Keep dry eye patients flowing into your office with this time-honored technique

By Abby Gillogly, OD, Nicole Stout, OD, Nate Lighthizer, OD

Optometry’s dry eye armamentarium has increased significantly in recent years to include condition-specific artificial tears, anti-inflammatories, better lid disease treatments, amniotic membranes and autologous serum. These have all come about in an effort to treat the growing dry eye epidemic.

Collagen temporary plugs are inserted into the puncta using forceps. Technically, this is an intracanicular plug.

With all of these new treatment options available, it’s easy to forget that lacrimal occlusion is a tried-and-true—and often effective—treatment for dry eye. In fact, punctal plugs have been on the market since the 1970s and have become one of the most popular minor procedures in optometry today. One of the many reasons for this is that approximately 25% of tears are lost to evaporation, while the remaining tears drain from the eyes through the minute orifices on the upper and lower eyelids known as the lacrimal puncta.

Maintaining a higher level of moisture on the eye is often achieved through temporary remedies such as artificial tears. But a more permanent method of symptom management can be achieved with the insertion of punctal plugs. The punctal ducts can be occluded with these plugs to help reduce tear drainage and thus retain moisture on the eye, bringing lasting relief to the dry eye sufferer. The growing popularity of this treatment has given way to a large variance of plug sizes, shapes and compositions.

This article examines the process of lacrimal occlusion with both intracanalicular and punctal plugs.

Lacrimal Occlusion

The procedure is a non-pharmacological therapy used to increase the retention of the patient’s own tears. It is primarily used for dry eye syndrome when relief of symptoms is not achieved with first-line treatments, such as ocular lubricants. The inhibition of tear drainage results in increased tear volume and increased contact time of natural tears on the ocular surface. The latter is why lacrimal occlusion may also be used to retain topical medications on the ocular surface.

Here you can see the patient’s punctum prior to occlusion.

Lacrimal occlusion may be temporary, semi-permanent or permanent and can be achieved with the use of intracanalicular plugs, punctal plugs or punctal cautery. Temporary plugs are most commonly intracanalicular and made of collagen. These plugs dissolve and are typically used diagnostically to determine if semi-permanent or permanent lacrimal occlusion should be pursued. Semi-permanent plugs tend to be made of silicone and are considered semi-permanent because they don’t dissolve; however, they can be removed if necessary. Semi-permanent plugs can be punctal or intracanalicular. Permanent lacrimal occlusion is achieved via surgical intervention.

The advantage of intracanalicular plugs is that they may be less irritating to the patient after insertion than punctal plugs; however, it is not easy to confirm their presence after insertion and they can only be removed with lacrimal irrigation. Conversely, punctal plugs remain visible at the surface of the puncta, making it easy to confirm their presence after insertion and making them easy to remove with forceps if needed; however, they can fall out and they may cause minor ocular discomfort.

Patient Selection

Contraindications to lacrimal occlusion include significant inflammation of the ocular surface, inflammation of the eyelids, active infection of the lacrimal system (dacryocystitis), epiphora and silicone allergy (for silicone plugs), or allergy to bovine collagen (for temporary collagen plugs).1,2 It is advisable to ensure there is no abnormal discharge indicative of infection associated with the lacrimal drainage system by applying slight manual pressure to the area.

Punctal occlusion is commonly considered and highly indicated in patients with symptoms of dryness such as ocular irritation/burning sensation, redness and reflex tearing.1,2

Many studies report success improving patient-reported symptoms of dry eye and the procedure is considered both safe and effective when compared to artificial tear use alone.4-6

Young age does not contraindicate the use of punctal plugs. In fact, a study reports that punctal occlusion is safe and effective even for children with symptoms of dry eye—particularly since compliance with other treatment options such as ocular lubricants is difficult in this age group.7

Other indications for punctal occlusion include treatment of assorted ocular surface conditions such as pterygium, pingueculitis, blepharitis, keratitis, corneal ulcers, conjunctivitis, recurrent corneal erosions and other external ocular diseases.1,2 The wound-healing aspect of punctal occlusion is associated with decreased frictional forces against the ocular surface.3

In cases of active ocular inflammation, consider the clinical picture. For example, the increased tear volume attainable through punctal occlusion may not be an acceptable treatment option in many cases of allergic conjunctivitis, as stasis of the offending allergen in the tears may increase a patient’s symptoms.

Procedural Steps

Use of a topical anesthetic agent prior to punctal plug insertion is not necessary, though it can be used if desired. Two suggested methods are to either instill a drop into the conjunctival sac or to hold a cotton-tipped applicator soaked in anesthetic against the punctum for approximately 30 seconds.2

Once the plug is inserted into the punctum, tap it down using the forceps. It should only take a little pressure for it to fit into place.


The following steps are common to the insertion of both intracanalicular and punctal plugs (steps are listed assuming the inferior punctum has been chosen to occlude first):

  1. Instruct the patient to look up and temporally (away from the inferior punctum).
  2. Pull the lower lid down to expose the punctum.
  3. Determine the appropriate size plug needed, either by using a punctal gauge or by careful examination, the former being preferred. The punctal gauge can determine the appropriate size (diameter) of plug. If the gauge is too small, there will be no resistance when inserting it; however, if the gauge is too large there will be a significant amount of resistance upon insertion.
  4. Dilate the punctum with a punctal dilator if needed.1-2

Following punctal dilation, the following steps are involved in inserting intracanalicular plugs:

  1. Using forceps, insert the plug partially into the punctum vertically, then pull laterally, straightening the lacrimal canal, and insert the plug the rest of the way, tilting it towards the nose.
  2. Often, the plug can be released from the forceps once it is partially inserted. The tip of the forceps can then be used to push the plug the rest of the way into the punctal opening and into the canaliculus.
  3. After insertion, ask the patient to blink a few times to ensure that the plug is in the correct position.
  4. Repeat the procedure on the superior punctum if desired. The patient should be instructed to look down and temporally for ease of access to the superior punctum and so the patient is always looking away from where the plug is going to be inserted. To expose the superior punctum, pull the upper lid up.1

If inserting punctal plugs following punctal dilation:

  1. Using the applicator that comes with the punctal plug, insert the plug into the punctum until the top of the plug is flush with the lid margin.
  2. After insertion, ask the patient to blink a few times to ensure that the plug is in the correct position.
  3. Repeat the procedure on superior punctum if desired.

a) The patient should be instructed to look down and temporally.
b) To expose the superior punctum, pull the upper lid up.2

If the plugs fall out, you may consider permanently occluding the puncta. Using an Ellman unit we performed a little punctal cautery to occlude the puncta. This isn’t an option in all states, but it is a procedure that takes only a matter of seconds.

