Punctal plugs are tiny, silicone or collagen based devices that are inserted into the tear ducts to help retain moisture on the eye’s surface. For patients with moderate to severe dry eye disease (especially those with aqueous-deficient dry eye), punctal plugs can offer significant relief. But despite their widespread use, this treatment isn’t without debate. Here’s what you need to know.
The Pros
Generally speaking, punctal plug insertion can be a quick, cost-effective, and minimally invasive procedure to help retain the tears on the eye's surface. There are a few different plug options available, but dissolvable temporary plugs are usually recommended to start with, and then moving to permanent plugs if a positive outcome is achieved.
1. Increased Tear Retention
By simply and physically blocking tear drainage, punctal plugs help to preserve both natural and artificial tears, improving ocular lubrication and comfort. They can also help to lengthen the effect of any other ocular surface treatments that your doctor prescribes or recommends.
2. Non-Surgical and Reversible
Insertion is quick and can be done in-office. Most plugs can be easily removed if needed.
3. Effective for Moderate to Severe Dry Eye
Studies show punctal plugs can improve tear breakup time, ocular surface health, and patient-reported symptoms when other treatments fail.
4. Variety of Options
Temporary and permanent plug options offer flexibility based on patient needs and tolerance.
The Cons
Any eye procedure, even quick and minimally invasive ones, come with some amount of risk. The risk level with a punctal plug insertion is still relatively low, and with the availability of temporary dissolvable plugs for a trial, there are not many adverse events seen with them in practice. However, here are the few cons concerning punctal plugs that you should know about.
1. Risk of Epiphora (Excessive Tearing)
Over-retention of tears can lead to chronic eye watering, especially if tear quality is very poor. Other eye conditions and diseases could still occur thereafter, causing more inflammation and watering - and with blocked tear drainage, this could be more excessive than normal.
2. Potential for Inflammation
Inflammation is a key component in the vicious circle of worsening dry eye disease. Trapping inflammatory markers or poor-quality tears on the eye's surface may actually worsen symptoms for some patients. This is another reason that the temporary plug trial is done prior to inserting any permanent plugs.
3. Plug Displacement or Loss
Plugs may fall out spontaneously, requiring replacement. Intracanalicular plugs, while potentially longer-lasting, may need surgical removal if complications arise.
4. Limited Long-Term Evidence
While short-term benefits are documented, systematic reviews highlight a lack of high-quality, long-term studies comparing plug types and outcomes.
The Controversy
The main debate centers on when and for whom punctal plugs are appropriate. Some dry eye specialists caution against early use, especially in patients with active inflammation or poor tear quality. Trapping “unhealthy” tears can exacerbate symptoms rather than relieve them. Experts recommend ensuring tear health—often through anti-inflammatory drops or eyelid hygiene—before considering occlusion.
Conclusions
Punctal plugs can be a valuable tool in the assortment of dry eye treatment options, particularly for patients with moderate to severe dry eye who haven’t responded to other therapies. However, proper diagnosis and patient selection are critical. If you're considering punctal plugs, consult with your optometrist to determine whether your tear quality and ocular surface health are suitable for this intervention. Consider temporary plugs before opting for permanent and always follow-up with your eye doctor if your symptoms do not resolve or if they worsen after your treatment.
References:
- Chen, Kai-Yang, Hoi-Chun Chan, and Chi-Ming Chan. "How effective and safe are punctal plugs in treating dry eye disease? A systematic review and meta-analysis." Contact Lens and Anterior Eye (2025): 102438.
- Lee, Jong-Ha, and Byung Yi Ko. "Efficacy, retention, and complications of two types of silicone punctal plugs in dry eye patients." Journal of the Korean Ophthalmological Society62.6 (2021): 754-761.
- Ervin, Ann-Margret, Andrew Law, and Andrew D. Pucker. "Punctal occlusion for dry eye syndrome: summary of a Cochrane systematic review." British Journal of Ophthalmology 103.3 (2019): 301-306.
- Song, Jong Suk, et al. "Five misconceptions related to punctal plugs in dry eye management." Cornea 37 (2018): S58-S61.
- Tong, Louis, et al. "Effects of punctal occlusion on clinical signs and symptoms and on tear cytokine levels in patients with dry eye." The ocular surface 14.2 (2016): 233-241.
- Said, Azza Mohamed Ahmed, et al. "Corneal sensitivity, ocular surface health and tear film stability after punctal plug therapy of aqueous deficient dry eye." International journal of ophthalmology 9.11 (2016): 1598.
Contributors:
Sarah Farrag, OD
Dr. Sarah Farrag is originally from Halifax, Nova Scotia, and is happy to be practicing optometry in her hometown. She graduated with honors from the University of Waterloo Doctor of Optometry program in June 2015. In addition to routine optometric care, Dr. Farrag also facilitates an advanced dry eye clinic offering specialty consultation and treatment for severe dry eye.
