To plug or not to plug, that is the question

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To plug or not to plug, that is the question

The American Academy of Ophthalmology (AAO) publishes guidelines called preferred practice patterns (PPP). In the staged management of dry eye disease as per the PPP, punctal occlusion (plugs) for dry eye disease has been a level II (step 2) option for many years. It has been an excellent solution for treating dry eyes, so much so, that the American Board of Ophthalmology (ABO) would “grade” ophthalmologists on whether plugs were attempted in dry eye disease treatment.



Recently, punctal occlusion has become less popular with the advent of so many new treatment options including thermal eyelid pulsation (iLux, MiboFlow, LipiFLow), Maskin probing, iTear tear stimulation  (and the now defunct, TrueTear lacrimal gland stimulation), serum eye drops, Xiidra, Azasite amongst others and new treatments are coming along in the pipeline every day.

However, like all treatment options, punctal occlusion is not a panacea and has it’s downsides. Punctal plugs can and often fall out; they can rub on the conjunctiva and cause irritation; and plugs can cause nasal lacrimal sac infection and canaliculitis. Similarly, cauterizing the punctum is a “permanent” and invasive procedure. As described in the AAO’s PPP, cautery is a level IV (step 4) option and never a first line option for punctal occlusion. In general, cautery should never be performed before a trial of plugs first.  Moreover, some dry eye specialists argue that occlusion prevents inflammatory mediators (i.e toxic tears) from being flushed away and can exacerbate inflammation. Tears that are overly salty can be similarly irritating.

However, punctal occlusion via plugs or cautery definitely has its place in dry eye disease management and probably needs to be utilized more often than currently occurs in many dry eye practices.  As part of my intensive dry eye workup at FishmanVision, I rely on precise measurements of tear film levels using OCT anterior segment imaging. Anterior OCT allows me to accurately measure the level of tears present and is much more reliable than Schirmer testing. When the patient has a scant tear volume as measured by OCT, I have found the patient benefits greatly from punctal occlusion.  In my experience, while iTear, Cyclosporine, Lifitegrast, fish oils, etc (all of which I utilize) are somewhat helpful for increasing tear film levels, for those patients with a low tear film, these treatment options rarely achieve sufficient relief and occlusion often works best.

Of course, the real question is the etiology of why tear volume is so low in these patients. I will cover etiology in a future blog.

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