As awareness of the prevalence of dry eye disease (DED) increases, many doctors are prioritizing strategic dry eye treatment within their practices. Because dry eye affects millions of Americans1,2 —many of whom are asymptomatic—I evaluate every patient for dry eye.
Recently, much discussion has taken place within the dry eye community regarding the role of punctal plugs in the treatment of dry eye. In my own practice, punctal occlusion has increased in conjunction with expanded utilization of advanced diagnostic tools, such as the TearLab Osmolarity System (TearLab Corporation) and InflammaDry test (Rapid Pathogen Screening, Inc.) that detects matrix metallopeptidase 9 (MMP-9), an inflammatory marker.
Through trial and error, I have learned that punctal occlusion can be a great tool to manage dry eye disease in the appropriate patients. Ensuring there is no significant inflammation in the tear film prior to plugging is critical because leaving inflamed tears on the ocular surface can result in a less than optimal outcome.
Previously from Dr. O'Dell: Uncover patient lifestyle habits that lead to OSD
A positive InflammaDry test indicates anti-inflammatory treatment is required prior to considering maintenance therapy with punctal occlusion. After a negative result from the InflammaDry test is determined (indicating no detectable levels of MMP-9 present), plugs can be considered.
In my experience, patient subgroups who do especially well with plugs are those with autoimmune diseases—including rheumatoid arthritis, lupus, or Sjogren’s—thyroid patients, contact lens wearers, and avid computer users. Patients who do not fully blink or who have lagophthalmos or inadequate nocturnal lid seal may also benefit because the plugs aid in increasing the volume of tears.
Diagnosis and treatment
At my practice, all patients are screened in the exam room with tear break-up time (TBUT), staining of the cornea and conjunctiva, and transillumination. If any concerns are discovered, a formal dry eye evaluation, including point-of-care testing with TearLab Osmolarity and InflammaDry and meibography with LipiView II (TearScience), is scheduled. This allows for more time with the patient for education, another critical part of successful dry eye management.
Related: Understanding and defining MGD
Prior to any treatment, I establish a proper diagnosis of DED: Is the patient aqueous deficient or evaporative, a combination of both, affected by allergies, or suffering from a corneal problem, such as anterior basement membrane dystrophy or recurrent erosions?
The type of DED will help determine the appropriate treatment. My diagnostic protocol involves assessing the health of the cornea, conjunctiva, lids, and overall health of the glands through the use of all point-of-care testing currently available, including a validated survey, such as the SPEED questionnaire and staining with both fluorescein and lissamine green.