Punctal Cauterization

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Article initiated by:

Aaron R. Kaufman, MD, Reza Dana, MD, MPH, MSC

All contributors:

Reza Dana, MD, MPH, MSC, Colleen Halfpenny, M.D., Michael T Yen, MD, Shannon S. Joseph, M.D., Aaron R. Kaufman, MD

Assigned editor:

Neha Shaik, MD, Shannon S. Joseph, M.D.

Review:

Assigned status Update Pending

 by Shannon S. Joseph, M.D. on May 10, 2024.

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Contributing Editors:	add

Introduction

Punctal cauterization is a form of permanent punctal occlusion in which the eyelid punctum (and also usually the vertical canaliculus) is surgically closed using thermocautery (electocautery). Punctal cauterization was first described by William P. Beetham, MD, in 1934 and techniques have subsequently been refined, including utilization of modern cauterization devices. By occluding the punctum, punctal cauterization aims to increase tear film volume and retention on the ocular surface to treat ocular surface disease. Punctal cauterization may be a useful treatment modality alongside other forms of punctal occlusion such as dissolvable punctal inserts, silicone punctal plugs, argon laser photocoagulation of the punctum, and surgical occlusion/destruction of the punctum and canaliculus.

Indications and Patient Selection

Punctal cauterization is most frequently utilized for ocular surface diseases associated with aqueous-insufficient dry eye disease (including but not limited to primary dry eye syndrome, Sjögren syndrome, ocular graft versus host disease, mucous membrane pemphigoid [ocular cicatricial pemphigoid], and Stevens-Johnson syndrome). Punctal cauterization can also be utilized in other pathology that may benefit from increased surface lubrication, such as radiation keratitis, recurrent corneal erosion, herpetic keratitis, or microbial keratitis. Patients with very severe ocular surface disease who present with very low tear menisci (associated with low single-digit Schirmer tests) and who are at risk of corneal stromal breakdown and possible perforation are good candidates for punctal cauterization as a first therapeutic measure.

Punctal cauterization is well suited to patients who have had a good effect from temporary punctal inserts and for whom a more permanent form of punctal occlusion is desired. Other patients who may particularly benefit from punctal cauterization are those who have poor retention of silicone punctal plugs (i.e. recurrent punctal plug loss), are difficult to fit with silicone plugs, or who do not tolerate the presence of punctal plugs. Recanalization after punctal cauterization (discussed in more detail below) can also be an indication for repeat punctal cauterization in order to restore the punctal occlusion.

Technique

Punctal cauterization can be readily performed in the outpatient clinic setting, but it can also be performed in a minor or major operative room setting when dictated by patient factors, such as cooperation, positioning, or comfort issues. When performed in the operative room setting, punctal cauterization may be performed in combination with other ocular surface procedures such as resection of conjunctivochalasis. The upper and lower puncta for a patient’s eye can be treated in a single session, or one punctum can be treated at a time to allow titration of the effect.

Variations of punctal cauterization have been described by multiple authors. One approach is as follows:

1. A drop of proparacaine or tetracaine is instilled on the ocular surface. Lidocaine gel is then directly applied to the punctum using a cotton-tip applicator or cellulose eye spear.
2. The eyelid and eye are then cleaned with betadine solution in the usual ophthalmic fashion.
3. A subcutaneous injection of lidocaine is performed, infiltrating the medial canthus and peri-punctal area. 1% or 2% lidocaine without epinephrine is a suitable concentration. Adequate time (approximately 5 minutes) is allowed for achievement of regional analgesia and anesthesia. Gentle self-applied pressure by the patient can assist with analgesia by promoting absorption from the wheal into adjacent tissue.
4. A disposable handheld low-temperature cautery device is prepared (such as Bovie AA00 low-temperature fine-tip cautery device [Bovie Medical Corporation, Clearwater, FL]). If needed, the tip can be flattened and narrowed (such as by applying pressure from the cautery device cap) to allow it to more easily cannulate the punctum. The device should be tested externally to ensure that it is functional and reaches adequate temperature. Alternatively, electrocautery (monopolar or bipolar) or radiofrequency cautery can also be used.
5. Under slit lamp or loupe magnification, a cotton-tip applicator is used to evert the punctum, and the tip of the cautery device is inserted through the punctum into the vertical canaliculus. When treating the lower punctum the patient should be asked to look up, and when treating the upper punctum, the patient should be asked to look down.
6. Short pulses of cautery are applied, each lasting less than a second, while the cautery device is gradually retracted. In this manner, the vertical canaliculus is treated first, followed by treatment of the punctum itself. The endpoint of cauterization is whitening and shrinkage of the punctum. The entire procedure normally takes less than 15-20 seconds.
7. Over-treatment of the canaliculus and punctum should be avoided, as this may ensnare the tip of the cautery device in the cauterized tissue, and it may then be difficult to extricate the tip without causing tissue trauma or debridement of the treated punctum.
8. When retracting and withdrawing the cautery tip, caution should be exercised to avoid inadvertent contact with the ocular surface or the patient’s face, since a thermal burn may result.
9. Erythromycin (or alternate antibiotic) ointment is applied to the treated punctum, and the patient will continue to apply ointment two times per day for one week.

Outcomes

Punctal cauterization is efficacious in improving both patient symptoms of ocular dryness and objective markers of disease severity. Wang et al reported a study of punctal cauterization for 171 puncta of 80 patients. In this cohort, 45% of patients had ocular graft versus host disease, 19% had primary dry eye disease, 8% had Stevens-Johnson syndrome, 6% had Sjögren syndrome, and the remaining 22% had other conditions. Pre-treatment corneal staining was classified as severe in 21% of eyes and moderate in 25% of eyes. At 12-month follow-up these proportions had decreased to 6% severe and 17% moderate (p = 0.0006). At 3 months after cauterization, 54% of patients had improvement in symptoms, 32% had unchanged symptoms, 4% had worsening of symptoms, and 10% were unsure about if their symptoms had changed. Ohba et al reported a study of 70 puncta of 28 patients with dry eye syndrome. In their cohort 57% had Sjögren syndrome and 21% had mucous membrane pemphigoid. A statistically significant improvement in symptom score was reported at 3 months after cauterization. In addition, statistically significant improvements in best corrected visual acuity, fluorescein staining, rose Bengal staining, tear film breakup time, and Schirmer test results were also reported.

Rates of recanalization after punctal cauterization are variable. In the study by Wang et al, the mean follow-up was 27 months and over this period the 36 of 171 treated puncta (21%) recanalized. The median time from cautery to recanalization was 12 months. A higher rate of recanalization was observed in patients treated with steroids (30%) versus those who were not treated with steroids (15%), p = 0.0003. In the study by Ohba, the recanalization rate was 1 of 70 treated puncta (1.4%) over the mean follow-up of 973 days. Knapp et al found that the rate of recanalization is lower when the vertical canaliculus is additionally cauterized, in comparison to when the punctum alone is cauterized. It is notable that clinically visible proximal punctal recanalization does not necessarily mean normal flow through the canaliculus. Recanalization rates appear to be lower for cauterization than for punctal occlusion using argon laser photocoagulation.

Overall, punctal cauterization is tolerated well by the patient. Self-limited post-procedural pain and swelling may occur. As for all forms of punctal occlusion, epiphora may be a complication of punctal cauterization. The likelihood of epiphora may be reduced by patient selection; for example, a successful trial of punctal occlusion by dissolvable punctal inserts without epiphora, may indicate a greater likelihood for tolerating punctal cauterization without epiphora. Dacryocystitis has been reported as a rare complication of punctal cauterization.