COMPREHENSIVE OPHTHAm-LOLOGY UPDATE
`
`VOLUME 7, NUMBER 5 SEPIEDwEBER—OCI‘OBER 2006
`
`CLINICAL PRACTICE
`
`Update on Punctal Plugs
`
`MEHRYAR TABAN, MD, BENSON CHEN, MD, AND JULIAN D. PERRY, MD
`
`Abstract. Punctal plugshave offered a safe and often reversible treatment for aqueous-deficient
`dry eye for over three decades. However, they represent only one tool in our armamentrarium to
`help patients with dry eyes, and plugs do have limitations. This article briefly reviews the history of
`occlusive treatments for aqueous tear deficiency and provides an update of recent advancements in
`punctal and canalicular occlusive materials and techniques. (Comp Ophthalmol Update 7: 205-
`12, 2006)
`
`Key words. canalicular plug ' dry eye ' punctal occlusion ' punctal plug
`
`Introduction
`
`Punctal plugs have offered a safe
`
`and often reversible treatment option
`for aqueous-deficient dry eye for over
`three decades.1 This article briefly
`reviews the history of occlusive
`
`tear
`aqueous
`for
`treatments
`deficiency and provides an update of
`recent advancements in punctai and
`canalicular occlusive materiais and
`
`techniques.
`
`Brief History
`
`benefit from permanent ciosure?’
`Freeman developed the
`first
`reversible,
`longaterm occlusive
`treatment using nondissolving
`punctal plugs in 1975.1
`Over
`the past
`three decades,
`modifications to plug design and
`position have improved comfort and
`retention while minimizing
`
`complications. A wide variety of
`temporary and permanent materials
`are now available in different shapes
`for punctal orintracanalicular
`placement.
`
`Indications
`
`In 1935, Beetham reported the first
`successful treatment of dry eye
`symptoms by cautery occlusion of
`the
`tear
`drainage
`system.2
`Unfortunately,
`some patients
`developed epiphora from this
`permanent procedure. In 1961,
`Foulds proposed the use of
`
`6Y6
`
`or
`syndrome,
`Dry
`keratoconjunctivitis sicea, has been
`defined as a tear film abnormality
`resulting from either inadequate
`secretion or excessive evaporation,
`leading to oeular surface damage or
`discomfort.‘1 The cyclic nature of
`
`Dr.s. Taban, Chen, and Perry are af—
`
`filiated with the Division of Oph~
`thalmology, Cole Eye Institute, the
`Cleveland Clinic Foundation, Clever
`land, OH.
`
`Reprint address: Division of Ophu
`thalinology, Cole Eye Institute, Desk
`1-32, the Cleveland Clinic Founda4
`
`tion, 9500 Euclid Ave, Cleveland,
`OH 44195
`
`APOTEX 1040, pg. 1
`
`

`

`Comp Ophthalmol Update 7 (5) September—October 2006
`TABLE 1
`Ocular Conditions Shown to Benefit from Punctai OcciusionfiW
`
`Dry eye syndrome
`Penetrating keratopiasty
`Superior iimbic keratoconjunetivitis
`Neurotrophie keratitis
`Ocular cicatrizing disease
`Recurrent erosion syndrome
`Seventh nerve paisy
`Thyroid eyelid retraction
`Postbiepharopiasty eyelid retraction
`Lagophthaimos
`Persistent epithelial defect
`Toxic epitheliopathy
`Contact tens intolerance
`Steven-Johnson syndrome
`
`disruption of the normal reflex
`tearing feedback loop, often resuits
`in a highly variable association
`between discomfort and damaged
`This lack of congruity between
`symptoms
`and
`signs
`complicates management
`and
`compliance“ Lacrimal outflow
`I‘l’lOfC
`occlusion often offers
`
`continuous relief, particularly for
`those patients who experience
`difficulty with topical therapy.
