Punctal stenosis

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 by Michael T Yen, MD on November 1, 2020.


Disease

Punctal stenosis is narrowing or occlusion of the external opening of the lacrimal canaliculus, the punctum.1 It can be diagnosed when the punctum is less than 0.3 mm in diameter. The patient may present with tearing and evaluation for distal nasolacrimal duct obstruction should be performed as this may occur simultaneously.1

Etiology

Many factors have been linked to the development of punctal stenosis, including the following:

Congenital- anophthalmos, microphthalmos,2 congenital stenosis Idiopathic- aging, female sex3 Inflammatory- chronic blepharitis, dry eye syndrome, ocular cicatricial pemphigoid, lichen planus4 Mechanical- lid malposition, trauma, tumors, local irradiation, photodynamic therapy for macular disease5,6 Infectious- HSV, trachoma, chlamydia, actinomyces, HPV3,7 Iatrogenic- punctal electrocautery, suture closure Topical medications: timolol, latanoprost, betaxolol, dipivefrine hydrochloride, echothiophate iodide, pilocarpine, prednisolone acetate- phenylephrine hydrochloride, adrenaline, chloramphenicol, tobramycin, indomethacin, dexamethasone, tropicamide, naphazoline, artificial tears8 Systemic medications: 5-fluorouracil, docetaxel,9 paclitaxel, idoxuridine Systemic diseases: acrodermatitis enteropathica, porphyria cutanea tarda, Stevens-Johnson Syndrome,10 graft-versus-host disease

Pathophysiology

As the entry point for tears, the punctum is exposed to all the possible soluble irritants that can be found on the ocular surface. Chronic inflammation of the external punctum leads to gradual fibrotic changes in the ostium followed by progressive occlusion of the duct.11,12

Diagnosis

Punctal stenosis is clinically defined as a punctum caliber restricting tear drainage in the absence of distal tear drainage abnormalities, namely canalicular obstruction or nasolacrimal duct obstruction. In the literature, punctal stenosis has been defined as a punctal diameter of less than 0.3 mm or inability to intubate the punctum with a 26 G cannula without dilation.1

Signs

Signs include epiphora, increased tear lake, narrowing of punctum and inability to insert a probe or cannula without dilation. “Tissue sign” – the patient is walking into clinic with a handful of tissues.

Symptoms

Overflow of tears on the cheek, excessive moisture in eyes Eye irritation or redness from constant tissue use

Clinical diagnosis

-Slit lamp exam can identify a membrane or fibrosis of the punctum as well as punctum size, tear meniscus height, eyelid malposition, and signs of previous surgery -Schirmer test can help quantify basal tear production, differentiating an obstructive cause from dry eye with reflex tearing. Tear break up time, ocular surface staining, tear meniscus height, and careful exam of the lids and conjunctiva help identify associated ocular surface abnormalities. -Presence of fluorescein in fornix 7 minutes after instillation indicates a delay in dye disappearance -Lacrimal probing or cannulation with irrigation of the canal can help to differentiate punctal stenosis from canalicular or nasolacrimal duct obstruction. In punctal stenosis, there is difficulty passing the probe past the punctum.

Laboratory test

Lab tests are rarely needed for patients with punctal stenosis. Conjunctival biopsy with direct immunofluorescence staining may be considered in those rare cases where an underlying disorder such as ocular cicatricial pemphigoid is suspected, chiefly in bilateral cases in younger patients or with symblepharon or other signs of ocular surface abnormality

Differential diagnosis

Epiphora due to dry eye with reflex tearing; canalicular obstruction; nasolacrimal duct obstruction; congenital glaucoma

Management

There is no medical management of punctal stenosis. Punctal dilation can be performed as an initial step, although it is mostly done for diagnostic purposes to allow evaluation of the remainder of the nasolacrimal system. Most patients require one of the surgical options listed below. The goals of surgery include creating an adequate opening, maintaining punctal position against the lacrimal lake, improving tear access from the lacrimal lake to the punctal opening, and preserving function of the lacrimal pump. -Punctoplasty -One snip13 -Two snip -Three snip14-16 -Four snip17,18 -(+/- intraoperative mitomycin C for resistant cases)19 -Snip procedure with perforated punctal plug insertion20-22 -Punctal punching -Wedge punctoplasty23 -Laser punctoplasty24

Surgical follow up

If a bicanalicular or monocanalicular stent (mini monoka) is placed, it should be removed at 2-4 months

Additional Resources

EyeRounds.org tutorial under “punctoplasty” http://eyerounds.org/video/plastics/index.htm

References

1. Soiberman U, Kakizaki H, Selva D, Leibovitch I. Punctal stenosis: definition, diagnosis, and treatment. Clinical ophthalmology (Auckland, NZ). 2012;6:1011-1018.

2. Schittkowski MP, Guthoff RF. Results of lacrimal assessment in patients with congenital clinical anophthalmos or blind microphthalmos. The British journal of ophthalmology. 2007;91(12):1624-1626.

