Sir,

We appreciate the interest shown by Vahdani et al1 in a surgical technique we recently described2 and their comments. We are glad to hear that this technique has been practised by fellow colleagues with similar good results achieved. We would also like to take this opportunity to address certain differences in techniques between practices.

Both series achieved high anatomical and functional success with punch punctoplasty using Kelly Descemet’s membrane punch—95% anatomical success and 90% functional success compared to 94% anatomical success and 92% functional success in our series. In terms of surgical technique, compared to our methods, Vahdani et al described a more limited posterior ampullectomy involving only the vertical component of the canaliculus, with two to three bites. Review of literature revealed no existing reference suggesting the exact amount of tissue to be removed in punch punctoplasty. In our practice, we chose to extend the ampullectomy to 2–3 mm beyond the vertical component of the canaliculus as we believe that scarring and contraction during the healing process will eventually cause the punctal opening to become smaller. With our current technique, the extent of tissue trauma is still much less compared to the conventional 3-snip procedure, taking a balance between adequate tissue removal to prevent re-approximation of the raw cut ends of the ampulla causing failure, while limiting the destruction of the capillary action of the canaliculus to the punched out segment only. In our series, we did not encounter any major complications, but we may consider to further reduce the amount of tissue removal similar to that described by Vahdani et al.

Postoperatively, patients were prescribed topical antibiotics solely in Vahdani et al series. In our clinic, steroid and antibiotic combination eye drops are widely used, and we did not encounter steroid-related complications, given the short duration of usage. We believe the addition of steroid drops during early post-operative phase can reduce inflammation, and may theoretically slow down the scarring process and re-stenosis of the punctum.

With the presence of further evidence to support the use of punctoplasty using Kelly Descemet’s membrane punch as an effective and minimally invasive treatment for symptomatic punctal stenosis, we hope its use can become more widespread in the future.