Punctal Stenosis

How tears drain

Tears are made by glands above the eye, spread across its surface by blinking, and drain through the puncta into small channels (canaliculi), then into the tear sac and down the nasolacrimal duct into the nose. Each punctum is normally about 0.3 mm wide. If it narrows, tears overflow even when tear production is normal.

Causes

• aging: the most common cause; the punctal opening gradually narrows
• chronic blepharitis and meibomian gland dysfunction: inflammation and scarring at the lid margin
• long-term eye drops: especially glaucoma medicines, and preservatives
• chemotherapy: docetaxel, paclitaxel, 5-fluorouracil and capecitabine can scar the puncta and canaliculi
• eyelid malposition: ectropion (lid turning outward) exposes and dries the punctum, causing it to narrow
• infections: herpes, trachoma, chronic conjunctivitis
• skin conditions: rosacea, ocular cicatricial pemphigoid
• radiation to the eye area
• trauma or surgery
• congenital absence of a punctum (rare)

Symptoms

• watery eye (epiphora), often worse outdoors, in wind or cold
• tears running down the cheek
• blurred vision from excess tears
• red, irritated skin of the lower eyelid from constant wiping
• mild irritation or sticky discharge

Pain and swelling are not typical of punctal stenosis alone and suggest infection or another problem.

Diagnosis

An eye doctor examines the eyelids and puncta with a slit lamp microscope, and checks:

• the size and shape of the punctal openings
• eyelid position and blink
• tear film and signs of blepharitis or dry eye (a dry eye can paradoxically cause reflex watering)
• dye disappearance test: fluorescein dye drops are placed in each eye and the amount remaining after 5 minutes is assessed
• lacrimal irrigation: once the punctum is dilated, saline is flushed through the drainage system to look for further blockages, such as nasolacrimal duct obstruction

Treatment

Treat the underlying cause

• lid hygiene and warm compresses for blepharitis
• switching to preservative-free drops where possible
• correction of ectropion
• during chemotherapy, early referral helps, since temporary stents can prevent scarring

Procedures

• Punctal dilation: stretching the opening with a fine instrument. Simple, but the effect is often temporary.
• Punctoplasty: a small procedure under local anesthetic that enlarges the opening, often by removing a tiny wedge of tissue (one-, two- or three-snip punctoplasty). It has high success rates.
• Perforated punctal plugs or stents: placed after dilation to keep the opening patent while it heals.
• Further surgery: if the canaliculi or nasolacrimal duct are also blocked, procedures such as dacryocystorhinostomy (DCR) may be needed.

Complications

• chronic skin irritation from tears
• infection of the tear drainage system (dacryocystitis)
• recurrence after dilation

Frequently asked questions

What is punctal stenosis?

Punctal stenosis is narrowing of the small openings at the inner corners of the eyelids that drain tears. When they narrow, tears cannot drain normally and overflow onto the cheek, causing a constantly watery eye.

What causes punctal stenosis?

Common causes include aging, chronic eyelid inflammation (blepharitis), long-term use of glaucoma eye drops, certain chemotherapy drugs, eyelids turning outward, infections and radiation. Sometimes no cause is found.

How is punctal stenosis treated?

Mild cases may be treated by dilating the opening. Most persistent cases are treated with punctoplasty, a quick procedure under local anesthetic that enlarges the opening. Stents or plugs may be used to keep it open while it heals.

Can punctal stenosis cause watery eyes?

Yes. Watery eyes are the main symptom. Because tears cannot drain through the narrowed openings, they spill over the eyelid and run down the cheek, especially in wind or cold air.

Is punctoplasty painful?

Punctoplasty is done under local anesthetic, so it is not usually painful during the procedure. Mild soreness or irritation for a few days afterward is common and usually managed with eye drops and over-the-counter pain relief.