Sir,

Punctal plugs (PP) insertion is an effective and reversible method to treat dry eye syndrome (DES) and some other ocular surface diseases. Non-absorbable plugs made of silicon are the most commonly used types and are relatively safe with minimal complications.1 We report a case of corneal ulcer secondarily to localized irritation from a fragmented cap of silicon PP in a patient with DES.

Case report

A 55-year-old man is presented to emergency eye clinic with a watery, sore, and red left eye. He gave a history of having silicone PPs inserted into both eyes 5 years earlier. Examination showed a peripheral corneal ulcer, 2 × 1 mm in size at 8 O'clock, separated from the limbus by a zone of clear cornea in his left eye. A provisional diagnosis of marginal keratitis was made and treatment with topical antibiotic and steroid combination was initiated. After 2 weeks with an interim follow-up visit, the patient reported little improvement in his symptoms and was still found to have active corneal ulceration. Slit-lamp examination revealed that on adducting his left eye, the ulcerated corneal margin comes into direct contact with the cap of the lower lid PP (Figure 1a–d). The cap was seen partially broken and hence was removed. Complete resolution of the ulcer was observed a week later.

Figure 1
figure 1

White arrows point to the PP and the corneal ulcer (a), coming in direct apposition on adduction (b). The lower lid is pulled to show PP broken cap (c). The whole plug is shown after removal (d, left), compared to an illustrated new plug with a torn lip (d, right).

Full size image

Comment

The most popular PP design was first described by Freeman in 1975.2 This style of PP has a wide disc-shaped top/cap that sits level on the punctal opening to prevent plug migration into the canaliculus. Conjunctival irritation caused by this exposed part of PP may warrant plug removal in a small number of treated patients (1.5%).3 However, apart from spontaneous PP extrusion and loss (40% by 6 months),4 other complications are rare and include bacterial conjunctivitis and punctal granuloma formation.

In literature, peripheral corneal ulceration has not been described in association with silicone PP. Although co-existing ocular surface disorder may have initiated the corneal ulceration in our case, the intermittent irritation by the edge of the fragmented PP top may have played a major role in maintaining it.

PP design with no exposed part (intracanalicular) theoretically eliminates local irritation; however, such design is associated with canaliculitis and dacryocystitis.5 Among others, these complications should be addressed in future designs of PP. For early diagnosis of PP-associated complications, careful examination of the punctum area is necessary in patients presenting with red eye and a history of PP insertion.