Punctal plugs an overlooked but effective treatment for dry eye syndrome

Plugs may also be useful after ocular surgical procedures and work alone or in combination with artificial tears and/or anti-inflammatories.

Issue: April 25, 2016

ByMitchell A. Jackson, MD

While sometimes overlooked in favor of other treatments, punctal plugs are an effective tool in the treatment of dry eye syndrome, or DES. With more than 5 million senior Americans significantly affected by DES, as well as millions more affected on a lesser level, providing effective treatment options for this condition is essential.

DES can vary in severity, duration and etiology, although the condition is often caused and/or exacerbated by factors including contact lens use, environmental factors such as weather and allergy conditions, prior refractive eye surgeries, postmenopausal age and female gender, and certain medications, especially antihistamines, anti-depressants and anti-anxiety medications, and various high blood pressure medications. Often resulting from insufficient tear production, excessive evaporation or abnormal composition, DES can cause extreme discomfort, with some patients experiencing sensations of itching and burning, redness, and even reduced visual acuity/visual fluctuation or light sensitivity.

Testing and treatment

The severity of the condition and whether the patient suffers from aqueous-deficient DES or evaporative DES determines treatment. Following the International Task Force Delphi Panel on Dry Eye grading and management guidelines can ensure appropriate care and increased positive outcomes. Testing typically includes assessing stability, production and flow of the tear film, as well as the health of the ocular surface. Tear film osmolarity testing (TearLab) is also useful in diagnosing DES.

The first step in any treatment course is determining if inflammation is present as confirmed by MMP-9 testing (InflammaDry, RPS). If there is inflammation, for the first few weeks I place my patient on an appropriate drop, such as Lotemax gel (loteprednol etabonate ophthalmic suspension 0.5%, Bausch + Lomb), and simultaneously start Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan), as that takes up to 12 weeks to take effect. I will see the patient again after 6 weeks and re-evaluate. If the patient is responding well, I will continue the course with the appropriate lubricating drop and Restasis and add other treatment modalities if needed.

Employing a treatment such as punctal occlusion may cause the inflammatory mediators to create more damage if placed prior to treating inflammation. However, if the patient’s condition has not improved by week 6 or is still not where it should be after 12 weeks, then the next step is punctal occlusion. While the non-dissolvable silicone plugs may sometimes cause irritation on the conjunctival surface due to their shape, punctal plugs have been shown to improve DES symptoms. I typically only plug an eye with aqueous deficiency. I will not plug an evaporative dry eye unless there is an aqueous deficiency component as well.

Dissolvable vs. non-dissolvable punctal plugs

Silicone plugs, such as the Comfortear punctum plug (Paragon BioTeck), comprised of a proprietary blend of 100% liquid silicone rubber, have been shown to have a satisfactory retention rate with few complications. However, in my experience, the dissolvable plugs tend to have a higher retention rate, which helps safeguard against patients losing their plugs due to eye rubbing, incorrect placement or other factors. Because I do not see my patients for several weeks to months after insertion, I prefer to use the Comfortear Lacrisolve 180 absorbable punctum plug, composed of polydioxanone; these plugs dissolve within approximately 180 days. Because the Comfortear Lacrisolve 180 is less prone to falling out than a silicone plug that rests on the surface of the punctum, I can evaluate if the therapy is effective without installing a plug that may need to be removed. If I determine the plug therapy is working, I may recommend a permanent surgical closure.

In conjunction with topical anti-inflammatory lubrication, plugs are also useful after many ocular surgical procedures, including corneal inlay and cataract surgery, in which studies have shown that up to 87% of patients experience dry eye postop. The use of punctal occlusion to combat dry eye and ocular surface issues, both alone and in combination with artificial tears and/or anti-inflammatories, in a multitude of circumstances, can help ensure more favorable outcomes for patients.

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For more information:
Mitchell A. Jackson, MD, can be reached at Jacksoneye, 300 N. Milwaukee Ave., Suite L, Lake Villa, IL 60046; email: mjlaserdoc@msn.com.

Disclosure: Jackson reports he is a shareholder of and has an MAB position with Paragon BioTeck.