Study: Self-closing puncta in GVHD...

Well, those who have struggled for years with plug discomfort, dropout, and above all cost might wish their puncta would occlude themselves... though on balance I'm sure they would not want to switch places with any of the patients described in this study.

Spontaneous Lacrimal Punctal Occlusion Associated with Ocular Chronic Graft-versus-Host Disease.

Kamoi M, Curr Eye Res. 2007 Oct;32(10):837-42.

Purpose: To investigate the clinical features of spontaneous lacrimal punctal occlusion (SLPO) after allogeneic hematopoietic stem cell transplantation (HSCT).

Methods: One hundred nineteen recipients after HSCT who visited Keio University between 2001 and 2004 were examined. The condition of the lacrimal punctum, severity of dry eye, meibomian gland secretion, and presence of systemic chronic graft-versus-host disease (cGVHD) were determined with or without SLPO by retrospective chart review.

Results: Among the 119 recipients, SLPO was diagnosed in 8. All the patients with SLPO after HSCT had meibomian gland dysfunction (MGD), dry eye, and systemic cGVHD. The percentage of patients with dry eye, MGD, and systemic cGVHD were significantly higher in recipients with SLPO than non-SLPO recipients (p < 0.0013, p < 0.00015, p < 0.0008, respectively).

Conclusions: SLPO is a clinical presentation of ocular cGVHD and may be an indicator of the severity of dry eye and systemic cGVHD after HSCT.

Study: Dry eye after, yes, CATARACT surgery

I really appreciated this study and hope to see more on the subject. I get calls regularly from people who had a cat surgery anywhere from 3-12 months previously, who are experiencing dry eye for the first time, and who have been told flatly by their doctor that cataract surgery is unrelated to dry eye. According to this study... there is enough risk to warrant finding out more and above all to be sensitive to how much BAK is thrown at the cornea postoperatively including strong attention to patient instruction and compliance monitoring.

Investigation of dry eye disease and analysis of the pathogenic factors in patients after cataract surgery.

Li XM, Hu L, Hu J, Wang W. Cornea. 2007 Oct;26(9 Suppl 1):S16-20.

PURPOSE: To study dry eye and analyze pathogenic factors in patients after cataract surgery.

METHODS: A total of 37 patients (50 eyes) were studied by using a 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ25) and Ocular Surface Disease Index (OSDI) 3 days before and 1 week, 1 month, and 3 months after cataract surgery. Slit-lamp microscope examination, cornea and conjunctiva fluorescein staining, tear breakup time (BUT), Schirmer test I (STI), and impression cytology (IC) were carried out at the same time. Cytologic specimens for IC were obtained from the upper lid-covered region, explosive region, and lower lid-covered region of the globe conjunctiva. The average density of goblet cells on these 3 regions was measured, and the pathogenic factors of dry eye after cataract surgery were analyzed.

RESULTS: After cataract surgery, the incidence of dry eye increased dramatically; NEI-VFQ25 and OSDI indicated that most patients developed this symptom after surgery. The lacrimal river line became narrow, and BUT and STI decreased in patients after cataract surgery. IC suggested the presence of serious squamous metaplasia in the epithelial layer of the globe conjunctiva, especially the lower lid region.

CONCLUSIONS: Dry eye can develop or deteriorate after cataract surgery if not treated in time. Misuse of eyedrops is one of the major pathogenic factors that causes dry eye after cataract surgery. Eyedrops should be carefully administered before and after cataract surgery to avoid or reduce the occurrence of dry eye postoperatively.

Study: Here's one for the Genteal Gel fans

Efficacy, tolerability and comfort of a 0.3% hypromellose gel ophthalmic lubricant in the treatment of patients with moderate to severe dry eye syndrome.

Tauber J. Curr Med Res Opin. 2007 Nov;23(11):2629-36.

OBJECTIVE: To evaluate efficacy, safety and comfort of a 0.3% hypromellose (HM) eye gel (GenTeal Lubricant Eye Gel), with a sodium perborate preservative system and carbomer gelling agent, in patients with dry eye....

CONCLUSIONS: In a small, open-label study, this 0.3% HM eye gel showed statistically significant effects in relieving ocular symptoms and provides a well-tolerated formula that effectively reduced symptoms and improved ocular comfort in patients with dry eye syndrome.

