a. Inspect the patient's puncta to determine which size plug to use.

b. Remove the sterile packet from the box, peel back the lid (exposing the plug and insertion tool) and hold in your hand like a pencil.

c. While using magnifying loupes or a slit-lamp, have the patient look away from the point of insertion and evert the eyelid with your finger or cotton-tipped applicator.

d. Guide the tip of the plug partially into the vertical canaliculus until the collapsible bell rests on the punctum (fig 1).

e. Move the top of the insertion tool laterally until it is parallel with the lid margin (fig.2).This straightens the angle between the vertical and horizontal canaliculus allowing for easier insertion.

f. Advance the plug (toward the nose) completely through the punctum (fig. 3).As the plug passes into the vertical canaliculus it will collapse upon itself. Once beneath the punctum the bell will reopen.

g. Advance the plug 3 to 5 mm beyond the punctal opening to ensure that it has been positioned beyond the vertical canaliculus into the horizontal canaliculus.

h. Withdraw the insertion tool from the punctum, being careful not to touch the eye, and inspect the tool to confirm that the plug has been released.

i. Reinsert the insertion tool as if repeating steps c. through h. this will ensure that the plug is inserted properly and not lodged in the angle between the vertical and horizontal canaliculus.

Should the plug remain on the insertion tool after steps c. through h., use sterile forceps to remove and remount the plug on the tool and repeat steps c. through i.

After placement, the plug will migrate several millimeters where it becomes lodged in the medial horizontal canaliculus (fig. 4).

For maximum benefit, after placement of the OPAQUE Herrick Lacrimal Plug in the upper punctum, retest the inferior punctum with dissolvable test plugs to determine if OPAQUE Herrick Lacrimal Plugs should be placed inferiorly.

Follow steps a. through i. for placement of plugs into inferior canaliculi. (See video instructions)

Removal

"Pressure" saline irrigation with the TruPro™ Lacrimal Cannula or West Lacrimal Cannula (combines irrigation and probing), are the preferred methods for plug removal. Probing the canaliculus should always be followed with saline irrigation.

These procedures are intended to advance the plug through the nasolacrimal duct into the nose or throat where it eventually leaves the body. (See video instructions)

In rare cases, surgical methods may be appropriate to achieve plug removal.

Patients experiencing irritation or tearing after plug insertion may benefit from shallow probing (3 to 5 mm only) or repositioning of the plug within the horizontal canaliculus.

Cautions/Considerations

Lacrimal/Punctal Occlusion enhances the efficacy of ocular topical medications. After insertion of OPAQUE Herrick Lacrimal Plugs, use a single drop of topical antibiotic to prevent complications related to plug insertion.

Seeing OPAQUE Herrick Lacrimal Plugs

Anytime after insertion (see video instructions), or during removal (see video instructions) procedures, use a simple light source to transilluminate the eyelid and visualize the location and movement of OPAQUE Herrick Lacrimal Plugs.

Disclosure Requirements

Patients being treated with Lacrimal/Punctal Occlusion should first be informed about benefits and risks, and alternative treatments. Have patients sign an Informed Consent Form (Request for Treatment) to document receipt of this information.

Page 1 - Introduction to OPAQUE Herrick Lacrimal Plugs® Non-dissolvable (Long-Term)