Punctal Plug Retention Rates for the Treatment of Moderate to Severe Dry Eye: A Randomized, Double-Masked, Controlled Clinical Trial


      To compare retention rates of Super Flex (Eagle Vision, Memphis, Tennessee, USA; Softplug-Oasis Medical Inc, Glendora, California, USA) vs Parasol (Odyssey Medical, Memphis, Tennessee, USA; Beaver Visitec International, Waltham, Massachusetts, USA) punctal plugs.


      Randomized, double-masked, interventional controlled clinical trial.


      Institutional study at Hotel Dieu Hospital (Queen's University) of 50 eyes, from patients with moderate to severe dry eye. Each eye from eligible patients was separately randomized to receive Super Flex or Parasol punctal plugs. The main outcome measure was plug retention at 6 months. Secondary outcome measures included objective tests of Schirmer I (mm), tear meniscus height (mm), tear break-up time (s), inferior fluorescein corneal staining (National Eye Institute [NEI] scale), and average lissamine green conjunctival staining (NEI scale).


      Punctal plug retention was significantly different at 6 months (P = .011). Sixty-eight percent of Parasol plugs were retained compared to 32% of Super Flex plugs. Parasol plugs required less frequent artificial tear use at 6 months (P = .024). There was a statistically significant improvement in all secondary outcome measures (Schirmer, tear meniscus height, tear break-up time, fluorescein corneal staining) at 6 months within plug groups except conjunctival staining. There were no additional significant differences between groups and no plug complications reported.


      Punctal plugs improve symptoms of moderate to severe dry eye; however, retention rates differ significantly. These data will allow us to guide patient decision making for the safe and effective treatment of punctal plugs for moderate to severe dry eye.
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        • Lemp M.A.
        Epidemiology and classification of dry eye.
        Adv Exp Med Biol. 1998; 438: 791-803
        • Kaido M.
        • Ishida R.
        • Dogru M.
        • Tsubota K.
        Visual function changes after punctal occlusion with the treatment of short BUT type of dry eye.
        Cornea. 2012; 31: 1009-1013
      1. The definition and classification of dry eye disease: report of the definition and classification subcommittee of the International Dry Eye WorkShop (2007).
        Ocul Surf. 2007; 5: 75-92
        • Friedman N.J.
        Impact of dry eye disease and treatment on quality of life.
        Curr Opin Ophthalmol. 2010; 21: 310-316
        • Baxter S.
        • Laibson P.
        Punctal plugs in the management of dry eyes.
        Ocul Surf. 2004; 2: 255-265
        • Jackson W.B.
        Management of dysfunctional tear syndrome: a Canadian consensus.
        Can J Ophthalmol. 2009; 44: 385-394
        • Balaram M.
        • Schaumberg D.A.
        • Dana M.R.
        Efficacy and tolerability outcomes after punctal occlusion with silicone plugs in dry eye syndrome.
        Am J Ophthalmol. 2001; 131: 30-36
        • Parikh N.B.
        • Francis J.H.
        • Latkany R.A.
        Retention rate of silicone punctal plugs placed by residents in a general clinic setting.
        Ophthal Plast Reconstr Surg. 2010; 26: 400-402
        • Kaido M.
        • Ishida R.
        • Dogru M.
        • Tsubota K.
        Comparison of retention rates and complications of 2 different types of silicon lacrimal punctal plugs in the treatment of dry eye disease.
        Am J Ophthalmol. 2013; 155 (Ar-653): 648
        • Sakamoto A.
        • Kitagawa K.
        • Tatami A.
        Efficacy and retention rate of two types of silicon punctal plugs in patients with and without Sjogren syndrome.
        Cornea. 2004; 144: 249-254
        • McCabe C.
        Punctal occlusion reduces dry eye symptoms and improves vision.
        Rev Ophthalmol. 2009; 16: 55-58
        • Carter K.D.
        • Nelson C.C.
        • Martonyi C.L.
        Size variation of the lacrimal punctum in adults.
        Ophthal Plast Reconstr Surg. 1988; 4: 231-233
        • Willis R.M.
        • Folberg R.
        • Krachmer J.H.
        • Holland J.E.
        The treatment of aqueous-deficient dry eye with removable punctal plugs.
        Ophthalmology. 1987; 94: 514-518
        • Cohen E.J.
        Punctal occlusion.
        Arch Ophthalmol. 1999; 117: 389-390