Punctal Plug Insertion Procedure Note

Procedure Note: Punctal Plug Insertion

Date: [Date of procedure]
Patient: [Full name] | [DOB] | [MRN]
Procedure: Punctal plug insertion (punctal occlusion by plug) — [Specify laterality and punctum: RLL / RUL / LLL / LUL] (List all treated puncta)
Operator: [Clinician name], [Credential]
Location: [Clinic/office setting]

Procedure Summary

• Pre-procedure diagnosis: [Aqueous-deficient dry eye disease / Sjögren-related keratoconjunctivitis sicca / Post-refractive surgery dry eye / Evaporative dry eye / Mixed dry eye / Other: specify]
• Post-procedure diagnosis: [Same as pre-procedure / Specify]
• Procedure performed: Punctal occlusion by plug
• Anatomic site(s) treated: [RLL / RUL / LLL / LUL] (List each punctum treated)
• Plug type: [Punctal plug / Intracanalicular] — [Temporary absorbable / Non-absorbable]
• Anesthesia: [None / Topical anesthetic: specify]
• Immediate outcome: [Successful placement / Partial placement / Aborted / Other: specify]
• Complications: [No immediate complications observed / Specify event(s) and punctum(s)]
• Disposition: [Discharged in stable condition / Remained in clinic for observation / Other: specify]

Indication and Medical Necessity

[Clinical rationale for punctal occlusion, including relevant symptoms and functional impact] (Summarize dry eye subtype if known: aqueous-deficient, evaporative, mixed. Include key objective findings if available: TBUT, Schirmer, ocular surface staining, tear meniscus height. Reference a same-day comprehensive dry eye evaluation rather than duplicating content when applicable.)

[Prior or concurrent therapies and response] (Include artificial tears, lid hygiene, prescription anti-inflammatories, and any contraindications or intolerance to alternatives that support plug placement. Document rationale for plug type choice and site selection when clinically relevant.)

Pre-Procedure Assessment

• Active ocular infection/inflammation: [None / Present: specify] / [Not assessed]
• Anatomic considerations: [Normal / Punctal stenosis / Malposition / Prior lacrimal surgery: specify / Other: specify] / [Not assessed]
• Medication allergies: [None / Specify agents and reactions] / [Not assessed]

(If any item above was not assessed, explicitly document "not assessed" rather than leaving blank.)

Consent

[Written / Verbal] consent obtained. Risks discussed included epiphora, foreign body sensation, extrusion, punctal enlargement, plug migration, canaliculitis, pyogenic granuloma, and potential need for removal or replacement. Benefits (tear retention, symptom improvement) and alternatives (continued lubrication therapy, anti-inflammatory therapy, punctal cautery, no procedure) were discussed. Patient questions addressed and patient agreed to proceed.

(Only document consent as obtained if it was actually obtained.)

Verification

Patient identity, procedure, and laterality/site verified prior to procedure.

Device Information

(Document for each punctum treated.)

• [Punctum: RLL / RUL / LLL / LUL]
  • Device: [Punctal plug / Intracanalicular] — [Absorbable / Non-absorbable] — [Material: Collagen / Silicone / Hydrogel / Other: specify]
  • Manufacturer/Model: [Specify / Not available]
  • Size: [Specify]
  • Lot/Expiration/UDI: [Specify / Not available]
  • Final position: [Seated flush with punctal opening, no ocular surface contact / Appropriate intracanalicular position]

Procedure Technique

[Patient positioning]. [Topical anesthesia: none / specify agent]. [Punctal assessment and sizing: performed / not performed]. [Punctal dilation: performed / not performed]. [Insertion technique per punctum: preloaded inserter / forceps placement]. [Final position confirmed]. [Patient tolerance: well-tolerated / mild discomfort / other: specify].

Complications

[No immediate complications observed / Specify complication(s)] (If complications occurred, specify the punctum involved, management steps taken, and patient status at completion.)

Post-Procedure Status

[Patient condition: stable / comfortable / mild irritation]. [Pain level: none / mild / moderate / severe]. Plug position verified prior to discharge. [Return to normal activities: yes / with precautions].

Discharge and Follow-Up

• Instructions provided: Expected symptoms, activity precautions, medication instructions, and return precautions (increasing pain, redness, swelling, discharge, persistent foreign body sensation, significant epiphora, concern for migration)
• Patient understanding: [Verbalized understanding / Teach-back performed]
• Follow-up: [1 week / 2 weeks / Other: specify] — reassess symptoms, ocular surface, plug retention, and complications
• Staged plan: [Trial plug followed by longer-duration plug if beneficial / Consider additional puncta at subsequent visit / Continue baseline dry eye regimen / None] (Include only if applicable)