Punctal Plug Insertion Research Articles

Dacryoendoscopic Findings of Intracanalicular Punctal Plug Migration With or Without Canaliculitis

An 83-year-old woman with Sjögren syndrome underwent insertion of large punctal plugs in the right upper and lower puncti. Nine months later, she presented with upper canaliculitis, although the plugs were not found in the puncti. Dacryoendoscopic examination revealed punctal plug migration, granulation, and a large amount of debris in the upper canaliculus. The plug was situated parallel to the canaliculus, occluding the intracanalicular space. The lower canaliculus also showed plug migration, but little granulation and debris were present. The plug was situated perpendicular to the intracanalicular space, securing a space around the plug. The migrated plugs were pushed directly toward the nasal cavity by the dacryoendoscope. Curettage was performed in the upper canaliculi. Bicanalicular silicone intubation was performed, and removal was performed 3 months later. The patient remained symptom-free for 6 months postoperatively.

Comparison of Retention Rates and Complications of 2 Different Types of Silicon Lacrimal Punctal Plugs in the Treatment of Dry Eye Disease

To investigate the retention rate and complications of 2 different types of silicon lacrimal punctal plugs with the focus on the relationship to punctum size. A prospective, nonrandomized, interventional, comparative study. Forty-four patients with dry eye syndrome received lacrimal punctal plug insertion with the Punctal Plug F (FCI Ophthalmics) and 30 patients received plug insertion with the Super Flex plug (Eagle Vision; Softplug-Oasis Medical Inc). In total, 110 plug insertion regions were performed using the Punctal Plug F (group A) and 110 insertion regions were carried out using Super Flex plug (group B). The gauging system of Eagle Vision was used before the lacrimal punctal plug insertion in all subjects. Plug conditions (retention rates, spontaneous plug loss, and removal) and complications related to lacrimal punctal sizes were compared between the 2 groups. Retention rates were 70.4% in group A and 30.1% in group B at 6months. Spontaneous plug loss occurrence was significant with the larger lacrimal punctum size in group A (P < .05), whereas no significant differences were observed between lacrimal punctum sizes and spontaneous loss in group B. Spontaneous plug loss occurrence was significant in elderly patients in group B (P < .05). Granuloma and injector troubles were observed in 1 and 2 cases in group A, respectively. The Punctal Plug F seems to be more applicable for insertion into the smaller punctal sizes. Punctum size and age seem to be important factors in determining the appropriate types of lacrimal punctal plugs.

Longitudinal Evidence on Punctal Plug Use in an Elderly Population

The purpose of this study was to determine whether changes in Medicare reimbursement for punctal plug insertion were associated with a decrease in the incidence of insertion and dry eye diagnosis. Incident cases of dry eye syndrome (DES) diagnoses and punctal plug insertions among Medicare beneficiaries were identified from Medicare 5% Part B from 1994 to 2008, using a 3-year look-back. Dry eye syndrome diagnoses and punctal plug insertion codes were ascertained from the international classification of diseases and current procedural terminology codes. Medicare payment data were obtained from the Centers for Medicare and Medicaid Services from 1994 to 2008 for punctal plug insertion. Rates were calculated for both the incidence of DES and the use of punctal plugs. From 2001 to 2008, inflation-adjusted Medicare reimbursement for punctal plug insertion decreased 55.1%, whereas the Medicare population-adjusted incidence of dry eye diagnosis increased 23.3%. Nine percent of individuals diagnosed with DES between 1991 and 2008 underwent punctal plug placement with a mean of 2.0 plugs placed per patient. Total punctal plug placement increased 322.2% between 1994 and 2003, and then reached a plateau. First-time punctal plug insertion rates within 365 days of DES diagnosis increased 111.8% from 1994 to 2002, and then declined 47.0% from 2002 to 2008. Although the frequency of DES diagnosis in the Medicare population has increased over time, first-time punctal plug insertion rates, especially within the first year following DES diagnosis, have declined coincidently with the increasing presence of a medical alternative and declining Medicare payment. Choice of therapies may have cost and care implications.

