This document discusses surgical treatments for dry eye disease (DED), including lacrimal occlusive devices and tarsorrhaphy. Punctal plugs are described as the most common lacrimal occlusive device used to reduce tear clearance by blocking the puncta. Absorbable plugs dissolve within days while non-absorbable silicone or acrylic plugs can last permanently. Complications include extrusion, granulation, and biofilm formation. Tarsorrhaphy involves suturing the eyelids together to reduce exposure and evaporation; it can be temporary or permanent. The document outlines different tarsorrhaphy techniques and potential complications such as trichiasis, granuloma, and

1. Surgeries for Dry Eye
Treatment:
Punctal Plug and
Tarsorrhaphy
Marjan Mazouchi MD,
Labbafinejad Medical Center, SBUM.

2. Overview
Introduction
Surgical Options for
DED
Lacrimal Occlusive
Devices
Tarsorrhaphy

3. The definition of DED by the TFOS DEWS 2:
Multifactorial disease:
Loss of homeostasis of the tear film,
Ocular symptoms,
Tear film instability,
Hyper-osmolarity,
Ocular surface inflammation and damage,
Neurosensory abnormalities.

5. Why We Should Treat
DED?
Mild and Severe DED
in QoL similar to Mild
Psoriasis and Moderate- Severe
Angina.

7. Surgical Options for DED
1- To reduce the tear clearance. (punctal/ canallicular occlusion)
2- To supply tear lake. (artificial tear reservoirs, surgery of the
salivatory gland)
3- To reduce the area of exposed. (tarsorrhaphy, induced ptosis)
4- To treat conditions associated with DED. (LSCT, AMT)

8. Lacrimal Occlusive Devices
• Punctal Plugs: Easily visible and removable without much difficulty.
• Canalicular Plugs:
Not visible,
Extrusion unlikely,
Increasing the risk of migration ,
Difficulty in localizing their position without ultrasound.

9. Punctal Plugs (PPs)
1-Semi-permanent
2-Dissolvable (Temporary)

10. Indications
Any condition that would benefit from aqueous retention on the ocular
surface, including:
• Dry eye stage 2, 3
• Symptomatic contact lens wear
• DED related to refractive surgery
• ADDE secondary to a variety of systemic diseases ( Sjogren ,GVHD,
Autoimmune diseases) / After control of ocular surface inflammation.

11. Indications
• Superior limbic keratoconjunctivitis (SLK)
• Any corneal irregularities or scarring that affect tear stability
• Lid palsy or lid closure abnormalities
• Toxic Epitheliopathy

12. Contraindications/ Controversy
• Allergy to any of the materials.
• Lacrimal outflow obstruction.
• Ectropion.
• Active ocular infection.
• Ocular surface inflammation. (pro-inflammatory
cytokines )
Inflammation should be treat prior to insertion of PPs.

13. Absorbable Devices
• “Test” devices.
• Collagen-based plugs, absorbs within 4 to 7 days.
At 4 c or under, Atelocollagen dissolves. It turns into a white colored gel at
body temperature.
• Certain polymer-based plugs last for 3 days to 6 months.

14. Non-Absorbable Devices
• Non-absorbable or “permanent” plugs are often silicone-based.
• Made of long-lasting materials : silicone, teflon, hydroxyethyl
methacrylate (HEMA), polycaprolactone (PCL) .

15. Characteristics of
Punctal Plugs
Effectiveness and to complications.
Head shaped like an umbrella.
Facilitates removal of the PP.
Slender neck
Cone-shaped thicker base.

16. The criteria for designing the PPs :
Purpose of application. (tear retention or drug delivery)
Required length of retention. (short-term or long-term)
Patient compliance.
Commercial value.

17. Types of PPs
1-Umbrella. Easy to spot and remove.
2-Slanted or low profile cap. Comfort, extra stability.
3-Tapered. Exerts extra force horizontally to keep the
PPs in place.

18. 4-Reservoir. Captures and holds tears, reduce FB
sensation and increase comfort.
5-Perforated PPs. Central lumen; in treating punctal
stenosis and partial occlusion.

20. Some PPs coated with a "slick"
surface for easier insertion.
Soft, pliable PPs increase
comfort and conform more
readily to the shape of the tear
drainage channels.

21. Older people benefit from soft PPs
with aging, tear drainage channels
enlarge and muscular lining less
elastic.
In this case, softer punctal plugs
are more likely to stay in place than
harder ones.

