Functional and anatomical outcomes of punctoplasty with Kelly punch

Sir,

Acquired punctal stenosis represents a common cause of epiphora due to partial or complete lacrimal outflow obstruction. A variety of surgical procedures have been described involving punctal dilatation or surgical enlargement, sometimes augmented with lacrimal stenting or perforated punctal plugs.

We read with interest the article by Wong et al¹ regarding the long-term outcomes of punch punctoplasty with Kelly Descemet’s membrane punch. In this report the successful anatomical and functional rates were 94% and 92%, respectively.

The authors would like to add the results of our 86 consecutive case series of Kelly punch punctoplasty performed on 65 patients (21 bilateral cases) with symptomatic punctal stenosis. The average follow-up was 6 months. At the last follow-up, 95% (82/86) achieved anatomical success, compared to 90% (78/86) functional success rate. Three puncta (3.4%) were noted to be re-stenosed at last visit. No significant complications were recorded.

In terms of surgical technique, Wong et al¹ describe an extended ampullectomy up to 2–3 mm beyond the vertical component of the canaliculus, by partially de-roofing and marsupializing the lower canaliculus, aiming to counteract the postoperative scarring and contracture of the punctal opening. However, in our experience a posterior ampullectomy involving only the vertical component of the canaliculus, with two to three bites, was sufficient for achieving adequate punctal opening enlargement in majority of the cases. In cases of short or stenosed vertical component, this can be slightly extended by (~1mm). Postoperatively, patients were prescribed a topical antibiotic solely (typically g. chloramphenicol 0.5%).

Our series provides further support for punctoplasty using Kelly Descemet’s membrane punch as a simple, effective, and minimally invasive procedure for patients with symptomatic punctal stenosis. Satisfactory outcomes can be achieved with minimal tissue removal, potentially with less alteration of the lacrimal pump system.