The use of punctal plugs in children

Background/aimsTo evaluate the safety and efficacy of punctal plugs in children with dry eye syndrome.MethodsA retrospective case series of patients who had an insertion of silicone punctal plugs for dry...

Treatment of a Lacrimal Pneumocele With Punctal Plug Insertion

A 37-year-old man presented with symptoms of air and mucus reflux from the right medial canthus on blowing his nose. Examination showed crepitus in the region overlying the right lacrimal sac, and he was able to produce bubbles in his conjunctival lake on instillation of topical 2% fluorescein. Dacryoscintigraphy showed symmetrical slow passage of tracer from the lacrimal sac in the nasolacrimal duct indicating delay at the postsac level. Dacryocystography showed that the right lacrimal system contained round filling defects, suggesting the presence of soft tissue tumors. However, a CT scan showed an enlarged right lacrimal fossa with air in the nasolacrimal duct and no evidence of a mass. Following lower punctal plug occlusive canaliculoplasty on the right, using a preloaded silicone plug, the patient noted an immediate resolution of reflux symptoms.

Mycobacterial Chelonae Lacrimal Canaliculitis in A Patient After Punctal Plug Insertion for Post-LASIK Dry Eye

Mycobacterial Chelonae Lacrimal Canaliculitis in A Patient After Punctal Plug Insertion for Post-LASIK Dry Eye

Ophthalmic delivery of cyclosporine A by punctal plugs

Dry eyes are treated by instillation of eye drops of cyclosporine A emulsion or by punctal plug insertion in canaliculus to block tear drainage. This paper focuses on a novel approach of developing a punctal plug that can also release cyclosporine A to provide a dual mechanism for treating dry eyes. The punctal plug consists of a cylindrical hydroxy ethyl methacrylate core containing drug microparticles surrounded by an impermeable silicone shell that covers about 50% of the core, with the uncovered part directed towards the eyes. The geometry of this design is significantly different from those in patent literature, which are mostly designed to be rods. Plugs release cyclosporine A for a period of about 3 months at zero-order at a rate of about 3 μg/day. The in vivo release rates are expected to be about half of this value. A mathematical model is presented that provides an accurate estimate of the release without any fitting parameter. Pharmacokinetic models are also developed for drug delivered through Restasis® and punctal plugs, and based on these models the release rate of about 1.5 μg/day may be therapeutically effective. The predictions of the ocular pharmacokinetic model are in reasonable agreement with reported measurements in humans.

Retention Rate of Silicone Punctal Plugs Placed by Residents in a General Clinic Setting

To evaluate the retention rate of silicone punctal plugs placed in patients with dry eye in a general clinic setting by ophthalmology residents. A cohort study reviewing charts of 88 patients who underwent punctal plug placement in the resident clinic at The New York Eye and Ear Infirmary from January 2007 to November 2008. Information recorded included age and sex of the patients, date of insertion, initial versus replacement plug, type and size of plug, location of insertion, and retention versus spontaneous extrusion versus removal of plugs at follow-up visits. Follow-up data were recorded at 30 and 60 days. Follow-up data for 106 plug placements were available at 30 days. A total of 71.7% were retained, 23.6% were lost, and 4.7% were removed. At 60 days, data were available for 96 plug placements. A total of 50.0% were retained, 47.9% were lost, 5.2% had been removed prior to 60 days, and 2.1% had been replaced prior to 60 days. Spontaneous extrusion is a common complication in punctal plug insertion, and the retention rate in a general clinic setting with ophthalmology residents is low. This may suggest that attention should be placed on improved instruction in placement techniques and sizing, better patient education on avoidance of rubbing, and importance of follow-up. It may also support the need for better designed plugs or considering alternatives to the silicone plugs, or the placement of such plugs in a dedicated punctal plug clinic under supervision of an experienced attending physician.

