Punctoplasty Technique

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

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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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