Punctal plugs, also known as punctum plugs, lacrimal plugs, or occluders, are a method of treating dry eyes. Punctal plugs can relieve dry eye symptoms when eye drops or ointments fail. Punctal plugs are placed in the opening of the tear duct, reducing the natural drainage of tears and keeping the eyes moist. Punctal plugs can be a temporary or permanent solution to dry eyes.
Typically, a temporary or dissolvable punctal plug is implanted in the lower drainage channel of the eye, which is responsible for most of the eye’s tear drainage. These temporary plugs will usually last a few days to several months. If there is a successful response to the temporary punctal plug, a more permanent punctal plug is implanted or punctual cautery applied.
Punctal plugs come in a few different shapes and sizes, and are no larger than a grain of rice. The plug may be placed in the lower or upper eyelid or both eyelids. Implantation takes only a few seconds in a physician’s office.
Tear Duct Probing, Irrigation, Intubation
A nasolacrimal duct obstruction, more commonly known as a tear duct obstruction, is a common condition that affects infants and is present at birth. Tears usually drain through small openings in the corners of the eyelids, known as puncta, and enter the nose through the nasolacrimal duct. When an obstruction exists, tears cannot properly drain from the eyes and may well up on the surface of the eye and overflow on the eyelashes and eyelids. The eyelids may also become red and swollen with yellow or green discharge. This pathology in children is usually different than that in adults.
While most cases of tear duct obstructions clear on their own during the first year of life, certain measures can be taken to ensure that the eye is kept clean and free of infection, such as a tear duct massage performed three times a day or antibiotic eye drops to relieve discharge. If an obstruction does not clear up by the time the child is a year old, a minimally invasive procedure using a probe to relieve the obstruction may be used. This procedure involves passing a soft probe through the tear duct and into the nose to open any obstruction within the path. The procedure takes about 10 minutes to perform.
Adults may also benefit from the probing procedure, however some cases may need to be treated with surgery to clear the obstruction of the duct.
If tear blockage cannot be effectively treated through conservative methods, surgery will likely be recommended. A procedure known as dacryocystorhynostomy or dacryocystorhinostomy (DCR) will be performed to construct a new tear drain. This type of surgery is usually performed as an outpatient procedure, either using local anesthesia and sedation or general anesthesia. Given the difference in cause, this is usually the treatment for tear duct obstruction in adults, as opposed to the probing and irrigation noted above for children.
With the traditional external form of this surgery, the doctor would make an incision on the side of the nose and create an opening between the tear drainage system and the nose. With the endoscopic approach, this procedure is formed without the skin incision. The surgeon uses an endoscope -a thin, flexible, lighted tube with a microscopic camera on the end. The camera helps the doctor guide other tiny instruments used in the procedure, through the nasal opening to access the tear duct area this way.
A new tear drain opening is then created, providing a fresh route between the eyes and nose avoiding the obstruction. A tiny stent (silicone tube) may be placed in the new tear drain and kept there for several months after the procedure ensuring the duct will remain open. In cases in which the tear drain blockage cannot be cleared, a small drain, known as a Jones tube, may need to be inserted in the area. This offers a permanent solution to keeping the tear duct clear.
Canalicular Reconstruction & Repair
Canalicular lacerations are breaks in the normal tear duct drainage system, which originates with the puncta, which acts as a conduit for tears to travel from the eyelid through the nasolacrimal sac into the nose. This type of injury often results from blunt or sharp trauma.
If there is obvious damage, surgery is usually more effective within 48 hours of the injury, once the surrounding tissue swelling has healed. The surgical technique used for canalicular reconstruction and repair will depend on the extent of the patient’s injuries, and may be performed under local or general anesthesia.
Balloon Dacryoplasty, also known as balloon dacryocystoplasty, is a surgical procedure that opens a blocked tear duct without making an incision in the nose or face. During the procedure, a thin wire will be inserted through the hole in the corner of the eye, through which tears drain. The wire, which contains a tiny, deflated balloon, is then threaded through to the obstructed area, and the balloon is inflated with a liquid. The pressure of the balloon will open and expand the blocked duct. The balloon will next be deflated, and removed, along with the wire. The procedure is usually performed under deep conscious sedation or general anesthesia in the operating room. As with most operations, antibiotics will be taken for several days after this procedure, in order to prevent infection.
Lacrimal Gland Plication
The Lacrimal Gland is a small, almond-shaped structure, which produces tears and is located just above the upper, outer corner of the eye. The lacrimal gland helps keep the surface of the eye lubricated, and moistened. Excess tears will drain into the small ducts, which empty into the nasal cavity.
If the lacrimal gland protrudes, the condition is usually a result of inflammatory disease, such as sarcoidosis. Symptoms of lacrimal gland dysfunction may include dry eye syndrome. Plication is a surgery which repositions the lacrimal gland, so that tears will be more effectively produced and swelling/protrusion limited.
Lacrimal Gland Biopsy
A Lacrimal Gland Biopsy may be performed if a lacrimal gland growth or enlargement is noted, to rule out malignancies and provide a diagnosis allowing for treatment. Symptoms of lacrimal gland tumors may include eyelid swelling that lasts for several months or pain in this area. A biopsy is usually conducted based on radiographic tests, which will indicate the size of the tumor in the area.
An incisional biopsy, which removes a sample of the growth inside the gland, may be performed if it cannot be determined if the tumor is benign or malignant. Following an incisional biopsy, the specimen will be examined by an attending pathologist. If the tumor is found to be malignant or worrisome the entire gland may be removed.