`The defense of the corneal surface
`
`consists of an extraordinarily intricate
`system regulating tear secretion and
`blink rate (Figure 1). Normally, only
`10% of secreted tears evaporate,
`while 90% typically drain into the
`nasolacrimal sac.7 Punctal occlusion
`in several
`immediate
`
`advantages. Increasing the tear lake
`volume provides aqueous support
`and prolongs the duration and
`amount of contact between the
`
`corneal epithelium and local growth
`factors and immunomodulatory
`
`SCHSOIY,
`
`of
`complex
`sympathetic, and parasympathetic
`nerves links the iacrimal system into
`a homeostatic loop; its essential roie
`is to protect and support the ocular
`surface. This homeostatic loop may
`
`sensation to invoke an autoregulatory
`mechanism that
`returns
`tear
`
`production, tear clearance, and ocular
`surface sensation to preocclusion
`levels 14 days to 17 days after punctal
`occiusion.g Corneal sensation,
`
`modulated through bradykinin and
`substance P secretion, tear nerve
`
`growth factor (NGF) levels, and
`neuronal nitric oxide synthase may
`play a role in modulating tear
`production?"9 \Vhile future treatments
`should solve aqueous~deficient dry
`eye by modulating this autoe
`regulatory mechanism, punctal plugs
`currently offer relief for many
`
`patients.
`When
`
`considering
`
`punctal
`
`occlusion, other patient parameters
`affect occlusive treatment decisions.
`
`For example, female patients with
`similar aqueous—deficiency testing
`parameters as maies may require
`more
`treatment.
`aggressive
`Significant reflex secretion may allow
`for occlusion of only the lower
`punctum, while its absence may call
`for both lorver and upper outflow
`Occlusion.
`
`Numerous other disorders of the
`
`ocular surface may benefit from tear
`drainage occiusion as well (Table 1).10
`Occlusion also enhances the efficacy
`
`uitimately limit the improvement
`
`and safety of
`
`topical ocuiar
`
`TABAN
`predicts efficacy and tolerance of
`more
`permanent
`occlusive
`procedures.” It can optimize tear
`volume and quality during the early
`postoperative period after LASIK.
`Symptomatic partiai punctal stenosis
`may be improved by insertion of a
`modified punctal plug perforated
`with a hollow iumen.“15 These
`
`modified punctal plugs can widen
`the drainage passage, and the lumen
`may allow for more outflow than the
`stenotic punt: tum.
`
`Contraindications
`
`Lacrimal drainage occiusive
`devices are contraindicated in
`
`patients with known allergy to the
`device material (silicone, bovine
`collagen, glycolic acid, tritnethylene
`carbonate, etc.). Patients with signs
`of ocular infection or irritation
`
`(blepharitis or meibomian gland
`dysfunction)
`further
`require
`evaluation and treatment before
`
`considering tear drainage occlusion,
`as occlusion may increase local
`cytokines to increase irritation and
`epithelial destruction. Epiphora due
`to lacrimal drainage obstruction
`contraindicates placement of a
`lacrimal occlusive device.
`
`Objective Measurements
`
`\Vhile punctal and canalicular
`occlusion often provide relief of
`symptoms
`from aqueous tear
`deficiency, objective tests to reach the
`diagnosis and assess possible benefits
`of occlusion should be considered.
`
`Schirmer testing can be used to
`diagnose abnormal tear secretion.16
`
`
`
`APOTEX 1040, pg. 2
`
`

`

`207 UPDATE ON PUN CTAL PLUGS
`
`increases
`Tear Fllm Layer
`
`Increase Tear
`Production
`Corneal irritation slimu‘ztes
`reflex secretion
`
`Decrease Evaporation
`Increase blink rate & duralion,
`Narrow palpebral fissure
`
`Decrease Tear Drainage
`Punctal, unafwlar occlusion
`
`Enlarged punctal opening
`Pump I‘arwe
`
`Decrease Tear
`Production
`Comeat hypoesmesla
`. LASIK or ocular sudace damage
`
`Increase Evaporation
`Light in! film deficiency
`Decrease blink rate
`Widen pdpebra! fissure
`
`Increase Tear Drainage
`
`Fig. 1. Yin-Yang of a balanced lacrimal tear film.
`
`collagen plugs,27 among others.23
`Collagen intracanalicular plugs come
`in a range of lengths (1.6 mm to 3
`mm) and diameters (0.2 mm to 0.6
`mm). The intracanalicular location
`
`allows for flexible sizing and avoids
`the discomfort associated with
`
`punctal dilation. Typical insertion
`techniques begin with instilling a drop
`of topical anesthetic. The rod-
`shaped implants can then be inserted
`under slit—lamp magnification using
`jeweler's forceps. Careful complete
`insertion into the vertical or horizontal
`
`canaliculi prevents ocular surface
`irritation.
