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Punctal eversion with silicone plug resulting in ocular surface trauma
  1. Brad P Barnett1,
  2. Esen K Akpek2 and
  3. Albert S Jun2
  1. 1Ophthalmology, Duke Medicine, Durham, North Carolina, USA
  2. 2Ophthalmology, Johns Hopkins Medicine Wilmer Eye Institute, Baltimore, Maryland, USA
  1. Correspondence to Dr Brad P Barnett; bradley.barnett{at}

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A woman in her 70s with a history of chronic mixed mechanism ocular surface disease presented with an epithelial defect in her left eye. She was status post lower punctal cautery and was currently on Xiidra (lifitegrast ophthalmic solution, 5%) two times per day. On presentation, she endorsed foreign body sensation with 4/10 pain in her left eye. She was found to have a circular epithelial defect 1.5 mm in diameter (figure 1). Additionally, she had a vertically oriented, roughly linear area of conjunctival hyperaemia and chemosis nasally (figure 1). She endorsed her symptoms began to worsen approximately 1 month ago when she had undergone placement of an UltraPlug Silicone Plug (Angiotech, Vancouver, BC, Canada) in her left upper punctum.

Figure 1

(A) Left eye slit lamp photograph demonstrating primarily a nasal conjunctival injection with prominent UltraPlug Silicone Plug (Angiotech, Vancouver, BC, Canada) well seated in a pouting punctum. (B) Slit lamp photograph of the same eye with fluorescein staining demonstrating an epithelial defect, with inset photograph showing punctal plug abrading cornea in the same position when patient adducts the eye. (C) Slit lamp photograph of the same eye demonstrating a linear conjunctival hyperaemia, with inset photograph demonstrating apposition of the plug to conjunctiva with vertical deviation of the eye.

In the setting of the pouting configuration of the upper punctum, the silicone plug, though well seated, caused direct contact of the plug to the ocular surface. With removal of the plug, the corneal epithelial defect and conjunctival inflammation resolved. Previous case reports describe granuloma formation1 and canaliculitis2 resulting from punctal plugs. Moreover, it is known that silicone punctal plugs can traumatise the ocular surface in the setting of partial extrusion of the plug, especially in the context of rigid plugs with thick collarettes.3 This case highlights the ocular surface trauma that may result when the plug’s collarette is oriented towards the ocular surface. It further highlights the importance of evaluating the punctal position prior to and after plug placement, to ensure that no direct apposition of the plug to the ocular surface occurs. As evidenced by this case, significant ocular surface trauma can occur with a silicone plugged pouting punctum. It is likely that in all instances of punctal plugs with an external collarette, some degree of ocular surface trauma is incurred. This case highlights the importance of considering punctal configuration and final plug position when performing punctal occlusion.

Learning points

  • Use of a punctal plug in the setting of punctal eversion may lead to ocular trauma.

  • After punctal silicone plug placement, it is critical to observe final plug position.

  • Silicone plugs with larger collarette or increased rigidity can lead to ocular surface damage.



  • Contributors BPB, EKA and ASJ performed substantial contributions to the conception or design of the work, or the acquisition, analysis or interpretation of data; drafting the work or revising it critically for important intellectual content; final approval of the version published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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