To report the rate of recanalization and the efficacy of punctal occlusion surgery with a high heat-energy–releasing cautery device in patients with severe dry eye disease and recurrent punctal plug extrusion.
Prospective, interventional case series.
Seventy puncta from 44 eyes of 28 dry eye patients underwent punctal occlusion with thermal cautery. All patients had a history of recurrent punctal plug extrusion. A high heat-energy–releasing thermal cautery device (Optemp II V; Alcon Japan) was used for punctal occlusion surgery. Symptom scores, best-corrected visual acuity, fluorescein staining score, rose bengal staining score, tear film break-up time, and Schirmer test values were compared before and 3 months after the surgery. Rate of punctal recanalization also was examined.
Three months after surgical cauterization, symptom score decreased from 3.9 ± 0.23 to 0.56 ± 0.84 ( P < .0001). Logarithm of the minimal angle of resolution best-corrected visual acuity improved from 0.11 ± 0.30 to 0.013 ± 0.22 ( P = .003). Fluorescein staining score, rose bengal staining score, tear film break-up time, and the Schirmer test value also improved significantly after the surgery. Only 1 of 70 puncta recanalized after thermal cauterization (1.4%).
Punctal occlusion with the high heat-energy–releasing cautery device not only was associated with a low recanalization rate, but also with improvements in ocular surface wetness and better visual acuity.
Dry eye is a major health problem causing not only ocular surface damage, but also impaired visual function. Among several types of dry eye, dry eyes associated with Sjögren syndrome, ocular cicatricial pemphigoid (OCP), or chronic Stevens-Johnson syndrome are considered as most severe states associated with aqueous tear deficiency (ATD).
Topical artificial tears, punctal occlusion with punctal plugs, or both have been the mainstay of treatment for aqueous-deficient dry eyes. Although punctal plug occlusion has been reported to be an efficient method, plug extrusion or recurrent loss remain the main problems of this treatment method. Plug extrusion may be accompanied by granuloma or bacterial biofilm formation. Surgical punctal occlusion seems to be the final choice in patients with recurrent plug extrusion or plug-related complications, including granuloma formation. Surgical approaches include thermal cautery, diathermy, laser coagulation, and punctal suturing after using a corneal rust ring burr. Among them, thermal cauterization has been reported to be very efficient in attaining punctal occlusion, with a recanalization rate reported to be 26.1%.
Recently, we reported improvements of tear film stability or tear meniscus height after punctal occlusion with a high heat-energy–releasing cautery device in ATD dry eye. We report herein the rate of recanalization and the efficacy of punctal occlusion surgery using this device in the present study in patients with severe dry eye disease and recurrent punctal plug extrusion.
Subjects and Inclusion Criteria
The present study was conducted at the Dry Eye Subspecialty Clinic of the Department of Ophthalmology, Tsurumi University, Kanagawa, Japan. Twenty-eight consecutive severe dry eye patients (2 males and 26 females; mean age, 68.2 ± 8.8 years) with recurrent punctal plug autoextrusion were included in this study. Japanese dry eye criteria were used for diagnosis of dry eye. Sixteen patients (26 eyes) were diagnosed with Sjögren syndrome using the criteria of Fox and associates, and 6 patients (8 eyes) were diagnosed with OCP. Seventy puncta with a history of recurrent punctal plug autoextrusion from 44 eyes of the 28 patients were included and underwent surgical punctal occlusion using thermal cautery. All patients in this study did not respond to or were not satisfied with conventional dry eye treatments, including artificial tear eye drops and hyaluronic acid eye drops. Cases with intracanalicular punctal plug migration or canaliculitis were excluded from the study. Patients with severe conjunctivochalasis also were excluded.
First, the temperatures from the tip of a conventional cautery device (Optemp; Alcon Japan, Tokyo, Japan) and a new high heat-energy–releasing cautery device (Optemp II V; Alcon Japan) were measured by an infrared thermometer (Horiba, Kyoto, Japan) held 1 cm away from the tip of the device. The Optemp II V cautery heated up to 105 C instantly, whereas the tip of the conventional cautery heated up to 54 C.
