OBJECTIVE: To evaluate the long-term maintenance rate and associated factors of silicone punctal plugs in patients with Sjögren\'s syndrome (SS).
METHODS: We retrospectively reviewed the medical records of 163 patients with SS who underwent silicone punctal plug insertion between December 2013 and July 2021 at Severance Hospital. The status of punctal plug insertions was classified into the following three categories by the clinician: maintenance, spontaneous loss, and intended removal. Cox proportional hazards model was used to evaluate the risk factors for spontaneous loss.
RESULTS: The mean maintenance period was 12.8±15.3 (median 7.07) months. The rate of spontaneous loss was 58%, and the rate of punctal plug removal by the clinician was 14%. The number of prior plug insertions was a risk factor for spontaneous loss [hazard ratio (HR) 1.055, p=0.035]. The upper eyelid punctum was at a higher risk than the lower one (p=0.042). Small-sized plugs showed a significantly higher risk for spontaneous loss than large-sized ones (HR 1.287, p=0.035). Flow-controller type plugs were more vulnerable to spontaneous loss than complete occluders [Micro Flow™ vs. EagleFlex® (HR 2.707, p=0.008) and Micro Flow™ vs. Ultraplug™ (HR 3.402, p=0.005)]. The most common reason for removal was tear overflow (5.6%).
CONCLUSIONS: In repeated insertion, characteristics of the punctal plug, including the type and size, and location of plug insertion, influenced the spontaneous loss of plugs. The management of punctal plugs, including insertion, maintenance, and removal, requires personalized strategies for versatile situations.

The burden of irreversible vision loss from Glaucoma continues to rise. While the disease pathogenesis is not well understood, intraocular pressure (IOP) is the only modifiable risk factor identified to prevent glaucomatous vision loss. Medical management remains the first-line of treatment in most adult glaucomas and the evolution of medical therapy for glaucoma has followed an exponential curve. This review tracks the rapid development of new medications and drug delivery systems in the recent years. Introduction of Rho kinase inhibitors with an entirely new mechanism of action from that of the currently used anti glaucoma medications has been a significant milestone. Latanoprostene Bunod is a novel, single molecule which provides two active metabolites that work through two different pathways for reducing intra ocular pressure. Bimatoprost implants and travoprost punctum plugs attempt to ease chronic medication use in glaucoma patients. Nanotechnology is an evolving route of drug delivery. Role of cannabinoids in medical management of glaucoma remain equivocal. The relatively short term effect on IOP, the risks of developing tolerance and side effects impacting patients\' neurocognitive health greatly outweigh the potential benefit. Research on Latrunculin B, Adenosine receptor agonists, Specific gene silencing and Stem cell therapy are poised to make an impact on glaucoma treatment. While there is some evidence to support the role of Brimonidine in neuroprotection, further research is needed to clarify the role of Memantine and Neurotrophins. Evidence for benefit from dietary supplementation with Alpha lipoic acid, Forskolin , and Ginko Biloba is limited.

Purpose: To present a recently described surgical technique for the treatment of optic disc pit (ODP) and evaluate its outcomes. Methods: A patient presented with refractory serous macular detachment and secondary full thickness macular hole associated with ODP, for which he had already undergone pars-plana vitrectomy with internal limiting membrane peeling and autologous serum application over the optic disc pit. A recently described surgical technique was carried out to treat this case. In this procedure, a silicone punctal plug was used to close the ODP. The macular hole was closed with a human amniotic membrane graft. Endotamponade was carried out with 1000cs silicone oil. Results: Postoperatively, the serous macular detachment subsided and the punctal plug and amniotic membrane graft were in situ. Patient\'s visual acuity improved from counting fingers to 6/38 at one year postoperative. Conclusion: This technique appears to be safe and effective in resolving long standing serous macular detachment associated with ODP, which was refractory to the conventional intervention. However, more cases and longer follow-ups are needed to affirm the safety and efficacy of this recently described procedure.

OBJECTIVE: To evaluate the effectiveness of different treatment modalities for dry eye in primary Sjögren\'s syndrome with their potential overlapping influences.
METHODS: This study included 199 patients with newly diagnosed primary Sjögren\'s syndrome from 2005 to 2020. Various treatment modalities for primary Sjögren\'s syndrome were compared. Improvement of corneal staining based on Sjögren\'s International Collaborative Clinical Alliance (SICCA) scores was the primary outcome.
RESULTS: The average follow-up period was 5.4 ± 3.1 (range, 2.0-14.1) years. Analysis of the individual treatments showed that punctal plug insertions in the lower and upper eyelids were strongly associated with improvement of SICCA scores (β = 2.70 and 1.80, p < 0.001 and <0.001, respectively). With ocular surface inflammation, corneal staining scores improved significantly with steroid eye drops. Prednisolone (1%) had the strongest association with improvement of corneal staining scores (β = 1.48, p < 0.001); this was based on the frequency of administration. Without ocular surface inflammation, diquafosol (3%), carbomer gel, and lanolin ointment were effective (β = 1.37, 1.06, and 1.17; p = 0.003, 0.003, and <0.001, respectively).
CONCLUSIONS: Punctal plug insertion, primarily targeting aqueous deficiency, is the mainstay of the treatment for dry eye in primary Sjögren\'s syndrome even in the presence of ocular surface inflammation. Furthermore, the effectiveness of treatment modalities for dry eye in primary Sjögren\'s syndrome was dependent on the presence of ocular surface inflammation.

