Can You Wear Eye Makeup With Punctal Plugs

For contact lens intolerance, extreme discomfort, consider punctal occlusion

Many practitioners volition say that a patient's dry heart does not need to exist a severe instance to consider punctum plugs every bit a solution. However, a number of factors are taken into consideration when deciding whether or not to perform the procedure. If a patient is suffering from itching, called-for or watering sensations or is experiencing increased contact lens intolerance, it may be time to broach the subject of punctal occlusion.

"Optometrists hear contact lens wearers complain about decreased wearing time a lot. That should send up a blood-red flag," said Albert Morier, OD, an teacher in clinical ophthalmology at Albany Medical College.

Oft, patients who opt for punctal occlusion have also tried lubricating drops with limited or no success. Objective findings, such every bit a slit-lamp examination showing decreased tear meniscus and punctate epithelial keratitis, as well as objective tests, such every bit Schirmer's or a Zone Quick phenol red thread test (Menicon, Clovis, Calif.) for aqueous deficiency, can likewise help in determining that punctal occlusion may be warranted. Just the conclusion whether or not to insert punctum plugs lies in the easily of the patient besides as the practitioner.

Ease the patient's anxiety

The optometrist can certainly recommend what he or she feels to be the right course of action, but, in the end, the patient makes the final decision. To make certain y'all and your patients are on the aforementioned wavelength, talk over the subject and come to a conclusion together, suggested Kathleen Foster Elliott, OD, in private family unit practice. "I give them all of the pros and cons, and so we decide together," she said. "If they feel uncomfortable almost it or are at all opposed to information technology, I permit them know that it's but 1 option."

J. James Thimons, OD, executive manager of TLC The Laser Eye in Connecticut, said to address whatever fears or questions the patient may have nigh the procedure, no thing how unlikely it may seem, and be prepared with alternatives.

"In developing a relationship, the patient needs to feel very comfortable that the recommendation you're making is something that benefits him or her," he said. "Some individuals are profoundly concerned about the implantation of silicone, no matter what the size. Obviously, silicone breast implant concerns take been raised, and they have been addressed in literature over time, simply those initial concerns linger in the public's mind. In those individuals who don't want silicone, we can either continue to apply tears or shut the tear duct with a laser or cautery unit. Then there is an alternative, but that's a rarely used one."

Dr. Morier suggested talking to a patient honestly and describing the procedure thoroughly to boost its acceptance rating with patients. "I did a survey over the Cyberspace, and I received near lx responses from practitioners," he said. "I asked what percent of people balk at the procedure. About 50% said that they got a ten% to 50% acceptance rate, and the other 50% had a 90% or higher up acceptance rate. That tells me that doctors believe in the procedure, simply they're not explaining it carefully. This tells me that the doctors must believe in the procedure and get that message across to the patient."

Sizing the puncta: Find the right fit

Practitioners tin use the system of measuring that the manufacturer includes with the punctum plugs, or some are comfy just judging the correct size past sight. "I by and large gauge by sight now because I've been doing it for 5 years," said Dr. Elliott, "only if in that location is a plug that I'one thousand not sure of or if I desire to employ a unlike blazon, I do take all of the measuring devices at my disposal. If doctors are just starting out, I encourage them to utilise the gauging devices until they become more familiar with how each of them volition react to the eye."

Dr. Thimons said that he takes into consideration not only the credible size of the puncta, simply the age of the patient to gauge how snugly the plug may fit. "I dispense the puncta slightly prior to the process to see how elastic the punctal ring is so I tin can go an thought of how tightly the unit of measurement's going to fit," he said. "In a younger patient, you lot typically finish up with a slightly tighter ring, and then you lot want to utilise a smaller unit that will fit well."

Get-go with a collagen trial

A collagen trial is a good indicator of what size silicone plug to use, advised Dr. Morier. A scrap of trial and mistake is involved, but the dissolvable plugs permit the patient to requite the practitioner a feel for what size would best suit the patient's needs. "You lot can easily put two or iii plugs in a canal, and I often put 2 in," he said. "So you tin can start with a .3, and and then if information technology goes in too easily, get up to a .4. If information technology works well for 2 to 3 days, then apply the punctal gauge arrangement and cull the appropriate size."

