Absorbable punctal plug and its application in dry eye / 中华实验眼科杂志

The punctal plug is a small implant inserted into the tear ducts, which is currently the main clinical treatment for dry eye.The use of punctal plugs can maintain natural tears on the ocular surface and has a good effect on solving the long-term dry eye problem.The plug structure can mechanically block the lacrimal duct to maintain tears.The material of the puntal plug must have good biocompatibility to achieve the therapeutic effect without causing tubulitis or other complications.Therefore, the selection of a suitable punctal plug material has always been a hot spot in medical research.In general, punctal plug materials must be biocompatible, safe and comfortable.At present, common punctal plug materials are mainly divided into absorbable and non-absorbable.The absorbable punctal plugs are often biocompatible, safe and degradable compared to the non-absorbable ones.The use of absorbable punctal plug materials and their application in the dry eye were reviewed in this article.

Role of punctal plugs as a primarily treatment modality in moderate to severe dry eye

Background:In dry eye syndrome tear film disrupts which lead to ocular discomfort. Treatment of dry eye is very challenging and time consuming.Multiple treatment options are available for treating dry eye and one of them is punctal plugs.It blocks the drainage of tear by occluding puncta which helps in the preservation of natural tears on the ocular surface and relieve dry eye symptoms.This study was conducted to assess the safety and efficacy of punctal plugs as a primary treatment modality in moderate to severe dry eye.Methods:Fifty patients were included in this study and they were divided into two groups.In group A which included 25 patients punctal plugs were inserted and in group B (25 patientsor 50 eyes) artificial tear drop was prescribed.The primary treatment outcome was the improvement in dry eye symptoms and secondary outcome was Schirmer test score,tear break up time and rose bengal staining score.Results:There was drastic improvement in dry eye symptoms in group A (punctal plugs) compared to group B(artificial tear group).Schirmer test score,tear break up and rose bengalstaining score also improved in punctal plug group. Conclusions: This study has shown that punctal plug can be used as a primary treatment modality in moderate to severe dry eye as it improves greater symptomatic relief and also improves the condition ofdamaged ocular surface

A Case of SmartPlug Partial Extrusion through Canalicular Mucosa

PURPOSE: To report a case of a SmartPlug that partially extruded through the canalicular mucosa. CASE SUMMARY: A 62-year-old female patient visited our Department of Ophthalmology for redness and discharge in her right eye that began worsening a week prior. The patient was diagnosed with severe dry eye syndrome via Sjogren's syndrome. The SmartPlug was inserted into her left lower punctum 12 years prior, and another plug was inserted in the right 9 years prior. Nothing notable was found in her history. The best corrected visual acuity and intraocular pressure at the initial visit was 1.0 and 14 mmHg, respectively, in both eyes. Swelling, erythema, and tenderness at the right lower punctum were identified. As we irrigated the lower lacrimal system, partial obstruction was suspected and a large amount of mucopurulent discharge in the conjunctival fornix with conjunctival injection was seen. Under the right lower punctum, a 1 × 1 mm yellowish foreign body was partially extruding from the canalicular mucosa. The foreign body was removed, and a round defect was left. The patient's symptom completely resolved after 4 weeks of topical antibiotics and ointment treatment. CONCLUSIONS: In patients who have a SmartPlug inserted prior to visits for redness and discharge, a SmartPlug plug extrusion should be considered.

Diagnosis and Treatment of Chronic Canaliculitis

PURPOSE: To report on the clinical manifestations, species and treatments of patients with chronic canaliculitis. METHODS: From August 2003 to February 2012, 77 eyes of 77 patients who were diagnosed with chronic canaliculitis at our hospital were retrospectively analyzed. RESULTS: The mean period from the onset of symptoms to diagnosis was 4.7 months. The most common systemic disease associated with chronic canaliculitis was diabetes (18 eyes, 23%), and 13 eyes (17%) were related to punctual plug insertion. Main symptoms consisted of epiphora with discharge and pouting punctum. In the culture results of 55 eyes, streptococci, staphylococci, and actinomyces among other bacteria were identified. Seventy-two eyes (94%) were cured with one-snip punctoplasty with curettage. CONCLUSIONS: Chronic canaliculitis is rare, and the clinical aspect can be obscured by chronic conjunctivitis, thus the diagnosis is often delayed. In patients who have systemic diseases such as diabetes or past history of punctual plug insertion, chronic canaliculitis should be differentiated by observing the punctum more closely. If the diagnosis is accurate at the time, chronic canaliculitis could be easily cured by a relatively simple procedure such as one-snip punctoplasty with curettage.

Canaliculitis Associated With SmartPlugtrade mark Punctal Plug Insertion: Clinical Features and Management

PURPOSE: To report the clinical features and treatment of canaliculitis associated with SmartPlug punctal plug insertion. METHODS: Case selection criteria included patients with canaliculitis, who were managed at Seoul National University Hospital from January 2006 to October 2008, presenting with a history of punctal plug insertion. The operation reports were reviewed to identify patients in whom SmartPlug was discovered during the operation. Six patients (8 eyes) were identified, and a retrospective chart review was performed for all the patients. RESULTS: The mean age of the patients was 34.3+/-8.6 years, and there were 1 men and 5 women. Common symptoms were mucous discharge (6 eyes) and conjunctival injection (2 eyes). The mean time from insertion of the plug to onset of symptoms was 27.0+/-27.0 months (range 4 to 77 months). All patients underwent surgical removal of the punctal plug by one-snip punctoplasty, canalicular retrograde compression using 2 cotton-tipped applications (2 eyes), or canalicular curettage (6 eyes). All patients had resolution of symptoms after the procedure. CONCLUSIONS: Canaliculitis should be considered when there is conjunctival discharge or injection in patients with SmartPlug. One-snip punctoplasty and retrograde compression of canaliculus can be attempted preferentially as a minimally-invasive treatment option.

