The Mini-Monoka punctocanaliculoplasty.

Punctal stenosis is an elusive disorder with most of the cases being idiopathic.[1] Antiglaucoma medications, chronic blepharitis, involutional changes, and cicatricial disorders are however some of the recognized causes.[12] It is really disheartening to notice that while there is a plethora of literature on the management of obstruction of the distant lacrimal system, there is a paucity for that of the proximal lacrimal system, including punctal stenosis. Management of punctal stenosis along with other proximal lacrimal system obstruction is challenging, and so far, there is no clear guideline or management protocol.

The basic principles in managing punctal stenosis involve creating an adequate opening, maintaining apposition of the punctum to the lacus lacrimalis, and preserving the lacrimal pump. Numerous procedures have been tried and described with varying success rates. The 3-snip punctoplasty however remains the most popular and is widely practiced by oculoplastic surgeons as well as general ophthalmologists with a reported anatomical success rate of 94.1% and a functional one of 62.5%.[3]

Over the past few years, concerns have been raised regarding the procedure violating the anatomical boundaries and providing an ineffective tear access from the lacrimal lake to the punctal opening, leading to a poor functional outcome: often resulting in significant epiphora despite a patent lacrimal system. This was proved in the study by Shahid et al., where the anatomical success was 91% but the functional success dropped down to a significant low of 64%.[3]

The remedy was partially provided by the rectangular 3-snip where an ampullectomy was done with two vertical snips along the medial and lateral boundaries of the vertical canaliculus (described as 2-snip by Shahid et al.).[3] This modification of the routine triangular 3-snip preserved the horizontal portion of the canaliculus and provided an opening much closer to the anatomy of a normal punctum. The procedure had a markedly improved functional success rate of 94%.[4]

Two main problems associated with the management of punctal stenosis are restenosis and associated canalicular fibrosis. While the rectangular 3-snip addresses the restenosis problem, it still has no answer for the associated canalicular fibrosis which is seen in almost 46% of cases.[5] Punctal dilation augmented with Mini-Monoka, which is termed as Mini-Monoka punctoplasty(Mini-Monoka punctocanaliculoplasty [MMPC]) by Hussain et al., not only preserves the normal punctal anatomy but also addresses the associated canalicular fibrosis.[5] Although the use of Mini-Monoka is well established during the reconstruction of traumatic eyelid margin injuries involving the canaliculus,[6] it has not been considered widely for other proximal lacrimal system pathologies. Kashkouli et al. describe the use of these stents in combination with 1-snip punctoplasty for acquired punctal stenosis with 85% functional success.[7]

Gupta, et al. have reported their results of cases of primary punctal stenosis managed by punctal dilation and Mini-Monoka with anatomical and functional success of 93.3%.[8] Their follow-up period of 6 months is long enough to suggest that it prevents restenosis. It would have been better had they included the cases associated with canalicular fibrosis and compared the results since most of the cases of punctal stenosis have associated canalicular fibrosis.[7] The length of the Mini-Monoka stent is 25 mm and it is essential to trim the excess length to both allow easy passage and prevent intubation of the distal lacrimal system and stent migration.

The MMPC offers promising outcomes for cases of punctal stenosis whether isolated or associated with canalicular fibrosis. The rectangular 3-snip punctoplasty too has good success rates and cannot be completely ruled out as a management option, especially when Monoka may not be universally affordable.