This article will discuss different surgical procedures for dry eye syndrome, how to prepare, what happens on the day of surgery, and what to expect in recovery.
What Is Dry Eye Surgery?
Dry eye surgery procedures often involve improving performance of the tear ducts, which keep the eyes moist.
Dry eye procedures include:
Punctal plugsCauterizationAmniotic membraneSalivary gland transplantation
Here’s what you need to know about these procedures.
Punctal Plugs
Like a stopper in a sink, punctal plugs serve as a barrier blocking your natural tears from draining away too soon. Depending on your needs, these plugs can either slowly drain fluid or fully block it.
Punctal plugs are placed by the doctor in an area called the puncta, where tears usually drain out of the eye. With the plug in place, your own tears, as well as any artificial tears you place in your eye, will collect rather than drain.
The idea is to allow these tears to remain on the surface of the eye to keep the area moist.
The two different punctal plugs are:
Temporary plugs: Made of collagen (a type of protein found in the skin, joints, muscles, and bones), these dissolve over time on their own. They may be in the eye for just a few days or for several months. Semipermanent plugs: Made out of a silicone material, these are long-lasting.
Potential Risks
There is a small risk of eye infections from the procedure, but this risk is rare. There is also the possibility you may react to the punctal plugs themselves, with irritation causing swelling and yellowish discharge from the tear duct.
Also, if you have a cold or other upper respiratory infection, it’s possible that when you’re blowing your nose, the germs may get pushed backward and make their way into the ducts. This may require you to take antibiotics and, in some cases, have the plugs removed.
The punctal plugs may function even better than expected, causing excessive tearing. If need be, the doctor can remove the plugs. They can either be replaced with another type of plug or another approach may need to be taken.
Also, be aware that the plugs can potentially fall out if you rub your eyes. They could move elsewhere in the drainage area, too, which can cause swelling and pain.
No recovery time is needed after the plugs are inserted.
Cauterization
Another approach that may be taken is the use of thermal cautery. The idea is to shrink tissues around the area of your tear ducts with the aid of a heated wire, which slows the flow of tears.
Cauterization is usually tried in cases in which medications and punctal plugs have failed. Unlike plugs, which can be removed, cautery is a permanent solution.
While uncommon, some patients may suffer from excessive tearing with this approach.
Use of Amniotic Membrane
For those with keratitis (inflammation of the cornea, the clear dome covering of the iris and pupil) from dry eye, an amniotic membrane is an option.
This is tissue ethically obtained from the placenta during cesarean deliveries (C-sections). This tissue not only acts as a physical barrier to protect the surface of the eye, but it also helps to heal the eye and reduce any pain caused by friction on the surface.
There are two types of amniotic membrane. These include:
Cryopreserved AM: This frozen tissue is stored at minus 80 degrees Celsius, but brought up to room temperature for use. Dehydrated AM: This dehydrated tissue is vacuum-preserved and stored at room temperature.
Salivary Gland Transplantation
Sometimes it’s the tear glands themselves that are the problem. If yours are not creating enough tears, your doctor may opt to transplant salivary glands from your lower lip to the eye area.
This is not a typical procedure for dry eye, but, rather, it’s reserved for people with autoimmune disorders that attack the mucous membranes. The purpose of this transplant is to prevent damage to your eye tissues by keeping them moist.
Purposes of Dry Eye Surgery
Those typically considered for dry eye surgery are people with severe symptoms who haven’t responded well to standard measures like artificial tears and medications.
Before recommending surgery, your doctor will likely try everything from home remedies (like applying heated washcloths to your lids) to artificial tears to prescription medications, such as Restasis or Cequa (cyclosporine) or Xiidra (lifitegrast).
To determine if your tears are sufficient before recommending surgery, your doctor is likely to:
Check to see if you’re making enough tearsLook to see how long it takes for your eyes to fill with tears and how long these remain
How to Prepare
Knowing what to expect can make dry eye surgery go much more smoothly.
Procedures to alleviate dry eye such as punctal plug insertion or thermal cautery are done on an outpatient basis under local anesthesia, which should not affect what you eat or drink beforehand. These are relatively low-key procedures.
Likewise, the amniotic membrane procedure is handled right in your doctor’s office and is a minimally invasive procedure. Do be sure to bring your insurance card with you to the office.
