For dry eye patients punctal plugs offer flow control

Key Points

"Punctal plugs are beneficial for a large number of patients with dry eye. However, there are circumstances in which the total occlusion of the puncta in the upper and lower lids provided by standard punctal plugs is excessive, and when patients have reflex tearing they have tears running down their faces, as might happen on a windy day," he said. "The flow control design allows some of the extra tears to move through the opening in the plug, which is a smaller orifice than the puncta of most patients. So less tears are flowing out, but there is some outflow, which is basic fluid mechanics." Dr. Kirby is in private practice in Chattanooga, TN.

In his practice, he does not use the flow control plugs as the first treatment in patients who receive punctal plugs but uses them to fine-tune the results. The standard nonperforated plugs may be adequate in some patients but too much occlusion in others. In the latter group, some patients may have intermittent epiphora, and the standard plug can be removed and replaced with a perforated plug.

He also said that he uses the perforated plug for patients being treated with cyclosporine (Restasis, Allergan) whose clinical situation has been improving as a result of treatment with the drug, but is not yet perfect.

"These perforated plugs represent an interim step in the treatment of these patients who don't need full occlusion," Dr. Kirby said.

"Some of the happiest patients in my practice are those who had a nonperforated plug in the upper lid that was replaced with a perforated flow control plug. This change gives them the slight adjustment that they needed," he added.

The plugs, introduced December 2008, come preloaded on a disposable inserter and are available in two sizes, 0.6 and 0.7 mm. The insertion technique is the same as that used with a standard punctal plug, Dr. Kirby said.

"The usefulness of this product lies in its ability to fine-tune the treatment of moderate and severe dry eye. These patients need some outflow of tears when the total occlusion provided by the standard punctal plugs is too much," he concluded.