Normal lid contour, with proper anatomic positioning of the punctae within the tear meniscus, is required for adequate tear drainage. Displacement of the punctum from its normal position is most frequently the result of lower eyelid ectropion. Evaluation and appropriate surgical correction of eyelid malpositions should be completed before undertaking any lacrimal drainage system repair. When punctal stenosis is a secondary phenomenon, caused by chronic punctal eversion, simple correction of the underlying eyelid malposition along with punctal dilation may be sufficient to reestablish drainage.

In addition to external and slit-lamp examinations, the likely site of obstruction within the lacrimal drainage system can be identified by the following series of functional tests.

Fluorescein dye disappearance test

The fluorescein dye disappearance test is a rapid, semiquantitative screening method for the presence of lacrimal drainage system obstruction. The test is best performed by simultaneously instilling a single drop of concentrated 2% fluorescein solution into each inferior fornix. Five minutes after instillation, the degree of fluorescein clearance is grossly quantified. Observing the patient at a distance with the cobalt blue light of the slit lamp may be of aid in detecting subtle differences. Any asymmetry between eyes or an obvious delay in the clearance of dye from both eyes can be easily appreciated. Symmetric delays are more difficult to diagnose and require detailed study with the primary and secondary Jones dye tests.

If the fluorescein dye disappearance test documents a functional delay in the presence of a stenotic punctum, a review of possible etiologic factors should first be conducted. Punctal stenosis may be caused by trauma, such as that induced by repeated canalicular probings; chronic use of topical cholinesterase inhibitors or antiviral agents; ocular pemphigoid; infections, such as herpes zoster; and the presence of a congenital punctal membrane.

With the elimination of etiologic factors and verification of the functional block, punctal stenosis is managed by means of a punctoplasty procedure. Attempts to repeatedly dilate the punctum frequently lead to restenosis and risk possible iatrogenic trauma and creation of false passageways. The technique of punctoplasty is discussed later.

Lower lacrimal system obstruction

If the puncta have been evaluated and considered normal, attention is turned to the lacrimal sac and nasolacrimal duct. In the normal individual, the lacrimal sac is never palpable. Should the initial examination of a patient complaining of epiphora demonstrate a distended lacrimal sac, a nasolacrimal duct obstruction is almost certainly present. Likewise, expression of purulent discharge with gentle pressure over the lacrimal sac is all but pathognomonic for nasolacrimal duct obstruction. If neither punctal stenosis nor distension of the sac is present, then Jones I and II dye tests are needed to further localize the site of obstruction.

Jones I test

The presence of dye is described as a positive test, which indicates a patent drainage system and obviates the need for further testing. The absence of dye, or a negative test, is suggestive of two possibilities. First, fluorescein dye failed to enter the sac due to an upper system (i.e., punctum, canaliculus, or common punctum) obstruction. In this situation, a delay in dye clearance during the dye disappearance test should corroborate this finding. Second, fluorescein dye was able to enter into the sac but could not be recovered under the inferior turbinate due to either a partial or complete nasolacrimal duct obstruction. In both circumstances, dye clearance would also be delayed. To further localize the site of obstruction, or to differentiate a partial from a complete nasolacrimal duct obstruction, a Jones II test is performed.

Jones II test

Following a negative Jones I test, the fornices are irrigated free of remaining fluorescein. A lacrimal irrigation cannula (23–27 gauge) on a saline-filled 3-ml syringe is inserted through the lower punctum and into the canaliculus. While the patient’s head is tilted forward and the nose positioned over a metal basin, saline is gently irrigated into the sac. There are three potential outcomes:

1. Recovery of dye-tinged fluid from the nose indicates a patent canalicular system, but a partial nasolacrimal duct obstruction. The dye is able to enter into the sac but cannot be passively recovered in the nose; hence, a negative Jones I test, because of resistance at the level of nasolacrimal duct. However, in this instance, the resistance is overcome by the pressure of the irrigating fluid.

2. Recovery of only clear fluid from the nose indicates a relative stenosis of the upper canalicular system, usually at the level of punctum or common canaliculus. In this situation, dye is not able to enter into the sac; hence, no dye is recovered in the nose with active irrigation of the sac. A delay in dye clearance (on dye disappearance test) coupled with the detection of canalicular stricture on probing should be confirmatory.

3. No fluid recovered from the nose, with fluid reflux out of the canaliculi. Three possible scenarios may occur in this particular circumstance:

• Reflux of clear fluid around the irrigation cannula, without distension of the lacrimal sac. This is indicative of a severe canalicular stricture, involving the canaliculus intubated with the irrigation cannula.
  
• Reflux of clear fluid out of the unintubated canaliculus, without distension of the lacrimal sac. Occasionally, a jet stream of fluid may be seen refluxing out of the upper canaliculus upon irrigation. This is indicative of a complete stricture at the level of common canaliculus.
  
• Reflux of clear or dye-tinged fluid, with distension of the lacrimal sac. This is suggestive of a complete nasolacrimal duct obstruction. The presence of dye in the fluid refluxing out indicates that the dye was able to enter into the sac through a patent upper system, but became stagnant within the sac because of an outlet obstruction.

Based on the outcome of these functional tests, one can identify a likely point of obstruction and initiate appropriate treatment. In this chapter, surgical treatment of isolated punctal stenosis is discussed. Management of partial or complete nasolacrimal duct obstructions will be reviewed in subsequent chapters.

Several punctoplasty procedures have been described in the past. In the one-snip procedure, a single vertical incision into the ampulla is made through the posterior wall of the punctum with a sharp Westcott scissors. In most instances, such a slit will close soon after the procedure. The second variation, a Jones two-snip punctoplasty, is performed by creating a 2-mm high, V-shaped opening posteriorly. Even with excision of a wedge of punctal tissue, appositional closure of the punctum can occur. To reduce the incidence of postoperative closure, we have had the most success with a three-snip punctoplasty followed by placement of a circular silicone stent within the canalicular system. The rationale for the placement of a silicone stent here is analogous to stent placement to ensure patency of the internal ostium following a dacryocystorhinostomy. The silicone stent not only prevents appositional closure secondary to the healing process but also mechanically dilates the stenotic canaliculi.

Three-snip punctoplasty procedure

After application of topical anesthetic, peripunctal infiltration of the inferior punctum is carried out with 2% lidocaine with epinephrine. The punctum is dilated with a punctal dilator.

Figure 22-1. The posterior rim of the punctum is grasped with a 0.12-mm forceps and one blade of a sharp Westcott scissors is inserted into the ampulla. A vertical snip incision is made at the lateral aspect of the posterior rim.