Under sterilization and anesthesia (infratrochlear nerve block with 1 ml 2% lidocaine), punctal occlusion with the high heat-energy–releasing cautery device was performed as reported previously. Briefly, the tip of the Optemp II V cautery was inserted into the lacrimal punctum, the vertical portion of lacrimal canaliculus, and the horizontal portion of lacrimal canaliculus. The device then was applied in close contact with the walls of the lacrimal punctum and canaliculus until the surrounding punctal tissue color became white. A mean of 12.2 ± 2.2 seconds was necessary for the tissue color to change to white. A few drops of normal saline were applied around the punctal tissue and the tip of the cautery. The cautery device then was pulled out gently. No suture was placed, and ofloxacin ointment was prescribed 3 times daily. The healing and epithelialization of the surgical lesion was checked with slit-lamp examination using fluorescein staining.
Subjective symptoms, best-corrected visual acuity (BCVA), corneal fluorescein staining score, corneal and conjunctival rose bengal staining scores, tear film break-up time (BUT), and Schirmer test values were measured and compared before and 3 months after the surgery.
Subjective symptoms of ocular dryness were scored using the following scale: 0, none; 1, mild; 2, moderate; 3, moderate to severe; and 4, severe. BCVA was measured with Landolt C charts. The cornea was examined by fluorescein staining in slit-lamp examination. A 2-μl volume of preservative-free solution consisting of 1% fluorescein dye was applied to the conjunctival sac. The intensity of fluorescein staining of the cornea ranged from a minimum of 0 to a maximum of 3 points, allocated to upper, middle, and lower cornea with a maximum total staining score of 9 points. Tear film BUT was measured 3 times, and the measurements were averaged. Then, a 2-μl volume of preservative-free solution consisting of 1% rose bengal dye was applied to the conjunctival sac. The intensity of rose bengal staining in the cornea and conjunctiva was recorded according to the method of van Bijsterveld with the maximum score set at 9 points. Thirty minutes after the vital staining tests, the standard Schirmer test without topical anesthesia was performed. The standardized strips of filter paper were placed in the lateral canthus away from the cornea and left in place for 5 minutes. Readings were reported in millimeters of wetting length for 5 minutes.
Observation of Punctal Recanalization after Surgery
Punctal recanalization was checked with slit-lamp microscopy and presence of fluorescein dye pooling or backflow. The patients also were asked specifically they experienced epiphora after surgery. The mean follow-up period after punctal occlusion surgery was 973.3 ± 392.8 days.
All data are presented as mean ± standard deviation. Ocular examination results, including subjective symptoms and visual acuity test results, were compared and analyzed by Wilcoxon matched-pairs signed-rank test. GraphPad Instat software version 3.0 (GraphPad Software, Inc, San Diego, California, USA) was used for statistical analysis. A P value <.05 was accepted as statistically significant.
After 4 weeks from surgery, all 70 puncta were checked with slit-lamp examination and fluorescein dye staining. Sixty-nine of 70 puncta (98.6%) were epithelialized without recanalization with achievement of punctal anatomic occlusion. A representative case is shown in the Figure . A patient with OCP who had undergone previous recurrent punctal plug autoextrusion and previous recanalization of puncta after surgical punctal occlusion with 10-0 nylon suturing experienced recanalization after application of the current technique with findings of fluorescein dye backflow from the very small punctum (1/70 puncta, 1.4%). After 3 months, the current method was applied again to this patient and punctal anatomic occlusion then was achieved after 4 weeks without any recanalization at the final follow-up of 14 months.
The examination results before and 3 months after the treatment are summarized in the Table . After 3 months from surgical cauterization, subjective symptom score significantly decreased from 3.9 ± 0.25 to 0.56 ± 0.84 ( P < .0001). The logarithm of the minimal angle of resolution BCVA improved from 0.11 ± 0.30 to 0.013 ± 0.22 ( P = .003; from 0.77 to 0.97 in decimal notation). Fluorescein staining score decreased from 4.5 ± 2.8 points to 1.1 ± 1.7 points ( P < .0001). Rose bengal staining score decreased from 4.4 ± 2.7 points to 2.4 ± 1.6 points ( P = .02). Tear film BUT extended from 1.3 ± 1.1 seconds to 4.6 ± 2.4 seconds ( P < .0001). The Schirmer test value increased from 2.6 ± 3.9 mm to 6.0 ± 5.3 mm ( P = .0003). The rate of punctal recanalization was 1.4% (1/70 puncta) one month after surgery as a result of recanalization of the above patient with OCP. The recanalization rate was 0% (0/70 puncta) at the final follow-up in all cases (mean, 973.3 ± 392.8 days; range, 231 to 1535 days). Postoperative epiphora was observed in 1 eye of another patient with OCP.