On the other hand, salivary gland transplantation is major surgery performed under general anesthesia. You will need to double-check with your doctor about any medications that may interfere with anesthesia, as well as what you may be able to eat or drink on the day of the procedure.
What to Expect
Here is what you can expect on the day of surgery.
Before the Surgery
Before inserting punctal plugs, your practitioner may measure the size of your puncta opening to make sure the inserts will fit snugly in place. This measurement, however, may not be needed if a one-size-fits-all plug is used.
Your eye practitioner is likely to recommend that you try punctal plugs first before undergoing cauterization, since plugs can easily be removed. On the other hand, cauterization is permanent.
The amniotic membrane procedure can also be done in the doctor’s office. In some cases, the membrane can be inserted just like a contact lens or applied to the eye’s surface and then covered with a contact lens.
Salivary gland transplantation will require general anesthesia, and there will be additional procedures on the day of surgery.
During the Surgery
In some cases of punctal plug surgery, a local anesthetic may be needed to numb the eye. But this is not necessary for everyone. Also, the puncta opening may be dilated with the aid of an instrument to make putting the plugs in easier.
The tiny plugs may be visible in your eye or may be placed down further in the drainage system, where they can’t be seen. These are referred to as intracanalicular plugs as they are placed in the canaliculus, a part of the drainage area.
The good news is that once in place, these also cannot be felt beyond the initial slight discomfort.
With thermal cauterization, a local anesthetic will be given to numb the eye first. You should not feel any pain during the procedure. A heated tip will be applied to the duct opening, burning it closed. The procedure itself only takes a few minutes. Your vision should return to normal within a few days.
During an amniotic membrane procedure, the surface of your eye will be numbed. Then either the ring of tissue will be inserted or the membrane will be placed directly on your eye surface, with a contact lens placed over it.
During surgery for salivary gland transplantation, tissue will be removed from your lower lip and placed in the area where your tear ducts should be. This should help to keep your eyes moist since tears and saliva are very similar, although not exactly the same.
After the Surgery
After punctal plug placement, you should be able to go about your daily activities and can even drive yourself home from this minor procedure. While you will likely tolerate the plugs, if you do need to have them removed, this easily can be done.
In the case of silicone plugs, forceps can be used to gently remove these from the ducts. Or the doctor may try flushing these out with the aid of saltwater solution. However, if your plugs are the kind that have been pushed deeper into the eye in the canaliculus, surgery will be needed to remove them.
If you undergo thermal cautery, keep in mind that in most cases the closure is permanent. However, in a few cases the closure may reopen at some point. If this happens, the procedure will have to be repeated.
If you’ve received the amniotic membrane, you may experience temporary blurring. Also, if a ring of tissue was inserted, you may have some mild discomfort. The amniotic membrane itself usually dissolves over one week. If you have a ring, this will be removed by the doctor once this is dissolved.
After salivary gland transplantation, research shows that you are likely to see improvements in annoying dry eye symptoms such as sensitivity to light, feeling as if you have something stuck in your eye, or feeling pain in the area.
Summary
Surgery may be needed for dry eye syndrome after self-care and medications have not provided relief. Punctal plugs are the most common type of surgery. Punctal cautery or amniotic membrane placement may also be considered. These are all in-office procedures. In more severe cases, salivary gland transplantation may be required, which is done under general anesthesia.
A Word From Verywell
If you have reached the point in which you are considering a surgical solution for your dry eyes, the good news is that, for the most part, these are relatively minimally invasive procedures your doctor can perform in a medical office.
Even so, these are not procedures that your practitioner is likely to recommend until you have exhausted your other options. These procedures can offer you relief if standard therapy has been unable to help.
Early approaches may include using artificial tears, making lifestyle changes such as quitting smoking or using a humidifier, and using medications to increase your tear production. It is only after such measures are unsuccessful that surgery may be considered.
However, LASIK does itself cause dry eye. This can occur when some of the nerves to the cornea (the transparent covering of the colored part of the eye and the pupil) are cut during the procedure. Because of this, the eye may not sense when it is dry and will produce fewer tears. This may in turn cause dry eyes.
This medication belongs to a new class of drugs known as lymphocyte function-associated antigen 1 (LFA-1). It is taken twice a day, just like another prescription dry eye medication, Restasis.
Xiidra is for people needing more than artificial tears. Also, it may be tried by those who have not had enough relief from Restasis or Cequa.
