Friday, July 14, 2017

Punctal Plugs for Dry Eye Treatment- Pros and Cons.

 Punctal Plugs for Dry Eye Treatment- Pros and Cons.


In patients who do not find symptomatic relief despite medical therapy and maximal lubrication, punctal occlusion is often indicated. Rather than applying an artificial tear, punctual occlusion helps to preserve any remaining natural tear fluid, which has by far the best wetting and nutrient capacity for the ocular surface. Preserving the patient’s own natural tears by blocking the lacrimal drainage system, thereby increasing tear volume and decreasing tear osmolarity, can successfully maintain the integrity of the ocular surface, corneal transparency and visual acuity. In patients with moderate or severe dry eye, it is capable of improving quality of life and preventing vision loss.

Punctal Occlusion for Dry Eye Syndrome

The idea behind punctal occlusion is straightforward: increase the aqueous component of the tear film by blocking tear outflow..Punctal occlusion helps to retain the patient's own tears on the ocular surface. This intervention is highly effective and usually used after environmental control, drop therapy, omega-3 fatty acid supplementation and topical prescription eye drop prove inadequate. Preferably performed after surface inflammation is brought under control, occlusion methods include punctal plugs as well as thermocautery, electrocautery, laser ablation or direct surgical closure.
Before performing a procedure to occlude a punctum permanently, many authors suggest a trial of temporary punctal occlusion using various plugs. While this is prudent, one must keep in mind some of the intrinsic limitations of these devices. More specifically, failure of collagen plugs to predict epiphora after permanent punctal occlusion. One systematic review7 showed a relative scarcity of controlled clinical trials assessing the efficacy of punctal occlusion therapy in dry eye. Although the evidence is very limited, the data suggest that silicone plugs can provide symptomatic relief in severe dry eye. Moreover, temporary collagen plugs appear similarly effective to silicone plugs on a short-term basis.

The reported results of punctal plugs vary. It seems to work for patients with dry eye of mostly mild to moderate severity. The magnitude of the treatment effect was more striking following implantation of non-dissolvable silicone plugs, but occlusion with temporary collagen plugs also had an apparent beneficial influence on the clinical course of dry eye, as indicated by significantly lower scores for several study parameters in comparison with the control group.

Punctal Plugs and Inflammation

One area of interest is the relationship of pharmacologic therapies with punctal occlusion. Punctal occlusion has been shown to improve objective and subjective measures of dry eye but may exacerbate ocular surface inflammation in subjects with overt clinical inflammation. Because of this issue, an international panel of experts developing comprehensive treatment guidelines for ocular surface disorders recommended that the inflammatory condition be treated before punctal occlusion.

Punctal Plugs and Increased Ocular Bacterial Infections

Because puntal plugs back up tears – which does not allow debri and bacteria from draining. Some patients will experience ocular bacterial infections, which require anti-biotic eye drops for treatment.


Although punctal occlusion is an effective therapy for dry eye disease, there are complications related to punctal plug insertions.Recognized complications of conventional silicone plugs include
  • epiphora - over flow of tears onto the face
  • punctal ring rupture,
  • abrasion of the corneal and conjunctival surface,
  • suppurative canaliculitis - infection of lacrimal gland causing surface abnormalities that sometime require surgical interventions.
The retention rates for the different kind of silicone plugs have been reported to be about 50% after one year,extrusion of silicone plugs is common, occurring within three months in up to 50% of cases.


Careful patient selection is critical for successful punctal occlusion. It should be performed only when appropriate, and when the likelihood of benefit far outweighs the risk and cost. A variety of techniques are available to choose from on the basis of the duration of desired effect and the severity of aqueous tear deficiency and associated ocular surface disease. Punctal occlusion can dramatically improve the quality of life in many patients with moderate cases of dry eyes and can prevent visual loss in patients with severe cases of dry eyes
How TheraLife Eye can help!

TheraLife Eye is clinically proven to be 80% effective in dry eye relief for first time users.  TheraLife Eye is effective when puntal plugs, prescription eye drop, eye drops failed. The reason is because TheraLife Eye work on restoring normal cell functions to tear secretion glands,  intracellularly.

To learn more: click here

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1. American Academy of Ophthalmology. Punctal occlusion for the dry eye. Ophthalmology 1997; 104: 1521.
2. Freeman JM. The punctum plug: Evaluation of the new treatment for the dry eye. Trans Am Acad Ophthalmol Otolaryngol 1975; 79: 874–87.
3. Dohlman CH. Punctal occlusion in keratoconjunctivitis sicca. Trans Am Acad Ophthalmol Otolaryngol 1978; 85: 1277-1281.
4. Cohen EJ. Punctal occlusion. Arch Ophthalmol 1999; 117: 389–90.
5. Glatt HJ. Failure of collagen plugs to predict epiphora after permanent punctal occlusion. Ophthalmic Surg 1992; 23: 292–3.
6. Redmond JW. Correspondence: Punctal occlusion with collagen implants. Ophthalmic Surg 1992; 23: 642.
7. Ervin AM, Wojciechowski R, Schein O. Punctal occlusion for dry eye syndrome. Cochrane Database Syst Rev 2010 Sep 8;(9):CD006775.
8. Geldis JR, Nichols JJ. The impact of punctal occlusion on soft contact lens wearing comfort and the tear film. Eye Contact Lens 2008 Sep; 34(5): 261-5.
9. Nava-Castaneda A, Tovilla JL, Rodriguez L, et al. Effects of lacrimal occlusion with collagen and silicone plugs in patients with conjunctivitis associated dry eye. Cornea2003; 22: 10-14.
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11. American Academy of Ophthalmology Preferred Practice Patterns. Dry Eye Syndrome. 2003. Available at:
12. Dursun D, Ertan A, Bilezikci B, et al. Ocular surface changes in keratoconjunctivitis sicca with silicone punctum plug occlusion. Curr Eye Res 2003; 26: 263–269.
13. Pflugfelder SC. Anti-inflammatory therapy for dry eye. Am J Ophthalmol 2004; 137: 337–342.
14. Behrens A, Doyle JJ, Stern L, et al. The Dysfunctional Tear Syndrome Study Group. Dysfunctional tear syndrome: a Delphi approach to treatment recommendations. Cornea 2006; 25: 900–907.
15. Yang H, Fujishima H, Toda I, et al. Lacrimal punctal occlusion for the treatment of superior limbic keratoconjunctivitis. Am J Ophthalmol 1997; 124:80–7.
16. Sugita J, Yokoi N, Fullwood NJ, et al. The detection of bacterial biofilms in punctal plug holes. Cornea 2001; 20: 362–365.
17. Murube J, Murube E. Treatment of dry eye by blocking the lacrimal canaliculi. Surv Ophthalmol 1996; 40: 463-480.
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