Patent Publication Number: US-2023136791-A1

Title: Lacrimal plug inserter

Description:
FIELD OF THE INVENTION 
     The present invention relates, in general, to medical instruments and methods which facilitate the occlusion of the lacrimal duct by the insertion of either an intracanalicular or punctal plug. More particularly, it relates to a single lacrimal plug inserter that provides for both the functions of punctal dilation and plug engagement, insertion and disengagement, thereby providing more efficient and robust treatment methods. 
     BACKGROUND OF THE INVENTION 
     Dry eye is a common ailment for which there are different treatments including what is known in the art as lacrimal occlusion, where lacrimal refers to the lacrimal puncta which are small openings in the tear duct for draining tears secreted by the lacrimal gland and occlusion refers to the blocking of these ducts by the insertion of small plugs. An individual duct is referred to as a punctum, for which there are two basic types of occlusions; the first referred to as punctal occlusion and the second as intracanalicular occlusion. With punctal occlusion, a practitioner inserts into the punctum a punctal plug, usually including a flanged end, where the plug inserts into the punctum up to the flange but no further, thus leaving the flange exposed facilitating the extraction of the punctal plug if necessary, by allowing the plug to be pulled out from the punctum by the flange end. In the second type of intracanalicular occlusion, a practitioner inserts into and through the punctum an intracanalicular plug not including a flanged end, such that the intracanalicular plug can be pushed into the interior of the lacrimal (tear) duct referred to as the canaliculus. 
     In either type of occlusion, the plugs typically range in diameter between 0.4 mm and 0.8 mm and in price from $50 to over $250. In the most common type of lacrimal occlusion procedure having been practiced for over the last 40 plus years, three separate instruments are required, namely: 1) a punctal sizer, 2) a dilator, and 3) thumb forceps, all of which are well-known in the art. The procedure is typically performed by a practitioner without the aid of an assistant, and as such it is necessary that the practitioner switch their gaze between a concentration on the patient&#39;s punctum and a concentration on the selecting of instruments necessary for performing the occlusion, and more specifically switching between a dilator instrument and the thumb forceps during the more critical insertion portion of the process. The sizer instrument is used prior to the plug insertion process to help determine the size of the patient&#39;s punctum and therefore the diameter of an appropriate plug. The plug insertion process typically commences with the practitioner using the dilator tool to enlarge the orifice of the punctum after which the practitioner puts down the dilator instrument, picks up the thumb forceps, and then uses the thumb forceps to select the proper plug. After selecting the plug, the practitioner maintains a grasp of the plug by continuing to put a closing pressure on the thumb forceps, while then at the same time moving the plug to the punctum and then inserting the plug into the punctum. Once successfully inserted, the practitioner releases the applied closing pressure on the thumb forceps disengaging the plug that is partially inserted into the punctum. After releasing, the practitioner typically uses the distal end of the thumb forceps to further push the plug into the punctum as required by the type of plug. For a single patient, it is often necessary for the practitioner to insert multiple plugs, thus increasing the overall duration and cost of the procedure. 
     In this typical lacrimal occlusion process, there are several drawbacks including: 1) the plugs are small and somewhat soft (based upon their material composition, for example being collagen for temporary plugs or silicone for longer lasting plugs), where the combination of size and softness increases the dexterity required of the practitioner to apply the sufficient closing force for grasping the plug without excessive force that could damage the plug; 2) while applying the sufficient closing force and simultaneously moving the plug towards and into the punctum, it is not uncommon to drop the plug, where the loss of plugs is expensive, increases the mental stress of both the practitioner and the patient as the entire process duration is increased, and 3) when attempting to insert the plug, it is not uncommon that the practitioner determines that the punctum requires further dilation, thus requiring that the practitioner first disengage the plug by releasing the closing pressure on the thumb forceps, put down the forceps, pick up the dilator instrument, dilate the punctum, put down the dilator instrument, pick up the forceps, reengage the plug and attempt to again insert the plug, the combination of steps of which both add mental stress to the practitioner and patient, increase the duration of the process, increase the likelihood of dropping the plug, and distract the practitioner as they switch their gaze away from the patient&#39;s punctum. 
     BRIEF SUMMARY OF THE INVENTION 
     The present invention is a new medical instrument that combines the functions of bulldog forceps in combination with a dilator, thus providing a single instrument replacing the traditional two instruments including a separate dilator and separate thumb forceps. Unlike the thumb forceps which require a continuous closing pressure to be applied by the practitioner in order to maintain engagement of a plug, bulldog forceps only require an opening pressure (which is then relaxed) to engage the plug and an opening pressure to then disengage the plug (after insertion into the punctum). After applying opening pressure to separate the distal ends of the bulldog forceps in the process of surrounding the plug for engagement by the distal ends, the practitioner releases the opening pressure (or inversely stated applies closing pressure) that allows the distal ends to converge and engage the plug. Once so engaged, the positive pressure inherent between the distal ends of the bulldog forceps maintains the grasp of the plug without requiring any additional pressure from the practitioner (e.g. closing pressure if using thumb forceps). This removal by the present invention of the need for the practitioner to maintain an additional pressure offers many benefits to be described herein. 
     The presently described medical instrument also includes a dilator on the end of the instrument opposite to the distal end of the bulldog forceps (used for engaging a plug), where the distal end of the combined instrument is the functioning end of the instrument and always closest to the patient&#39;s punctum for the purposes of inserting or adjusting a plug. Given this two-in-one instrument, with a simple rotation of the instrument, the dilator that was proximal becomes distal and therefore also the functioning end. Conversely, with a second rotation of the instrument, the bulldog forceps distal ends become the distal and functioning end of the instrument. Given this convenient arrangement of not requiring additional pressure applied by the practitioner and including a dilator with the instrument easily accessed by a simple rotation of the instrument, it is now possible for the practitioner to: 1) be able to make the more delicate hand movements required for efficiently inserting the plug because the only physical hand exertion is to handle and move the instrument (and not also to additionally keep the distal ends of the instrument closed and engaging the plug as with thumb forceps), 2) be less concerned with dropping or damaging plugs as with the use of thumb forceps since the bulldog forceps maintain the appropriate continuous closing pressure without further concentration or effort from the practitioner, and 3) be able to switch from attempting to insert the plug to further dilating the punctum, and then back to attempting to insert the plug using a single tool simply rotated in the practitioner&#39;s hand, where then the practitioner is not required to divert their gaze from the patient&#39;s punctum thus improving the process and minimizing the process duration. 
     The present invention provides for further adaptations such that the two-in-one instrument becomes a three-in-one instrument, wherein the traditional function provided by a separate punctal-sizer is incorporated into the instrument&#39;s dilator, thus becoming a sizer-dilator. Hence, whereas a traditional lacrimal occlusion procedure requires three instruments including a punctal sizer, a dilator, and thumb forceps, the further adapted present invention provides each of these functions in a single convenient tool, thus saving valuable processes time for the practitioner, where this reduction in process time at least reduces the mental stress on the patient. 
     Other adaptations are provided for allowing the herein taught medical instrument to support a multiplicity of detachable end tips or end tip sleeves for engaging at least the punctal plugs, or a multiplicity of detachable dilators or detachable sizer-dilators for dilating the punctum and sizing the punctum. Using these further adaptations for detachable proximal or distal ends, it is also shown that the instrument is useful for at least other medical procedures such as trichiasis using a cilia style end tip and is also anticipated to be useful for other non-medical processes. With respect to the detachable end tip sleeves, the present invention teaches a new rack comprising one or more boxes, each box comprising two trays, each tray for holding a sleeve for use with a distal end of the instrument. In combination with the herein taught medical instrument, the rack, box and tray solution provides a convenient way for the practitioner to quickly select, replace or switch between a number of different end tips using only a single hand, thus further facilitating the optimization of at least medical procedures such as lacrimal occlusion. 
     And finally, the herein taught bull-dog mechanism is further adapted with various mechanical clamp-limiting means such that the practitioner can decrease the maximum clamping pressure the instrument will inherently provide, offering advantages in situations such as where the grasped material is of a softer composition for which the inherent closing pressure of the instrument is ideally limited to avoid possible damage to the material. At least one variation of the herein taught clamp-limiting mechanisms is shown to conveniently allow the practitioner to use the end tips in a separation function as opposed to a grasping function, for example to provide tissue separation and holding during a medical procedure such that the practitioner can then have access to the patient through the gap opened in the tissue. 
     As will be discussed with greater detail herein, the present invention therefore offers both a new lacrimal plug inserter with distinct advantages over traditional instruments and offers a new process that is significantly more efficient in terms of at least time duration (by minimizing practitioner movements) and average cost (by minimizing the dropping and loss of plugs and minimizing total procedure time.) Other objects and advantages are detailed forthwith in the remainder of the specification while still other objects and advantages will be obvious to those skilled in the art of lacrimal occlusion, trichiasis and other medical procedures. 
    
    
     
       BRIEF DESCRIPTION OF THE SEVERAL VIEWS OF THE DRAWINGS 
       The novel features of the invention are set forth with particularity in the appended claims. The invention itself, however, both as to organization and methods of operation, together with further objects and advantages thereof, may best be understood by reference to the following description, taken in conjunction with the accompanying drawings in which: 
         FIG.  1    is a perspective drawing of a novel medical instrument  10  comprising bull-dog style crossing arms  2  and  4  substantially for engaging, disengaging and otherwise manipulating a plug such as  60  or  62  used in a lacrimal occlusion medical procedure. Attached to arms  2  and  4  is dilator  50  such that tool  10  is easily manipulated by a practitioner between a dilator instrument and a plug grasping and insertion instrument. 
         FIG.  2    is a flow chart describing the steps involved with a traditional lacrimal occlusion process  100  that relies upon the use of three distinct tools including a sizer instrument, a dilator instrument and a thumb forceps instrument. 
         FIG.  3    is a flow chart describing the steps involved with the lacrimal occlusion process  200  according to the present invention that relies upon two distinct tools including a sizer instrument and the present medical instrument  10  as depicted in  FIG.  1   , where instrument  10  provides for both the functions of punctal dilation and plug engagement, insertion and disengagement. 
         FIG.  4 A  is a perspective drawing of medical instrument  10  where base  10   a  has been further adapted to accept a detachable dilator  50  (not depicted) or a sizer-dilator  51  (depicted). Sizer-dilator  51  provides both the dilator function of dilator  50  along with the sizer function traditionally provided by a separate punctal-sizer instrument, thereby allowing further adapted instrument  10  to provide all three traditional lacrimal occlusion functions of: 1) sizing the punctum; 2) dilating the punctum, and 3) inserting a plug into the punctum in a single convenient tool. Sizer-dilator  51  further includes various markings  51 - m   1 ,  51 - m   2 ,  51 - m   3  and  51 - m   4  covering the sizer profile  51 - p   1 , where the various markings are usable for determining the appropriate plug size for selecting between plugs such as  60 - 1 ,  60 - 2 ,  60 - 3  and  60 - 4  of at least differing diameters. 
