Punctal plugs are another option when Restasis isn't the appropriate direction due to the above complications.  Punctal plugs are small collagen or silicone cylinders, typically less than 1 mm in width and around 3 mm in length, that are inserted into the puncta of the eyelid.  The puncta is the drainage opening of the eyelid, where tears drain down into the nasolacrimal duct.  If we "plug" the puncta, tears are collected onto the eye for a longer period of time.  If your tears are staying on the eye longer, you will be experiencing much less dryness.

Not everyone is a candidate for punctal plugs.  If you have blepharitis/meibomian gland dysfunction/ocular rosacea symptoms that are greatly flared up, plugs will keep the inflammatory mediators on the surface of your eye which results in more redness and irritation.  We have to treat this inflammation first before plugs would be a good option.

I preferably insert dissolvable collagen plugs into the lower puncta of each eye.  Some doctors may also insert plugs into the upper puncta in cases of severe dryness, but this is much less common.  Dissolvable plugs are placed all the way into the puncta, so they are not visible when you look in the mirror.  They typically last 3 months (and as long as 6 months) before being completely dissolved.  That means that they would need to be replaced on a regular basis to offer continue relief.  The benefits of dissolvable plugs is that there is very little infection or inflammation risk. 

Silicone permanent plugs are also available and offer longer term relief.  They typically sit on top of the puncta so that they could be removed with tweezers if needed.  While these plugs are permanent, if you have an eye infection it is best to remove them and then have a new plug inserted when the infection is cleared. They can also fall out (especially if you are rubbing your eyelids quite a bit), or fall down into the tear duct.  If these plugs fall down inside of your tear duct, they aren't dissolvable so they will always be there.  If they need to be removed, they can be either irrigated or surgically removed.  Because of this risk, I tend to insert dissolvable plugs more frequently.

The Procedure: 

On the day of your punctal plug insertion, expect the procedure to be surprisingly fast and easy!  Almost all of my patients are apprehensive at first, and then are surprised when I am finished that the procedure was already over.  Your doctor may first insert a drop to numb your eye, just to make you more comfortable during the procedure.  In the microscope, they will first use a device called a "dilator" to open your puncta to ease the insertion process.  Then it is time for the plugs to be inserted.   Temporary plugs have to be inserted further into the puncta so they may take a little longer to put in place compared to the permanent plugs that sit on top of the lid margin.  Usually everything is finished in less than 10 minutes.  The first day you may experience mild discomfort around the inner corner of your eyes, but symptoms should be no worse than that.  Marked pain or discharge should not occur.  Just make sure not to rub your eyes too much because the plugs can come dislodged!  After a day or two at most, you shouldn't even be able to feel that something is there!

When Should Plugs Start Working?

This depends on how dry your eyes were prior to plug installation.  You have to give your eye time to heal -- and dry eye can be ongoing for years before some patients seek treatment, so we are trying to reverse years of damage.  On average, I expect patients to be feeling significant improvement if plugs are going to be effective treatment in 1 month, but it could be much faster for milder cases.  I have had patients note improvement as quickly as within a week!

The Tranquileyes moisture goggles.  These sometimes come with a gel bead packet that can be heated and used to treat Meibomian Gland clogging at the same time!

Restasis comes in individual vials.  To save on copays, I always recommend recapping the vials, storing in a nice clean environment with the vial upright if possible, and then using the same vial again for your nighttime dose.

10 year old patient complains of distance blur at school.  When you ask a few more questions, they also state that sometimes when they are reading they have headaches or blurry vision.  Sometimes they even tell you that their distance vision is blurry after they read (though it is rare for a young child to be this perceptive).  

When vision is checked, acuity is typically 20/25 to 20/40 unaided.  Usually worse at distance than near, but they read the 20/20 line really slowly up close.  Their ending prescription is anywhere from +0.50 (low hyperopia or far sightedness) to -0.50 (low myopia or near sightedness), but the 20/20 line is still hard for them to read.  Note: I know ODs out there know what I mean when I say myopia or hyperopia, but I am including the other terms for all other readers to the blog!

Kids and the phoropter: not exactly a match made in heaven.  Best to  not confuse things too much with subjective testing that is difficult to understand (like phorias or fused cross cylinder).

Then you switch to near testing.  Depending on the patient, only certain tests yield good results.  Cover test is normal (most kids don't do well with phorias and vergences!).  You might be able to get a binocular fused cross cylinder on older children if you are lucky. The responses vary. My two best tests are NRA/PRA and near retinoscopy (such as MEM).   Classic NRA/PRA readings are low usually on both plus and minus blur points.  They typically do very poorly with PRA (the minus blur points).  You can of course also do an accommodative facility test (with the +2.00/-2.00 flippers and a timer), but in the real world this test is very time consuming to perform in a routine exam.

Near Retinoscopy: I should do it more that I do -- lots of great information can be gleaned.   But I don't have these cards in every exam room, so I typically rely on NRA/PRA results and then trialing loose lenses at near subjectively.