Study: Egg whites, milk, toothpaste... and MGs and dry eye

No, this is not about dietary factors in dry eye... just innovative descriptions for what comes out of the MGs and which type of abnormal crud was most closely associated with dry eye.

Hey, I'm happy when an ophthalmologist deigns to even press on those little MG orifices and watch, let alone come up names for what comes out.

Abnormal property of meibomian secretion and dry eye syndrome

Gao Y et al, Yan Ke Xue Bao. 2007 Jun;23(2):121-5.

PURPOSE: To study the relationship between meibomian secretion and dry eye.

METHODS: To observe 68 outpatients (136 eyes) consecutively. Routine check up included vision, anterior segment and fundus, scoring of tear break up time (BUT), Schirmer I test and rose bengal staining (rb). Recorded the property of meibomian secretion. Defined the dry eye as mild and severe.

RESULTS: Meibomian secretion was sorted as egg-white-like secretion (n=28), milk-yellowish secretion (n=26), granular secretion (n=30) and toothpaste-like secretion (n=52). The result declared that BUT and rb scoring stepped up consecutively in the above secretions, that was higher in toothpaste-like secretion than in other groups (all P < 0.01). Schirmer I scoring was below 1 in all groups, and there was no difference in the groups. Fifty-four eyes (40%) met the criteria of dry eye syndrome. The incidence of dry eye stepped up in groups as egg-white-like secretion (2/28) 7.1%, milk-yellowish secretion (4/26) 15%, granular secretion (8/30) 27% and toothpaste-like secretion (40/52) 77%. The incidence was higher in granular secretion than in egg-white-like secretion (P < 0.05), while the incidence was higher in toothpaste-like secretion than in any of other 3 groups (P < 0.01). There was no severe dry eye in egg-white-like secretion and milk-yellowish secretion, while dry eye was found in 2 out of 8 in granular secretion, and in 19 out of 40 in toothpaste-like secretion. Incidence of severe dry eye was found higher in toothpaste-like secretion than in non toothpaste-like secretion (P < 0.05).

CONCLUSION: Abnormal meibomian secretion affects the stability of ocular surface. The patients with toothpaste-like secretion are prone to dry eye and tend to have a worse dry eye than other secretion groups.

Study: (yawn) Another Restasis cocktail

Evaluation of an isotonic tear in combination with topical cyclosporine for the treatment of ocular surface disease.

Hardten DR et al, Current medical research and opinion, 2007 Sep;23(9):2083-91

PURPOSE: To determine whether a new category of artificial tear product, carboxymethylcellulose 0.5% with compatible solutes (CMC-solutes) (Optive, Allergan, Inc., Irvine, California) improves clinical outcomes when used adjunctively with topical cyclosporine 0.05% (Restasis, Allergan, Inc., Irvine, California) for the treatment of ocular surface disease. METHODS: Nineteen patients with ocular surface disease treated with cyclosporine 0.05% for at least 3 months and who had previously used other artificial tears adjunctively were enrolled. Patients discontinued their previous artificial tear and used CMC-solutes, concomitant with topical cyclosporine 0.05%. Corneal evaluation and tear production parameters were evaluated before and during combined CMC-solutes/cyclosporine treatment. Patients also completed a questionnaire before and during treatment with combined CMC-solutes/cyclosporine. Follow-up was at 1 and 3 months. RESULTS: Most objective measures of ocular surface health were unchanged, but an improvement in conjunctival lissamine green staining and tear break-up time was found. Conjunctival lissamine green staining scores improved from 3.4 +/- 2.5 to 1.9 +/- 2.5 by Month 3 (p = 0.004). Tear break-up time improved from 4.6 +/- 3.9 s pre-treatment to 5.3 +/- 3.8 s post-treatment (p = 0.049). Ocular Surface Disease Index (OSDI) scores improved from 16.2 +/- 9.4 at baseline to 11.5 +/- 8.9 at month 3 (p = 0.007). Subjectively, patients graded their ocular discomfort as 2.7 at baseline and as 2.3 at Month 3 (p = 0.049). At Month 3, 89.5% of patients said they liked CMC-solutes as well or better than previous drops they had used. All patients said CMC-solutes provided similar or improved relief of symptoms of dry eye than previous eye drops. There were no tear-related adverse events reported. CONCLUSIONS: In this study, CMC-solutes, when used in conjunction with cyclosporine 0.05%, provided patients with an improvement in objective signs and subjective symptoms of ocular surface disease compared to their previous artificial tears. Further studies are warranted.

