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Punctal occlusion for dry eye syndrome: summary of a Cochrane systematic review
  1. Ann-Margret Ervin1,
  2. Andrew Law1,
  3. Andrew D Pucker2
  1. 1 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
  2. 2 Department of Optometry and Vision Science, University of Alabama at Birmingham, Birmingham, Alabama, USA
  1. Correspondence to Ann-Margret Ervin, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA; aervin{at}


Dry eye disease is a disorder of the tear film associated with ocular signs and symptoms. Punctal occlusion aids the preservation of natural tears. We conducted a Cochrane systematic review to assess the effectiveness of punctal plugs for managing dry eye. Randomised and quasi-randomised trials were included. The primary outcome was symptomatic improvement (SI) at 2–12 months. Nine databases were searched with no date or language restrictions. Two authors assessed trial quality and extracted data. Summary risk ratios and mean differences were calculated. Ten trials were included. In two trials of punctal plugs versus observation, there was less dryness with punctal plugs. The mean difference (MD) in the dry eye symptom score at 2 months was −28.20 points (95% CI –33.61 to −22.79, range 0 to 105, one trial). Three trials compared punctal plugs with artificial tears. In a pooled analysis of two trials, punctal plug participants reported more SI at 3 months than artificial tear participants (MD −4.20 points, 95%  CI −5.87 to −2.53, scales varied from 0 to 6). In the remaining five trials comparing punctal plug placement, acrylic and silicone plugs, or comparing plugs with cyclosporine or pilocarpine, none of the investigators reported a clinically or statistically meaningful difference in symptomatic improvement at 2–12 months. The effectiveness of punctal plugs for treating dry eye symptoms and common signs are inconclusive. Heterogeneity in the type of punctal plug, type and severity of dry eye being treated, and trial methodology confounds the ability to make decisive statements regarding the effectiveness of punctal plugs.

  • lacrimal drainage
  • tears
  • ocular surface
  • treatment medical

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  • Contributors A-ME and AL coordinated the review. A-ME, RW, OS, IG and LR designed the search strategies. IG and LR conducted the searches of the literature. A-ME and AL screened the search results, appraised the quality of the papers, extracted data from the papers, obtained and screened data on unpublished studies, and entered and analysed the data. All authors contributed to the interpretation of the data and the writing of the review. A-ME is the guarantor for the review.

  • Funding AL received funding from grant 1 U01 EY020522, National Eye Institute, National Institutes of Health, USA for his work on the Cochrane Review.

  • Competing interests None declared.

  • Patient consent Not required.

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