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Punctum plugs: Often the last resort in dry eye treatment
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Typically, practitioners turn to punctal occlusion only after topical therapy to treat inflammation, management of environmental factors and the resolution of systemic issues fail to improve the signs and symptoms of dry eye. With the multitude of plugs available on the market today, plug choice depends on clinician comfort with the product and the anatomy of patients’ puncta.
When to use plugs
Deciding whether or not to resort to punctal occlusion depends on a patient’s response to traditional treatments and his or her dry eye history, slit lamp evaluation and tear break-up time.
According to Scot Morris, OD, FAAO, “Current medical philosophy is to use them as a secondary agent behind traditional inflammatory mediators such as Restasis [cyclosporine ophthalmic emulsion, Allergan] or steroids. Most practitioners — me included — will treat inflammation first with steroids, Restasis and artificial tears, treat the eyelid margin and manage the environment and whatever systemic issues they have for the first 8 to 12 weeks. If we haven’t gained what we needed to from a dry eye standpoint, then plugs are usually the next thing off the shelf,” he said in an interview with Primary Care Optometry News.
Intracanalicular plugs
Punctum plugs are typically classified into two categories: intracanalicular plugs that are buried in the canaliculi and surface plugs that have a cap on top.
Intracanalicular plugs are made of dissolvable collagen, hydrophobic acrylic, silicone and hydrogel materials. They are inserted beyond the puncta and are, therefore, rarely felt by the patient.
Chris White, OD, uses intracanalicular plugs frequently and recommends them in cases where the anatomy of a patient’s lid and the proximity of the puncta to the conjunctiva make the use of surface plugs uncomfortable.
“There are cases where surface plugs will cause conjunctival abrasion due to lid anatomy,” he told PCON. “[Intracanalicular plugs] are comfortable, work well, are tolerated by patients extremely well and don’t seem to cause secondary infections.”
Unfortunately, some practitioners find intracanalicular plugs difficult to remove and visualize, even when using transillumination. In rare cases, intracanalicular plugs are not able to be flushed with saline and must be removed surgically.
Thomas D. Gilbert, OD, FAAO, sometimes uses intracanalicular plugs and has seen the potential complications. “[A granuloma] may grow around the plug, and patients will have to have them surgically removed because they won’t slide through,” he told PCON in an interview.
Another potential complication is an infection called canaliculitis, which can be treated by antibiotics, irrigation of the canaliculus and drainage of suppurative material.
Surface plugs
One obvious advantage of using a surface plug is that they can be easily seen and removed without patient discomfort or complication. Surface plugs are made of a variety of materials, including dissolvable collagen, polyethylene, silicone and acrylic.
Dr. Gilbert tends to use surface plugs more often because of their accessibility. “I prefer a plug that has a cap on it so I can see it’s in there; I can also remove it easily if I need to,” he said.
One problem seen with surface plugs is abuse of the product, according to Dr. White, which can cause serious problems with unappealing surgical options. “The greatest complication I’ve seen is the result of a surface plug being pushed down into the canaliculus,” he said. “When a patient develops a granuloma around a plug that is ill-positioned, the surgical repair is not attractive to the patient.”
More commonly, surface plugs may be lost. If the plug’s cap is sticking out, it can cause irritation, Dr. Gilbert said. “Patients may rub their eyes if they itch and, suddenly, the plug is gone.”
Plugging the superior vs. inferior puncta
With studies suggesting 60% of tear drainage occurs through the inferior canaliculi, most practitioners will see improvement by plugging only the inferior puncta and leaving the superior puncta open.
“It’s extremely rare for me to plug the superior puncta — in fact, it’s been years since I have done that,” Dr. Morris said. “Also, I don’t believe in blocking all four puncta. No outflow causes just as many problems as having poor in-flow. Not having enough tears is not a great thing, but then concentrating all of the inflammatory mediators and antigens on the surface by blocking all four puncta is just as bad and creates just as many problems.”
Dr. White uses a different approach in determining which puncta should be plugged. “Depending on the anatomy of the lid margin where the puncta meets the conjunctiva, I’ll make a judgment on upper or lower. Also, staining patterns can help determine which will be more prudent. So, based on anatomy, evaluation in a slit lamp, diagnosis, history of previous occlusions — success or lack of success — that the patient might be able to report will all drive my thinking on upper or lower,” he said.
When not to plug
Punctum plugs are an effective way to prevent tears from draining too quickly, but according to Dr. Morris, they must be used ethically and when appropriate in patients with ocular surface disorders.
“I’ve had numerous doctors come up to me when I speak and say, ‘We just do it so we can make the money.’ Dry eye is a profitable business; we don’t need to do things that are unethical.” he said.
For more information:
- Scot Morris, OD, FAAO, 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.
- Chris White, OD, can be reached at drwhite@cweyes.com.
- Thomas D. Gilbert, OD, FAAO, can be reached at TLC Laser Eye Centers: Mid-Atlantic Region, 8415 Pulsar Place, Suite 120, Columbus, OH 43240; (614) 436-1000; fax: (614) 430-9388; e-mail: tom.gilbert@tlcvision.com.
- Drs. Morris, White and Gilbert have no direct financial interest in the products mentioned in this article, nor are they paid consultants for any companies mentioned.