         FIG.  4 B  shows a reference art drawing illustrating the use of three different dimensioned punctal sizers to best determine the size of a patient&#39;s punctum. Also depicted in an alternative sizer profile  51 - p   2  for use with sizer-dilator  51 , where alternative profile  51 - p   2  is based upon the combination of at least two of the reference art punctal sizer shapes, and where the profile  51 - p   2  preferably includes an optional dilator tip  51 - t.    
         FIG.  5    is a flow chart describing the steps involved with the lacrimal occlusion process  300  according to the present invention, where process  300  relies upon the use of only one distinct tool that is the present medical instrument  10  such as depicted in  FIG.  4    including sizer-dilator  51  as opposed to the dilator  50  shown in  FIG.  1   . Instrument  10  that has been further adapted to include sizer-dilator  51  provides for all of the functions of process  300  including punctal sizing, punctum dilation and plug engagement, insertion and disengagement. 
         FIG.  6 A  depicts eight various types of thumb forceps known in the art, and more specifically depicts different forms of distal ends (herein also called tips) found to be useful for either the lacrimal occlusion procedure, such as the “angled-tip plug insertion (API)” tip, or other various medical procedures such as “cilia” tip for performing trichiasis, where any of these same or similar tips, or indeed any of the many distal ends known in the art, may be incorporated with the present invention. 
         FIG.  6 B  is a perspective drawing of medical instrument  10  where holding surface  10   d  has been further adapted to comprise bases  48 -base and  28 -base for accepting a detachable distal end tip  48 -tip 1  and  28 -tip 1 , respectively, where for example tips  48 -tip 1  and  28 -tip 1  are in the form of cilia style distal ends used for trichiasis, or alternatively of any shapes herein described or otherwise known in the reference art such as depicted in  FIG.  6 A . 
         FIG.  6 C  is a second view of the perspective drawing of medical instrument  10  further adapted to accept a detachable distal end tip  48 -tip 1  as shown in  FIG.  6 B , where the present figure depicts the detachable distal end  48 -tip 1  including key  48 -tip 1 - k  in a detached and orthogonal rotation prior to insertion into lock  48 -base-l of distal end base  48 -base. 
         FIG.  6 D  is a perspective drawing of the distal end of instrument  10 , where distal end  48   a  and  28   a  have been further adapted to include latches  48   a - l  and  28   a - l , respectively, for securing tip sleeves  49   a  and  29   a , respectively, and where sleeves  49   a  and  29   a  further include interior latches (not depicted) for engaging latches  48   a - l  and  28   a - l  and exterior latches  49   a - l  and  29   a - l  for engaging a tray (see  FIG.  6 E ). 
         FIG.  6 E  is a perspective drawing of sleeve box  70 , comprising sleeve trays  49   a - t  and  29   a - t  for receiving, holding and discharging any of sleeves  49   a  and  29   a , respectively. Each tray  49   a - t  and  29   a - t  such as  49   a - t  preferably further comprises a first tray cavity  49   a - tc   1  for holding the non-tip portion of a sleeve such as  49   a , a second tray cavity  49   a - tc   2  for holding the tip portion of a sleeve such as  49   a , an interior latch  49   a - tl  for impeding the lateral exit motion of a sleeve such as  49   a  and a lateral tray entrance  49   a - te  for receiving a distal end of instrument  10  such as  48   a  being inserted into a sleeve such as  49   a  held within tray  29   a - t.    
         FIG.  6 F  is a perspective view of instrument  10  further adapted as described in  FIG.  6 D  to comprise distal ends  48   a  and  28   a  partially inserted into sleeves  49   a  and  29   a , respectively, where sleeves  49   a  and  29   a  are being held within trays  49   a - t  and  29   a - t , respectively, comprising sleeve box  70  as described in  FIG.  6 E . 
         FIG.  6 G  is a side view diagram depicting three steps 1, 2 and 3 for first inserting (steps 1 and 2) via substantially a lateral motion distal ends such as  48   a  comprising latch  48   a - l  into sleeves such as  49   a  held within sleeve box  70 , and second removing (step 3) via substantially a perpendicular motion sleeves such as  49   a  now secured via an interior latch (not depicted) to a distal end latch such as  48   a - l , where in the perpendicular motion exterior latch  49   a - l  of sleeve  49   a  is substantially unimpeded by tray box  70 . Whereas steps 1, 2 and 3 allow for the engagement and removal of sleeves such as  49   a  from the tray box  70  by instrument  10 , a reversal of steps 1, 2 and 3 further allow for the replacement and disengagement of sleeves such as  49   a  from tray box  70  by instrument  10 , wherein during the reversal of step 3 tray box  70  substantially impedes the removal of a sleeve such as  49   a  by catching exterior latch  49   a - l  during the extracting lateral motion, thereby disengaging a sleeve such as  49   a  from a distal end such as  48   a.    
         FIG.  6 H  is a side-perspective view of a tray rack  72  for example comprising three tray boxes  70 - 1 ,  70 - 2  and  70 - 3 , where instrument  10  is depicted as removing (or replacing) sleeves from tray box  70 - 1  in accordance with the steps 1, 2 and 3 described  FIG.  6 G . 
         FIGS.  7 A and  7 B  depict the distal end  48  of presently taught medical instrument  10  that has been further adapted as distal end  48   b  comprising a screw type clamp-limiting means including knob  48   b - k  for turning by the practitioner, where turning the knob  48   b - k  causes screw  48   b - s  to raise or lower commensurately into the holding space between distal ends  48   b  and  28 , thereby proportionately effecting the tip gap and associated closing (positive) pressure of instrument  10 . Also depicted are markings  48   b - m  for indicating the direction and amount of turning of knob  48   b - k  that corresponds to desired plug sizes as prior determined using a sizer-dilator with associated markings on profile  51 - p   1  (see  FIG.  4 A ). 
         FIGS.  8 A and  8 B  depict the distal end  48  of presently taught medical instrument  10  that has been further adapted as distal end  48   c  comprising a sliding wedge type clamp-limiting means including knob  48   c - k  for pushing forwards and backwards by the practitioner, where pushing the knob  48   c - k  causes wedge  48   b - w  to slide commensurately forwards or backwards into the holding space between distal ends  48   c  and  28 , thereby proportionately effecting the tip gap and associated closing (positive) pressure of instrument  10 . 
         FIGS.  9 A and  9 B  depict the distal end  48  of presently taught medical instrument  10  that has been further adapted as distal end  48   d  comprising a rotating oblong wheel type clamp-limiting means including knob  48   d - k  for turning by the practitioner, where turning the knob  48   d - k  causes oblong wheel  48   d - w  to rotate commensurately into the holding space between distal ends  48   d  and  28 , thereby proportionately effecting the tip gap and associated closing (positive) pressure of instrument  10 . 
         FIGS.  10 A and  10 B  depict the wide portions  24  and  44  of presently taught medical instrument  10  that have been further adapted as wide portions  24   e  and  44   e  comprising a rachet type clamp-limiting means including pivoting rachet arm  44   e - r  in combination with return pressure spring  24   e - s , where, as the practitioner applies normal opening pressure upon wide portions  24   e  and  44   e  rachet combination  44   e - r  and  24   e - s  causes the wide portions  24   e  and  44   e  to essentially remain fixed at the closest separation of portions  24   e  and  44   e  obtained prior to the release of the opening pressure by the practitioner, thereby inverse proportionately effecting the tip gap and associated closing (positive) pressure of instrument  10 . 
         FIGS.  11 A and  11 B  depict the distal ends  28  and  48  of the further adapted medical instrument  10  including a rachet type clamp limiter as taught in relation to  FIGS.  10 A and  10 B , to be further adapted as tissue separating style distal ends  28   t - 2  and  48   t - 2 . 
     
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
     Referring to  FIG.  1   , there is shown a perspective view of a first embodiment of medical instrument  10  that resembles a surgical (or “bulldog”) forceps well-known in the medical art for the occlusion of blood vessels. Instrument  10  is about 60 mm long, although the length may vary, and comprises a first arm  2  and a second arm  4 . First arm  2  is an elongated member made of a metal such as stainless steel or a rigid, medical grade plastic. Starting from the proximal end, the first arm  2  comprises a proximal portion  22 , a wide portion  24  angled outwardly from the proximal portion, a narrow portion  26  angled inwardly from the wide portion  22 , and a distal portion  28  angled outwardly from the narrow portion  26 . The second arm  4  is like the first arm  2 , comprising a proximal portion  42 , a wide portion  44  angled outwardly from the proximal portion  42 , a narrow portion  46  angled inwardly from the wide portion  44 , and a distal portion  48  angled outwardly from the narrow portion  46 . Proximal portions  22  and  42  are joined to one another, the combination of which form the base  10   a . Wide portions  22  and  42  are detached from one another, the combination of which form a grasping surface  10   b  whereupon a practitioner preferably maintains hold of and operates instrument  10 . It is preferred that at least the outer grasping surfaces of wide portions  24  and  44  include surface changes for increasing grip, such as a series of etched groves as depicted in the present figure with respect to portion  44 . Narrow portions  26  and  46  are detached from one another, the combination of which form the inflection point  10   c . Distal portions  28  and  48  are detached from one another and movable such that in a normal resting state portions  28  and  48  are touching while in an opening state portions  28  and  48  are separated by some distance, where the combination of distal portions  28  and  48  form the holding surface  10   d  for engaging and disengaging a plug such as  60  or  62 . The present invention anticipates that at least the touching (and facing) surfaces of distal portions  28  and  48  can be any of smooth, rough, serrated or even hollowed shaped to best grasp a particular plug such as  60  or  62 , and that preferably the combined closed tip ends of portions  28  and  48  form a sharp point, but can also form a blunt point. 
     Still referring to  FIG.  1   , as will be well understood by those familiar with the treatment of dry eye using lacrimal (or punctal) occlusion, there are many types of plugs for use in this procedure including for example intracanalicular plugs such as  60  without a flange and punctal plug  62  including a flange, where such plugs  60  and  62  come in various sizes, shapes and material compositions. 
     As will be understood by those familiar with bulldog forceps, a practitioner applies three distinct types of pressure to properly operate the instrument  10 , including what is herein referred to as a handling pressure, an opening pressure and a closing pressure (where a closing pressure is actually the relaxing of the opening pressure). Using handling pressure, the practitioner is able to pick up, move about and put down the instrument  10  without causing any relative changes in the distance between the distal ends  28  and  48  of holding surface  10   d . Hence, if the distal ends  28  and  48  are not already engaging a plug such as  60  or  62 , then the ends  28  and  48  are touching and remain touching given only handling pressure. If the distal ends  28  and  48  are already engaging a plug such as  60  or  62 , then the ends  28  and  48  are substantially separated by some distance as dictated by the size, shape and material composition of the plug  60  or  62  and the location in which the plug was engaged, and this separation distance remains substantially unchanged given only handling pressure. It is important to see that once a plug such as  60  or  62  is engaged by the practitioner using the holding surface  10   d  of instrument  10 , there is only a minimum handling pressure required by the practitioner to then move about the plug  60  or  62  as is necessary for preforming the lacrimal occlusion procedure, where this minimum handling pressure does not further include any of opening or closing pressure. 
