Punctal Plugs

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What are Punctal Plugs for Dry Eyes?

Dry eyes are an inconvenience. But did you know they can also affect your eye health? 

Dry eye occurs when the eyes do not make enough tears (or the quality of the tears isn’t enough to keep the eyes lubricated). 

Symptoms of dry eyes include:

  • Itching
  • Burning
  • Redness
  • Stinging
  • Blurred vision
  • Stringy mucus around eyes
  • Sensitivity to light
  • Sensation of there being a foreign object in the eye
  • Difficulty wearing contact lenses
  • Poor night vision when driving
  • Watery eyes
  • Eye fatigue

Many treatments are available for dry eyes. Some people use over-the-counter or prescription eye drops for moisture. In severe cases, punctal plugs are an option. 

Punctal plugs are tiny plugs – about the size of a grain of rice – that are inserted into the tear ducts of the eyelid to prevent tears from draining out of the eyes. The plugs force the liquid from tears to remain in the eyes, increasing the natural tear film and lubricating the cornea of the eye. 

Punctal plugs are also called:

  • Lacrimal plugs
  • Punctum plugs
  • Tear duct plugs
  • Intracanalicular plugs
  • Occluders

Punctal plugs can be installed temporarily or permanently. 

What Causes Dry Eyes?

Dry eyes are linked to a variety of external and internal eye health issues. Something as simple as spending a day in a dusty environment can trigger the condition. You can also develop dry eyes any time healthy tear film is affected. 

Tear film is made up of three layers:

  • Fatty oils (lipids)
  • Mucus
  • Aqueous 

These three substances work together to keep the surface of the eyes lubricated. An issue with any of these substances can cause dry eyes. Tear film can be insufficient for a variety of reasons, including:

  • Hormone changes
  • Oil gland inflammation (meibomian gland dysfunction)
  • Allergies
  • Autoimmune disease

Additionally, dry eyes might also be caused by:

Decreased Tear Production

When your eyes don’t produce enough tears, it’s known as keratoconjunctivitis sicca

The most common reasons why tear production decreases include:

  • Corneal nerve desensitivity related to contact lens use, laser eye surgery, or nerve damage
  • Medications, including antihistamines, hormone replacement therapy, decongestants, antidepressants, birth control, and more
  • Certain medical conditions, including rheumatoid arthritis, lupus, scleroderma, sarcoidosis, thyroid disorders, and more

Increased Tear Evaporation

When the glands that produce the lipid layer of tear film become clogged, dry eyes can develop. 

Causes of increased tear evaporation include:

  • Meibomian gland dysfunction or posterior blepharitis
  • Not blinking enough
  • Eye allergies
  • Eyelid problems
  • Exposure to wind, smoke, or dry air
  • Vitamin A deficiency
  • Preservatives in topical eye drops

When are Punctal Plugs Necessary? 

People who have tried eye drops and gels without relief often turn to punctal plugs. The plugs are a common solution for people with dry eye syndrome and keratoconjunctivitis sicca. They may not be recommended for people with evaporative dry eye or other types of inflammatory eye disease, as punctal plugs can make the inflammation worse. Some people use temporary punctal plugs following refractive or other anterior segment eye surgery. 

Most doctors won’t recommend punctal plug for patients complaining of dry eyes or irritation until other less-invasive treatments have failed. It’s a relatively safe procedure, but like any surgery, the insertion of punctal plugs carries risks (e.g., infections and scarring). 

How Do Punctal Plugs Work?

Punctal plugs work to keep moisture in the eyes. The plugs are inserted into the drainage holes in the eyelids. They prevent drainage, so the eyes stay moist and comfortable.

Types of Punctal Plugs

There are three different types of punctal plugs, including:

1. Temporary Punctal Plugs (Dissolving)

Temporary punctal plugs, or dissolving punctal plugs, are made of a material that gradually breaks down and is absorbed by the body. Collagen is one of the most common types of dissolving punctal plugs.

Temporary plugs can last for a few days (sometimes up to a few months). This type of plug is commonly used for keeping the eyes moist after having corrective eye surgery, such as LASIK

Some people considering permanent punctal plugs try temporary ones on a trial basis. 

