A Closer Look at Punctal Plugs

Punctal plugs are a concept that sounds quite scary when presented to a patient for the first time, but could have a number of benefits for multiple ocular conditions.  A new article by Review of Optometry features all of the unsung potential uses for plugs.  For a treatment once thought out of date due to the advent of Restasis, more and more doctors are returning to plugs for helping their patients achieve relief from dry eye.  Now we are finding new applications for this quick and painless procedure!

Properly inserted permanent plug

DRY EYE 
We recently discussed punctal plugs and their benefits for patients with dry eye, and Dry Eye Syndrome is still the most popular use for these devices.  Punctal plugs prevent rapid drainage of your own tears through your nasolacrimal tear duct, keeping a healthy layer of tear film on the eye for a longer time.  I especially prefer plugs on patients where there is minimal to no meibomian gland dysfunction and:

• Contact Lens Wearers with poor comfort due to dryness
• filamentary keratitis from advanced dry eye
• pre or post-op LASIK --- a healthy tear film will improve comfort and post-LASIK visual outcome!

Remember it is ok to use plugs AND Restasis!  Restasis will help increase tear production, and plugs will just keep the tears on the eye longer.  We just want to treat any inflammatory component before plugging the eye.

Pyogenic Granuloma with embedded plug

Why I use Dissolvable Plugs 

Permanent plugs are perfectly healthy and can easily be removed in most cases.  But sometimes permanent plugs can fall into the puncta and be lodged there.  Now, in most cases the plug will either stay there harmlessly, offering continued relief from dryness.  Sometimes, however the body can mount an inflammatory reaction to the embedded plug (this is called a pyogenic granuloma) and the plug may even have to be surgically removed.  This is very rare, but already in my short career I have seen a buried plug (where it falls into the punctal opening and cannot be retrieved).  Dissolvable plugs do have to be replaced more frequently, but there is NO risk involved, which makes things a lot easier when explaining an already intimidating procedure idea to the patient.  For other OD's out there: buried plugs are a big risk when you have a patient who is a frequent eye rubber, or when you have a patient who has a very large puncta.

OTHER USES FOR PUNCTAL PLUGS

Sometimes when doctors prescribe an eye drop, they will recommend you closing your eyes or putting a finger over the nasal corner of your eye to prevent systemic absorption of the drop.  This is called punctal occlusion, a procedure that reduces the amount of drug getting into your bloodstream and travelling to other areas of the body, as well as increases the amount of drug absorbed by your eye!  The longer the drop is in contact with your ocular tissue, theoretically there should be a better therapeutic effect.  A punctal plug would do the same thing that your finger would, and could be very effective in patients with:

• Glaucoma, using topical eye drops to increase the contact time of the drop
• bacterial corneal ulcers to increase the amount of antibiotic on the surface of the eye
• corneal dystrophies or recurrent corneal erosion to keep the eye lubricated 
• history of herpetic infections to protect the eye from dryness or other ocular stressors that could reactivate the virus

THE FUTURE OF PUNCTAL PLUGS

For people using daily eye drops (sometimes four or five times a day!) for the treatment of glaucoma, less dosing is a great improvement to quality of life.  There have been numerous studies reporting that the more drops required, compliance with dosage greatly decreases, which can directly result in further damage to the optic nerve and vision!  A company called QLT has proposed using a punctal plug filled with Latanoprost (a glaucoma medication) that can be inserted just like any other plug and provide sustained release of medication.  The patient would no longer need to remember to insert drops!!  This could be an incredible new therapeutic option that could be incorporated into the treatment of other ocular conditions where regular dosing of drugs is needed.   Imagine a punctal plug filled with Restasis!  I'm sure someone is working on this as we speak.