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PUNCTAL NASOLACRIMAL OCCLUSION
WORKSHOP
Walter Potaznick, OD
The New England College of Optometry
[email protected]
Punctal occlusion is an excellent treatment modality for those patients who suffer from moderate
to severe dry eyes. In severe cases when patients do not find symptomatic relief with artificial
tears or lubricants, then punctal occlusion should be considered.
This workshop is designed to get you thinking about incorporating this mode of treatment into
your practices, especially in those cases where artificial tears are not adequate.
The procedure is very easy to perform, its non-invasive, and can be done in a time efficient
manner.
The clinical examination must include: A comprehensive case history including asking about
symptoms and associated risk factors. Perform diagnostic tests to look at the quality and quantity
of tears. All findings MUST be documented for proper record keeping and for insurance
purposes.
Punctal Occlusion:
-Used to retain the patients own natural tears:
1. Temporary (using collagen plugs),
2. Semi-Permanent yet reversible (silicon or thermo-plastic plugs) or
3. Permanent
Indications For Punctal Occlusion:
- Aqueous deficient dry eye not adequately controlled with tear supplements
- May be beneficial for patients following eye surgery to reduce the complications of dry eye and
increase healing. Refractive surgery patients may benefit pre and postoperatively with the use of
punctal occlusion and possibly thereafter if necessary.
- To enhance the efficacy of topical ocular medications. (GL Therapy)
- To prevent drugs from entering the nasolacrimal system in susceptible patients. (Topical beta
blockers for cardiovascular disease)
Contraindications of Punctal and Lacrimal Occlusion:
- Acute or chronic dacryocystitis.
- Inflammation of the eyelids
- Entropion: conjunctival irritation
- Allergy to bovine collagen
- Allergy to silicone
I) Permanent Occlusion: Methods for permanently scarring the punctum and canaliculus may
be indicated when the patient’s predisposing condition is severe and chronic.
a. Thermal or electric cautery (simple, inexpensive, effective)
-can be painful
-can cause scaring
b. Laser punctal occlusion (Punctoplasty)
-Argon laser is not as efficacious as thermal or electric cautery
-can spontaneously re-open (20% or more)
-expensive: $1000 for argon laser
-Less scaring
c. Surgical repositioning of the punctum / lids
II. Temporarily Occlusion
- Collagen implants
- Diagnostic procedure
- The collagen implants remain in the eye for approximately 3-4 days or up to 90 days
(depending on the plug used) allowing the patient to evaluate the benefits of tear duct
closure. The plugs dissolve and wash away with the tears through the naso lacrimal
system.
- Increases corneal wetting by greatly reducing tear outflow
- 75% of all tears evaporate: The remaining 25%: 80% drain through the inferior
punctum and 20% through the superior punctum. If you occlude the inferior punctum
60% will drain through the superior punctum.
- Collagen Implants: Come in (five) diameters, 0.2, 0.3, 0.4, 0.5, 0.6mm and 1.6mm +
2.0mm lengths. The boxes contain 12 sterile packages with six plugs. The plugs are packaged in
a sterile lint-free foam holder. (0.3mm is the most common size
prescribed)
**NEW: Oasis Medical: Recently obtained FDA approval for their new “Soft Plug Extended
Duration”. Made to last in the canaliculus about 90 days instead of the current collagen which
last approximately 3-4 days. (Available in 0.2, 0.3, and 0.4mm sizes).
Surgical Specialties: 30 day extended soft collagen plug (.2, .3, .4mm)
PROCEDURE:
- First inspect the patient’s punctum to determine the size of the implant to be used as well as the
condition of the eyelids.
-AN ANESTHETIC IS USUALLY NOT INDICATED
- Open the sterile package and remove the plug with jeweler’s forceps. (can either be done
behind the slit-lamp or outside of the slit-lamp)
- If using the slit-lamp comfortably position the patient.
- If performing the procedure without the slit-lamp rest the patients head firmly against the
headrest.
- Pull the lower lid margin down and have the patient look up when inserting the
implant into the inferior punctum and down when inserting the superior punctum.
- Place the plug half way into the punctum and release the forceps.
-It may be necessary to pull laterally on the eyelid to straighten the angle between the vertical
and the horizontal canaliculus.
-Use one blade of the forceps to push the remainder of the implant into the punctum until it is out
of sight or just sitting at the edge of the punctum.
- Be sure to re-inspect all punctum following the procedure.
- For easier insertion the tip-end of the implant can be moistened with the tears before inserting
the plug
- Philosophy of inserting (inferior vs. one eye etc.)
- Should follow up with the patient in one or two weeks. If the patient reports an improvement
with symptoms then the use of the permanent silicone plugs should be considered.
3. Permanent (Yet Reversible): NON-Dissolvable Silicone Plugs
Punctal occlusion requires the practitioner to perform a couple of minor procedures
before inserting plug: Anesthetic, Sizing Gauge, and Dilate.
MATERIALS:
- Silicone plugs, punctal gauge, disposable dilator (or stainless steal), topical anesthetic
PACKAGING:
-Available in five sizes: 0.4-0.9mm diameters.
-Come on pre—loaded dilator/inserter instruments.
TYPES OF PLUGS
1. Ciba: Vision Tear Saver
2. EagleVision: Tapered ‘aft /Flow Controller/FlexPlug
3. FCI: “Ready Set” (slanted collarette) / Flow Controller: Recently introduced its new
Slimline Mini and the Slimline Petite. The design has a narrower and more pointed tip for
easier insertion. Can be inserted with little or no dilation. The slimline plugs does NOT
have the slanted collarette likes its other FCI plugs.
