Therapeutic Closure of the Lacrimal Drainage System
In cases of severe dry eye disease, occlusion of the lacrimal puncta may be helpful. Dissolvable collagen plugs may be used on a trial basis, or permanent silicone plugs may be used. Permanent intracanalicular plugs are not recommended. Although punctal plugs are usually well tolerated, complications are occasionally encountered. Minor problems include ocular surface irritation and a foreign-body reaction. Pyogenic granulomas may develop, requiring removal of the plug. In most cases, the pyogenic granuloma regresses once the plug is removed, but surgical excision is needed on occasion. More serious complications usually relate to plug displacement.
Plug extrusion or migration is not uncommon. The ophthalmologist can best avoid these complications by using a plug that is the appropriate size. An instrument that measures punctal diameter is available. When appropriately fitted, punctal plugs usually stay in place. In most cases, a plug that is too small will simply be extruded. However, if the plug migrates within the lacrimal drainage system, obstruction of either the canaliculus or the NLD can result. Canaliculitis may result from canalicular plugs or from punctal plugs that have migrated to the canaliculus.
When occlusion with plugs is not successful, the clinician may consider surgical occlusion. Surgery is typically reserved for severe cases and must be performed with caution. If a patient experiences subsequent epiphora, no simple solution is available; most cases require a CDCR. To avoid this complication, all patients should undergo a trial of temporary closure before permanent closure.
Once the decision has been made to proceed with surgical occlusion, the puncta are closed in a stepwise fashion, one punctum at a time. Complete loss of lacrimal outflow can result in epiphora, even in patients with fairly severe dry eye disease.
There are numerous surgical techniques for occluding the lacrimal drainage system. Thermal obliteration of the puncta and adjacent canaliculi can be performed with a handheld cautery unit or a needle-tip unipolar cautery unit. Ampullectomy can be performed with either direct closure or placement of an overlying conjunctival graft. Often, despite aggressive attempts, the puncta persist or reform. In these recalcitrant cases, the punctal and adjacent canalicular epithelia can be completely excised, or the canaliculus can be transected and reconstructed with the severed ends offset from one another.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.