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Punctal Plugs for the
Treatment
of Dry Eye Syndrome |
Imagine you want to keep water in your bathtub for
longer. You could put a stopper in the drain, right? The
same principle can be used to help patients who don’t
produce enough tears. Tiny “stoppers” called “punctual
plugs” can be placed, quickly and painlessly, into the
small drain holes in the inner corner of the eyelids to
help keep tears from draining out. Punctal plugs allow
tears to stay on the eye longer, and can help relieve
the itching, burning, feeling of sand, and excess
“reflex” tearing that are common symptoms in dry eye
syndrome patients. Inserting punctual takes only
seconds, does not require any surgery, and can be done
right at the exam room microscope with just a drop of
anesthetic.
Plugs come in two basic types – dissolvable and
“permanent.” Dissolvable plugs are made of a protein
called collagen which can last between a few days and a
few months, depending on the brand and style used.
Permanent plugs are made of non-dissolvable plastic and
can last indefinitely. |
At One-to-One
EyeCare, we
can determine whether punctual plugs might help your dry
eye problem. We’ll take as much time as needed to
explain all of the advantages and the potential
complications, which are very rare. To schedule your
dry eye evaluation, call us at 858.273.0200.
Punctal plugs, which can be inserted into the lower or
upper punctum, or both, have become a more common office
procedure to treat patients with dry eye symptoms which
do not respond to topical treatment.
There are several types of punctal plugs, which have
different properties and uses depending on the material
from which they are composed. They are commonly divided
into punctal (or punctum) plugs, which are placed at the
top of the puncta, with the tops visible and
intracanalicular plugs, which are inserted into the
canaliculus, and thus cannot be seen after insertion and
need to be flushed out with irrigation for removal. In
practice, both types are plugs are commonly referred to
as “punctal plugs”.
Collagen implants are dissolvable punctal plugs that may
be used as a trial to assess if occlusion will
ameliorate the patient’s symptoms and to rule out
intolerable epiphora due from occlusion before
irreversible punctal occlusion is performed. They
dissolve within 4-7 days and do not cause complete
canalicular occlusion. They are available in a variety
of sizes and from a variety of manufacturers (see below
for list of some manufacturers). Collagen implants may
be used as a trial of punctal occlusion prior to more
permanent treatment, for temporary enhancement of
topical medications, for post-operative reduction of dry
eyes and in the assessment of the effect of aqueous tear
deficiency on ocular surface disease. |
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Silicone punctal
plugs come in a variety of shapes and sizes, and
usually remain for several months to years
unless they are manually displaced or are too
loose at the time of insertion. Most are
umbrella shaped with the “umbrella” portion of
the plug resting on the eyelid margin at the
punctum. The benefit of these plugs is that they
are visible at the slit lamp and can be manually
displaced. Of note, once a plug has been
displaced from a punctum, subsequent plugs are
more likely to be displaced from that punctum,
and overdilation of the punctum should be
avoided. There are several risks to the
placement of silicone punctal plugs. The plugs
can be advanced too deeply, causing inadvertent
insertion into the nasolacrimal system, which
necessitates surgical removal. Other risks of
plug placement include the development of a
pyogenic granuloma, canaliculitis, or
dacryocystitis, although these are infrequent
side effects. More common risks include
spontaneous extrusion of the plug (which occurs
in almost 40% of patients within the first six
months), local irritation at the site of the
plug, or epiphora which is intolerable to the
patient. Excessive tearing is more common when
both the upper and lower punctal are blocked. In
cases of intolerable epiphora, the plug can be
removed at the slit lamp.
There are several companies which manufacture
both collagen and silicone punctal plugs,
including Eaglevision, US-IOL, FCI Ophthalmics,
Delta Life Science, Odyssey, Angiotech, Medenium,
Lacrimedics, Oasis and others. While collagen
and silicone plugs have been available for some
time, newer technologies have developed such as
the SmartPLUG (by Medennium), which uses a
hydrophobic acrylic polymer and the Oasis
Hydrogel Intracanalicular Long-term Plug, which
uses a hydrogel material. These materials change
shape when exposed to body temperature and
tears, respectively, allowing them to reshape
into soft, gel-like plugs that occlude the
punctum. In addition, silicone plugs have been
modified to have varying shapes and sizes, with
some designed to regulate the lacrimal drainage
for cases in which total occlusion may cause
epiphora. The Herrick dissolvable plugs (from
Lacrimedics) function as medium-term occlusion
treatment, lasting approximately 4-6 months.
They have the same indications as collagen
implants, but a longer duration of action. They
are made of polydiaxonone and are placed in the
horizontal canthus similarly to intracanalicular
collagen implants. |
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