الفهرس 
Anatomy of the precorneal tear filmOnly 14 pages are availabe for public view
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Abstract
Dry eye syndrome is an extremely common and often disabling ocular
condition afflicting millions of citizens. Although recently there has been an
enhanced recognition of the prevalence of this condition, there is still a
dearth of data on its epidemiology, associated economic costs, and the long
–term efficacy of currently available treatment modalities.
Iatrogenic occlusion of the lacrimal drainage system with plugs is the
second most frequent method of treating the dry eye as plugs is usually
easier to reserve than surgical approaches and are easy to insert and monitor.
It preserves natural tears or prolongs the retention time of artificial tears
on the ocular surface and can substantially improve the quality of life of
patients by relief of symptoms and maintain the integrity of ocular surface
and visual acuity in moderate /severe dry eye.
In the present study it was found that the use of smart plugs and silicone
punctual plugs can be an effective step in the management of moderate to
severe dry eye that is unresponsive to topical lubricant therapy alone.
In the present study 90 eyes of 45 patients of moderate and severe dry
eye after proper case selection , were subjected to acrylic (smart plug)
inserted in the lower punctum of one eye and the other eye subjected to
silicone plug and were subjected to careful history taking and
opthalmological examination .
Fluorescein tear break –up time, Schirmer’s test with topical anathesia ,
corneal surface integrity by rose bengal and fluorescein vital staining of
ocular surface and finally , conjunctival impression cytology were subjected
to the patients before plug insertion and 1month, 3months and 6 months
after plug insertion.
The present study found that, there were no improvement in the patients’
symptoms scores and also the vital stains after 1month to 3months, there
were gradual improvement from 3 months up to 6 months post insertion in
both the acrylic hydrophobic and the silicone plugs patients.
As regard the symptoms score both types shown similar significant
improvement only 3 months post plug insertion but after 6 months, we
found that acrylic thermosensitive plug has significant higher effect than the
silicone plugs.
This study found that both the acrylic thermo-sensitive ( Smart plug ) and
the conventional (Silicone plug) increased aqueous tear volume and thus
resulting in objective and subjective recovery in all cases thus the efficacy
of the two types of plugs was similar in short- term follow up ( after 3
months and before 6 months ), but with long term, the complications with
poor reliability of the patients also with high loss associated with the use of
silicone plug , makes the acrylic thermosensitive plug more effective both
in objective and subjective outcome.
As regard to the special tests , the present study found significant
improvement of TBUT , Schirmer’s test values , ocular surface staining with
rose bengal and flurosceine , conjunctival impression cytology specially the
degree of keratinization in comparison to pretreatment results and the
improvement mostly occurred 6 months post-plug insertion as most the
study cases suffering from moderate and severe dry eye.
As regard to the frequency of tear supplements use ,it seems that the
acrylic hydrophopic plug group show significant decrease in the
dependance on the tear supplements use after 6 months but ,although there
was decrease in the dependance on the tear supplements use in the silicone
plug group but it didn’t show any significance as these conventional type
show protruding cap which cause continuous irritation which may force the
patients to alleviate it by applying more artificial tear supplements,
however this was not found in the acrylic t hydrophopic group .
As regard the complications, it was found that the only complication
found in the acrylic hydrophopic group is the canaliculitis which may be
due to default in the insertion. It was speculated that if the acrylic
hydrophopic plug was inserted too deep in the canaliculus, there was an
increased risk of canaliculitis .
Care must be taken not to insert the smart plug too distal in the
canaliculus, with the final position ideally just inside the ostium.
Regarding the silicone plug group, the present study found that, many
complications were found such as discomfort and a high rate of spontaneous
loss due to extrusion were a relevant disadvantage. However, the substantial
rate of plug loss call for patient education regarding this outcome, as well as
regular follow-up to monitor plug retention and ensure adequate control of
the disease and to the proper gauging and effective selection of the proper
size that reduced the rate of loss. The intracanalicular position of the acrylic
thermosensitive plug contributed to the lower rate of extrusion.
These results confirm relatively high losses of silicone plugs and the
question the economic value of continuing use of these plugs.
The acrylic hydrophopic plug offered several potential advantages
compared with silicone plugs. Because the acrylic hydrophopic plug
material accommodated the canalicular anatomy, accurate punctal gauging
is unnecessary before installation. There was no exposed portion to irritate
the ocular surface, so the risk of spontaneous extrusion was reduced.
A disadvantage of the acrylic hydrophopic plug was the inability to
visually confirm plug location. The imaging of intracanalicular plugs by
using high- resolution ultrasound scanning has been described but was not
widely available in clinical practice.