The Place of Punctal Plugs in Dry Eye Treatment

Punctal Plugs Are Here To Stay

David B. Glasser, MD

Nondissolvable punctal plugs, placed at the ostium of the punctum with the tip exposed, have been a mainstay of therapy for aqueous-deficient dry eye for decades. Plugs significantly increase ocular comfort, reduce the need for topical lubricants and improve vital dye staining compared with use of lubricants alone. Punctal plugs are clinically successful about 75% of the time.^1-4

Among reported complications of plug use are epiphora, corneal and conjunctival abrasion, extrusion, spontaneous loss, biofilm-associated conjunctivitis, granuloma formation, intracanalicular migration and punctal incarceration. These are all rare and are easily reversible with plug removal. Dacryocystitis, rarely reported, can be avoided by ensuring that the lacrimal drainage system is patent prior to placing plugs. Proper sizing and insertion techniques and use of newer plug designs reduce the risk of plug loss and intracanalicular migration. Plug loss is the most common complication, occurring in up to 50% of patients by 3 months. Even after loss, proximal canalicular stenosis associated with the plug may provide some measure of ongoing relief.^1,4-6

More frequent and severe problems are associated with intracanalicular plugs, which may be difficult to remove. Dissolvable plugs are less likely to cause lasting complications, but it is impossible to be certain of their position or if they are effectively impeding tear drainage.

The role of plugs has been challenged since the introduction of topical cyclosporine. Cyclosporine is effective, but it can take 3 months or longer to work, must be used regularly and chronically, is expensive, is effective in only 60% to 75% of patients, and results in complaints of burning in about 15% of patients. In contrast, punctal plugs work immediately and pose no ongoing cost or burden to the patient.

I tend to place plugs in those patients who desire more immediate relief and wish to minimize their dependence on medication. I don’t hesitate to use both plugs and cyclosporine, since they complement each other.^4,7-10 Punctal plugs and cyclosporine will both continue to play important roles in treatment of aqueous deficient dry eye.

Back to the Shelf for Punctal Plugs

W. Barry Lee, MD, FACS

Punctal plugs have been a mainstay of treatment for dry eye disease (DED) and were often considered a first-line therapy in the past.^1,3,11 However, our understanding of dry eye has expanded, and studies now indicate that inflammation plays a key role in the pathogenesis of the condition.^12,13

Given our current understanding of DED, punctal plug efficacy is limited in that it addresses only aqueous-deficient dry eye and has little effect on evaporative dry eye and concurrent blepharitis and no effect as an anti-inflammatory agent.

In fact, punctal plugs may actually worsen dry eyes and blepharitis by trapping cytokines, chemokines, metalloproteinases and T cells on the ocular surface with ultimate worsening of dry eye symptoms.¹⁴ The inflammatory component of the disease has become a main focus for successful therapeutic regimens, as we know this is a progressive condition that can eventually lead to significant ocular surface damage if inflammation is not managed appropriately.^13,14

Initial treatment with topical cyclosporine carries several advantages over initial punctal plug use. Cyclosporine increases tear production, tear break-up time and goblet cell density and decreases corneal staining with vital dyes with subsequent decreased need for artificial tear use.^7,8,13-15 Topical corticosteroids may also be used in short courses either prior to or concurrent with cyclosporine to lessen dry eye symptoms until the cyclosporine reaches appropriate efficacy, so we can avoid placing artificial devices in the puncta and eliminate the risk of potential epiphora, canaliculitis, canalicular obstruction, granuloma formation, extrusion and corneal or conjunctival abrasions over time.^16,17

Punctal plugs remain an adjunct therapy to enhance dry eye treatments in patients with aqueous tear deficiency. However, plugs should no longer be used as a first-line agent as they have the potential to adversely affect the inflammatory component of dry eye. In addition, plugs should be used only after control of inflammation has been implemented and its resulting symptoms have been addressed with appropriate anti-inflammatory agents.

References

Balaram M, Schaumberg DA, Dana MR. Efficacy and tolerability outcomes after punctal occlusion with silicone plugs in dry eye syndrome. Am J Ophthalmol. 2001;131:30-36.
Ervin AM, Wojciechowski R, Schein O. Punctal occlusion for dry eye syndrome. Cochrane Database Syst Rev. 2010;9(CD00679):1-31.
Tai MC, Cosar CB, Cohen EJ, Rapuano CJ, Laibson PR. The clinical efficacy of silicone punctual plug therapy. Cornea. 2002;21:135-139.
Lemp MA. Management of dry eye disease. Am J Manag Care. 2008;14:S88-S101.
Kaido M, Ishida R, Dogru M, Tsubota K. A new punctual plug insertion technique to prevent intracanalicular plug migration. Am J Ophthalmol. 2009;147:178-182.
Bolden I, Klein A, Haller-Schober EM, Horwath-Winter J. Long-term follow-up of punctual and proximal canalicular stenoses after silicone punctual plug treatment in dry eye patients. Am J Ophthalmol. 2008;146:968-972.
Sall K, Stevenson OD, Mundorf TK, Reis BL. Two multicenter, randomized studies of the efficacy and safety of cyclosporine ophthalmic emulsion in moderate to severe dry eye disease. CsA Phase 3 Study Group. Ophthalmology. 2000;107:631-639.
Perry HD, Solomon R, Donnenfeld ED, Perry AR, Wittpenn JR, Greenman HE, et al. Evaluation of topical cyclosporine for the treatment of dry eye disease. Arch Ophthalmol. 2008;126:1046-1050.
Roberts CW, Carniglia PE, Brazzo BG. Comparison of topical cyclosporine, punctal occlusion, and a combination for the treatment of dry eye. Cornea. 2007;26:805-809.
Trattler W, Katsev D, Kerney D. Self-reported compliance with topical cyclosporine emulsion 0.05% and onset of the effects of increased tear production as assessed through patient surveys. Clin Ther. 2006;28:1848-1856.