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Punctal Occlusion for the Dry Eye
Ophthalmic Procedures Assessment*
Punctal Occlusion for
the Dry Eye
AMERICAN ACADEMY OF OPHTHALMOLOGY
*The purpose of the Committee on Ophthalmic Procedures Assessment is to evaluate on a scientific basis new and existing ophthalmic tests, devices, and procedures for their safety, efficacy, clinical effectiveness and appropriate uses. Evaluations include examination of available literature, epidemiological analyses when appropriate, and compilation of opinions from recognized ex perts and other interested parties. After appropriate review by all contributors, including legal counsel, assessments are submitted to the Academy's Board of Directors for consideration as official Academy policy.
the eye, and especially the corneal surface, is contin uously protected by a smooth, lubricating liquid surface. The goals oftherapy are to relieve discomfort, to provide a smooth optical surface, and to prevent structural dam age to the cornea. Forms oftherapy for specific tear film abnormalities are listed below. One or more therapies are frequently used simultaneously regardless of the pri mary mechanism responsible for the dry eye. Volume abnormality Increased humidity Avoid anticholinergic drugs Control air currents Artificial tears Punctal plugs Punctal occlusion Mucin abnormality Artificial tears Lacrisert Acetylcysteine Mechanical removal Lipid abnormality Lid hygiene Hot compresses Topical antibiotics Topical steroids Oral tetracycline
INTRODUCTION The dry eye, I-4 caused by keratoconjunctivitis sicca or other diseases or injuries which affect tear production or composition, has an abnormal tear film that produces symptoms varying in severity from simply increased eye awareness to severe pain and incapacitating inability to keep the eyes open. Tear film abnormalities have been grouped into those affecting the aqueous tears, tear mucin, tear lipids, tear spreading, and the tear base. The best therapies for dry eye attempt to correct or compen sate for specific tear deficiencies.
THERAPY FOR THE DRY EYE Various types of therapies are used in an effort to correct or compensate for tear film abnormalities so that Prepared by the Ad Hoc Committee on Ophthalmic Procedures Assess ment and approved by the Academy's Board of Directors on June 21, 1987. Committee members are David L. Guyton, MD, Chairman, Howard C. Joondeph, MD, Richard L. Lindstrom, MD. The Committee is staffed by Lea Gamble.
71
72
OPHTHALMOLOGY
•
INSTRUMENT AND BOOK SUPPLEMENT 1988
Surface abnormality Artificial tears Ointments Taping lids shut Tarsorrhaphy Other lid surgery Scleral shell Tear base abnormality Therapeutic soft contact lens Corneal graft Systemic therapy such as immunosuppressants for pemphigoid The most commonly used therapy for the dry eye is artificial tear instillation. Various artificial tear formula tions are available which offer relief of dry eye symp toms. Unfortunately, the improvement enjoyed by many patients when artificial tears are instilled is short lived because of drainage through the lacrimal outflow channels and evaporation.
PUNCfAL OCCLUSION FOR THE DRY EYE Punctal occlusion, or closure of the lacrimal outflow system at the level ofthe punctum, is based on the ratio nale that partial or complete occlusion of the outflow system will preserve the natural tears and prolong the effect ofartificial tears which are instilled. 4 Some studies have indicated that punctal occlusion can decrease ele vated tear osmolarity and rose-bengal staining of the ocular surface. 5•6 Impression cytology may be helpful in documenting beneficial effects. 7•8 Other studies have in dicated that tear drainage increases as tear volume in creases. If the reverse occurs with decreased tear flow, a decrease in tear drainage may occur with decreased tear volume such that a physiologic block of tear drainage may actually occur in the dry eye. Because tear flow and composition are difficult to measure, the clinician must often depend on the subjective response in the dry eye patient and the subtle, highly variable objective signs of the dry eye to determine the benefit of punctal occlu sion.