Whether or not to anesthetize, lubricate

Deciding to use a topical anesthetic or lubricant ofttimes depends on the personal preference of the dr., as well as the emotional land of the patient about to undergo the procedure. "I seldom employ a topical anesthetic unless the patient is extremely jumpy," said Dr. Morier. "Most (95%) of the time, I don't utilise anything. Some people may use a lubricant to make it go in smoother, just I find that that's not necessary. I like it to be nigh dry in society to screw it in."

Dr. Elliott said that she will often identify a drib of coldhearted in the patient's eyes prior to the procedure for comfort. Dr. Thimons will opt for a topical anesthetic unless he will exist probing the area first, in which case he will use a lavage system. "I've plant that most patients do not need more than a topical driblet to subtract the sensitivity effectually the area," he said. "One technique is to place a pledget soaked in anesthetic on the puncta and accept the patient gently blow his or her nose, which pulls the tears and the textile into the punctal area. For a really sensitive person, you can use something stronger, such as topical lidocaine."

Dr. Thimons added that condolement levels during the procedure differ between age groups equally well. "Younger patients are more sensitive to the placement of the silicone device," he said. "Older patients don't have quite the level of sensitivity; for them, it's more than finding the correct plug size and making sure that it fits well. Condolement is not usually a big problem with them; they're more tolerant."

Inserting the plug

Because the manufacturer usually offers a plug gauging system and self-inserter for use with their plugs, nigh of the doctors agreed that additional tools are not usually necessary. Dr. Morier suggested that when inserting plugs into the upper puncta, inverting the lid then the punctum points out or upward helps make the process easier. "Use a swab, and invert the lid equally if you were checking the tarsal plate for giant papillary conjunctivitis," he said. "Inverting the lid makes it much stiffer."

Dr. Thimons said that no matter what materials or process you may use, making certain that everything is sterile at the time of insertion is of utmost importance. "The infectious risk can be minimized to zero in curt lodge by using a sterile technique, and then you tin can wash your hands thoroughly or wear gloves," he advised. "The instrumentation and plugs are sterile, and it'southward very important that they be kept that way throughout the process. It'south not advisable to have the unit out and identify it on a surface while you lot're doing other things, because it could exist inoculated with local flora. With those minor precautions, information technology'southward a very safety and hands accomplished process."

After-care for punctum plugs

Later on the plugs have been inserted, there are sure points to keep in mind to help the patient adjust to them and ensure that the plugs remain in identify for a long fourth dimension. Dr. Thimons advises patients to slowly subtract their current employ of wetting agents, with the end issue typically a abeyance of the drops altogether. "I don't normally accept them get cold turkey because I don't recall that the plugs have an instantaneous effect," he said. "Information technology takes several days for the tear quality and residuum to accomplish a betoken of equilibrium, so I have them keep the wetting agents. Over a calendar week or so, I'll have them slow those down appreciably and see when they brainstorm to experience symptoms."

The doctor should likewise advise the patient to accept intendance when rubbing his or her eyes, Dr. Elliott said, for fierce rubbing will often force the plug out of the puncta. "I tell them not to briskly rub the corner of their eyes because they could dislodge the plug or damage the eye," she noted. "Especially for female person patients who wear make-up, I instruct them how to properly clean around the area and so every bit not to extricate the plug."

Under normal circumstances, notwithstanding, most plugs will stay where they belong, Dr. Morier said. He said that while, in his feel, they practise autumn out about 25% of the time — unremarkably occurring within the first month of vesture — a patient can expect the plugs to terminal months or even years. "Usually, when people ask how long the plugs volition last, I'll tell them that when someone digs up their graves 200 years from at present to put in a parking lot for a mall, they'll open up the casket and all that'southward going to exist left are two piffling plugs. They get the point," he explained.

