Punctal plugs: keeping tears in the eye

On this page

1. What punctal plugs are
2. Who the treatment may suit, and who it may not
3. Temporary or long-lasting: how to choose
4. How the treatment is done at the clinic, step by step
5. What it feels like, and what happens after the treatment
6. How you know whether it is helping
7. Possible side effects and risks
8. How plugs fit with other treatments
9. Cost

This page is for people whose eyes produce few tears, and who feel that even frequent lubricating drops do not last. Here you will find what punctal plugs are, what types there are, how they are inserted, who they may suit and what the risks are.

What punctal plugs are

In the inner corner of each eyelid, upper and lower, there is a tiny opening called the lacrimal punctum (plural: puncta). Through it, tears drain into a canal and from there into the nose. A punctal plug is a very small device that is inserted into this opening or into the canal beneath it, and slows the drainage of tears. This way, natural tears and lubricating drops stay on the surface of the eye for longer.

There are two main types:

• Temporary plugs that dissolve on their own after a period. They are sometimes used as a trial, to see whether closing the drainage helps and does not cause excessive watering.
• Long-lasting plugs made of a flexible material such as silicone, which stay in place until they are removed, or until they fall out. Some sit in the opening of the punctum and some deeper inside the canal.

Who the treatment may suit, and who it may not

Plugs may suit people who:

• Have a shortage of tear fluid found on testing (for example on the Schirmer test).
• Have Sjögren's syndrome or another condition that affects tear production.
• Use lubricating drops many times a day and still suffer from dryness.
• Have damage to the eye surface because of dryness, despite treatment with drops.

Plugs are less suitable, or require prior treatment, when:

• There is active inflammation of the eyelid margins or blocked meibomian glands. In this situation the plug may keep "inflammatory" tears on the eye, so the inflammation is usually treated first.
• There is an infection of the tear ducts or the eye.
• The eyes already tend to water.
• There is a known sensitivity to the plug material.

Temporary or long-lasting: how to choose

The choice depends on how severe the dryness is, on what is found on examination and on your preferences. A temporary plug makes it possible to check, without commitment, whether closing the drainage helps, and if there is excessive watering it passes when the plug dissolves. A long-lasting plug is more suitable when it is already clear that the treatment helps, or in severe, persistent dryness, such as in Sjögren's syndrome. Sometimes only the lower puncta are plugged first, and plugs are added to the upper ones only if needed.

How the treatment is done at the clinic, step by step

1. Examination. Dry eye testing confirms that there is a shortage of tear fluid, and the size of the puncta is checked.
2. Choosing a plug. Together we decide on the type of plug (temporary or long-lasting), the size, and which puncta to insert it into.
3. Preparation. You sit at the slit lamp. Numbing drops are sometimes put in.
4. Insertion. Using a gentle instrument, the plug is inserted into the punctum. Sometimes the opening is widened slightly first. This takes a short time for each punctum.
5. Checking the position. We make sure the plug is seated correctly and does not touch the eye.
6. Follow-up. At a follow-up visit we check whether the symptoms have improved, whether the plug is in place, and whether there is excessive watering.

What it feels like, and what happens after the treatment

The insertion itself is usually not painful, and most people feel only slight pressure. Some patients notice in the first few days that the eye stays moister and that they need drops less often, while for others the change is more gradual or small. It is worth noting how you feel ahead of the follow-up visit. In the first few days there may be a foreign-body sensation in the corner of the eye, which usually passes. You can return to your routine straight away. It is important not to rub the corner of the eye hard, so as not to move the plug.

How you know whether it is helping

At the follow-up visit we ask about your symptoms, how often you need to use drops, and whether there is excessive watering. On slit lamp examination we check the position of the plug, the tear meniscus (the strip of tears along the lower lid) and the condition of the eye surface. If the plug helps and does not cause excessive watering, it can be left in. If not, it can be removed or a different solution chosen.

If you started with a temporary plug and it helped, that is a sign that closing the drainage suits you, and switching to a long-lasting plug can be considered together.

Possible side effects and risks

• Excessive watering: the eye may water too much. If this is bothersome, the plug can be removed or replaced.
• Loss or movement of the plug: a plug can come out on its own, sometimes without you noticing.
• Irritation and a foreign-body sensation in the corner of the eye.
• Infection: rarely, an infection of the tear canal (canaliculitis) develops, with redness, swelling and discharge in the inner corner of the eye. In this case, get checked. Sometimes the plug has to be removed.
• Granulation tissue (growth of a small amount of tissue near the plug): uncommon.

A Cochrane review (Ervin 2017) found that the evidence on the benefit of plugs is limited and inconsistent. In some patients they help a great deal, and in others less so.

How plugs fit with other treatments

Plugs do not replace drops, but help them work. That is why it is important that the drops themselves are gentle on the eye surface, because they stay on it for longer. Usually you continue to use preservative-free lubricating drops. When there is also a problem with the meibomian glands, it is treated at the same time, for example with gland expression. In severe dryness, plugs are sometimes combined with autologous serum eye drops, and when the eye surface is very damaged, also with a bandage contact lens.

Cost

The cost is set and discussed at the consultation, according to the treatment that suits you.

Want a basic explanation first?For basic information on dry eye treatment options: the guide on the Mitzmutz site

Frequently asked questions

Can I feel the plug in my eye?

Most people stop feeling it after a short time. Some feel a foreign body in the corner of the eye in the first few days. If the sensation persists, the position of the plug can be checked or the plug can be replaced.

Can the plug be removed?

Temporary plugs dissolve on their own. Most long-lasting plugs that sit in the opening of the punctum can be removed at the clinic. Plugs that sit deeper in the canal are harder to remove.

What if my eye starts watering too much?

Excessive watering is a known side effect. In that case the plug can be removed or replaced, or a plug can be left in only one punctum.

Can I stop my drops after getting plugs?

Not necessarily. The plugs help tears and drops stay on the eye, and some patients can use drops less often. This is checked at the follow-up visit.

Sources

1. Ervin AM, Law A, Pucker AD. Punctal occlusion for dry eye syndrome. Cochrane Database Syst Rev. 2017;6:CD006775.
2. Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017;15(3):575-628.
3. Akpek EK, Amescua G, Farid M, et al. Dry Eye Syndrome Preferred Practice Pattern®. Ophthalmology. 2019;126(1):P286-P334.
4. Foulks GN, Forstot SL, Donshik PC, et al. Clinical guidelines for management of dry eye associated with Sjögren disease. Ocul Surf. 2015;13(2):118-132.

The information on this site is general only. It is not medical advice and does not replace an examination by an eye doctor.