- Author: John Tong, MD; Chief Editor: Hampton Roy, Sr, MD more...
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.
Punches have also been used to perform punctoplasty.[15, 16, 17, 18]
The 1-snip procedure consists of a vertical incision through the posterior wall of the punctum and vertical canaliculus.
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.
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.
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:
- Instill a drop of topical anesthetic ophthalmic drop on the eye
- Inject the 1% or 2% lidocaine with 1:100,000 epinephrine subcutaneously under the lower eyelid punctum
- Dilate the punctum with a punctal dilator
- Grasp the posterior wall of the punctum with the 0.3-mm toothed forceps
- 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
- 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
- Apply the antibiotic ophthalmic ointment 3 times a day for 5 days to the site
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].