COMPREHENSNEOPHTI-IALi\!OLOGYUPDATE
`
`VOLUME 7, NUlvffiERS SEPTElvffiER-OCfOBER2006
`
`CLINICAL PRACTICE
`
`Update on Puncta! Plugs
`
`MEHRYAR TABAN, MD, BENSON CHEN, MD, AND JULIAN D. PERRY, MD
`
`Abstract. Puncta! plugs have 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
`puncta! and canalicular occlusive materials and techniques. (Comp Ophthalmol Update 7: 205-
`12, 2006)
`
`Key words. canalicular plug • dry eye • puncta! occlusion • puncta! plug
`
`Introduction
`
`Puncta! plugs have offered a safe
`and often reversible treatment option
`for aqueous-deficient dry eye for over
`three decades.' This article briefly
`reviews the his tory of occlusive
`treatments
`for aqueous
`tear
`deficiency and provides an update of
`recent advancements in punctal and
`canalicular occlusive materials and
`techniques.
`
`Brief History
`
`benefit from permanent closure. 3
`Freeman developed
`the
`first
`reversible, long-term occlusive
`treatment using nondissolving
`puncta! plugs in 197 5. 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 or intracanalicular
`placement.
`
`Indications
`
`In 1935, Beetham reported the first
`successful treatment of dry eye
`symptoms by cautery occlusion of
`sys tern. 2
`the
`tear
`drainage
`Unfortunately, some patients
`developed epiphora from this
`permanent procedure. In 1961,
`Foulds proposed
`the use of
`dissolvable gelatin plugs prior to
`cautery to test which patients would
`
`or
`syndron1e,
`eye
`Dry
`keratoconjunctivitis sicca, has been
`defined as a tear film abnormality
`resulting from either inadequate
`secretion or excessive evaporation,
`leading to ocular surface damage or
`discomfort. 4 The cyclic nature of
`ocular surface and lacrin1al gland
`inflammation, combined with
`
`Dr.s. Taban, Chen, and Perry are af(cid:173)
`filiated with the Division of Oph(cid:173)
`thalmology, Cole Eye Institute, the
`Cleveland Clinic Foundation, Cleve(cid:173)
`land, OH.
`
`Reprint address: Division of Oph(cid:173)
`thahnology, Cole Eye Institute, Desk
`I-32, the Cleveland Clinic Founda(cid:173)
`tion, 9500 Euclid Ave., Cleveland,
`OH 44195
`email: perryj1@ccf.org
`
`© 2006 by Comprehensive Ophthalmology Update, LLC.
`All rights reserved.
`
`205
`
`APOTEX 1040, pg. 1
`
`

`

`206
`
`Comp Ophthalmol Update 7 (5) September-October 2006
`TABLE 1
`Ocular Conditions Shown to Benefit from Puncta/ Occlusion. 8
`
`Dry eye syndrome
`Penetrating keratoplasty
`Superior limbic keratoconjunctivitis
`Neurotrophic keratitis
`Ocular cicatrizing disease
`Recurrent erosion syndrome
`Seventh nerve palsy
`Thyroid eyelid retraction
`Postblepharoplasty eyelid retraction
`Lagophthalmos
`Persistent epithelial defect
`Toxic epitheliopathy
`Contact lens intolerance
`Steven-Johnson syndrome
`
`disruption of the normal reflex
`tearing feedback loop, often results
`in a highly variable association
`between discomfort and damage. 5
`This lack of congruity between
`disease symptoms and signs
`complicates management and
`compliance. 6 Lacrimal outflow
`occlusion often offers more
`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°/o of secreted tears evaporate,
`while 90% typically drain into the
`nasolacrimal sac. 7 Punctal occlusion
`results 1n
`several
`immediate
`advantages. Increasing the tear lake
`volume provides aqueous support
`and prolongs the duration and
`an1ount of contact between the
`corneal epithelium and local growth
`factors and immunomodulatory
`cytokines.
