27.1 Goals

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  To widen the punctal opening in patients with punctal stenosis.

  
  
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  To maintain good punctal position against the tear lake.

  
  
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  To preserve the function of the lacrimal pump. ¹

27.2 Advantages

The three-snip punctoplasty (TSP) is an essential surgical skill for the oculoplastic surgeon in treatment of the patient with symptomatic epiphora due to punctal stenosis with a patent nasolacrimal duct. The advantage of this procedure is that it is minimally invasive with few side effects and can be easily done in the office. TSP results in symptomatic relief in a majority of patients without placement of a foreign body.

27.3 Expectations

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  Resolution of symptoms ranges in the literature from 57 to 92%. ^{2 ,​ 3 ,​ 4 ,​ 5}

  
  
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  With the subsequent placement of a stent, previously unsuccessful cases had resolution of symptoms in a study by Murdock et al. ²

27.4 Key Principles

Punctal stenosis results in epiphora due to interruption of the tear drainage system by blocking the entry of tears into the nasolacrimal outflow system. The exact incidence is unknown and ranges in the literature from 8 to 54%. ⁶ The cause can be congenital or acquired. The most common acquired cause is involutional/idiopathic. Other secondary causes are chronic inflammation (blepharitis), dry eye, trauma, neoplasm, long-standing use of antiglaucoma or chemotherapeutic drops, and radiation. ^{2 ,​ 7} In one study of presumed idiopathic punctal stenosis, 47.8% were found to have underlying etiologies for their stenosis through histopathologic examination and direct immunofluorescence. ⁸

The clinical understanding of a “normal” punctum is poorly defined in the literature, and it likely is the reason for the wide range of symptomatic relief reported. Optical coherence tomography (OCT) and infrared (IR) imaging studies hope to better predict who will be successful. The diameter just within the punctum may be more predictive of success of the procedure rather than that of the punctal entrance. OCT is also able to measure the intrapunctal tear meniscus, which has been shown to be significantly higher in patients with epiphora when compared to controls, suggesting that there may be a distal obstruction not detected by irrigation alone. ³

27.5 Indications

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  Symptomatic epiphora due to punctal stenosis without distal obstruction and no active secondary process.

27.6 Contraindications

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  Ongoing inflammatory process.

  
  
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  Anatomic abnormalities.

  
  
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  Suspected neoplasm in the area of punctum.

  
  
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  Ocular cicatricial pemphigoid in a non-immunomodulated patient.

  
  
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  Significant dry eye syndrome where punctual occlusion is desirable.