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Literature search highlights pros, cons of various lacrimal drainage plugs for dry eye
In select cases, plugs may be more cost-effective than continued use of lubricants.
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Lacrimal drainage plugs improve the signs and symptoms of moderate dry eye and are well tolerated in eyes that do not benefit from topical lubrication, according to 27 level 2 and 3 studies culled from the PubMed and Cochrane Library databases.
The report by the American Academy of Ophthalmology, which appeared in Ophthalmology, was generated because of the widespread prevalence of dry eye. “For example, overall dry eye affects about 15% of adults,” lead author Marcus M. Marcet, MD, FACS, a clinical assistant professor of ophthalmology at the University of Hong Kong, said. “And in an ophthalmology clinic, it is often the most common presenting concern for patients.”
Previously, Marcet served on the medical faculty at the University of Chicago, where he observed dry eye as a common symptom. “However, I have now seen firsthand that dry eye is a global problem,” he said.
In addition, lacrimal plugs are a common treatment option for patients with moderate to severe dry eye, “which remains symptomatic after topical lubricants,” Marcet told Ocular Surgery News. “We wanted to answer the question of whether lacrimal plugs work and whether the plugs are safe.”
Plugs improve symptoms
The authors were surprised that their search results did not identify any level 1 evidence. Also startling was the fact that about 40% of punctal plugs fall out.
“Personally, I find that dilating the punctum first and choosing a larger size plug helps keep the plug more securely in place,” Marcet said.
Based on the literature search, punctal plugs improve dry eye symptoms in 50% to 94% of patients. “It is worth noting that typically these are patients with moderate to severe dry eye who were unimproved by topical therapies,” Marcet said.
All of the four studies that evaluated the efficacy of intracanalicular plugs found significant improvement in dry eye symptoms. The data on dissolving plugs also indicate that patients experience improvement in their dry eye symptoms.
“However, the main limitation of dissolving plugs is that the improvement is temporary,” he said. Still, dissolving plugs may serve as a trial plug for patients, although the safety data on dissolving plugs are limited.
Image: Marcet MM
Accessibility of plugs
Punctal plugs were found to be generally safe. The main concern, though, is plug loss, Marcet said. Furthermore, about 10% of patients report an excess of tears in the form of epiphora.
“However, because the plug sits at the punctum, it can easily be removed, if needed,” Marcet said.
Intracanalicular plugs are not readily accessible after they are placed in the canaliculus.
“This is why they are sometimes referred to as permanent plugs,” Marcet said. “The intracanalicular plugs also have a higher association with inflammation, such as canaliculitis and pyogenic granuloma formation.” A minority of patients with intracanalicular plugs required more invasive treatments such as canaliculotomy and dacryocystorhinostomy.
Plugs are dispensed for other types of dry eye as well, such as in contact lens wearers and in patients after LASIK surgery.
The authors hope that their literature search will provide practical data for discussions between clinicians and their patients about lacrimal plugs.
“In certain patients, the placement of plugs may be more cost-effective than the continued use of lubricants,” Marcet said.
Studies have shown that dry eye significantly impacts a patient’s quality of life.
“Common symptoms of dryness include blurred vision, eye pain, irritation, foreign body sensation and redness,” he said. “If untreated, more severe cases of dry eye can result in vision loss due to corneal scarring. However, in the studies on lacrimal plugs, we found there was a general lack of quality-of-life measures.”
The AAO report “identifies gaps in the current literature,” Marcet said. “We really need rigorous studies, including randomized controlled trials.” – by Bob Kronemyer
- Reference:
- Marcet MM, et al. Ophthalmology. 2015;doi:10.1016/j.ophtha.2015.04.034.
- For more information:
- Marcus M. Marcet, MD, FACS, can be reached at Department of Ophthalmology, University of Hong Kong, Room 301, Block B, Cyberport 4, 100 Cyberport Road, Hong Kong; email: marcet@hku.hk.
Disclosure: Marcet reports no relevant financial disclosures.
Perspective
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Damien F. Goldberg, MD
The take-home message in Marcet et al.s review of articles on lacrimal drainage plugs is that there is a benefit of using the plugs for dry eye, even though the majority of the studies reviewed are not of ideal study quality. Level 1, level 2 and level 3 studies were rated, with level 1 being very high quality, well-controlled studies and level 3 being not so well controlled. The majority of the articles were level 2 or 3.
The reality is that, over four decades, there have not been great randomized clinical study trials, but punctal plugs do improve symptoms of moderate dry eye when artificial tears cant seem to control the symptoms. Personally, I think punctal plugs are cost-effective and inserting them in the office is easy to perform. Not every patient sees improvement but the majority do. Better randomized control trials are needed, and more quality-of-life research should be done.
I would like to see more randomized study comparing plugs to alternative dry eye therapies, such as topical cyclosporine. I believe there would be general interest in more of these dry eye therapy comparisons.
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