Several punctal abnormalities can result in epiphora. Puncta may be stenotic, too large (usually iatrogenic), malpositioned, or occluded by adjacent structures.
Punctal stenosis and occlusion can be due to numerous causes, including
Punctal stenosis may be associated with punctal ectropion or atrophy in the absence of tear flow. It may be treated with dilation, punctoplasty, or stenting. Most often, the benefits of dilation are short-lived, and punctoplasty is required. This is usually accomplished with a snip procedure, in which a small portion of the ampulla is excised. If stenosis recurs, stenting may be required during healing to prevent contraction. Treatment of complete occlusion consists of surgical canalization and, in most cases, stenting.
Abnormally large puncta can also cause epiphora due to disruption of the lacrimal pump (Fig 15-16). The expanded opening prevents formation of an adequate seal when the eyes are closed, interfering with the usual development of negative pressure needed to drain the tears. Punctal enlargement is typically iatrogenic in nature and can occur from “cheese-wiring” of a stent secured too tight intranasally (Fig 15-17), punctoplasty, excision of adjacent lesions, or even from rough dilation and probing that cause damage to the normal fibrous ring around the punctum. Damage to the puncta may be difficult to correct.
If the punctum is not in the tear lake, the anatomical abnormality (most commonly ectropion) must be corrected by a medial spindle conjunctivoplasty or horizontal eyelid tightening (see Chapter 12 in this volume for more on both of these topics). Punctal stenosis may require punctoplasty. Puncta may also become obstructed by adjacent structures, such as a hypertrophied caruncle or conjunctivochalasis (see Fig 15-12), which can be corrected by reducing the excess tissue.
Figure 15-16 Inferior puncta. Punctum with normal caliber (arrow) on the right (A), and an abnormally large punctum (arrow) on the left (B).
(Courtesy of Bobby S. Korn, MD, PhD.)
Figure 15-17 Slit inferior punctum caused by tight intranasal fixation of a bicanalicular lacrimal stent (arrow).
(Courtesy of Don O. Kikkawa, MD.)
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.