Canaliculitis masquerading as Dacryocystitis: Rhinologist's Dilemma

ABSTRACT Aim To highlight canaliculitis masquerading as chronic dacryocystitis that may mislead a rhinologist. Background Canaliculitis is an inflammation of the lacrimal canaliculi caused by infection or as a complication of punctal plug insertion. It is often misdiagnosed, leading to a delay in diagnosis. Case report We report a case of a 20-year-old female patient who presented with complaints of watering from left eye since 1 year and was referred to the Department of Ear, Nose, and Throat for endoscopic dacryocystorhinostomy (DCR). She had a history of silicone punctal plug insertion in the same eye for “dry eye” following an attack of herpes zoster 12 years earlier. She was asymptomatic for 10 years following punctal plug insertion, but started complaining of epiphora since the last 2 years. Punctal plug was removed 1 year back by an ophthalmologist but the epiphora persisted. Regurgitation of purulent discharge on pressure over lacrimal sac area made it look like dacryocystitis. Syringing through lower punctum was blocked while through the upper punctum it was patent. Thus, possibility of nasolacrimal duct block was ruled out. An occuloplasty opinion was sought and a diagnosis of lower canaliculitis with possibility of retained plug was made. Conclusion Canaliculitis should be considered as a differential diagnosis in cases presenting with epiphora as canaliculitis is a close masquerade of dacryocystitis. Clinical significance As more and more rhinologists are getting direct referrals of cases needing endoscopic DCRs, it is important for them to be well aware of other associated pathologies of proximal lacrimal system. This will help them to reach a correct diagnosis before going ahead with endoscopic DCR. How to cite this article Gupta N, Das S, Chawla N. Canaliculitis masquerading as Dacryocystitis: Rhinologist's Dilemma. Clin Rhinol An Int J 2017;10(2):91-92.

Canaliculitis Associated With SmartPlug™ Punctal Plug Insertion: Clinical Features and Management

Purpose: To report the clinical features and treatment of canaliculitis associated with SmartPlug punctal plug insertion. Methods: Case selection criteria included patients with canaliculitis, who were managed at Seoul National University Hospital from January 2006 to October 2008, presenting with a history of punctal plug insertion. The operation reports were reviewed to identify patients in whom SmartPlug was discovered during the operation. Six patients (8 eyes) were identified, and a retrospective chart review was performed for all the patients. Results: The mean age of the patients was 34.38.6 years, and there were 1 men and 5 women. Common symptoms were mucous discharge (6 eyes) and conjunctival injection (2 eyes). The mean time from insertion of the plug to onset of symptoms was 27.027.0 months (range 4 to 77 months). All patients underwent surgical removal of the punctal plug by one-snip punctoplasty, canalicular retrograde compression using 2 cotton-tipped applications (2 eyes), or canalicular curettage (6 eyes). All patients had resolution of symptoms after the procedure. Conclusions: Canaliculitis should be considered when there is conjunctival discharge or injection in patients with SmartPlug. One-snip punctoplasty and retrograde compression of canaliculus can be attempted preferentially as a minimally-invasive treatment option.

A New Punctal Plug Insertion Technique to Prevent Intracanalicular Plug Migration

To evaluate the intracanalicular migration rate during plug insertion with a new plug insertion technique compared with a standard technique. Interventional, nonrandomized, comparative study. Forty-five patients with dry eye syndrome underwent a punctal plug insertion with the new technique, and 33 patients underwent a punctal plug insertion with a standard technique at the dry eye subspecialty outpatient clinic of the Department of Ophthalmology at Keio University. Tear function examinations and ocular surface evaluations, including the Schirmer test, tear film breakup time, fluorescein and Rose Bengal vital staining scores, were performed before punctal plug insertion. Super Flex Punctum Plugs (Eagle Vision, Memphis, Tennessee, USA; Softplug-Oasis Medical Inc, Glendora, California, USA) were implanted in all subjects with both techniques. In total, 120 procedures were carried out with the new technique and 132 procedures with the standard technique. There were no statistical differences between the two groups in tear function and ocular surface staining scores (P > .05). There was no intracanalicular plug migration with the new insertion technique, whereas there were 18 incidents of intracanalicular migration of 132 standard plug insertion procedures (13.6%). The new plug insertion technique seems to be effective in eliminating intracanalicular plug migration during the insertion procedure.