My translation: (Forgive me, or put it down to PMS...)

PURPOSE: To keep as many patients on Restasis as possible by finding yet another drop which if taken with Restasis might make them feel better. Oh, and to sell yet another Allergan product.

METHODS: Hand 19 random Restasis users (hm, wonder how long they had been on Restasis and whether they were at the magic 3 month point - or is the the magic 7 month point - or is it the magic 12 month point now?) yet another artificial tear (hm, wonder what they used to use and which ones the discontinuation of which is most likely to lead to improved comfort?) to try. Most of those tears have a honeymoon period before they join the drawerful of rejects in the bathroom, so there's always a chance they might like it better for long enough to capture some useful data.

RESULTS: No need to translate this part, I'll just quote: "Most objective measures of ocular surface health were unchanged". Ah, but OSDI improved. Go figger.

CONCLUSIONS: Start prescribing Optive with Restasis to patients who aren't yet showing any benefit from Restasis until somebody publishes a study with better results than this.

Like I said, I'm a cynical old thing, especially of a Wednesday morning without caffeine. Down in the depths of my heart...somewhere... I do sincerely appreciate all the efforts to make Restasis more tolerable.

Study: The search for hormonal links goes on...

This one found no differences in testosterone levels amongst women with and without dry eye.

Total testosterone level in postmenopausal women with dry eye

Duarte MC et at, Arg Bras Oftalmol. 2007 May-Jun;70(3):465-9

PURPOSE: The purpose of this study was to compare total testosterone blood level among three groups of postmenopausal women: control, mild to moderate dry eye and severe dry eye.
METHODS: Twenty-nine postmenopausal women were selected. The exclusion criteria were: hormone replacement therapy in the last 8 weeks, mechanical palpebral abnormalities, pterygium, lacrimal obstructions, intraocular inflammation or contact lens use. A blood sample was collected for total testosterone level determination, and the patients were submitted to an ophthalmologic examination (emphasizing on dry eye detection) and answered the OSDI (Ocular Surface Disease Index) questionnaire. Five patients were excluded. Postmenopausal women were divided into three groups according to OSDI score and the ophthalmic examination.
RESULTS: Five patients were classified in the no dry eye group (control), fifteen in the mild to moderate dry eye group and four in the severe dry eye group. There were no statistically significant differences regarding mean age (p=0.3915); instruction level (p=0.9333); number of comorbidities (p=0.2551); medication taken (p=0.2844) and total testosterone level among those groups (p=0.1275).
CONCLUSION: Further research with a greater bigger sample is necessary to establish the relation of androgen levels in dry eye patients.

Study: Bleph underdiagnosed, undertreated

Well golly, I'd kinda noticed that - based on the number of people visiting Dry Eye Talk or calling who had never heard of it but from whose description of their symptoms almost certainly have it. Seems like sometimes it only gets diagnosed if the patient's got horribly crusty lid margins.

Chronic blepharitis. Pathogenesis, clinical features, and therapy

Auw-Haedrich C, Reinhard T, Ophthalmologe, 2007 Sep;104(9):817-26; quiz 827-8

Chronic blepharitis is one of the most common diseases of the eyelids, but surprisingly, it is not often recognized. Frequently, a skin disease such as seborrheic dermatitis, atopic dermatitis, or acne rosacea is the underlying cause of chronic blepharitis. Bacterial pathological lipase, cholesterylesterase production, and bacterial lipopolysaccharides are pathogenetically relevant. Only rarely do genuine bacterial infections play a role. Collarettes occur at the base of the eye lashes, and the Meibomian glands show either abundant fluid secretion or inspissated secretion with obstruction of the orifices. Chronic blepharitis can include sequelae including dry eye and corneal and lid contour changes. The basic treatment comprises attendance of the underlying dermatological disease and lid hygiene. In addition, preservative-free tear film substitutes, antibiotics, immunomodulatory agents, or even surgical intervention may become necessary.

Study: OCI an alternative to OSDI?

The "Ocular Comfort Index"

Measurement of ocular surface irritation on a linear interval scale with the ocular comfort index.
Johnson ME, Murphy PJ, IOVS, 2007 Oct;48(10):4451-8.Click here to read

PURPOSE: To examine the psychometric properties of the Ocular Comfort Index (OCI), a new instrument that measures ocular surface irritation designed with Rasch analysis to produce estimates on a linear interval scale.