     Still referring to  FIG.  1   , in a typical use case, prior to a plug being engaged, a practitioner grasps instrument  10  for example placing their thumb somewhere on the wide portion  24  and their pointer finger somewhere on the wide portion  44 , essentially encompassing grasping surface  10   b . While in this plug-unengaged state of instrument  10 , distal portion  28  is in contact with distal portion  48 . When the practitioner the presses their grasping thumb and pointer finger&#39;s together to apply an opening pressure, wide portions  24  and  44  are brought together, and due to the crossing arrangement of narrow portions  26  and  46  forming inflection point  10   c , distal portions  28  and  48  are thereby separated and no longer in contact. In a normal operation, while applying this opening pressure, the practitioner moves the distal ends  28  and  48  to surround some portion of a plug such as  60  or  62  and then applies a closing pressure by relaxing the opening pressure, thus causing distal ends  28  and  48  to engage the plug in some selected location. The practitioner is then free to move the plug such as  60  or  62  about as necessary without the additional strain of maintaining a closing pressure to secure the engaged plug, which is required when using the traditional thumb forceps for engaging a plug such as  60  or  62 . 
     Still referring to  FIG.  1   , there is also shown separator  52  located preferably along an inside edge of either wide portion  44  (as depicted) or wide portion  24  (not depicted). The function of separator  52  is to limit the minimum separation distance between wide portions  24  and  44  as caused by the application of opening pressure by the practitioner. This limit is set to both allow sufficient separation distances between distal ends  28  and  48  to be achieved for engaging and disengaging plugs such as  60  and  62  while also disallowing a maximum opening pressure that might for example cause wide portions  24  and  48  to come into contact causing harmful strain on arms  2  and  4  or even breaking instrument  10 . As will be obvious to those skilled in the art of instrumentation manufacturing, there are many possible locations for placing separator  52 , and many shapes and sizes for separator  52 , and even other means for accomplishing the same function. It is even possible to use multiple separators  52 , for example each aligned to oppose each other thus essentially equally splitting the minimum limit. What is important to see is that preferably, but not necessarily, some adaptation is added to instrument  10  to function as a means for limiting the minimum separation distance between wide portions  24  and  44  as caused by the application of opening pressure by the practitioner. 
     Still referring to  FIG.  1   , instrument  10  preferably also includes a dilator  50  attached to the base  10   a  of instrument  10  such that the dilator  50  points in the opposite direction of distal portions  28  and  48 , thus providing instrument  10  with a dual-function of both dilating a patient&#39;s punctum with dilator  50  and engaging and disengaging a plug such as  60  or  62  with distal portions  28  and  48 . The preferred shape of the dilator  50  is wider at the point of attachment to the base  10   a , tapering off to form a point at the functioning end. In the preferred arrangement, dilator  50  is permanently attached to the base  10   a . However, it is further anticipated that the dilator  50  can be detachable from the base  10   a , for example where dilator  50  includes a threaded screw (or “key and lock”, see upcoming  FIG.  4 A ) and therefor can be screwed into an appropriately sized threaded opening in the base  10   a . Using this detachable dilator  50  alternate embodiment of instrument  10 , it is then possible to allow instrument  10  to further adapt to different sized dilators  50  and even to further adapt to other types of tools for use in combination with the clamping arms  2  and  4 . The present invention anticipates that the functioning tip end of dilator  50  can be sharp or blunt, or have various other shapes and designs commonly utilized within the ophthalmology industry, where for example the detachable dilator  50  can vary in any of these features. 
     And finally, in the lower right-hand corner of  FIG.  1   , juxtaposed with exemplary plugs  60  and  61  there is depicted an exemplary end tip adaptation referred to as plug receptacle  48   a . In one possible operation of instrument  10 , after the practitioner uses distal ends  48  and  28  (in any tip configuration, for example see upcoming  FIG.  6   ) to first engage a plug, second partially insert the plug, and third disengage the plug, the practitioner then uses the plug receptacle  48   a  as a means for better manipulating the plug for further insertion into the punctum, where better manipulating includes receiving the end of the plug currently protruding from the punctum into the concavity of receptacle  48   a , such that once received the practitioner is better able to guide and apply directional pressure upon the plug for insertion into the punctum. 
     As will be clear based upon a careful consideration of the purposes of plug receptacle  48   a , especially to those familiar with medical instruments and the lacrimal occlusion procedure, there are many possible forms and arrangement for plug receptacle  48   a  and thus the present depiction should be considered as exemplary, rather than as a limitation of the present invention. For example, plug receptacle  48   a  as currently depicted with a concavity parallel to the grasping and therefore plug insertion axis, could alternately be rotated for example 90 degrees to be perpendicular with the direction of plug insertion. Additionally, and alternatively, the plug receptacle  48   a  could be a of different size, shape or attached location while still providing for the essential means of receiving the plug to improve the practitioner&#39;s control during the insertion process. And finally, with respect to variations of plug receptacle  48   a , it is even possible that the receptacle  48   a  is divided into two left-right partitions, centered with respect to each other and located between the tips  48  and  28 , where for example the “left half” of divided receptacle  48   a  (comprising essentially half of  48   a ) is comprised within the tip of distal end  48  and where essentially the remaining “right half” of  48   a  is comprised within the tip of distal end  28 , such that after disengaging a plug and due to the inherent positive pressure of instrument  10  the two distal ends  48  and  28  are in contact and collectively form the receptible  48   a  by bringing the left and right halves of divided alternate receptacle  48   a  together between the tips for a similar usefulness of receiving and more easily guiding the a plug. 
     Referring next to  FIG.  2   , there is shown a flow diagram describing the basic steps for performing the lacrimal occlusion process  100  as currently and commonly practiced in the art. First, it should be noted that the current process  100  requires three distinct tools, namely: 1) a first sizer instrument for measuring the size of the patient&#39;s punctum into which a plug such as  60  or  62  is to be inserted, sometimes referred to as a punctal sizing gauge; 2) a second dilator instrument for inserting into the punctum to cause the opening to enlarge in preparation for receiving the plug, and 3) a third thumb forceps instrument for grasping and holding a plug such as  60  or  62  using a continuous closing pressure while attempting to insert the plug into the punctum. 
     Still referring to  FIG.  2   , in a first step  101 , the practitioner uses one or more sizer instruments to probe and estimate the size of the patient&#39;s punctum, for example determining that the punctum size is 0.6 mm. In step  102 , the practitioner decides if the punctum should first be dilated prior to attempting to insert a plug such as  60  or  62 . If the decision is “no,” the practitioner proceeds to step  104 , and otherwise if “yes” then performs step  103  using a separate dilator instrument to apply pressure on the punctum slightly enlarging its orifice. Next, in step  104  the practitioner selects an appropriate plug such as  60  or  62  based upon the chosen medical procedure (for example an intracanalicular plug such as  60  without a flange for inserting through the punctum into the interior of the lacrimal duct (canaliculus), and punctal plug  62  for partially inserting into the canaliculus such that the flange is still protruding from the puncta, all as is well known in the art). In step  105 , the practitioner uses a traditional thumb forceps instrument that is in an open position in the resting state (i.e. without external closing pressure being applied by the practitioner), to first surround and then grasp the selected plug, where grasping means that the practitioner applies a closing pressure on the arms of the thumb forceps in order to cause the distal ends of the forceps&#39; arms to close and engage the plug. 
     Continuing with step  106 , the practitioner then attempts to insert plug such as  60  or  62  into the punctum. It is important to note the following difficulties with this step: 1) the step is performed around the patient&#39;s eye which is both uncomfortable for the patient and puts the patient at some risk, therefore the step duration is ideally limited; 2) both the punctum and the plug are small requiring precise movements from the practitioner; 3) the practitioner is required to maintain a sufficient closing pressure for continuing to secure the plug with the thumb forceps while at the same time moving their hand to direct the plug into the punctum, where this combination of exertion is delicate increasing the likelihood of either dropping the plug or having the plug slip in its initial position with respect to the grasping forceps (thus needing to be set down and repositioned delaying the total step time), and 4) the plugs such as  60  or  62  are easily dropped (for example by releasing closing pressure during step  106 ) or damaged (for example by applying too much closing pressure during step  106 ), which is costly as a typical plugs range in price from $50 to over $250 each. 
     Still referring to  FIG.  2   , at some point in step  106  the practitioner will decide as step  107  if the plug is fitting through the punctum. If “yes,” this fitting results in at least a partial insertion of the plug through the punctum into the canaliculus such that the practitioner in step  108  is then able to release closing pressure disengaging the plug from the distal end of the thumb forceps to remain at least partially inserted through the punctum. In final step  109 , the practitioner then typically uses the distal end of one of the forceps&#39; arms to further push the plug into the canaliculus but still protruding from the punctum (e.g. if a punctal plug  62 ), or all the way into the canaliculus and not still protruding from the punctum (e.g. if an intracanalicular plug  60 ), where full insertion often requires the practitioner to switch from using the forceps to using the dilator instrument since the dilator has a single narrowed and elongated point that is ideal for pushing the plug deeper into the canaliculus, and where then this switching has the negative effects of both drawing the attention of the practitioner away from the patient&#39;s punctum and further increasing the duration of the process. 
     It should be noted that the distal end of one of the arms of the forceps is not an ideal tool for pushing the plug further into the punctum, for example as compared to a single ended tool such as a dilator instrument, where the pointed end of the dilator can be better used to push the plug. In a careful consideration, one of the problems with using the thumb forceps to further push the plug is that while the distal end of one arm is being used to push upon the plug, the distal end of the opposing arm is free and separated presenting itself closer to the patient&#39;s eye depending upon the motions chosen by the practitioner. In any case, it is not ideal that the practitioner take their eyes off the plug or otherwise divert their attention during the continuous performance of steps  106  through  109 , (during which for example the patient could blink or in some way cause the plug to dislodge and therefore requiring a restart with a new plug). Since the practitioner is required to maintain their focus on the plug and since the practitioner typically does not have an assistant to which they could hand the thumb forceps and request a different tool such as the dilator instrument, the practitioner is forced to continue the fitting in step  109  using the thumb forceps. 
     Referring still to  FIG.  2   , if the practitioner decides that the plug is not fitting, i.e. “no,” in step  107 , then rather than proceed to step  108  the process continues to step  110 . In step  110 , regardless of the reason that the plug such as  60  or  62  is not fitting, the practitioner is forced to disengage the plug from the thumb forceps to be set down preferably on a sterile surface. This disengagement is caused by the practitioner relaxing their continuous closing pressure being applied in step  106 , thus resulting in opening pressure that causes the distal ends of the forceps to separate, thus dropping (i.e. disengaging) the plug. In step  111 , the two main reasons why the decision of step  107  is “no” are: 1) a different sized plug is needed, or 2) the punctum orifice should be further expanded using a dilator. Both situations are common, but it is most often the case that the practitioner simply needs to further dilate the punctum (i.e. returning to step  103 ). As a careful consideration will show, since the practitioner must maintain a closing pressure on the plug using the thumb forceps, it is not possible to keep the plug engaged by the forceps before returning to step  103 , this is even true if the forceps where further adapted to include an attached dilator. Hence again, if in step  107  the practitioner decides “no” that the plug is not fitting for any reason, it is always necessary to perform step  110 , i.e. disengaging the plug from the thumb forceps where this step only further unfavorably delays the entire process and increases the risk of dropping or damaging the plug. 
