Punctoplasty

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Punctoplasty can be performed to widen the punctal opening and to improve the drainage of tears in patients with punctal stenosis, which is an abnormal narrowing of the lacrimal punctum, oftentimes caused by inflammation. ^[1] Punctal stenosis can cause a total or relative obstruction of the drainage system of the eye, resulting in excessive epiphora.

Punctoplasty is indicated for excessive epiphora that is secondary to outflow obstruction from punctal stenosis.

Punctoplasty is contraindicated when excessive tearing is not secondary to punctal stenosis.

Stenosis recurrence can occur if the raw cut edges of the punctum and canaliculi re-approximate and heal together. This is especially true with the 1-snip and 2-snip procedures. Because of this, mitomycin C ^{[2, 3]} , punctal plug/Mini Monoka use ^{[4, 5]} , self-retaining bicanaliculus stent, ^[6] and externalization of the canaliculus ^[7] have been described as adjuncts to try to improve the success rate.

Anatomical success rates after a punctoplasty have been reported to range from 89%-96%. ^{[8, 4, 9]} Functional success rates range from 64%-93%. ^{[10, 11, 8, 4, 9, 12, 13]}

The lacrimal punctum is the entrance to the nasolacrimal duct system. It is the opening located on the medial eyelid margin of each upper and lower eyelid. Each punctum is positioned in the center of a small mound of tissue called the lacrimal papilla.

The inferior lacrimal punctum is slightly more lateral than the superior punctum. The lacrimal punctum connects to the canaliculus, which has a 2-mm vertical section followed by an 8-mm horizontal section. Where the vertical and horizontal canaliculi join is called the ampulla.

Port AD, Chen YT, Lelli GJ Jr. Histopathologic changes in punctal stenosis. Ophthal Plast Reconstr Surg. 2013 May-Jun. 29(3):201-4. [Medline].

Lam S, Tessler HH. Mitomycin as adjunct therapy in correcting iatrogenic punctal stenosis. Ophthalmic Surg. 1993 Feb. 24(2):123-4. [Medline].

Ma’luf RN, Hamush NG, Awwad ST, Noureddin BN. Mitomycin C as adjunct therapy in correcting punctal stenosis. Ophthal Plast Reconstr Surg. 2002 Jul. 18(4):285-8. [Medline].

Kashkouli MB, Beigi B, Astbury N. Acquired external punctal stenosis: surgical management and long-term follow-up. Orbit. 2005 Jun. 24(2):73-8. [Medline].

Kristan RW. Treatment of lacrimal punctal stenosis with a one-snip canaliculotomy and temporary punctal plugs. Arch Ophthalmol. 1988 Jul. 106(7):878-9. [Medline].

Chalvatzis NT, Tzamalis AK, Mavrikakis I, Tsinopoulos I, Dimitrakos S. Self-retaining bicanaliculus stents as an adjunct to 3-snip punctoplasty in management of upper lacrimal duct stenosis: a comparison to standard 3-snip procedure. Ophthal Plast Reconstr Surg. 2013 Mar-Apr. 29(2):123-7. [Medline].

Offutt WN 4th, Cowen DE. Stenotic puncta: microsurgical punctoplasty. Ophthal Plast Reconstr Surg. 1993. 9(3):201-5. [Medline].

Kim SE, Lee SJ, Lee SY, Yoon JS. Outcomes of 4-snip punctoplasty for severe punctal stenosis: measurement of tear meniscus height by optical coherence tomography. Am J Ophthalmol. 2012 Apr. 153(4):769-773.e2. [Medline].

Shahid H, Sandhu A, Keenan T, Pearson A. Factors affecting outcome of punctoplasty surgery: a review of 205 cases. Br J Ophthalmol. 2008 Dec. 92(12):1689-92. [Medline].

Caesar RH, McNab AA. A brief history of punctoplasty: the 3-snip revisited. Eye (Lond). 2005 Jan. 19(1):16-8. [Medline].

Chak M, Irvine F. Rectangular 3-snip punctoplasty outcomes: preservation of the lacrimal pump in punctoplasty surgery. Ophthal Plast Reconstr Surg. 2009 Mar-Apr. 25(2):134-5. [Medline].

Ali MJ, Ayyar A, Naik MN. Outcomes of rectangular 3-snip punctoplasty in acquired punctal stenosis: is there a need to be minimally invasive?. Eye (Lond). 2015 Apr. 29 (4):515-8. [Medline].

Murdock J, Lee WW, Zatezalo CC, Ballin A. Three-Snip Punctoplasty Outcome Rates and Follow-Up Treatments. Orbit. 2015 Jun. 34 (3):160-3. [Medline].

JONES LT. The cure of epiphora due to canalicular disorders, trauma and surgical failures on the lacrimal passages. Trans Am Acad Ophthalmol Otolaryngol. 1962 Jul-Aug. 66:506-24. [Medline].

Carrim ZI, Liolios VI, Vize CJ. Punctoplasty with a Kelly punch. Ophthal Plast Reconstr Surg. 2011 Sep-Oct. 27(5):397-8. [Medline].

Edelstein JP, Reiss G. Introducing the Reiss punctal punch. Arch Ophthalmol. 1991 Sep. 109(9):1310. [Medline].

Edelstein J, Reiss G. The wedge punctoplasty for treatment of punctal stenosis. Ophthalmic Surg. 1992 Dec. 23(12):818-21. [Medline].

Hughes WL, Maris CS. A clip procedure for stenosis and eversion of the lacrimal punctum. Trans Am Acad Ophthalmol Otolaryngol. 1967 Jul-Aug. 71(4):653-5. [Medline].

John Tong, MD 

John Tong, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Cosmetic Surgery, American Association for Pediatric Ophthalmology and Strabismus, American College of Surgeons, American Academy of Ophthalmology, American Society of Ophthalmic Plastic and Reconstructive Surgery

Disclosure: Nothing to disclose.

Andrew A Dahl, MD, FACS Assistant Professor of Surgery (Ophthalmology), New York College of Medicine (NYCOM); Director of Residency Ophthalmology Training, The Institute for Family Health and Mid-Hudson Family Practice Residency Program; Staff Ophthalmologist, Telluride Medical Center

Andrew A Dahl, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Intraocular Lens Society, American Medical Association, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Medical Society of the State of New York, New York State Ophthalmological Society, Outpatient Ophthalmic Surgery Society

Disclosure: Nothing to disclose.

Punctoplasty

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