Plugging In

Both collagen and silicone plugs come in a range of diameters. A common error with plug insertion is failing to use adequately sized plugs or over-dilating the punctum resulting in plug extrusion, or both. A small amount of ocular lubricant can be used on the intracanalicular or punctum plug to aid in insertion through the punctal opening.

Possible complications of lacrimal occlusion include discomfort and irritation at the site of the plug, epiphora, infection, plug migration into the lacrimal drainage system, spontaneous plug extrusion, punctal stenosis, canalicular stenosis, canaliculitis, dacryocystitis and pyogenic granuloma formation.3

The risk of these complications is minimal, but you’ll still want to inform patients of them and advise them to return to the clinic immediately if they experience any symptoms of pain, redness or swelling.

Following plug insertion, follow up in a week or two to reassess the patient’s symptoms and evaluate for side effects. Following punctal occlusion, a patient may continue using ocular lubricants and other medications.

As previously mentioned, lacrimal occlusion may increase the contact time of topical medications on the ocular surface; this may be beneficial in some cases, but you may also consider reducing the dosage of such medications when appropriate.

In the event that collagen plug removal is necessary before the plug dissolves, the intracanalicular plug can be removed by lacrimal saline irrigation—pushing the collagen plug through to the nose or throat.1 A punctal plug can be removed by grasping it with forceps below the exposed plug head and pulling it out of the punctum.

Here you can see the patient’s punctum after occlusion with permanent silicone plugs.

The most common reasons to remove a plug include local discomfort and epiphora. If the lacrimal occlusion improved overall dry eye without epiphora but was irritating to the patient or spontaneously dislodged, consider punctal occlusion by cautery as an alternative (and permanent) solution. If epiphora is experienced by the patient, a plug that only partially reduces tear drainage may be considered.2

Lacrimal Occlusion in the Literature

Research published in Cornea demonstrates the effectiveness of lacrimal occlusion in a prospective double-masked study, the results of which demonstrated a 94.2% reduction in dry eye symptoms (dryness, watery eyes, itching, burning, sandy/foreign body sensation, fluctuating vision, light sensitivity) and a 93.0% reduction in conjunctival sign/symptoms (redness, discharge) at the eight-week follow-up after progressive occlusion with collagen and silicone plugs.

In contrast, the dry eye and conjunctival symptoms for the control group remained unchanged throughout the eight-week follow-up period. This study also found that eight weeks after progressive lacrimal occlusion, 76.7% of patients were relatively symptom free and 100% of patients were no longer dependent on the daily use of moisturizing agents.8

A 2016 study looked at symptomatic change and fluorescein staining, as well as tear cytokine levels in 29 dry eye patients prospectively. They found significant symptomatic improvement in patient-reported dryness and a decrease in staining on the ocular surface, except inferiorly. They found no decrease in the composition percentage of pro-inflammatory cytokines or MMP-9 by punctal occlusion. Due to the inflammatory nature of ocular surface disease, consider initiating anti-inflammatory therapy at the time of punctal occlusion, as opposed to delaying this treatment.4

In a retrospective literature review, the overall success rate of silicone punctal plug treatment was 76.8% at four weeks and the mean retention time for a silicone punctal plug was 85.1 weeks.9

An observational punctal plug retention and complication study shows an 84.2% three-month retention of silicone plugs, decreasing to 55.8% at two years. It also shows that canalicular stenosis was the most common complication following spontaneous plug extrusion (34.2% at two years); however, patients were asymptomatic to the clinical finding. It is presumed that mechanical stress and accumulation of debris are to blame for the stenosis. Granulomatous proliferation occurred in 3.2% of cases; their review reports that this formation is most likely to occur two to three months after plug insertion. The cause is not completely known, though mechanical injury has been suggested. Two patients in this study experienced plug intrusion as a result of the granuloma, removed under local anesthesia.10

With all this evidence, it is important to keep this simple procedure near the top of your list when treating dry eye patients. Don’t be afraid to reach for the plugs, either canilicular or punctal. Your patients will thank you and tell their friends how you plugged their drain, improved their dry eye, and the dry eye patients will start flowing in.

Dr. Stout is currently completing a family practice residency with an emphasis in ocular disease at Northeastern State University Oklahoma College of Optometry.  

Dr. Gillogly is currently completing a cornea and contact lens residency at Northeastern State University Oklahoma College of Optometry.

Dr. Lighthizer is the assistant dean for clinical care services, director of continuing education, and chief of both the specialty care clinic and the electrodiagnostics clinic at NSU Oklahoma College of Optometry. 

This article originally appeared in the Review of Optometry

  1. Oasis Soft Plug Intranalicular Plug package insert.
  2. Oasis Soft Plug Punctum Plug package insert.
  3. Bourkiza R, Lee V. A review of the complications of punctal occlusion with punctal and canalicular plugs. Orbit. 2012;31(2):86-93.
  4. Tong L, Beuerman R, Simonyi S, et al. Effects of punctal occlusion on clinical signs and symptoms and on tear cytokine levels in patients with dry eye. The Ocular Surface. 2016 Apr;14(2):233-41.
  5. Farrell J, Patel S, Grierson DG, et al. A clinical procedure to predict the value of temporary occlusion therapy in keratoconjunctivitis sicca. Ophthalmic Physiol Opt. 2003;23:1-8.
  6. Hirai K, Takano Y, Uchio E, et al. Clinical evaluation of the therapeutic effects of atelocollagen absorbable punctal plugs. Clin Ophthalmol. 2012;6:133-8.
  7. Mataftsi A, Subbu R, Jones S, Nischal K. The use of punctal plugs in children. Br J Ophthalmol. 2012;96:90-2.
  8. Nava-Castaneda A, Tovilla-Canales J, Rodriquez L, et al. Effects of lacrimal occlusion with collagen and silicone plugs on patients with conjunctivitis associated with dry eye. Cornea. 2003;22(1):10-4.
  9. Tai M, Cosar C, Cohen E, et al. The clinical efficacy of silicone punctal plug therapy. Cornea. 2002;21(2):135-9.
  10. Horwath-Winter J, Thaci A, Gruber A, et al. Long-term retention rates and complications of silicone punctal plugs in dry eye. Am J Ophthalmol. 2007;144(3):441-4.