Plugs made of a clear, polished silicone surface.
4. Oasis: Soft Plug (model)
5. Odyssey Medical: Parasol Punctal Occluder (flexible self-adjusting nose and low- profile
dome for easy removal) **NEW**: Odyssey Medical: Introduced their new “Punctal
Occluder Shuttle Delivery System” Incorporates a reusable insertion device:
Cost saving solutions.
6. Lacrimedics: Herrick intracanalicular lacrimal plugs:
**NEW**: Opaque Herrick Lacrimal Plug: Easily viewed within the canaliculus by
transillumination of the eyelids. Can determine the plugs location, presence, or. absence (following removal techniques).
7. Sharpoint (Surgical Specialties Corporation): **NEW**: Made in 0.4mm-0.8mm.
8. **NEW** -Alcon The Tears Naturale PORT Punctal Ocduder: A solid thermosensitive
plastic material is delivered into the canaliculus via a battery-operated, handheld delivery
system. The solid is liquefied by the device. A pre-measured amount is injected into the
canaliculus. Once injected the liquid polymer solidifies and takes the shape of the
patient’s canaliculus. The plug may be visualized using retroillumination. The plug may
be removed either by using an oil-based ointment (Refresh PM or Tears Naturale PM)
along with a warm saline irrigation. Has been recently FDA approved but not to be
marketed by Alcon.
9. Mendenium: Smart Plug
PROCEDURE:
A) First inspect the punctum and lids
B) Anesthetize the punctum with a topical anesthetic. Saturate a cotton swab with .5%
proparacaine and place over the punctum for approximately one minute.
C) Punctal Gauging System: Consists of two instruments with a gauge on either end. (0.4mm,
0.5mm, 0.6mm, 0.7mm, 0.8mm, 0.9mm)
-The correct fitting of the gauge will seat the punctal ring around the neck portion of the
instrument, just beyond the gauge tip.
This will allow the practitioner to determine the exact size plug needed for occlusion.
DO NOT push the shank portion of the gauge too far into the punctum because it may overdilate the punctum.
* Too large: will offer a lot of resistance going in and out
* Too Small: will not offer any resistance
* Correct fit will moderately flex the punctal ring when both entering and exiting.
D) Dilate the punctum. Dilate the punctum prior to inserting the plug. Insert the dilator
approximately 2mm into vertical canaliculus and then 4-5mm into the horizontal canaliculus. (30
seconds)
- Insert the plug into the punctum using a slight downward rolling motion until the domed base
sits on the lid margin. The body of the plug will sit in the vertical canaliculus. if the plug seems
too small try another one. Do not force the plug. II the punctum constricts before you insert the
plug, re-dilate and insert is quicker the next time. (30 seconds)
-Once the plug is properly inserted, depress the release button.
-Inspect the plug following insertion
- The silicone plug can easily be removed. Just use a pair of forceps, gently grasp below
the dome of the plug and gently pull up along the plug axis.
- The plug should be easily viewed and apparent
Intra-canalicular Plugs (Lacrimedics mc)
- Less irritating to the patient than punctal plugs
- Difficult to know if the plug has been extruded
- Removed by irrigation and probing
- Educate patient about not rubbing lids too hard because it may dislodge plug.
- Some patients may need to continue using artificial tears following occlusion
- Minor discomfort is normal following the procedure for a few hours
REIMBURSEMENT
-Documentation of symptoms and signs’ as well as accurate coding are required in order too
obtain proper reimbursement from third party payers.
-Symptoms must be appropriate for the diagnosis of dry eye
-The time interval between the diagnostic procedure and treatment procedure is between 10 to 14
days
-Important to keep in mind that the requirements for the use of punctum plugs when treating dry
eye will vary according to insurance provider
-Probably best to ask your insurance carrier their preferences and protocols
-Many punctal plug companies have billing assistance services
Common Diagnostic Codes:
* 375.15: Tear Film Insufficiency
* 370.33: Keratoconjunctivitis Sicca
* 379.93: Eye Redness or discharge
* 379.91: Pain in or around eye
CPT Procedure Codes:
* 68761: Punctal Closure by Implant (10 day post-op waiting period)
* 68801: Dilation of lacrimal puncta
Supply Codes:
* A4263: Permanent Silicone Plugs - Medicare
* 99070: Miscellaneous Supply code
Modifiers:
* 50: Bilateral
* 51: Additional Procedure
* 25: Significant Separately identifiable: Used with other Exam Code, not Procedure Code i.e.
99012, 99213, 99212
- Depending on your location E code modifiers are used or RT / LT may be used
Necessary Testing and Documentation:
* History
* Examination
* Treatment
CONCLUSION:
Dry eye is a common problem that can be frustrating for both the provider and patient. Accurate
diagnosis and treatment will help to maintain the quality of life for these individuals. Punctal
occlusion is a viable management and treatment option that is easy, non-invasive, and can be
done very efficiently in the office. Patients should be followed up periodically to ensure the
effectiveness of the treatment and should be asked to seek evaluation should the onset of
symptoms recur.
Acknowledgements: My thanks to Dr. David Lampariello and Dr. Clifford Scott for their
significant help in developing this outline and fine tuning of the workshops themselves