2. Semi-Permanent Punctal Plugs 

Semi-permanent punctal plugs are made of longer-lasting medical plastic. Silicone and acrylic are common.

Semi-permanent plugs stay in the eye for years. They can be removed by an eye doctor if needed.

3. Permanent Punctal Plugs

Permanent punctal plugs are an option for people who have success with temporary plugs. This is also known as punctal cautery

In most cases, punctal cautery is only used after a very successful trial of long-lasting silicone plugs. Cautery is performed thermally or with a laser.

Side Effects & Risks of Punctal Plugs

Punctal plugs are an effective treatment for people dealing with dry eyes. However, like all medical treatments, the procedure comes with side effects and risks. 

Side effects of punctal plugs include:

  • Scratchiness or irritation in the corner of the eye
  • Watering eyes
  • Shifting in the eye, usually from rubbing
  • Improper fit, causing the plug to stick out of the duct and cause irritation
  • Redness
  • Inflammation

Risks of punctal plugs include:

  • Infection
  • Scarring
  • Problems during the insertion process

How to Insert Punctal Plugs (Procedure Steps)

The insertion procedure is relatively simple. It is performed on an outpatient basis and takes just a few minutes. Patients are awake during the process. They are given a few anesthetic eye drops to protect against discomfort during the insertion. 

Doctors use a special instrument to insert the plugs. Most people don’t feel them as long as they are the proper size and placed correctly.

What is the Recovery Process Like?

The recovery process following punctal plug insertion is simple. Most people resume normal activities, including driving, immediately

Some people are asked to return for a follow-up visit to discuss how their plugs are performing. If they have dissolving plugs, their doctor will make sure the plugs are gone. 

If there are problems with punctal plugs, an infection develops, or they are not working, you should contact your doctor as soon as possible to discuss your options.

How to Remove Punctal Plugs

In rare cases, punctal plugs cause problems and must be removed. Removal is an option if plugs cause pain or irritation, or an infection develops.

The removal procedure varies depending on whether someone has permanent, semi-permanent, or dissolving plugs. 

Silicone plugs are removed with forceps. They can also be flushed out with a saline solution. Flushing the plug out pushes it into the nose or throat.

Deeply inserted plugs must be removed surgically.

Are Punctal Plugs Right for You?

Punctal plugs might be right for people who have tried other methods of treating dry eyes. People with aqueous deficiency tend to have greater success with the plugs. 

Punctal plugs likely won’t be right for people with: 

  • Eye inflammation or soreness
  • Ocular rosacea
  • Difficult cases of blepharitis

You should discuss with your doctor ways to get inflammation and soreness under control. If these issues are resolved, and your eyes are still dry, punctal plugs could be an option.

Alternative Treatment Options 

If you aren’t ready to try punctal plugs, or have concerns that they won’t work for you, alternative treatments are available. 

In addition to OTC and prescription eye drops, people with dry eyes can:

  • Rest their eyes frequently. Staring at computer screens all day and night irritates the eyes. If you have no choice but to use a computer during your workday, avoid eye strain at night by setting your phone and other devices aside.
  • Use a humidifier to keep moisture in the air.
  • Use an air filter to minimize dust and other irritants in the air.
  • Avoid direct airflow by not sitting near fans or air conditioning vents. Stay inside on windy days.
  • Wear sunglasses when outdoors and regular glasses when inside. If you don’t have prescription eyeglasses, consider investing in a pair of blue light glasses that offer protection from the blue light emitted by computers and other screens.
  • Avoid foods that trigger inflammation, including unhealthy and processed foods. 

Gently wash your eyes with no tears or “baby” shampoo to remove any irritants safely.

Resources
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(1) “Punctal Plugs.” American Academy of Ophthalmology, 26 May 2021. 

(2) “Dry Eyes - Symptoms and Causes.” Mayo Clinic, 2019.

(3) Maurer, Kristin. Punctal Plugs. Apr. 2015. 

(4) “Punctal Plugs.” Mayo Clinic. 

(5) Song, Jong Suk, et al. “Five Misconceptions Related to Punctal Plugs in Dry Eye Management.” Cornea, Sept. 2018, p. 1, 10.1097/ico.0000000000001734.

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