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Middle East African Journal of Ophthalmology Middle East African Journal of Ophthalmology
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Year : 2018  |  Volume : 25  |  Issue : 3  |  Page : 170-172  

Punctal plug as a treatment option for dry eye associated with congenital supernumary puncta

1 Oculoplastic Division, King Khaled Eye Specialist Hospital, Riyadh 12329, Saudi Arabia; Department of Ophthalmology, Rio Hortega University Hospital, 47012, Valladolid, Spain
2 Oculoplastic Division, King Khaled Eye Specialist Hospital, Riyadh 12329, Saudi Arabia
3 Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, School of Medicine of Ribeirão Preto–University of São Paulo, Brazil
4 Department of Ophthalmology, Galindo Clinic, 47003, Valladolid, Spain; Department of Ophthalmology Faculdade de Medicina de Botucatu- UNESP, São Paulo, Botucatu, SP, 18607-621, Brazil

Date of Web Publication4-Jan-2019

Correspondence Address:
Dr. Alicia Galindo-Ferreiro
Department of Ophthalmology, Rio Hortega University Hospital, Valladolid, Spain

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/meajo.MEAJO_102_16

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This study aims to describe a case of double lower lacrimal punctum-canaliculi in a dry eye patient treated with a punctal plug. A 60-year-old healthy female presented with complaints of tearing, itchy eyes, and foreign body sensation in the right eye for many years. There was no history of trauma or inflammation. Two patent independent supernumerary puncta and canaliculi were present on the right lower eyelid. The Schirmer Test II (with anesthesia) was zero, the tear breakup time was 2 s, and superficial punctate erosions were present in the right eye. A long-term nonabsorbable punctal plug was inserted into one of the lower puncta. At 9-month follow-up, the dry eye symptoms decreased markedly, the Schirmer Test II improved and superficial keratitis resolved.

Keywords: Congenital, double puncta-canaliculi, dry eye, lacrimal drainage, punctal plug

How to cite this article:
Galindo-Ferreiro A, AlGhafri L, Akaishi P, Galvez-Ruiz A, Galindo-Alonso J, Schellini S, Cruz A. Punctal plug as a treatment option for dry eye associated with congenital supernumary puncta. Middle East Afr J Ophthalmol 2018;25:170-2

How to cite this URL:
Galindo-Ferreiro A, AlGhafri L, Akaishi P, Galvez-Ruiz A, Galindo-Alonso J, Schellini S, Cruz A. Punctal plug as a treatment option for dry eye associated with congenital supernumary puncta. Middle East Afr J Ophthalmol [serial online] 2018 [cited 2019 Sep 19];25:170-2. Available from: http://www.meajo.org/text.asp?2018/25/3/170/249319

   Introduction Top

A rare congenital anomaly of the lacrimal drainage system is a double lacrimal puncta which has rarely been reported in the literature.[1],[2],[3],[4] The majority of patients with this condition are asymptomatic or have unilateral epiphora in the affected eye.[1],[2]

This case presents a congenital supernumary puncta (double lacrimal puncta-canaliculi) with patent lacrimal system associated to the dry eye that was successfully treated with a punctal plug.

   Case Report Top

This case report was approved by Institutional Review Board of King Khaled Eye Specialist Hospital (KKESH), Riyadh, Saudi Arabia. A 60-year-old healthy female presented to the Oculoplastic Clinic at the KKESH, complaining of tearing, itchiness, and foreign body sensation of the right eye with duration of several years. There was no previous history of trauma or inflammation. On examination, two puncta (0.5 mm apart) were noted. The punctum was oval shaped 1.5 mm diameter in the right lower eyelid. Two Bowman probe 0-00 were inserted into both puncta at the same time and a double canaliculus was confirmed. This proved that both puncta had independent canaliculi, which may lead to the common canaliculus or directly to the sac. Normal saline irrigation into both puncta passed freely to the nose. The Schirmer Test II was 0 mm, the tear break up time was 2 s, and the lower tear meniscus height was 1 mm. Fluorescein staining of the right cornea indicated superficial punctate erosions. The rest of anterior and posterior segment eye examination was within normal limits, including the upper punctum (0.8 mm diameter). Examination of the left eye was unremarkable. A long-term nonabsorbable plug (SmartPlug; Medennium Inc., Irvine, CA, USA) was inserted in the lacrimal punctum that was most lateral in the right lower eyelid [Figure 1]. The smart plug is a rod of thermoplastic material that was inserted into the vertical portion of the canaliculus and then shrinks to the horizontal portion so that the end of the plug does not protrude from the punctum. Nine months after insertion of the punctal plug, the dry eye symptoms had markedly decreased. The Schirmer Test II was 5 mm, the meniscus height was 6 mm, and superficial keratitis had resolved.
Figure 1: Right double lower puncta-canaliculi (left), punctal plug inserted in the lateral punctum (right)

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   Discussion Top

Congenital supernumerary lacrimal puncta-canaliculi are rare.[1] Less than 30 cases have been published.[2],[3] Satchi and McNab[3] evaluated 22 cases, 18 had nasolacrimal duct obstruction with epiphora, and 4 cases were asymptomatic. Bair et al.[1] reported a case of supernumerary punctum-canaliculi associated with dry eye that was surgical treated with punctal occlusion resulting in marked resolution of symptoms.