SELECTION OF DRY EYE PATIENTS FOR PUNCfAL OCCLUSION Improvement of symptoms has been dramatic in many severely affected dry eye patients after punctal occlusion. 9 Objective changes in the ocular surface have also been demonstrated as noted above. Mildly affected dry eye patients frequently do not respond to punctal occlusion just as they frequently do not have significant relief from the instillation of artificial tears, suggesting that other problems are causing the symptoms. The suc cess of puncta! occlusion in the dry eye patient is com monly predicted by the presence of rose-bengal staining
of the conjunctiva in the exposure zone and staining of the inferior cornea. Also a trial of other forms oftherapy can be helpful, such as artificial tears and moist chamber spectacles which give significant short-term relief. De spite these precautions, some patients' symptoms have worsened after punctal occlusion. For this reason, a par tial occlusion (of only the upper or lower puncta) by a reversible means such as silicone plugs, suture, or colla gen rods is preferable initially to determine the effect on dry eye symptoms and findings, and to be certain that epiphora will not be a problem, before permanent clo sure.10·11 Even with improvement ofsymptoms after one of these methods, permanent closure of the lacrimal drainage system by punctal occlusion becomes neces sary only when the suture or plug becomes loose, locally irritating, or falls out.
METHODS FOR PERFORMING PERMANENT PUNCfAL OCCLUSION Permanent closure of the punctum is accomplished by injuring or removing punctal tissue to induce closure by scar tissue. This may be accomplished by cautery, electrodesiccation, or simple excision. In order to avoid bleeding and the necessity of suturing, electrodesicca tion is most commonly done. A hyfercation needle is inserted into the punctum and along the distal portion of the canaliculus, and the power is increased until de struction of tissue occurs. One seeks to produce only the minimal amount of tissue destruction necessary to per manently close the lacrimal punctum. Some have pro duced thermal tissue destruction with the argon laser. The slit-lamp delivery system provides magnification and allows precise placement of laser bums on the punctum, but one would expect the resulting scarring to be so superficial and so distal in the canaliculus that recanalization would be more likely to occur than by cautery or electrodesiccation. Such a superficial closure can be performed most simply by applying a heated spatula to the punctum. The cost of the equipment (and the expense to the patient) for "laser punctoplasty" is considerably in excess of that required for cautery or electrodesiccation, and for no established additional therapeutic gain.
CONCLUSION Puncta! occlusion is indicated in the moderately se vere to severe dry eye patient in order to prevent drain age and thus conserve the natural tears and instilled artificial tears. Punctal occlusion is a surgical procedure that is most commonly used after reversible methods of occlusion and in conjunction with other nonsurgical therapeutic methods. If permanent punctal occlusion is believed to be desirable, electrodesiccation of the cana liculus and punctum appears to be the method most
AAO •
PUNCTAL OCCLUSION FOR THE DRY EYE
widely used and effective in producing permanent clo sure.
ACKNOWLEDGMENTS Original draft-R. Linsy Farris, MD; Contributors-Jeffrey P. Gilbard, MD, David W. Lamberts, MD, J. Daniel Nelson., MD; Editor-David L. Guyton, MD; Approved by-Board of Directors, June 21, 1987.
REFERENCES 1. Farris FL. The dry eye: Its mechanisms and therapy. CLAO J 1986; 12:234-46. 2. Mishima S, Gasset A, Klyce SO, Baum JL. Determination of tear volume and tear flow. Invest Ophthalmol1966; 5:264-76.
73
3. Lemp MA, Dahlman CH, Holly FJ. Corneal desiccation despite nor mal tear volume. Ann Ophthalmol1970; 2:258-84. 4. Dahlman CH. Punctal occlusion in keratoconjunctivitis sicca. Trans Amer Ophthalmol Soc 1975; 78:567-628. 5. Gilbard JP. Tear film osmolarity and keratoconjunctivitis sicca. CLAO J 1985; 11 :243-50. 6. Van Bijsterveld OP. Diagnostic tests in the sicca syndrome. Arch Ophthalmol1969; 82:10-4. 7. Egbert PR, Lauber S, Maurice DM. A simple conjunctival biopsy. Am J Ophthalmol1977; 84:798-801. 8. Nelson JD. Ocular surface impressions using cellulose acetate filter material: Ocular pemphigoid. Surv Ophthalmol1982; 27:67-9. 9. Tuberville AW, Frederick WR, Wood TO. Punctal occlusion in tear deficiency syndromes. Ophthalmology 1982; 89:1170-2. 10. Fouids WS. Intra-canalicular gelatin implants in the treatment of kera toconjunctivitis sicca. Br J Ophthalmol 1961; 45:625-7. 11. Patten JT. Punctal occlusion with N-Butyl cyanoacrylate tissue adhe sive. Ophthal Surg 1976; 7:24-6.