`
`Although reports show highly
`variable absorption rates, dry eye
`symptoms typically improve for '12
`weeks. Patients are instructed to
`
`record symptoms and the need for
`supplemental lubrication for the first
`few days after insertion. Evidence of
`
`including signs of
`intolerance,
`allergies or epiphora, should be
`noted. Collagen plugs may improve
`dry eye parameters in similar amounts
`as silicone plugs in the short term,
`and satisfaction with intracanalicular
`
`collagen plugs can predict relief of
`symptoms with punctal plugs.29
`However, intracanalicular plugs only
`partially occlude outflow, so some
`patients who tolerate absorbable
`plugs can still develop epiphora with
`more permanent plugsn‘30
`Newer, slower absorbing materials,
`such as PCL (Escaprolactone—L-
`lactide copolymer), monofilament
`(UltraPlugm, Surgical Specialties
`Corporation, Reading, PA), and the
`Extended Duration intracanalicular
`
`plug (Oasis Medical, Glendora, CA),
`offer similar case of insertion, and
`
`last up to 6 months. The ProLongm
`absorbable plug (FCI Ophthalmics,
`Marshfield Hills, iVLA), a copolymer
`of glycolic acid and trimethylene
`
`Tear clearance can be assessed by the
`dye disappearance test to rule out
`lacrimal outflow obstruction as the
`
`cause of epiphora. Surface vital
`staining (fluorescein, lissamine green,
`rose bengal) and conjunctival
`impression cytology (decreased
`goblet cells,
`increased nucleo—
`cytoplasm ratio) confirm ocular
`surface damage.”“5 Histologic
`improvements with punctal oc-
`clusion may take much longer than
`symptomatic relief.”
`Because the tear film and cornea
`
`work together as a focusing lens,
`visual
`acuity can provide a
`quantitative measure of ocular
`surface dysfunction when acuity is
`diminished in the absence of other
`
`causes. Continuous visual acuity
`measurements improve after lacrimal
`occlusion,20 and can help determine
`the need for further occlusive therapy
`Tear quality can be assessed by the
`tear break—up time (BUT), which
`typically improves after punctal
`occlusion.“ Tear meniscus height, an
`indicator of tear volume, also
`improves after occlusion.22 Punctal
`occlusion increases tear quality by
`normalizing
`tear
`lactoferrin,
`lysozyme, osmolarity, IgA and
`albumin levels, although these
`measurements are not typically used
`clinicallyu'z“
`While objective measures can help
`determine the need for and success
`
`of punctal occlusion therapy,
`subjective symptoms often guide
`
`therapy. Objective measures can
`underestimate symptoms, and a self—
`assessment questionnaire better
`measures symptoms and response to
`therapy.25 Symptoms may also point
`to the likely response to plug therapy;
`In our experience, epiphora due to
`hypersecretion responds well to plug
`placement, while photophobia,
`which may be due to underlying
`inflammation, does not. Symptoms
`suggestive of underlying surface
`inflammation should be corrected
`
`prior to punctal plug placement.
`
`Lacrimal Occlusive Devices
`
`INSERTS:
`ABSORBABLE
`INTRACANALICULAR
`
`(VERTICAL
`
`OR HORIZONTAL)
`
`Absorbable
`
`intracanalicular
`
`implants provide for safe and
`temporary relief of aqueous—
`deftcient dry eyes. These temporary
`plugs were originally developed to
`predict the efficacy and tolerance of
`the more permanent occlusive
`procedures, such as electrocautery
`and silicone punctal plugs. A wide
`range of materials has been used,
`including gelatin,3 gut suture,26 and
`
`
`
`Numemusipswa
`.drainageocclusio.n.-x .. ..
`
`-'
`
`APOTEX 1040, pg. 3
`
`APOTEX 1040, pg. 3
`
`

`

`Comp Ophdtaimol UEdate 7 (5) September-October 2006
`TABLE 2
`List of Commercially Available Panels! and Cenalicuier Plugs
`
`Locafion Other Remarks
`Manufacturer MateriallAbsorbabitity
`Advantagelelsadvantages
`
`TABAN
`
`Herrick Lacrimai Lacrimedics, Inc.