`sensory,
`of
`A
`complex
`sympathetic, and parasympathetic
`nerves links the lacrimal system into
`a homeostatic loop; its essential role
`is to protect and support the ocular
`surface. This homeostatic loop may
`ultimately limit the improvement
`achieved with lacrimal outflow
`occlusion. Puncta! occlusion in
`normal subjects may decrease tear
`production and ocular surface
`
`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 puncta!
`occlusion. 8 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
`9 \V'hile future treatments
`production.8
`'
`should solve aqueous-deficient dry
`eye by modulating this au to~
`regulatory mechanism, puncta! plugs
`currently offer relief for many
`patients.
`considering puncta!
`When
`occlusion, other patient parameters
`affect occlusive treatment decisions.
`For example, female patients with
`similar aqueous~deficiency testing
`parameters as males may require
`more
`aggress1ve
`treatment.
`Significant reflex secretion may allo\v
`for occlusion of only the lower
`punctum, while its absence may call
`for both lower and upper outflow
`occlusion.
`Numerous other disorders of the
`ocular surface may benefit from tear
`drainage occlusion as well (Table 1). 10
`Occlusion also enhances the efficacy
`and safety of topical ocular
`medications by prolonging ocular
`availability and decreasing systemic
`absorption. 11
`12 Temporary occlusion
`'
`treats causes of transient dry eye and
`
`TAB AN
`predicts efficacy and tolerance of
`more
`permanent
`occlusive
`proceduresY It can optimize tear
`volume and quality during the early
`postoperative period after LASIK.
`Symptomatic partial punctal stenosis
`may be improved by insertion of a
`modified punclol plug perforated
`with a hollow lumen. 14
`15 These
`'
`modified puncta! plugs can widen
`the drainage passage, and the lumen
`may allow for n1ore outflow than the
`stenotic punctum.
`
`Contraindications
`
`Lacrimal drainage occlusive
`devices are contraindicated in
`patients with known allergy to the
`device material (silicone, bovine
`collagen, glycolic acid, trimethylene
`carbonate, etc.). Patients with signs
`of ocular infection or irritation
`(blepharitis or meibomian gland
`dysfunction)
`require
`further
`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
`
`While puncta! 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
`
`· Focus PoiQt #1
`Recent moclific~tions in plug
`design allow for increased
`tolerance.and retention.
`
`APOTEX 1040, pg. 2
`
`

`

`UPDATE ON PUNCTALPLUGS
`
`Increases
`Tear Film Layer
`
`Increase Tear
`Production
`Corneal irritation stimu~.o~tes
`reflex secrellon
`
`Decrease Evaporation
`lnete.ase O!in.k rate & dura~on.
`Narrow palpebraJ fissure
`
`Decrease Tear Drainage
`Punctal, cane:JCular occrus~on
`Pump fa~we
`
`Fig. 1. Yin-Yang of a balanced lacrimal tear film.
`
`Decrease Tear
`Production
`Corne at h~poesthes.la
`· l.ASlK or 0<\J!at sUlfa~ damag.>
`
`Increase Tear Drainage
`Enlarged punctaJ open-Ing
`
`therapy. Objective measures can
`underestimate symptoms, and a self(cid:173)
`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 puncta! plug placement.