3. Kashkouli MB, Beigi B, Murthy R, Astbury N. Acquired external punctal stenosis: etiology and associated findings. American journal of ophthalmology. 2003;136(6):1079-1084.

4. Mohebbi M, Mirghorbani M, Banafshe Afshan A, Towfighi M. Lichen Planus in Ocular Surface: Major Presentations and Treatments. Ocular immunology and inflammation. 2018:1-8.

5. Mainville N, Jordan DR. Etiology of tearing: a retrospective analysis of referrals to a tertiary care oculoplastics practice. Ophthalmic plastic and reconstructive surgery. 2011;27(3):155-157.

6. Yim JF, Crofts KP. Bilateral punctal-canalicular stenosis following photodynamic therapy for choroidal neovascularization. Cutaneous and ocular toxicology. 2011;30(1):78-79.

7. Yulish M, Pikkel J. Presumed Virus-Induced Punctal Occlusion. Advances in medicine. 2014;2014:809851.

8. McNab AA. Lacrimal canalicular obstruction associated with topical ocular medication. Australian and New Zealand journal of ophthalmology. 1998;26(3):219-223.

9. Skolnick CA, Doughman DJ. Erosive conjunctivitis and punctal stenosis secondary to docetaxel (taxotere). Eye & contact lens. 2003;29(2):134-135.

10. Auran JD, Hornblass A, Gross ND. Stevens-Johnson syndrome with associated nasolacrimal duct obstruction treated with dacryocystorhinostomy and Crawford silicone tube insertion. Ophthalmic plastic and reconstructive surgery. 1990;6(1):60-63.

11. Reddy AK, Baker MS, Maltry AC, Syed NA, Allen RC. Immunopathology and histopathology of conjunctival biopsies in patients with presumed idiopathic punctal stenosis. The British journal of ophthalmology. 2017;101(2):213-217.

12. Port AD, Chen YT, Lelli GJ, Jr. Histopathologic changes in punctal stenosis. Ophthalmic plastic and reconstructive surgery. 2013;29(3):201-204.

13. Kristan RW. Treatment of lacrimal punctal stenosis with a one-snip canaliculotomy and temporary punctal plugs. Archives of ophthalmology (Chicago, Ill : 1960). 1988;106(7):878-879.

14. Caesar RH, McNab AA. A brief history of punctoplasty: the 3-snip revisited. Eye (London, England). 2005;19(1):16-18.

15. Murdock J, Lee WW, Zatezalo CC, Ballin A. Three-Snip Punctoplasty Outcome Rates and Follow-Up Treatments. Orbit (Amsterdam, Netherlands). 2015;34(3):160-163.

16. Park SJ, Noh JH, Park KB, Jang SY, Lee JW. A novel surgical technique for punctal stenosis: placement of three interrupted sutures after rectangular three-snip punctoplasty. BMC ophthalmology. 2018;18(1):70.

17. Kim SE, Lee SJ, Lee SY, Yoon JS. Outcomes of 4-snip punctoplasty for severe punctal stenosis: measurement of tear meniscus height by optical coherence tomography. American journal of ophthalmology. 2012;153(4):769-773, 773.e761-762.

18. Shoaib KK. Outcomes of 4-snip punctoplasty for severe punctal stenosis: measurement of tear meniscus height by optical coherence tomography. American journal of ophthalmology. 2012;154(1):209; author reply 209-210.

19. Ma'luf RNMD, Hamush NGMD, Awwad STMD, Noureddin BNMD. Mitomycin C as Adjunct Therapy in Correcting Punctal Stenosis. Ophthalmic Plastic & Reconstructive Surgery. 2002;18(4):285-288.

20. Konuk OMD, Urgancioglu BMD, Unal MMD. Long-term Success Rate of Perforated Punctal Plugs in the Management of Acquired Punctal Stenosis. Ophthalmic Plastic & Reconstructive Surgery September/October. 2008;24(5):399-402.

21. Abd El Ghafar AS, El-Kannishy AM, Elwan MM, Sabry D, Kishk HM, Elhefney EM. Perforated punctal plugs with adjuvant use of mitomycin-C in management of acquired external punctal stenosis grades 0 and 1. Canadian journal of ophthalmology Journal canadien d'ophtalmologie. 2017;52(6):606-610.

22. Konuk O, Urgancioglu B, Unal M. Long-term success rate of perforated punctal plugs in the management of acquired punctal stenosis. Ophthalmic plastic and reconstructive surgery. 2008;24(5):399-402.

23. Edelstein J, Reiss G. The wedge punctoplasty for treatment of punctal stenosis. Ophthalmic surgery. 1992;23(12):818-821.

24. Awan KJ. Laser punctoplasty for the treatment of punctal stenosis. American journal of ophthalmology. 1985;100(2):341-342.