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.

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.

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:

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.

Punctal plugs are another option when Restasis isn't the appropriate direction due to the above complications.  Punctal plugs are small collagen or silicone cylinders, typically less than 1 mm in width and around 3 mm in length, that are inserted into the puncta of the eyelid.  The puncta is the drainage opening of the eyelid, where tears drain down into the nasolacrimal duct.  If we "plug" the puncta, tears are collected onto the eye for a longer period of time.  If your tears are staying on the eye longer, you will be experiencing much less dryness.

Not everyone is a candidate for punctal plugs.  If you have blepharitis/meibomian gland dysfunction/ocular rosacea symptoms that are greatly flared up, plugs will keep the inflammatory mediators on the surface of your eye which results in more redness and irritation.  We have to treat this inflammation first before plugs would be a good option.

I preferably insert dissolvable collagen plugs into the lower puncta of each eye.  Some doctors may also insert plugs into the upper puncta in cases of severe dryness, but this is much less common.  Dissolvable plugs are placed all the way into the puncta, so they are not visible when you look in the mirror.  They typically last 3 months (and as long as 6 months) before being completely dissolved.  That means that they would need to be replaced on a regular basis to offer continue relief.  The benefits of dissolvable plugs is that there is very little infection or inflammation risk. 

Silicone permanent plugs are also available and offer longer term relief.  They typically sit on top of the puncta so that they could be removed with tweezers if needed.  While these plugs are permanent, if you have an eye infection it is best to remove them and then have a new plug inserted when the infection is cleared. They can also fall out (especially if you are rubbing your eyelids quite a bit), or fall down into the tear duct.  If these plugs fall down inside of your tear duct, they aren't dissolvable so they will always be there.  If they need to be removed, they can be either irrigated or surgically removed.  Because of this risk, I tend to insert dissolvable plugs more frequently.

The Procedure: 

On the day of your punctal plug insertion, expect the procedure to be surprisingly fast and easy!  Almost all of my patients are apprehensive at first, and then are surprised when I am finished that the procedure was already over.  Your doctor may first insert a drop to numb your eye, just to make you more comfortable during the procedure.  In the microscope, they will first use a device called a "dilator" to open your puncta to ease the insertion process.  Then it is time for the plugs to be inserted.   Temporary plugs have to be inserted further into the puncta so they may take a little longer to put in place compared to the permanent plugs that sit on top of the lid margin.  Usually everything is finished in less than 10 minutes.  The first day you may experience mild discomfort around the inner corner of your eyes, but symptoms should be no worse than that.  Marked pain or discharge should not occur.  Just make sure not to rub your eyes too much because the plugs can come dislodged!  After a day or two at most, you shouldn't even be able to feel that something is there!

When Should Plugs Start Working?

This depends on how dry your eyes were prior to plug installation.  You have to give your eye time to heal -- and dry eye can be ongoing for years before some patients seek treatment, so we are trying to reverse years of damage.  On average, I expect patients to be feeling significant improvement if plugs are going to be effective treatment in 1 month, but it could be much faster for milder cases.  I have had patients note improvement as quickly as within a week!