Lacrifill Injection into Punctum for Dry Eyes

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.