Punctal Plugs for Dry Eye Treatment- Pros and Cons.

 Punctal Plugs for Dry Eye Treatment- Pros and Cons.

 Introduction

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.

Complications

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.

Conclusion

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
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