Punctal Occlusion in Keratoconjunctivitis Sicca

PUNCTAL OCCLUSION IN KERATOCONJUNCTIVITIS SICCA CLAES H. DOHLMAN, MD BOSTON, MASSACHUSETTS

Occlusion of the lacrimal puncta is a useful and underutilized procedure in the treatment of keratoconjunctivitis sicca. When artificial tears no longer ameliorate symptoms and the Schirmer tests are 2 mm/5 min or less (repeatedly), combined with positive rose bengal staining, punctal occlusion is indicated. Diathermy is the most practical technique for permanent closure, whereas various punctum plugs can be applied for a temporary effect. DRY eyes, because of low tear production, is the most commonly missed diagnosis in external disease. Advanced forms are usually restricted to persons with concomitant rheumatoid arthritis (Sjogren's syndrome). Milder forms of keratoconjunctivitis sicca, however, are actually quite common, not only in elderly persons, but also in younger persons, especially in women, usually without systemic disease. Countless persons receive prolonged office treatment with antibiotics for chronic conjunctivitis because the signs of abnormality are usually minor, and the possibility of keratoconjunctivitis sicca simply does not occur to the ophthalmologist. However, the lower tear meniscus should

Submitted for publication Oct 4, 1977. From the Cornea Service, Massachusetts Eye and Ear Infirmary, and the Department of Cornea Research, Eye Research Institute of Retina Foundation , Boston. Presented at the Eighty-second Annual Meeting of the American Academy of Ophthalmology and Otolaryngology, Dallas, Oct 2-6, 1977. Reprint requests to Eye Research Institute of Retina Foundation, 20 Staniford St, Boston, MA 02114.

always be evaluated during slitlamp examination in suspect cases, and an unusually small meniscus should tip off the physician to proceed with a Schirmer test and staining with rose bengal. These simple diagnostic procedures (observation of the tear meniscus and performing a Schirmer test) are vastly underutilized in office ophthalmology in general. Once the diagnosis of keratoconjunctivitis sicca is made on the basis of discomfort combined with Schirmer values of 0 to 3 mm/5 min (without topical anesthetics), and with or without rose bengal staining, the following treatment modalities should be considered: (1) artificial tears; (2) closure of puncta; (3) soft lens; and (4) humid climate, indoor humidifier, periodic eye closure, goggles, and others. Artificial tears are always the first treatment of choice in milder cases and may be sufficient for the rest of the patient's life. We have not found any brand of tear substitute that is superior to the others. A humid atmosphere also helps to reduce the evaporation rate from the ocular surface and thereby lessens the subjective symptoms. If artificial tear solutions are not sufficient to ameliorate the patient's symptoms, closure of both upper and lower lacrimal puncta should be considered. This procedure was originally described by Beetham. 1 Closing the puncta preserves the tear fluid longer, makes the lower

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tear meniscus reservoir more voluminous, and therefore, through blinking, mixes the preocular tear film more efficiently. In keratoconjunctivitis sicca, the damage to the surface cells is caused by the tear film becoming too hypertonic between blinks. 2 After punctal occlusion, resulting in increased tear volume, one has to assume that tonicity is kept closer to normal, since the results in terms of comfort and objective signs are usually good. Punctal occlusion is usually an irreversible procedure; therefore, one has to make sure that tear production is not fluctuating and that symptoms and signs are of adequate severity. The following criteria should be fulfilled: (1) considerable discomfort, (2) rose bengal staining, and (3) a repetitive Schirmer test of 2 mm/ 5 min or less. Punctal occlusion is most easily performed by diathermy.l The proced ure used by us is the following: (1) Infiltration of the inner canthal area with about 0.5 ml of an anesthetic agent such as lidocaine with epinephrine, using a 25-gauge needle (Fig 1). (2) A diathermy unit (eg, HyFrecater) with a thin needle (Fig 2) is employed. The setting of the current-intensity dial cannot be described, since it can vary with the length of the needle, type of instrument, and other factors. (3) The needle is introduced about 5 mm into the lower canaliculus (Fig 3). The current is turned on and gradually increased until a slight whitening and shrinkage is observed over the canaliculus. The diathermy is then stopped and the needle withdrawn. (4) Finally, the punctum itself is moderately cauterized (Fig 4). It is important to have reduced the current considerably beforehand,

Fig I.-Inner canthus region i s infiltrated with anesthetic.