     Assuming the most common case that the reason the plug is not fitting is that the punctum needs further dilation, it will then be shown in upcoming  FIG.  3    a distinct advantage of the presently described medical instrument  10 . In this most common case, using the traditional thumb forceps, the practitioner must: 1) disengage the plug and set down the thumb forceps (step  110 ), 2) pick up the dilator tool and further dilate the punctum (step  103 ), 3) set down the dilator tool and then re-select (at least requiring a refocusing of vision and attention) the plug for reinsertion (step  104 ), and then must 4) pick up the thumb forceps and reengage the selected plug. As will be shown with respect to upcoming  FIG.  3   , in the most common case of needing further dilation in response to steps  107  and  111 , the present invention avoids: 1) step  110  of disengaging the plug followed by setting down the thumb forceps; 2) picking up a separate dilator tool to perform step  103  which draws the practitioner&#39;s gaze away from the patient&#39;s punctum (as opposed to flipping the medical instrument  10  in the practitioner&#39;s hand to present the dilator  50  as the functioning end of the instrument  10  while at the same time the practitioner continues to focus their gaze on the punctum); 3) setting down the separate dilator tool in order to pick up the thumb forceps to perform step  105  which draws the practitioner&#39;s gaze away from the punctum (as opposed to flipping the medical instrument  10  in practitioner&#39;s hands to present the distal ends  28  and  48  still engaging the plug as the functioning end of the instrument  10  while at the same time the practitioner continues to focus their gaze on the punctum), and 4) re-focusing on (i.e. selecting) the plug in step  105  and applying closing pressure on the thumb forceps to re-engage the plug which further draws the practitioner&#39;s gaze away from the punctum and delays the medical procedure (again, as opposed to flipping the medical instrument  10  in practitioner&#39;s hands to present the distal ends  28  and  48  still engaging the plug as the functioning end of the instrument  10  while at the same time the practitioner continues to focus their gaze on the punctum). 
     Still referring to  FIG.  2    and the process of the prior art implemented using thumb forceps, at least steps  106  and  110  are especially problematic, and then also steps  103 ,  105  and  109  are non-ideal. 
     Referring next to  FIG.  3   , there is shown a flow diagram describing the basic steps for performing the lacrimal occlusion process  200  using the preferred and herein taught medical instrument  10 . As with traditional process  100 , in the preferred process  200  steps  101  and  102  are first performed by the practitioner for determining both the size of the patient&#39;s punctum (step  101 ) and deciding if the punctum should be dilated (step  102 ). If it is decided that the punctum does not require dilation, the practitioner then proceeds to step  104 , which is the same as in process  100 . If it is decided that the punctum does require dilation, then in step  203  the practitioner selects new medical instrument  10  (rather than a separate dilator) and orients the instrument  10  such that the dilator  50  end is the functioning end (i.e. currently pointing outward/away from the practitioner&#39;s hands and body for use on the patient). After picking up instrument  10 , the practitioner dilates the patient&#39;s punctum using dilator  50  attached to instrument  10 . 
     Still referring to  FIG.  3   , and now proceeding from step  203  to step  104 , the practitioner then selects the appropriately sized plug such as  60  or  62  by scanning with their eyes to find the plug&#39;s location and to confirm the plug&#39;s type and size. Once located and confirmed in step  104  (that is substantially like step  104  in process  100 ), unlike step  105  in process  100 , the practitioner performs a simplified step  205  in process  200 . Specifically, since the practitioner is already holding instrument  10  (for using the dilator  50  in step  203 ), the practitioner then continues to maintain a grasp of instrument  10  rotating the instrument  10  such that the distal ends  28  and  48  are now the functioning end, after which the practitioner applies opening pressure to arms  2  and  4  of instrument  10  to separate distal ends  28  and  48  for surrounding and engaging the selected plug such as  60  or  62 , where a careful consideration will show that after surrounding the plug the practitioner relaxes the opening pressure (thus applying closing pressure) that allows the distal ends  28  and  48  to engage the plug using the positive pressure inherent in the proper construction of instrument  10  (that is typically a spring tension as implied in the depiction of instrument  10  in  FIG.  1   , although many solutions are available as will be well known to those familiar with bulldog forceps). 
     Proceeding now to step  206 , there is another substantial difference to be considered between the present invention and the prior art. In step  206 , as opposed to process  100  step  106 , the practitioner does not need to apply any closing pressure because this closing pressure is being provided by the instrument  10 . Instead, the practitioner is free to use handling pressure alone to manipulate the instrument  10  and thereby the plug such as  60  or  62 , guiding and directing it into the patient&#39;s punctum. As will be clear upon a careful consideration, in process  100  the physical effort of maintaining a sufficient but not excessive closing pressure on the plug using thumb forceps, while then also moving the hand to adjust the plug&#39;s location, is significantly more complex than the presently described step  206  and often exacerbates the unwanted shaking of the practitioner&#39;s hand which further places the patient at risk. As prior discussed, this present instrument  10  and process  200  have many benefits including: 1) reducing any likelihood that the plug is dropped, where dropped plugs cost significant money; 2) decreasing the muscle movement complexity required by the practitioner thus reducing mental stress and physical handing shaking; 3) enhancing the efficiency of the procedure as the practitioner is no longer concerned with dropping the plug and can move the instrument  10  with greater ease, where the increased efficiency results in a minimum of process duration for the patient thus reducing the patient&#39;s mental stress, and 4) decreasing the likelihood of inadvertently touching and possibly hurting the patient&#39;s eye due to the need to manage a greater volume of space created by the separated distal ends of normal resting state thumb forceps as compared to the lesser volume of space created by the touching distal ends  28  and  48  of normal resting state instrument  10  (see step  209 ). Other benefits will be clear to those familiar with the lacrimal occlusion procedure. 
     Still referring to  FIG.  3   , after achieving at least partial insertion of the plug such as  60  or  62  into the patient&#39;s punctum, like process  100 , the practitioner decides in step  107  if the plug is fitting. If the answer is “yes,” then in step  208  the practitioner applies opening pressure to separate the distal ends  28  and  48  of instrument  10  in order to disengage the plug. After disengaging the plug, the practitioner then relaxes the opening pressure (thus applying closing pressure) to the cause the distal ends  28  and  48  to return to a resting, disengaging and touching position. The careful reader will note the advantages that distal ends  28  and  48  of instrument  10  are touching (thus taking up less volume) as opposed to the distal ends of a traditional thumb forceps that are separated while in the resting and disengaged state (thus taking up more volume). As prior mentioned, the total volume encompassed by the touching distal ends  28  and  48  of instrument  10  are less than the total volume encompassed by the distal ends of traditional thumb forceps, thus creating a safer tool for use near the patient&#39;s eye and also making it easier for the practitioner to adjust the instrument  10  for prodding the plug, pushing it further into the punctum as dictated by the chosen medical procedure. 
     If the answer to step  107  (is the plug fitting) is “no,” then unlike process  100  the practitioner is not required to always disengage the plug but rather may first consider in step  210  if a different sized plug is necessary. If a different plug is necessary, then the practitioner completes step  212  and disengages the plug by applying opening pressure. Once disengaged, the practitioner is then free to proceed to step  104  to repeat process  200  from the point of selecting a plug. As those familiar with lacrimal occlusion procedures will understand, it is more often the case that the answer to step  210  (is a different sized plug needed) is “no.” In this case, the present invention offers another significant benefit in that the practitioner is not required to: 1) disengage the plug (process  100 , step  110 ); 2) set down the thumb forceps, and 3) pick up the separate dilator instrument all prior to further dilating the patient&#39;s punctum (process  100 , step  103 ). Furthermore, as a careful comparison of process  200  versus  100  will show, in process  100  after this second dilation (i.e. process  100 , step  103 ) the practitioner then must proceed to step  104  through  105  before again attempting to insert the plug in process  100  step  106 , whereas in process  200 , after completing step  203  the practitioner is enabled to proceed directly to step  206  (i.e. skipping steps  104  and  205  in favor of simply rotating instrument  10  to present the distal ends  28  and  48  still engaging the plug as the functioning end of the instrument  10 ). 
     In summary of the present inventive step  211 , the practitioner keeps the instrument  10  in their hands while rotating the instrument  10  such that the dilator  50  is the functioning end. Once this simple rotation is made, the practitioner is free to dilate the patient&#39;s punctum. After dilation, rather than having to then set down a separate dilator instrument and proceed to a process  100  step  104 ,  105 , etc. using thumb forceps, the practitioner simply rotates the distal ends  28  and  48  (currently and still engaging the prior selected plug), such that the distal ends are the functioning end of instrument  10 . Once rotated, the practitioner then proceeds to step  206  as prior described. 
     Referring now to both  FIGS.  2  and  3   , what is clear is that the new instrument  10  and process  200  offer significant advantages over traditional thumb forceps and a traditional thumb forceps-based process  100 . The use of new instrument  10  and process  200  have many benefits including: 1) reducing any likelihood that a plug is dropped, where dropped plugs cost significant money; 2) decreasing the muscle movement complexity required by the practitioner thus reducing both mental stress and physical hand shaking; 3) enhancing the efficiency of the procedure as the practitioner is no longer concerned with dropping the plug and can move the instrument  10  with greater ease, where the increased efficiency results in a minimum of process time for the patient thus reducing the patient&#39;s mental stress; 4) avoiding the need to always disengage the plug, set down the thumb forceps, and pick up a separate dilator instrument if all that is required during the insertion process is a further dilation of the patient&#39;s punctum, where after dilation the present invention then also avoids needing to set down the separate dilator, pick up the thumb forceps, find and re-engage the plug prior to continuing the insertion step, the excessive combination of which distracts the practitioner&#39;s attention from the patient and increases the duration of the process and the patient&#39;s mental stress; 5) decreasing the likelihood of inadvertently touching and possibly hurting the patient&#39;s eye during adjustment step  209  due to the reduced volume of space taken up by the touching distal ends  28  and  48  of instrument  10  as compared to step  109  where the normally separated distal ends of the thumb forceps create an increased volume making their use as a prodding tool more difficult; and 6) providing the practitioner a single instrument  10  choice between means for prodding, pushing and adjusting the plug during step  209 , where the choice is to use the touching distal ends  28  and  48  or to rotate instrument  10  and use the dilator  50 , where the dilator  50  is especially useful for pushing a intracanalicular plug such as  60  deeper into the canaliculus especially as opposed to using separated thumb forceps distal ends. Other benefits will be clear to those familiar with the lacrimal occlusion procedure, for example, it is sometimes the case that after insertion the practitioner decides it is necessary to remove the plug such as  60  or  62 , in which a careful consideration will show that it is far more efficient for the practitioner to remove the plug using instrument  10  if just prior to this the same plug was being pushed further into the punctum using a dilator therefore requiring a switch back from the dilator to a grasping tool (such as thumb forceps or the distal ends  28  and  48  of instrument  10 ). 
