Ocular surface disease relief

Punctal plugs could help for intravitreal injection-related dry eye problems

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John D. Pitcher III MD
Retina specialists could take a page from their refractive surgery colleagues by using punctal plugs to reduce ocular surface discomfort associated with intravitreal injections used to treat age-related macular degeneration, reported researchers at the Association for Research in Vision and Ophthalmology (ARVO) 2018 Annual Meeting in Honolulu. Anti-VEGF agents administered by the intravitreal route have revolutionised the treatment of age-related macular degeneration and other retinal vascular diseases. However, these patients require regular intravitreal injections for many years. A common side-effect of these injections is discomfort associated with dry eye disease. These side-effects are related to toxic effects of povidone iodine, which is typically used for its antiseptic capabilities to reduce the risk of endophthalmitis, the most feared complication of intravitreal injections. This problem prompted researchers at the University of New Mexico School of Medicine, Albuquerque, US, to conduct a study based on the idea that punctal plugs could provide some relief to these patients. The observational case series included 27 patients who were seen at a regional tertiary care retina clinic. All of the patients were receiving monthly intravitreal injections for retinal disease and all had signs and symptoms of ocular surface disease at the onset of the study. The patients were assessed for signs and symptoms of ocular surface disease using the Ocular Surface Disease Index (OSDI) questionnaire. The OSDI is a scale used for the assessment of symptoms related to dry eye disease and their effect on vision. Patients answer several questions in 12 categories, providing responses on a five-point Likert scale. Categories include actual ocular symptoms such as pain, grittiness and reduced vision, along with questions about daily activities such as reading, watching television and driving at night. Patients completed questionnaires immediately before an intravitreal injection, and then subsequently after a punctal plug was placed. Study participants completed a series of five questionnaires immediately before and three days after each intravitreal injection. An inferior punctal plug was placed prior to the second questionnaire. The mean OSDI score at the beginning of study was 34.43. These scores did not change after the first intravitreal injection. However, following punctal plug placement, OSDI scores dropped by nearly 50%, with a mean score of 18.3 points. This highly statistically significant decline was maintained for three-to-five days after anti-VEGF injections. “We are encouraged by the opportunity to provide an option for patients to ease ocular surface discomfort after intravitreal injections. The OSDI is a validated metric that provides quantitative identification of patients with baseline dry eye, who may have the most irritation following betadine prep. Punctal plug placement, an FDA-approved treatment for dry eye, can reduce post-injection discomfort in patients with a high OSDI. Incorporating this option for patients in a retina practice can improve compliance with recommended injection schedules, and therefore achieve better outcomes from anti-VEGF therapy,” John D. Pitcher III MD, Vision Research Centre, Albuquerque, US, told EuroTimes. John D. Pitcher III: jdpitcher@eyenm.com
Tags: ocular surface disease, punctal plugs