....CONCLUSIONS: The OCI was shown to have favorable psychometric properties that make it suitable for assessing the impact of ocular surface disease on patient well-being and changes in severity brought about by disease progression or therapeutic strategies.

With more scientifically validated instruments emerging to measure how people with ocular surface disease feel... there is even less excuse for failing to employ them.

It's not hard. Your tech hands the patient a sheet of paper where they answer 12 simple questions. Slip it into their medical record. Repeat in six months. Not too painful now was it?

Some suggested times for doing it... And no, this is NOT a multiple-choice test.

1) Every time a dry eye patient comes in for a checkup.
2) Every 6 months for your glaucoma patients who are on BAK-preserved drops.
3) Every LASIK pre-operative exam.
4) The 1-, 3-, 6- and 12-month LASIK follow-up exams - and not just for the patients who are actually complaining about discomfort. If you don't measure them all, you won't know. I'm generously assuming you might like to.

Dry eye PATIENTS - you can self-administer these tests. For those of you who are compulsively trying new therapies, consider undergoing the discipline of actually finding out whether they're working by limiting yourself to one at a time, and using one of these questionnaires before you start and 3 months later. Oh, and keep your copies, and ask the technician at your eye doctor's office to place it in your medical records.

Study: Usefulness of OSDI

We keep saying it... we keep saying it... I hope more doctors will start employing it! This is a great, EASY, quick little tool for assessing dry eye symptoms. That the results don't correlate with Schirmer should not be thought of as a drawback - since there has always been lack of correlation between symptoms and schirmer scores no matter how you measure them.

Ocular surface disease index for the diagnosis of dry eye syndrome

Ozkura F et al, Ocular Immunology and Inflammation, 2007 Sep-Oct;15(5):389-93.

Purpose: Evaluation of ocular surface disease index (OSDI) questionnaire for the diagnosis of dry eye syndrome. Methods: Sixty-eight patients admitted to the Ophthalmology Polyclinic of the Dumlupinar University between December 2005 and April 2006 were randomly studied. The OSDI questionnaire was performed before, and the Schirmer and tear film breakup time (TBUT) tests were performed after the routine ophthalmologic examination. Results: There was a significant inverse correlation between the OSDI and TBUT test scores, but no correlation between the Schirmer test scores and OSDI (r = -.296, p = .014, r = -.182, p = .138, respectively). Although there was a significant difference between the low and high OSDI having cases according to the TBUT test scores (p = .043), there was not according to the Schirmer test scores. Conclusions: The OSDI is a standardized instrument to evaluate symptoms, and can easily be performed and used to support the diagnosis of dry eye syndrome.

And by the way, in case you don't have a copy handy, here's a link to a downloadable copy of OSDI.

Newsblurb: Thank you to a Beverly Hills "opthamalagist"

What a great state of things compared to a year ago: There is now getting to be so much mainstream press coverage of dry eye that I no longer feel obliged to post blurbs about every half-witted press report about dry eyes out of exquisite gratitude to any journalist willing to give such a dull sounding topic the time of day.

But this one caught my eye and the obsessive English major in me (ok, so I did drop out... what's your point?) could not help herself.

No cure for dry eyes, but there are many effective new treatments

She went to see Beverly Hills opthamalagist Dr. Kerry Assil because she wanted Lasik eye surgery. But he told her it would make her dry eye condition even worse.

I thought that on Dry Eye talk I had already seen every possible way to butcher the spelling of this word but...

"OPTHAMALAGIST"??????????

However, my indignation over their orthography quickly gave way to pleasure at reading that someone was actually told not to get LASIK because of dry eye. Thank you, thank you, thank you.

(By the way, I wouldn't exactly describe artificial tears, Restasis, plugs and steroids as "new" treatments, but never mind.)

Update on my BSLs

Just a quick update on my Boston Sclerals for those who are interested.

I've been wearing the BSLs since June 2006, and went back for an "update" recently.

Two reasons for new lenses -
1) Poor vision in my left eye. Entirely my fault, because I had to leave the clinic earlier than scheduled when I was being fitted back in 06, so we never got a chance to either review the fit of the left lens or optimize the vision. After that I just never managed to scrape together enough time to go back to BFS and do something about it. I'm right eye dominant and was so thrilled with the vision in that eye that I just didn't make it a priority.