     Referring next to  FIG.  4 A , there is shown a perspective drawing of medical instrument  10  where base  10   a  has been further adapted to accept a detachable dilator  50  (not depicted) or a sizer-dilator  51  (depicted). Sizer-dilator  51  provides both the dilator function of dilator  50  along with the sizer function traditionally provided by a separate medical instrument. In particular, the distal end of sizer-dilator  51  includes a sizer profile  51 - p   1  that is preferably an elongated conical shape increasing continuously and smoothly in diameter starting at the distal tip proceeding at least part way towards the base of sizer-dilator  51 , where the base of sizer-dilator  51  includes a mechanism for attaching to the base  10   a  of instrument  10 . While those familiar with mechanical systems will recognize that many possible mechanisms for attaching a detachable sizer-dilator  51  or dilator  50  to base  10   a  are possible, for example a simple screw/screw hole combination, the preferred detachable sizer-dilator  51  (or detachable dilator  50 ) includes what is herein referred to as a key/lock combination. In the present depiction, the key  51 - k  comprises a “T” shaped member for inserting into a similarly shaped lock  10   a - l  provided by instrument base  10   a . Once the key  51 - k  is inserted into lock  10   a - l , the exemplary sizer-dilator  51  is then rotated or twisted orthogonally with respect to the longitudinal axis of instrument  10  such that the “T” shaped member is then substantially rotated by 90 degrees from its original insertion orientation. 
     Still referring to  FIG.  4 A , as will be clear to those familiar with the lacrimal occlusion process, a sizer is necessarily similar in diameter to a dilator, as both must essentially fit into the patient&#39;s punctum. A traditional punctal sizer is a cylindrical shape that is not increasing in diameter starting at the distal end. Therefore, a traditional single punctal sizer instrument typically includes two opposing ends, where the first end includes a cylinder shape of a first diameter and the second end includes a cylinder shape of a second diameter. Given that the punctum sizes of typical patients range between at least four different orifice diameters, such as 0.2 mm, 0.4 mm, 0.6 mm and 0.8 mm, it is typically necessary for the practitioner to have at least two and often three separate punctal sizer tools for use when determining the size of the patient&#39;s punctum (see step  101  in  FIG.  2    and  FIG.  3   ). As will be clear to those familiar with the lacrimal occlusion process, having a single sizer tool, or a removable sizer-dilator such as  51  comprising a sizer profile  51 - p   1  sufficient for distinguishing between two or more distinct sizes offers significant advantage to be discussed further with respect to upcoming  FIG.  5   . The depicted sizer profile  51 - p   1  of the present figure with an elongated conical shape is more convenient and efficient than working with multiple tools. 
     The preferable sizer, such as sizer-dilator  51 , further includes multiple size markings such as size 1 marking  51 - m   1 , size 2 marking  51 - m   2 , size 3 marking  51 - m   3  and size 4 marking  51 - m   4 , where for example the segment of the elongated conical shape marked as  51 - m   1  has a maximum diameter of 0.2 mm, while the segment of the elongated conical shape marked as  51 - m   2  has a maximum diameter of 0.4 mm, the segment of elongated conical shape marked as  51 - m   3  has a maximum diameter of 0.6 mm, and the segment of elongated conical shape marked as  51 - m   4  has a maximum diameter of 0.8 mm. 
     Still referring to  FIG.  4 A , in the anticipated use of sizer-dilator  51  attached to instrument  10  base  10   a , the practitioner first inserts the sizer-dilator  51  (in step  301 - 303 ,  FIG.  5   ) into the patient&#39;s punctum, continuing to insert sizer-dilator  51  up and until it is recognized that the sizer-dilator  51  has substantially filled the orifice of the punctum. Once reaching this substantially filled depth, the practitioner determines preferably a color of the marked segment such as  51 - m   1 ,  51 - m   2 ,  51 - m   3  or  51 - m   4  that is best representative of the size of the punctum&#39;s orifice, where after the practitioner is then able to select an appropriately sized plug such as  60 - 1 ,  60 - 2 ,  60 - 3  or  60 - 4 , respectively. It is further anticipated that at least some portion of the plugs such as  60 - 1 ,  60 - 2 ,  60 - 3  or  60 - 4  are also color coded or marked in a matching scheme with the markings  51 - m  of sizer-dilator  51 . 
     Referring next to  FIG.  4 B , there is shown on the left a reference art drawing for the traditional substantially cylindrical, single size punctal-sizer instrument, where the instrument is inserted into the patient&#39;s punctum to test the “resistance” provided by the punctum to the substantially cylindrical shape, where each shape is a different “gauge size”. The correct gauge size gives the correct resistance upon both entering and exiting the punctum, where the resistance is fundamentally a judgment made by the practitioner. As will be clear to the careful observer, the combination of for example a small, medium and large gauge size tools is a discontinuous measurement system, whereas the profile  51 - p   1  described in  FIG.  4 A  is a continuous profile capable of determining sizes without resorting to increments such as small, medium and large, and therefore accommodates punctum sizes that are essentially in between for example small and medium, or medium and large. 
     Still referring to  FIG.  4 B , to the right of the reference art drawing there is shown an alternative sizer-profile  51 - p   2  for use with the sizer-dilator  51  (or even a non-detachable version of sizer-dilator  51 ). Rather than providing an elongated conical shape continuously and smoothing increasing in diameter starting at the distal tip proceeding at least part way towards the base of sizer-dilator  51  as depicted in  FIG.  4 A , the sizer-profile  51 - m   2  commences on the far distal end with an optional dilator tip  51 - t , followed by at least one and preferably at least two distinct substantially cylindrical shaped profiles, for example substantially similar to the profiles shown in the reference art drawing of the present figure such as small, medium and large. The present invention further anticipates providing for a traditional separate sizer tool that includes two or more different gauge sizes on a single end of the tool. Those familiar with the lacrimal occlusion process will recognize the benefit of using a traditional separate sizer instrument that has been so adapted to have a profile including at least two gauge sizes (such as presently depicted as profile  51 - p   2 ) as this increases the efficiency of the practitioner whereby choosing for example a further adapted separate traditional sizer tool that includes the sizes small and medium on one end of the instrument and medium and large on the other end at least reduces the number of separate sizer tools thus making the overall procedure more efficient. 
     Based upon a careful consideration of the teachings presented herein, especially those familiar with the lacrimal occlusion procedure and furthermore with traditional sizer instruments for use in determining the size of the patient&#39;s punctum will recognize that multiple various profiles such as  51 - p   1  or  51 - p   2  are possible without departing from the spirit of the invention, and as such the present depictions of sizer profiles  51 - p   1  and  51 - p   2  should be considered as exemplary, rather than as limitations of the present invention. 
     Referring next to  FIG.  5   , there is shown a flow diagram describing the basic steps for performing the lacrimal occlusion process  300  using the preferred and herein taught medical instrument  10  that has been further adapted to use a sizer-dilator  51  (depicted in  FIGS.  4 A and  4 B ) as opposed to dilator  50  (depicted in  FIG.  1   ). A careful comparison with process  200  depicted in  FIG.  3    will show the following differences between process  300  and process  200 . The major difference is that steps  101  (using sizer instrument, determine size of punctum),  102  (should punctum be dilated) and  103  (using dilator  50  on instrument  10 , dilate punctum) have been replaced by a single step  301 - 303 . 
     This is referred to as a single step ( 301 - 303 ) because it is accomplished using a single further adapted instrument  10 , rather than a separate traditional punctal sizer and an instrument  10  as described for use in process  200 . To further highlight the benefit of providing a single instrument  10  capable of providing both the punctal sizing and punctal dilation functions, it should be understood that in traditional practice there is not one punctual sizer tool but often at least a set of three separate punctal sizers, where each punctual sizer in the set accommodates two distinct sizes, one size on each of the instrument&#39;s end points. By providing a single sizer-dilator  51  on instrument  10  with a continuous profile such as  51 - p   1  it is now possible to cover at least two or more punctal sizes with a single detachable sizer-dilator  51 . In an ideal situation the continuous profile  51 - p   1  is usable to determine the entire range of punctal sizes (e.g. 0.2 mm through 0.8 mm) and as such a single instrument  10  is further adapted to include such an ideal profile sizer-dilator  51  as either a detachable sizer-dilator  51  using a key-and-lock (as depicted in  FIG.  4 A ) or alternative detachable mechanism or a permanently affixed sizer-dilator  51  (similar to dilator  50  as depicted in  FIG.  1   .) 
     Still referring to  FIG.  5   , if an ideal sizer-dilator  51  profile is used, then step  301 - 303  is accomplished with a single tool  10  as taught herein, where the practitioner commences the process  300  in step  301 - 303  by solely using the further adapted instrument  10  including a sizer-dilator such as  51  with a single ideal profile. In a variation of process  300 , it is also possible that the entire range of possible punctum sizes is divided into N ranges, where a range N includes at least 2 of the traditional sizes, such as small and medium, or 0.4 mm and 0.6 mm. Each of the N ranges therefore preferably includes a unique sizer-dilator  51  with a profile such as  51 - p   1  or  51 - p   2  covering the traditional sizes of that range. Each of these unique sizer-dilators  51  is then preferably in a detachable form (such as the key-lock form depicted in  FIG.  4 A ) such that in a first step  301  (i.e. rather than a combined step  301 - 303 ) the practitioner makes a visual judgment and selects the anticipated best detachable sizer-dilator  51  for attaching to instrument  10  as a part of performing a separate step  301 . If the visual judgment selection is correct, then the practitioner is able to both determine the punctal size and dilate the punctum using the selected sizer-dilator  51  that has been attached to instrument  10 . If the visual judgement selection is incorrect, then the practitioner disengages the first selected sizer-dilator  51  in favor of a second selected sizer-dilator  51  accommodating different traditional sizes. As a careful consideration will show, as the total number of ranges N decreases, meaning that each range includes more possible punctal sizes, the number of possible separate sizer-dilator  51  choices decreases, where again, the ideal is a single range such that N=1 and covers all sizes. 
     Referring still to  FIG.  5   , a careful consideration will show that it is also possible that the N ranges are overlapping in size, for example a first range covers sizes 0.2 mm-0.5 mm, a second range covers sizes 0.4 mm-0.7 mm and a third range covers sizes 0.6 mm-0.9 mm. In such an arrangement, the practitioner&#39;s judgment call is made simpler since for example the practitioner could consider the first range to be “small”, the second range to be “medium” and the third range to be “large”, where the presumption is that the majority of the time the practitioner is then able to make a visual examination of the patient&#39;s punctum and then properly select the correct small, medium or large punctal sizer-dilator  51  thus accomplishing step  301 - 303  using a single instrument  10 . It should also be noted that it is possible that the practitioner has in this example 3 distinct instruments  10 , each distinct instrument  10  with a different small, medium or larger sizer-dilator  51  that is permanently attached. Using three instruments then avoids the requirement of selecting a detachable sizer-dilator and then attaching the sizer-dilator  51  to the instrument  10  prior to use. As will be understood by those familiar with the lacrimal occlusion process, creating a combined instrument  10  that preforms all of the sizer, dilator and plug insertion functions has significant advantages and that of the many variations discussed herein, there are different benefits to each variation. As will also be clear, other variations are possible while still staying within the spirit of a 3-in-1 lacrimal plug inserter. 