`
`Lacrimal Occlusive Devices
`
`INSERTS:
`ABSORBABLE
`INTRACANALICULAR
`(VERTICAL
`OR HORIZONTAL)
`
`intracanalicular
`Absorbable
`implants provide for safe and
`temporary relief of aqueous(cid:173)
`deficient 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 puncta! plugs. A wide
`range of materials has been used,
`including gelatin/ gut suture,26 and
`
`Tear clearance can be assessed by the
`dye disappearance test to rule out
`lacrimal outflow obstmction as the
`cause of epiphora. Surface vital
`staining (fluorescein, lis sa mine green,
`rose bengal) and conjunctival
`impression cytology (decreased
`goblet cells, increased nucleo(cid:173)
`cytoplasm ratio) confirm ocular
`surface damageY· 18 Histologic
`improvements with puncta! oc(cid:173)
`clusion may take much longer than
`symptomatic relief. 19
`Because the tear frlm 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. 21 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
`2
`clinically. 23
`•
`"'
`\Vhile objective measures can help
`determine the need for and success
`of puncta! occlusion therapy,
`subjective symptoms often guide
`
`207
`collagen plugs,27 among others. 28
`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
`puncta! dilation. Typical insertion
`techniques begin with instilling a drop
`of topical anesthetic. The rod(cid:173)
`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 1-2
`weeks. Patients are instructed to
`record symptoms and the need for
`supplemental lubrication for the first
`few days after insertion. Evidence of
`intolerance, including signs of
`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 puncta! plugs. 29
`However, intracanalicular plugs only
`partially occlude outflow, so some
`patients who tolerate absorbable
`plugs can still develop epiphora with
`30
`more permanent plugs.22
`•
`Newer, slower absorbing materials,
`such as PCL (E-caprolactone-L(cid:173)
`lactide copolymer), monofilament
`(UltraPlug"', Surgical Specialties
`Corporation, Reading, PA), and the
`Extended Duration intracanalicular
`plug (Oasis Medical, Glendora, CA),
`offer similar ease of insertion, and
`last up to 6 months. The ProLongTI<
`absorbable plug (FCI Ophthalmics,
`Marshfield Hills, iYlA), a copolymer
`of glycolic acid and trimethylene
`
`APOTEX 1040, pg. 3
`
`

`

`208
`
`Comp Ophthalrnol Update 7 (5) Scetembcr-October 2006
`TABLE2
`List of Commercially Available Puncta! and Canalicular Plugs
`
`TAB AN
`
`Plug Name
`
`Manufacturer Material/Absorbability
`
`Location
`
`Advantages/Disadvantages
`
`Other Remarks
`
`Herrick Lacrimal Lacrimedics, Inc. Either polydioxanone
`absorbable (-6 months) or
`Plugs"'
`Eastsound, WA
`silicone nonabsorbable
`
`Horizontal
`canaliculus
`
`No puncta! dilation required
`
`Sizes: 0.3, 0.5, 0.7 mm
`
`Form Fit"'
`
`Oasis Medical,
`Glendora, CA
`
`Hydrogel (absorbs tears),
`absorbable
`
`Vertical
`canaliculus
`
`One size fils all; low extrusion; Conforming
`removed by flushing punctum
`
`Extended
`Duration
`
`Oasis Medical,
`Glendora, CA
`
`Oasis Silicone
`Plugs
`
`Oasis Medical,
`Glendora, CA
`
`Absorbable (-90 days)
`
`lntracanalicular
`
`NIA
`
`Three sizes: 0.3, 0.4, 0.5 mm
`in diameter
`
`Silicone, nonabsorbable
`
`Puncta!
`
`Preloaded or non loaded
`
`Sizes: 0.4-0.8 mm
`
`SmartPiug""
`{updated)
`
`Medennium,
`Irvine, CA
`
`Thermo-sensitive acrylic
`polymer, absorbable
`
`Vertical
`canaliculus
`
`Small box (storage); no
`puncta! dilation required;
`difficulty reversal
`
`Conforming
`
`UltraPiug~
`
`Surgical
`Specialties
`Corporation,
`Reading, PA
`
`PCL monofilament,
`absorbable
`
`lnlracanalicular
`
`NIA
`
`Three sizes
`
`Atelocollagen
`
`Koken
`Bioscience
`Institutes, Japan
`
`Injectable bovine dermis
`extract, absorbable
`
`lntracana!icular
`
`NIA
`
`Snug Plug
`(FDA approval
`pending)
`
`FCI Ophtha!mics, Silicone, nonabsorbable
`Marshfield
`Hills, MA
`
`Puncta!
`
`One size fits all; no puncta!
