Complications of intracanalicular plugs: a case series

Lacrimal Canaliculitis: A Major Review

Lacrimal canaliculitis is an inflammation of the proximal lacrimal drainage system. It classically presents with symptoms of redness, mucopurulent discharge, medial canthal swelling, epiphora, and pouting punctum. Despite having classical clinical characteristics it is frequently misdiagnosed. The cause can be primarily due to various infectious agents or secondary mostly due to the use of punctal plugs. There are no universally accepted guidelines for the management of canaliculitis but different medical and surgical options have been employed with varying success rates and it is notorious for recurrences and failure to therapy. The present review summarizes the existing literature on lacrimal canaliculitis published over the past 15 years to provide an overview of this uncommon condition. A total of 100 articles published in the literature were anlaysed during this period. The mean age at diagnosis was 57.09 ± 16.91 years with a female preponderance. Misdiagnosis was common with many patients misdiagnosed as conjunctivitis and dacryocystitis. Primary canaliculitis was found to be more frequent than secondary with inferior canaliculus involved more commonly than the superior. Staphylococcus, Streptococcus, and Actinomyces were the most common microbes isolated. Surgical management was employed in 74.25% of cases while medical management was done in 20.82% of cases. The review presents an insight into the complexities of canaliculitis, its diagnosis, and management which will further help to improve the understanding of this uncommon infection of the lacrimal system.

Immediate and Delayed Effects of Punctal Plug Insertion on Tear Meniscus Height in Severe Aqueous-Deficient Dry Eye

PURPOSE

The aim of this study was to assess the immediate and delayed effects of tear punctal occlusion with punctal plugs on tear meniscus height (TMH) in severe aqueous-deficient dry eye (ADDE) disease.

METHODS

Consecutive patients with severe ADDE related to Sjögren syndrome or ocular graft-versus-host disease underwent inferior and superior occlusion with punctal plugs. TMH was measured using the LacryDiag ocular surface analyzer platform before, 10 minutes, and at least 1 month after punctal occlusion. The corneal fluorescein staining (CFS) score was graded with the Oxford scale (from 0 to 5). Ocular symptoms were graded with a visual analog scale (from 1 to 10).

RESULTS

We included 24 eyes of 24 patients (mean age 61 ± 9 years; mean follow-up 7 ± 5 months). The mean TMH was 0.19 ± 0.06 mm at baseline and increased significantly to 0.41 ± 0.13 mm (P < 0.001) and 0.46 ± 0.17 mm (P < 0.001) at 10 minutes after punctal plug insertion and at the end of follow-up, respectively. The median CFS score decreased from 3 ± 1 before plug insertion to 1 ± 2 at the end of follow-up (P < 0.001). Many patients (67%; n = 16) reported subjective improvement of symptoms. TMH was negatively correlated with the CFS score and visual analog scale score assessing symptoms.

CONCLUSIONS

Upper and lower punctal occlusion increased TMH in patients with severe ADDE as soon as 10 minutes after plug insertion. TMH remained stable over time, which led to the relief of symptoms and reduced corneal staining.

Plug-related canaliculitis: a rare or underdiagnosed disease?

CLINICAL RELEVANCE

Conjunctivitis, chalazion and blepharitis are routinely managed by optometrists. However, it is especially important to consider the diagnosis of canaliculitis in patients with chronic or recurrent conditions.

BACKGROUND

This study aimed to report the clinical features, radiological findings and treatment outcomes in patients with plug-related canaliculitis.

METHODS

This retrospective study included patients with canaliculitis secondary to plug insertion between 2007 and 2020. All data regarding epidemiological characteristics, clinical presentation, isolated microorganisms, computed tomography imaging findings, treatment, and outcomes were analysed.

RESULTS

A total of 20 plug-related canaliculitis from 19 patients (18.3%) among all 109 cases of canaliculitis were identified. All patients with plug-related canaliculitis were females with a past history of lacrimal plug insertion for dry eye (mean age: 58.2 years). Most patients were initially treated as conjunctivitis with the mean time lapse to a diagnosis of 5.2 months. The average time from plug insertion to onset of symptoms was 5.1 years. Eighteen patients underwent canaliculotomy, and one patient received lacrimal irrigation. Plugs were identified in 18 cases, with SmartPlug in 13 cases (72%), followed by EaglePlugTM (two cases), Herrick Lacrimal Plug (two cases), and migrated FCI Painless Plug (1 case). Cultures of discharge, concretions, and/or infected plugs mostly revealed Pseudomonas aeruginosa (42%). Orbital computed tomography in four cases with SmartPlug revealed central radiolucency with surrounding soft-tissue enhancement. No recurrent canaliculitis was observed throughout a mean follow-up period of 13.7 months. No patient needed re-plugging after canaliculotomy and plug removal, with only one required additional lubricants for recurrent dry eye.

CONCLUSION

Plug-related canaliculitis is often underdiagnosed due to late onset and similar symptoms to common ocular diseases. Awareness of plug insertion history as well as meticulous removal of the plug, concretion and/or granulation tissue is important for early diagnosis and to ensure a good outcome.

