A 39-year-old female patient presented with a foreign body sensation in right lower lid. It started two days ago, and had intensified within the last few hours. She suspected her punctal plug had become loose.
Her ocular history included LASIK three years prior, after which we inserted bilateral, permanent, inferior lid punctal plugs. Medical history included taking oral contraceptives and Claritin D for allergies. At the time of her most recent exam, she was using TheraTears throughout the day. She had no known drug allergies.
History
External exam revealed the plug resting horizontally above the punctum (left, magnified view at right.)
The patients pre-LASIK evaluation revealed a history of slight contact lens intolerance, a tear break-up-time (TBUT) of 10 seconds O.U. and a normal tear meniscus without any visible blepharitis or meibomian gland dysfunction. One month after her uneventful and successful LASIK procedure, the patient complained of persistent dry eye. Schirmer test (with anesthesia) showed only 4mm O.U. of wetting after five minutes, a TBUT of 3 seconds O.U., and 2-3+ meibomitis. I instructed the patient to commence warm compresses tid for five minutes at each setting, with only light lid massage secondary to her recent LASIK, and to use unpreserved artificial tears frequently.
At her next visit a month later, she was still symptomatic, but the meibomitis was improved. I inserted three 0.3mm temporary collagen punctal plugs in both inferior puncta, and asked her to return in a week. She reported that her symptoms had resolved four days after the collagen plugs were inserted.
I inserted medium silicone plugs in both inferior puncta. She returned in a few weeks disappointed that the silicone plugs were not as effective as the collagen plugs had been. Slit lamp exam revealed the plugs in excellent position, but the meibomitis had returned.
I again asked her to commence warm compresses. For the following two and a half years, she was mostly symptom-free as long as she was compliant with the warm compress and massage on a nightly basis.
Diagnostic Data
Best corrected visual acuity at this visit was 20/20 O.U., with NCT readings of 11mm Hg O.U. External exam revealed the entire punctal plug resting horizontally above the punctum (see figures 1 and 2 on page 79). The cone, or bottom of the plug, was pointed toward the conjunctiva, causing the foreign body sensation when the patient blinked. There was minimal conjunctival staining adjacent to the plug.
I presumed the plug had come out of the punctum. To my surprise, there was resistance when I tried to remove the plug with forceps. Upon closer inspection, I could see tissue that appeared conjunctival in nature around the neck of the plug. When I attempted to lift it, I could see that the tissue appeared to originate from the canaliculus inside the punctal opening.
Diagnosis
I first thought a pyogenic granuloma had encircled the punctal plug. After subsequent research, I found that spontaneous dissection of the canalicular mucosa caused the tissue to encircle the plug and forced it to extrude out.
Treatment and Follow Up
I instilled two drops of proparacaine in her right eye, and placed a proparacaine-soaked cotton applicator on her punctum for 20-30 seconds. I was able to free the pug by pulling from the bottom, while pulling down on the lower lid. The tissue that had surrounded the plug bled slightly but stopped very quickly when I applied pressure with a cotton-tipped applicator. Immediately after removing the plug, some of the tissue remained protruding from the punctum (See figure 3 above). I instilled two drops of Tobradex (tobramycin and dexamethasone, Allergan) O.D., followed by Maxitrol ointment (neomycin and polymyxin B sulfate ointment, Alcon) in the punctum area. I prescribed Tobradex q2h, and asked her to return in four days.
The tissue has receded below the punctum, but it is barely patent. However, the patient is comfortable and without epiphora. I decided against inserting another plug in that eye. She continues to control the meibomitis with warm compresses qhs. I offered her oral doxycycline, but she prefers not to take oral antibiotics. The plug in her left lower lid remains without complication.
Discussion
Although both punctal and lacrimal plugs are generally safe, there is a possibility of associated complications.1 Some of these include epiphora, plug migration, pyogenic granuloma, canaliculitis, dacryocystitis and partial or complete plug extrusion.2
The extruded plug in this case had a fibrous band that was not very vascular, and did not bleed easily even after removal. A histological study in France revealed that the fibrous bands encircling the neck of the plug consist of connective tissue derived from the canalicular mucosa, and that the overlying epithelium was consistent with that of canalicular mucosa epithelium.3 Analysis of the epithelium revealed a pseudo-atrophic pattern resulting from mechanical stress on the canaliculus by the silicone plug.
Spontaneous dissection of the canalicular mucosa.
We believe the strip of canalicular mucosa was probably dissected from the canalicular lumen. Eye rubbing or improper insertion may have caused displacement of the plug, causing it to rock within the canaliculus. This caused the mucosa to erode and the dissection to occur. The canalicular mucosal strip then encircled the neck of the plug. Persistent irritation resulted in epithelial hyperplasia and infiltration of the dissected tissue and caused the plug to protrude from the punctum.3
Recent studies caution against punctal occlusion in patients who have chronic meibomitis.1,4,5 Researchers believe that these patients have gland secretions that have broken down into toxic fatty acids and soaps. Inserting plugs allows these inflammatory products to collect in the patients tear film, worsening symptoms. Treatment of meibomian gland disorders using warm compresses, oral doxycycline or minocycline, and possibly essential fatty acids is now the preferred method of treating lipid-based evaporative dry eye.5 This patient likely had subclinical meibomitis that was undetected at the initial pre-LASIK evaluation.
To help reduce the likelihood of associated retained extruded punctal plugs and pyogenic granulomas, caution patients not to rub their eyelids, make sure plugs are secure, and have the patients return for periodic follow-up visits. Its also crucial to inform these patients that this procedure is not always reversible. Permanent scarring and closure of the punctum and canaliculus, as well as distal migration of the plug necessitating nasolacrimal surgery, is possibile.
Dr. Gutierrez is in private practice in San Antonio, Texas and specializes in primary eyecare and corneal refractive therapy.
1. Morris, S. Plugs, drugs and tears: a dry eye update, part two. Optometric Management 2002;37 (10):36-42.
2. Soparkar CN, Patrinely JR, et al. The perils of permanent punctal plugs. Am J of Ophthalmol 1997;123 (1):120-1.
3. Fayet B, Assouline M, et al. Silicone punctal plug extrusion resulting from spontaneous dissection of canalicular mucosa. Ophthalmology 201;108 (2):405-9.
4. Cohen EJ. Punctal occlusion. Arch of Ophthalmol 1999;117 (3):389-90.
5. Balaram M, Schaumberg DA, Dana MR. Efficacy and tolerability outcomes after punctal
occlusion with silicone plugs in dry eye syndrome. Am J Ophthalmol 2001;131 (1):30-6.
