Punctal occlusion in Sjögren's syndrome needs clarification

Rocha et al. (Punctal occlusion in Sjögren's syndrome needs clarification. Nat. Rev. Rheumatol. doi.10.1038/nrrheum.2012.53-c1)¹ have questioned the role of punctal occlusion in the treatment of primary Sjögren's syndrome (SS), as described in our Review (Topical and systemic medications for the treatment of primary Sjögren's syndrome. Nat. Rev. Rheumatol. 8, 399–411; 2012),² claiming that studies indicate that this procedure is not a viable option. Unfortunately, none of the four studies cited by the authors in support of their view (references 7–10)¹ evaluated punctal occlusion in patients with primary SS. The first two of these studies were published more than 20 years ago and investigated patients with chronic dacryocystitis, the third study evaluated punctal occlusion in healthy individuals and the fourth was a controlled trial that randomized 19 patients with dry eye caused by contact lenses. By contrast, in addition to the articles cited in our review,² a recent study³ has described significant improvements (P <0.0001) in the Schirmer tests, Rose Bengal and fluorescein stainings, and tear break-up time in 19 patients with primary SS at 24 months after thermal punctal occlusion. Therefore, when scientific evidence about the usefulness of punctal occlusion in primary SS is analysed, all available studies (some of which have do have design limitations) support the idea that this therapy should be considered a viable option, rather than the contrary.

Most importantly, Rocha et al.¹ do not address what could be considered the key point: in which patients should punctal occlusion be considered as a therapeutic option? This was clearly stressed in both the text and figure of our Review.2 We suggested that, in the most refractory cases (no response to cyclosporine A, oral muscarinic agonists or autologous serum), temporary occlusion of the puncta through the insertion of plugs may be recommended. In the absence of therapeutic alternatives, the use of a treatment not associated with significant adverse events in patients with severe, refractory dry eye seems to be common sense whilst we await future, well-designed, randomized controlled trials on this topic, although the personal experience of the attending ophthalmologist on the use of punctal occlusion must always be taken into account.