`dilation required; preloaded;
`one-step insertion
`
`NIA
`
`NIA
`
`ProLong"'
`
`FCI Ophthalmics, Absorbable copolymer
`(-3 months)
`Marshfield
`Hills, MA
`
`Puncta!
`
`Ideal for post-LASIK
`
`Three sizes: 0.3, 0.4, 0.5 mm
`in diameter and 2.0 in
`length
`
`Puncta!
`
`NIA
`
`7 sizes (0.4-1.0 mm)
`
`Ready-Set
`
`FC! Ophthalmics, Silicone, nonabsorbable
`Marshfield
`Hills, MA
`
`PVP Perforated
`Plugs
`
`FCI Ophthalmics, Silicone with PVP coating
`Marshfield
`Hills, MA
`
`Puncta!
`
`For partial occlusion or stenosis Sizes: 0.7 mm and 0.9 mm
`
`SuperEagle"'
`
`SuperFiex"
`
`Eagle Vision,
`Memphis, TN
`
`Eagle Vision,
`Memphis, TN
`
`Flow Controller Eagle Vision,
`Memphis, TN
`
`Eagle FlexPiug"" Eagle Vision,
`Memphis, TN
`
`EaglePiug"'
`
`Eagle Vision,
`Memphis, TN
`
`Silicone, nonabsorbable
`
`Puncta!
`
`Newest; good retention
`and comfort
`
`Three sizes (range 0.4-1.1
`mm)
`
`Silicone, nonabsorbable
`
`Puncta!
`
`Good retention
`and comfort;
`easy insertion;
`multiple sizes
`
`8 sizes {0.4-1.1 mm)
`
`Silicone, nonabsorbable
`
`Puncta!
`
`For partial puncta! occlusion;
`tapered shaft
`
`4 sizes (0.5-0.8 mm)
`
`Silicone, nonabsorbable
`
`Puncta!
`
`Flexible; good fit and comfort
`
`8 sizes (0.4-1.1 mm)
`
`Silicone, nonabsorbable
`
`Puncta!
`
`Original plug; inexpesnive
`
`5 sizes (0.4-0.8 mm)
`
`DuraPiug""
`
`Eagle Vision,
`Memphis, TN
`
`PCL, absorbable
`(60-180 days)
`
`Puncta!-
`canalicular
`
`Ideal for post-LASIK
`
`N/A
`
`Parasol:o Plus"'
`Occluder
`
`Odyssey Medical, Silicone, nonabsorbable
`Inc.,
`Memphis, TN
`
`Parasol® Puncta! Odyssey Medical, Silicone, nonabsorbeble
`Occluder
`Inc.,
`Memphis, TN
`
`Quintess'"
`
`Cynacon/Ocusofl, Silicone, nonabsorbable
`Inc.,
`Richmond, TX
`
`Puncta!
`
`NIA
`
`Puncta!
`
`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)
`
`Puncta!
`
`Minimal foreign body sensation Sizes: 0.3-0.9 mm
`
`Collagen
`
`Various
`manufacturers
`
`Collagen, absorbable (days)
`
`Puncta!
`
`For trial of puncta! occlusion
`
`NIA
`
`APOTEX 1040, pg. 4
`
`

`

`ts up to
`Recent reports describe canalicular
`Atclocollagen (Koken Bioscience
`Instimtes,Japan) injection producing
`outflow occlusion for up to 8
`32 The material is extracted
`\veeks.31
`•
`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 significantly less ocular
`surface irritation and risk of
`extrusion than puncta! plugs. These
`absorbable materials may carry less
`risk of
`infection, untoward
`inflammation, and permanent
`canalicular obstruction compared to
`permanent materials.
`
`NONABSORBABLE
`INSERTS: PUNCTAL PLUGS
`
`The original permanent puncta!
`plug described by Freeman in 1975
`resembled an asymmetric dumbbell
`configuration. \V'hen placed properly,
`these plugs sit visibly at the punctum,
`with a wide internal 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 puncta! 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.