`Eastsound, WA
`
`Either polydioxanone
`absorbable (-6 months) or
`siiicone nonabsorbable
`
`Horizontal
`canalicuius
`
`No punctal dilation required
`
`Sizes: 03. 0.5, 0.? mm
`
`Hydrogel (absorbs tears),
`absorbable
`
`Vertical
`canaliculus
`
`One size fits all; low extrusion:
`removed by flushing punctum
`
`Conforming
`
`Absorbable (~90 days)
`
`Intracanalicular
`
`Nl'A
`
`Three sizes: 0.3, 0.4, 0.5 mm
`in diameter
`
`Silicone, nonabsorbable
`
`Punctal
`
`Preloaded or nonloaded
`
`Sizes: 0.4—0.8 mm
`
`Thermo-sensitive acrylic
`polymer, absorbable
`
`Vertical
`canalicutus
`
`Small box (storage); no
`punctal dilation required;
`difficulty reversal
`
`Conforming
`
`F'Cl. monofilament,
`absorbable
`
`Intracanalicular
`
`Nl'A
`
`Three sizes
`
`Oasis Medical,
`Glendora, CA
`
`Oasis Medical,
`Glendora, CA
`
`Oasis Medical.
`Glendo{a, CA
`
`Medennium,
`Irvine, CA
`
`Surgical
`Specialties
`Corporation,
`Reading, PA
`
`Koken
`Blosclance
`Institutes, Japan
`
`FCI Ophthalmics,
`Marshfield
`Hills. MA
`
`injectable bovine dermis
`extract, absorbable
`
`Siticone, nonabsorbable
`
`Intracanalicular
`
`NJ'A
`
`Punctat
`
`Punctal
`
`One size fits all; no punctal
`dilation required; preloaded;
`one-step insertion
`
`ideal for post—LASIK
`
`FC! Ophthalmics, Absorbable copolymer
`Mershfield
`(~3 months)
`Hills, MA
`
`FCi Ophthalmics,
`Marshfield
`Hills, MA
`
`Silicone, nonabsorbable
`
`Punctal
`
`WA
`
`NIA
`
`Nl'A
`
`Three sizes: 0.3, 0.4, 0,5 mm
`in diameter and 2.0 in
`length
`
`7 sizes (0.4—1.0 mm)
`
`FCI Ophthalmics, Silicone with PVP coating
`Marshfield
`Hills, MA
`
`Eagle Vision,
`Memphis, TN
`
`Eagle Vision,
`Memphis, TN
`
`Eagle Vision,
`Memphis, TN
`
`Eagle Vision,
`Memphis, TN
`
`Eagle Vision,
`Memphis, TN
`
`Silicone, nonabsorbahle
`
`Silicone, nonabsorbable
`
`Silicone, nonabsorbable
`
`Silicone, nonabsorbable
`
`Silicone, nonabsorbable
`
`Punctal
`
`Punctal
`
`Punclal
`
`Punctal
`
`Punctal
`
`Punctal
`
`For partial occlusion or stenosis
`
`Sizes: 0.? mm and 0.9 mm
`
`Newest; good retention
`and comfort
`
`Three sizes {range 0.4—1.1
`mm)
`
`Good retention
`and comfort;
`easy insertion;
`multiple sizes
`
`8 sizes (044.1 mm)
`
`For partial punctal occlusion;
`tapered shalt
`
`4 sizes (0.5-03 mm)
`
`Flexible; good fit and comfort
`
`5 sizes (0.4—1.2 mm)
`
`Original plug; inexpesnive
`
`5 sizes (0.4—0.8 mm)
`
`Eagle Vision,
`Memphis, TN
`
`PCL, absorbable
`(60—160 days)
`
`Punctal-
`canalicular
`
`ideal for post-LASIK
`
`NiA
`
`Parasol? Punctal
`
`Odyssey Medical,
`Inc.,
`Memphis. TN
`
`Odyssey Medical,
`Inc...
