Recommeded steps and type for Success with Punctal Plugs

[JoeB]

Hello,

My eye doctor recommended punctal plugs to help my dry eye. I've read quite a bit on this board, and it seems there are many routes and pitfalls.

Could someone, especially someone who is having success with plugs, make a recommendation as to the steps and which type that I should try for a successful outcome with punctal plugs?

Your advice is highly appreciated.

JoeB.

[kitty]

The type of plugs to try should be a decision made jointly by you and your doctor. The are pros and cons, risks and benefits to each type on the market. Typically, one starts with a trial of dissolvable plugs that last 2-5 days, to see how the person responds. If the eyes feel better during the trial, then it is time to move on to 6 month dissolvable or permanent plugs. The 2-5 day trial is not always sufficient to know if the plugs will be helpful. If you are not sure after the short term trial, you can try the 6 month dissolvable before committing to the permanent plugs. You can read more about Punctal Occlusion here.

[indrep]

There are two types of occlussion with plugs. The most common are silicone plugs that have a cap that rests on the pucntal opening. These are visible so you know if they are there or not. This cap also can contribute to them becoming displaced. When you wash your face or wipe the "morning goo" out of your eye can all be times when you inadvertently pull out the plug. Also some types of anatomy make this plug difficult to retain, slit shaped puncta, the lid margin facing the eye, etc. Also if they are not correctly sized and implanted you could lose the plugs. The good news most manufacturers now make their plugs out of a soft durometer material and have small caps for reduced opportunities at patient discomfort. I would stay away from the plug that has a tilted cap, some have reported that the plug will turn and the raised side of the cap becomes an irritant. The second type is intracanalicular. These are plugs that are implanted into the intracanaliculus. There are three manufacturers of these and they are all different. The first of these is the Herrick plug. It is a silicone golf tee shaped plug. It is blue and can be seen with transillumination. It has some reported issues and is no longer widely used. The second type is from Medinium, the Smart Plug. This is a temprature sensitive Acrylic material that shrinks in length and expands in diamter as it is inserted. It can not be seen with transillumination. This plug has gained popularity and the only issues seem to be some patients complain of foriegn body sensation and the removal of the plug can be difficult. The only other issue is insertion can be tricky but this is only an issue for the doc. The third is the OASIS Form Fit plug. This is a Hydrogel material that is 90% water when implanted and in its expanded state. It only fills the vertical space and due to the water content is less likely to dislodge or cause foreign body sensations. It cannot be seen with transillumination. If it needs to be removed it easier to irrgiate out than the other two in that it will come apart under irrigation.

In the end Joe you will ahve to talk with your doc and decide what is best for you in relationship to his experience with the different types of occlussion available.

[JoeB]

How long is permanent?

Thanks Kitty and Indrep.

I was wondering after what you said, how long is permanent?

The 'permanent' ones can be taken out, right?

I've heard that a lot of times they are lost. Is it mainly because of washing the face, or being the wrong size? And once the size is correct, does it rarely come out?

May I ask, which kind are you using (Brand name, material, temporary or permanent) and why have you decided to go with that type?

What is the cost of the first pair temporary or permanent, and do the doctors charge for each pair that is has to be replaced? It seems like it might get pretty expensive if one were to keep losing them.

Thanks again. I'm glad I've come here because obviously this stuff isn't that simple.

JoeB

[indrep]

Permanent is probably the wrong term, Long Term might be better. The silicone plugs can be easily removed. The intracanalicular plugs take a little more doing and really only one of those would I consider to removeable every time.

If the plug is sized correctly and no dilation is used prior to insertion, then the plug should still be there in 12 months with proper care on your part. The reason I say 12 months is that is when the study ended.

I am not a big fan of the temporary plugs first, unless you are skeptical of the benefit of plugs. If your situation could be temporary then I would most likely try the external sitting silicone plugs first. The reason I say this is they are easiest to remove should your circumstance change. If they are uncomfortable you can always go to the intracanalicular version.

The insertion of plugs is a "global remibursed" procedure, meaning the reimbursement to the doc is the same regardless of temporary or permanent plugs. There typically is no reimbursement to the doc for the "cost" of the plugs. If you are paying out of pocket, yes it could become expensive to keep replacing lost plugs.

[JoeB]

Query about Caps

Hello Indrep,

In your answer below about steps to success with punctal plugs, you said that manufacturers now make some with smaller caps. Are the punctal plugs with the smaller caps more likely to migrate and get lost in the canal? or more likely to fall out completely (perhaps due to a less sng fit)?

