Where should the top of the punctal plug be when inserted in the eye?

[JoeB]

Hi All,

I have found a doctor who says he can do punctal plugs.

This is what he said. Please tell me what you think. And please think about this question that entitles this thread.

I am in Austria. The doctor uses pretty good English, but is not perfect.
He says he'll put plugs into the lower puncta.(upon my request, not collagen). I wanted silicone, but he said that some patients have had reactions to them, so he uses a plastic kind.

They have caps. He uses no dilation because he says it will cause trouble with future fitting of plugs (I was glad to hear he does not use dilation).

I said, "Will I be able to see them?"

He said, "No, I put them in deep enough so they will not be seen. You could see them with a microscope."

I said, "How will I know that they are not lost?"

He said, "The tear quantity will be different."


I said, "What if they are lost inside the puncta canal?"

He said, "That has never happened."

I said, "But I've talked to people who have lost them inside the puncta canal and who say they can cause infection if that happens."

He said, "Where would they go, the nasal cavity?"

So, what do you think?

Should I be able to see the top of the punctal plug? Would others see it if I can see it?

My puncta turn inwards a little towards the eyeball. If the cap is sticking out, might it scratch my eye?

So, basically, where should the cap of the puncta plug be and how should I tell the doctor? Perhaps he really never has experienced a case where the punca plugs have gotten lost inside the puncta.

Please help? As a further question, is there any danger at all in the insertion process for punctal plugs?

Thanks.

JoeB

[DrG]

So, what do you think?

Should I be able to see the top of the punctal plug? Would others see it if I can see it?

My puncta turn inwards a little towards the eyeball. If the cap is sticking out, might it scratch my eye?

So, basically, where should the cap of the puncta plug be and how should I tell the doctor? Perhaps he really never has experienced a case where the punca plugs have gotten lost inside the puncta.

Please help? As a further question, is there any danger at all in the insertion process for punctal plugs?

Why not ask the doctor to give you the name of the plug he proposes to use, and either draw a picture of the process or give you a written explanation for the process for that particular plug? That would be proper informed consent, and then you would know for sure.

As you know, there are many different types of plugs, but they can be broken down into two basic kinds: intracanalicular and punctal. Intracanalicular include Herrick and Smart Plugs. The Smart Plug is a rod of themoplastic material that is inserted into the vertical part of the canaliculus, and then shrinks so that the end of the plug does not protrude from the punctum. The Herrick is silicone, looks like a dart, and is on the tip of a long stylus, or wire. It is inserted into the horizontal part of the canal. I'm sure that there have been cases where the canal has been inadvertently pierced by the stylus by someone who lacked experience.

All punctal plugs have a flange that keeps them from migrating into the canaliculus. Most are silicone, and some are soft silicone that allows them to be inserted without dilating the punctum. It is possible that the flange will rub the conjunctiva, in which case the plug can easily be removed. Also, there are different size plugs with different size flanges.

There is a poster here by the name of indrep who has a great knowledge of different kinds of plugs, including some I am not familiar with. You might do a search. My preference is to use punctal plugs, although I have used the Herricks. In most cases, the plugs I use do not need to be explanted, but a few -- perhaps one in five or less -- need to be because of irritation.

[np1981]

I said, "What if they are lost inside the puncta canal?"

He said, "That has never happened."

I said, "But I've talked to people who have lost them inside the puncta canal and who say they can cause infection if that happens."

What are the consequnces of a plug (silicone) getting trapped in the canal?

[Silverlady]

Infection

I had one that caused an infection. It took two rounds of antibiotics and it had to be removed by my eye doctor. Not fun.
B

[Rebecca Petris]

What are the consequnces of a plug (silicone) getting trapped in the canal?

I have a friend who had one work its way out her eyelid. (Her doctor thought it was gone, so he re-plugged her.) Four surgeries later, she's not in very good shape. That, of course, is a very rare and exceptionally bad case.

[DrG]

Let's not make any mistake about it. If you put a small punctal plug into a large punctum, it can migrate into the canaliculus, even with a flange, if the sphincter is loose.

I almost had that happen to me last week. Fortunately, I was on my toes and withdrew the plug immediately. The next size larger worked fine.

