Introduction

Dry eye is a common condition that occurs when the eye either does not have enough oil lubrication from the meibomian glands (called Meibomian Gland Dysfunction) and/or the eye’s lacrimal gland does not produce enough tears to keep the eye moist, comfortable, pain-free, and give crisp vision. 

When relief from dry eye is not achieved by using warm compresses, cleaning with diluted Tea tree oil or Avenova spray (see video), increased oral Omega 3, artificial tears, or other lubricating products, Dr. Cremers often recommends punctal plugs of the eyelid’s puncta or permanent occlusion (if the plugs help but keep falling out). 

A Punctal plug is a tiny devices that occludes the 1 of the 4 puncta or drainage opening of the tear drainage system of the eye, so tears cannot drain into the nose. Punctal plugs are a non-drug procedure for dry eye when artificial tears do not sufficiently decrease dry eye symptoms (burning, redness, foreign body sensation, tearing, itching). This blockage tries to keep your natural tears in your eye longer and improve the quality and quantity of the tear film. One or all 4 openings can be covered or blocked at a time. Doctors often plug both lower eyelids first. If this is not enough, sometimes we will plug the upper puncta as well. If the lower 2 punctal plugs irriate the eye, we will take them out and plug the upper two puncta (or vice versa). 

The most common side effects of occlusion are epiphora (overflow of tears), inhibited tear clearance, and desensitization of the corneal surface, or it does not help symptoms. Very rarely, the plug can lead to an infection in the area of the lacrimal sac or get stuck requiring surgical removal (I have not seen such a case occur but it has been reported).

Punctal Plugs can be classified according:


A. Location of placement:
1. Punctal (at surface of puncta opening)
2. Intracanalicular (deeper into punctal structure)


B. Duration of Placement:
1. Short Duration: Absorbable: made of animal collagen which absorb in about 4-14 days
2. Extended Duration/Semi-Permanent: do not absorb: usually stay in for 2-6 months but have seen them stay in for years. 

C. Punctal plugs can be made out of:

1. Silicone: which are semi-permanent; non-dissolving and may be removed in the future if desired or necessary.

2. Collagen: are temporary
3. Other less commonly used materials:
a. hydrogel
b. polydioxanone
c. acrylic

D. 1 study from Egypt used Botox to cause punctal occlusion after LASIK but not usually done. 

Collagen plugs generally dissolve within four to seven days, while silicone plugs either dislodge spontaneously or are removed by a technician, OD, or MD. 

Surgeons typically prescribe the silicone punctal plugs first unless the patient really wants to try collagen plugs first as the collagen plugs dissolve in a few days (also there are more reports of complications with collagen plugs than silicone plugs as the silicone plugs have a little rim to generally prevent them from falling into the canal too deeply): see below report. 

If the plugs keep falling out, thermal cautery or argon laser achieves permanent occlusion of the puncta.

Punctal occlusion is a permanent (irreversible) alternative to plugs. Should your dry eye symptoms disappear after the temporary or semi-permanent plugs, which keep falling out, you should talk to Dr. Cremers about considering permanent punctal occlusion. If permanent punctal occlusion is considered desirable, the methods most widely used and most effective in producing permanent closure are:

• Electrodesiccation – closing off with electricity 

• Thermal cautery – closing off with heat

• Argon Laser– closing off with Laser: not covered by insurance

 Very occasionally, permanent occlusion may need to be repeated in order to be fully effective. If a patient wants to “undo” the permanent closure, it may require a plastic surgeon to reopen the puncta and canal. 

Similar to punctal occlusion, intracanalicular plugs also block tear drainage, though they act by blocking the canaliculus instead of the punctum so they are pushed further down into the canal.  Most surgeons prefer not to use these as there have been a couple of reports of these causing more risks of infection.

 This is what the inserter looks like: It is about the real size.

 This silicone plug is being placed onto the inserter for placement: it is very small and about the size of the letters “In G” on the dime below. 

There are NO randomized controlled studies to prove one punctal plug is better than the other. Also, given the complexity of the dry eye syndrome and disease, there are no good studies to conclusively prove punctal plugs improve dry eye symptoms for every patient or for even the majority of patients. Still, this procedure is worth a try as it is very low risk and does help patients with their dryness. It may not work for you, but it is worth a try in most patients. It can help prevent the need for using steroid drops for dryness which has the risk of cataract requiring surgery and glaucoma (which is a potentially blinding disease) and is covered by most insurances.

More Information about These Procedures and Permanent Occlusion:

Surgical procedure

Plug insertion is performed in an examination room; it does not require a surgery center. Once you have been checked in and settled comfortably, drops will be used to numb your eye; no injections are needed.

We will ask you to look up and away from your nose. If plugs are being inserted, a forceps-like applicator will be used to place one into the corner of your eye to insert the plug into the orifice of the punctal canal. The entire procedure takes only a few minutes.

The procedure is basically the same for permanent occlusion, only a small injection of anesthesia is given to numb the area. A device is used to seal off (cauterize) the opening and nothing is inserted.

Recovery

Many patients report immediate relief from dry eye symptoms and resume normal activities immediately. Serious complications with punctal occlusion are extremely rare, but like any medical procedure, it does have some risks. If you experience any discomfort with the semi-permanent plugs, Dr. Cremers can easily remove them.

Here is more information about Systemic Reviews of all the data on Punctal Plugs.

Sandra Lora Cremers, MD, FACS

1.

Ophthal Plast Reconstr Surg. 2009 Sep-Oct;25(5):413-4. doi: 10.1097/IOP.0b013e3181b57c01.

Canaliculitis with a papilloma-like mass caused by a temporary punctal plug.

Ahn HB1, Seo JW, Roh MS, Jeong WJ, Park WC, Rho SH.

Author information

Abstract

Absorbable plugs are used before attempting permanent occlusion to observe whether the patient will be amenable to treatment for dry eye. Little is known about the complications of absorbable plugs. The authors present a case of canaliculitis with a papilloma-like mass caused by long-standing unabsorbed collagen plug that had been placed 3 years earlier. This is an uncommon clinical presentation that may be encountered in patients who have canaliculitis symptoms and a history of intracanalicular temporary plug placement.

2. Cochrane Database Syst Rev. 2017 Jun 26;6:CD006775. doi: 10.1002/14651858.CD006775.pub3.

Main results