`
`Focus Point#3
`
`Newer .absorbable materials
`offer longer relief of dry eye
`·
`·
`·
`symptom~:.
`
`Fig. 2. External photograph demonstrates erythema
`with acute canaliculitis in the area of a previously placed canalicular plug. 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 cellarette offered on some
`Ready-Set models (FCI Ophthalmics,
`Marshfield Hills, J\-IA.), may improve
`the profile over the punctum. This
`plug line also offers the Slim plug,
`with a smaller bulb for easier
`insertion.
`Some plugs offer a central
`perforation. One version, the PVP
`plug (FCI Ophthalmics, Marshfield
`Hills, .MA) is lined with poly(cid:173)
`vinylpyrrolidone to prevent mucous
`from occluding the lumen. This
`lumen may allow for some tear
`outflm~;~ t.J-,ts 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 nt
`offers contoured edges with a solid
`nose.
`While the PVP plug uses a silicone(cid:173)
`lined material, other plugs use silicone
`rubber to change performance
`characteristics. The Quintessn1 plug
`(Cynacon/Ocusoft, Inc., Richmond,
`TX) offers microreservoir collarette
`indentations to create a barrier
`between the plug and the ocular
`surface.
`Some newer plugs decrease the
`need for sizing. Snug Plug (FCI
`Ophtalmics, i'viarshfield Hills, i'vlA.,
`FDA approval pending) is a silicone
`
`puncta! plug manufactured in one
`universal size. The SuperEaglen1
`(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 placement without punctal
`gaugrng.
`
`Insertion Technique
`
`A typical insertion technique for
`nonabsorbable silicone puncta! plugs
`is described below; hmvever, specific
`variations should follow manufac(cid:173)
`turer1s recommendations. Topical
`anesthesia with a drop of 0.5%
`proparacaine instilled into the
`conjunctival cul-de-sac is usually
`sufficient. Some patients, however,
`may benefit from applying direct
`pressure on the punctum using a 4°/o
`lidocaine-soaked cotton applicator.
`Manufacturers typically offer puncta!
`size gauging systems for their
`products, which can minimize the
`waste of trial-and-error techniques.
`Optimal sizing balances the risk of
`ext1usion and downward migration
`for plugs that are too small with the
`risk of pyogenic granuloma
`formation and discomfort associated
`with plugs that are too big."·" The
`ideal plug size should fit with gentle
`pressure.
`
`APOTEX 1040, pg. 5
`
`

`

`210
`
`Focus Point#4
`
`Seyeral newer conformiri(l
`Intr<tcanalicular plugs gffer
`improvedsymptoms with less
`risk of irritation. ·. ·
`
`Comp Ophthalrnol Update 7 (5) September-October 2006
`the canaliculus, resting at the junction
`of the vertical and horizontal
`canaliculus. \Xlith proper insertion, the
`expanded plug remains just beneath
`the surface of the punctum. For
`patients unable to tolerate standard
`plugs, 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 Pit'" (Oasis Medical, Glendora,
`CA) produces an expanding
`intracanalicular plug that absorbs up
`to 20 times its weight in tears over
`10 minutes. SmartPlug"' (Nleden(cid:173)
`nium, Irvine, CA) is a thermo(cid:173)
`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.
`
`The punctum is dilated by inserting
`the dilator vertically into the puncta!
`os, then directing it medially with
`lateral tension on the eyelid.
`Immediately after dilation, the nose
`of the puncta! 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.
`
`INTRACAN ALI CULAR
`PLUGS
`
`Nonconforming (Horizontal
`Canaliculus)
`
`Herrick Lacrimal Plugs'" (HLP)
`(Lacrirnedics, 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
`37
`38
`inflammation or infection. 35
`•
`•
`Removal requires more invasive
`measures,
`including
`surgical
`intervention. 39 In a Lacrimedics, Inc.(cid:173)
`sponsored study, 7o/o of patients
`reported wishing to reverse the
`procedure due
`to
`intolerable
`epiphora 27 Saline perfusion may
`resolve the symptoms in the majority
`of patients27
`; however, some may
`require surgical intervention. 40
`
`Conforming
`(Vertical Canaliculus)
`
`Conforming intracanalicular plugs
`represent the most recent entrants into
`the canalicular occlusion market.
