Efficacy of punctal plugs depends on timing

Issue: November 2006

ByJennifer Byrne

Punctal plugs are criticized by some due to their possible connection to granulomas and dacryocystitis. For this reason, some clinicians may hesitate to treat their dry eye patients with punctal occlusion. However, many other practitioners consider it to be a safe and effective treatment option.

“I believe that plugs still play an important role in the treatment of dry eyes,” Scot Morris, OD, of Eye Consultants of Colorado, told Primary Care Optometry News. “In the right patient at the right time, plugs are instrumental in maintaining a healthy ocular surface.”

When to use plugs

According to Robert A. Ryan, OD, FAAO, a practitioner at the offices of DePaolis and Ryan in Rochester, N.Y., punctal occlusion is best used in cases of aqueous-deficient dry eye.

“This is often determined by clinical evaluation, looking for a thinned or decreased tear prism and through fluorescein and lissamine green staining of the ocular surface,” Dr. Ryan told Primary Care Optometry News. “This type of dry eye is also often found in patients with autoimmune disorders such as arthritis, lupus and Sjögren’s. One needs to carefully evaluate the lids in an effort to differentiate evaporative dry eye from aqueous dry eye.”

Dr. Ryan said in making this differential diagnosis, he also looks at lid position, lid tautness to the globe and the presence of posterior lid disease.

“Any of these findings would suggest more of an evaporative component and are less likely to be remediated by punctal occlusion,” he said. “Diagnostic testing for aqueous-deficient dry eye would include tear volume tests, such as Schirmer’s, or perhaps phenol red thread tests.”

Suspect findings in these tests would support a diagnosis of aqueous deficient dry eye, Dr. Ryan said. “Such cases are more likely to benefit from punctal occlusion,” he said.


Potential complications: Punctal granuloma (left), canalicular granuloma (center) and canaliculitis (right) are all potential complications of punctal occlusion. Images: Morris S and Ryan RA

First-line treatment?

Dr. Ryan added, however, that he does not necessarily reach for punctal plugs as his first-line treatment strategy.

“We will often exhaust various artificial tear and lubrication therapies, as well as environment modifications,” he said. “I also look at systemic medications that patients are taking, which might contribute to ocular surface drying.”

Dr. Ryan said he evaluates each of these factors before suggesting punctal occlusion.

Punctal occlusion [photo]
Dry eye relief: Many patients experience relief from dry, red eyes with punctal occlusion.
Image: Ryan RA

Punctal dilation [photo]
Punctal dilation: Most punctum plugs require punctal dilation before insertion.
Image: Morris S

“A typical stepwise approach would be to prescribe ocular surface lubricants, investigate environmental and systemic contributing factors and modify where able,” he said. “I also suggest management of posterior lid disease.”

According to Paul M. Karpecki, OD, FAAO, a Primary Care Optometry News Editorial Board member who practices at Moyes Eye Center in Kansas City, Mo., timing is important in the effective use of punctal plugs.

“I am a big fan of punctal plugs, I am just not a fan of inserting them at the wrong time,” Dr. Karpecki said in an interview with PCON. “For example, there are a number of conditions that I believe worsen when occluded, such as allergies, meibomianitis and highly inflamed dry eye. I would prefer to consider punctal plugs after these conditions are treated.”

He said even standard cases of dry eye seem to respond better if the occlusion is performed after treatment with medications to target the root cause of dry eye.

“The root cause of dry eye is inflammatory, so I would start a patient on medications such as Lotemax (loteprednol etabonate 0.5%, Bausch & Lomb) and Restasis (cyclosporine ophthalmic emulsion, Allergan Labs, Irvine, Calif.),” he said. “I would consider punctal occlusion after about 3 months of treatment with topicals, if the condition has only marginally improved.”

The topical treatment regimen would be 2 months of loteprednol and 3 months of Restasis, Dr. Karpecki said.

“As a result, the punctal occlusion produces a higher quality of tears,” he said.

Dr. Morris said if the patient has inflammatory ocular surface disease, he typically does not pursue punctal occlusion as a first line of treatment.

“I prefer to decrease the inflammatory cytokines on the surface, using one of the immunomodulating agents before utilizing occlusion,” he said. “I do not want to trap these cytokines on the surface and worsen the damage to the ocular surface.”

After addressing the inflammatory aspect of the condition, Dr. Morris then reassesses the tear prism and ocular surface. “If the patient is still tear deficient or has significant ocular surface staining, then I utilize occlusion appropriately,” he said.

Maximizing efficacy of punctal occlusion

Dr. Karpecki said to attain the full benefits of punctal occlusion, a certain quality of tear is needed. “I believe that plugs are an effective treatment option,” he said. “It’s just that a better quality of tear is needed.”

He added that post-LASIK dry eye seems to respond particularly well to punctal plugs, even without prior treatment with loteprednol or Restasis.

Dr. Morris said he also finds that post-LASIK patients respond well to plugs. “With patients who suffer from mechanical dry eyes (post-LASIK), I use occlusion as first-line therapy in conjunction with artificial tears,” he said.

Dr. Morris said punctal plugs fail to yield maximum benefits only when they are not used appropriately.

“Punctal plugs, like the immunomodulating agents, need to be used at the appropriate time for the appropriate reason,” he said. “The main reason they are being criticized is that many clinicians, both OD and MD, have used plugs as first-line therapy strictly due to financial issues, when plugs may not be the appropriate first choice.”

In such cases, he said, the plug therapy does not have the desired effect, “and occlusion is blamed.”

For more information:

Scot Morris, OD, can be reached at Eye Consultants of Colorado, 10791 Kitty Drive, Suite B, Conifer, CO 80433; (303) 250-0376; fax: (303) 816-7218; e-mail: smorris@eyeconsultantsofco.com. Dr. Morris has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

Robert A. Ryan, OD, FAAO, can be reached at DePaolis and Ryan Eye Associates, 169 Rue de Ville, Rochester, NY 14618; (585) 271-2990; fax: (585) 271-6321; e-mail: rardoc@rochester.rr.com. Dr. Ryan has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

Paul M. Karpecki, OD, FAAO, is a Primary Care Optometry News Editorial Board Member. He can be reached at Moyes Eye Center, Barry Medical Park, St. Luke’s Northland Campus, 5844 N.W. Barry Road, Ste. 200, Kansas City, MO 64154; (816) 746-9800; fax: (913) 681-5584; e-mail: PaulK-VC@kc.rr.com. Dr. Karpecki is a paid consultant for Allergan and Bausch & Lomb.