A 50-year-old who wears a specialty multifocal lens design came in for her yearly eye exam not wearing her lenses. Her chief complaint was that her lenses started feeling drier over the last two to three months. And, she reported infrequently wearing the lenses other than for special occasions. She said that even with her glasses, her eyes were feeling dry. Additionally, she believed that her vision wasn’t as clear with her glasses or her lenses as it had been before.

Careful inspection of the ocular surface viewed with a cobalt blue light and a Wratten filter revealed significant micropunctate staining OD and OS (Figure 1A). The tear film breakup time (TBUT) was reduced and measured 2 seconds in both eyes. The lids were healthy, including fluid meibomian gland secretions upon expression with a meibomian gland evaluator. Assessing meibomian gland structure also revealed long, healthy glands. Phenol red thread testing revealed 5mm of wetting during a 15-second period. A matrix metallo­proteinase-9 (MMP-9) test was negative OD and OS.

Figure 1. The patient’s initial presentation (A) and at a two-week follow up (B).

The patient has had chronic sinus issues for which she has been using both oral loratadine and pseudoephedrine nasal decongestant for about three months. Additionally, she has been taking bupropion for the last several years.

What Is the Next Step?

MMP-9 testing is positive if the levels are great than 40ng/mL. Her results were negative, indicating lower levels in the normal range. Meibomian gland function also seemed to be normal, but there were surface findings indicative of low levels of aqueous being produced to support the ocular surface.

With a history of medication use that is known to have ocular drying effects, we discussed options. The symptoms of dryness seemed to coincide with the start of the antihistamine and decongestant. Interestingly, she had no symptoms that were consistent with ocular allergies.

To help the ocular surface remain moist and to support improved vision and lens wear, we discussed the use of punctal plugs along with an artificial tear (as needed) to both retain and add lubrication to the ocular surface. Intracanalicular dissolvable collagen plugs that are 0.4mm x 2.0mm were placed into the canaliculi through the lower puncta OD and OS.

At the two-week follow up (Figure 1B), there was significant improvement in TBUT as well as the corneal staining that was originally noted. At this follow-up visit, we placed a six-month dissolvable intracanalicular plug in the lower puncta in both eyes. She is still doing well with both comfort and vision.

The Verdict

Punctal plugs do not help improve the underlying cause of ocular dryness, but can provide an option for patients in times of environmentally, medication-, or contact lens-induced dry eye in the absence of excessive ocular surface inflammation. If disregarding punctal plugs is the new norm, we don’t want to be normal. CLS