Primary anterior punctal malposition presenting as Centurion syndrome.

An 18-year-old girl presented with complaints of epiphora from both eyes since childhood, right more than left. On examination tear meniscus height was raised in both eyes. Slit lamp examination showed bilateral inferior puncta to be out of lacus lacrimalis (Fig.1A and B). Both puncta were visible without any manual eversion and were directed vertically up and not in proper apposition with the globe. However both the eyelids were well apposed to the globe. A presumptive diagnosis of Centurion was thought of; however there were no other features (e.g. anterior medial canthal tendon insertion and prominent nasal bridge) suggestive of Centurion syndrome. On pulling the puncta further away from the globe it was found to be placed anterior to the summit of lacrimal papilla in both eyes (Fig 1C). A fine row of misdirected eye lashes was also seen just behind the puncta in the left eye. Regurgitation on pressure over lacrimal sac (ROPLAS) was positive in right eye while left eye lacrimal sac irrigation was patent. A diagnosis of bilateral anterior punctal malposition with right sided primary acquired nasolacrimal duct obstruction was made. Patient was advised bilateral medial spindle conjunctivoplasty with a right sided dacryocystorhinostomy.

Figure 1

A and B: Slit lamp photographs of the right and left puncta, without any manual eversion, suggesting punctal malposition. Note that both the puncta are directed vertically up and not apposed to the globe (Arrows). C: Close-up view of the right punctum, with lid being stretched showing the puncta to be lying just anterior to the lacrimal papilla. (Arrow: lacrimal papillae, Arrow head: punctum).

Comment

Lacrimal puncta are situated over an elevated structure, 0.2–0.3 mm in diameter, known as lacrimal papilla which is itself surrounded by a fibrous ring. The papillae are surrounded by the muscle of Riolan which pulls it postero medially. Both puncta are apposed to the globe and open near the plica semilunaris.

Normally the punctum is placed directly over the summit of lacrimal papilla and hence it is well apposed to the globe. Primary punctal malposition is an extremely rare entity. Secondary punctal malpositions are usually noted in eyelid malpositions such as entropion and ectropion or secondary to anterior placement of medial canthal tendon as in the Centurion syndrome, and in all these cases the puncta lies directly over the summit of lacrimal papilla. The anterior malposition in the present case was a contributing factor to the epiphora. It is important to differentiate this condition from secondary punctal malpositions, most importantly Centurion syndrome since the later can be managed successfully by procedures such as medial canthal tendon release and medial conjunctivoplasty.

Conflict of Interest

The authors declared that there is no conflict of interest.