Dry Eye Relieved With Lacrimal Drainage Plugs, Review Shows

Jenni Laidman

June 15, 2015

A technology assessment report by the American Academy of Ophthalmology showed that more than half of all lacrimal drainage plug placements led to reduced dry eye symptoms, improved ocular surface health, reduced artificial tear use, and improved contact lens comfort. The review was published online May 30 in Ophthalmology.

However, the authors note a lack of "methodologically sound randomized clinical trials" comparing plug types or comparing plug placement with sham treatment.

The review, conducted by Marcus M. Marcet, MD, clinical assistant professor, Department of Ophthalmology, University of Hong Kong, Cyberport, and colleagues examined 27 studies involving 2499 patients identified in a broad survey of PubMed and Cochrane Library databases through March 9, 2015. The studies were all observational, with 21 case series, and rated as level II or III evidence.

"The lack of level I evidence was a surprise," Dr Marcet told Medscape Medical News in an email. "Also surprising was that about 40% of the punctal plugs fall out. It seems as if it should be lower."

"Given the general acceptance of punctal plugs, it is interesting that there is not more data on them over the years," Kristin Hammersmith, MD, fellowship director, Cornea Service, Wills Eye Hospital, Philadelphia, Pennsylvania, told Medscape Medical News in an email. Dr Hammersmith was not involved in the current review. She is also an associate professor at Thomas Jefferson University in Philadelphia.

Although randomized controlled trials "best evaluate the effectiveness of a procedure," Dr Hammersmith said, "the studies that are evaluated here do support that punctal plugs are helpful and have a very low side effect profile. This is in keeping with what we [generally] believe." However, she said, infection rates for intracanalicular plugs were a concern.

The review showed that about 9% of punctal plug patients experienced epiphora, and 10% had plugs removed because of irritation. Intracanalicular plugs led to canaliculitis in about 8% of patients. Other complications, which occurred in less than 4% of patients, included tearing, discomfort, pyogenic granuloma, and dacryocystitis.

Evidence showed that serious complications from plugs were rare.

The authors reviewed efficacy and safety of punctal plugs, intracanalicular plugs, and dissolving plugs. Although the authors called the seven studies of punctal plugs "methodologically weak," they conclude, "taken together they suggest that punctal plugs improve dry eye signs and symptoms." In the five studies that evaluated dry eye symptoms after punctal plugs, 70% of patients experienced symptom improvement. All studies reported improved ocular surface health. Four studies indicated reduced artificial tear use, and two reported more comfort with contact lens use.

Thirteen studies looked at punctal plug safety, with 11 studies reporting plug movement, the most frequent complication. Plug loss occurred in 40% of patients (range, 9.5% - 50.7%). Partial extrusion or migration occurred in 3% of patients (range, 0.9% - 7.1%). Epiphora was reported in 9 of the studies and 10% (range, 1.9% - 36.5%) of patients. Other reported complications included pyogenic granuloma (range, 0.0% - 6.7%), canaliculitis (range, 0.0% to 5.6%), and discomfort leading to plug removal (range, 2% - 19%).

A total of 180 subjects were included in studies evaluating the efficacy of intracanalicular plugs, all indicating substantial improvement in dry eye symptoms. Three studies reported a decrease in use of artificial tears. One study included contact lens wearers and reported statistically significant improvement in contact lens comfort. Nine studies, involving 773 subjects, looked at intracanalicular plug safety. Two studies reported plug movement, including plug loss in 2.2% of patients in both studies. Five studies reported epiphora in an average of 6.5% of patients. Five reported complications of inflammation.

Four studies with 211 patients looked at efficacy in dissolving plugs; all of these studies indicated some improvement in dry eye symptoms. "On the basis of the limited findings of this assessment, the dissolving plugs seem to be effective in short-term reduction of symptoms and signs of dry eye," the authors write. Three studies looked at safety data in 149 patients. Reported complications included canaliculitis in 3.6% of patients in one study and localized irritation in 2.0% of patients in another study.

The authors conclude that future research should include randomized controlled trials investigating safety and effectiveness in plug location, comparing one plug type with another, and comparing plugs with other treatments. Further, studies needed to consider more quality-of-life measures, as well as cost-effectiveness analyses.

The authors and Dr Hammersmith have disclosed no relevant financial relationships.

Ophthalmology. Published online May 30, 2015. Abstract

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