The development of congenital supernumerary puncta is likely due to irregular budding of the ectodermal core, which invades the mesoderm of the lid, from which the lacrimal canaliculi are derived.[1],[2]

A greater frequency of supernumerary puncta was reported on the right lower lid with the accessory punctum nasal to the normal punctum.[1],[2] Similar to previous reports, our patient had the right lower eyelid affected and the accessory punctum had an accessory canaliculus that could lead into a common canaliculus or an independent canalicular opening in the lacrimal sac as previously described.[2],[4]

Although we did not definitively document the anatomy of our patient, dacryocystography can be used for this purpose.

Both right lower puncta of our patient were larger than the upper punctum. In normal population, generally, lower lid puncta are larger than the upper lid puncta.[5] This is clinically significant in the dry eye as normal lacrimal system patients who require punctal plugs of various sizes. In addition, this observation supports the treatment performed for the current case. We elected to place a punctal plug to improve dry eye symptoms. We randomly selected the more lateral punctum to decrease drainage. A literature review stated that the supernumerary puncta are located nasally, however, the review offered no evidence for this statement.[6]

Standard treatment for dry eye is the placement of punctal plugs. Punctal plug insertion allows greater fluid accumulation in the conjunctival sac and improves corneal and conjunctival epithelial disorders. Hence, we elected to initially occlude the outer inferior punctum and then assess ocular surface over a 9-month period.

Alternatively, other authors have performed thermal cautery with good outcomes in cases of double punta-canaliculi.[1] We believe that plug insertion is advantageous because it is a faster procedure, less traumatic, and reversible.

Although the patient can be asymptomatic, various symptoms have been associated with double puncta including tearing and dacriocystitis due to duct obstruction and canaliculitis.[1],[2],[4],[6],[7] In the current case, the patient had dry eye with a patent nasolacrimal duct similar to the case describe by Bair et al.[1]

Dry eye in our case was likely associated to the supernumerary puncta-canaliculi. One possible explanation is the increased outflow of the supernumerary system and the increased tear excretion in the affected eye.[1] However, Satchi and McNab[3] concluded that the site of origin of the accessory canaliculus and the relationship with Horner's muscle might determine the direction of tear flow within the accessory canaliculus, and thus the effect of its presence on canalicular function and symptoms. Quantitative lacrimal scintigraphy (with time-activity curves) would be ideal to accurately measure lacrimal clearance from the conjunctival fornices. In addition, scintigraphy can be used to study the physiology of the lacrimal “pump” to elucidate the pathophysiology of dry eye.

   Conclusion Top

Patients with double puncta can have associated dry eye. We are reporting one case with this condition, successfully treated with punctal plug to occlude one of the supernumerary puncta.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Bair PJ, Tsai YY, Lin JM. Congenital reduplication of the lacrimal punctum and canaliculus in a patient with dry eye. Ophthalmic Surg Lasers Imaging 2004;35:156-8.  Back to cited text no. 1
Chignell AH. Double punctum and canaliculus. Am J Ophthalmol 1968;65:736-9.  Back to cited text no. 2
Satchi K, McNab AA. Double lacrimal puncta: Clinical presentation and potential mechanisms of epiphora. Ophthalmology 2010;117:180-3.e2.  Back to cited text no. 3
Yong KC, Kah TA, Annuar FH. Canaliculitis in supernumerary puncta and canaliculi. Clin Pract 2011;1:e59.  Back to cited text no. 4
Carter KD, Nelson CC, Martonyi CL. Size variation of the lacrimal punctum in adults. Ophthal Plast Reconstr Surg 1988;4:231-3.  Back to cited text no. 5
Solomon A, Feiler-Ofry V, Lazar M. Congenital reduplication of the lacrimal punctum and canaliculus. Ann Ophthalmol 1981;13:727.  Back to cited text no. 6
Flom L, Levitt JM. Double lacrimal puncta and dacryops. AMA Arch Ophthalmol 1955;54:760-1.  Back to cited text no. 7


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