|Probing and irrigation of canaliculi and lacrimal system|
|Assess for co-existent punctal ectropion|
|Rule out any conjunctival cicatrizing disorder|
|Assess lower eyelid laxity|
|Prior eyelid, facial surgery or trauma|
Punctal stenosis often occurs in conjunction with punctal ectropion. Punctal stenosis may be one of the first signs of the spectrum of lower eyelid ectropion, which first begins with the medial aspect of the eyelid and then involves the entire margin. Punctal stenosis also may occur as part of conjunctival cicatrizing disorders. Ocular cicatricial pemphigoid, Stevens–Johnson syndrome, and pseudo-pemphigoid can all affect the puncta and may cause progressive stenosis that is difficult to manage.
In patients with isolated punctal stenosis, snip punctoplasty can be performed as an in-office procedure or in conjunction with other lower eyelid procedures. Our preferred approach is to use a Kelly Descement punch to perform the punctoplasty. This allows more precise and controlled enlargement compared to the classic three-snip punctoplasty. Placement of silicone stents at the time of punctal stenosis can also improve long-term patency ( Chapter 60 ). Canalicular stenosis and nasolacrimal duct stenosis, however, may be co-existent and, if present, should be also addressed appropriately. After dilation of the puncta, probing and irrigation are essential to diagnose and treat associated lacrimal obstructions.