Not commonly considered a surgery, punctal occlusion is indeed a minor surgical procedure. Diagnoses that support its medical necessity include tear film insufficiency, superficial keratitis, keratoconjunctivitis sicca and rheumatoid arthritis.
The question remains: Where did all the plugs go? Traditionally, punctal occlusion had been a frequently used second-line treatment (after artificial tears) for patients suffering from dry eye disease. Results were often variable, with some patients showing vast improvement in symptoms while others felt the plugs made no difference at all.
As we learned more about the role of inflammation as the underlying cause of dry eye disease, use of anti-inflammatory and immunomodulating medications became the mainstay of therapy, eclipsing punctal occlusion in many cases. According to the ITF guidelines, punctal plugs should be considered for Severity Level 3, along with tetracyclines. On the other hand, the Dry Eye Workshop report suggests that plugs may be beneficial in earlier stages of the disease.
||View a narrated video of a punctal occlusion.|
Partial occlusion can be performed with silicone punctal plugs that have a fenestrated central area to allow the passage of some tears. Lastly, permanent occlusion can be performed with silicone material and inserted into the canaliculus or punctal area. Another alternative for permanent occlusion is thermal cautery.
With the exception of cauterization, punctal occlusion is reversible. Regarding most types of plugs, the safety profile is very high; epiphora, conjunctival irritation and extrusion typically are the most common––yet infrequent––complications.
Other rare complications include canaliculitis and dacryocystitis, which are caused by common bacterial pathogens, such as Actinomyces israelii, Staphylococci, Streptococci and diphtheroids. In the event of complications, patients may require plug removal as well as anti-inflammatories and antibiotics. Rarely, surgical removal of plugs is indicated.
Patient education is important whenever discussing treatment options for dry eye disease. Stress to patients that punctal occlusion is safe, quick, reversible and widely performed; however, it will not cure their disease. Inform patients why you are performing temporary (diagnostic) vs. permanent occlusion along with the risks, benefits and alternatives to the procedure. For those on topical therapy, explain that plugs may help increase the contact time of medications, will help them retain their natural tears, and will not interfere with their normal tear production.