`Memphis, TN
`
`CynaconiOcusofl,
`lnc.,
`Richmond, TX
`
`Silicone, nonabsorbable
`
`Punctal
`
`NlA
`
`Silicone, nonabsorbeble
`
`PUHCtEII
`
`Self-dilating plug
`
`Sizes: small (0.4 mm) to
`extra-large {0.9 mm)
`
`Sizes: extra-small {0.2 mm)
`to large (0.9 mm)
`
`Silicone, nonabsorbable
`
`Punctal
`
`Minimal foreign body sensation
`
`Sizes: 0.3—0.9 mm
`
`APOTEX 1040, pg. 4
`
`

`

`209
`UPDATE ON PUNCTAL PLUGS
`
`carbonate, lasts up to 3 months.
`Recent reports describe canalicular
`Atelocollagen (Koken Bioscience
`Ins titutcs,]apan) injection producing
`outflow occlusion for up to 8
`weeks.“32 The material is extracted
`
`from bovine dermis, and enzymatic
`processing removes the antigenic
`portions from the collagen molecule
`to create a well—tolerated injectable
`solution used to augment soft tissue
`defects.33 The intracanalicular location
`
`
`
`provides significantiy less ocular
`surface irritation and risk of
`
`extrusion than punctal plugs. These
`absorbabie materials may carry less
`risk of
`infection,
`untoward
`
`inflammation, and permanent
`canalicular obstruction compared to
`permanent materials.
`
`NONABSORBABLE
`INSERTS: PUNCTAL PLUGS
`
`The originai permanent punctal
`plug described by Freeman in 1975
`resembled an asymmetric dumbbell
`configuration. When placed properly,
`these plugs sit visibly at the pane tum,
`with a wide internai anchoring bulb
`
`portion that prevents extrusion, and
`an external cap or collar that prevents
`the plug from descending into the
`canaliculus. A narrow cylindrical shaft
`connects the bulb and the collar. This
`
`basic punctal plug design preserves
`the remaining secreted tears against
`the ocular surface.
`
`Design Variations
`
`Recent modifications to the
`
`component sections and materials
`have improved comfort and fit while
`minimizing risks of spontaneous loss,
`extrusion, or downward migration.
`
`
`
`Fig. .External p otograph demonstrateserytheinamand edema consistent
`with acute canaliculitis in the area of a previously placed canalicular piug. The
`infection resolved after a course of topical and oral antibiotics, and surgical
`removal of the occlusive device.
`
`Variations in the collar, such as the
`slanted collarette offered on some
`
`Ready-Set models (FC1 Ophthalmics,
`Marshfield Hills, 31A), may improve
`the profile over the punctum. This
`plug line also offers the Slim plug,
`with a smaller bulb for easier
`insertion.
`
`a central
`Some plugs offer
`perforation. One version, the PVP
`plug (FCI Ophthalmics, Marshfield
`Hills, BIA)
`is lined with poly-
`vinylpyrrolidone to prevent mucous
`from occluding the lumen. This
`lumen may allow for some tear
`outflow.”15 The Parasol® occluder
`
`(Odyssey Medical, Inc., Memphis,
`TN) is hollow, but to allow for
`
`collapse and easier fit, rather than for
`partial outflow. The Parasol® Plus“;
`offers contoured edges with a solid
`nose.
`
`\Vhile the PVP plug uses a silicone
`lined material, other plugs use silicone
`rubber to change performance
`characteristics. The Quintessm plug
`(Cynacon/Ocusoft, Inc, Richmond,
`Tm offers microreservoir collarette
`indentations to create a barrier
`
`between the plug and the ocular
`surface.
`
`punctal piug manufactured in one
`universal size. The SuperEaglem
`{Eagle Vision, Memphis, TN),
`
`another newer silicone plug, comes
`in three sizes. This plug has a tapered
`shaft and a flexible nose to allow for
`
`easier piacement without punctal
`gauging.
`
`Insertion Technique
`
`A typical insertion technique for
`nonabsorhable silicone punctal plugs
`is described below; however, specific
`variations should follow manufac—
`
`turer's recommendations. Topical
`anesthesia with a drop of 0.5%
`proparacaine instilled into the
`conjunctival cul—de-sac is usually
`sufficient. Some patients, hO\VCVCE,
`may benefit from applying direct
`pressure on the punctum using a 4%
`lidocaine-soaked cotton appiicator.