2) Dr. Rosenthal came out with a new lens design (the T6) that I wanted to try.

I almost hesitate to tell you how efficiently Dr. Rosenthal nailed the new lenses for me - I don't want to set expectations for anyone else, because in most cases it takes several iterations and patients need to be there for 1-2 weeks. But... I can't help gloating over what a genius he is. In both cases, he nailed it in the very first lens he made.

The T6 is awesome. Incredibly comfortable. It was good before and better now. As for the vision, well, I suppose part of my response is due to having been walking around substantially undercorrected in my left eye for more than a year but I was blown away by how well I am seeing now. I flew home Tuesday night and after a long day followed by 7 hours of WESTbound travel, I was able to DRIVE myself and my daughter home (1.5 hours away from the airport) in the middle of the night. No chance of getting sleepy at the wheel, I was drinking in how clear everything looked and enjoying not being blinded by headlights. Granted - that was with freshly re-inserted lenses so I don't by any means expect it to be that way most evenings, but at least I known it CAN be if I refill them.

Another new thing for me: I tend to get some debris under the lenses, particularly the left. Dr. Rosenthal showed me a trick to reduce this which I am going to continue experimenting with: He told me to fill the lens partway with Celluvisc and top it off with Unisol. The idea is that the added viscosity will slow down fluid exchange so gunk can't work its way under the lens so quickly. It really worked very well the day I tried it at the clinic - most intriguing. However, I hate methylcellulose and couldn't bring myself to go buy some celluvisc, so I decided to try this with Dwelle. Did it yesterday successfully. Today I was short on time and stuck with just plain Unisol so I'll see how the performance compares. I will continue experimenting with this in both eyes and see how it goes.

BFS is such an amazing place. It's always inspiring to be there, seeing people who have been in pain and/or unable to see well for years suddenly have a whole new world opened to them when they get fitted. The combination of scientific brilliance, total focus on patient experience, and compassion make that a truly unique facility.

Other BFS updates - satellite offices opening in Houston (Baylor) and LA (Doheeny) in due time. Satellite newly opened in Tokyo.

I'm working on stocking all consumables for BSL users in The Dry Eye Shop, with the exception of cheap locally available items (hydrogen peroxide and Unisol). We currently have plungers - both for insertion and removal - and Lobob cleaner, and expect soon to have Miraflow, hydrogen peroxide neutralizing tablets, new contact lens cases specifically for sclerals, and some specialized plungers outfitted with lights for people who have difficulty inserting the lenses.

Will post on update when I've had a month or two in these new T6 lenses.

Study: Benefits of flaxseed oil in Sjogrens/RA/Lupus patients

This looks to have been a decently thorough study (OSDI, Schirmer, BUT, impression cytology) and we sure need studies like this for oral supplements. I particularly like that there was no specific commercial product to be pushed (at least not that can be determined from the abstract).

Oral flaxseed oil (Linum usitatissimum) in the treatment for dry-eye Sjögren's syndrome patients

Pinheiro MN Jr et al, Arg Bras Oftalmol 2007 Jul-Aug;70(4):649-55.

PURPOSE: To evaluate if oral flaxseed oil (Linum usitatissimum), which reduces the inflammation in rheumatoid arthritis, may help keratoconjunctivitis sicca's treatment in Sjögren's syndrome patients. METHODS: In a randomized clinical trial, 38 female patients with rheumatoid arthritis or systemic lupus erithematosus associated with keratoconjunctivitis sicca and Sjögren's syndrome were consecutively selected from patients of the Department of Rheumatology of the Amazonas University Hospital. Keratoconjunctivitis sicca diagnosis was based on a dry-eye symptom survey score (Ocular Surface Disease Index - OSDI), Schirmer-I test, fluorescein break-up time, 1% Rose Bengal staining of ocular surface measured by the van Bijsterveld scale. All patients had ocular surface inflammation evaluated and quantified by conjunctival impression cytology, before and after the study. The subjects were divided into three groups with 13 (Group I), 12 (Group II) and 13 (Group III) patients. Group I received flaxseed oil capsules with a final 1 g/day dosis, Group II flaxseed oil capsules with a final 2 g/day dosis and Group III - controls - placebo, for 180 days. RESULTS: Comparing the results at the beginning and at the end of the treatment, statistically significant changes (p<0.05) in symptoms (OSDI), ocular surface inflammation quantified by conjunctival impression cytology, Schirmer-I test and fluorescein break-up time occurred in Groups I e II when compared to controls. CONCLUSIONS: Therapy with oral flaxseed oil capsules 1 or 2 g/day reduces ocular surface inflammation and ameliorates the symptoms of keratoconjunctivitis sicca in Sjögren's syndrome patients. Long-term studies are needed to confirm the role of this therapy for keratoconjunctivitis sicca in Sjögren's syndrome.

