What Are Punctal Plugs?

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

Dry eye occurs when the eyes don’t make enough tears or the quality of the tears isn’t enough to keep the eyes lubricated. Many treatments are available for dry eyes.

Some people use over-the-counter eye drops or artificial tears for moisture. In severe cases, punctal plugs are an option.

What are Punctal Plugs for Dry Eyes?

Punctal plugs are tiny plugs inserted into the tear ducts of the eyelid. They prevent tears from draining out of the eyes. This increases the natural tear film and lubricates the eye’s cornea.

Punctal plugs are also called:

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

Punctal plugs can be installed temporarily or permanently. The plugs are inserted into the drainage holes in the eyelids. They prevent drainage, so the eyes stay moist and comfortable.

When are Punctal Plugs Necessary? 

People who have tried eye drops and gels without relief turn to punctal plugs.

The plugs are a common solution for people with dry eye syndrome and keratoconjunctivitis sicca. Some people use temporary punctal plugs following refractive or other anterior segment eye surgery. 

However, punctal plugs may not be recommended for people with evaporative dry eye or other types of inflammatory eye disease. The plugs can make the inflammation worse.

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

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 a few days or sometimes up to a few months. This plug type is commonly used for keeping the eyes moist after 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 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, the procedure has side effects and risks like all medical treatments. 

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’s performed on an outpatient basis and takes just a few minutes. 

You’re awake during the process. You’ll be 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 if they are suitably sized 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 perform. If they have dissolving plugs, their doctor will ensure they 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.

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

Are Punctal Plugs Right for You?

Punctal plugs might be suitable 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 suitable for people with: 

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

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

What Causes Dry Eyes?

Dry eyes are linked to various external and internal eye health issues. Something as simple as a day in a dusty environment can trigger the condition. Here are some common causes of dry eyes:

Tear Film Irritation 

You can also develop dry eyes any time healthy tear film is affected. The tear film has 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

Decreased Tear Production

It's known as keratoconjunctivitis sicca when your eyes don’t produce enough tears. 

The most common reasons why tear production decreases include:

• Corneal nerve desensitivity. This can result from issues related to contact lens use, laser eye surgery, or nerve damage
• Medications. This includes antihistamines, hormone replacement therapy, decongestants, antidepressants, birth control, and more
• Certain medical conditions. This includes 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

Symptoms of Dry Eyes

You may need punctal plugs when you experience the symptoms of dry eyes. These symptoms include:

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

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. Humidifiers keep moisture in the air so that your eyes stay comfortable. 
• Use an air filter. Air filters minimize dust and other irritants that can affect your eyes. 
• Avoid direct airflow. You can do this 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. This may include unhealthy and processed foods. 
• Gently wash your eyes. You can use no tears or “baby” shampoo to remove any irritants safely.

Summary

• Punctal plugs are devices that provide relief from dry eyes
• Various punctal plug types are available – temporary, semi-permanent, and permanent
• Punctal plug insertion is done on an outpatient basis and doesn’t require downtime
• Alternative options such as OTC and prescription eye drops and lifestyle changes can also help you overcome dry eye symptoms