Punctal occlusion: clinicians encourage its use, whether in the upper puncta

Issue: December 2000

Either one works well

Albert M. Morier, OD: This is a great question in that both answers are correct. The bottom line is that punctal occlusion works, period. I know several of my colleagues feel strongly that the upper should be done first. I always plug the inferior puncta first because it is much easier for me. The upper puncta are more difficult to work with. Cliff Scott, OD, from New England College of Optometry, gave me a great clinical pearl when he advised me to invert the upper lid. This gives me better access and rigidity to the upper puncta. Nonetheless, I find the lower easier for the patient and me. If the patient’s symptoms are improved but not completely, I occlude the upper puncta with collagen for trial. If this causes epiphora, I know not to occlude both puncta. I will then use a flow control plug in the upper puncta. Following a logical and sequential approach, such as this, makes sense to me and the patient.

Meyer and colleagues, in Ophthalmology (October 1990), showed that the puncta are fairly equal in tear drainage. This has been my clinical impression as well. You will get good results from using either puncta. The bigger issue is that the majority of practitioners do not perform punctal occlusion at all. I would like to see more of my colleagues performing this procedure, whether they occlude the upper or lower first.

Albert M. Morier, OD, is an instructor in clinical ophthalmology at the Lion’s Institute of Albany Medical College. He may be reached at 35 Hackett Blvd., Albany, NY 12208; (518) 355-0956; E-mail: amorier1@nycap.rr.com. Dr. Morier has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

It depends on the cause

Robert L. Davis, OD, FAAO: This great dry eye debate continues to plague the minds of eye care practitioners.

The lower puncta drains approximately 60% of the tears that reach the lower conjunctival fornix. The receding tri-layer wall of tears coats the eye with the blink. As the tears are percolated through glands of Krause and Wolfring, the negative pressure during the blink draws tears from the upper meniscus into the upper puncta. As the process becomes exaggerated, the medial aspects of the eye develop dry eye anomalies such as pinguecula, pterygium, vascular limbal keratitis or 3:9 staining. Tears not adhering to the cornea pool in the lower meniscus and run into the lower puncta, and the patient develops dry eye and epiphora.

The answer to the question lies in the etiology of the dry eye anomaly and the reason for punctal occlusion. At the most basic level, punctal occlusion can improve lubrication, dilute the tear components, increase tear volume or enhance and retain medication. The lower punctum’s main function is draining any excess of lacrimal components. This can be in the form of tear components or medication. The upper punctum drains only components that reside in the upper third of the cornea. The lower punctum drains the runoff.

When the goal is to preserve the lacrimal components that promote wound healing, retain medication, reduce systemic absorption of topical pharmaceuticals, increase tear volume, dilute tear components, preserve tear components or reduce the outflow of tears into the nasal mucosa or sinus cavities, lower lid punctal occlusion is the therapeutic choice.

If the cause of the dry eye is a poor mucoid layer or poor oily layer, the upper punctum will drain off the benefits of the tri-layer tear film. If a reduced aqueous layer causes the dry eye, plugging the lower punctum will result in more tears within the tear meniscus.

Another approach is to quantify the area of corneal staining. If the staining occurs in the lower third of the cornea, plugging the lower punctum will add to a therapy. If the medial aspect or the upper third of the cornea stains, plugging the upper punctum will help resolve the dry eye anomaly.

The patient’s complaint will lead you to the appropriate punctum to occlude during the case history. Develop a good therapeutic plan with the principals of punctal occlusion. Punctal occlusion is an additional tool to resolve the problems of an open drainage system into the nasal cavity that has a difficult time regulating itself during an ever-changing ocular environment.

Robert L. Davis, OD, FAAO, can be reached at 4663b West 95th Street, Oak Lawn, IL 60453; (708) 636-0600; Fax: (708) 636-0606; E-mail: eyemanage@visionoutpost.com. Dr. Davis has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

Lower is easier

Arthur B. Epstein, OD: Most clinicians who regularly work with dry eye patients find punctal occlusion to be of substantial benefit. Silicone plugs are easy to insert and offer the added advantage of reversibility if problems arise. The majority of patients do well clinically with occlusion of either upper or lower puncta. However, selecting which set of puncta to occlude remains controversial.

The contribution of upper and lower puncta to overall lacrimal drainage has been thoroughly investigated. Some authorities feel that the inferior puncta carry more of the drainage load than do the superior puncta. However, most research has indicated that both contribute almost equally to tear drainage. When one set is occluded, the other set takes up most of the load.

Although many studies indicate that plugging either upper or lower puncta alone should have no significant overall effect, this is one of those situations where clinical experience paints an entirely different picture. In my personal experience, plugging either uppers or lowers will usually produce significant clinical and symptomatic improvement in the vast majority of patients. In severe dry eye, occlusion of both puncta may be necessary.

I usually prefer to occlude the lower puncta first because it is more easily accomplished. The only exception is when patients present with significant meibomianitis or blepharitis. These patients typically have a significant evaporative component to their dry eye, which is effectively countered by punctal occlusion. Unfortunately, they also have a high concentration of bacterial toxins (secondary to lid over-colonization) as well as high levels of free-fatty acids (from abnormal lipid production) in their tear film. The toxins pool inferiorly, producing a characteristic inferior rose bengal staining pattern. In addition to concurrently treating their lid disease, I also occlude the superior puncta first. This facilitates inferior tear clearance and more rapid removal of these irritants.

Arthur B. Epstein, OD, is director of the contact lens service of North Shore University Hospital, New York University School of Medicine and is an adjunct assistant professor at the Northeastern State University College of Optometry. He can be reached at North Shore Contact Lens and Vision Consultants, PC, 1025 Northern Blvd., Ste. 94, Roslyn, NY 11576, (516) 627-4090; fax: (516) 627-4169; artepstein@attglobal.net. Dr. Epstein has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.