Study: Restasis in Sjogrens vs. APLD

Heh. Interesting.

So, dry eye buddies, would you rather have a wetter Schirmer strip or better feeling eyes?

Effect of topical cyclosporine on tear functions in tear-deficient dry eyes.
Jain AK et al, Annals of Ophthalmology 2007 Spring;39(1):19-25

We evaluated the efficacy of topical 2% cyclosporine drops in the treatment of tear-deficient dry eye because of acquired primary lachrymal disease (APLD; 15 patients) and Sjögren syndrome (SS; 15 patients). Symptoms of dryness tended to improve in patients with SS. Schirmer score improved in patients with APLD. Topical CsA 2% drops appears to be safe and effective in the treatment of dry eye patients because in patients with APLD and SS, there is trend toward improvement.

Study: More on immunosuppressants and...

Okay... so what have we here:
1) Something that's supposed to be better than cyclosporine or tacrolimus
and
2) Another plug for that drug-plug thingymabob.

I'm not sure the "can be highly effective in... dry eye syndrome" bit is simply referencing the known use of cyclosporine in dry eye or whether they're hinting that after ISA-247/LX-211's succesful clinicals for uveitis they're going after the dry eye market (note all these 'wider therapeutic window' comments). Time will tell.

Next-generation calcineurin inhibitors for ophthalmic indications.
Anglade E et al, Expert Opinion on Investigational Drugs, 2007 Oct;16(10):1525-40

Calcineurin inhibitors (CNIs) are potent immunosuppressants that reversibly inhibit T-cell proliferation and prevent the release of pro-inflammatory cytokines by blocking the activity of calcineurin, a ubiquitous enzyme that is found in cell cytoplasm. CNIs can be highly effective in immune-mediated ophthalmic diseases such as uveitis, dry eye syndrome and inflammatory blepharitis, as well as for the prevention of rejection in corneal transplants. ISA-247/LX-211 is a novel CNI that is in Phase III clinical development for the treatment of various forms of non-infectious uveitis. ISA-247/LX-211 is a rationally designed analog of ciclosporin A that exhibits more predictable pharmacokinetic and pharmacodynamic properties and a 4-fold greater calcineurin inhibition than its parent compound, ciclosporin A. ISA-247/LX-211 has been observed to be effective, well-tolerated, and safe in early clinical trials, exhibiting a much wider therapeutic window compared with classic CNIs, such as ciclosporin A and tacrolimus. An alternative approach to widening the therapeutic window for the therapy of ophthalmic disorders lies in local delivery of CNIs through polymeric implants that release the drug over long periods of time. The silicone matrix episcleral implant LX-201 is in Phase III development at present for the prevention of rejection in high-risk cornea transplantation.

Study: Another Smartplug complication

Pyogenic granuloma following Smart Plug insertion.
Arch Soc Esp Oftalmol 2007 Oct;82(10):653-6.

CASE REPORT: We report the case of a 65-year-old woman with dry eye syndrome who was referred because of a red mass in the internal left canthus. Three years previously two Smart Plugs had been introduced into both lacrimal punctums of that eye. We diagnosed a pyogenic granuloma and removed it. Two weeks later a new granuloma developed so both the granuloma and the punctal plug were removed. The patient became asymptomatic following this latter procedure. DISCUSSION: A pyogenic granuloma in a Smart Plug punctum is described. This rare complication is generally associated with the use of silicone punctal plugs, being possibly caused by the chronic irritation of the accumulated detritus and necessitating removal of the plug.

I always get irritated when I read about somebody getting two durable plugs placed in the same punctum. If there's no reliable way to figure out whether the first one is still there, is it ever safe to shove another one in?