Halleran ARVO 2015 Poster 3

Download the full-size poster

0216_coverA new frontier is emerging for dry eye disease (DED) care with several point-of-care tests now available for use in our offices. Point-of-care testing has the ability to improve our decision making during examinations and allows us to provide a personalized approach to patient care. This article examines important considerations for implementing point-of-care testing in your practice and offers a summary of what testing is available and what is on the horizon…

Read full article by Dr. Leslie O’Dell at eyetubeOD

Manual Expression AAO 2015The International Workshop on Meibomian Gland Dysfunction defines MGD as “a chronic, diffuse abnormality of the meibomian glands, commonly characterized by terminal duct obstruction and/or qualitative and quantitative changes in the glandular secretion. It may result in alteration of the tear film, eye irritation, clinically apparent inflammation, and ocular surface disease.”

In this presentation, Dr. Leslie O’Dell and Dr. Milton M. Hom explore the following questions:

  • Does in-office manual expression improve symptoms for patients with MGD?
  • Does in-office manual expression improve MG function for patients with MGD?

Download the full presentation

Our patients are suffering from reduced comfort, but they don’t have to. Teach them how small lifestyle changes can produce big results.

By Leslie O’Dell, OD

Using the Korb-Blackie light test, the examiner places the transilluminator at the lid crease and then evaluates the lash margin, looking for light to spill out, indicating inadequate lid closure. Photo: Caroline Blackie, OD.

Maintaining a patient’s contact lens comfort and lens wear success often comes down to one invaluable element: patient education. Imparting the knowledge a patient needs to ensure proper contact lens replacement and care is integral to maintaining comfort. However, it’s not always easy to cover all the contingencies in the initial patient encounter, and practitioners must be careful not to take anything for granted. For instance, a contact lens patient recently presented to my office with an emergency exam for bilateral chemical burns from using a store-bought eyeglass cleaner to store her contacts overnight.

Patients, especially those new to contact lenses, require repeated step-by-step instructions to retain the basics of contact lens care and develop an understanding of how real-world factors such as routine care, allergies, injuries and even their occupations can impact contact lens comfort.

Discomfort should not be an acceptable reason for contact lens dropout—it is an eminently correctable problem when it does occur, and careful attention to patient education, particularly at the initial encounter, can help avoid it in the first place. This article focuses on patient education for contact lens wearers, and how doctors and patients alike can maintain an awareness of potential causes for discomfort before complaints arise.

Pre-fitting Evaluation

Ocular surface symptoms, namely dryness and discomfort, are the leading causes of contact lens drop out for both soft and rigid lenses.1 Contact lens patients are 50% more likely to experience these symptoms than those who do not wear contacts.2 You may be able to prevent this discomfort before it starts by first evaluating the ocular surface health of all your patients before fitting them with contact lenses.

Investigators estimate that 10% of patients will discontinue contact lens wear.3,4Developing a protocol for evaluating all contact lens patients, new and long-time wearers alike, is the first step to reducing these rates. This protocol should include:

  • A dry eye questionnaire, such as the SPEED or OSDI—both validated questionnaires. These can help identify patients with ocular discomfort before initiating contact lens wear.
  • Obtaining a comprehensive history, including daily wear time, digital device use, cleaning habits, lens replacement schedule and hobbies—even occupation and social history. These are important factors to consider for long-term lens comfort.
  • A clinical evaluation, including vital dye staining to test for lid wiper epitheliopathy (LWE) as well as corneal/conjunctival staining indicative of dry eye disease.
  • An osmolaritiy test.
  • Testing for matrix metalloproteinase 9.
  • Lid and meibomian gland evaluation.
  • Lash evaluation.

Patients often apply make-up directly to the meibomian gland orifices. However, even when applied properly, make-up debris can migrate to the lid, conjunctiva and even deposit on contact lenses, ultimately leading to discomfort.

These tests are designed to help identify common causes for dry eye, non-obvious meibomian gland dysfunction (MGD), Demodex infestation, blepharitis, lid wiper epilethiopathy (LWE) and lid-parallel conjunctival folds, as well as aqueous deficient dry eye.

To institute this protocol start by educating your staff about risks associated with contact lenses and the need to treat any pre-existing ocular conditions before dispensing the lenses.

Also, be sure to update the protocol, as investigators learn more regarding knowledge of the underlying causes of contact lens discomfort.

Likely Discomfort Causes

Research shows contact lens patients have a higher incidence of dryness and end-of-day irritation than non-contact-lens-wearing patients.5 These complaints may or may not be part of a prior dry eye condition. For patients who did not experience any pre-existing symptoms or display any signs of dry eye prior to fitting, we must search for other causes. In some cases, contact lens materials or cleaning solutions may play a role.

To determine the cause of this discomfort, develop a treatment plan and decrease our rate of contact lens discontinuation, doctors must put on their sleuthing hats. Start by listening to patients’ complaints, with an acute awareness of dry eye triggers.

Therapeutic Factors

The history for a contact lens patient should include a comprehensive list of medications. Many medications can cause ocular surface dryness. The prime culprits include antihistamines, blood pressure medications, oral contraceptives, antidepressants and cholesterol-lowering medications.7-9

Non-prescribing physicians should not discontinue medications; however, alternative choices are often available with a lower risk of ocular side effects from dryness. Keeping the line of communication open between the primary care providers, OB-GYN, allergists and immunologists, rheumatologists and cardiologists can create a more comprehensive treatment approach.


In addition to a dry eye questionnaire, it is also helpful to add a few key questions before your exam. Questions may include: ‘How do your eyes feel upon awakening?’ or ‘Do you have fluctuations in your vision throughout the day, with reading for any length of time or when using a computer?’ A patient with complaints upon waking in the morning should be evaluated for inadequate lid seal, corneal conditions such as recurrent corneal erosions and even Demodex blepharitis. Fluctuations in vision throughout the day is a common symptoms for underlying ocular surface dryness.