Which brand(s) has the smaller cap?

Finally, you mention that most companies use a soft durometer material. Is that a kind of silicone?

Thank you.

Joe

There are two types of occlussion with plugs. The most common are silicone plugs that have a cap that rests on the pucntal opening. These are visible so you know if they are there or not. This cap also can contribute to them becoming displaced. When you wash your face or wipe the "morning goo" out of your eye can all be times when you inadvertently pull out the plug. Also some types of anatomy make this plug difficult to retain, slit shaped puncta, the lid margin facing the eye, etc. Also if they are not correctly sized and implanted you could lose the plugs. The good news most manufacturers now make their plugs out of a soft durometer material and have small caps for reduced opportunities at patient discomfort. I would stay away from the plug that has a tilted cap, some have reported that the plug will turn and the raised side of the cap becomes an irritant. The second type is intracanalicular. These are plugs that are implanted into the intracanaliculus. There are three manufacturers of these and they are all different. The first of these is the Herrick plug. It is a silicone golf tee shaped plug. It is blue and can be seen with transillumination. It has some reported issues and is no longer widely used. The second type is from Medinium, the Smart Plug. This is a temprature sensitive Acrylic material that shrinks in length and expands in diamter as it is inserted. It can not be seen with transillumination. This plug has gained popularity and the only issues seem to be some patients complain of foriegn body sensation and the removal of the plug can be difficult. The only other issue is insertion can be tricky but this is only an issue for the doc. The third is the OASIS Form Fit plug. This is a Hydrogel material that is 90% water when implanted and in its expanded state. It only fills the vertical space and due to the water content is less likely to dislodge or cause foreign body sensations. It cannot be seen with transillumination. If it needs to be removed it easier to irrgiate out than the other two in that it will come apart under irrigation.

In the end Joe you will ahve to talk with your doc and decide what is best for you in relationship to his experience with the different types of occlussion available.

[indrep]

Joe,
The cap has nothing to do with migration of the plug into the canal. It is mostly used to visualize that the plug is in place and to serve as a stopping point for insertion. Twenty years ago everyone thought the biggest plug you can force in the better. That has now been proven to be the wrong approach. Now the correct size is the best plug to put in. As plug sizes got smaller the cap on top did not always get correspondingly smaller. About five years ago that started to change and now most if not all have the smaller cap. Durometer is a measure of softness in the silicone material.

[JoeB]

Dilation

If the plug is sized correctly and no dilation is used prior to insertion, then the plug should still be there in 12 months with proper care on your part.

Hello Indrep,

Thanks for your answer. I thought I read somewhere that the doctor usually will use dilation to fit the plug in properly. Is that the case? I assume that using dilation means that the plug is less likely to stay put. If that is a correct assumption, should I ask the doctor to not use dilation when they insert the plugs?

If the doc says he/she must dilate, should I then find another doc?

Thanks once again for your helpful answers.

Joe

[SusieD]

Sorry not Indrep but I think dilation is just used to make the plug easier to get in - I had that done because I have very small punctal openings in one eye.

Someone correct me If Im wrong but I wouldnt have though it makes the plug more likely to fall out - there would be no point.

[indrep]

Susie,
You are correct in that it does make it easier to get the plug in, but, the punctal ring is a sphincter muscle. It does play a crucial role in holding silicone plugs in place. In very small punctas less than .4mm a gentle dilation, or touch, just enough to relax the sphincter is all that is needed to insert a punctal plug.

What can happen with dilation is the rupture of the sphincter and then it will be very difficult to retain a plug long term. This goes back to the days when large plugs were used and aggresive dilation was needed to insert them. When sized correctly very little is needed to insert the plugs. The sizing instruments used are actually measuring this punctal ring or muscle.

[JoeB]

Fitting of Punctal Plugs

Thank you SusieD and InDrep. Obviously, then, a great deal of care needs to be taken for the insertion.

Regards,
JoeB

Susie,
You are correct in that it does make it easier to get the plug in, but, the punctal ring is a sphincter muscle. It does play a crucial role in holding silicone plugs in place. In very small punctas less than .4mm a gentle dilation, or touch, just enough to relax the sphincter is all that is needed to insert a punctal plug.

What can happen with dilation is the rupture of the sphincter and then it will be very difficult to retain a plug long term. This goes back to the days when large plugs were used and aggresive dilation was needed to insert them. When sized correctly very little is needed to insert the plugs. The sizing instruments used are actually measuring this punctal ring or muscle.