22. Canalicular Plugs
• Horizontal and Vertical / Temporary and Permanent.
• Temporary made of animal collagen and last for 4–14 days.
• Temporary extended/ Permanent last from 2 to 6 months. Made of different
materials such as glycolic acid with trimethylene carbonate, and polydioxanone
(PDS).
• The diameter of the plug is more important than its length.

28. Complications of Punctal Plugs
• Extrusion:
Hard PPs (silicone PPs) are more likely to dislodged and
fall out.
Hard PPs tend to trigger complications.
Even in soft PPs, complications occur if finishing of the
edge is not satisfactory or the figuration tends to
stimulate tissues.

29. • Granulation:
Granulation is the most frequently observed complication of PPs.
Large plug size was the major risk factor leading to granuloma formation.
mucosal dissection by the plug edges necrosed tissue
pyogenic granuloma PP extrusion

30. • Biofilm formation.
Punctal silicone plugs contaminated with microbes.
In more than 50% of cases, staphylococcus.
Acrylic plugs may portend a lower risk of infection than silicone plugs.
Carefully monitor these plugs.

31. Complications of Punctal and Intra-Canalicular Plugs

32. • Insoluble lacrimal canaliculus plugs associated with complications
such as infections (canaliculitis, dacryocystitis) and inflammations
• No serious complications associated with lacrimal canaliculus
collagen plugs.

33. PPs as Controlled Drug Delivery Implants
• PPs advantages :
• in loss of drug and/or formulation,
• in lacrimal drainage of drug,
• Patient compliance,
• in costs.
Latanoprost, Olopatadine, Cyclosporine-a

34. Punctal Cauterization
• Cautery,
• Diathermy ,
• Argon laser.
Today, disposable, hand-held thermal cautery is the most widely
used method.

36. • Very few complications with cauterization:
• Epiphora
• Recanalization
Superficial cauterization have a higher rate of recanalization, and
that deeper surgical procedures may increase the success rate.

37. Irreversible Obstrauction of the Lacrimal Punctum
or Canaliculs
By Surgery:
1- Suturing the lacrimal punctum
Removal of the punctal epithelium.
Diathermy and excision.
2- Suturing the canaliculus
3- Excision of the canaliculus
By Glue:
• Acrylate glue.
• Pressure over the lacrimal fossa.
• Can exert toxic effects.
• Complications: canaliculitis,
dacryolithiasis, dacryocystitis,
dilatation of a canaliculus

38. Punctal Occlusion with a Conjunctival Flap or Graft

40. Tarsorrhaphy
Ocular surface exposure,
Evaporation of the tear film
the traumatic effect of the moving lids on the healing epithelium.
Indications:
Persistent epithelial defects.
Severe dry eye that is refractory to medical Tx and punctal occlusion.
Exposure keratopathy.

41. There are four basic
types of tarsorrhaphy
• 1-Short-duration tarsorrhaphy
without sutures.
Tape, adhesive glue (lasts for a few
days), or Levator paralysis by
botulinum toxin injection.
• Induced Ptosis
1- Ptosis induced by botulinum toxin
* About 6-8 weeks
2- Ptosis induced by implantation of gold
weights
* Well tolerated.
* Complications: Displacement of the
implant and anterior bulging .

42. • 2-Temporary suture tarsorrhaphy, with or
without a bolster. (Blepharorrhaohy)
Various suture materials (e.g. Catgut, Silk,
Nylon, or Prolene) can be used. A suture
tarsorrhaphy may last up to 4 to 6 weeks.

43. 3-Permanent tarsorrhaphy:
Excising opposing lid margins so
they heal together and form a strong
adhesion.
Which can be opened later.

45. • 4-The most extensive type of tarsorrhaphy is mobilization of skin or tarsal
plate flaps:
Lids are split into anterior and posterior lamellae. Either lamella can be resected
in the upper or lower lid and filled with advancement of the opposite lamella.
The “tongue and groove” method , tarsal flap of one lid is inserted between the
lamellae of the other lid.
It is difficult to reverse these tarsorrhaphies at a later date.

48. Complications after Tarsorrhaphy
Localized trichiasis and distichiasis.
Pyogenic granuloma of the eyelid.
Lid margin deformities.
Focal cellulitis.
Premature separation.
Cheese-wiring of the sutures, skin breakdown.
Entropion after lysis of a permanent tarsorrhaphy.

49. Thank you for your patience