     And finally, still referring to  FIG.  5   , process  300  after step  301 - 303  is substantially identical to process  200  with only the small exception that process  200  step  211  (using dilator  50  on instrument  10 , dilate punctum) is replaced with process  300  step  311  (using sizer-dilator  51  on instrument  10 , dilate punctum). 
       FIG.  6 A  depicts eight various types of thumb forceps known in the art, and more specifically depicts different forms of distal ends (herein also referred to as “tips”) found to be useful for either the lacrimal occlusion procedure or other various medical procedures, where any of these same ends may be incorporated with the present invention. Thus, as will be clear to those skilled in the art, the present invention may be further adapted to include other types of distal ends for example as found on traditional thumb forceps whereby the other advantages of the present instrument  10  are then combined with the advantages of the existing art instrument distal ends. For example, the distal ends  28  and  48  of the present invention  10  as depicted and described in relation to  FIGS.  1  and  1 B  can alternately be implemented to look and function substantially like what is referred to in the art as an “angled-tip plug Insertion (API)” tip, whereby instrument  10  is still intended for use in the lacrimal occlusion medical procedure. Alternatively, the prior described distal ends  28  and  48  could be implemented to look and function substantially like what is referred to in the art as a “cilia” tip, whereby instrument  10  has therein been further adapted for use in the medial procedure referred to as trichiasis. 
     What is important to see is that there are many benefits herein taught with respect to instrument  10 , wherein these benefits are not strictly relegated to the form of distal ends  28  and  48 , as many forms are possible and will be apparent to those skilled in the art, especially with respect to the lacrimal occlusion procedure, but also with respect to other medical procedures, and even to non-medical procedures. Thus, in keeping with the spirit of the invention, the various instrument  10  parts depicted herein such as distal ends  28  and  48 , proximal end dilator  50  or sizer-dilator  51 , or even arms  2  and  4  should be considered as exemplary rather than as limitations of the present invention. Those skilled in the art of medical instruments will realize that each of the various parts of instrument  10  described herein may be altered with respect to form or material construction without departing from the intentions and purposes of the respective parts, and therefore many variations are anticipated. 
     Referring next to  FIG.  6 B , there is shown a perspective drawing of medical instrument  10  that has been further adapted to allow instrument  10  to function with an interchangeable range of possible distal end tips, such as those depicted in  FIG.  6 A . In reference to prior  FIG.  1   , holding surface  10   d  was taught to be formed by the distal ends  28  and  48  of arms  2  and  4 , respectively, where in  FIG.  1    distal ends  28  and  48  where non-detachable (i.e. permanent). In the present  FIG.  6 B , distal end  28  of arm  2  has been further adapted to include permanent base  28 -base for receiving any of detachable tips such as “cilia” style tip  28 -tip 1 . Likewise, distal end  48  of arm  4  has been further adapted to include permanent base  48 -base for receiving any of detachable tips such as “cilia” style tip  48 -tip 1 . As will be clear from a careful consideration of the present figure and the teaching provided herein, instrument  10  may be implemented with any combination of: 1) a permanent proximal end such as dilator  50  depicted in  FIG.  1    or an interchangeable proximal end for receiving for example detachable sizer-dilator  51  including any number of profiles such as  51 - p   1  or  51 - p   2 , and 2) a permanent distal end such as distal ends  28  and  48  depicted in  FIG.  1    or an interchangeable distal end including bases  28 -base and  48 -base, respectively, for receiving for example detachable cilia style tips  28 -tip 1  and  48 -tip 1 , respectively, or an adaptable distal end including latches for receiving tip sleeves (see upcoming  FIGS.  6 D,  6 E,  6 F,  6 G and  6 H ). 
     Referring next to  FIG.  6 C  detachable distal tip  48 -tip 1  is show as detached from distal base  48 -base and furthermore rotated orthongally with respect to the final attached position depicted in  FIG.  6 B . Distal tip  48 -tip 1  is depicted as including an attaching member such as key  48 -tip 1 - k  while distal base  48 -base is depicted as including a receiving member such as lock  48 -base-l. This “key-and-lock” system is preferably the same as prior described in  FIG.  4 A  in relation to detachable sizer-dilator  51  including key  51 - k  and instrument base  10   a  including lock  10   a - l . As also prior mentioned in relation to  FIG.  4 A , those familiar with mechanical systems will recognize that there are many possible mechanisms for attaching a detachable distal end tip such as  28 -tip 1  or  48 -tip 1  to a base such as  28 -base or  48 -base, respectively, and as such the present depiction should be considered as exemplary rather than as a limitation of the present invention. It is even possible that the key-lock mechanical systems depicted in both  FIG.  4 A  and the present  FIG.  6 C  can be modified while still staying with the spirit of a key and lock, where for example the shapes of the key such as  48 -tip 1 - k  and lock such as  48 -based are modified in such a way that the detachable tip such as  48 -tip 1  is limited to being inserted into lock  48 -based from only one of the two possible (preferably, but not necessarily) orthogonal rotations. Furthermore, the interior (not depicted) of a lock such as  48 -base-l may be shaped in such a way that after insertion of a key such as  48 -tip 1 - k  into lock  48 -base-l, tip  48 -tip 1  may only be rotated in a single direction, for example clockwise when viewed from the distal end of instrument  10  looking towards the proximal end of instrument  10 , as presently depicted. 
     Referring next collectively to  FIGS.  6 D,  6 E,  6 F,  6 G and  6 H , there is depicted a further adaptation to instrument  10  for attaching and detaching tip sleeves that substantially slide over and cover each or either of distal ends  48  and  28  in order to provide the practitioner with different optional distal end tips such as those depicted in  FIG.  6 A  or otherwise well-known in the reference art. The figures collectively teach the adaptations to instrument  10  and introduce new tip sleeves, trays for holding tip sleeves, boxes for holding trays and racks for holding boxes. 
     Referring next exclusively to  FIG.  6 D  there is shown a perspective drawing of the distal end of instrument  10 , where distal end  48   a  and  28   a  have been further adapted to include latches  48   a - l  and  28   a - l , respectively, for securing tip sleeves  49   a  and  29   a , respectively, and where sleeves  49   a  and  29   a  further include interior companion latches (not depicted) for engaging latches  48   a - l  and  28   a - l  and exterior companion latches  49   a - l  and  29   a - l  for engaging a tray (see  FIG.  6 E ). As will be well understood by those familiar with mechanical systems, there are many types of latches, especially those including spring action, the many of which are sufficient for the present purposes. In one embodiment as herein depicted, the distal end latch such as  48   a - l  comprises an indentation of some shape into which the interior companion latch (not depicted) within tip sleeve such as  49   a  at least partially engages, or enters, as the tip sleeve  49   a  is slide onto and over the distal end such as  48   a . For example, the interior companion latch of sleeve  49   a  could be a ball mounted with an opposing spring essentially pushing the ball in the direction of the surface of distal end  48   a  comprising latch  48   a - l . In this regard, the exact shape of distal end  48   a , as well as the location on the surface of  48   a , wherein a securing latch such as  48   a - l  (and therefore also its companion latch within sleeve  49   a ) is located is not restricted, as many options are available and possible. Furthermore, the number of latches  48   a - l  (where two are depicted although only one is labeled) and companion latches within sleeve  49   a  is also optional. What is most important to see is that: 1) the latch such as  48   a - l  operates automatically to engage the companion latch comprised within the respective tip sleeve such as  49   a , for example in response to the sliding on and over of a tip sleeve such as  49   a , and 2) the latch or latches such as  48   a - l  as well as the companion latches within sleeve  49   a , in any form, number or combination, causes what is herein referred to as a sleeve holding pressure, and that collectively the latches operate together as a securing means for a replace tip such as  49   a.    
     As a careful consideration of the teachings herein provided will see, in the normal uses anticipated for instrument  10 , there is anticipated to be minimal forces opposing this sleeve holding pressure, but in any case the types, forms, locations, or number of implemented securing latches may be designed and implemented accordingly such that the combined sleeve holding pressure is sufficient to ensure that a tip sleeve such as  49   a  remains securely attached to its companion distal end such as  48   a  after engagement and during normal operation of the present instrument  10 . 
     Still referring to  FIG.  6 D , it is possible that a given latch operates at least in part using a magnet either or both located or secured within the distal end such as  48   a  or the tip sleeve such as  49   a . Still other considerations will show that the tip sleeve such as  49   a  may have alternate designs where the sleeve includes interior posts substantially oriented in the direction of engagement, and that these interior posts slid into interior post holes co-located within the distal end such as  48   a . Conversely, the posts could be included on the distal end such as  48   a , whereas the post holes could be co-located within the sleeve such as  49   a . One advantage of the present depiction of latches such as  48   a - l  (of some type and in some form, location and number) as opposed to the co-location of one or more posts and post holes is that using this latch type design the existing distal end  48   a  may include a usable tip-type of its own, such as the pointed tips as shown (see also  FIG.  1   ), as long as this usable tip is able to slide within a given tip sleeve such as  49   a . Given the considerations and teachings of  FIG.  6 D , it should therefore be understood that the present depictions and descriptions are exemplary and should not be considered as limitations of the present invention as many variations are possible and anticipated as within the scope of the present invention. 
     Referring next to  FIG.  6 E , there is shown a perspective drawing of sleeve box  70 , comprising sleeve trays  49   a - t  and  29   a - t  for receiving, holding and discharging any of sleeves  49   a  and  29   a , respectively. Each tray  49   a - t  and  29   a - t  such as  49   a - t  preferably further comprises a first tray cavity  49   a - tc   1  for holding the non-tip portion of a sleeve such as  49   a , a second tray cavity  49   a - tc   2  for holding the tip portion of a sleeve such as  49   a , an interior latch  49   a - tl  for impeding the lateral exit motion of a sleeve such as  49   a  and a lateral tray entrance  49   a - te  for receiving and discharging the distal end of instrument  10  such as  48   a  being either inserted into or removed from a sleeve such as  49   a  held within tray  29   a - t , all of which is further best understood in light of upcoming  FIGS.  6 F and  6 G . Similar to the discussions respective of distal end latches such as  48   a - l  and  28   a - l  and corresponding interior companion latches (not depicted) located within tip sleeves  49   a  and  29   a , it is possible that for example tip sleeve  49   a  exterior companion latch  49   a - l  (see  FIG.  6 D ) and corresponding interior latch  49   a - tl  of tray  49   a - t  be of many various types, forms, locations and multiplicities. 
     As a careful consideration will show, the presently depicted tray interior latch  49   a - tl  forms a lip segregating the portion of tray  49   a - t  serving as the tray entrance  49   a - te  (that is therefore narrower in dimension) from the portion of the tray  49   a - t  serving as the first cavity  49   a - tc   1  (that is therefore wider in dimension), all as depicted. Given such an arrangement as depicted, and as further shown with respect to upcoming  FIGS.  6 F and  6 G , the use of the present lip  49   a - tl  restricts the movement of any tip sleeve such as  49   a  resting within tray cavities  49   a - tc   1  and  49   a - tc   2  from being extracted from the tray in a lateral motion with respect to the tray&#39;s longitudinal axis, where this extraction is essentially impeded by the narrowed potion of tray entrance  49   a - te  with respect to the wider potion of tray cavity  49   a - tc   1 . 