`These plugs morph to the shape of
`
`Complications of Lacrimal
`Occlusive Devices
`
`Standard nonabsorbable plugs can
`cause mech..'lnical conjunctivitis or
`keratopathy from plug collar.
`Subconjunctival hemorrhage has
`been reported to occur in up to 2o/o
`of puncta! plug patients. 10 Pyogenic
`granuloma formation can lead to
`discharge or plug extrusion. Intra~
`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. l'viild epiphora occurs in
`up to 36% of patients 41 Most
`patients tolerate the epiphora, but up
`to 5°/o request removal. A trial using
`a temporaty intracanalicular plug can
`help predict which patients will
`develop epiphora if a permanent
`punctal plug is placed; however, it is
`not 100% reliable.30 Migrated plugs
`may cause irreversible epiphora due
`
`TAB AN
`to canalicubr stenosis or nasolacrimal
`duct obstruction.
`Although spontaneous distal
`migration is uncommon due to wide
`rin1 design, improperly small puncta!
`plugs carry a higher risk.34 l'vligrating
`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 fistulas. 3
`5
`38
`42.43
`,
`•
`High-frequency B-scan ultrasound
`may help detect silicone puncta! plugs
`within the canalicular system.
`Sonography can confirm stable
`intracanalicular positioning for the
`higher reflectivity silicone Herrick
`Lacrimal Plugs'ID and lower reflectivity
`acrylic polymer SmartPlugs"'.44
`Removal of puncta! 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 be performed if
`symptomatic epiphora persists. A
`pigtail probe can be introduced
`through the opposing canaliculus to
`push rl1e 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
`arc more likely to develop early
`extrusion. 19 Patients who h,·we lost an
`
`.
`
`.
`
`Foc~i Poihi•#s
`_/·_-· ---
`''·"--:· ... --" '·::·._
`.
`--_:·_-:. __ .~:
`·Lacrimal oulflow.o~c::lusion
`can . result . in .. several
`important complications ..
`
`APOTEX 1040, pg. 6
`
`

`

`UPDATE ONPUNCTAL PLUGS
`initial plug are twice as likely to lose
`a replacement plug. 10 Upper puncta!
`plugs are at greater risk of loss
`compared with plugs inserted in the
`lower puncta. 45
`46 Extrusion rates
`•
`differ for different plug models. One
`study
`found
`that 72% of
`EaglePlugs=
`(Eagle Vision,
`Memphis, TN) ;~re lost at a mean of
`59 days versus a 56% loss rate of
`FCI puncta! 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 months
`versus 68.6% for EaglcPlugs=.+7
`Reinsertion following extrusion
`usually requires a larger plug, 48
`although granulation tissue occluding
`the canaliculus can confound
`reinsertion. 49 Softer polymers, such
`as Elast-Eon= (AorTech, Surrey,
`United Kingdom) (liquid silicone/
`rubber elaston1er), may improve
`comfort while reducing the incidence
`exttusion. Securing plugs with 10-0
`polypropylene suture may improve
`long-term success. 5°
`While pyogenic granuloma
`formation due to silicone punctal
`plugs was thought to be rare, a recent
`report describes a higher incidence.36
`~lean presentation occurred
`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, Wilmington, DE) and
`hydroethyl-methacrylate (fear Saver"
`Plus, CIBi\ Vision, Duluth, GA), may
`reduce tissue reactivity.
`Canaliculitis and dacryocystitis can
`occur in patients with distal punctal
`plug migration,
`or
`from
`intracanalicular plugs (Pigure 2).