Addressing punctal irritation

Oft, when a patient complains of irritation the first days post-obit the process, an ill-fitting punctum plug is the culprit. After checking the lid apposition and examining the area surrounding the conjunctiva for irritation past using a fluorescein stain or rose bengal, Dr. Thimons said to and then investigate the plug itself. "The next issue is to look at the actual plug and see if it's as well tight or also large," he said, "because patients volition often confuse irritation from the plug with an eye irritation. If, in fact, information technology is due to an oversized plug, I'll have it out, expect a couple of weeks and insert a smaller one."

Dr. Elliott said that she informs her patients that they may experience some irritation initially, but the sensation should go away in a relatively short flow of time. Dr. Morier explains to his patients the deviation betwixt a normal reaction to having plugs inserted and an aberrant i. "I tell my patients that in that location are three ways that they can feel this plug," he said. "One is not at all. 2 is that they can feel information technology when they think about it, the same manner you might feel a contact lens when information technology's offset in and yous're very aware of it. Merely number 3 is dissimilar: if that corner becomes crimson or irritated that aforementioned twenty-four hour period, we have to remove information technology. It shouldn't distract you if yous're watching tv or hurt you." If it does, Dr. Morier said, he chooses a dissimilar type of plug or a smaller size or refers the patient for punctal cautery.

Removal easier than insertion

If plug removal is necessary, due to either an ill-fitting plug or excessive lacrimation, the simple procedure is often faster and easier than the insertion, Dr. Thimons said. After placing the patient under the slit lamp, a number of instruments, such as jewelers' forceps, can be useful in their removal. "The key to removal is simply to lift the edge of the flap slightly and grasp beneath the edge," he said. "I so identify my finger on the base of the lid correct beneath the punctum itself so that the lid doesn't tug upwards when you pull. I endeavor to requite a trivial twist to it, because if you merely lift vertically, a suctioning effect occurs. If you have a gentle, lateral massage, it's relatively simple to have the plug disengage from the punctal margin."

Dr. Thimons said that if a new plug is needed, he will typically wait a calendar week or ii until the center returns to its normal state. A topical antibiotic or antibody steroid may also be used if there is local inflammation around the margin, he noted.

Long-lasting benefits

Although some patients may need to go along using drops afterwards punctal occlusion has been performed, it is much less ofttimes, and patients should save money in the long run, Dr. Thimons said. "Using a multidose system two or 3 times a day vs. an unpreserved solution six or eight times a day chop-chop offsets the toll of punctal occlusion," he said. "A lot of people think that it'south an expensive technique, simply, in fact, the expense is primarily driven equally a i-time cost vs. chronic costs of using unpreserved solutions, which are splendid, but are non inexpensive over the long run. I recall these plugs are a magnificent alternative to annihilation that we currently accept."

Dr. Elliott is pleased with the vast selection of punctum plugs from which to choose to assistance resolve a trouble that affects a big number of people. "Dry out heart syndrome is probably one of the most underdiagnosed atmospheric condition of the eye, and a lot of patients get from dr. to doctor, trying a different drop each time, without going to the root of the problem, which is lack of tears," she said. "Then, I'yard very excited about the new applied science in the area of punctum plugs, which will requite us more options for our patients."

For Your Data:

Albert Morier, OD, is an instructor in clinical ophthalmology at Albany Medical College, Albany, NY, 12208; (518) 355-0956; fax: (518) 355-1208; electronic mail: amorier1@nycap.rr.com. Dr. Morier has no straight financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

Kathleen Foster Elliott, OD, may exist reached at PO Box 719, Bristow, OK 74010; (918) 367-2020; fax: (918) 367-9542; e-post: IDoctors@aol.com. Dr. Elliott has no straight financial interest in the products mentioned in this article, nor is she a paid consultant for any companies mentioned.

J. James Thimons, OD, is the executive managing director of TLC The Laser Center Connecticut and the medical director of a referral, secondary and tertiary level exercise. He can be reached at Ophthalmic Consultants of Connecticut, 165 Stella Lane, Fairfield, CT 06432; (203) 255-6196; fax: (203) 265-1467. Dr. Thimons has no direct fiscal interest in the products mentioned in this article, nor is he a paid consultant for whatever companies mentioned.