What Are Punctal Plugs?

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Punctal plugs are very small devices that are placed in the tear ducts of your eyes. They are used to slow or stop the drainage of tear fluid to prevent dryness in your eyes. You may be recommended punctal plugs by medical professionals for moderate to severe dry eyes and other conditions that affect your eyes. As more of your natural tears stay on the surface of your eyes, you can be less reliant on eye drops and artificial tears. 

Read on to learn more details on how your tears are drained from your eyes and why punctal plugs, also known as punctal occlusions, are used to treat medical conditions.

Understanding eyes and tears

Your eyes produce tears to lubricate the surface of your eyes and to protect them from irritants such as dust or allergens. Tears are made up of liquids, oils and mucus and are produced by the tear glands. The tear system is the process of forming tears and draining tears away and the puncta, sometimes referred to as lacrimal puncta, are part of this system.

The puncta are tiny openings on the waterline of your eyelids that are situated in the inner corner of your eyes. They drain the tears away from your eyes and into a duct called the canaliculus which leads to your nose. There are 4 puncta in total, one on each upper and lower eyelid and when you blink, tears are drained away. Punctal plugs block this drainage system which leaves more tears so that your eyes can remain moisturised.1

Having dry eyes can mean that you don’t have enough tears to prevent your eyes from drying out. It can be due to not producing enough good quality tears or tears evaporating quickly from the eye. 

Types of punctal plugs

Depending on what is best suited for your eyes, different types of punctal plugs can be used. Punctal plugs that are inserted in the opening of the puncta have a cone shape which allows for easy insertion and a wide cap to prevent it from shifting too deep into the tear duct. This allows for easier insertion and maintenance but can mean that it is at higher risk of falling out. 

Canalicular plugs are usually small cylinders that are inserted further along the tear drainage system. This lowers the risk of it falling out but can mean that there is a risk of it shifting and moving away from its intended position.2

Temporary punctal plugs

These are usually made from collagen which can be dissolved naturally by your body after a few weeks of insertion. It is recommended to use temporary plugs if you haven’t had punctal plugs before and if they are successful, permanent plugs can be recommended. 

Permanent punctal plugs

These plugs sit on the opening of your tear duct and are usually made from silicone or acrylic. They do not dissolve and can be used for years. As there is a risk of them falling out, different designs of plugs have different features to best fit your puncta. If needed the plugs can be removed by forceps.

Intracanalicular plugs

These types of punctal plugs are a type of permanent plugs which are inserted further down the tear duct and different types can last for many years. They are usually used when you have had a good result from the previous types of plugs and if your eyes are suitable. The most common types require surgery to remove them. Some types of canalicular plugs are more temporary, lasting for a few weeks and can be absorbed and dissolved by your body

Specialised plugs

Perforated punctal plugs have small openings that allow tears to pass through. They are used to treat punctal stenosis which allows for better tear drainage if the tear drainage system is blocked. 

Medicated plugs are coated in medication or have medication-releasing cores to deliver treatment over time. 

Why are punctal plugs used?

Punctal plugs are mainly used to treat dry eyes. This is usually because your tear glands are not producing enough tears or if your tears are not able to retain moisture and evaporate too easily.4 Symptoms of dry eyes include:

  • Eye redness
  • Stinging or burning sensation in your eyes
  • Scratchy or feeling of something in your eyes
  • Blurred vision
  • Eye fatigue
  • Sensitivity to light
  • Discomfort when wearing contact lenses

Some dry eyes occur on their own or it can be due to the environment and medical conditions including:

  • Corneal damage
  • Autoimmune conditions such as lupus (SLE), Sjögren’s syndrome, rheumatoid arthritis or graft vs. host disease (GVHD)
  • Medication side effects such as antidepressants, antihistamines, beta-blockers or antipsychotic medications
  • Side effects from laser eye surgery or contact lens use. Usually temporary. 
  • Vitamin A deficiency
  • Dry climates and low humidity
  • Air pollution and smoking
  • Occupational such as chemical fumes
  • Increasing age
  • Hormonal changes, such as menopause

Punctal plugs are also used to treat punctal narrowing (stenosis) causing watery eyes. Plugs with holes can allow for more tears to be drained away if there is too much in the eyes.  

Reducing tear drainage can also allow topical medications and eye drops to remain on the eye longer. This can be useful for conditions such as glaucoma to ease the chronic use of medications.5

How punctal plugs are inserted?

Punctal plugs are usually inserted in the lower eyelids first but can be used in the upper and lower puncta. Numbing drops called topical anaesthetics can be used before the insertion but are not required and lubricating drops can make it easier to insert. A punctal gauge is used to measure the size and diameter of your puncta so the right size plug can be used. For some designs of plugs, a lacrimal dilator is required to widen the puncta to make insertion easier. After preparing the puncta, an inserter is usually used to guide and release the plug into the opening of the tear duct which is usually painless.  

