If you suffer from chronic dry eyes and your eyes do not produce enough tears, punctal plugs might be a valid treatment option. These tiny plugs are inserted into the tear ducts in your eyelids to stop the tears from flowing out of your eyes. Instead, they force the tears to stay in the eye, which increases the tear film and bathes the cornea in tears.
Punctal plugs may also be known as lacrimal plugs, tear duct plugs, punctum plugs, intracanalicular plugs, and occluders, and the procedure is often called punctal occlusion. Most of them are about the size of a grain of rice. Usually, these become an option if eye drops and gels do not help keep the eyes wet enough, and they work especially well for those who suffer from aqueous deficient dry eye.
As mentioned, those with aqueous deficiency do not produce enough tears. When the lacrimal gland fails to produce enough tears for the eyes to be comfortable and function properly, extreme dry eyes can result. Aqueous deficiency is often due to Sjogren’s syndrome, and it is actually categorized as either Sjogren’s syndrome dry eye and non-Sjogren’s syndrome dry eye.
For those with Sjogren’s, this autoimmune condition attacks the salivary and lacrimal glands of the eyes. This causes extreme dry mouth as well as dry eyes. Those without Sjogren’s may have aqueous deficiency due to the following (not an exhaustive list):
For anyone with aqueous deficiency, the lack of tears makes the tears incredibly hyperosmotic, or salty. This leads to inflammation over time and further issues with dry eye and possible corneal changes. By inserting punctal plugs into the drainage holes of the eyelids, more tears can be kept in the eyes instead of draining as usual. This often greatly improves eye comfort and helps to lessen inflammation when combined with eyelid hygiene and proper anti-inflammatory nutrition.
At this point, there are two main types of plugs — though that could always change in the future. The first type are semi-permanent plugs that are made of silicone or other acrylic polymers and are meant to last a long time. In most cases, these are used after dissolvable plugs once the patient and doctor know that there will be benefit from using the plugs. This variety has the potential to last years, although they may fall out after some time.
If you find that punctal plugs are working very well for you, there is also the permanent option of having punctal cautery done. In our opinion, punctal cautery should only be used after a very successful trial of long-lasting silicone plugs. We want to ensure that the patient is super happy with having these drainage holes occluded before we make anything permanent. Punctal cautery can be performed thermally or with a laser.
The other type of punctal plugs are dissolvable plugs made of materials easily absorbed by the body, such as collagen. Temporary plugs can last anywhere from a few days to a couple of months (most often, one week) and may be used primarily to determine if the plugs work for that patient before upgrading to the semi-permanent varieties.
Plugs come in many shapes and designs including hollow, tapered, reservoir, perforated, umbrella, and slant or low-profile cap. While you definitely don’t need to know what these mean, it is important to know that you have options. Materials used in making punctal plugs include collagen, silicone, hydrogel, polydioxanone, and hydrophobic acrylic polymer. Some of them even have a slick coating on the surface to make insertion easier for the doctor and maybe even more comfortable for you. Win-win!
When you and your doctor have decided that punctal plugs are the best next step for you, there are a few things to expect before your doctor will be inserting the plugs. First, your eye doctor will take a look at your puncta (or tear ducts) and may measure the openings. A proper fit is vital to balance both comfort and keeping the plugs firmly in place. However, there are also some versions of the plugs that conform to fit almost all eyes without needing to measure. Your eye doctor should know the fit choice for you, but don’t be afraid to ask questions or know the other options as well and why your specialist thinks one is better than another.
In many cases, there won’t be a need for any anesthetic, but your doctor may suggest it to make you more comfortable. If it’s used, it’s simply an eye drop and some many be placed directly over your tear duct opening as well. Let your professional know if you have a particularly low tolerance for pain, or if you prefer not to have any drugs. These plugs may be inserted in the tear duct openings of your lower lids, your upper lids, or both.
Treatment for dry eye disease is typically covered by medical insurance, and your optometrist or ophthalmologist will be able to bill for your visits to their office. In most cases, you may have a small copay each time you visit them for any reason. In addition to this, punctal occlusion can range anywhere from $250-$650 when billed directly to you, but your insurance is likely to pick up some of this cost. As long as your doctor properly documents the procedure, shows that this was not their first line of treatment for dry eyes and that other things have been tried, and bills correctly, most insurance companies (as well as Medicare) should pay for the procedure at least in part.
The use of punctal plugs on a patient with any ocular surface inflammation is controversial, because the thought is that the plugs would merely back up the inflammation onto the eyes. If true, this would make the situation worse, especially for those with meibomian gland dysfunction (MGD), rosacea, and blepharitis. However, recent studies suggest that this issue may not be as worrisome as it seems.
One such small study showed that punctal plugs inserted into patients with moderate dry eye disease actually lessened corneal staining or dryness and greatly improved symptom scores. In addition to this, an increase in inflammatory cytokines was not found.
In general, those with a lower Schirmer score before plug insertion did better than those with a higher score, but this is to be expected because lower scores usually indicate worse aqueous deficiency. Plugs have been shown to offer a statistically significant improvement in symptom scores, corneal dryness, tear volume, tear break up time (TBUT), and most patients found that they could decrease their reliance on artificial tears and other eye drops.
For many of the patients we’ve seen, plugs have been beneficial when inserted into the tear ducts of the right person. Those with aqueous deficiency will tend to benefit more, while those with lots of inflammation in the eyes may want to skip this treatment (even though studies have shown some improvement for them as well).
If you're suffering from ocular rosacea, MGD, or a difficult case of blepharitis and your eyes are very red, sore, and inflamed, this treatment may not be for you. We would recommend working with your doctor to get the severe inflammation under control before placing plugs. This may include perfecting an eyelid hygiene regimen or even using anti-inflammatory eye drops, such as steroids, for a short time.
Most patients say they feel some initial discomfort, but the eyes easily adjust to the change and after that, you shouldn’t feel them at all. They can be removed if there’s a problem, but that also needs to be done by an eye specialist.
Complications that have been documented include ocular discomfort, canaliculitis or dacryocystitis, granulomas, other infections, and spontaneous extrusion and loss of the plug. If you have those symptoms right away or at a later point, contact your eye doctor right away.
Side effects are rare, but rubbing the eyes can dislodge the plugs and then you may have irritation in the eyes from the material being where it shouldn’t be. Also, eye infections can occur, but this is not common. Either way, initial irritation is often common because some people are able to feel the plugs when they are first inserted. This is only because you are not used to them, and this feeling of irritation will subside as you wear them.
If you were to get an infection, symptoms to watch out for are swelling of the corner of the eye and down the nose, yellow discharge, and pain in the area. If you notice anything more than minor irritation for a day or so, please contact your doctor.
Discomfort, like irritation, is quite common in the first few hours after having tear duct plugs inserted. However, if your discomfort persists, know that it is not normal. One issue that can cause discomfort is an increase in epiphora after insertion of the plugs. Epiphora is the scientific term for an overflow of tears onto the face, and this can occur if the plugs are actually working “too well”.
Epiphora can not only be frustrating, but it can also cause discomfort because the skin of the eyelids can become red and raw due to constant watering. If you are noticing an excess of tearing well beyond what you had expected, it may be that tear duct plugs are not the best option for you. Alternatively, you may benefit from one of the perforated plugs on the market.
Have you tried punctal plugs? How did they work for you? Let us know in the comments below!