instrumental strategies
The Extend Synthetic Plug
This versatile punctal plug fits a broad range of indications.

As punctal occlusion becomes an ever more present part of optometric practice, we must become more aware of the various options available. This article will focus on the newest variety of absorbable synthetic punctal plugs, Extend, available through Odyssey Medical. I'll discuss my experience as well as suggested indications and contraindications for extended temporary occlusion.

Here's the lowdown

The new extended duration synthetic punctal plug is composed of an absorbable copolymer of glycolic acid and trimethylene carbonate. The Extend synthetic plug is marketed in three sizes and in a variety pack. The sizes range from 0.3 mm, 0.4 mm and 0.5 mm in diameter and are 2.0 mm in length. I prefer to use the 0.4 mm diameter plug and, if necessary, use two adjacently.

	Odyssey Medical's Extend punctal plug.

Totting up the advantages

Extend plugs are easier to insert than conventional short-duration plugs because the synthetic matrix of fibers present in them appears to decrease immediate absorption of water. That also may be one of the reasons for the extended plug life -- up to three or more months in the canaliculi for most patients. As the synthetic plug absorbs water, the synthetic matrix fibers become less tightly bound and begin to swell and conform to the structure of the canaliculi, giving what I feel is a better long-term fit.

Because of their composition, small amounts of fluid and metabolic debris are able to diffuse through the drainage mechanism. I feel that this diffusion is advantageous and may prevent metabolic buildup in the nasal canthus and subsequent hyperosmolarity issues in the nasal conjunctiva. One of the best attributes is the green color that makes the plug easier to see during and after insertion.

Plugs go the extra mile

Lacrimal occlusion is an important and effective treatment option when used correctly. Punctal occlusion prevents or decreases natural tear film drainage, tear supplements and other medical regimens. Whereas conventional collagen plugs are helpful in evaluating subjective symptomatic improvement and clinical effectiveness, they're only short-term in nature.

I find the extended duration plugs especially helpful in treating dry eye conditions after ocular surgery, especially corneal refractive surgery. I also find them useful in providing short-term relief while waiting for other therapeutic regimens to work. Additionally, I use intermediate occlusion to prevent complications from desiccation as well as to relieve the symptomatic effects of comfort and visual function. With an accurate history, proper testing, correct diagnosis and proper insertion, clinicians can enhance visual quality and reduce patient symptoms.

Does your plug do this?

The Extend fits a broad range of indications including:

• Symptomatic OSD
• Meibomian gland dysfunction
• Trial for permanent occlusion
• Increased lens wearing time
• Failed artificial tear therapy
• Compliance issues for artificial tear therapy
• Post-surgical dry eyes.

The Extend is contraindicated for stenotic/atretic puncta and epiphora.

DR. MORRIS IS A MEMBER OF THE SPIVACK VISION CENTERS REFRACTIVE SURGERY TEAM AND THE AMERICAN OPTOMETRIC ASSOCIATION. HE'S ALSO A FELLOW OF THE AMERICAN ACADEMY OF OPTOMETRY.