In people where eye drops did not work, eye doctors may use punctal plugs as a modality of dry eyes treatment. The idea of punctal plugs is to shore up what ever little tears are produced by preventing it from draining through the tear duct. In people with moderate to severe dry eyes, who can still produce tears, this treatment may increase the quality of their lives. The negative aspect is, using punctal plugs may result in allergic reactions to the materials used in the plugs causing the plugs to fall out, or result in eye infections.
There are different ways to plug up tear drainage.
1. Punctal Plugs
2. Thermocautery - use heat to close off the tear ducts permanently
3. Electorcautery - use electronic tool to seal off tear ducts
4. Laser ablation
5. Surgical cauterization- to close up tear duct.
Punctal plugs can be removed if neccessary, in case the person is allergic to the plug material or the plugs can fall out by themselves. About 50% of the plugs fall out within the first year. Methods 2-5 are permanent and cannot be reversed.
Punctal occulusion should be performed after surface inflammation is under control. 1
Before performing a procedure to occlude a punctum permanently, many eye doctors suggest a trial of temporary punctal occlusion using various plugs.4 While this is advised, being able to tolerate the temporary plugs does not give an accurate prediction of side effects of the permanent plugs.
The reported results of punctal plugs vary. It seems to work for people 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 relief dry eyes.
Punctal Occlusion and Inflammation
Punctal plus has been shown to improve objective and subjective measures of dry eye12 , but may increase ocular surface inflammation in subjects with high levels of clinical inflammation.13 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.14
Punctal Plugs and Increased Ocular Bacterial Infections
Because puntal plugs back up tears – which does not allow debri and bacteria from draining. Some people will see an increase in eye bacterial infections, which require anti-biotic eye drops for treatment.
Complications
Although punctal occlusion is an effective therapy for chronic dry eyes, there are complications related to punctal plug insertions. Some of these complications aree
- epiphora - over flow of tears onto the face.
- punctal ring rupture,
- abrasion of the corneal and conjunctival surface,
- suppurative canaliculitis - infection of lacrimal gland ( located at the upper and lower eye lids) causing surface abnormalities that sometime require surgical interventions.
Conclusion
For the right person, punctal plugs could work. Careful selection is critical evaluating risks and benefits. A variety of techniques are available. Punctal occlusion can dramatically improve the quality of life in many people with moderate cases of dry eyes and can prevent visual loss in people with severe cases of dry eyes
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REFERENCES
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.
10. Yazdani C, McLaughlin T, Smeeding JE, et al. Prevalence of treated dry eye disease in a managed care population. Clin Ther 2001;23:1672–1682.
11. American Academy of Ophthalmology Preferred Practice Patterns. Dry Eye Syndrome. 2003. Available at: http://www.aao.org/aao/education/library/ppp/upload/Dry-Eye-Syndrome.pdf.
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.
18. Kojima K, Yokoi N, Nakamura Y, et al. Outcome of punctal plug occlusion therapy for severe dry eye syndrome. Nippon Ganka Gakkai Zasshi 2002; 106: 360–364.
19. Balaram M, Schaumberg DA, Dana MR. Efficacy and tolerability outcomes after punctal occlusion with silicone plugs in dry eye syndrome. Am J Ophthalmol 2001; 131: 30-36.
Punctal plugs or tear duct cauterization are still being used as treatments for dry eyes. Learn the pros and cons of this approach, shoring up tears for dry eye relief.
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