title: Lodged intracanalicular plugs as a cause of lacrimal obstruction.
abstract: OBJECTIVE
  To evaluate the complications and success of treatment of migrated or lodged intracanalicular and punctal plugs.
  
  
  METHODS
  A retrospective chart review of all cases having either a dacryocystorhinostomy or surgical removal of an intracanalicular or punctal plug from 1992 to 2006, in a single physician referral oculoplastics practice, was performed to identify cases in which a retained lacrimal plug required surgical intervention. Patients presented with symptoms of tearing, infection, or granuloma formation. The charts of 998 surgical cases were reviewed, from which 66 eyes (6.6%) were determined to have had lodged lacrimal plugs that required surgical removal, thus qualifying them for inclusion in this study. Patients were followed after surgery until reconstructive silicone tubing was removed (range, 6 weeks to 6 months), and each patient was questioned regarding symptoms. A comparison group of 336 eyes that had collared punctal plugs placed served as the control group.
  
  
  RESULTS
  All cases were noted to have complications from intracanalicular plugs. No complications were noted from other forms of lacrimal plugs. All eyes in this series required a canaliculotomy or a dacryocystorhinostomy after office irrigation failed to dislodge the plug. Five eyes presented with canaliculitis, 28 eyes presented with epiphora, and 29 eyes presented with dacryocystitis. Four of 66 eyes (6%) in this cohort presented with a pyogenic granuloma. Five eyes (8%) presented with canaliculitis. Forty-nine of 66 eyes (74%) were asymptomatic following treatment, with no observable infection or epiphora. Seven of 66 eyes (11%) had some improvement in symptoms and another 10 of 66 eyes (15%) had no change in symptoms after treatment. No complications requiring surgical intervention were encountered in the control group of collared punctal plugs.
  
  
  CONCLUSIONS
  Intracanalicular-type plugs may lodge in the lacrimal outflow system. This may result in epiphora, canaliculitis, or dacryocystitis that may require major reconstructive surgery. Despite surgical intervention, these symptoms do not always resolve (26% of eyes in this study had persistent epiphora). Intracanalicular plugs were observed to be associated with a higher rate of granulation tissue formation in the lacrimal outflow tract when compared with other forms of punctal plugs. As a result of the increased number of complications seen with intracanalicular plugs, caution is advised with respect to use of these devices. The relative infrequency of complications seen with collared punctal plugs suggests a safer alternative. Data from this study lead the authors to advocate the consideration of other forms of lacrimal occlusion due to the high number of complications noted with intracanalicular plugs, and the availability of other reversible forms of punctal occlusion.
authors.affiliation: Eye Plastic Surgery Associates, Dallas, Texas 75231, USA. mmazow@eyeplasticsurgery.net
authors.forename: Mark L
authors.initials: ML
authors.lastname: Mazow
authors.forename: Tyrone
authors.initials: T
authors.lastname: McCall
authors.forename: Thomas C
authors.initials: TC
authors.lastname: Prager
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003607:Dacryocystitis / Q000209:etiology / Q000601:surgery; D003608:Dacryocystorhinostomy; D020878:Device Removal; D015352:Dry Eye Syndromes / Q000601:surgery; D005260:Female; D005548:Foreign-Body Migration / Q000209:etiology* / Q000601:surgery; D017789:Granuloma, Pyogenic / Q000209:etiology / Q000601:surgery; D006801:Humans; D007765:Lacrimal Apparatus / Q000473:pathology / Q000601:surgery; D007767:Lacrimal Duct Obstruction / Q000209:etiology*; D008297:Male; D008875:Middle Aged; D019736:Prostheses and Implants / Q000009:adverse effects*; D019919:Prosthesis Implantation; D012189:Retrospective Studies