We thank Dr Shoaib for his comments. In the results we clearly state 'The indication for insertion was based on the presence of ocular surface changes and poor tear film meniscus, with a previous unsuc- cessful management by lubrication and topical medication alone. Overall, 18 of the 25 patients had a concurrent systemic disorder (table 1).' Schirmer's test is , we believe , a poor test for dry eye in children. It often results in reflex tearing and is of little clinical value in children. Tear break up time is only of value if we know what the normal value is in CHILDREN. This is in fact the subject of our next manuscript which is in review as I write this. In children under 12 years of age and over 4 years of age , the non-invasive tear break up time using the Tearscope ( Keeler , Windsor ,UK) is over 25 seconds ( unpublished data as yet). So in children we looked at tear meniscus and ocular surface changes such as PEE. We not only relied on subjective improvement but also objective signs of improvement of ocular surface changes. As for the comparison of cases of BKC, we can only comment on our own paper which Dr Shoaib cites(1) . Please note that the majority of the children in the 'Punctal Plug' manuscript had a systemic disorder which led to secondary lid and corneal changes. In the article cited regarding BKC (1) many of the children had neovascularisation of the cornea and lubrication is clearly mentioned but not punctual plugs. We clearly state here in the 'Punctal Plug' article that children who failed lubrication were offered plugs. None of the cohort from the 2007 manuscript were in this manuscript. Finally, it is precisely because children can be so difficult to assess that there has been no previous manuscript, to the best of our knowledge, discussing punctual plugs exclusively in children.

1 Jones SM, Weinstein JM, Cumberland P, Klein N, Nischal KK. Visual Outcome and Corneal Changes in Children with Chronic Blepharokeratoconjunctivitis. Ophthalmology 2007;114:2271-2280

Conflict of Interest:

None declared

We thank Drs Hanovar and Ali for their comments. The main impetus for publishing this data was to show that children are NOT prone to infections with this strategy. In fact while steroid injections were given in cases of severe corneal neovascularisation such as K.I.D. syndrome and ectodermal hypoplasia , the fact that no child got a canaliculitis or other infection even when steroids were used, re-affirms that infection is not a risk that should prevent the clinician from using silicone punctal plugs if appropriate. Furthermore , clinically if spontaneous extrusion occurred after 6 months we often found that the symptoms had improved. We really wanted to know if using the plugs was a redundant manouevre , hence discussing the rate of extrusion within 6 months of placement , which we considered to be high in any case ( 19%). Perhaps the most striking fact is that we were unable to cite any other article dedicated to children with respect to the use of punctal plugs . We hope this article will encourage Drs Ali and Hanovar and others to share their experiences.

Conflict of Interest:

None declared

A Mataftsi et al1 published an interesting article regarding punctal plugs in children. One of their aim was to establish the efficacy however they have not mentioned any test (Schirmer, Tear film break-up time, Rose Bengal staining, osmolarity) to confirm the diagnosis of dry eye and to calibrate the tear deficiency. It was only the clinical impression (flouresein staining is not specific for dry eyes and therefore cannot be used as diagnostic). In the follow up also, there was no yardstick to measure and compare the post procedure improvement with the pre procedure status. Only subjective feelings (patients or parents) are difficult to gauge and therefore a scientific test at this stage would have established the exact positive role of the plugs which could have been counterchecked and verified by other workers. These tests could have been done in the same sitting/ anesthesia and would not have required any additional visit or anaesthesia. A few points of this article differed markedly from previous articles. In "Blepharokeratoconjunctivitis in children: diagnosis and treatment"2 by M Viswalingam et al in which patients in Moorfields Eye Hospital, London, UK, were analyzed, there is no mention of dry eye in either the text or Table 1- Classification of the severity of blepharokeratoconjunctivitis (BKC) in children and Table - 3 Clinical symptoms and signs. Punctate erosions were present in only 9 % (all Asian) of their patients. Their patients improved without any dry eye treatment. Similarly in "Visual Outcome and Corneal Changes in Children with Chronic Blepharokeratoconjunctivitis"3 by Jones SM et al, in patients analyzed in Great Ormond Street Hospital for Children, London, UK, from1999 to 2005 (same hospital and almost same time period as is of the present article), there was no mention of dry eye and punctate epithelial erosions (PEE) were found in 31% of eyes. "In the authors' experience, effective treatment for BKC should include a combination of both systemic and topical antimicrobial therapy, along with topical steroids" was the authors' recommendation in the above mentioned article and no punctal plugs were mentioned. Now in the present article, authors have found a lot of dry eyes (out of which 14 required punctual plugs) in BKC (and PEE in 100%) among the almost same record which was used for the above mentioned article and now they claim "plugs were successful in treating a variety of causes of dry eye in our cohort, with more than half of the children presenting with lipid deficiency secondary to meibomian gland dysfunction".

Despite these observations, authors deserve appreciation for introducing the new concept of punctal plug use in children.

References: 1. Mataftsi A, Subbu RG, Jones S, Nischal KK. The use of punctal plugs in children. Br J Ophthalmol 2012;96:90-92. 2. Viswalingam M, Rauz S, Morlet N, Dart JK. Blepharokeratoconjunctivitis in children: diagnosis and treatment. Br J Ophthalmol. 2005 Apr;89(4):400- 3. 3. Jones SM, Weinstein JM, Cumberland P, Klein N, Nischal KK. Visual Outcome and Corneal Changes in Children with Chronic Blepharokeratoconjunctivitis. Ophthalmology 2007;114:2271-2280

Conflict of Interest:

None declared

We read with great interest the article by Mataftsi A et al.1 We congratulate the authors for providing insights into the use of punctal plugs in children. We would like to articulate a few of our observations. In seven cases where a secondary procedure was undertaken like a subconjunctival steroid injection or placement of contact lens, we believe these would be confounding factors in the final analysis even if we presume that this was a combination effect and not replacing one another? 30/64 (46.8%) of the plugs had spontaneous extrusion and these figures should have been highlighted in a clearer way. It would be of interest to know the additive effects of bipunctal versus monopunctal occlusion as well as the results of those who underwent a repeat punctal occlusion. We once again congratulate the authors for highlighting the beneficial effects of this therapeutic modality and for their commendable work.

Conflict of Interest:

None declared