Asking patients about their hobbies can clue you in to the potential for environmental hazards that can lead to CL discontinuation. Take a soccer mom for example: exposure to wind and dust while watching kids’ sporting events can dry out lenses and lead to foreign body sensation. Many of our patients are active in exercise, biking, running and swimming. Exposure to sand, sweat, water and suntan lotion can also complicate contact lens routines. Riding in a car with either the heat or air conditioning on, or even with the windows down, can also cause discomfort due to evaporative stress to the ocular surface and tear film.

We are also a nation obsessed with appearance and youthful skin. Ask patients what, if any, skin creams they are applying around the eye. Retinol has been found to damage meibomian glands leading to dry eye symptoms.10 This is present in many OTC and high-end face and eye creams. Eye make-up is another area of concern. Mascara, eyeliners and eye shadows are commonly applied to the lid and sometimes even to the meibomian gland orifices. These contain pigments and talcs that can block the glands and irritate the ocular surface, not to mention deposit on the contact lenses themselves.

Eyelash growth products like Latisse, eyelash extensions and false eyelashes give the appearance of extended lashes. However, these products also can lead to ocular surface discomfort and possibly contact lens discontinuation.

Occupational Hazards

One issue to consider when evaluating patients with contact lens discomfort is the patient’s job. Some occupations, like those that predispose one to reduced or incomplete blinking, are notorious for the negative impact they can have on contact lens comfort. Spending hours using a computer increases the risk for end-of-day dryness. And one group of professionals you might overlook are staring at you each morning in the mirror and the office—health care workers.

Cylindrical debris around lashes, as seen here, is a hallmark of Demodex blepharitis.

Doctors in most any setting, ranging from routine care to surgical, are a group at risk for MGD. The more concentrated someone is on a task, the less likely they are to blink, resulting in evaporative stress to the ocular surface.11 Advise patients to take breaks from screen time and follow the “20/20 rule”; that is, for every 20 minutes of computer use, take a 20-second break. Also, start introducing the idea of blink exercises for patients who spend a lot of time in front of computers and have impartial blinks. Instruct the patient to take 10 consecutive, thoughtful blinks, holding each for two seconds.

Air quality also has an impact on comfort. Pilots and flight attendants work in low humidity environments. Construction workers and military personnel are often exposed to large amounts of dust and dirt from their environments.

Another group of patients that might have higher risk of contact lens discontinuation is first responders (e.g., firefighters, EMTs, military personnel and police). These professionals may have to spring into action and feel they cannot be bothered to remove and insert contact lenses. In my practice, I’ve seen these patients sleep in their lenses frequently for the convenience of being able to see immediately when they awake.


Recurring discomfort problems for contact lens wearers can stem from allergies and increased pollen counts.

In my experience, patients blame much of their contact lens discomfort on allergies. But, a proper diagnosis requires more than a patient’s intuition.

Ruling allergies in or out can be a tremendous help in patient education and also determining a proper course of treatment. Fortunately, we now have in-office allergy tests (e.g., DoctoRx, new IgE tear analyses, TearScan) that can play a role.

Systemic Disease

Ask contact lens patients, “Do you struggle with dry mouth?” If a patient suffers from both dry eye and dry mouth symptoms, you may consider advising them to explore the potential influence of underlying autoimmune diseases, such as Sjögren’s syndrome or rheumatoid arthritis, as a possible cause for this combination of symptoms.


Once the root cause of contact lens discomfort is identified, the next step is to develop a treatment plan that will help keep the patient satisfied with the prescribed lenses.

Maintaining Comfort

Treat the underlying condition(s) whenever possible. If aqueous deficient dry eye is present, Restasis is often a great option to maintain comfort in a lens. Remember that clinical improvement may be delayed (taking up to six months in some patients) and initial burning is an acceptable side of effect of treatment. Restasis should be used 10 minutes prior to lens insertion and again after the lens is removed at the end of the day. When MGD is present, treat it aggressively. Controlling any underlying dry eye will help improve comfort.

Ask patients how they are washing their hands with before lens insertion. Patients who describe a strong urge to remove lenses at the end of the day and who gain little relief from rewetting drops should be counseled on the type of solution they are using as well as the type of soap to use when handling lenses. Glycerin soaps can be used to help prevent chemical build-up on the lens during instillation. Removing the lenses mid-day to soak and rehydrate in their case, as well as using artificial tears compatible with contact lenses, are also good management methods.Lens material, cleaning solutions and replacement schedules are modifiable and easy ways to improve patient comfort. Increasing replacement frequency improves the comfort of the lens. There are many daily lens options available with a wide variety of parameters to assure good comfort and good vision for patients. Preservative-free peroxide-based cleaning systems also improve comfort of the lens when dailies are not an option. This simple change to a daily routine can increase wear time and comfort with little effort on either the patient or doctor’s part.

Talk to your patients about their make-up use and removal habits. I recommend avoidance of any waterproof mascara or liners, as they often contain pigments that make them more difficult to remove. Replacing eye make-up on the recommended three-month cycle will also help decrease the risk for bacterial overgrowth. Coconut oil can be used to remove make-up without the exposure to harsh chemicals.

Listening Can Build a Practice

Take the extra time with your patients to discuss the exam findings and the importance of compliance to your treatment plan. Educate all new contact lens patients—and, in the case of juveniles, their parents—about lens discomfort. Let them know that once discomfort begins, it’s time to call the office. The earlier we intervene, the better the end result. Educate patients about end-of-day dryness and recommend ways to keep ahead of this to retain contact lens wear late in the day.

Take the time to listen and work with patients to solve their discomfort issues. Not only will it aid you in creating customized solutions that will make a huge difference in their day-to-day life, it will help you develop a strong bond with your patient and give them a reason to refer their friends.

Ensuring comfortable contact lens wear has no “one-size-fits-all” approach. We must offer curated care that takes into consideration how individual patients behave in the real world. Collecting a variety of information during your encounter with the patient, from critical testing to anecdotal interactions, will help you develop a tailored education and treatment plan that will allow patients to remain comfortable long-term in their lenses.

