Stage 3 Dry Eye Treatments: Punctal Cautery

Part 3 of a four-part series about treatments for advanced dry eye disease.

By Abby Gillogly Harsch, OD, and Nicole Stout, OD, with Nathan Lighthizer, OD, and Richard Mangan, OD

Stage 3 dry eye disease (DED) is an advanced disease state characterized by significant corneal staining and limitations of lifestyle activities. Patients have generally been treated with multiple treatment modalities without relief, and more advanced treatment is needed. In this series, we are exploring the options for treating patients with stage 3 DED by asking experts to weigh in on frequently asked questions. Previous installments have examined the use of autologous serum and amniotic membrane transplantation. This installment looks at another option, punctal cautery. The final installment will discuss the use of scleral contact lenses in this difficult patient population.

Punctal cautery creates a blockage of the lacrimal drainage system through intentional scarring of the punctum, resulting in the retention of tears on the ocular surface. We asked Nathan Lighthizer, OD, and our own series editor, Richard Mangan, OD, to address the use of punctal cautery in patients with stage 3 DED.

—Abby Gillogly Harsch, OD, and Nicole Stout, OD

In what type of patient with DED would punctal cautery be most beneficial?

Richard Mangan, OD: I find punctal cautery to be beneficial under the following circumstances:

• In patients who have had a successful trial with punctal occlusion;
• In patients who have had a history of poor retention (i.e, intrusion or extrusion) of punctal plugs;
• In patients with a history of ocular allergy and/or frequent eye rubbing.

Nathan Lighthizer, OD: Punctal cautery can be useful in any patient with DED who has had significant success with punctal plugs but in whom, for some reason, the plugs keep falling out. Any aqueous deficient DED patient will potentially benefit from closing the puncta and keeping as many tears on the surface as possible. We generally shy away from using this procedure in patients with inflammatory DED.

What do you recommend as a follow-up schedule for patients undergoing this treatment?

Dr. Mangan: Current Procedural Terminology code 68760—closure of the lacrimal punctum by thermocauterization, ligation or laser surgery—has a 10-day global period. Because most patients respond to treatment well and the risk of infection is low, patients are most often scheduled for follow-up at anywhere from 2 to 4 weeks.

Dr. Lighthizer: Typically, I see patients back in approximately 2 to 3 weeks. They usually notice a benefit fairly quickly after the procedure. The comment that I receive most often is, “Yes, it feels like it did when the punctal plug was in.”

Figure 1. Probe inserted into the lower punctum OS; treatment has not yet been applied.

Figure 2. Treatment just completed in the lower punctum OD. Notice the white ring around the orifice of the punctum.

Figure 3. Probe has just been removed after completion of the procedure OS. Notice the whitening of tissue indicating the tissue’s response to the treatment.

In what time frame do you expect patients to notice improvement of their symptoms with this treatment?

Dr. Mangan: It may take up to 2 weeks before any iatrogenic irritation, inflammation, and reflex tearing settles. At that time, patients should feel that their symptoms are better, or at least the same, compared with their punctal plugs.

Dr. Lighthizer: We usually notice an improvement very quickly; usually, within a week, patients will notice improvement. At the 2-to-3-week follow-up, they almost always report noticing improvement of their symptoms.

What, if any, are the clinical contraindications for this treatment?

Dr. Mangan: Patients are contraindicated who have had no previous trial with punctal plugs; have active ocular, lid, or nasolacrimal duct infection; have active sinusitis; have undergone dental, ophthalmic, or sinus surgery within the previous 2 weeks; or are known keloid formers.

Dr. Lighthizer: Patients must understand that this is a permanent surgical fix. It can be reversed if absolutely needed, but we don’t want to go down that road if we don’t have to. So the patient needs to understand the nature of the procedure. If the patient has inflammatory DED, just as with regular punctal plugs, permanent punctal occlusion may not be the best option. Closing the puncta gives the inflammatory markers the potential to stay on the ocular surface longer.

What, if any, are the risks for the patient with this treatment?

