Ophthalmology (2001) 108: 1835-1837
© 2001 American Academy of
Ophthalmology
Iatrogenic complications related to the use of herrick lacrimal plugs
William L. White, MD1, George
B. Bartley, MD2, Michael J. Hawes,
MD3, John V. Linberg, MD4 and
David B. Leventer, MD4
1 The Eye Foundation, Department of Ophthalmology,
University of Missouri Kansas City, Kansas City, Missouri
2
Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
3
Department of Ophthalmology, University of Colorado Health Sciences Center,
Denver, Colorado
4 Department of Ophthalmology, West Virginia
University, Morgantown, West Virginia
Reprint requests to William L. White, MD, 1004 Carondelet,
Suite 405, Kansas City, MO, 64114
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Abstract |
PURPOSE:
To report a series of lacrimal complications associated with a
specific type of lacrimal plug (Herrick Lacrimal Plug; Lacrimedics
Incorporated, Rialto, CA.)
DESIGN: Retrospective, noncomparative case series and survey.
METHODS: Members of the American Society of Ophthalmic Plastic and
Reconstructive Surgery were asked to submit personally treated cases
of patients referred for treatment of complications after placement
of a Herrick Lacrimal Plug.
MAIN OUTCOME MEASURES: Failure of the device to be removed by simple lacrimal
irrigation.
RESULTS: The clinical courses of 41 patients were analyzed. Patients
ranged in age from 19 to 81 years, and all had symptomatic epiphora
related to the presence of the lacrimal plug. Several interventions
were used to treat lacrimal obstruction. Nasolacrimal duct probing
with irrigation was used in 15 lacrimal systems, whereas six
systems were probed and subsequently stented with silicone tubing.
Eyelid margin cutdown was used in eight cases. Balloon dacryoplasty
was performed in three systems, dacryocystorhinostomy in 18
instances, and conjunctivodacryocystorhinostomy in two patients.
CONCLUSIONS: The Herrick lacrimal occlusion device sometimes cannot be
removed by simple irrigation and is capable of inducing permanent,
irreversible, symptomatic lacrimal drainage system obstruction.
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Introduction |
Punctal or
canalicular occlusion is commonly performed to treat patients with
dry eyes.1–3
There are at least three commonly used methods of achieving punctal
occlusion: tamponade, cautery, and surgery.2
Within each such category are several options. Reversibility is a
desirable attribute, if not an absolute requirement, for all types of
lacrimal occlusion in the treatment of dry eye patients. Placement of
removable silicone plugs is one of the more commonly used methods of
achieving punctal occlusion by tamponade.
There are two general styles of plugs used to occlude the punctum
or canaliculus. One variety is shaped like an arrow or umbrella
and is placed into the vertical portion of the canaliculus (the
ampulla). It has a collar or ring on the top of the plug with a
narrow neck or midsection. The punctal ring usually constricts around
the neck to hold the plug in position. The collar also facilitates
retrograde plug removal if necessary and decreases the risk of the
plug migrating into the lacrimal drainage system. The other plug
type, shaped like a fluted funnel or golf tee, is designed to be
placed in the horizontal portion of the canaliculus. These plugs
theoretically are removable in an antegrade fashion by lacrimal
irrigation.4
Complications related to the use of punctal plugs previously have
been reported to include difficulty in removal of the plugs and
permanent nasolacrimal occlusions.5–7
We have observed what appears to be a disproportionate number of
complications related to one specific collarless intracanalicular
plug (Herrick Lacrimal Plug; Lacrimedics Incorporated, Rialto,
CA).
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Patients and methods |
After
several members of the American Society of Ophthalmic Plastic and
Reconstructive Surgery requested assistance in treating patients who
incurred complete symptomatic nasolacrimal duct obstruction after
placement of Herrick Lacrimal Plugs, all members of the American
Society of Ophthalmic Plastic and Reconstructive Surgery e-mail
discussion group were queried as to whether they had treated any
similar cases. When multiple members responded that they had indeed
seen and treated such patients, concern arose within the group about
the overall safety of using the device in question. A datasheet was
developed and case reports were solicited from the group. The
collective data are presented in Table
1.
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Results |
Forty-one
patients had sufficient data submitted to be included for analysis.
Unless the patient had onset of bilateral simultaneous obstructive
symptoms, only the first eye presenting with symptoms was included.
All patients had been referred for treatment of infection or
epiphora, so data regarding age at onset of dry eye and treatment
before placement of plugs were generally unavailable.
