Definition and Overview

A punctoplasty, more commonly known as watery eye surgery, is an ophthalmic surgical procedure performed to correct punctal stenosis (a condition that causes tears to overflow from the eyes) by widening the punctal opening to allow the tears to drain with ease.

Watery eye is caused by either the excess production of tears or when the eye’s drainage system is too narrow or is blocked.

Who Should Undergo and Expected Results

A punctoplasty is beneficial for all patients who suffer from watery eye, a condition wherein a person’s tears overflow from the eyes, a symptom known as epiphora. Thus, it is helpful for those who have a condition called punctal stenosis, wherein the puncta, or the little holes in the eyelids that allow tears to drain, are too narrow or are blocked. This condition, which is more common among the elderly, is sometimes caused by the chronic inflammation of the eyelids (blepharitis) and the use of topical antihypertensive medications.

A punctoplasty is also helpful for patients whose lacrimal glands produce too much tears, which can be caused by several factors, such as eye irritation or dryness that causes the glands to compensate by producing more tears than normal. This is why some patients who suffer from watery eyes are treated using artificial tears. By first resolving the dryness of the eyes, the excess tear production is also prevented.

Records show that watery eye surgery has a high success rating of 86% to 96%.

How Does the Procedure Work?

A punctoplasty or watery eye surgery is a simple ophthalmic procedure that takes just 10 to 30 minutes. It is done on an outpatient basis and requires only local anaesthesia, which is usually administered in the form of ophthalmic drop. Patients can undergo the procedure while lying down on an operating table or sitting in an exam chair.

Prior to the procedure and after the anaesthesia has been administered, the surgeon injects epinephrine subcutaneously and uses a punctal dilator to dilate the punctum. The surgical site is also prepped by grasping the punctal wall with forceps and opening up the area where the incisions are to be made.

Ophthalmologic surgeons use different methods to perform a punctoplasty. It is possible to widen the punctal opening using a special instrument called a Kelly punch. Another alternative is to temporarily use a perforated punctal plug, a small plug with a hole for drainage that can be left in place for up to 6 weeks to enlarge the punctum, allowing tears to drain in a more efficient manner.

However, the most common technique used is cutting out a small piece of the punctum. This can be done using four different approaches, namely:

  • One-snip punctoplasty, which involves making a single vertical incision through the punctal wall
  • Two-snip punctoplasty, which involves making vertical incision through the punctal wall followed by a horizontal incision along the canaliculus
  • Triangular three-snip punctoplasty – In this procedure, the surgeon makes a vertical incision through the punctal wall, a horizontal incision along the canaliculus, and a diagonal incision to connect the first two incisions.
  • Rectangular three-snip punctoplasty – This involves making two vertical incisions through the punctal wall and the vertical canaliculus, which are then connected by a horizontal incision.
    These procedures all effectively enlarge the opening of the punctum, allowing tears to drain more easily.

After the procedure, patients are allowed to return to their normal activities, as long as they follow the surgeon’s post-procedural instructions.

Possible Risks and Complications

A punctoplasty is associated with the following risks:

  • Infection
  • Pain or discomfort – Patients may experience some discomfort especially due to the injection. The anaesthetic eye drops may also sting a bit. However, both do not affect a person’s vision after the surgery.
  • Recurrence of punctal stenosis – The rate of recurrence is higher in 1-snip and 2-snip procedures because there is a tendency for the edges of the punctal and canaliculi incisions to heal together. This can be prevented by using punctal plugs.
  • Trauma to the eye – This is a theoretical risk that exists in any kind of surgery performed near or around the eyes, but it rarely occurs.
  • Temporary blurring of vision – This is a common side effect of the use of antibiotic ointments and will resolve once the medication period ends. However, it may keep patients from doing certain activities, such as driving, for some time after the ointment is administered.
    If incisions were made, there is some risk of bruising usually at the inner part of the lower eyelid. This will resolve on its own after a few days. Scarring is not usually a concern as the surgery does not leave any visible marks.

To help minimise the risks of a watery eye surgery, ophthalmologists prescribe antibiotic and anti-inflammatory ointments or eye drops such as erythromycin, which the patients are instructed to use 3 times a day, usually for 5 days following the procedure. These help facilitate proper healing of the surgical site. Before administering the medications, patients are instructed to wash their hands. They are also taught how to properly clean the eye regularly, and are advised to refrain from touching or rubbing the eye.

Patients are also advised to keep their follow-up visit, which is usually scheduled a few days after the surgery was performed to check for signs of infection and ensure that the procedure successfully resolved the problem.

Ophthalmologists also usually schedule another follow-up check several months after the surgery to check for signs of recurrence.

Reference

  • Hurwitz JJ. The lacrimal drainage system. In: Yanoff M, Duker JS, eds. Ophthalmology. 4th ed. St. Louis, Mo: Mosby Elsevier; 2013:chap 12.15.
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