Ophthalmology & Optometry/SmartPlug removal


QUESTION: I had LASIK in 2001, resulting in severe dry eye.  After several trials with a variety of plugs, I had SmartPlugs insterted in all 4 puncta in 2003, which greatly relieved my symptoms.  However, unexpectedly in 2009 I began getting recurring infections and in 2010 I had both lower SmartPlugs irrigated out to "give my punctum a break."  Optometrist reinsterted SmartPlugs in lower puncta 6 weeks later and I was infection-free for about a year.  Then infections began again in 2012.  My optometrist successfully irrigated the lower left but, after two separate office visits was unsuccessful with the right lower and referred me to an ophthalmologist.  Ophthalmologist has irrigated on 3 separate occasions and gets saline right through every time.  She claims there in nothing blocking the puncta and that nothing could possibly be lodged, stuck, or left behind.  However, I continue to experience epiphora in the right eye only along with constant discharge.  It clears up somewhat with antibiotics but the relief is only temporary.  I went back to the original optometrist, who again attempted to irrigate and again was unable to pass saline through the lower right puncta.  Could something still be in there?  How can I get it out?
Thank you so much,

ANSWER: It could be that there was something in there, it could also be that the plugs in the superior puncta are causing the problems/discharge etc. If they can't be irrigated out they can be surgically removed. Chronic, recurrent infections aren't good, but before a surgical consult I would see another opinion. It's odd that one doctor could irrigate, with seemingly no problems, and the other couldn't.
Good Luck!

---------- FOLLOW-UP ----------

QUESTION: Thank you for your help.  I should have mentioned that I had both superior plugs irrigated at one of these appointments and they came out easily.  Is it possible to get saline through even when something is still in there?  I have been to one optometrist and two ophthalmologists now.  When the 1st ophthalmologist irrigated, he was very aggressive with the dilation tool to the point where my face ached for days afterwards.  I keep thinking he maybe pushed the plug off to one side and that's why saline was able to get through effortlessly at that visit whereas everything seemed blocked at previous attempts by my optometrist.

With effort you can irrigate past a plug, especially if they were forcefully dilated/probed.  I hate that you're having such problems with them.  If saline can't easily pass through, then neither can your tears.  They are going to get 'backed up,' infected, etc, like a clogged sink.
If the doctor(s) can't easily irrigate then something is blocking the way.  If you can't irrigate the plug out, there are some other, more surgical options. I would get a consult with an oculoplastics doctor... an ophthalmologist trained specifically for plastic surgery techniques,etc, and get their opinion.
Good Luck,

Ophthalmology & Optometry

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John M. Dovie, OD, FAAO


As a residency-trained Fellow of the American Academy of Optometry I am able to answer most questions regarding eye and vision health. Anything is welcome, ranging from dry or allergy eyes, bifocal contact lenses, or thoughts on LASIK surgery. As I am not a surgeon, detail-oriented surgical-related questions may be better answered by an ophthalmologist.


Selected to participate in the PCO residency program in Philadelphia at The Eye Institute, where I worked OD and MD specialists gaining invaluable experience in various clinics including glaucoma, cornea and cataract, oculo-plastics, retinal disease, neuro-ophthalmic disease, primary care, emergency medicine, and special populations. Have practiced and trained in numerous settings including hospital, academic, retail and private practice. I earned my Fellowship in the American Academy of Optometry (FAAO). There are currently only about 3000 active fellows worldwide, and there are only about 70 Fellows in the state of Virginia. I currently own and operate my own optometric practice/clinic.

American Academy of Optometry, American Optometric Association (Contact Lens/Cornea Section member since 2001), Southwest Virginia Optometric Association, Virginia Tech Alumni Association

“Nyctalopia as the Presenting Sign of Vitamin A Deficiency: A Late Complication of Gastric Bypass Surgery.” Clinical Case Study Poster presented at The American Academy of Optometry Denver, Colorado, December 2006, co-authored with Bradley Lane, OD.
“The Importance of Considering Paranasal Sinus Mucocele as a Differential Diagnosis in Diplopia.” Clinical Case Study Poster presented at The American Academy of Optometry San Diego, California, December 2005, co-authored with Kelly Malloy, OD, FAAO and Cherie Farkash, OD.
“Acute Onset of Halos and Glare: Bilateral Keratitis—An Atypical Presentation of Amiodarone Keratopathy.” Clinical Case Study Poster presented at The American Academy of Optometry Tampa, Florida December 2004. Also Presented to New Jersey Academy of Optometry, Neptune, New Jersey March 2005.
“The Opportunity for an Optometrist to Save a Life.” Clinical Case Study and Grand Rounds Presentation presented at The Pennsylvania College of Optometry, Philadelphia, Pennsylvania, September 2004.
“Corneal whorls cause wonder.” Clinical Challenges Quiz, co-authored with Andrew Gurwood, OD, FAAO, Review of Optometry. Published 10/15/2006.
“Acute onset of halos and glare: bilateral corneal epithelial edema with cystic eruptions--atypical presentation of amiodarone keratopathy.” Co-authored with Andrew Gurwood, OD, FAAO. Published February, 2006, Optometry.
“Pondering the posterior polka-dots.” Clinical Challenges Quiz, co-authored with Andrew Gurwood, OD, FAAO, Review of Optometry. Published 5/15/2005.
Professional Involvement:
“AION: Amiodarone-Induced or Anterior Ischemic Optic Neuropathy?” Participated as a peer-review referee for Expert Review of Ophthalmology (London, UK); refereed 10/2006.

Bachelor of Science, Cum Laude, Virginia Tech. Bachelor of Science, Pennsylvania College of Optometry. Doctorate (OD), Pennsylvania College of Optometry Residency, Pennsylvania College of Optometry Fellow of the American Academy of Optometry

Awards and Honors
Winner, First Place, "Best Beside Manner" by Our Health Magazine: 2012, 2013, 2014 Winner, First Place, "Best Eye Doctor" by The Roanoke Times: 2013, 2014 Recognized as a Fellow of the American Academy of Optometry, December, 2006 Recipient of the Onofrey G. Rybachok Memorial Scholarship, 2000-2001 Member: The Golden Key International Honor Society Member: The National Biological Honor Society Member: The National Honor Society Eagle Scout awarded 1994

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