Dr. O’Dell is an optometrist at the May Eye Care Center & Associates in Pennsylvania, and a member of the Pennsylvania Optometric Association and the American Optometric Association.

This article originally appeared in the Review of Optometry

  1. Richdale K, Sinnott LT, Skadahl E, Nichols JJ. Frequency of and factors associated with contact lens dissatisfaction and discontinuation. Cornea 2007;26:168-74.
  2. Chalmers RL, Begley CG. Dryness symptoms among an unselected clinical population with and without contact lens wear.  Cont Lens Anterior Eye 2006;29:25-30.
  3. Dumbleton K, Woods CA, Jones LW, Fonn D. The impact of contemporary contact lenses on contact lens discontinuation. Eye Contact Lens. 2013 Jan;39:93-99.
  4. Pritchard N, Fonn D, Brazeau D. Discontinuation of contact lens wear: a survey. Int Contact Lens Clin. 1999 Nov;26(6):157-62.
  5. Begley CG, Chalmers RL, Mitchell GL, et al. Characterization of ocular surface symptoms from optometric practices in North America. Cornea. 2001 Aug;20:610-8.
  6. Young G, Chalmers R, Napier L, et al. Soft contact lens-related dryness with and without clinical signs. Optom Vis Sci. 2012 Aug;89:1125-32.
  7. Bartlett JD. Ophthalmic toxicity by systemic drugs. In: GCY Chiou, ed. Ophthalmic Toxicology. 2nd ed. Michigan: Taylor and Francis, 1999:225-83.
  8. Jaanus SD. Ocular side effects of selected systemic drugs. Optom Clin. 1992;2(4):73-96.
  9. Jaanus SD, Bartlett JD, Hiett, JA. Ocular effects of systemic drugs. In: Bartlett JD & Jaanus SD (eds.). Clinical Ocular Pharmacology, 3rd ed. Boston: Butterworth-Heinemann, 1995:957- 1006.
  10. Ding J, Kam W, Dieckow J, Sullivan D. The Influence of 13-cis Retinoic Acid on Human Meibomian Gland Epitheilial Cells. Invest Ophthalmol Vis Sci. 2013 Jun;54:4341–50.
  11. Portello JK, Rosenfield M, Chu CA. Blink rate, incomplete blinks and computer vision syndrome. Optom Vis Sci. 2013 May;90(5):482-7.

Such a protocol betters documentation, clinical tracking, and foundation for treatment

Leslie E O’Dell, OD, FAAO

Focusing on dry eye management is a great practice builder, but is not without challenges. These challenges lie in making the proper diagnosis, implementing new technology, properly training staff, developing an effective treatment plan and the time it takes to properly educate patients.

When facing any challenge, establishing and following a set protocol helps. The Tear Film and Ocular Surface Society (TFOS) Workshop on meibomian gland dysfunction (MGD) helped to organize the evaluation of a patient when MGD is suspected, listing the appropriate tests needed for proper diagnosis.1 (Table 1) Let’s go through each one and create a step-by-step approach to a vast and complicated disease, MGD. For all testing, be sure to develop a standard of care that is universal for every patient encounter to track improvement during subsequent exams.

Understanding the definition of MGD is the foundation. Through the work of TFOS, MGD was formally defined as a “chronic, diffuse abnormality of the meibomian gland, commonly characterized by terminal duct obstruction and/or qualitative/quantitative changes in the glandular secretion. It may result in alteration of the tear film, symptoms of eye irritation, clinically apparent inflammation, and ocular surface disease.”1

Step 1: History

Questionnaires can expedite your history intake. These can be validated surveys, such as the Ocular Surface Disease Index (OSDI) and Standard Patient Evaluation of Eye Dryness (SPEED) questionnaires, as well as customized questionnaires. Here are a few important questions to ask for all patients—symptomatic or not.

  • How do your eyes feel in the morning when you are waking? For some patients, morning complaints clue us into other potential problems with demodex blepharitis, nocturnal lagophthalmos, and recurrent corneal erosion high on the list of differentials.
  • How long can you read or use a computer before your vision blurs or you become aware of your eyes?

Because a lot of patients coming in for an exam are already using an over-the-counter drop or have tried one, also ask if the drop she is currently using provides some relief to her symptoms.

For a contact lens patient, the questions can seem endless:

  • What brand of lens is he wearing?
  • What’s the replacement schedule for the lenses?
  • How compliant is he to replacement and cleaning?
  • What does he use for disinfecting his lenses?
  • How often does he sleep in lenses?
  • Is he aware of the lens during the day?
  • Is his vision stable even with blinking?

When reviewing medications and other systemic conditions that contribute to MGD, ask if the patient is also experiencing dry mouth symptoms. For many dry eye sufferers, taking the time to talk about their symptoms is like opening Pandora’s box. Once you have a chance to take back over control of the conversation, you can start your examination.

Step 2: Take a step back

Before a slit lamp evaluation, take a step back from the patient to evaluate her external appearance. Look for signs of rosacea, abnormalities to the lid-globe congruity, blink rate, and overall appearance of the eye.

Next, pick up your transilluminator and evaluate the patient for inadequate lid seal. Ask the patient to close her eyes as if she were resting—no forced closure—and rest the transilluminator on the top eyelid (Figure 1). Evaluate the lid for inadequate lid seal centrally, nasally, and temporally. Then start your slit lamp evaluation.

Step 3: The bread and butter of MGD: slit lamp examination

Through research studies, I have developed superior techniques for using vital dyes to best determine corneal and conjunctival staining as well as lid wiper epitheliopathy.

A formal dry eye strip can be used to measure tear break-up time (TBUT) and is applied to the superior conjunctiva with the patient looking down. This applies a very thin amount of fluorescein. Average TBUT for three blink cycles per eye and record. If you don’t have time for this or access to dry eye strips, use a fluorescein strip applied superiorly and record it in a way that is the same for every patient encounter; simply stating “decreased TBUT” or “instant TBUT.”