`Manufacturers typically offer punctal
`size gauging systems for their
`products, which can minimize the
`waste of trial-and-error techniques.
`Optimal sizing baiances the risk of
`extrusion and downward migration
`for plugs that are too small with the
`risk of pyogenic granuloma
`
`APOTEX 1040, pg. 5
`
`

`

`Comp 0 hthalmol U date 7 (5) September—October 2006
`the canaliculus, resting at thejunction
`of the vertical and horizontal
`
`
`
`The punctum is dilated by inserting
`the dilator vertically into the punctal
`05, then directing it medially with
`tension on the eyelid.
`
`Immediately after dilation, the nose
`of the punctal plug is inserted
`vertically into the punctal os until it
`slips into the ampulla and the plug
`rim rests flush with the lid surface.
`
`After releasing the plug from the
`dispenser, proper fit and positioning
`is confirmed under the slit lamp.
`
`INTRACANALICULAR
`
`Nonconforming (Horizontal
`Canaliculus)
`
`Herrick Lacrimal Plugs® (HLP)
`(Lacrimedics, Inc., Eastsound, WA)
`are cone—shaped silicone plugs for
`insertion into the horizontal canaliculi.
`
`No dilation is typically required, and
`insertion is usually well tolerated.
`Complications include canalicular
`inflammation or infection?!“33
`
`Removal requires more invasive
`measures,
`including
`surgical
`intervention.39 In a Lacrirnedics, Inc.-
`sponsored study, 7% of patients
`reported wishing to reverse the
`procedure due to intolerable
`epiphora.27 Saline perfusion may
`resolve the symptoms in the majority
`of patients”; however, some may
`require surgical intervention.“"0
`
`Conforming
`(Vertical Canaliculus)
`
`canaliculus. With proper insertion, the
`expanded plug remains just beneath
`the surface of the punctum. For
`patients unable to tolerate standard
`piugs, particularly those with lid laxity
`or dilated puncta at high risk of
`extrusion, the customized fit offers
`
`a valuable nonsurgical option.
`Conforming plugs rely upon the
`physical properties of the canalicular
`mucosa to induce shape change.
`Form Fitm (Oasis Medical, Glendora,
`an
`CA) produces
`expanding
`intracanalicular plug that absorbs up
`to 20 times its weight in tears over
`10 minutes. SmartPlugm (Meden-
`nium, Irvine, CA) is a thermo-
`sensitive acrylic polymer rod that
`softens and molds upon warming to
`body temperature. These plugs
`require no dilation or separate sizes.
`Similar to the nonconforming plugs,
`reversal may prove challenging in
`some patients.
`
`Complications of Lacrimal
`Occlusive Devices
`
`Standard nonabsorbable plugs can
`cause mechanical conjunctivitis or
`keratopathy from plug collar.
`Subconjunctival hemorrhage has
`been reported to occur in up to 2%
`of punctal plug patients.10 Pyogenic
`granuloma formation can lead to
`discharge or plug extrusion. Intrav
`canalicular placement minimizes the
`possibility of mechanical irritation.
`The incidence of epiphora after plug
`placement varies considerably due to
`the subjective nature of the symptom
`and its overlap with dry eye
`symptoms. i’viild epiphora occurs in
`up to 36% of patients.“1 Most
`patients tolerate the epiphora, but up
`to 5% request removal. A trial using
`a temporary intracanalicular plug can
`help predict which patients will
`
`TABAN
`
`to canalicular stenosis or nasolacrimal
`
`duct obstruction.
`
`Although spontaneous distal
`migration is uncommon due to wide
`rim design, improperly small punctal
`plugs carry a higher risk?4 Migrating
`fragments may lodge at the junction
`of the common canaliculus and
`
`lacrimal sac, producing complete
`functional occlusion. Patients with dry
`eyes often tolerate this obstruction
`well, as it simulates an intracanalicular
`silicone plug. Other patients develop
`epiphora, canaliculitis, dacryocystitis,
`cellulitis, or cutaneous ftstulasisdgfll43
`High- frequency B—scan ultrasound
`may help detect silicone punctal plugs
`within the canalicular system.
