Lacrifill Injection into Punctum for Dry Eyes
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Dry eye disease (DED) represents a multifactorial condition characterized by tear film instability and ocular surface inflammation that affects millions of individuals worldwide, with a global prevalence estimated at 11.59%.1–3 The condition is manifested through symptoms including ocular discomfort and visual disturbances, which can significantly impact quality of life. Traditional management strategies have incorporated artificial tears, intense pulsed light (IPL), anti-inflammatory agents, and punctal occlusion to address these symptoms.4–6
Punctal occlusion has been established as an effective intervention for patients with aqueous-deficient dry eye by reducing tear drainage through the lacrimal system.7 Recently, injectable matrix solutions such as Lacrifill Canalicular Gel (LCG) have been introduced as an alternative to traditional punctal plugs. These solutions offer a promising advancement in the management of dry eye disease by conforming precisely to the individual patient's lacrimal drainage anatomy. This video provides a step-by-step demonstration of the LCG injection technique into the punctum.
LCG is an innovative solution in the management of dry eye disease. The matrix solution is composed of a biocompatible, crosslinked, hyaluronic acid gel that is formulated to be injected directly into the punctum, thereby occluding the lacrimal drainage system. Unlike traditional punctal plugs, which are manufactured in predetermined sizes, this injectable matrix adapts to the natural anatomy of the patient's canalicular system, providing a customized fit that may improve comfort and retention rates. The hydrophilic properties of the matrix also allow it to expand slightly upon contact with tear fluid, ensuring complete occlusion.
Before the LCG injection procedure, anesthetic eye drops (typically proparacaine 0.5% or tetracaine 0.5%) are administered to ensure patient comfort. It should be noted that the anesthetic utilized in this procedure is not a mydriatic agent, and therefore, pupillary dilation is not expected to occur. This distinction is important to communicate to patients who may have concerns about post-procedural visual function. Following the application of anesthetic drops, a brief period of 3–5 minutes is allowed for the medication to take effect before proceeding with the examination and injection. During this time, patients may experience a temporary reduction in blink reflex and corneal sensitivity, which are normal physiological responses to topical anesthesia.
Before the LCG injection can be performed, a thorough examination of the punctum is conducted. During the assessment, it has been observed that punctal size can vary considerably between the eyes of the same patient, as well as between individuals. The examination is typically performed using magnification at the slit lamp to ensure clear visualization of the punctal aperture. In cases where the punctum is stenotic or difficult to identify, gentle dilation may be required to facilitate successful injection. Conversely, when a punctum is notably large, special attention must be paid to ensure complete occlusion is achieved.
The injection of LCG into the punctum is performed under direct visualization, usually 10x magnification. The patient is positioned appropriately with their chin and forehead secured against the examination apparatus to minimize movement during the procedure.
The cannula of the delivery system is carefully aligned with the punctal opening, and the patient is directed to look away from the midline to facilitate access to the punctum. This lateral gaze helps to expose the punctum and straighten the canaliculus, which improves the accuracy of the injection. Additionally, looking away helps prevent accidental corneal abrasion.
The injectable matrix is then slowly introduced into the lower punctum. Gel extrusion from the upper punctum may occur in approximately one-third of cases and indicates that the injection procedure can be concluded. If excess gel obstructs the patient’s vision, it can be irrigated from the ocular surface. If resistance is encountered or if the initial attempt does not result in successful placement, the procedure may be repeated. Caution should be taken not to be too aggressive with cannulation to avoid iatrogenic injuries.
Following the LCG injection procedure, patients can be informed that no specific maintenance is required. They should avoid rubbing the eye vigorously for the first 24 hours. The occlusive effect of the injectable matrix is expected to persist for approximately six months, although individual results may vary depending on tear composition and lacrimal drainage anatomy.8,9
A follow-up appointment is typically scheduled one week after the procedure to assess the effectiveness of the treatment and to monitor for any complications, such as canaliculitis, granuloma formation, or premature extrusion of the material. Additional follow-up appointments depend on the severity of each patient’s dry eye needs, but a six month appointment is indicated for washout and/or additional refill of Lacrifill.
The Lacrifill injection procedure for punctal occlusion represents a significant advancement in the management of dry eye disease, particularly for patients with aqueous deficiency who have not responded adequately to conventional therapies. The advantages of this approach include a customized fit to individual anatomy, minimal foreign body sensation, and potential for longer retention compared to traditional punctal plugs.
Ocular Surface Toxic Soup Syndrome (OSTSS) is an important consideration in the context of punctal occlusion. OSTSS arises from inadequate tear drainage, leading to the accumulation of inflammatory mediators—such as cytokines and chemokines—on the ocular surface, which can result in toxic keratoconjunctivitis with symptoms like conjunctival hyperemia, irritation, and epiphora. Although punctal occlusion aims to improve hydration by retaining tears, it may worsen OSTSS in patients with partial or complete nasolacrimal obstruction.10
This detailed demonstration of the Lacrifill injection procedure, from patient preparation through to injection technique and follow-up care, provides valuable information for ophthalmologists, optometrists, and other eye care professionals who treat patients with dry eye disease and are seeking to expand their therapeutic options. As with any interventional procedure, appropriate training and careful patient selection are essential for optimal outcomes.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
This article was created independently, without financial support or sponsorship from external entities. Any opinions expressed are solely those of the author(s) and do not reflect the views of any affiliated organizations. The author is an advisor to Nordic Pharma.