Long-term Success Rate of Perforated Punctal Plugs in the Management of Acquired Punctal Stenosis

To give the long-term success rates of punctal dilatation with insertion of perforated punctal plugs (PPP) for the management of acquired punctal stenosis. A series of 44 eyes of 26 patients who underwent PPP implantation for the management of acquired punctal stenosis were retrospectively evaluated in terms of the severity of acquired punctal stenosis, associated eyelid disorders, implantation technique of PPP, and long-term success rate of PPP for the treatment of epiphora. In all patients, punctal dilation was performed prior to the insertion of plugs. Patients demonstrating moderate or severe horizontal eyelid laxity underwent a lateral tarsal strip procedure before PPP implantation. Complete stenosis of the punctum was treated with the radiofrequency unit before PPP implantation. The plugs were extracted at 2 months in every patient. The mean age of the patients was 63.6 +/- 10.5 years. The median interval between the onset of epiphora and PPP implantation was 15 months. There were 14 complete stenoses, 29 partial punctal stenoses, and 1 squamous papilloma involving the inferior punctum causing epiphora. Associated eyelid laxity was detected in 14 of 44 eyes (31.8%), and 8 eyes underwent a lateral tarsal strip procedure before PPP implantation. The mean follow-up time was 19.0 +/- 13.4 months. Success was achieved in 37 of 44 eyes (84.1%), with relief of epiphora. Of the 7 eyes with continued epiphora, 3 eyes demonstrated recurrent punctal stenosis and 4 eyes demonstrated mild horizontal eyelid laxity. The long-term success rate of PPP implantation for the treatment of acquired punctal stenosis is satisfactory. Associated eyelid pathologies should be evaluated for their contribution to epiphora and be treated before PPP implantation.

Wavefront Sensing and the Dynamics of Tear Film

To summarize our previous studies regarding the influence of tear-film dynamics on optical quality after blinking. Sequential higher-order aberration (HOA) measurements were performed by using a wavefront sensor. During the measurements, subjects were asked to blink every 10 seconds. The obtained aberration data were analyzed in the central 4-mm diameter for coma-like, spherical-like, and total HOAs up to the sixth-order Zernike polynomials. Serial measurements of HOAs in healthy eyes showed variations even in clinically normal subjects and were classified into 4 groups by pattern: stable, small-fluctuation, sawtooth, and others. The sequential postblink change in HOAs after punctal plug insertion was quantitatively evaluated in a patient with dry eye who complained of paradoxical visual impairment with epiphora despite improvement of dry eye. Wavefront sensing is a useful objective method to evaluate sequential changes of visual performance related to tear-film dynamics. Serial measurement of HOAs might show a relationship between tear dynamics and quality of vision clinically.