`Sonography can confirm stable
`intracanalicular positioning for the
`higher reflectivity silicone Herrick
`Lacrirnal Plugs® and lower reflectivity
`acrylic polymer SmartPlugsm.“
`Removal of punctal plugs involves
`grasping the rim and shaft with
`forceps under the microscope and
`lifting vertically. Shaft fracture may
`occur
`resulting in downward
`migration of the bulb or nose
`portion into the canalicular system.
`Saline irrigation to flush the plug bulb
`downstream can he performed if
`symptomatic epiphora persists. A
`pigtail probe can be introduced
`through the opposing canaliculus to
`push the plug proximally out of the
`canaliculus. Occasionally, distal plug
`migration
`requires
`surgical
`intervention.
`‘
`
`Various plug designs allow for
`stable placement in many cases, but
`extrusion occurs within 3 months in
`
`up to 50% of cases. Patients with pre—
`existing eyelid laxity and large punctae
`are more likely to develop early
`extrusion.” Patients who have lost an
`
`mpofiamE-Ombticatisn-
`
`APOTEX 1040, pg. 6
`
`

`

`UPDATE ON PUNCTAL PLUGS
`
`initial piug are twice as likely to lose
`a replacement plug.m Upper punctal
`plugs are at greater risk of loss
`compared with plugs inserted in the
`45'“ Extrusion rates
`lower puncta.
`differ for different plug models. One
`found
`study
`that
`72% of
`EaglePlugsm (Eagle Vision,
`Memphis, TN) .are lost at a mean of
`59 days versus a 56% loss rate of
`FCI punctal plugs at a mean of 287
`days.46 Another study showed loss
`rate of 30.8% for Flex Plugs (Eagle
`Vision, Memphis, TN) at 4 monthsW 47
`versus 68.6% for EaglePlugs .
`Reinserrion following extrusion
`usually requires a larger plung
`although granulation tissue occluding
`the canaiiculus can confound
`
`reinsertiond‘9 Softer polymers, such
`as ElastiEonm (AorTech, Surrey,
`United Kingdom) (liquid silicone/
`rubber elastomer), may improve
`comfort while reducing the incidence
`extrusion. Securing plugs with 100
`polypropylene suture may improve
`long—term success.SD
`granuloma
`W’hile
`pyogenic
`formation due to silicone punctal
`
`plugs was thought to be rare, a recent
`report describes a higher incidence.“
`Mean
`occurred
`presentation
`approximately 5 months following
`insertion and typically resolved within
`3 weeks of removal. The geometric
`shape and plug size likely influence
`the risk.36 Coating materials, such as
`polytetrafluoroethylene (Teflon®,
`DuPont, \X/ilmington, DE) and
`hydroethyl~methacryiate (Tear Saver®
`Plus, CIBA Vision, Duluth, GA), may
`
`reduce tissue reactivity.
`
`Canaliculitis and dacryocystitis can
`occur in patients with distal punctal
`plug
`from
`migration,
`or
`intracanalicular plugs (Figure 2).
`Treatment often requires plug
`removal
`and
`dacrocystoru
`
`hinostomy.37
`
`minimized the need for permanent
`occlusive surgery. For some patients,
`however, permanent occlusion may
`represent the most practical option.10
`Electrocautery offers excellent long
`term closure.51 Other modalities
`
`include diathermy, glues, and Argon
`laser, which has a peak efficacy of
`only 40% at 1 month, decreasing to
`only 33% at 6 months?“52
`
`8.
`
`Conclusion
`
`Punctal occiusion therapy often
`benefits patients with aqueous
`deficiency, providing symptomatic
`relief and clinically measurable
`improvements. However, punctal
`plugs represent only one tool in our
`armamentarium to help patients with
`dry eyes, and plugs do have
`limitations. Evidence of adaptation
`
`to punctal plugs suggests that some
`patients benefit only temporarily
`from occlusive treatment. Under-
`
`standing the neuromodulatory
`feedback mechanisms and the role
`
`of inflammatory mediators in ocular
`surface disease will offer exciting new
`
`medical therapies for dry eye.
`
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`APOTEX 1040, pg. 7
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`48.
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`52.
`
`The authors reported no proprietary or
`commercial interest in any product men-
`tioned or concept discussed in this
`update.
`
`APOTEX 1040, pg. 8
`
`