Punctal Plugs

By Dr. Abdalrahman Alabsi – Ophthalmologist | Last reviewed: October 2026

​

Punctal Plugs (Tear Duct Plugs)

​

The lacrimal drainage system

Tears collect from the ocular surface at the inner (nasal) corners of the eyelids and reach the small tear-duct openings in the corners of the upper and lower eyelids (the puncta). From there they pass into the canaliculi, which join to drain into the lacrimal sac, and finally into the lower nasal cavity through the nasolacrimal duct.

​

Punctal and canalicular plugs work by partially or completely closing the tear drainage pathway, allowing natural tears and eye drops to stay on the ocular surface longer.

​

Where can punctal plugs be placed?

Plugs used to close the tear drainage openings are classified by placement as follows:

​

Punctal plugs: placed at the opening of the tear drainage duct, with the conical tip inside and the wide cap resting on the surface so its edges remain visible at the opening, where it can be seen and easily removed when needed. However, these plugs can be lost or fall out.

​

Canalicular plugs: placed deep inside the canaliculi (the small tear drainage channels). They are cylindrical with a flared end for anchoring and cannot be seen from outside. They are less likely to come out but more likely than punctal plugs to migrate within the tear drainage system.

​

What types of tear duct plugs are there, and how long do they last?

​

1. Temporary / absorbable plugs

Made of natural collagen or other biopolymers. They are often used as a trial before placing permanent plugs to avoid excessive tearing, or temporarily after refractive surgery (surface laser techniques such as PRK and TransPRK, and LASIK, FemtoLASIK, and Femto SMILE).

​

How long they last:

Short-acting: dissolve within a short period of 1 to 3 weeks.

Long-acting: dissolve over a longer period of 3 to 6 months.

​

2. Semi-permanent and permanent plugs

Made of medical-grade silicone, acrylic, or hydrogel. They can last for years because they do not dissolve, and they are removed by the doctor when needed.

Duration: they can last for years without dissolving and are removed only by the doctor when needed.

​

What are drug-eluting plugs?

These are special punctal plugs that can carry specific doses of medication, which are released slowly onto the ocular surface.

Systems are currently available that release steroidal anti-inflammatory drugs (corticosteroids) such as dexamethasone, and glaucoma medications (such as bimatoprost) to lower eye pressure continuously over weeks or months.

​

Reasons for using punctal plugs:

Dry eye syndrome: especially aqueous-deficient dry eye, including dry eye caused by chronic autoimmune diseases (such as Sjögren's syndrome, systemic lupus erythematosus, and rheumatoid arthritis), environmental factors, or systemic diseases at the neurovascular stage, as in diabetes.

After refractive surgery: to protect the ocular surface and speed up corneal healing after refractive surgery (surface laser techniques such as PRK and TransPRK, and LASIK, FemtoLASIK, and Femto SMILE).

Increasing the effectiveness of topical medications: by keeping drops on the ocular surface longer, which reduces drainage, increases effectiveness, and reduces how often they need to be used.

​

* Perforated plugs are available for other indications, such as acquired punctal stenosis (narrowing of the tear drainage opening).

​

How punctal plugs are placed:

Measuring the punctal opening: the diameter of the tear drainage opening is determined with a special gauge to find the exact size.

Dilating the punctal opening: a punctal dilator supplied with the plug inserter is used to prepare the opening to receive the plug.

Inserting the plug: the plug is inserted using a dedicated inserter matched to the previous measurements and is released once it is properly positioned.

​

How punctal plugs are removed:

Depending on their position:

Surface plugs (silicone plugs): easily pulled out in the clinic by the doctor using medical forceps.

Deeper plugs: can be flushed out with saline irrigation of the tear duct so that they pass toward the nose or throat; in some complex cases, surgical intervention may be needed.

​

Possible complications of punctal plugs:

Although punctal plugs are very safe, they may cause some side effects:

Foreign body sensation: felt as itching or irritation in the corner of the eye (it usually eases or disappears as you get used to it).

Excessive tearing (epiphora): if complete closure causes tears to accumulate without draining (watery eyes).

Partial or complete extrusion of the plug: may happen due to vigorous eye rubbing.

Plug migration: occurs when plugs move deeper into the lacrimal sac.

Tear duct infections.

Corneal surface scratches: caused by a plug that does not fit the punctal opening properly and protrudes.

​

References

1. Ervin AM, Law A, Pucker AD. Punctal occlusion for dry eye syndrome. Cochrane Database Syst Rev. 2017;6(6):CD006775. doi:10.1002/14651858.CD006775.pub3

2. Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017;15(3):575-628. doi:10.1016/j.jtos.2017.05.006

3. Jones L, Craig JP, Markoulli M, et al. TFOS DEWS III: Management and Therapy. Am J Ophthalmol. 2025;279:289-386. doi:10.1016/j.ajo.2025.05.039