     Still referring to  FIG.  6 E , those familiar with latches specifically and mechanical systems in general will understand that many variations are possible while staying within the spirit of the present invention. What is important to see is that any tip sleeve such as  49   a  has an entrance/exit path into the corresponding cavities  49   a - tc   1  and  49   a - tc   2  of tray such as  49   a - t  of box  70  that is limited to a specific and substantially unimpeded direction, in this case perpendicular to the longitudinal axis of tray  49   a - t  of box  70  (see especially upcoming  FIG.  6 G  for further discussion). As a careful consideration will show, the present and preferred design provides first and second cavities  49   a - tc   1  and  49   a - tc   2  sufficient for receiving the entirety of a tip sleeve such as  49   a  being lowered into (or raised from) tray  49   a - t  substantially unimpeded in the perpendicular direction with respect to the longitudinal axis of tray  49   a - t . What is also important to see is that while resting within tray  49   a - t , tip sleeve  49   a  can be either engaged or disengaged by a distal end of instrument  10 , such as distal end  48 , where this direction of engagement/disengagement is substantially different from the direction of removal/replacement (see  FIG.  6 G ), for example being an lateral direction with respect to the longitudinal axis of tray  49   a - t , where as depicted the lateral direction is substantially parallel to the longitudinal axis of tray  49   a - t  and therefore also substantially orthogonal to the perpendicular path of removal/replacement. 
     As will be clear from a careful consideration of the present  FIG.  6 E  and related  FIGS.  6 D,  6 F and  6 G , tray latch  49   a - tl  effectively provides a resistive impedance for overcoming the combined sleeve holding pressure as prior described in relation to  FIG.  6 D , such that when the distal end such as  48   a  is being extracted from a corresponding and currently engaged sleeve  49   a , where the sleeve  49   a  is already resting within tray  49   a - t , the tip sleeve  49   a  is thereby caused by the resistive impedance of tray latch  49   a - tl  to disengage from the distal end  48   a  such that the distal end  48   a  is extracted from within the sleeve  49   a , within the tray  49   a - t , exiting through tray entrance  49   a - te , whereas the tip sleeve  49   a  remains situated within the tray  49   a - t . It should be noted that the resistive force available from tray latch  49   a - tl  is dependent upon the forces that secure box  70  to a surface upon which box  70  is resting during the normal use of the proposed box  70 . For example, box  70  may be resting upon a rubberized mat on a table where the rubberized mat provides a frictional force that sufficiently exceeds the combined sleeve holding pressure (force) such that the box  70  does not slip or slid across the resting surface during the extraction of a distal end such as  48   a  from a sleeve such as  49   a . Alternatively, the box  70  could be attached or mounted to the resting surface below the box, or even heavily weighted, where many variations are possible as will be well understood by those familiar with mechanical systems, all of which are considered within the scope and spirit of the present invention. 
     Still referring to  FIG.  6 E , it is preferable but not mandatory that the end of box  70  comprising entrances such as  49   a - te  be of a greater first height  70 - h   1  respective to a lesser second height of  70 - h   2  corresponding to the opposite end of box  70  comprising second cavities such as  49   a - tc   2 . As a careful consideration of the present teachings will make clear, given this disparity between heights  70 - h   1  and  70 - h   2 , box  70  will essentially appear to a practitioner situated on the entrance side (comprising  49   a - te ) of box  70  to lean down and away. As will also be clear based upon a mental visualization of the hand motions required of the practitioner with respect to the use of instrument  10  with respect to tray  70 , the practitioner must rotate the instrument  10  such that the distal ends  48   a  and  28   a  are aligned side-by-side with respect to the surface upon which box  70  resides, where in this alignment it is preferred that the practitioner&#39;s hand is facing palm-up verses palm-down. 
     In such a palm-up orientation, the fingers and knuckles of the practitioner&#39;s hand that is holding instrument  10  are facing substantially downward and therefore not obscuring the view of the practitioner with respect to the box  70  and sleeves such as  49   a  and  29   a  resting within the box  70 . Furthermore, a careful consideration will also show that by leaning the trays such as  49   a - tc   1  downward and away from the practitioner and the entrance such as  49   a - te  of box  70  (corresponding to height  70 - h   1  being greater than  70 - h   2 ), additional clearance space is provided for the downward facing fingers and knuckles of the practitioner&#39;s hand that is holding instrument  10 . Other alternative box  70  constructions are possible without departing from the spirit of the present invention and the core teachings provided herein. For example, the heights  70 - h   1  and  70 - h   2  could be substantially similar (or even reversed where height  70 - h   2  exceeds height  70 - h   1 ) and the box  70  could be adapted to situated at the edge of a mounting surface (such that the practitioner&#39;s fingers do not encounter the surface as the practitioner&#39;s hand moves the distal ends  48   a  and  28   a  of instrument  10  into their respective tray entrances such as  49   a - te  (and a similar  29   a - te  not depicted). Alternatively, the box  70  could have downward facing mounting posts or be enlarged to increase the effective distance between the bottommost interior height of a tray such as  49   a - t  and the surface upon which the box  70  is situated, thereby also or additionally creating further clearance for the practitioner&#39;s downward facing fingers. And finally, its is possible that box  70  comprise a single tray such as  49   a - t  and therefore comprises no second tray such as  29   a - t , wherein for example instrument  10  has only a single replaceable distal end such as  48   a  (and therefor  28   a  is obviated in favor of distal end  28  without securing means) or both distal ends  48   a  and  28   a  are included in instrument  10  where the practitioner chooses to fasten a single tip sleeve such as  49   a  at a time, where it should then be seen by a careful consideration that a single tray such as  49   a - t  holding a single sleeve such as  49   a  could service either distal end such as  48   a  or  28   a . Thus, the presently depicted box  70  (and upcoming rack of boxes  72  shown in  FIG.  6 H ) should be considered as exemplary, rather than as a limitation of the present invention as many variations are possible and anticipated without departing from the spirit of the invention. 
     Referring next to  FIG.  6 F , there is shown a perspective view of instrument  10  further adapted as described in  FIG.  6 D  to comprise distal ends  48   a  and  28   a  partially inserted into sleeves  49   a  and  29   a , respectively, where sleeves  49   a  and  29   a  are being held within trays  49   a - t  and  29   a - t , respectively, comprising sleeve box  70  as described in  FIG.  6 E . The purpose of  FIG.  6 F  is to provide an additionally clarifying perspective view of tray  70  as described in  FIG.  6 E  holding tip sleeves  49   a  and  29   a  as described along with partially inserted instrument  10  distal ends  48   a  and  28   a  all as described in  FIG.  6 D . 
     Referring next to  FIG.  6 G , there is shown a side view diagram depicting three steps 1, 2 and 3 for first inserting (steps 1 and 2) via substantially a lateral motion distal ends such as  48   a  comprising latch  48   a - l  into sleeves such as  49   a  held within sleeve box  70 , and second removing (step 3) via substantially a perpendicular motion sleeves such as  49   a  now secured via an interior latch (not depicted) to a distal end latch such as  48   a - l , where in the perpendicular motion exterior latch  49   a - l  of sleeve  49   a  is substantially unimpeded by tray box  70 , and where the combination of steps 1, 2 and 3 is pictorially shown as “engage” and “remove”. Whereas steps 1, 2 and 3 allow for the engagement and removal of sleeves such as  49   a  from the tray box  70  by instrument  10 , a reversal of steps 1, 2 and 3 further allow for the “replacement” and “disengagement” of sleeves such as  49   a  from tray box  70  by instrument  10 , wherein during the reversal of step 3 tray box  70  substantially impedes the removal of a sleeve such as  49   a  by catching exterior companion latch  49   a - l  during the extracting lateral motion, thereby disengaging a sleeve such as  49   a  from a distal end such as  48   a.    
     Referring next to  FIG.  6 H , there is shown a side-perspective view of a tray rack  72  for example comprising three tray boxes  70 - 1 ,  70 - 2  and  70 - 3 , where instrument  10  is depicted as removing (or replacing) sleeves from tray box  70 - 1  in accordance with the steps 1, 2 and 3 described  FIG.  6 G . As will be obvious to those skilled in the arts for which the instrument and tip sleeves are intended, such as but not limited to one or more medical or non-medical applications including the lacrimal occlusion procedure, the number of trays such as  70 - 1 ,  70 - 2  and  70 - 3  in a given rack such as  72  may be varied as desirable without departing from the scope and spirit of the present invention. Many other rack  72  designs are possible, where the number and size of trays such as  70 - 1  are varied, as well as their relative arrangements. It is not mandatory that the racks such as  70 - 1 ,  70 - 2  and  70 - 3  are in a horizontal arrangement and can alternately or additionally be provided in a vertical arrangement, although such an arrangement must necessarily leave sufficient space over each tray for ease of tip sleeve replacement and removal. Therefore, the presently depicted rack  70  should be considered as exemplary, rather than as a limitation of the present invention, as many other configurations of trays are possible and anticipated. 
     Referring next collectively to  FIGS.  7 A,  7 B,  8 A,  8 B,  9 A,  9 B,  10 A and  10 B , there are depicted four different mechanisms for providing the function of clamp-limiting, where the holding surface  10   d  is mechanically blocked from completely closing given the absence of any engaged plug such as  60  or  61 . As prior discussed, unlike thumb forceps where the closing pressure is applied by the practitioner as a continuous pressure to be maintained throughout at least the plug insertion step  106  (see  FIG.  2   ), the present instrument  10  provides inherent positive (closing) pressure between distal ends  28  and  48  such that the practitioner only maintains holding pressure to maneuver the instrument  10  during plug insertion step  206  (see  FIG.  3   ), regardless of the form of the distal ends such as pointed, rounded, curved, or any of the various reference art shapes including those depicted in  FIG.  6 A , and regardless of the type of the distal ends such as permanent ( FIG.  1   ) versus detachable ( FIGS.  6 B,  6 C,  6 D,  6 F and  6 G ). As those familiar with plugs and the lacrimal occlusion medical procedure, as well as other medical procedures for which a clamping action is desired, the ability to limit the clamping pressure for example when engaging a larger sized plug made of a softer material has significant advantages. 
     Referring next exclusively to  FIG.  7 A , there is shown distal end  48   b  that has been further adapted to include a first clamp-limiting screw type mechanism that includes a knob  48   b - k  for turning by the practitioner. As those familiar with screw action will understand, as the practitioner turns the knob  48   b - k  both the knob  48   b - k  and screw  48   b - s  extending from the knob  48   b - k  are either lowered into the holding space between distal ends  48   b  and  28  or are raised out of the holding space between distal ends  48   b  and  28 . As will be clear from a careful consideration of the present figure, the length of the screw  48   b - s  present in the holding space has a proportional effect on the tip gap between the distal ends, such that by limiting the tip gap to some non-zero amount, where with a zero amount gap distal end  48   b  comes into contact with distal end  28 , it is possible to thereby limit the clamping pressure. 
