Punctoplasty

Punctoplasty is a surgical procedure performed in people with punctal stenosis (narrowing) to help in widening the punctum for better drainage of tears.

Punctal stenosis occurs when lacrimal punctum is narrowed.  

The lacrimal punctum (plural puncta) are small openings located near the inner corner of the eye on the upper and lower lids. 

Each punctum is connected to a canaliculus, which is a short passageway that helps the tears to drain into the tear sac. The two canaliculi join to form a common canaliculus by bending at an angle, this makes a small verticle part (vertical canaliculus) and a small horizontal tube (horizontal canaliculus). The common canaliculus opens into the lacrymal sac.

Narrowing of punctum lead to inability of the punctum to clear excess tears, which may show up as watery eyes among other problems. 

The ophthalmologist (eye doctor) will recommend a punctoplasty if you have punctal stenosis with symptoms such as:

• Excessive moisture in the eyes
• Tears overflowing onto the cheeks
• Irritation or redness in the eyes due to constant tissue use

This surgery is contraindicated if excessive tearing is caused due to reasons other than punctal stenosis, such as nasolacrimal duct obstruction or canalicular stenosis.

Before the surgery, you will need the following preparation:

• The doctor may take your complete medical history and ask about any allergies you have or medications you are taking.
• He/she may also perform the following tests:
  • The Schirmer test - to rule out the excessive production of tears.
  • Visual field test - to measure the visual accuracy (how clearly you are able to see) in both high and low illumination (light) and intraocular pressure (pressure inside your eye), ocular motility (movement of your eye muscles) and binocularity (the ability of your eyes to focus on something and create a single image).
• You may need to discontinue aspirin or any similar medication 10 days prior to surgery. You may also need to stop taking blood-thinning medications.
• Your doctor will ask you to quit smoking before surgery as it may increase the risk of complications.
• Your doctor may also advise you to use antibiotic eye drops before punctoplasty to prevent any infection.
• You may need to stop wearing contact lens and applying any creams or makeup, and may also have to wash your eyelashes thoroughly to remove any debris before the surgery. 
• Do not drink alcohol a day before and after the surgery. 
• You will be asked to not drink or eat anything after midnight the night before the surgery.
• Your doctor will ask you to sign a consent form allowing him to perform the procedure on your eye.

Punctoplasty is performed under local anaesthesia (which numbs the area to be operated upon, but you will be awake). You will need to lie on the procedure table or sit on an examination chair.

The doctor will sterilise the eye and surrounding tissue with an ophthalmic solution and cover you with a sterile drape (to prevent any contact with unsterilized surfaces).

He/she will then instil a drop of anaesthesia in your eye and also inject it subcutaneously (under the skin) near the eye.

Punctoplasty can be performed in the following ways:

• One-snip procedure: The surgeon will make a 1 to 2 mm vertical incision (cut) on the posterior (back) wall of the punctum and vertical canaliculus. 
• Two-snip procedure: Along with the snip made in the one-snip procedure, the surgeon will make an additional horizontal incision of about the same size on the horizontal canaliculus.
• Triangular three-snip procedure: In addition to the two incisions made in the two-snip procedure, the surgeon will make a third incision diagonally from the start of the vertical incision to the end of the horizontal incision, leading to a triangular tissue being removed. 
• Rectangular three-snip procedure: The doctor will make two vertical cuts through the posterior wall of the punctum and vertical canaliculus and a horizontal incision to join the ends of the vertical incisions with a rectangular-shaped tissue being removed.

After the operation, you will be under observation in the recovery room.

You should take the following care at home:

• You should rest for about 24 hours after a punctoplasty. 
• Your doctor may advise pain medications to help ease the discomfort. You may also use an ice pack. 
• Do not drive or fly for some time. 
• Avoid bending, swimming, engaging in vigorous exercise, or lifting any heavy articles after the surgery. 
• Wear an eye shield or protective glasses to protect your eye from any injury. 
• Do not apply any eye makeup for a few weeks after surgery. 
• Your doctor may recommend using some eye drops for a few weeks to prevent pain, infection, or inflammation.

Punctoplasty is a procedure that helps to improve the drainage of tears.

When to see the doctor?

If you observe the following symptoms, report it to the doctor immediately:

• Severe pain 
• Vomiting 
• Nausea

The possible complications include:

• If the punctoplasty is too large, it can lead to impaired functioning of the lacrimal pump (a system in the eye that controls the washing out of tears from the eye surface)
• Failure of the procedure due to an undiagnosed canalicular stenosis
• Inflammation leading to recurring stenosis
• Damage to distal lacrimal apparatus (the system that contains the structures for tear drainage and production)

Your follow-up visit will be scheduled in a few days after the surgery where the doctor will check for any infection or reappearance of punctual stenosis.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.