3-Snip punctoplasty

Sir,

I enthusiastically read the article by Caesar and McNab¹ on 3-snip punctoplasty for punctal stenosis. The authors have stated that there is still debate as to how best to perform a punctoplasty, and whether it is effective. In our experience and in the published literature,^{2, 3, 4} recurrent punctal stenosis related to healing of the cut edge of a punctoplasty procedure is a disadvantage of this procedure. As a result, different approaches such as punctoplasty with adjunctive intraoperative mitomycin C² and punctoplasty with punctal plug insertion³ have been introduced to overcome the problem of restenosis. Moreover, we demonstrated an association of canalicular and especially internal punctal stenosis in more than 45% of patients with acquired external punctal stenosis (AEPS).⁵ To address this and also restenosis, a one-snip punctoplasty and mini Monoka tube insertion was proposed (Kashkouli MB, Beigi B, Astbury N. Acquired External Punctal Stenosis, surgical management and long-term follow-up. Orbit, in press, OR050, P03). We found 96.2% anatomical success and 85% functional success among 53 eyes with AEPS with a mean follow-up time of 18.5 months.

The authors have rightly commented that there is no commonly agreed definition of what constitutes punctal stenosis. We, however, found chronic blepharitis (44.9%), involutional changes (26.9%), ectropion (23.1%), systemic chemotherapy (1.2%), and antiglaucoma drops (3.6%) as the underlying causes in our series of 78 eyes with AEPS.⁵

Caesar and McNab used a simple clinical test for diagnosis of punctal stenosis without considering the severity of stenosis among different cases.¹ There is a proposed grading system for external punctal stenosis (grades 0–2) and slit punctum (grades 4 and 5)⁵ based on slit-lamp examination and the way to enter a #00 Bowman probe. This grading system is very helpful in assessing pre- and postoperative state of a stenotic punctum (Kashkouli MB, Beigi B, Astbury N. Acquired External Punctal Stenosis, surgical management and long-term follow-up. Orbit, in press, OR050, P03). A study of its reliability and interobserver variation is now being conducted in our center.

The authors mentioned that the indication for punctoplasty was symptomatic punctal stenosis.¹ Some of our patients with symptomatic punctal stenosis associated with blepharitis were treated conservatively for the blepharitis. This group of patients became asymptomatic in spite of remained punctal stenosis. In fact, it should be taken into consideration that some patients may benefit from punctal stenosis for their pre-existing dry eye.