     Referring next exclusively to  FIG.  7 B , distal end  48   b  has been further adapted to include markings  48   b - m  including  48   b - m   1 ,  48   b - m   2 ,  48   b - m   3  and  48   b - m   4  for corresponding with sizer markings such as  51 - m   1 ,  51 - m   2 ,  51 - m   3  and  51 - m   4 , respectively (see also  FIG.  4 A ). Preferably, markings  48   b - m  also include a marking  48   b - m   0  representing a zero-amount gap (that does not have a corresponding  51 - m   0  marker), where marking  48   b - m   0  represents the fully closed tip gap as opposed to markings  48   b - m   1 ,  48   b - m   2 ,  48   b - m   3  and  48   b - m   4 , each corresponding to some non-fully-closed tip gap. As will be clear from a careful consideration of the present figure, by arranging the markings  48   b - m  around the knob  48   b - k  and by including a mark on the top surface of the knob for indicating the current turning position (see the dark triangle), it is possible to provide the practitioner with a visible indication as to the amount of knob turning necessary to reach a desired tip gap based upon for example the size of the punctum as determined using a sizer-dilator  51  with markings  51 - m   1 ,  51 - m   2 ,  51 - m   3  and  51 - m   4 . As will be clear to those familiar with mechanical systems and medical tools, other variations of markings such as  48   b - m  are possible without departing from the spirit of the invention, and as such the present markers depicted, including the number of markings such as  48   b - m   0 ,  48   b - m   1 ,  48   b - m   2 ,  48   b - m   3  and  48   b - m   4 , as well as at least the color, size, shape and location of the markings  48   b - m  should be considered as exemplary, rather than as a limitation of the present invention. 
     Referring next collectively to  FIGS.  8 A,  8 B,  9 A,  9 B,  10 A and  10 B , it is herein noted that for the sake of clarity and focus on the depicted clamp-limiting mechanisms, no markings like  48   b - m  such as  48   b - m   0 ,  48   b - m   1 ,  48   b - m   2 ,  48   b - m   3  and  48   b - m   4  have been depicted in these upcoming figures. However, the present invention anticipates the use of some type of markings such as  48   b - m  depicted in  FIG.  7 B  for each of the various clamp-limiting means herein taught with respect to  FIGS.  8 A,  8 B,  9 A,  9 B,  10 A and  10 B , such that regardless of the type of clamp-limiting means implemented in the instrument  10 , markings such as  48   b - m  are made available to assist the practitioner with setting the mechanical clamp-limiting mechanism to correspond to a determinized size of for example a punctum orifice. As will be clear upon a careful consideration of the upcoming clamp-limiting means as depicted in  FIGS.  8 A,  8 B,  9 A,  9 B,  10 A and  10 B , many variations of markings such as  48   b - m  are possible and further anticipated within the spirit of the present teachings. 
     Referring next to  FIGS.  8 A and  8 B , there is shown an alternative distal end  48   c  that has been further adapted to include mechanical means for limiting the clamping pressure of instrument  10 , where the mechanical means is a sliding wedge  48   c - w  that is moved forward by the practitioner pushing the sliding wedge knob  48   c - k  towards the distal end of instrument  10  to widen the tip gap (and therefore further limit the closing pressure), and is moved backward by the practitioner pulling the sliding wedge know  48   c - k  away from the distal end of instrument  10  to narrow the tip gap (and therefore further increase the closing pressure). 
     Referring next to  FIGS.  9 A and  9 B , there is shown an alternative distal end  48   d  that has been further adapted to include mechanical means for limiting the clamping pressure of instrument  10 , where the mechanical means is a rotating oblong wheel  48   d - w  that is rotated for example clockwise by the practitioner likewise rotating knob  48   d - k  clockwise to widen the tip gap (and therefore further limit the closing pressure), and is rotated for example counter-clockwise by the practitioner likewise rotating knob  48   d - k  counter-clockwise to narrow the tip gap (and therefore further increase the closing pressure). 
     Referring next to  FIGS.  10 A and  10 B , there is shown alternative wide portions  24   e  and  44   e  comprising grasping surface  10   b  that have been further adapted to include mechanical means for limiting the clamping pressure of instrument  10 , where the mechanical means is pivoting rachet arm  44   e - r  pivotally attached to wide portion  44   e  that slides through an opening in wide portion  24   e  as the practitioner exerts an opening pressure (as prior described in relation to  FIG.  1   ) upon wide portions  24   e  and  44   e  so as to reduce the arm space and inversely increase the tip gap, and where the mechanical means further includes a return pressure means such as spring  24   e - s  located within the opening in wide portion  24   e  that applies return pressure upon rachet arm  44   e - r  so as to cause rachet arm  44   e - r  to catch and re-catch upon wide portion  24   e , all as will be well understood by those familiar with a rachet mechanism. The effect of the operation of rachet  44   e - r  and spring  24   e - s  is that as the practitioner releases the applied opening pressure upon wide portions  24   e  and  44   e  spring  24   e - s  causes the rachet  44   e - r  to catch up wide portion  24   e  such that the normal inherent closing (positive) pressure of the bulldog forceps is impeded, thus fixing the arm space and therefore tip gap at a distance substantially determined by the extent of the opening pressure applied by the practitioner. In order to restore the maximal closing (positive) pressure inherent within the design of instrument  10 , the practitioner exerts a forward pressure upon the portion of rachet  44   e - r  protruding through the opening in wide portion  24   e  that moves the rachet  44   e - r  forwards towards the distal end of instrument  10 , where this exerted forward pressure counteracts and overcomes the return pressure applied by spring  24   e - s  thus allowing wide portions  24   e  and  44   e  to fully separate increasing the arm space to a maximum while inversely decreasing the tip gap to a minimum. 
     Referring next to  FIGS.  11 A and  11 B , the distal ends  28  and  48  of rachet type clamp-limiting medical instrument  10  as taught in relation to  FIGS.  10 A and  10 B  have been further adapted as distal ends  28 tip 2  and  48 tip 2  including tissue separating style tips. As those familiar with medical instruments will understand, there are multiple designs currently known and otherwise possible for facilitating the tissue separating function and therefore the present depictions should be considered as exemplary rather than as a limitation of the presentation invention. What is important to see is that the medical instrument  10  that has been further adapted with a rachet style clamp-limiting means such as taught in relation to  FIGS.  10 A and  10 B  provides a means for separating tissue substantially proportional to the amount of opening pressure applied by a practitioner to wide portions  24   e  and  44   e , where increased opening pressure causes increased separating pressure applied on the tissue (or matter to be separated) by distal tips  28 tip 2  and  48 tip 2 . Once a preferred tissue separation pressure and therefore also tissue separation distance has been achieved by the practitioner in operation of the further adapted instrument  10  as presently depicted and described especially in relation to  FIGS.  10 A and  10 B , the included rachet mechanism serves to lock-in the substantially final separation of distal end  28 tip 2  and  48 tip 2 . Also, as prior discussed, the practitioner releases this final applied separating pressure thus reducing the final achieved separating distance between distal end  28 tip 2  and  48 tip 2  by exerting a forward pressure upon the portion of rachet  44   e - r  (see the teachings in relation to  FIGS.  10 A and  10 B ), thus disengaging the rachet. 
     CONCLUSION AND RAMIFICATIONS 
     Thus, as the reader can see, the present two-in-one inventive medical instrument  10  and lacrimal occlusion process  200  includes at least the following improvements with respect to process traditional process  100 : 1) increasing the continuous concentration and focus of the practitioner thus reducing the likelihood of inadvertent physical harm to the patient; 2) reducing the practitioner&#39;s physical muscle stresses and potential attendant hand shaking by eliminating the need for applying continuous closing pressure while simultaneously moving the instrument  10  for plug insertion; 3) reducing the overall mental stresses on both the patient and the practitioner; 4) reducing the likelihood of dropping plugs and therefore decreasing the average material cost to the practitioner, and 5) reducing the average process time duration and therefore also average time cost to the practitioner. Other important benefits have been detailed herein and will be obvious to those skilled in the art of lacrimal occlusion. 
     Furthermore, based upon the further adaptation of medical instrument  10  providing for a combined sizer-dilator  51 , and thus a three-in-one tool, the reader can see that the lacrimal occlusion process  300  includes at least the following improvements with respect to process  200 : 1) further increasing the continuous concentration and focus of the practitioner thus reducing the likelihood of inadvertent physical harm to the patient; 2) further reducing the overall mental stresses on both the patient and the practitioner, and 3) further reducing the average process time duration and therefore also average time cost to the practitioner. 
     As the reader will also see, the present instrument  10  further provides for permanent or detachable proximal or distal ends, where for example based upon the orientation of the instrument  10  the proximal ends could be a dilator  50  or a sizer-dilator  51  and the distal ends could be any of various end tips such as  48 -tip 1  or  28 -tip 1 , or end tip sleeves such as  49   a  or  29   a , where the shape and function of these various end tips and tip sleeves can at least match any of the shapes and functions currently used in the reference art for various medical procedures including lacrimal occlusion, trichiasis, and tissue separation. Those skilled in other non-medical arts will recognize that the many teachings of the present invention provide significant benefits for non-medical uses. With respect to the detachable distal end sleeves  49   a  and  29   a , the present reader will also see that a new system has been provided for allowing the practitioner to efficiently select, replace or switch between a number of different end tip sleeves using only a single hand, thus further facilitating the optimization of at least medical procedures such as lacrimal occlusion. This new system comprises at least one box  70  comprising two trays  49   a - t  and  29   a - t , where each tray holds a replaceable sleeve  49   a  or  29   a , respectively, for one of the instrument&#39;s  10  distal ends such as  48   a  or  28   a , respectively. It is further anticipated herein that this same teaching for replaceable distal end tips complete with the rack, box and tray system, is also applicable for implementation with the detachable proximal ends, hence supporting multiple dilators or sizer-dilators. This anticipated further adaptation thus additionally provides for allowing the practitioner to efficiently select, replace or switch between a number of different dilators or sizer-dilators using only a single hand. In one distinction, the proximal end tray system only requires one tray per box, as will be obvious to the careful reader. 
     And finally the reader will also see that the present teachings provide mechanical means for allowing the practitioner or user of the instrument  10  to limit the inherent closing (positive) pressure applied by the end tips, where this clamp-limiting is useful both to set the smallest tip gap (for example for use in a grasping function) and to maintain the largest tip gap (for example for use in a separating function.) 
     The careful reader familiar with the necessary technologies for manufacturing instruments such as described herein will understand that many embodiments are possible for implementing the functional teachings of the present invention. As such, it will be well understood that the preferred and alternate embodiments of the presently taught apparatus and methods, as well as the many taught use cases, should be considered as exemplary, rather than as limitations to the present invention. While certain features of the invention have been illustrated and described herein, other modifications and changes will occur to those skilled in the art. It is, therefore, to be understood that the appended claims are intended to cover all such modifications and changes as fall within the true spirit of the invention.