Fig 2.- Thin long diathermy needle s uitable fo r procedure.

otherwise the sparks will create too much tissue damage. (5) The same procedure is then repeated for the upper canaliculus (otherwise the technique is not fully effective). The other side may be treated at the same time or at a later occasion. Performed in the way described, punctal occlusion with diathermy

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canaliculus can be surgically excised, a procedure which is 100% effective. However, there is a definite risk of distortion of the lids and resultant interference with the lid-ocular surface congruity. Therefore, this approach is rarely used.

Fig 3.-Needle is introduced into canaliculus as far as possible. Diathermy is th en performed.

Fig 4.- Punctum is gen tly cauterized.

is a simple procedure that is permanent in about three fourths of the cases. Should the canaliculus open again in a few months, the diathermy is simply repeated with a slightly stronger intensity. There is little difficulty in ultimately achieving total sealing of all four puncta. There are other techniques for blocking the passage of tears from the eye to the nose. A piece of each

Several techniques have been developed for plugging the puncta temporarily so that the effect on tear volume and tear flow can be studied before irreversible action with diathermy is resorted to. Plugs of gelatin3 and cyanoacrylate adhesive 4 have been advocated, and presently similar devices of silicone rubber are being evaluated. 5 The silicone rubber seems to be easily inserted into the lower punctum but not the upper. Still, the lower tear meniscus volume seems to increase by eliminating drainage through the lower canaliculus only. However, more experience with these techniques is necessary before their place in the treatment of dry eyes can be finalized. Closure of the lacrimal puncta does not increase lacrimal gland secretion; it can only increase the volume of the tear meniscus by blocking outflow (Fig 5). If no tears at all reach the eye from the tear gland, such as in advanced cases of pemphigoid or Stevens-Johnson syndrome, punctal occlusion is meaningless. Also, if tear production is fluctuating, and the Schirmer tests are not repeatedly 2 mm/ 5 min or lower, the procedure could result in annoying epiphora. However, within the indications described, the results are generally good. Almost uniformly the patient feels amelioration of symptoms, and rose bengal stainability usually diminishes. We usually decide on punctal occlusion before resorting to a trial of soft contact lens therapy, which

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Fig 5.-Tear volume in normal eye, keratoconjunctivitis sicca (KCS), and KCS after punctal occlusion.· Lower portions of bars represent volume of tears lodged in fornices. Middle (empty) portions refer to volume of precorneal tear film. Upper portions represent volume in menisci. After punctal occlusion tear volume increases in menisci, while other portions remain essentially constant.'

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gives variable long-term results. There is no question that punctal occlusion is underutilized as a therapeutic measure in moderate and severe keratoconjunctivitis sicca based on diminished lacrimal gland secretion.

ACKNOWLEDGMENTS This work was supported in part by Public Health Service research grant No. EY-000208, Institutional National Service Award No. EY07018, Core Facilities grant No. P30EY01784 from the National Eye Institute, and in part by the Massachusetts Lions Eye Research Fund , Inc.

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REFERENCES 1. Beetham WP: Filamentary keratitis. Trans Am Ophthalmol Soc 33:413-435, 1935. 2. Gilbard JP, Farris RL, Santamaria J : The osmolarity of tear microvolumes in normal eyes and keratoconjunctivitis sicca. Read before the Association for Research in Vision and Ophthalmology Meeting, Sarasota, Fla, April 1977. 3. Foulds WS: Intra-canalicular gelatin im· plants i n the treatment of kerato-conjunc· tivitis sicca. Br J Ophthalmol 45:625-627, 1961. 4. Scherz W, Doane M, Dohlman CH: Tear volume in normal eyes and keratoconjunctivitis sicca. Albrecht von Graefes Arch Klin Ophthalmol 192:141-150, 1974. 5. Freeman JM: The punctum plug: Evaluation of a new treatment for the dry eye. Trans Am Acad Ophthalmol Otolaryngol

79:0P-B74-0P·B79 , 1975.

Key Words: Keratoconjunctivitis sicca; dry eyes; Sjogren's syndrome; punctal occlusion; diathermy of canaliculus.

6. Patten JT: Punctal occlusion with N· butyl-cyanoacrylate tissue adhesive. Ophthalmic Surg 7:24-26, 1976.