Favorable Effects of Lacrimal Plugs in Patients with an Anophthalmic Socket

Background: The use of punctal plugs in the treatment of dry eyes is well established. Anophthalmic patients have less tears in the anophthalmic socket in comparison to their normal side, due to an absent corneal reflex (,b). Many of those patients complain of dry eye symptoms, even when they are treated with tear replacement therapy. The authors wished to examine whether they could improve their dry socket complaints with punctal plugs. Purpose: To evaluate the clinical efficacy and tolerability of punctal plug (Smart Plugs®) insertion in anophthalmic patients with symptoms of dry eye. Patients and methods: Interventional case series. Fifteen anophthalmic patients with dry eye symptoms, a Schirmer test of less than 3 mm and an open lacrimal passage were examined before and after insertion of punctal plugs. The patients were asked for their subjective evaluation of the treatment and were examined to evaluate the change. Schirmer tests were compared. Bacterial cultures were taken at both visits. Results: Schirmer results of less than 3 mm in the anophthalmic socket were obtained in 75% of patients with dry eyes symptoms; 87% of patients in whom punctal plugs were inserted reported an improvement in dry eye sensation. More than half of the patients demonstrated less discharge (p ≤ 0.05). Schirmer tests improved from 1.4 mm to 1.9 mm (p ≤ 0.05). Patients with a Schirmer outcome of 2 mm or more tended to have less pathogenic bacterial cultures (p = 0.11). Conclusion: Punctal plugs improve the symptoms and signs of dry socket. Punctal plugs seem to reduce the pathogenic bacterial growth in the anophthalmic socket.

Paradoxical increase of visual impairment with punctal occlusion in a patient with mild dry eye

We report a paradoxical increase in visual impairment after punctal plug placement despite improvement in corneal epithelial damage caused by mild dry eye. Ocular higher-order aberrations (HOAs) were measured sequentially with a wavefront sensor before and after punctal plug insertion in a patient with mild dry eye. Although postblink HOAs tend to increase in normal subjects or patients with dry eye, after treatment there was a maximum spike in HOAs for a few seconds that decreased gradually. Excessive retention of tear film by punctal occlusion may cause inferosuperior asymmetrical distribution in precorneal tear-film thickness, possibly leading to slower wavefront on the inferior cornea and increased coma-like aberrations. Increased visual impairment might occur paradoxically despite improvement in the corneal epithelial damage caused by dry eye.

Recent advances in the management of ocular complications of sjögren’s syndrome

Sjögren's syndrome (SS) is an autoimmune disorder, the principal ocular manifestation of which is decreased tear production leading to chronic irritation and damage to the corneal and conjunctival epithelium. The most important advance in the treatment of ocular manifestations of SS is the introduction of topical anti-inflammatory agents such as cyclosporine A, which increases tear production and decreases symptoms without any significant side effect. Stimulators of tear secretion, both topical, such as diquafosol, and systemic, such as pilocarpine and cevimeline, are also effective, although they have been associated with frequent side effects. Topical use of autologous serum is another new and effective form of treatment, but problems in the preparations prevent their widespread use. Additionally, nonpharmacologic treatments, such as insertion of punctal plugs, are beneficial in the dry eye of SS, whereas several other modalities, such as anti-CD4 monoclonal antibody eye drops and gene transfer, are still in experimental phases.

Lacrimal Duct Occlusion for the Treatment of Dry Eye

The most widespread treatment for dry eyes in clinical practice is an instillation containing artificial tear fluid. When an instillation does not ameliorate dry eye, we use punctal plugs. The insertion of punctal plugs is an eminent curative that positively improves the corneal and conjunctival epithelial disorders and the amount of lacrimal fluid accumulated in the conjunctival sac. We shall introduce the lacrimal duct occlusion utilizing atelocollagen solutions, which solves many of the issues induced by conventional methods.

The clinical efficacy of silicone punctal plug therapy.

