Q. An O.D. asks, I recently consulted on a malpractice case in which a colleague inserted a punctal plug that was too small. The domed plug dropped down into the canaliculus, resulting in infection, epiphora and dacryocystitis. How can I protect myself and my patients from a similar situation?
A. Although punctal occlusion is a safe and effective option for treating many dry eye patients, complications can sometimes occur. You can protect yourself through every stage of this procedure, however, by following some simple guidelines.
First, when diagnosing the patient with dry eye, its important to make a distinction regarding the cause. Does the patient have tear-sufficient or tear-deficient dry eye? Tear-sufficient dry eye is characterized by an ocular surface disorder such as meibomian-gland dysfunction. These patients have an adequate supply of tears, but the tear-quality is bad. Punctal occlusion is not an option for this group. When you prevent the outflow of tears in patients with meibomian-gland dysfunction, inflammatory mediators remain in contact with the surface of the eye for a longer period of time and can cause further inflammation, says Daryl Mann, O.D., center director of SouthEast Eye Specialists in Chattanooga, Tenn.
Patients with tear-deficient dry eye who require artificial tears more than four times a day are candidates for punctal occlusion, says optometrist Paul Karpecki of Olathe, Kan. This group includes patients with:
A low tear volume secondary to medications or their occupation (i.e. computer user, flight attendant, etc.)
Pre- or post-surgical dry eye conditions.
Contact lens intolerance secondary to dry eye.
Arthritis who cannot put drops in their eyes effectively.
Tear-deficient dry eye in which artificial tears do not improve symptoms.
As with any surgical procedure, you must provide a patient consent form. A typical informed consent must be given to the patient including an overview of why you have chosen this option for the patient, documentation of the condition with symptoms and signs and a discussion of alternative treatment options, says Dr. Karpecki.
A pyogenic granuloma like this large one is a potential complication with punctal occlusion.
Also include what the patient can expect after the procedure, such as irritation in the punctal area for 24-48 hours after plug insertion. Dr. Mann also advocates counseling the patient on the cost of the procedure, third-party benefits and the risks involved.
When it comes to informed consent, document any condition that has ever been noted, documented or presented as a risk, even if they are not common with the type of plug you are using, says Dr. Karpecki. Examples include conjunctival erosion, irritation from the exposed punctal plug head, canaliculitis, epiphora, lost plugs and pyogenic granuloma formation. (For more on this potential complication, see Post-Op Punctal Plug Protrudes, in this issue.)
If youre at all confused about what to include in the consent form, many consulting groups provide templates, says Dr. Mann. Also, instruct the patient not to rub their eyes in the canalicular area. This will help limit irritation immediately following the procedure. Excessive rubbing could also cause the plug to migrate or fall out, says Dr. Karpecki. Of course, if there is any pain or redness at any point after the procedure, instruct the patient to call your office. Bottom line: clearly document in the chart what you have told the patient, in addition to having them sign a consent that clearly spells out all potential complications.
Q. How can I prevent potential complications in patients following punctal occlusion?
A. A trial run with collagen plugs is often a good idea in dry eye patients. This can help you determine whether plugs will provide the relief the patient needs and whether he or she might experience any undesirable side effects, Dr. Mann says. For a longer trial, extended duration collagen plugs may be beneficial. If the patient has no complaints, consider the option of permanent plugs.
Here are some additional tips on handling some common complications:
Puntctal plugs can sometimes migrate and cause a dacryocystitis infection.
Lost plugs. You can try to avoid this by using plugs that are available in a variety of sizes. Sometimes, a larger plug is necessary.
Epiphora. If this problem is persistent, you will need to remove the plug. Punctal plugs can be removed with forceps. Canalicular plugs require irrigation and are often more difficult to remove.
Dacryocystitis. Plugs can sometimes migrate into the lacrimal sac, where irritation can cause a secondary obstruction of tear outflow and possibly a dacryocistitis infection. You may be able to remove these plugs via irrigation. If not, dacryocystorhinostomy is necessary.
Use a reputable plug with a proven track record, be aware of the possible complications and make sure patients are informed. Punctal plugs are, in general, an effective treatment for patients with tear-deficient dry eye.
