Punctal Plugs

What are punctal plugs?

Punctal plugs are small inserts that block the outflow of tear fluid from your eyes. Blocking that outflow can help maintain eye moisture and keep your eyes from drying out.

Your eyes have a built-in drainage system for tear fluid. The first component in that system is a pair of circular openings called puncta (the word for one is “punctum”). Each eyelid has one punctum near the inside corner of your eye, so both eyes have two puncta. Each punctum is tiny — about the width of three human hairs.

The puncta are like drains that send tears into the nasolacrimal duct, which drains into your nose (which is why you get nasal congestion when you cry). Punctal plugs block the puncta, keeping tears from flowing out.

Are there different types of punctal plugs?

Punctal plugs come in many different types. Some are designed for temporary use, while others are meant to stay indefinitely. There are also plugs that have specific features to treat certain conditions.

One way to classify the different types of plugs is by the material in them and how long they last:

• Temporary (five to seven days). Temporary punctal plugs are made of substances like collagen, a protein similar to those that help gelatin (like in desserts) set and keep its shape.
• Semi-permanent (weeks to months). These plugs are often made of materials that dissolve over time and/or that your body can absorb.
• Permanent. These plugs are made of synthetic materials like silicone. They’re only permanent because they won’t dissolve or be absorbed. Your provider can extract them quickly and easily if they need to come out.

There are also two specific variants that offer different benefits:

• Medicated plugs. Some plugs have medication-releasing cores or are coated in medication.
• Perforated plugs. These plugs have a hollow center. They still allow tear fluid to drain but slow down how fast that happens.

What conditions do punctal plugs treat?

Punctal plugs mainly treat dry eyes, which typically happen when there’s an issue with your tear quality, causing them to evaporate too quickly, or if your tear glands don’t make enough tears to keep your eyes from drying out. Dry eyes can happen on their own or it can be due to other conditions or circumstances. Those conditions include:

• Autoimmune conditions like Sjögren’s syndrome, graft vs. host disease (GVHD) or lupus (systemic lupus erythematosus).
• Conditions that involve corneal damage, such as recurrent corneal erosions.
• Many types of medications, especially antipsychotic medications, antidepressants or beta-blockers, just to name a few.
• Low humidity, especially in areas with dry climates.
• Air pollution, including smoke from tobacco or vaping, chemical fumes and more.

A dissolvable type of punctal plug was developed in 1961 as a treatment for dry eyes. The invention of non-dissolvable silicone punctal plugs followed in 1975. These plugs work similarly to placing a stopper in a bathtub. The water level in the tub rises because it can’t drain out.

Perforated punctal plugs can also treat epiphora (watery eyes) from punctal stenosis, which is when the puncta are narrowed by something and it’s hard for tear fluid to drain.

What happens during the placement of punctal plugs?

Placing punctal plugs is a straightforward, quick and painless procedure. Your healthcare provider may use a topical anesthetic to numb your eyelid so you don’t feel discomfort. They’ll also likely use some kind of lubricant to make it easier to place the plug.

Your provider will hold your eyelid open and use a special tool to place the plug. It might look like the plug is going near your eye, but it isn’t going to touch your eye itself. While placing the plug, you might feel a little pressure or a slight tug on your eyelid as the plug goes into the punctum (you might not feel anything if your provider applied a topical anesthetic). Once the plug is in place, that’s it.

How long will I need punctal plugs?

The type of plug and how long it needs to stay in place depend on multiple factors. Your healthcare provider can tell you more about the exact material that makes up the plugs, how long the plugs last and how long they should stay in.

What are the potential benefits of punctal plugs?

Punctal plugs have many benefits, including:

• They’re safe. Complications or side effects from punctal plugs aren’t common, and they’re usually not serious.
• Placing them is quick, easy and painless. Your healthcare provider can do this in their office, and it takes just a few minutes.
• They don’t have to be permanent. Temporary plugs dissolve on their own within days. And your provider can remove semi-permanent and permanent plugs if necessary.
• They can boost the effectiveness of other treatments. Using punctal plugs along with artificial tears or other types of eye drops or medications can help those other treatments stay in your eyes longer.

How effective are punctal plugs?

Multiple studies over the last 30 years show that punctal plugs are effective. The effectiveness depends on multiple factors, including the specific type of plug, the condition it treats and more. Effectiveness in all but one study was over 70% (the one that showed lower effectiveness had 36 participants, and the success rate was 50%).

What are the risks or complications with punctal plugs?

Punctal plugs do have a potential for side effects or complications, but these are usually minor. The most common side effects or complications are:

• Plugs falling out. This is the most common complication of punctal plugs. It’s more likely to happen with plugs placed in the upper puncta.
• Watery eyes (epiphora). It’s often possible to remedy this complication with a switch to perforated plugs.
• Partial plug displacement. This is when the plug moved slightly out of position. If that happens, it can irritate the surface of your eye. It’s often possible to reposition the plug, but it’s also possible to remove it if necessary.

Rare complications include:

• Pyogenic granuloma. This is a growth that develops on or near a punctum due to irritation from the plug. It usually goes away with the removal of the plug and anti-inflammatory and antibiotic treatment.
• Punctal stenosis. This is narrowing of a punctum due to irritation from a punctal plug. It’s usually temporary. It typically happens after plug removal.
• Plug displacement further into your tear drainage system.This isn’t common with punctal plugs, but it does happen in rare cases. Punctal plugs currently in use have a collar-like ring at the top to prevent this.
• Toxic tear syndrome. This happens when a problem on the surface of your eye causes your body to release inflammatory proteins into your tear fluid. Punctal plugs can keep those proteins on your eyes for longer than expected, causing inflammation. This is often preventable with anti-inflammatory treatments before and along with plug placement.

How long will it take for me to feel better?

Punctal plug placement is quick and straightforward. Depending on the type of plug and whether or not you use any other treatments for dry eyes, you should notice a decrease in eye dryness within days or even hours.

Is there anything I can do to make punctal plugs more effective or avoid possible complications from them?

Your healthcare provider is the best source of information on how to help yourself and avoid issues after the placement of punctal plugs. Some general guidelines include:

• Avoid rubbing your eyes. This might dislodge a punctal plug. Your provider can show you a safe, effective way to deal with eye itchiness or discomfort that won’t jeopardize plug placement.
• Use other treatments as prescribed. Other medications or treatments, like artificial tears, usually work better if you have a punctal plug. Use them as prescribed for the best effects.
• Wash your hands before touching your eyes or face. This is good practice regardless of whether you have punctal plugs. But it’s even more important if you do have these plugs.

When should I call my healthcare provider?

If you have punctal plugs in place, you should call your provider if you experience any of the following:

• Eye pain.
• Eye irritation or redness.
• Feeling like something is stuck in your eye.
• Eyes that are unusually watery or dry.
• Swelling, redness, pain or irritation of your eyelids (blepharitis).

A note from Cleveland Clinic

Punctal plugs are tiny medical devices, but they can make a big difference in how you see and how your eyes feel. While it might feel uncomfortable to think about a provider placing one of these in the puncta on your eyelids, these devices are effective and safe, and complications or side effects are minor and rare.

If you have dry eyes or similar conditions, punctal plugs might offer you relief or help other treatments work better. That way, you can focus on the things in your life you want to prioritize and worry less about how your eyes feel.