Treatment of the Lacrimal Fistula with Punctal Plug

PURPOSE: To evaluate the results and complications of the punctal plug insertion through lacrimal fistula. METHODS: Four patients diagnosed with congenital lacrimal fistula had a punctual plug inserted through the lacrimal fistula without anesthesia from January to May 2005. RESULTS: Mean follow-up period was 6.8 months. In two pediatric patients whose mean age was 5.0 years, the fistula was not associated with nasolacrimal duct. In two adult patients, it was associated nasolacrimal duct obstruction, whose mean age was 49.0 years. In all cases epiphora improved. There was a puncal plug prolapse in one case and no other complications. CONCLUSIONS: Punctal plug insertion is considered a simple and useful technique for lacrimal fistula without congenital nasolacrimal obstruction in children especially whose parents refuse general anesthesia. Punctal plug insertion can be useful to reduce scarring in adult patients that receive endoscopic dacryocystorhinostomy with nasolacrimal obstruction.

Clinical Investigation of Therapeutic Effect and Extrusion Rate of Punctal Plug for Dry Eye Syndrome

PURPOSE: To investigte the extrusion rate of punctal plugs and to evaluate their long-term effectiveness related to punctal occlusion. METHODS: The subjects were 120 eyes of 60 patients with tear-deficient dry eye who underwent punctal occlusion using a silicone punctal plug from May 2003 to Jun 2004. They were followed up for 382.3+/-164.3 days. We studied the extrusion rate and the period of extrusion for each plug and examined the differences between the objective and subjective indicators of dry eye syndrome before and after plug insertion and between extruded and non-extruded punctal plugs. RESULTS: In this study, 25.8% of all plugs were extruded during the follow-up period. The majority of plugs (41.9%) were extruded within 100 days after plug insertion. As objective indicators, results of Schirmer test and BUT were significantly increased after plug insertion. As subjective indicators, the patients' clinical symptoms significantly improved. Patient use of artificial tear drops significantly decreased and was discontinued by 70.8% after plug insertion. There were however no significant differences between the extrusion group and the non-extrusion group in each case. CONCLUSIONS: Punctal plug occlusion therapy for tear-deficient dry eye is effective, but the extrusion rate is relatively high. Regardless of punctal plug extrusion, patients experienced a symptomatic improvement. Serious consideration of this fact may greatly aid in making therapeutic adaptations and maintaining a good relationship.

Cases of Complications after the Use of Punctal Plugs

PURPOSE: To report cases of complications after using punctual plugs with a literature review. METHODS: We studied 3 complicated cases after the use of punctual plugs: a 46-year-old female with recurrent mucopurulent discharge, a 42-year-old male with a pinkish mass over the punctum, and a 29-year-old female with recurrent epiphora. RESULTS: The 46-year-old female was diagnosed with canaliculitis caused by actinomyces, the 42-year-old male with chronic pyogenic granuloma, and the 29-year-old female with canalicular obstruction. All 3 cases improved after proper treatments. CONCLUSIONS: Complications after the use of punctal plugs are not common but they can be significant. They have to be used carefully after through evaluation and obtained proper informed consents from the patient.

Changes of Ocular Surface after Silicone Punctal Plug Insertion in Patients with Dry Eye Syndrome

PURPOSE: To evaluate the changes in tear film and the ocular surface before and after punctal occlusion by silicone punctal plug insertion in dry eye patients. METHODS: Twenty-four eyes of 19 patients with dry eye were included. We performed corneal sensitivity test, tear film break-up time (BUT), basal tear secretion test (BST), fluorescein staining, tear clearance test (Tcr), and conjunctival impression cytology and then compared the measurements before and after punctal occlusion. RESULTS: Before silicone pucntal plug insertion corneal sensitivity, BUT, BST, fluorescein staining score, and Tcr were: 52.50+/-6.55 mm, 4.47+/-1.33 sec, 4.07+/-1.86 mm, 4.74+/-3.21 and 3.83+/-1.62, respectively. The grade of conjunctival squamous metaplasia was 2.45+/-1.26, and goblet cell density was 131.82+/-125.53 cells/mm2 before punctal occlusion. After punctal plug insertion corneal sensitivity was 58.13+/-3.72 mm (p=0.015), BUT was 6.76+/-2.59 sec (p<0.01), BST was 5.57+/-3.32 mm (p=0.161), fluorescein staining score was 1.74+/-2.13 (p<0.01) and Tcr was 4.50+/-1.29 (p=0.198). The degree of conjunctival squamous metaplasia was 1.12+/-0.83 (p=0.019) and goblet cell density was 206.67+/-155.78 cells/mm2 (p=0.229) after punctal plug insertion. CONCLUSIONS: The tear films and ocular surface changes after punctal plug insertion in dry eye patients include increased corneal sensitivity, improved quality of tear films and decreased conjunctival squamous metaplasia.