Dry eye syndrome, or DES, is believed to be the most undertreated and underdiagnosed eye health problem. Those who have a DES diagnosis and find that their condition is chronic may consider punctal plus as a form of treatment. Most ophthalmologists agree that these plugs are quite beneficial, but that they should not fully replace other forms of treatment. In fact, they should often be used together with other forms of treatment.
That said, if tear supplementation, for instance, through artificial tears, is not sufficient to resolve the symptoms of DES, then punctal plugs may be considered. It should be noted, however, that because these are inserted into the eye, there is a chance of infection, albeit a small one.
What Are Punctal Plugs?
Simply put, they are very small, biocompatible tools that are inserted directly into the tear ducts, stopping the ducts from draining the tears. In so doing, dry eyes can find relief because the tear eye film is more stable, and the surface of the eye remains moisturized. Punctal plugs, also known as occluders or lacrimal plugs, are about the size of a grain of rice. There are two general types:
- Dissolvable plugs made from collagen or other materials, which the body absorbs over time. These plugs can last anything from a few days to a few months and are usually provided to those who have had refractive surgery or LASIK. They can also be used to determine whether punctal plugs are a viable treatment option.
- Semi-permanent plugs, generally made of silicone
How Punctal Plugs Are Inserted
Ophthalmologists will start by measuring the size of the puncta (openings of the tear ducts), so that they can choose the right plug. There are one size fits all solutions as well, particularly for the dissolvable models. You may receive a local anesthetic before the plug is inserted, but this is generally not needed. The plug itself is inserted using a type of forceps or a type of syringe. Most ophthalmologists have their own preference when it comes to how to insert them.
Because there are many different types of plugs, the insertion method to be used will vary. For instance, some can be seen, which means they can also be mechanically removed. Others are inserted into the canaliculus, which means they don’t protrude and aren’t felt either. If they must be removed, they will have to be flushed out.
The procedure is no more than uncomfortable. Once in place, you will not be aware of the plug at all. The procedure is completed on an outpatient basis, and you should be able to return to normal activities, including driving, immediately.
The Different Types of Punctal Plugs
The table below highlights some of the different types of punctal plugs.
Plug Type |
Details |
Pros |
| Umbrella | Sticks out slightly for easy removal.
Works best on people with severe DES. Made from silicone. |
One size fits all solution.
Easy to remove. Only a small piece of plug sticks out of the duct. Causes less irritation. More affordable. Can comfortably stay in place for two years. |
| Tapered | Exerts extra horizontal force to keep it in place. | Perfect for those with rapid tear breakup time.
Suitable for people with haloing, discomfort, and visual fluctuations. Easy to insert. Very physiological, making it more comfortable and easy to retain. |
| Low profile or slanted cap | Generally experienced as more comfortable.
Is more stable than other types. Generally made from silicone. |
Very comfortable.
Works on those with severe tear deficiency. Easy to insert. Very few complications. |
| Herrick Plug | Available in dissolvable collagen and harder silicone, which can last up to 2.5 years.
These are not covered by Medicare if used preoperatively. |
Perfect for long term use.
No dilation needed for insertion. Easy to remove through probing or flushing. Good for those with severe DES who do not respond to drops. Can be used by the elderly. Can be used following cataract surgery. Easy to insert. |
| Soft silicone | Made in a range of different sizes with a disposable inserter. | Very easy to insert.
Can be removed. Does not dissolve. Great for people who do not notice improvements with artificial tears. Can be used after LASIK. Works on crusted eyelid skin and eyelid margins. Can stay in place for long periods of time. |
| Clear silicone | These feel very natural because they are soft.
They are clear, which means they are not visible, which is more cosmetically acceptable. |
Very comfortable.
Can be left in place for many years. Very easy to remove. Can be used after LASIK. |
Depending on the type of punctal plugs used, they can be made of hydrogel, polydiaxonone, hydrophobic acrylic polymer, collagen, or silicon. Some have a slick coating to make it easier to insert them. There are also some that melt when they reach body temperature: they are made of a gelatin-like acrylic material. Hydrogel plugs hydrate and fill the tear duct cavity.
Side Effects and Issues with Punctal Plugs
In the vast majority of cases, the insertion of a punctal plugs is easy and there are no complications. However, there are some reported side effects. These include:
- Epiphora (excessive tearing), if the plug works too well. This may require removal of the plug, to be a replaced with a different model.
- Punctal plugs can get lost or be displaced, particularly if people rub their eyes. This is particularly common with harder types, which may fall out. If that happens, a replacement will need to be fitted.
- Eye infections, albeit rare. Some people are known to have developed canaliculitis as a reaction to the plugs, which is accompanied by yellowish secretions and swelling of the tear duct. This, in turn, can lead to infections in the upper respiratory tract, which can lead to germs going into the canaliculus due to excessive nose blowing. Antibiotics will be needed and the plug may need to be removed in this case.
- Migration of the plug deep into the drainage channels of the eye. This leads to blockage, which can cause dacryocystitis, leading to discomfort, pain, and swelling. Surgery may be required, particularly if irrigation is not effective.
- Tissue formation over rigid punctal plugs, which leads to stenosis (narrowing of the channel). The plug can then be removed. The extra tissue that has been developed will then start acting as a plug.
Removing Punctal Plugs
Semi-permanent plugs can last for many years. Most ophthalmologists do not know of any cases where the plugs have stayed in place for over three years, but it is theoretically possible. It is always easy to remove punctal plugs, either by simply gripping the top and pulling it out, or by flushing it out through irrigation.
If, for instance, you were to experience an eye infection, or you are worried about complex side effects, then you must speak with the ophthalmologist, who will be able to find out whether the plug should be removed. If so, forceps may be used, or flushing, running the plug into the nasal cavity.
Resources and References:
<a href=”http://www.aao.org/eye-health/news/choosing-wisely-punctal-plugs”>American Academy of Ophthalmology</a> – Choosing Wisely when It Comes to Eye Care: Punctal Plugs for Dry Eye (AAO.org)
<a href=”http://www.aao.org/eyenet/article/intracanalicular-plugs-use-with-caution”>American Academy of Ophthalmology</a> – Intracanalicular Plugs: Use with Caution (AAO.org)