Citations
- Papas EB. The global prevalence of dry eye disease: a Bayesian view. Ophthal Physiol Optics. 2021;41(6). doi:10.1111/opo.12888.
- McCann P, Abraham AG, Mukhopadhyay A, et al. Prevalence and incidence of dry eye and meibomian gland dysfunction in the United States: a systematic review and meta-analysis. JAMA Ophthalmol. 2022;140(12). doi:10.1001/jamaophthalmol.2022.4394.
- García-Marqués JV, Talens-Estarelles C, García-Lázaro S, Wolffsohn JS, Cerviño A. Systemic, environmental and lifestyle risk factors for dry eye disease in a mediterranean caucasian population. Contact Lens Ant Eye. 2022;45(5). doi:10.1016/j.clae.2021.101539.
- Gayton JL. Etiology, prevalence, and treatment of dry eye disease. Clin Ophthalmol. 2009;3(1). doi:10.2147/opth.s5555.
- Zemanová M. Dry eye disease. A review. Ceska a Slovenska Oftalmologie. 2021;77(3). doi:10.31348/2020/29.
- Messmer EM. Pathophysiology, diagnosis and treatment of dry eye. Dtsch Arztebl Int. 2015;112(5).
- Ervin AM, Law A, Pucker AD. Punctal occlusion for dry eye syndrome: summary of a Cochrane systematic review. Br J Ophthalmol. 2019;103(3). doi:10.1136/bjophthalmol-2018-313267.
- Lacrifill canalicular plug. Instructions for use. Visant Medical; 2022. Available at: https://lacrifill.com/wp-content/uploads/2024/03/NORD_7000_Lacrifill_Instructions_for_Use-V5_FNL_VIEWONLY.pdf. Accessed April 30, 2024.
- Packer M, Lindstrom R, Thompson V, et al. Effectiveness and safety of a novel crosslinked hyaluronate canalicular gel occlusive device for dry eye. J Cataract Refract Surg. 2024;50(10):1051-1057. doi:10.1097/j.jcrs.0000000000001505.
- Abbott KS, Pham P. Nasolacrimal lavage as a treatment for ocular surface toxic soup syndrome. J Vis Exp. 2025;(218):10.3791/68276. Published 2025 Apr 25. doi:10.3791/68276.
Cite this article
Martin A. Lacrifill injection into punctum for dry eyes. J Med Insight. 2025;2025(531). doi:10.24296/jomi/531.
Procedure Outline
Table of Contents
Transcription
CHAPTER 1
Hello, my name is Alexander Martin. I'm the Medical Director for Boston Vision in their Lawrence location. Today we're gonna do a procedure called Lacrifill. It's a brand new medication. And what we do with this is we're plugging up the drain in the eye, in the eyelid, the punctum. And historically, we've been able to do that with pieces of plastic or collagen, but now we have this new matrix solution that we can actually inject instead. By injecting it into that drainage system of the eye, we're able to make a situation where tears stay on the surface of the eye longer.
CHAPTER 2
So this is Lacrifill. It's a brand new product to the market. And what we're able to do, instead of the traditional putting punctal plugs in someone's punctum, now we can actually inject a matrix-like substance that will take up the space of the canal there. And by doing that, by plugging that surface up, we're able to keep more tears on the surface of the eye for longer.
CHAPTER 3
So I'm gonna have you just look up to the ceiling. So it's not a dilating drop, this is just to numb your eyes. One, two, nice work. Here's a tissue for you.
CHAPTER 4
All right, so then we'll just do chin and forehead in there. I'll bring it up for you a little bit. How about that, is that okay there? Yeah. Okay. Good, so we are all set up here. I just have to make sure that I'm in focus of the punctum. I will take a look at it and make sure that it is open. This one is very large, so this is gonna go well.
CHAPTER 5
And all I'm gonna have you do is actually look out over to this side. Perfect. There we go, nice work. And you just keep looking over there. And now I'm in the punctum. Good. Go ahead and just close your eyes for a second. I'm gonna do that one more time. There we go. Now we're actually in. Perfect. We're gonna do the same for the other eye. And then I'll have you just look up over that way. Perfect. And this one actually, the punctum is very, very small. Probably not gonna actually be able to get in it. No, this one's actually... Why is that? Well, you just have two different sizes, and this is pretty common. That's also why actually you're feeling so much more on your left eye compared to the right eye. On my left.
CHAPTER 6
[No dialogue.]
CHAPTER 7
Since we've changed the amount of tears on the surface of someone's eye after doing this procedure, we expect that their dry eye symptoms are gonna improve. I have lots of patients that are telling me that they do feel a lot better with this procedure, even if they've tried punctal plugs in the past. I'll see the patient back in about a week, make sure that their tear breakup time is actually improved and make sure that they're more comfortable. There's no maintenance involved with this procedure. What's really nice is that the studies, at least the initial studies, are showing that this lasts for at least six months for the patient. So this isn't something they have to do regularly, and whenever they want it topped off, we can top it off. So because the drainage system in our eye isn't a perfect circle, when we try to put plugs in there, we're always guessing at the right-size plug to fit in. Well, the advantage of doing this gel procedure is that the gel's gonna actually take up the space perfectly for the patient. And that's one of the biggest advantages of this.