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Abstract

The issues raised by Affeldt et al can be distilled into a single question: Is it reasonable to assume that lacrimal obstruction in all referred patients who had been previously treated with a Herrick Lacrimal Plug (HLP) is attributable to the plug and not another etiological factor? We believe that that such an assumption is indeed reasonable. Focal obstruction of the lacrimal drainage system is a relatively infrequent finding with a list of differential diagnoses that can be narrowed readily by a thorough history and physical examination. Once potential contributing factors such as topical or systemic drug use, antecedent viral conjunctivitis, or external trauma have been excluded, the history of an implanted device of any type becomes a prime suspect. In many instances, as summarized in the Table in our article, the patient’s symptoms began immediately after implantation of the HLP. If irrigation and probing of the lacrimal drainage system confirmed an obstruction in the distal canaliculus, an association with the recently implanted device is reasonable. In other patients, the symptoms commenced weeks to months later. If surgical intervention was required and the HLP was removed from the site of obstruction, causation could reasonably be implied. (Fig 1) We agree with the authors when they state, “In a prospective clinical trial, an adverse event (AE) probably related to treatment is conventionally defined as one that exhibits a reasonable temporal relationship between the AE and study treatment, and other factors such as concomitant drugs and/or underlying disease can be excluded.” According to their definition, the patients whom we reported experienced an adverse event. We cannot comment on the authors’ assertion that the incidence of such adverse events is less than or equal to 4 patients per 1000. Neither of the retrospective studies to which they refer is available through standard computer searches. Perhaps a properly designed prospective study should be considered by optometrists and ophthalmologists who use HLPs frequently. In the absence of such data, isolated adverse events that require major lacrimal surgery, such as dacryocystorhinostomy or conjunctivodacryocystorhinostomy, are notable and worthy of publication. The authors found baseless our statements that “We have observed what appears to be a disproportionate number of complications related to one specific collarless intracanalicular plug” and “we believe that the Herrick plugs are associated with a higher frequency and severity of complications than those with collars.” To be sure, lacrimal drainage obstruction may occur with collared punctal plugs. Instances of such have been published and were cited in our paper. In our experience and that of participants in the American Society of Ophthalmic Plastic and Reconstructive Surgery Internet discussion group, however, such occurrences are far more frequent with HLPs. Perhaps the absolute number of such cases can be explained by a proportional preference among eye care providers for HLPs over collared punctal plugs, but we are unaware of peer-reviewed data that quantify such practice patterns. Finally, it is noteworthy that another paper describing similar observations related to HLPs has been published since our article appeared.1Lee J. Flanagan J.C. Complications associated with silicone intracanalicular plugs.Ophthal Plast Reconstr Surg. 2001; 17: 465-469Crossref PubMed Scopus (32) Google Scholar