I hope this isn't turning into a punctal plug bashing exercise. They truly truly work most of the time. We tend to focus here on the exceptions rather than the rule.

[Rebecca Petris]

NP1981 asked a question about consequences of what is acknowledged to be a rare event, and got a couple of answers. I see no bashing exercise underway. Anybody can tell a patient what is expected to happen, but many people also want to know what can happen. On a bulletin board that by its nature will attract people who have experienced exceptional dry eye problems, a lot of exceptional or rare problems are going to be aired from time to time as a matter of course, especially when people ask.

[np1981]

I almost had that happen to me last week. Fortunately, I was on my toes and withdrew the plug immediately. The next size larger worked fine.

I hope this isn't turning into a punctal plug bashing exercise. They truly truly work most of the time. We tend to focus here on the exceptions rather than the rule.

Out of interest, how do you remove a plug that has migrated into the canaliculus?

Punctal plugs have helped me a lot, and I am happy with the silicone type with the cap (now that I am used to it) as opposed to the intracanalicular type.

The main reason I ask is because my local eye docs here in the NHS don't seem to have much experiance with punctum plugs at all, and it sometimes worries me that if something did happen they wouldn't be "on their toes" and sort it out. One eye doc at the hospital told me she had never seen them before which shocked me. I had to travel across the country to an optometrist to find someone who would plug me.

[DrG]

The plug had not yet slipped into the canal, but I could see that it might, especially if the patient rubbed her eye. But, that was the first time that had ever happened to me. Some resistance is always felt when inserting a punctal plug, but not in that case.

I'm not sure why I am even reporting this, except as a possible explanation for why a punctal plug could actually migrate down into the canal. I do have stainless steel gauges for measuring the puncta, but haven't needed them in quite awhile, having developed the ability to estimate the correct size. Well, I'm back to using them, at least for now.

[SusieD]

I have a friend who had one work its way out her eyelid. (Her doctor thought it was gone, so he re-plugged her.) Four surgeries later, she's not in very good shape. That, of course, is a very rare and exceptionally bad case.

Could you just clarify this? did she have the capped type and this worked its way into the canal - making her doctor assume it was gone. Not sure what you meant about 'worked its way out of her eyelid'.

Thanks.

[indrep]

JoeB,
I am not aware of any plug that can be put in that would be visible by microscope but not the naked eye. There are intracanalicular plugs but they can't be seen with a microscope. So I would go with Dr. G's recommendation of having the doc give you the name of the plug and a visual explanantion.

It is rare to have a silicone plug migrate into the canal without some external pressure. What happens is most is what Dr. G experienced on insertion. He was able to see the potential problem and reverse course. Unfortunately this does not always happen and a plug can be pushed below the punctal ring and then migration can happen. The cap of the plug should rest tight on top of the punctal ring.

As to the Doc's question regarding where can it go. Ideally, yes the nasal cavity is where you want it to go on expression. Unfortunately there is a little thing called the lacrimal sac that can get in the way of expression. This is where the problem can occur.

Personally I would go with silicone plugs first. You can see them and make sure they are in. If they stay in and you don not have any foreign body sensation then you are set. If they don't stay in or you have foreign body sensation then look into the intracanlicular plugs. The only I feel comfrotable recommending is the OASIS Form Fit. It is a hydrogel material (90% water when hydrated) and if you need it removed it will shred like mucos on irrgation.

[Rebecca Petris]

Could you just clarify this? did she have the capped type and this worked its way into the canal - making her doctor assume it was gone. Not sure what you meant about 'worked its way out of her eyelid'.

Thanks.

She had a silicone plug but I'm actually not sure whether it was capped or intracanalicular. Some time after it was inserted, her doctor examined her, could not see it (I don't know too much about this but you're supposed to be able to see them with retroillumination), decided it had flushed through and re-plugged her. Apparently the plug had worked its way out of the canaliculus to i-don't-know-where and over time as it continued to migrate it caused considerable damage to her eyelid.

It was a very, very unusual case and from what I heard involved some unacceptably poor care by her (then) ophthalmologist.

[JoeB]

Thanks everyone for your answers. I'm trying to find out the name of the kind of plug. Hopefully, I'll find out soon.

JoeB