Acquired obstruction
Primary punctal stenosis
Causes: (a) idiopathic, (b) chronic marginal blepharitis, (c) herpetic (simplex, zoster) lid infection, and (d) conjunctival cicatrization.
Diagnosis: narrow inferior punctum in the absence of punctal malposition.
Treatment: dilatation alone ( Fig. 2.1 ) rarely confers long-term improvement; surgical punctoplasty is usually necessary ( Figs. 2.2 and 2.3 ).
Fig 2.1
Fig 2.2
Fig 2.3
Secondary punctal stenosis
Diagnosis: narrow inferior punctum associated with punctal eversion ( Fig. 2.4 ).
Fig 2.4
Treatment
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Retropunctal cautery: for pure punctal eversion.
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Medial conjunctivoplasty: for medial ectropion without lid laxity ( Fig. 2.5 ).
Fig 2.5
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Wider lid positional abnormalities: addressed as appropriate ( Fig. 2.6 ).
Fig 2.6
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Canalicular obstruction
Causes: (a) congenital and (b) acquired (e.g. trauma, herpes simplex infection, drugs, irradiation, chronic dacryocystitis).
Diagnosis: site of obstruction will usually be evident on lacrimal irrigation as a ‘soft stop’ ( Fig. 2.7a ).
Fig 2.7
Treatment
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Intubation: silicone stents for partial obstruction.
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Canaliculodacryocystorhinostomy (CDCR): for total individual canalicular obstruction when there is 6–8 mm of patent normal canaliculus between the punctum and the obstruction.
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Lester Jones tube insertion: when it is not possible to anastomose the functional canaliculus to the sac (see below).
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Nasolacrimal duct obstruction
Causes: (a) idiopathic age-related stenosis (most common), (b) trauma, (c) Wegener granulomatosis, and (d) nasopharyngeal tumours.
Diagnosis
