Combating dry eye with punctal plugs

As awareness of the prevalence of dry eye disease (DED) increases, many doctors are prioritizing strategic dry eye treatment within their practices. Because dry eye affects millions of Americans^1,2 -many of whom are asymptomatic-I evaluate every patient for dry eye.  

Recently, much discussion has taken place within the dry eye community regarding the role of punctal plugs in the treatment of dry eye. In my own practice, punctal occlusion has increased in conjunction with expanded utilization of advanced diagnostic tools, such as the TearLab Osmolarity System (TearLab Corporation) and InflammaDry test (Rapid Pathogen Screening, Inc.) that detects matrix metallopeptidase 9 (MMP-9), an inflammatory marker.  

Through trial and error, I have learned that punctal occlusion can be a great tool to manage dry eye disease in the appropriate patients. Ensuring there is no significant inflammation in the tear film prior to plugging is critical because leaving inflamed tears on the ocular surface can result in a less than optimal outcome.

Previously from Dr. O'Dell: Uncover patient lifestyle habits that lead to OSD

A positive InflammaDry test indicates anti-inflammatory treatment is required prior to considering maintenance therapy with punctal occlusion. After a negative result from the InflammaDry test is determined (indicating no detectable levels of  MMP-9 present), plugs can be considered. 

In my experience, patient subgroups who do especially well with plugs are those with autoimmune diseases-including rheumatoid arthritis, lupus, or Sjogren’s-thyroid patients, contact lens wearers, and avid computer users. Patients who do not fully blink or who have lagophthalmos or inadequate nocturnal lid seal may also benefit because the plugs aid in increasing the volume of tears.  

Diagnosis and treatment

At my practice, all patients are screened in the exam room with tear break-up time (TBUT), staining of the cornea and conjunctiva, and transillumination. If any concerns are discovered, a formal dry eye evaluation, including point-of-care testing with TearLab Osmolarity and InflammaDry and meibography with LipiView II (TearScience), is scheduled. This allows for more time with the patient for education, another critical part of successful dry eye management.

Related: Understanding and defining MGD

Prior to any treatment, I establish a proper diagnosis of DED: Is the patient aqueous deficient or evaporative, a combination of both, affected by allergies, or suffering from a corneal problem, such as anterior basement membrane dystrophy or recurrent erosions?

The type of DED will help determine the appropriate treatment. My diagnostic protocol involves assessing the health of the cornea, conjunctiva, lids, and overall health of the glands through the use of all point-of-care testing currently available, including a validated survey, such as the SPEED questionnaire and staining with both fluorescein and lissamine green.

Regardless of presenting symptoms, I transilluminate every patient’s the meibomian glands at the slit lamp to evaluate the glands’ structure. Function is evaluated by the quality and quantity of oil expressed from the glands. My treatment protocols are derived from the work of Tear Film and Ocular Surface Society (TFOS) Dry Eye Workshop³ and Meibomian Gland Workshop.⁴  

For patients who are meibomian gland dysfunctional, plugs are particularly beneficial; however, it is important to first address any underlying clinical concerns first. LipiFlow (TearScience) is useful in diagnosing clogged glands, and we can then try to rehabilitate those glands. Once flow is improved, plugs are a suitable option. As a first-line treatment, I would plug patients who are solely aqueous deficient or who suffer from superior limbic keratoconjunctivitis (SLK), auto immune diseases, anatomy problems, and filamentary keratitis.

Permanent vs. absorbable plugs

Both silicone and absorbable plugs are advantageous for dry eye management, and I decide which to use on a case-by-case basis. The exception is when plugging the upper punctum, in which case I prefer absorbable plugs because of the intra-cannilucular positioning. An absorbable plug is easier to fit, and there is no contact with the eye causing foreign body sensation for patients.

Silicone plugs typically have few complications and a satisfactory retention rate.⁵ Silicone plugs come in many sizes and are a great option when the punctum is exceptionally large.

Related: First-class dry eye treatment

While I use both silicone and 180-day absorbable punctum plugs (Comfortear and Comfortear Lacrisolve, Paragon BioTeck), my preference is often for absorbable. Absorbable plugs have several advantages, especially when used for upper lids. They are more comfortable for the patient due to fewer tendencies to potentially rub against the eye. Absorbable plugs also work well for patients with SLK or other conditions that create an anatomically tight lid that rubs above the superior conjunctiva. 

