A Protocol for Managing Watery Eyes in Patients with Punctal Stenosis

Abstract

Purpose • To elucidate all factors resulting in watery eyes in patients with punctal stenosis. • To treat these factors pre-operatively and post-operatively following a horizontal 3-snip punctoplasty to achieve surgical success. Methods: 77 consecutive cases presenting to a tertiary care oculoplastics centre with watery eyes due to punctal stenosis/ occlusion were included. The clinical type of stenois/occlusion was identified. Co-existing factors causing lacrimation and epiphora, besides punctal stenosis, were identified and treated preoperatively. All cases had a rectangular 3-snip punctoplasty followed by repeated punctal dilatation in clinic, weekly for one month, and then 2 monthly for 6 months. The anti-inflammatory therapy was continued post-operatively for 2-4 months. Results: All cases had severe watery eyes (Munk grade 4-5). 69 cases (89.6 %) cases were on steroid-antibiotic topical therapy for recurrent blepharitis, while 12 cases (15.7%) were on anti-glaucoma therapy. 58 cases (75.3%) had previously failed punctoplasty. Ocular surface inflammatory disease (OSD) was present in all 77 cases (100%) causing lacrimation. It was notably severe in cases with pinpoint punctae. Membranous punctal occlusion was more common in the elderly patients with less severe OSD. Repeated punctal dilatation was necessary to maintain punctal patency post-operatively, achieving success rate of 97.4%, and 100% patient satisfaction. Conclusion: Disturbed balance between tear production and its drainage exists in patients with watery eyes. A protocol is suggested to restore that balance in patients with punctal stenosis: • Thorough clinical assessment, identifying factors causing lacrimation and treating them pre-operatively. • Identifying lower lid margin pathology that may be contributing to epiphora besides punctal stenosis and correcting it simultaneously with punctoplasty. • Rectangular 3-snip punctoplasty should be the preferred surgical procedure as it maintains the structure and function of the punctum. • Repeated punctal dilatation post-operatively and continued topical anti-inflammatory therapy to avoid punctal re-stenosis. • Patient education regarding recurrent nature of OSD and its early treatment to prevent punctal re-stenosis