The next step is to instill fluorescein dye using a strip. This is best applied inferiorally and temporally while the patient is looking up. It’s important to wait 60 to 90 seconds after instillation before evaluating the cornea for staining. During that time, bring the patient to the slit lamp and start evaluating his lid and lash margin for blepharitis or demodex. Instruct the patient to open his eyes and observe the bottom lid margin looking for obvious changes to the meibomian glands. You are looking for cicatricial changes of the glands, telangetatic vessels, meibomian gland cyst and/or a frothy tear film.

Next, observe the conjunctival tissue adjacent to the cornea both nasally and temporally looking for conjunctivochalsis, a bagginess to the episclera that can interfere with tear distribution as well as a continuous feeling of “my eyes are tearing” (Figure 2). Also, take this time to evaluate the tear meniscus height when enhanced with fluorescein dye. Once the wait time is up, the cornea can be evaluated for keratitis.

Using a standardized grading system will help when you follow the patient. I recommend looking at the cornea broken into five segments: central, superior, temporal, inferior, and nasal. Then grade superficial punctate keratitis (SPK) in each segment using a grading scale of Grade 0 to 3 where zero is no staining.2 (Figure 3). The location of keratitis helps to guide the diagnosis as well as best treatment plan.

Now add lissamine green stain using the same method as fluorescein, adding dye inferiorly and waiting 60 to 90 seconds before evaluating the conjunctiva for staining. During this time, start to evaluate meibomian gland secretions. This is best done using the Korb Meibomian Gland Evaluator developed by Dr. Donald Korb (TearScience). This gland evaluator provides a standardized pressure comparable to the pressure exerted with blinking to determine how many glands are secreting.3 With the patient looking upward, gently push on the bottom lid and section the glands in groups of five, grading the expressibility of the glands first on a scale of 0 for no secretion to 3 for easy secretion and thin healthy oil. When the time has lapsed for the lissamine dye, evaluate the conjunctival tissue looking for staining again on a scale of Grade 0-3 in the nasal and temporally quadrants. Again, using a standardized scale allows for easy documentation as well as uniformity in your charts to know when patients are getting better from your treatment or worse.

Step 4: MGD must-haves

There are a few essentials to an MGD evaluation that if you aren’t doing presently, you should add to your exam today. All are easy and don’t cost you a dime to add.

First, transillumination of the MG using a penlight at the slit lamp. This is a quick and easy method to evaluate for MG atrophy. Again, a grading scale should be used; a preferred grading scale was developed by Dr. Heiko Pult and is a great education tool for the patient as well4 (Figure 4).

A tool to express the glands in another must-have in a MGD evaluation. Being able to express the glands allows for grading of inspissation and obstruction. There are a few commercially available, some with flat metal plates, some with barrels that roll over the glands to aid in expression.

The evaluation of a dry eye patient now has diagnostic testing available to enhance our clinical skills and improve our ability to diagnose a patient. These include tear osmolarity (TearLab), InflammaDry (RPS), meibography (Oculus), interferometry (TearScience) and external photography and videos. These tests enhance patient education—seeing is believing for our patients. Think of our glaucoma patients. If we practiced in the days prior to optic nerve analysis, we could still diagnose a patient with glaucoma based on observations to their nerve fiber layer. The new diagnostics available with OCT and HRT improve our ability for early detection, but an optic nerve evaluation is still needed to correlate all the tests. The same is true with advancement in diagnostics for dry eye. A strong dry eye clinician can use these data points to develop a patient-centered treatment plan.

Step 5: Diagnosis

The next challenge is changing the way we document this disease. Consistent nomenclature is imperative, and we as a profession need to use the recommendations laid out by the MGD workshop.5Meibomian gland dysfunction can be classified as either low delivery (hyopsecretory/obstructive) or high delivery (hypersecretory) (Figure 5).

Making the right first diagnosis based on a complete history and examination with the proper testing using technology available within your practice sets the foundation for treatment.

This article originally appeared in Optometry Times

  1. Nichols KK, Foulks GN, Bron AJ, et al. The international workshop on meibomian gland dysfunction: executive summary. Invest Ophthalmol Vis Sci. 2011 Mar 30;52(4):1922-9.
  2. Barr JT, Schechtman KB, Fink BA, et al. Corneal scarring in the Collaborative Longitudinal Evaluation of Keratoconus (CLEK) Study: baseline prevalence and repeatability of detection. Cornea. 1999 Jan;18(1): 34-46.
  3. Korb DR, Blackie CA. Cornea. Meibomian gland diagnostic expressibility: correlation with dry eye symptoms and gland location. Cornea. 2008 Dec; 27(10): 1142-7.
  4. Pult H, Riede-Pult BH, Comparison of subjective grading and objective assessment in meibography. 
Cont Lens Anterior Eye. 2013 Feb;36(1):22-7.
  5. Nelson JD, Shimazaki J Benitez-del-Castillo JM, et al. The international workshop on meibomian gland dysfunction: report of the definition and classification subcommittee. Invest Ophthalmol Vis Sci. 2011 Mar 30;52(4):1930-7.

0815_coverLonger, fuller, thicker eyelashes are a highly sought-after beauty attribute and a big money maker for the cosmetics industry. A recent survey by the finance website found that women spend an average of $15,000 on makeup in their lifetime, with $3,770 going to mascara alone.

The eyelashes are part of ocular adnexa, and as eye care providers, we should be talking to our patients about their make-up habits. Mascara, like most cosmetic products, is not regulated by the US Food and Drug Administration. It can contain waxes, pigments, resins, and even talc.

When mascara does not do what it is meant to do, many women seek some other means to grow their lashes longer, fuller, and thicker or add to their lashes to extend them. Vaseline (petroleum jelly; Unilever), lavender essential oil, coconut oil, talc powder, eyelash enhancing serums, lash extensions, and fake lashes are a few of the options available.

A side effect of the glaucoma medication bimatoprost (Lumigan; Allergan) led to the FDA approval of this prostaglandin analogue as Latisse (bimatoprost 0.03%) in 2008. Since that time more than 5 million bottles have been sold, with the average price per bottle ranging from $100 to $120…

Read full article by Dr. Leslie O’Dell at eyetubeOD

0815_coverThe problem with the available red eye–reducing eye drops is that they contain a decongestant as the active ingredient for vasoconstriction. Naphazoline, tetrahydrozoline, and phenylephrine have relatively short durations of action and require frequent dosing, 1 to 2 drops up to four times daily.

