H04.561-563 Stenosis of Lacrimal Punctum

Stenosis of the lacrimal punctum produces a reduction in the tear outflow mechanism and it occurs when there is a constriction, narrowing or obstruction of the punctal orifice.  There are two types of acquired stenosis of the lacrimal punctum.

Primary Acquired Nasolacrimal Drainage Obstruction

• A condition that results in inflammatory scarring or fibrosis of the lacrimal punctum
• Unknown etiology
• This type is more common in middle-aged and elderly women

Secondary Acquired Nasolacrimal Drainage Obstruction

• Inflammatory scarring
• Chronic use of medications
• Bacterial, viral or fungal infections
• Surgical injury
• Neoplasm
• Trauma

Strucural Damage to the Eye and Adnexa

• Corneal staining may be involved
• Dry, hyperemic, irritated eyelids from the mechanical wiping

Functional Damage to the Eye

• Distorted, blurred or decreased vision 

The main goal of the diagnostic evaluation in a patient with punctal stenosis is to accomplish the following:

• Identify if the stenosis is from a primary or secondary obstruction
• Evaluate any structural obstructions
• Identify and exclude differential diagnoses
• Prescribe a treatment program

Patient History

It is important to differentiate between chronic epiphora, acute epiphora, and normal tearing. 

• Chronic epiphora usually results from a persistent or continuous disorder and is more likely to required a dilation procedure
• Acute epiphora usually results from irritative ocular conditions such as corneal foreign bodies, allergic conjunctivitis, dry eye syndrome, eyestrain, or environmental; factors such as wind or cold
• Increases in normal tearing occur during periods of emotional stress or sleep deprivation

External Exam

• Skin around eyelids may appear dry, irritated or red from excessive mechanical wiping

Adnexal Exam

• Eyelids (e.g., ptosis)
• Extraocular muscles
• Orbits
• Preauricular lymph nodes
• Lacrimal apparatus (a network of anatomical structures, appendages, ducts and glands that secrete tears and then drain them from the surface of the eye)

External Ocular Exam with Biomicroscopy

• Punctal stenosis
• Abnormal tear meniscus height (greater than 2 mm)
• Canaliculitis

Acquired stenosis of the lacrimal punctum are classified into non-specific (idiopathic) and specific acquired obstructions.

Non-specific acquired obstructions are thought to originate from an inflammation of the lacrimal sac.  These early inflammatory conditions encourage the mucus membranes in the nasolacrimal canal to release more inflammatory mediators resulting in obstruction of the punctum.

Specific acquired obstructions are caused by inflammatory conditions like sarcoidosis or Wegener’s granulomatosis as well as infections, trauma, surgical injury, foreign bodies, or neoplasm.

Pre-punctal disturbances of ocular surface tear flow

• Ocular allergy
• Dry eye syndrome
• Blepharitis

Non-obstructive causes of epiphora

• Eyelid malposition

Nasolacrimal system obstruction

• The nasolacrimal system may be obstructed rather than the punctum itself

Hordeolum or Chalazion

• These can cause epiphora and make it appear as if there is punctual stenosis

Neurogenic disorder

• Neurogenic disorders or trauma to the seventh cranial nerve can cause hypersecretion

Treatment is aimed at increasing the drainage of the tears and relieving the sypmtoms of epiphora.

• Dilation of the punctum with a lacrimal probe
• Topical anti-inflammatory eyedrops
• Warm compress

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