Although dislodged silicone plugs may cause a foreign body sensation, produce some discomfort, or fall out entirely, they are a good option for patients who prefer a long-term solution.  

Silicone plugs that remain in the punctum for extended periods of time can develop a biofilm which can contribute to further tear film disruption and ocular irritation. If this occurs, remove the plug and replace it with an absorbable plug. Planned replacement for silicone plugs requires more research but can help reduce these biofilms. Correct measurements are also vital-plugs cannot only fall out of the eye, but also fall further into the punctum as well, potentially creating complications. Because plugs can be difficult-if not impossible-to see once they have been inserted, there is a danger of multiple plugs being placed within the punctum (Figure 1). One advantage of the plugs I use is their violet coloring; they are visible using transillumination, allowing me to determine if a plug is already present (Figure 2).  

Case examples  

One elderly female patient presented with inferior staining on both of her corneas. Her previous doctor had noted her asymptomatic dry eye; however, nothing had been done to treat the condition.

When I initially examined the patient, staining was still present. My first protocol was to administer a corneal sensitivity test, which determined extreme diminishment in her left eye to the point she could not feel anything at all. This desensitivity was caused by chronic nocturnal exposure leading to corneal nerve deregulation.

Her treatment included punctal occlusion in both eyes using absorbable plugs. On the return visit, the patient’s corneal health and symptoms had improved significantly.

For this patient, plugs were important in her management due to her lack of symptoms. With corneal health and natural immunity on the decline, corneal infection was a concern. 

Another referred patient suffered from contact lens intolerance. Surprisingly, her meibomian glands had never been evaluated.

Related: How ODs can do better with dry eye

Her previous eyecare provider had placed her on Lotemax (loteprednol etabonate ophthalmic gel, Bausch + Lomb) to see if her symptoms improved. When those symptoms persisted, she was referred to my practice for a dry eye evaluation. I discovered meibomian gland dysfunction with advanced gland truncation. She was treated with a combination approach using absorbable plugs as well as LipiFlow thermal pulsation to improve the function of the remaining glands.

For this patient, plugs were placed prior to meibomian gland treatment due to the severity of her evaporative disease with reduced TBUT.  This combination approach improved her comfort allowing her to continue contact lens wear.

Recently, I have been considering expanded potential applications for plugs. Absorbable plugs would be very useful for cataract and corneal surgery patients because 87 percent of surgery patients suffer from dry eye post procedure.⁶ They would also be helpful in cases, such as bacterial ulcers, for which it is beneficial to retain medications on the eye for more extended periods of time. Glaucoma patients could benefit as well, considering the well-known issues many have with compliance and administration, provided that the medication used is a non-preserved or safe preservative medication.  

With the positive changes I have already seen in my patients, I am excited to see what the future holds for plug usage. 

References

1. Schaumberg DA, Sullivan DA, Dana MR. Epidemiology of dry eye syndrome. Adv Exp Biol Med. 2002;506(Pt B):989-98. 

2. Report on the Global Dry Eye Market. St. Louis, Mo. Market Scope, July 2004. 

3. Tear Film & Ocular Surface Society. 2007 Report of the Dry Eye WorkShop. Ocul Surf 2007;5920:65-204.

4. Geerling G, Tauber J, Bauson C, Goto E, Matsumoto Y, O’Brien T, Rolando M, Tsubota K, Nichols KK. The international workshop on meibomian gland dysfunction: report of the subcommittee on management and treatment of meibomian gland dysfunction. Invest Ophthalmol Vis Sci. 2011 Mar 30;52(4):2050-64.

5. Horwath-Winter J, Thaci A, Gruber A, Boldin I. Long-term retention rates and complications of silicone punctal plugs in dry eye. Am J Ophthalmol 2007 Sept;144(3):441-444. 

6. Kojima T, Watabe T, Nakamura T, Ichikawa K, Satoh Y. Effects of preoperative punctal plug treatment on visual function and wound healing in laser epithelial keratomileusis. J Refract Surg. 2011 Dec;27(12):894-8. 

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