Soparkar and colleagues reported in 1997 that misuse of these OTC eye drops can lead to chronic conjunctivitis. His study of 137 eyes demonstrated that, over the course of a median 3-year use cycle, OTC decongestant eye drops can produce both acute and chronic conjunctivitis, which can take several weeks to resolve. It is also well-known to eye care professionals that chronic use of these whitening agents can have a rebound effect, causing vasodilation and actually making the redness worse for the user. Some experience rebound effects, others experience tachyphylaxis, a rapid decrease in response to a drug after use….

Read full article by Dr. Leslie O’Dell at eyetubeOD

Leslie E. O’Dell, OD, FAAO

While There’s No “I” in Team – Teamwork is Essential to Successfully Treat Dry Eye

Building a successful dry eye practice starts with a team approach. A team comprised of doctors, front desk personnel, technicians and even a dry eye coordinator when possible. Once the team is assembled, it needs constant coaching and attention to keep everyone working together towards a common goal.


Start with a solid foundation. Create a mission statement for your dry eye center and develop a protocol for diagnosing and treating patients. This protocol should be agreed upon by all doctors within the practice and modified over time as technology and research develops. Educate your staff. Set aside time for staff training and education on a monthly or quarterly basis. Open and frequent communication sparks positivity and this will make it easier to introduce new diagnostics and treatments in the future.


Make sure all team members are committed and realize how important their role is to the big picture of a successful dry eye practice. This will foster trust and with that trust you can build your brand. Your staff is the embodiment of this brand. They are the first and last point-of-contact with patients. Within the team, choose a dry eye champion, one person that is quick to learn and has a passion for helping patients. This staff member can be trained to be your dry eye coordinator. After the doctor makes the diagnosis and develops a treatment plan, the coordinator can step in to continue the patient education and help discuss pricing for any fee-for-service procedures you offer.


Share your passion to treat the ocular surface with your staff. Share your commitment to put the patient first. Set monthly or quarterly goals and celebrate the successes as a team. A team that cares about the patient and the mission of the practice will be motivated to strive for excellence. Ongoing positive feedback on a job well done goes a long way.

This article originally appeared in Ocular Surface News

Structure and function are keys to understanding ocular surface disease.

Leslie E. O’Dell, OD, FAAO

A dry eye epidemic is upon us. You can choose to recognize this and actively seek out patients to treat, or you can miss an opportunity for practice growth by ignoring it. If you look, you will find that most of your patients have dry eye disease (DED) of some stage and type. Ocular surface disease (OSD) is a complicated process involving adequate quantity and quality of tears to maintain a healthy ocular surface. Many advances have been made over the years in defining the disease, in the diagnostic tests available, and in treatment options to help patients who experience what can often be life-altering symptoms. There is still much to learn, but maybe we do not have to reinvent the wheel.

Parallels: Dry Eye and Glaucoma

An understanding of DED is vital for cataract surgeons because achieving the best possible visual results postoperatively depends on a healthy ocular surface. The ocular surface is the first refracting surface in the eye’s ocular system, and its integrity determines the quality of subsequent refracting as incoming light proceeds to the retina.

This article presents five pearls that every cataract surgeon must know about dry eye. My approach to the topic is a little bit unusual, though, in that I discuss DED in relation to our understanding of glaucoma. Hopefully this analogy of the two diseases will help to illuminate these important points.

The philosophies used in the current understanding of glaucoma can be applied to OSD. A review of the history of glaucoma and the challenges faced in defining, diagnosing, and treating the disease may help to enhance our understanding of OSD and drive needed research.

The concept of high IOP and its relationship to glaucoma dates back to Demours in France in 1818.1 Optic neuropathy, the modern definition of glaucoma, was introduced by Drance only in 1973—155 years later.2

Korb first introduced the idea of meibomian gland dysfunction (MGD) in 1980,3 and the term meibum was coined by Nicolaides et al in 1981.4 Let us hope it does not take 155 years to achieve a better understanding of DED!

Pearl #1. Knowledge of the Relationship of Structure and Function in Dry Eye is Growing

As noted above, the scientific understanding of glaucoma has evolved, from a disease of elevated IOP to one involving optic nerve damage or optic neuropathy. The same type of evolution is taking place with DED. Through the efforts of the Dry Eye WorkShop and the International Workshop on Meibomian Gland Dysfunction, there has been a fundamental change in the understanding of the most common type of dry eye—from an aqueous deficiency to an evaporative deficiency.5,6

Diagnosis and treatment of glaucoma depends on the relationship of structure (optic nerve damage) and function (visual field constriction). This relationship determines when a patient is diagnosed with glaucoma and influences the course of treatment. Understanding of this relationship can lead to improvements in glaucoma detection and the management of individual patients.7

We are now learning more about how a structure-function relationship applies to the meibomian glands. Diagnostic testing is available to measure the structure of the meibomian glands through manual evaluation, transillumination of the lid at the slit lamp, meibography, and interferometry (Figure 1).

In early glaucoma, patients are asymptomatic while the nerve fiber layer is dropping out. In dry eye patients, the same is true. They can be asymptomatic in the early stages as the meibomian glands are slowly changing, becoming truncated, and eventually atrophying.

Figure 1. Transillumination of the lower lid. Although it is hard to photograph changes in meibomian gland structure, at the slit lamp it is easy to see gland dropout.

When is the best time to treat? Should we really be treating only once symptoms begin? In glaucoma management, that concept is long outdated. When sufficient risk factors are present, or when optic nerve damage is detected, a patient’s elevated IOP may be treated to prevent the development of visual field loss. The same may be true in dry eye; if structural changes can be detected with diagnostic technologies, DED can be treated even before it becomes symptomatic.

Pearl #2. Diagnostic Testing Allows Proactive Disease Management

When you see a patient you think is at risk for glaucoma for the first time, what is your treatment plan? It is safe to assume you would schedule a return visit to start a battery of diagnostic tests to aid in the diagnosis of glaucoma, and over time you would evaluate the stability of the disease. For glaucoma suspects, the known risks associated with glaucoma guide follow-up exams.

Figure 2. According to its manufacturer, the LipiView II now images meibomian glands with dynamic meibomian imaging, simultaneously employing noncontact surface illumination and high-definition transillumination to provide the most detailed gland images available (A, B). Atrophy is easily identified (C).

