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Punctoplasty Technique

  • Author: John Tong, MD; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: May 20, 2016
 

Approach Considerations

Many approaches to punctoplasty in the treatment of punctal stenosis have been described. They have been generally classified as 1-snip, 2-snip, and 3-snip procedures.[10, 11, 14, 9, 12, 13] The 3-snip procedure can be further subdivided into a rectangular and triangular variation. A modification of the rectangular variation has been termed the 4-snip procedure.[8]

Punches have also been used to perform punctoplasty.[15, 16, 17, 18]

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One-Snip Procedure

The 1-snip procedure consists of a vertical incision through the posterior wall of the punctum and vertical canaliculus.

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Two-Snip Procedure

The 2-snip procedure consists of a vertical incision through the posterior wall of the punctum and vertical canaliculus followed by a horizontal incision along a portion of the horizontal canaliculus.

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Triangular 3-Snip Procedure

The triangular 3-snip procedure consists of a vertical incision through the posterior wall of the punctum and vertical canaliculus, a horizontal incision along 2 mm of the horizontal canaliculus, and a diagonal incision connecting the start of the vertical incision with the end of the horizontal incision, resulting in a triangular excision of tissue.

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Rectangular 3-Snip Procedure

The rectangular 3-snip procedure consists of 2 vertical incisions through the posterior wall of the punctum and vertical canaliculus (one medial and one lateral) followed by a horizontal incision connecting the ends of the vertical incisions, resulting in a rectangular excision of tissue.

The technique for a 3-snip rectangular punctoplasty is as follows:

  1. Instill a drop of topical anesthetic ophthalmic drop on the eye
  2. Inject the 1% or 2% lidocaine with 1:100,000 epinephrine subcutaneously under the lower eyelid punctum
  3. Dilate the punctum with a punctal dilator
  4. Grasp the posterior wall of the punctum with the 0.3-mm toothed forceps
  5. Make a 1- to 2-mm vertical incision with Vannas scissors on either side of the forceps through the posterior wall of the punctum and vertical canaliculus
  6. Make a horizontal incision connecting the ends of the 2 vertical incisions to excise a rectangular portion of the posterior wall of the punctum and vertical canaliculus
  7. Apply the antibiotic ophthalmic ointment 3 times a day for 5 days to the site
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Contributor Information and Disclosures
Author

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.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

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

  3. 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].

  4. 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].

  5. 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].

  6. 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].

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

  8. 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].

  9. 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].

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

  11. 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].

  12. 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].

  13. 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].

  14. 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].

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

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

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

  18. 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].

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