Removal of permanent punctal plugs is not done unless there is a complication. Punctal plugs resting at the puncta's opening can be removed with forceps. Pressurised saline is used to remove plugs that are further in the drainage system or plugs that have shifted from their original position. Surgery to open the drainage system is used to remove canalicular plugs which have caused complications that make it more difficult to remove.6

Potential side effects

Complications from punctal plugs are not  common and are usually not serious. Talk to your medical provider if you are worried about your symptoms.7 Complications include:

  • Plugs falling out. This can be easily replaced by your eye care provider
  • Foreign body sensation. The feeling that there is something in your eye
  • Watery eyes (epiphora) can occur if too many tears remain in your eye
  • Partial displacement and corneal injury are when the plugs may loosen and rub onto the surface of your eye
  • Migration. The plug can shift further into your tear drainage system and away from its intended position
  • Canaliculitis is the inflammation or infection of the tear drainage ducts
  • Pyogenic granulomas are raised, small red bumps on the skin due to the rubbing of the punctal plug
  • Dacryocystitis is the inflammation and infection of the tear sac. Antibiotics can be used to treat it

An alternative to punctal plugs is punctal cauterisation where the puncta are scarred closed. 

Maintenance

To look after your punctal plugs and reduce the risk of them dislodging make sure to avoid rubbing your eyes. You can gently clean the corner of your eyes with a moist, clean cotton applicator to remove build up from sleep.

If you feel that you have dislodged your plug, you can easily have them replaced. It is important that you don’t try to replace them yourself.

Contact your healthcare provider if you feel discomfort and pain in relation to the insertion of your punctal plugs. Also, look out for redness and swelling and  tell your healthcare provider. 

It is important to continue to use the other treatments as prescribed. Artificial tears and medicated eye drops work better if you have a punctal plug.8

Always wash your hands before touching your face and eyes to reduce the risk of infection around your punctal plugs.

Summary

Dry eyes can have a big impact on your daily life. However, even though punctal plugs are such small medical devices they can significantly improve your vision and eye comfort. With many different types of punctal plugs, the best one that suits your needs can be found so discuss with your healthcare provider to assess their suitability for you.

References

  1. Paulsen FP, Schaudig U, Thale AB. Drainage of tears: impact on the ocular surface and lacrimal system. Ocul Surf. 2003 Oct;1(4):180–91.
  2. Yen MT, Pflugfelder SC, Feuer WJ. The effect of punctal occlusion on tear production, tear clearance, and ocular surface sensation in normal subjects. American Journal of Ophthalmology [Internet]. 2001 Mar [cited 2023 Nov 23];131(3):314–23. Available from: https://pubmed.ncbi.nlm.nih.gov/11239863/
  3. Jehangir N, Bever G, Mahmood SMJ, Moshirfar M. Comprehensive review of the literature on existing punctal plugs for the management of dry eye disease. J Ophthalmol [Internet]. 2016 [cited 2023 Nov 23];2016:9312340. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4800096/ 
  4. Messmer EM. The pathophysiology, diagnosis, and treatment of dry eye disease. Dtsch Arztebl Int. 2015 Jan 30;112(5):71–81; quiz 82. https://pubmed.ncbi.nlm.nih.gov/25686388/
  5. M C, S YC. Preliminary outcomes of temporary collagen punctal plugs for patients with dry eye and glaucoma. Medical hypothesis, discovery & innovation ophthalmology journal [Internet]. 2020 [cited 2023 Nov 23];9(1). Available from: https://pubmed.ncbi.nlm.nih.gov/31976344/ 
  6. American Academy of Ophthalmology [Internet]. 2023 [cited 2023 Nov 23]. Punctal plugs. Available from: https://www.aao.org/eye-health/treatments/punctal-plugs 
  7. Ervin AM, Law A, Pucker AD. Punctal occlusion for dry eye syndrome. Cochrane Eyes and Vision Group, editor. Cochrane Database of Systematic Reviews [Internet]. 2017 Jun 26 [cited 2023 Nov 23];2017(6). Available from: http://doi.wiley.com/10.1002/14651858.CD006775.pub3 
  8. Health Research Authority [Internet]. [cited 2023 Nov 23]. The Use of punctal plugs in glaucoma. Available from: https://www.hra.nhs.uk/planning-and-improving-research/application-summaries/research-summaries/the-use-of-punctal-plugs-in-glaucoma/

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This content is purely informational and isn’t medical guidance. It shouldn’t replace professional medical counsel. Always consult your physician regarding treatment risks and benefits. See our editorial standards for more details.

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Lisa Siqi Zhao

MBChB, medicine, Aston University, UK

Lisa is a Fourth Year Medical Student at Aston University with a strong interest in medical communications and research. She has gained a wide range of experience in the clinical and theoretical aspects of medical science through her training in an extensive variety of specialties. She has a background in teaching and has conducted research in the field of neurology on cell changes in Alzheimer’s disease. She is currently pursuing further studies and continuing to explore research opportunities.

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