Punctal Plugs Effective, Safe in Treating Moderate, Severe Dry Eye Disease

Punctal plugs were found to be effective and safe when used to treat patients with dry eye disease, with symptoms significantly improving in those who used them. The review, published in Contact Lens and Anterior Eye,¹ had low heterogeneity and minimal publication bias.

Dry eye disease is an eye condition that includes tear film instability, inflammation, surface damage, and hyperosmolarity that leads to a loss of tear film homeostasis. Prevalence of dry eye disease varies by country, with Dry Eye Directory estimating between 5% and 15% of US adults are currently living with the condition.² Severe aqueous-deficient dry eye can be treated with the use of punctal plugs, which can help to preserve natural tear film. However, evidence on the type of punctal plug, efficacy in dry eye disease, and the retention rate is less researched. This review aimed to establish the efficacy of punctal plugs when used to treat dry eye disease, along with retention rates and complications.

The researchers searched Embase, Web of Science, PubMed, Cochrane Library, and Scopus to collect data for this review. All studies needed to include patients aged 18 years or older who were diagnosed with dry eye disease. Any study that reported on outcomes specific to punctal plugs was included. Randomized controlled trials (RCTs) and nonrandomized studies were both included. Studies that included children, contraindications to punctal plugs, active ocular infections, surgical interventions, and studies without comparator groups were all excluded. The researchers extracted data from the included studies.

There were 17 studies that were included in the review overall. The studies came from the United States, Japan, the United Kingdom, China, Saudi Arabia, Austria, Egypt, France, and Canada, with the sample sizes ranging from 24 to 864 participants.

Retention rate in these studies was positive with an overall logit value of 1.78 (95% CI, 1.62-1.94) and an OR of more than 1. Silicone plugs also had a high pooled logit retention rate of 1.75 (95% CI, 1.59-1.92), and collagen plugs had a logit retention rate of 2.25 (95% CI, 1.38-3.12), even though it was only reported in 1 study. Spontaneous plug loss had a pooled logit event rate of –1.45 (95% CI, –1.71 to –1.19), or an approximate plug loss rate of 19%, which indicated a low risk of plug loss.

A significant improvement in posttreatment for tear breakup time (TBUT) was found after punctal plug use with an overall mean difference (MD) of 1.8 seconds (95% CI, 1.8-1.9). The MD was still 1.8 seconds (95% CI, 1.786-1.856) when comparing RCTs and non-RCTs. Tear production was also improved with an MD of 3.1 mm (95% CI, 3.1-3.2), measured by the Schirmer’s test. An improvement in the Ocular Surface Disease Index was also found with an overall MD of –20.6 (95% CI, –21.3 to –19.9). Plug retention rates were found to be 86% with spontaneous loss of 19%, which indicated a durable response to the punctal plugs.

Punctal plugs were found to be effective in patients with dry eye disease | Image credit: Dragana Gordic - stock.adobe.com

There were some limitations to this study. There was moderate bias in some of the studies included. Poor reporting and imprecision did not allow for more comparisons between artificial tears, cyclosporine, or pilocarpine. There was also a lack of comparative literature, and limited cross interpretation of thermal and surgical methods of treating TBUT.

The researchers concluded that punctal plugs were effective in treating dry eye disease and had a high retention rate. Symptom relief was high in patients using punctal plugs, including in TBUT, tear production, and Ocular Surface Disease Index. “In conclusion, the data reaffirm punctal plugs as an effective treatment modality for managing moderate to severe dry eye disease, offering significant improvement in both objective and subjective measures,” the authors wrote.

References

1. Chen KY, Chan HC, Chan CM. How effective and safe are punctal plugs in treating dry eye disease? A systematic review and meta-analysis. Cont Lens Anterior Eye. Published online May 19, 2025. doi:10.1016/j.clae.2025.102438

2. Dry eye statistics in 2023. Dry Eye Directory. 2024. Accessed May 27, 2025. https://dryeyedirectory.com/dry-eye-statistics/