Punctoplasty 

Updated: Feb 10, 2017
Author: John Tong, MD; Chief Editor: Andrew A Dahl, MD, FACS 

Overview

Background

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.

Indications

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

Contraindications

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

Complication Prevention

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.

Outcomes

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]

Relevant Anatomy

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.

 

Periprocedural Care

Pre-Procedure Planning

Equipment

The following equipment is used to perform punctoplasty:

  • Ophthalmic anesthetic drop (eg, proparacaine)

  • Lidocaine (1% or 2%) with 1:100,000 epinephrine

  • Punctal dilator

  • Vannas scissors

  • Toothed forceps, 0.3 mm

  • Antibiotic ophthalmic ointment (such as erythromycin)

Patient Preparation

Anesthesia

Punctoplasty can be routinely performed in an office setting using local anesthesia.

Positioning

Punctoplasty can be performed with the patient sitting in the examination chair or lying supine on a procedure table.

Monitoring & Follow-up

Patients should be examined several days after the procedure to monitor for infection and recurrence of the punctal stenosis.

Another follow-up examination may be performed in several months to check for recurrence of the punctal stenosis.

 

Technique

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]

One-Snip Procedure

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

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.

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:

  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