`Treatment often requires plug
`removal
`and
`dacrocystor(cid:173)
`hlnostomy.37
`
`Surgical Occlusion
`
`The wider selection of reversible
`canalicular occlusive devices has
`
`minimized the need for permanent
`occlusive surgery. For some patients,
`however, permanent occlusion may
`represent the most practical option. 10
`Electrocautery offers excellent long(cid:173)
`term closureY Other modalities
`include diathermy, glues, and Argon
`laser, which has a peak efficacy of
`only 40°/o at 1 month, decreasing to
`only 33°/o at 6 months. 51 ,52
`
`Conclusion
`
`Punctal occlusion therapy often
`benefits patients with aqueous
`deficiency, providing syn1ptomatic
`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 puncta! plugs suggests that some
`patients benefit only temporarily
`from occlusive treatment. Under(cid:173)
`standing the neuromodulatory
`feedback mechanisms and the role
`of inflammatory mediators in ocular
`surface disease will offer exciting new
`medical therapies for dry eye.
`
`References
`
`1.
`
`Freeman J0J: The punctum plug:
`evaluation of a new treatment for
`the dry eye. Trans Sect Ophthalmol
`Am Acad Ophthalmol Otolaryngol
`79: 874-9, 1975
`2. Beetham \W: Filamentary keratitis.
`Trans Am Ophthalmol Soc 33: 413-
`35,1935
`3. Foulds \VS: Intra-canalicular gelatin
`implants in the treatment of kerato(cid:173)
`conjunctivitis sicca. Br J Ophthalmol
`45:625-7,1961
`4. Lemp n-IA: Report of the National
`Eye Institute/Industry workshop
`on Clinical Trials in Dry Eyes. CLAO
`J 21:221-32,1995
`5. Nichols KK, Mitchell GL, Zadnik K
`The repeatability of clinical
`measurements of dry eye. Cornea 23:
`272-85, 2004
`6. Yen MT, Pflugfelder SC, Feuer WJ:
`The effect of punctal occlusion on
`tear production, tear clearance, and
`
`211
`ocular surface sensation in normal
`subjects. Am J Ophthalmol 131:
`314-23, 2001
`7. Mishima S, Gasset A, Klyce SD, et al:
`Determinacion of tear volume and
`tear flO\v. Invest Ophthalmol 5: 264-
`76,1966
`8. Ding C, Walcott B, Keyser KT:
`Neuronal nitric oxide synthase and
`the autonomic innervation of the
`mouse lacrimal gland. Invest
`Ophthalmol Vis Sci 42: 2789-94,
`2001
`9. Kovics I, Ludtl.ny A, Koszegi T, et
`al: Substance P released from sensmy
`nerve endings influences tear
`secretion and goblet cell function in
`the rat. Neuropeptides 39: 395-402,
`2005
`10. Tai MC, Cosar CB, Cohen EJ, et a1:
`TI1e clinical efficacy of silicone punctal
`plug therapy. Cornea 21: 135-9,2002
`II. Huang TC, Lee DA: Puncta!