Oculoplastic aspects of ocular surface disease and their management

The normal structure and function of the eyelids, eyelashes, conjunctival fornices, and lacrimal system are essential for the health of the ocular surface, and abnormalities of these structures accompany many cases of ocular surface disease. We describe the role of oculoplastic intervention in the context of ocular surface disease, focusing on blink disorders, lagophthalmos, entropion, lid scarring and keratinization, trichiasis, and punctal and lacrimal sac disease.

Comprehensive Review of the Literature on Existing Punctal Plugs for the Management of Dry Eye Disease

Numerous designs of punctal and canalicular plugs are available on the market. This variety presents challenges to ophthalmologists when choosing punctal plugs for the management of various ocular conditions. The aim of this literature review is to provide a classification system for lacrimal occlusive devices based on their location and duration of action as well as to identify different characteristics of each one of them. We want to give a comprehensive overview on punctal and canalicular plugs including their manufacturing companies, indications, and complications that have been reported in various articles. PubMed and Google Scholar were used to identify articles written in English as well as few articles written in Japanese, Chinese, Slovak, and Spanish that had abstracts in English. Nine different companies that manufacture punctal and canalicular plugs were identified and their plugs were included in this review. Punctal and canalicular plugs are used in the management of various ocular conditions including dry eye disease and punctal stenosis as well as in ocular drug delivery. Although they are a relatively safe option, associated complications have been reported in the literature such as infection, allergic reaction, extrusion, and migration.

Clinical features, microbiological profiles and treatment outcome of lacrimal plug-related canaliculitis compared with those of primary canaliculitis

AIMS

To compare the clinical features and treatment outcome between lacrimal plug-related canaliculitis and primary canaliculitis.

METHODS

Patients with plug-related canaliculitis and primary canaliculitis between 2007 and 2014 in a medical centre were collected. Charts were reviewed for clinical features, microbiological profiles, time lapse between plug insertion and symptom onset, type of plug and outcomes.

RESULTS

Of 76 eligible cases collected, 13 were plug-related canaliculitis and 63 were primary canaliculitis. The most common presenting symptom was discharge in both groups (85% and 79%, respectively). The average time interval from plug insertion to symptoms onset was 5.5 years. Most canaliculitis developed in women, especially for plug-related canaliculitis, when compared with primary canaliculitis (100% vs 65.1%; p=0.015). The most common isolated microorganism was Pseudomonas aeruginosa in plug-related canaliculitis (46%) and Streptococcus in primary canaliculitis (28%), respectively. Isolation of Pseudomonas was significantly higher in plug-related canaliculitis than in primary canaliculitis (46% vs 12%; p=0.029). Most plug-related canaliculitis resolved after removal of plugs by canaliculotomy (12 cases, 93%). Most identified plug was SmartPlug (seven cases), followed by EaglePlug (two cases) and Herrick Lacrimal Plug (two cases). There was no recurrence in patients with plug-related canaliculitis, however, recurrence developed in seven patients (11%) with primary canaliculitis.

CONCLUSIONS

In comparison with primary canaliculitis, plug-related canaliculitis appear to be more prevalent in women and show a different microbiological profile. Retrieval of infected plug by canaliculotomy and adequate antibiotics can achieve a good outcome. Long-term follow-up is required because canaliculitis may develop several years after plug insertion.

Biofilms in infections of the eye

The ability to form biofilms in a variety of environments is a common trait of bacteria, and may represent one of the earliest defenses against predation. Biofilms are multicellular communities usually held together by a polymeric matrix, ranging from capsular material to cell lysate. In a structure that imposes diffusion limits, environmental microgradients arise to which individual bacteria adapt their physiologies, resulting in the gamut of physiological diversity. Additionally, the proximity of cells within the biofilm creates the opportunity for coordinated behaviors through cell–cell communication using diffusible signals, the most well documented being quorum sensing. Biofilms form on abiotic or biotic surfaces, and because of that are associated with a large proportion of human infections. Biofilm formation imposes a limitation on the uses and design of ocular devices, such as intraocular lenses, posterior contact lenses, scleral buckles, conjunctival plugs, lacrimal intubation devices and orbital implants. In the absence of abiotic materials, biofilms have been observed on the capsule, and in the corneal stroma. As the evidence for the involvement of microbial biofilms in many ocular infections has become compelling, developing new strategies to prevent their formation or to eradicate them at the site of infection, has become a priority.

A review of the complications of lacrimal occlusion with punctal and canalicular plugs

Punctal and canalicular plugs are widely used for both temporary and permanent occlusion of the lacrimal puncta in dry eyes. There are many designs and materials available on the market. While their efficacy in improving dry eye symptoms is widely proven, the gamut of complications associated with these devices have never been subject to a general review, although there are numerous case series in the literature associated with one particular device. This review aims to examine the track record of a variety of plugs currently in use, to review the management of complications, and propose strategies for both the prevention of these complications and their treatment.