Punctal stenosis is narrowing or occlusion of the external opening of the lacrimal canaliculus, the punctum. It can be diagnosed when the punctum is less than 0.3 mm in diameter. The patient may present with tearing and evaluation for distal nasolacrimal duct obstruction should be performed as this may occur simultaneously.
Many factors have been linked to the development of punctal stenosis, including the following:
- Congenital: anophthalmos, microphthalmos, congenital stenosis
- Idiopathic: aging, female sex
- Inflammatory: chronic blepharitis, dry eye syndrome, ocular cicatricial pemphigoid, lichen planus
- Mechanical: lid malposition, trauma, tumors, local irradiation, photodynamic therapy for macular disease 
- Infectious: HSV, trachoma, chlamydia, actinomyces, HPV
- Iatrogenic: punctal electrocautery, suture closure
- Topical medications: timolol, latanoprost, betaxolol, dipivefrine hydrochloride, echothiophate iodide, pilocarpine, prednisolone acetate- phenylephrine hydrochloride, adrenaline, chloramphenicol, tobramycin, indomethacin, dexamethasone, tropicamide, naphazoline, artificial tears
- Systemic medications: 5-fluorouracil, docetaxel, paclitaxel, idoxuridine
- Systemic diseases: acrodermatitis enteropathica, porphyria cutanea tarda, Stevens-Johnson Syndrome, graft-versus-host disease
As the entry point for tears, the punctum is exposed to all the possible soluble irritants that can be found on the ocular surface. Chronic inflammation of the external punctum leads to gradual fibrotic changes in the ostium followed by progressive occlusion of the duct. 
Punctal stenosis is clinically defined as a punctum caliber restricting tear drainage in the absence of distal tear drainage abnormalities, namely canalicular obstruction or nasolacrimal duct obstruction. In the literature, punctal stenosis has been defined as a punctal diameter of less than 0.3 mm or inability to intubate the punctum with a 26 G cannula without dilation.
Signs include epiphora, increased tear lake, narrowing of punctum and inability to insert a probe or cannula without dilation. “Tissue sign” – the patient is walking into clinic with a handful of tissues.
- Overflow of tears on the cheek, excessive moisture in eyes
- Eye irritation or redness from constant tissue use
- Slit lamp exam can identify a membrane or fibrosis of the punctum as well as punctum size, tear meniscus height, eyelid malposition, and signs of previous surgery
- Schirmer test can help quantify basal tear production, differentiating an obstructive cause from dry eye with reflex tearing. Tear break up time, ocular surface staining, tear meniscus height, and careful exam of the lids and conjunctiva help identify associated ocular surface abnormalities.
- Presence of fluorescein in fornix 7 minutes after instillation indicates a delay in dye disappearance
- Lacrimal probing or cannulation with irrigation of the canal can help to differentiate punctal stenosis from canalicular or nasolacrimal duct obstruction. In punctal stenosis, there is difficulty passing the probe past the punctum.
Lab tests are rarely needed for patients with punctal stenosis. Conjunctival biopsy with direct immunofluorescence staining may be considered in those rare cases where an underlying disorder such as ocular cicatricial pemphigoid is suspected, chiefly in bilateral cases in younger patients or with symblepharon or other signs of ocular surface abnormality
Epiphora due to dry eye with reflex tearing; canalicular obstruction; nasolacrimal duct obstruction; congenital glaucoma
There is no medical management of punctal stenosis. Punctal dilation can be performed as an initial step, although it is mostly done for diagnostic purposes to allow evaluation of the remainder of the nasolacrimal system. Most patients require one of the surgical options listed below. The goals of surgery include creating an adequate opening, maintaining punctal position against the lacrimal lake, improving tear access from the lacrimal lake to the punctal opening, and preserving function of the lacrimal pump.
- One snip
- Two snip
- Three snip  
- Four snip 
- (+/- intraoperative mitomycin C for resistant cases)
- Snip procedure with perforated punctal plug insertion  
- Punctal punching
- Wedge punctoplasty
- Laser punctoplasty
Surgical follow up
If a bicanalicular or monocanalicular stent (mini monoka) is placed, it should be removed at 2-4 months
EyeRounds.org tutorial under “punctoplasty” http://eyerounds.org/video/plastics/index.htm
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