`occlusion and topical medications for
`glaucoma. Am J Ophthalmol 107:
`151-5, 1989
`12. Fraunfelder FT: Drug-Induced
`Ocular Side Effects and Drug
`Interactions. Philadelphia, Lea &
`Febiger, 1989, ed 3, p 595
`13. Battat L, i\facri A, Dursun D, et al:
`Effects oflaser in sihl keratomileusis
`on tear production, clearance, and the
`ocular surface. Ophthalmology 108:
`1230-5,2001
`14. Nialet T, Challier B, David N, et al:
`Clinical and scintigraphic comparison
`of silicone and polyvinylpyrrolidone
`coated silicone perforated plugs. Br J
`Ophthalmol82: 1416-9, 1998
`15. Bohlman H: Perforated punctal plug
`in the treatment of partial punctal
`stenosis. Optometry 74: 524-8,2003
`16. Schirmer 0: Study of physiology and
`pathology of tear film and tear
`production. Graefes Arch Clin Exp
`Ophthalmol56: 197-291, 1903
`17. Kim J, Foulks GN: Evaluation of
`the effect oflissamine green and rose
`bengal on human corneal epithelial
`cells. Cornea 18: 328-32, 1999
`18. Tseng SC: Staging of conjunctival
`squamous metaplasia by impression
`cytology. Ophthalmology 92: 728-
`33,1985
`19. Willis fuvl, Folberg R, Krachmer JH,
`et a!: The treatment of aqueous(cid:173)
`deficient dry eye with removable
`puncta! plugs. A clinical and
`impression-cytologic study. Oph-
`
`APOTEX 1040, pg. 7
`
`

`

`212
`
`Comp Ophthalmol Update 7 (5) September-October 2006
`thalmo1ogy 94: 514-8, 1987
`for lacrimal duct occlusion. Adv Exp
`20. Ishida R, Kojima T, Dogru M, et al:
`J\led Biol506: 1277-81,2002
`The application of a new continuous
`32. Hamano T: A tela collagen punctal
`functional visual acuity measurement
`occlusion for the treatment of the
`system in dry eye syndromes. 1\m J
`dry eye. Adv Exp Mcd Bioi 506:
`Ophthalmol 139: 253-8, 2005
`1283-4, 2002
`21. Miyata K, Otani S, lvliyai T, et al:
`33. Knapp TR, Kaplan EN, Daniels JR:
`Atelocollagen punctal occlusion in
`Injectable collagen for soft tissue
`augmentation. Phst Reconstr Surg
`dry eye patients. Cornea 25: 47-50,
`2006
`60:398-405,1977
`22. Farrell J, Patel S, Grierson DG, et al:
`34. Maguire LJ, Bartley GB:
`A clinical procedure to predict the
`Complications associated with the
`value of temporary occlusion d1erapy
`new smaller size freeman punctal
`In keratoconjunctivitis s1cca.
`plug. Case report. Arch Ophthalmol
`Ophthalmic Physiol Opt 23: 1-8,
`107:961-2,1989
`2003
`35. Rumelt S, Remulla H, Rubin PA:
`23. Reese V, Youngbar PR: The effect of
`Silicone punctal plug migration
`punctal occlusion on tear lactoferrin
`resulting in dacryocystitis and
`in agueous deficient dry eye patients.
`canaliculitis. Cornea 16: 377-9, 1997
`Adv Exp Med Bioi 506: 1269-71,
`36. Kim BM, Osmanovic SS, Edward
`2002
`DP: Pyogenic granulomas after
`24. Gilbard JP, Rossi SR, Azar DT, et al:
`silicone puncta} plugs: a clinical and
`Effect of punctal occlusion by
`histopathologic study. Am J
`Freeman silicone plug insertion on
`Ophthalmol139: 678-84,2005
`37. Takemura M, Yokoi N, Nakamura
`tear osrnolariry in dry eye disorders.
`CLAO J 15:216-8, 1989
`Y, et al: (Canaliculi tis caused by
`Actinomyces in a case of dry eye -..vith
`25. Chalmers RL, Begley CG, Edrington
`T, etal: The agreement between self-
`puncta! plug occlusion]. Nippon
`assessment and clinician assessment
`Ganka Gakkai Zasshi 106: 416-9,
`of dry eye severity. Cornea 24: 804-
`2002
`10,2005
`38. Yokoi N, Okada K, Sugita J, et al:
`Acute conjunctivitis associated with
`26. Neves RA, Doucas A, Chamon \'\~
`biofilm formation on a puncta! plug.
`et al: Provisional occlusion of
`Jpn J Ophthalmol44: 559-60, 2000
`lacrimal puncta with catgut suture.
`Arq Bras Oftalmol55: 218-20, 1992
`39. Lee J, Flanagan JC: Complications
`27. Henick RS: A subjective approach to
`associated with silicone intra(cid:173)
`the trea