Punctal Occlusion for
the Dry Eye
AMERICAN ACADEMY OF OPHTHALMOLOGY
*The purpose of the Committee on Ophthalmic Procedures Assessment is to evaluate on a scientific basis new and existing ophthalmic tests, devices, and procedures for their safety, efficacy, clinical effectiveness and appropriate uses. Evaluations include examination of available literature, epidemiological analyses when appropriate, and compilation of opinions from recognized ex perts and other interested parties. After appropriate review by all contributors, including legal counsel, assessments are submitted to the Academy's Board of Directors for consideration as official Academy policy.
the eye, and especially the corneal surface, is contin uously protected by a smooth, lubricating liquid surface. The goals oftherapy are to relieve discomfort, to provide a smooth optical surface, and to prevent structural dam age to the cornea. Forms oftherapy for specific tear film abnormalities are listed below. One or more therapies are frequently used simultaneously regardless of the pri mary mechanism responsible for the dry eye. Volume abnormality Increased humidity Avoid anticholinergic drugs Control air currents Artificial tears Punctal plugs Punctal occlusion Mucin abnormality Artificial tears Lacrisert Acetylcysteine Mechanical removal Lipid abnormality Lid hygiene Hot compresses Topical antibiotics Topical steroids Oral tetracycline
INTRODUCTION The dry eye, I-4 caused by keratoconjunctivitis sicca or other diseases or injuries which affect tear production or composition, has an abnormal tear film that produces symptoms varying in severity from simply increased eye awareness to severe pain and incapacitating inability to keep the eyes open. Tear film abnormalities have been grouped into those affecting the aqueous tears, tear mucin, tear lipids, tear spreading, and the tear base. The best therapies for dry eye attempt to correct or compen sate for specific tear deficiencies.
THERAPY FOR THE DRY EYE Various types of therapies are used in an effort to correct or compensate for tear film abnormalities so that Prepared by the Ad Hoc Committee on Ophthalmic Procedures Assess ment and approved by the Academy's Board of Directors on June 21, 1987. Committee members are David L. Guyton, MD, Chairman, Howard C. Joondeph, MD, Richard L. Lindstrom, MD. The Committee is staffed by Lea Gamble.
71
72
OPHTHALMOLOGY
•
INSTRUMENT AND BOOK SUPPLEMENT 1988
Surface abnormality Artificial tears Ointments Taping lids shut Tarsorrhaphy Other lid surgery Scleral shell Tear base abnormality Therapeutic soft contact lens Corneal graft Systemic therapy such as immunosuppressants for pemphigoid The most commonly used therapy for the dry eye is artificial tear instillation. Various artificial tear formula tions are available which offer relief of dry eye symp toms. Unfortunately, the improvement enjoyed by many patients when artificial tears are instilled is short lived because of drainage through the lacrimal outflow channels and evaporation.
PUNCfAL OCCLUSION FOR THE DRY EYE Punctal occlusion, or closure of the lacrimal outflow system at the level ofthe punctum, is based on the ratio nale that partial or complete occlusion of the outflow system will preserve the natural tears and prolong the effect ofartificial tears which are instilled. 4 Some studies have indicated that punctal occlusion can decrease ele vated tear osmolarity and rose-bengal staining of the ocular surface. 5•6 Impression cytology may be helpful in documenting beneficial effects. 7•8 Other studies have in dicated that tear drainage increases as tear volume in creases. If the reverse occurs with decreased tear flow, a decrease in tear drainage may occur with decreased tear volume such that a physiologic block of tear drainage may actually occur in the dry eye. Because tear flow and composition are difficult to measure, the clinician must often depend on the subjective response in the dry eye patient and the subtle, highly variable objective signs of the dry eye to determine the benefit of punctal occlu sion.