Dr. Mangan: Overall, this procedure has a strong benefit-to-risk ratio. The complication I prefer not to see postoperatively is excessive epiphora. The best way to ensure that this does not happen is with a lengthy trial utilizing punctal plugs before considering cautery. Should patients develop chronic epiphora after cautery, they will likely have to undergo a more invasive surgical procedure to reestablish patency of the punctum and nasolacrimal duct system.

Dr. Lighthizer: Risks include infection, bleeding, bruising, reopening of the puncta, and failure of the procedure to work. The first three risks in that list are related to the injection to anesthetize the area around the puncta. Before we consider the surgical procedure, the patient must have had good success with regular punctal occlusion and understand that tearing can be an issue. If patients did not have any major issues with tearing with the plugs, then they shouldn’t have any major problems with the permanent surgical closure. Still, we include this information in our consent form.

What is the most common positive and negative feedback you have received from patients who have undergone this treatment?

Dr. Mangan: Thankfully, the only negative feedback I have received is regarding the brief discomfort associated with the procedure itself. I have done the procedure both with and without an injected anesthetic. Considering the short duration of the cautery, topical anesthetics such as 4% lidocaine plus tetracaine 0.5% (Tetravisc, Accutome) provide a similar comfort profile when you consider the discomfort of the injection itself. The positive feedback is that, usually, the patient has less frequent follow-up visits and less concern about eye rubbing and the possibility of plug migration or extrusion.

Dr. Lighthizer: Fortunately, like Dr. Mangan, I have not received much negative feedback to this point. I have not had patients complain of bad epiphora after the procedure. The positive feedback has been that they feel the improvement and that it feels like it did when they had the plugs in.

What specific patient education is needed before this treatment is performed?

Dr. Lighthizer: We say that we are going to give a small numbing shot around the area to make sure the patient can’t feel the surgical closure of the hole. We tell patients they are going to feel a tiny needle stick and then the burn of the anesthetic. After that, they shouldn’t feel any part of the actual procedure.

Most important, patients must know what they are getting themselves into: This is a permanent surgical closure of the puncta. They need to understand that it is very difficult to reopen the puncta. Proper selection of patients for this procedure is critical. They must have had very good success with punctal plugs; if the plugs, for some reason, kept falling out, then the patient could notice a significant difference when the plugs were out.

Dr. Mangan: Always remind patients that spontaneous recanalization can occur. In my hands, the recanalization rate is approximately 4%; the literature reports rates as low as 1.5% and as high as 20% to 30%. I tend to err on the side of caution and educate patients that they have a 1 in 10 chance that we will need to repeat the procedure.

Please share some clinical pearls for this treatment method.

Dr. Lighthizer: This is a procedure that is relatively straightforward. It requires a small anesthetizing shot just before the procedure, and then it is simply a matter of putting the cautery probe into the punctum to coagulate or bring the inner linings of the punctal mucosa together (Figures 1-3). The procedure itself takes just a few seconds.

What methods for punctal cautery do you prefer?

Dr. Lighthizer: The puncta can be permanently closed with numerous surgical methods. An argon laser can be used to scar or burn the puncta shut. Electrocautery can be used to close the puncta. Our preferred method is to use a radio frequency surgical unit such as the Ellman device. It is much gentler on the tissue. It uses a little probe that you introduce into the punctum after the area is anesthetized. On the coagulation setting, it coagulates or brings the mucosa of the punctum together and scars it shut.

Dr. Mangan: Argon laser has been used for punctal cautery, but it is more expensive and has a higher rate of recanalization. I also prefer using the Ellman device when one is available. If not, disposable handheld monopolar cautery units work great, too.

Series Editor Richard B. Mangan, OD, FAAO
• assistant professor, department of ophthalmology, University of Colorado School of Medicine, Boulder, Colo.
• financial disclosure: none relevant

Nathan Lighthizer, OD, FAAO
• associate professor and assistant dean, Oklahoma College of Optometry, Tahlequah, Okla.
• financial disclosure: none relevant

Abby Gillogly Harsch, OD, FSLS
• optometrist, Nittany Eye Associates, State College, Pa.
• financial disclosure: none relevant

Nicole Stout, OD
• clinical assistant professor, Northeastern State University Oklahoma College of Optometry, Tahlequah, Okla.
• financial disclosure: none relevant