Sir,

We read with interest the article by Caesar et al1 on ‘A brief history of punctoplasty: the 3-snip revisited’. In the article, the authors reviewed the development of various surgical methods for treating punctal stenosis and reported their results of 3-snip punctoplasty. We feel that some issues that may affect the outcomes warrant further discussion.

All the patients were assessed for subjective improvement of epiphora at 1 week after operation. This relatively short-term symptomatic evaluation may not be reliable because some patients may, in contrary, experience increased epiphora in the early postoperative period due to surgical wound and associated inflammation.2 In the four cases (8%) without improvement of epiphora, the reasons could be restenosis of punctum, coexistence of other obstructions in the lacrimal drainage system, lacrimal pump failure, tear hypersecretion, or even dry eye.3 Information on patient selection, and outcome measures including anatomical success would be relevant in interpreting the results. To avoid operating on patients with symptoms of ‘epiphora’ caused by dry eye, we would recommend preoperative Shirmer test and fluorescein staining test.

Punctoplasty is usually performed under topical with or without adjacent subcutaneous anaesthetic agents.4 We observed that some patients may still experience variable degree of intraoperative pain. It is probably due to inadequate penetration of anaesthetic agent into the surgical field that involves excision of a tissue block from the posterior lamella of eyelids. We found that a small amount of local anaesthetic agent such as 2% lignocaine hydrochloride (IMS, CA, USA) into the subcaruncle area instead of subcutaneous injection provides excellent anaethetic result.

We congratulate Caesar and co-workers for their good work. We hope that the discussion would enhance our understanding and treatment of punctal stenosis.