Cover Feature: Cornea Tool Time
May 2007

by Christine Hamel
EyeWorld Contributing Editor

For the treatment of dry eye syndrome, punctal plugs are an important tool. Fortunately, serious complications with the use of these plugs are extremely rare. However, like any medical procedure, it does have some risks. According to Robert K. Maloney, M.D., Los Angeles, California, after refractive surgery many patients have reduced tear production and complain of symptomatic dry eyes. An inferior punctal plug in each eye can make them feel significantly more comfortable. “I want my patients after refractive surgery to be very comfortable. If they’re complaining of symptoms related to dryness, I’m quick to put plugs in,” says Dr. Maloney.

Dr. Maloney generally prefers permanent plugs over temporary plugs. He says, “My experience with temporary plugs is that they do not occlude tear flow very well, and they’re obviously temporary. I’d rather put a permanent plug in and if it’s ineffective take it out, rather than deal with incomplete occlusion yielded by temporary plugs.”

His general process for managing dry eye after refractive surgery is to first determine whether blepharitis is present, and once that is controlled for, he places an inferior punctal plug in the affected eyes if patients are still complaining of any symptoms of dryness. If symptoms continue, he then places a superior plug in each eye.

However, Dr. Maloney notes that it’s common for patients to develop epiphora when four punctal plugs are used. He says, “that’s very diagnostically helpful, because if the eyes are comfortable, even though they’re overflowing, then you can be very confident that it’s aqueous tear deficiency that’s causing the symptoms. On the other hand, if you have overflow tearing and they’re still uncomfortable, you have to look more carefully for other possible causes of discomfort.” In cases where epiphora develops, he removes the superior punctal plugs and replaces them with flow-control plugs, “It’s the equivalent of having one-and-a-half puncta occluded [in each eye].”

The rate of epiphora can be reduced if physicians avoid placing punctal plugs in the inferior puncta and place them in the superior puncta first. However, many physicians avoid placing them in the superior puncta, in order to avoid the complication of the feeling of a foreign body sensation and irritation. “I never put punctal plugs in the upper punctum, where the lid is moving, “ says James J. Salz, M.D., clinical professor of ophthalmology, University of Southern California, Los Angeles. “In the lower lid some patients feel some irritation from the plug, but in the upper lid almost everybody is going to feel irritation from it. So I tend to cauterize the upper punctum, rather than putting in a plug.”

However, he adds that some patients are reluctant to have their puncta cauterized, so he also recommends using a temporary punctal plug as a test for punctal cautery. “We won’t create a situation where you went from a dry eye to a wet eye, which can be just as annoying, so we use that as a test for punctal cautery,” says Dr. Salz.

Having a punctal plug fall out is another common complication. Although losing a plug is not painful, it may be inconvenient for the patient to return for a replacement. “Basically, you put them in, and they still fall out,” says Dr. Salz. “But I think they’re useful, and I have some patients who tolerate them well…. We’ve had some people who’ve had them in for over a year.” In cases where the plugs fall out, Dr. Maloney recommends the use of intracanalicular ocular plugs, like the SmartPlug (Medennium, Irvine, Calif.), which won’t fall out. However, he generally prefers using the mushroom-style plugs, using intracanalicular plugs only if the mushroom-style plugs keep falling out. “I try to avoid intracanalicular plugs, because it’s hard for me to determine if the plug is still there, because you can’t see it,” says Dr. Maloney. “If you need to remove it because of epiphora, you can irrigate it [through the lacrimal system], but you’re never quite sure if it’s free of occlusion.” “Fortunately, there’s almost no risk,” says Dr. Maloney. “The main complication is [intracanalicular ocular plugs] can cause canaliculitis or chronic dacryocystitis, if they get retained in the lacrimal sac or canaliculus, but that’s fortunately rare. Occasionally when you’re putting the mushroom-style plugs in, they can actually end up in an intracanalicular location by accident. Then you can’t remove them; you have to irrigate them through the lacrimal system,” says Dr. Maloney. “It can get stuck in there and then cause inflammation and occlusion of the system.” However, this complication is very rare. Overall, the complications of punctal plugs are rare and most are easily remedied, making punctal plugs an effective option in treating moderate to severe dry eye after refractive surgery.

Editor’s note

Neither Dr. Maloney nor Dr. Salz reported any financial interests related to their comments.

Contact Information

Maloney: 310-208-3937, erussell@maloneyvision.com
Salz: 310-360-0609, jjsalzeye@aol.com