Thirty-two of the patients (78%) were female. The average age was
52 years (range, 19–81 years). Time after plug placement to onset of
epiphora varied considerably, ranging from immediately after plug
placement to 48 months later. One patient experienced a cutaneous
fistula from the horizontal canaliculus. Various surgical approaches
were used by individual surgeons to treat induced lacrimal drainage
obstructions. Dacryocystorhinostomy with silicone intubation was the
most common procedure performed. Five patients (12%) remain
symptomatic and have declined surgery.
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Discussion |
Previous
authors have noted numerous problems associated with the use of
punctal plugs. We believe that our observations are noteworthy
because all of the complications occurred with one type of plug. The
collarless Herrick intracanalicular plugs are easier to place in the
lacrimal system than the collared varieties. We cannot estimate
either the number of Herrick plugs that are implanted annually or the
frequency of complications that require surgical intervention, but we
believe that the Herrick plugs are associated with a higher frequency
and severity of complications than those with collars.
A collared punctal plug is designed to be removable by extracting
it from the punctum in the reverse manner from which it was
placed. Fracture of such plugs during attempted removal has
been reported, as has spontaneous dislodgement of the plug distally
into the lacrimal system.6–9
Thus, no punctum plug is without some risk to the lacrimal system,
potentially requiring surgical intervention.
Collarless intracanalicular plugs, such as the Herrick design,
typically cannot be removed in a retrograde fashion without
surgically opening the punctum and canaliculus. Although collarless
plugs theoretically can be flushed downstream through the
nasolacrimal duct by lacrimal irrigation, the plug usually is not
recovered from the nose. Thus, successful removal cannot be
objectively documented.
The ultimate position of a collarless plug may be anywhere in the
lacrimal system, including the canaliculus, the common canaliculus,
the nasolacrimal sac, or the nasolacrimal duct. Observations of
pyogenic granulomas related to intracanalicular plugs indicate that,
at least in some patients, the plugs are associated with an
inflammatory process that can disrupt normal cellular functions,
leading to fibrosis and reactive masses.10
We hypothesize that in some patients the collarless plug facilitates
the overgrowth of bacteria and a chronic canaliculitis that can
result in canalicular obstruction. Alternatively, the plug may erode
through the canalicular mucosa, resulting in synechia, symptomatic
lacrimal stenosis, or even formation of a cutaneous fistula.
In each of the cases described herein, the surgeon correcting the
lacrimal problem was not the individual who placed the device. When a
seemingly routine office procedure results in a complication that
requires surgical correction, patients understandably are unhappy.
Some of the patients whom we and our colleagues have treated believed
that the device and its implantation were misrepresented with respect
to safety, reversibility, and the potential need for reparative
surgery.
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Footnotes |
Supported in part by an
unrestricted grant from Research to Prevent Blindness, Inc., New
York, New York.
None of the authors has any financial
interest in any of the products or devices mentioned in the
article.
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References |
- Giovagnoli D., Graham S.J. Inferior punctal occlusion with
removable silicone punctal plugs in the treatment of dry-eye related contact
lens discomfort. J Am Optometric Assoc 1992;63:481-485.
- Murube J., Murube E. Treatment of dry eye by blocking the lacrimal
canaliculi. Surv Ophthalmol 1996;40:463-480.[Medline]
- Beisel J.G. Treatment of dry eye with punctal plugs. Optom Clin
1991;1:103-117.
- Herrick R.S. A subjective approach to the treatment of dry eye
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Syndromes. New York: Plenum Press, 1994:571-576.
- Soparkar C.N.S., Patrinely J.R., Hunts J., et al. The perils of
permanent punctal plugs. Am J Ophthalmol 1997;123:120-121.[Medline]
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migration resulting in dacryocystitis and canaliculitis. Cornea
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- Maguire L.J., Bartley G.B. Complications associated with the new
smaller size Freeman punctal plug. Arch Ophthalmol 1989;107:961-962.[Medline]
- White W.L., Glover A.T. Difficulty in removal of silicone punctum
plugs. Ophthalmic Surg 1989;20:523.
- Levenson J.E., Hofbaver J. Problems with punctal plugs. Arch
Ophthalmol 1989;107:493-494.
- Rapoza P.A., Ruddart M.S. Pyogenic granuloma as a complication of
silicone punctal plugs. Am J Ophthalmol 1992;113:454-455.[Medline]
Received for publication February 20, 2001. Accepted for publication
May 1, 2001.
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Abstract
Introduction