The same can now be done for the patient with dry eye. Gone are the days of handing an artificial tear supplement to the patient as he or she leaves your office. New treatments and diagnostic tests are available. Yes, hand the patient an artificial tear that is best suited for the appropriate deficiency, aqueous or evaporative, but also take the next step: Schedule a return visit to evaluate how it is working.

As part of that follow-up, you can start to lay the foundation from which to evaluate the effectiveness of your treatments. Does the patient have MGD? What is the appropriate approach to treatment, and how do we best monitor progress? Is there, also or instead, an aqueous deficiency? How does that factor into the equation? The field of DED and its management is still evolving, and we need to determine when and how to best test these patients and what are the gold standards for diagnosis.

Pearl #3. Numerous Tests Are Emerging for Dry Eye Diagnosis

A number of structural and functional diagnostic tests have become available in recent years for DED. (All of the technologies discussed in this section are available in the US market, but their availability internationally may vary.) Still to be determined is which of these emerging dry eye tests will become the gold standards, similar to the established tests used for glaucoma patients.

In glaucoma, the standard functional test is the visual field exam. The function of the meibomian glands can be assessed with the Korb Meibomian Gland Evaluator (TearScience), which provides standardized pressure on the glands to allow objective evaluation of meibum expression.

What will become the dry eye equivalent of glaucoma structural analysis with a retinal nerve fiber layer analyzer? Meibography, introduced in 1977 by Tapie, is a method to directly visualize the meibomian gland structure.8 This technology is available on the Keratograph 5M (Oculus), and TearScience now has meibography available with the introduction of the LipiView II (Figure 2).

What about overall risk assessment, as is done in glaucoma with IOP measurement, pachymetry, and gonioscopy? Multiple diagnostics are available, including tear osmolarity measurement (TearLab), inflammatory marker detection (Inflammadry; Rapid Pathogen Screening), and interferometry with LipiView (TearScience) or TearScan (Advanced Tear Diagnostics). These tests measure either the tear film dynamics or components of the tears to evaluate for tear film dysfunction.

Pearl #4. The Basics Are Still Important

Relying solely on diagnostic tests, clinicians may either over- or underdiagnose glaucoma; the phenomenon of red disease has recently been described.9 Typically, OCT and retinal nerve fiber layer imaging devices display normal results in green and abnormal results in red. Clinicians who rely on these devices may assume that disease is present when they see a red result, but in reality the results may be due to flaws or limitations in the devices’ normative databases. There is a learning curve with any new diagnostic device, and clinicians must remember that these devices are adjuncts to clinical diagnosis.

The same can be true for DED with some of the new diagnostics described above. These tests can enable us to educate dry eye patients better, but they must be used in conjunction with good clinical evaluation.

For example, tear osmolarity is a helpful addition to aid in diagnosis and to track improvement in ocular surface health. But, much like red disease with OCT, an osmolarity number could influence the clinician to treat an evaporative dry eye patient for aqueous deficiency or vice versa. Hyperosmolar tears can be present in all types of dry eye.

Pearl #5. Clinical Registries Can Provide Valuable Information

Perhaps we need to change our thinking toward outcome-based medicine to better determine which dry eye treatments are working and to drive innovation in developing new treatments. The use of clinical registries to track and analyze patient outcomes is a relatively new concept that is gaining traction throughout medicine.

Right now, eye care providers may have no idea how effective their treatments actually are, or how what they are doing compares with what other providers are doing. That is the fundamental concept upon which outcome-based care is built. Participation in registries affords practitioners the opportunity to identify the most effective diagnostic and therapeutic processes to achieve the best outcomes for their patients. Registries can supply information that providers have never had access to before.


In the end, clinicians are all trying to improve quality of life for their patients. Research shows that both glaucoma and dry eye have negative impacts on patients’ quality of life, and both have been correlated with depression.10,11 Many of us see this firsthand, when we take the time to listen and consider the specific symptoms our dry eye patients are experiencing.

We must continue to search for answers that will further improve our understanding of DED. It is a real disease with real consequences, and it is not going away. Although some progress has been made recently, it is time that DED received the recognition, research, and collaboration among all types of eye care practitioners that it deserves.

If you have an interest or comment on the ideas in this article or an interest in participating in a dry eye registry with, please contact me.

This article originally appeared in the CRST Europe

  1. Mantzioros N. The history of the meaning of the word glaucoma. Accessed November 5, 2014.
  2. Morgan RW, Drance SM. Chronic open-angle glaucoma and ocular hypertension. Br J Ophthalmol. 1975;59(4):211-215.
  3. Korb DR, Henriquez AS. Meibomian gland dysfunction and contact lens intolerance. J Am Optom Assoc. 1980;51:243-251.
  4. Nicolaides N, Kaitaranta JK, Rawdah TN, et al. Meibomian gland studies: comparison of steer and human lipids. Invest Ophthalmol Vis Sci.1981;20(4):522-536.
  5. [no authors listed] The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of the International Dry Eye Workshop (2007). Ocul Surf. 2007;5(2):75-92.
  6. Nichols KK, Foulks GN, Bron AJ, et al. The international workshop on meibomian gland dysfunction: executive summary. Invest Ophthalmol Vis Sci. 2011;52(4):1922-1929.
  7. Sharma P, Sample PA, Zangwill LM, Schuman JS. Diagnostic tools for glaucoma detection and management. Surv Ophthalmol.2008;53(suppl1):S17-S32.
  8. Tapie R. Etude biomicroscopique des glandes de meibomius. Ann Ocul (Paris). 1977;210:637-648.
  9. Chong GT, Lee RK. Glaucoma versus red disease: imaging and glaucoma diagnosis. Curr Opin Ophthalmol. 2012;23(2):79-88.
  10. Kong X, Yan M, Sun X, et al. Anxiety and depression are more prevalent in primary angle closure glaucoma than in primary open-angle glaucoma [published online ahead of print November 14, 2013]. J Glaucoma.
  11. Labbé A, Wang YX, Jie Y, et al. Dry eye disease, dry eye symptoms and depression: the Beijing Eye Study. Br J Ophthalmol. 2013;97(11):1399-1403.