Then I like to demonstrate with loose lenses to the patient. Get them out of the phoropter as soon as possible!  Let them hold a near card or reading material.  Hold up a +0.75 lens and see their response.  It is usually quite dramatic.  Now sometimes the kid just wants glasses, so hold up a -0.75 or -1.00 and see what happens.  If they are really having accommodative issues, they aren't going to like this at all.  I will often show the patient what happens when they switch from near to distance with the lens to demonstrate that the glasses are only good for up close.

Prescription wise, I typically Rx +0.75 to +1.25 depending on the patient's distance prescription.  The hardest part in all of this, of course, is telling the patient's parents why they need glasses.  I always talk about Vision Therapy as an option too, but in my area, it is very expensive and of course not covered by insurances.  I always explain that the glasses are for reading only (any near activity they are going to perform for longer than 10 minutes).  A near activity I define as anything they are holding closer than arm's length.  That means they are going to have to take the glasses on and off at school, but believe me this goes over much better than telling them they need bifocals.  Here is my general discussion:

I hope this helps.  Telling a parent their child needs glasses is difficult in any situation, but when you tell them they need glasses for near when they have been complaining to mom and dad for months their distance vision is blurry, it is even harder.  Most parents only know myopia (or near sightedness), so any other use of glasses seems strange.  Again, especially when their child is coming home complaining of distance blur!  I always like to tell parents that studies have shown myopia can be related to eyes being over-strained at near, so hopefully the use of these glasses can help with delaying myopia onset.  If the parent is near sighted, they will appreciate any efforts to prevent their child from having a large myopic prescription.  In a future post I will detail a patient's guide to accommodative dysfunction to hopefully make things easier for parents to understand!  

How do you know if you have ocular rosacea or just regular old meibomian gland dysfunction?  I guess the important take home message is that it might not matter.  Treatment is generally the same except for the exacerbating factors (like heat!) that need to avoided in rosacea.  One thing to remember is that if you have been diagnosed with rosacea, you will definitely be more at risk for dry eye, so make sure you tell your eye care provider about this diagnosis and any medications or gels you may be using!  

1) Biotrue       This solution not only rated best for visual quality, causing the least amount of film build-up on the surface of the lens, it also had the best "contact angle" results which means improved wettability and comfort to the wearer!  For patients experiencing dryness with their Synergeyes Duette lenses, this solution should be your best choice.

2) Aquify  Had the second best scores in the study for comfort and clarity.

1) Opti-Free Pure Moist    This new solution has great moisturizers to improve comfort, but some patients are reporting a "film" or haze over their lenses with its use.  10-15 seconds of gentle rubbing of your lens would remove this problem if you are experiencing it.

2) ClearCare    Typically this is my go-to solution for improving dryness and comfort, but there are some drawbacks in its use with the Synergeyes Duette lens.  In some patients, ClearCare (which is a great preservative free option) is causing a white ring of depositing along the soft skirt of the lens.  This ring is apparently the result of a chemical reaction with the calcium levels in some people's tear film.  This finding was only in a very few number of patients, but more prevalent in people with dry eye from poor tear stability.

POOREST PERFORMER
Revitalens   Believe me, I was very surprised when I saw this result because this particular solution was being touted as the best choice for the Duette material.  Apparently it adversely affected the "contact angle" of the lens, resulting in the lowest scores in wettability and comfort.


TAKE HOME POINTS
Any multi-purpose solution is safe to use with these lenses, but for best comfort and vision, your cleaning methods and solution choices can have a big effect!  This is true for all contact lenses, not just the hybrid Synergeyes Duette.  If you are a Duette wearer and have been having dryness issues with your lenses, try switching to Biotrue and see if there isn't an improvement.  These lenses have a 6 month lifespan, so proper cleaning and hydration are essential to your comfort and this lens' optical performance.

For more information about the Synergeyes Duette lens, please visit:
http://eyedolatry.blogspot.com/2011/08/contact-lens-update-synergeyes-duette.html
http://eyedolatry.blogspot.com/2011/11/synergeyes-duette-update.html  (ignore the solution suggestions in this post; the lens is so new I was having to rely on rep suggestions and my own patient experiences until this study was published!!)

then Meibomian Gland Dysfunction (or also called blepharitis!) is likely the culprit.  Let's take a closer look at the anatomy of the lid to understand what is going on.

The meibomian glands are sebaceous (or oily secretion) glands that run vertically through the eyelids.  Their opening is just inner to the eyelashes.  The function of these  glands is to secrete the oily "top coat" of the tears, that helps prevent the tears from evaporating off the eye.  When the oily secretion is clogged inside the gland, the tear film is missing proper components and thus dries up very quickly, causing dry eye symptoms.  If the glands are actually clogged and capped, their yellow dome-like contents may be visible along your lids when you look in the mirror.  

CAUSES: Meiboiman gland dysfunction or blepharitis (inflammation along the eyelids) can be caused by dry skin or crusting along the lashline, poor gland secretion (typical with rosacea), staph bacteria (that normally is on our skin but can sometimes flare up), or hormone changes that affect the make-up of the glands and their secretions.

BLEPHARITIS: Scaly, crusty debris called "collarettes" hook onto the eyelashes, causing irritation, inflammation, a spike in staph bacteria count, and clogged meibomian glands!  You wouldn't be able to see it in the mirror, so make sure when you clean your lids, you massage or gently rub along the lashes to get rid of this debris!