SELECTION OF DRY EYE PATIENTS FOR PUNCfAL OCCLUSION Improvement of symptoms has been dramatic in many severely affected dry eye patients after punctal occlusion. 9 Objective changes in the ocular surface have also been demonstrated as noted above. Mildly affected dry eye patients frequently do not respond to punctal occlusion just as they frequently do not have significant relief from the instillation of artificial tears, suggesting that other problems are causing the symptoms. The suc cess of puncta! occlusion in the dry eye patient is com monly predicted by the presence of rose-bengal staining
of the conjunctiva in the exposure zone and staining of the inferior cornea. Also a trial of other forms oftherapy can be helpful, such as artificial tears and moist chamber spectacles which give significant short-term relief. De spite these precautions, some patients' symptoms have worsened after punctal occlusion. For this reason, a par tial occlusion (of only the upper or lower puncta) by a reversible means such as silicone plugs, suture, or colla gen rods is preferable initially to determine the effect on dry eye symptoms and findings, and to be certain that epiphora will not be a problem, before permanent clo sure.10·11 Even with improvement ofsymptoms after one of these methods, permanent closure of the lacrimal drainage system by punctal occlusion becomes neces sary only when the suture or plug becomes loose, locally irritating, or falls out.
METHODS FOR PERFORMING PERMANENT PUNCfAL OCCLUSION Permanent closure of the punctum is accomplished by injuring or removing punctal tissue to induce closure by scar tissue. This may be accomplished by cautery, electrodesiccation, or simple excision. In order to avoid bleeding and the necessity of suturing, electrodesicca tion is most commonly done. A hyfercation needle is inserted into the punctum and along the distal portion of the canaliculus, and the power is increased until de struction of tissue occurs. One seeks to produce only the minimal amount of tissue destruction necessary to per manently close the lacrimal punctum. Some have pro duced thermal tissue destruction with the argon laser. The slit-lamp delivery system provides magnification and allows precise placement of laser bums on the punctum, but one would expect the resulting scarring to be so superficial and so distal in the canaliculus that recanalization would be more likely to occur than by cautery or electrodesiccation. Such a superficial closure can be performed most simply by applying a heated spatula to the punctum. The cost of the equipment (and the expense to the patient) for "laser punctoplasty" is considerably in excess of that required for cautery or electrodesiccation, and for no established additional therapeutic gain.
CONCLUSION Puncta! occlusion is indicated in the moderately se vere to severe dry eye patient in order to prevent drain age and thus conserve the natural tears and instilled artificial tears. Punctal occlusion is a surgical procedure that is most commonly used after reversible methods of occlusion and in conjunction with other nonsurgical therapeutic methods. If permanent punctal occlusion is believed to be desirable, electrodesiccation of the cana liculus and punctum appears to be the method most
AAO •
PUNCTAL OCCLUSION FOR THE DRY EYE
widely used and effective in producing permanent clo sure.
ACKNOWLEDGMENTS Original draft-R. Linsy Farris, MD; Contributors-Jeffrey P. Gilbard, MD, David W. Lamberts, MD, J. Daniel Nelson., MD; Editor-David L. Guyton, MD; Approved by-Board of Directors, June 21, 1987.
REFERENCES 1. Farris FL. The dry eye: Its mechanisms and therapy. CLAO J 1986; 12:234-46. 2. Mishima S, Gasset A, Klyce SO, Baum JL. Determination of tear volume and tear flow. Invest Ophthalmol1966; 5:264-76.
73
3. Lemp MA, Dahlman CH, Holly FJ. Corneal desiccation despite nor mal tear volume. Ann Ophthalmol1970; 2:258-84. 4. Dahlman CH. Punctal occlusion in keratoconjunctivitis sicca. Trans Amer Ophthalmol Soc 1975; 78:567-628. 5. Gilbard JP. Tear film osmolarity and keratoconjunctivitis sicca. CLAO J 1985; 11 :243-50. 6. Van Bijsterveld OP. Diagnostic tests in the sicca syndrome. Arch Ophthalmol1969; 82:10-4. 7. Egbert PR, Lauber S, Maurice DM. A simple conjunctival biopsy. Am J Ophthalmol1977; 84:798-801. 8. Nelson JD. Ocular surface impressions using cellulose acetate filter material: Ocular pemphigoid. Surv Ophthalmol1982; 27:67-9. 9. Tuberville AW, Frederick WR, Wood TO. Punctal occlusion in tear deficiency syndromes. Ophthalmology 1982; 89:1170-2. 10. Fouids WS. Intra-canalicular gelatin implants in the treatment of kera toconjunctivitis sicca. Br J Ophthalmol 1961; 45:625-7. 11. Patten JT. Punctal occlusion with N-Butyl cyanoacrylate tissue adhe sive. Ophthal Surg 1976; 7:24-6.