc. • 888-905-7770 • odysseymed.com
TearLab Corp. • 855- 832-7522 • tearlab.com