UNASSIGNED: To determine patient preference and treatment outcomes with an intracanalicular dexamethasone (0.4 mg) insert compared to standard steroid drop regimen in the contralateral eye following bilateral RLE surgery.
UNASSIGNED: This is a prospective, open-label, interventional, randomized, controlled study in 20 subjects who underwent bilateral RLE. Each patient served as their own control with one eye randomized to the intracanalicular insert (Group A) placed at the time of surgery and the contralateral randomized to topical corticosteroid drops (Group B). All eyes received intracameral moxifloxacin at the time of surgery, and post-operatively, topical moxifloxacin QID for one week and topical NSAID daily for four weeks. Post-operative evaluations were performed on Day 1, Week 1, and Week 4-8.
UNASSIGNED: Twenty patients participated. At 4-8 weeks post-operation, 90% of patients evaluated with the COMTOL questionnaire preferred the intracanalicular insert while 10% preferred the topical steroid. Comparative analysis using the visual analog scale showed no difference in pain between the study and control group. No statistical difference was shown in post-operative corneal staining, anterior chamber cell count, anterior chamber flare or intraocular pressure. Mean LogMAR UCVA at 4-8 weeks post-operation was 0.06 (± 0.230) in the study group and 0.065 (± 0.241) in the control group, which was not statistically or clinically different (p > 0.05).
UNASSIGNED: Patients undergoing bilateral RLE expressed a strong preference towards the use of an intracanalicular insert over a topical steroid for post-operative steroid treatment. There was no clinically or statistically significant difference in outcomes, including rate of cystoid macular edema, visual acuity and elevation of intraocular pressure.
UNASSIGNED: 04549935.

Lacrimal occlusion with punctal or canalicular plugs have been used to treat dry eye disease for more than 40 years. Indeed, punctal plugs constitute a safe and effective tool to retain the natural tear film and prolong the effect of tear substitutes. A wide variety of plugs is available, differing in their design, location (punctal versus canalicular) and their resorbability. There indications have increasingly broadened, and they are now one of the treatment options for numerous ocular surface diseases. Current research focuses on using punctal plugs for extended delivery of drugs to the ocular surface. This review addresses physiology of lacrimal drainage, available models of punctal plugs, their indications, practical details of prescribing and placing punctal and canalicular plugs, and possible complications.

This study aims to describe a case of double lower lacrimal punctum-canaliculi in a dry eye patient treated with a punctal plug. A 60-year-old healthy female presented with complaints of tearing, itchy eyes, and foreign body sensation in the right eye for many years. There was no history of trauma or inflammation. Two patent independent supernumerary puncta and canaliculi were present on the right lower eyelid. The Schirmer Test II (with anesthesia) was zero, the tear breakup time was 2 s, and superficial punctate erosions were present in the right eye. A long-term nonabsorbable punctal plug was inserted into one of the lower puncta. At 9-month follow-up, the dry eye symptoms decreased markedly, the Schirmer Test II improved and superficial keratitis resolved.

Lacrimal occlusion with punctal or canalicular plugs have been used to treat dry eye disease for more than 40 years. Indeed, punctal plugs constitute a safe and effective tool to retain the natural tear film and prolong the effect of tear substitutes. A wide variety of plugs is available, differing in their design, location (punctal versus canalicular) and their resorbability. There indications have increasingly broadened, and they are now one of the treatment options for numerous ocular surface diseases. Current research focuses on using punctal plugs for extended delivery of drugs to the ocular surface. This review addresses physiology of lacrimal drainage, available models of punctal plugs, their indications, practical details of prescribing and placing punctal and canalicular plugs, and possible complications.

To investigate changes in signs, symptoms, and tear cytokines following punctal plug occlusion in patients with dry eye.
A single-center study was conducted at Singapore Eye Research Institute. Nonabsorbable punctal plugs were inserted in the lower punctum of both eyes in patients with moderate dry eye. Over 3 weeks, in the more severe eye, dry eye symptoms, fluorescein corneal staining, Schirmer I (without topical anesthesia) test, tear film breakup time (TFBUT), and safety were assessed. Cytokine and matrix metalloproteinase-9 (MMP-9) levels in tear samples were measured.
Twenty-nine patients (mean age 49.8 years) with moderate dry eye were evaluated. At baseline, mean (standard deviation) global symptoms score was 53.8 (26.5), Schirmer I test score was 5.1 (2.8) mm, and TFBUT was 2.2 (0.6) seconds. After 3 weeks, punctal occlusion significantly reduced global irritation symptoms score (P<.001) and decreased fluorescein staining in all zones (P<.01) except the inferior zone (P=.42). No significant association between levels of cytokines or MMP-9 and either TFBUT or global irritation symptoms were observed at baseline. Levels of several cytokines and MMP-9 were higher in patients with Schirmer I test scores ≤8 mm at baseline. After 3 weeks of punctal occlusion, no significant changes in overall cytokine or MMP-9 levels were observed.
Punctal plug occlusion provided symptomatic relief and reduced fluorescein staining in all except the inferior zone. However, insertion of punctal plugs had minimal effect on tear cytokines and MMP-9 levels, suggesting a need for earlier treatment with anti-inflammatory agents for management of dry eye disease.

Ocular drug delivery has many challenges due to the inherent physiology and natural barriers. Traditionally used eye drops are fairly inefficient with low ocular bioavailability, and drug delivery to the back of the eye currently requires invasive measures, such as implants or frequent intravitreal injections. These challenges, however, present unique opportunities for innovative drug delivery approaches. This review highlights several of these approaches, with special emphasis on those progressing in clinical development.