To evaluate the clinical efficacy and safety of silicone punctal plugs in various ocular surface disorders. Medical records of patients who underwent silicone punctal plug insertion from January 1996 to November 2000 were retrospectively reviewed. The clinical data collected included sex and age of the patients, indications for plug insertion, symptoms, corneal fluorescein staining and frequency of lubricant use at baseline and at 4 +/- 2 weeks after the insertion, location (upper versus lower punctum), initial versus replacement plug, spontaneous extrusion or removal of the plug, and percentage of complications and punctum cauterization. There were 203 eyes of 153 patients (126 women and 27 men) in the study group. The total number of silicone punctal plug procedures was 312. Dry eye syndrome was the most common indication for punctal plug treatment (127 eyes, 62.5%), followed by epitheliopathy after penetrating keratoplasty (32 eyes, 15.8%). The symptoms improved in 150 (73.9%) of 203 eyes at 4 +/- 2 weeks' follow-up. The mean score of the fluorescein staining of the cornea was reduced from 2.7 +/- 0.1 to 1.3 +/- 0.1 with silicone punctal plug treatment at 4 +/- 2 weeks' follow-up. This reduction was statistically significant (p< 0.01). The overall success rate at 4 +/- 2 weeks follow up was 76.8%. The frequency of the lubricant use was significantly decreased with punctal plug treatment (p< 0.001). Considering all plugs, the estimated probability of plug retention was 49.4% with 85.1 +/- 7.3 weeks as the mean survival time. There was no statistical difference in plug retention rates between lower (49.6%) and upper (48.7%) plugs (p= 0.15). Retention rate of first plugs (53.5%) was significantly higher than that of second plugs (32.0%) (p= 0.05). The spontaneous total extrusion of silicone punctal plug was the most common complication in our study (158 plugs, 50.7%). The plug was removed in 14 eyes (14 plugs, 6.9%) because of epiphora in 11 eyes and conjunctival erosion in three eyes. The percentage of punctum cauterization performed in our population was 10.8%. Punctal plug insertion is a simple, effective, safe, and reversible method to treat aqueous tear deficiency and other ocular surface diseases, such as epitheliopathy after penetrating keratoplasty, superior limbic keratoconjunctivitis, neurotrophic keratitis, recurrent corneal erosions, and toxic epitheliopathy not controlled by lubrication with preservative-free tears. However, spontaneous extrusion of silicone plug occurs commonly. Careful choosing of the optimal plug size and close follow-up are recommended to ensure the success of the treatment.

Silicon punctal plug insertion in the treatment of severe dry eye.

Silicone punctal plug insertion is often faster acting than eyedrops in treating severe dry eye. Punctal plug dropout may occur, and lacrimal punctal swelling or granulation may develop afterlong term identical plug use. We evaluated the long-term efficacy, safety, and stability of silicone punctal plugs in patients that were followed for 2 or more years after punctal plug insertions

Efficacy and tolerability outcomes after punctal occlusion with silicone plugs in dry eye syndrome

PURPOSE: Silicone punctal plugs are widely used to conserve moisture in tear-deficient eyes. We studied the efficacy and tolerability of punctal plugs in symptom reduction and improvement of ocular surface disease parameters in dry eye syndrome. METHODS: We reviewed the records of 50 consecutive patients with dry eye syndrome who were symptomatic despite maximally tolerable lubricant therapy and had bilateral lower punctal plug insertion. After plug insertion, all patients (41 women and nine men) had 6 months or more of follow-up. The subjects ranged in age from 22 to 57 years (mean, 30 years). We recorded subjective and objective improvement of ocular surface disease, frequency of lubricant use, need for upper punctal occlusion, and occurrence of complications after plug insertion. We determined plug retention rates using Kaplan–Meier analyses and assessed associated factors using Cox proportional hazards models. RESULTS: Six months after initial plug placement, 43 of 50 patients (86%) were symptom free, 28 of them (56%) with plugs alone, and 38 patients (76%) had stopped using lubricants on a daily basis. Spontaneous loss of plugs was common, especially in the initial 3 months of follow-up. Considering all plugs, the estimated probability of plug retention was 63% after 6 months of follow-up. Puncta refitted after initial plug loss were twice as likely to lose the replacement plug ( P = .02). Upper punctal plugs showed a 4.3-fold higher risk of loss compared with plugs inserted in lower puncta ( P < .0001). CONCLUSIONS: There is both a reduced dependency on artificial lubricants and relief of symptoms of dry eye after punctal plugs. However, spontaneous plug loss occurs in a substantial minority of patients. Patient education and close follow-up, particularly in the first 3 months, is recommended to detect plug loss and ensure adequate control of the disease.