Dry Eye Dx and Tx

When Punctal Occlusion is Too Much

dry eye dx and tx

When Punctal Occlusion is Too Much


A 54-year-old employee of a local university presented with complaints of ocular discomfort, blurring with reading and computer work, and frustration with her spectacles. She spent more than eight hours per day on the computer writing grants and working as an executive. After a complete dry eye evaluation, we diagnosed aqueous tear layer deficiency and meibomian gland dysfunction.

We initially started her on tear replacement therapy and aggressively treated her meibomian gland disease. After a month, she reported some improvement in symptoms but still complained of blurring with computer and near work. We inserted 0.4mm temporary collagen implants into her upper and lower puncta OD and OS and instructed her to continue with her treatment regimen.

Two days later she reported that the punctal occlusion was very helpful in relieving symptoms, so we set up appointments to implant non-dissolvable silicone plugs. We initially occluded the lower puncta with medium Parasol plugs (Odyssey Medical), and on follow up learned that the patient was much less symptomatic but still had problems with blurring. We asked her to return and inserted silicone plugs into the upper puncta.

She presented two weeks later and reported much improved comfort, but complained of constant bilateral epiphoria. Removal of the upper plugs caused recurrence of the dry eye symptoms.

In the interim, as part of a study, we received Micro Flow punctal flow restrictors (Odyssey Medical). Because our patient's eyes were too dry without occlusion of all four puncta and too wet with total occlusion, we decided to implant these devices in her upper puncta. We initially did so in one eye and after she reported good results, we repeated the procedure in the second eye. At her most recent visit, she reported very good comfort and function with the combination of punctal occluders and restrictors.

Occlusion Options

Punctal occlusion has been utilized as a form of therapy for dry eye disease for several decades. It has been shown to positively affect patient signs and symptoms.

In a study by Balaram et al (2001), researchers found that six months after bilateral implantation of silicone implants in the lower puncta of patients who were refractory to tear replacement therapy, 43 of 50 patients (86 percent) were symptom-free; 28 of them (56 percent) used no drops, and 38 patients (76 percent) stopped using lubricants daily, but continued to instill them intermittently.

Punctal occlusion is a safe, widely utilized procedure in eye care, but it is not without complications. Canaliculitis has been reported with several types of punctal plugs. Epiphoria may result from total canalicular occlusion because of hypersecretion induced by a foreign body sensation.

The use of a flow restrictor can reduce the extent of occlusion and serve as a “halfway point” in patients who benefit from occlusion but experience epiphoria with total occlusion of both upper and lower puncta.

Temporary occlusion of the puncta using collagen implants is usually a safe and effective way of predicting the positive or negative impact of occlusion with silicone punctal plugs. There are exceptions that have been documented and that we saw firsthand with our patient's case. Flow restrictors afford us with the resources to optimize the amount of punctal occlusion needed to reduce symptoms of dryness and epiphoria at the same time. CLS

For references, please visit and click on document #173.

Dr. Townsend practices in Canyon, Texas and is an adjunct faculty member at UHCO. He has received research funds from Alcon. E-mail him at