We continue our review of on punctal stenosis by providing a detailed discussion of management modalities, their complications, and outcomes. There is a significant change in the understanding of punctal and peripunctal anatomy, puncto-canalicular junction, and the lacrimal pump mechanisms. While the snip punctoplasty procedures are still practiced, there is an increasing trend toward nonincisional procedures. The nonincisional procedures in select cases appear to be equally effective as the incisional ones. Although simple to use, punctal plugs never became the mainstay of treatment because of design issues and the inability to address the coexisting canalicular stenosis. Placing stents only in the lower punctum in cases of upper and lower punctal stenosis should be discouraged, and management needs to address punctal stenosis and not which punctum is involved. Several types of stents are used in the management of punctal stenosis, mostly based on surgeon\'s preference. The benefits of adjuvant mitomycin C are uncertain. In view of literature on how stent biofilms can themselves cause chronic inflammation, placing them for prolonged periods should be reviewed and debated. Enhanced understanding of the molecular pathogenesis of punctal stenosis and addressing the current controversies in management would help standardize the therapeutic interventions available in the lacrimal armamentarium.

BACKGROUND: To investigate the geometric morphological differences of the lacrimal punctum by analyzing its shape in relation to age and sex in a normal population.
METHODS: 960 high-magnification slit-lamp images were obtained from 320 puncta of normal asymptomatic Indian individuals across eight decades of life. Using advanced geometric morphometric techniques, including Elliptic Fourier Analysis and Principal Component Analysis, the intricate details of the lacrimal punctum\'s shape in a diverse population sample were categorized by age and sex. High-resolution images of the lacrimal punctum underwent standardization for scale and orientation, followed by precise landmark identification and coordinate data extraction.
RESULTS: The geometric morphometry of the lacrimal punctum shows significant changes as one ages. However, the gender differences, in isolation, without consideration of age, remain subtle and are not pronounced. Interestingly, detailed Principal Component scores analysis revealed potential sex- and age-related variations specifically for the left and right lower puncta, which warrant further investigation. These changes could reflect unique aging changes in the proximal lacrimal drainage system.
CONCLUSIONS: The study is a starting point for geometric morphometric analysis of the lacrimal punctum and provides valuable insights into the punctal changes in size, orientation, and overall morphology across different age groups and between sexes. These findings highlight the significance of considering individual age-wise anatomical variations to better understand the lacrimal punctum.

UNASSIGNED: To present the clinical and histological characteristics of a basal cell carcinoma, which appears to emanate from the lacrimal punctum.
UNASSIGNED: An 81-year-old caucasian female presented with an irritating lesion arising from the left upper punctum for approximately four months. Examination demonstrated a pedunculated pinkish lesion emerging from the left upper punctum. The patient elected to pursue the removal of the lesion. An excisional biopsy was performed by placing a curette within the upper eyelid punctum, and the lesion was scooped out. Pathology showed invasive nodular basal cell carcinoma. Following the diagnosis, a wedge resection of the left upper punctal region was performed, which showed no residual carcinoma.
UNASSIGNED: This case describes a unique instance of a basal cell carcinoma clinically appearing to arise solely from the upper eyelid punctum. A level of suspicion should be maintained when excising benign-appearing eyelid lesions, and a histopathological analysis is warranted.

We aim to provide a detailed and updated literature review on the epidemiology, etiology, clinical presentations, histopathology, and ultrastructural features of punctal stenosis. There are inconsistencies in the definition and staging of punctal stenosis. While advanced optical coherence tomography imaging techniques have revolutionized the way the punctum and vertical canaliculi are assessed or monitored following treatment, the planes of measurement to characterize punctum anatomy need to evolve further. The current criteria for diagnosing and grading punctal stenosis are inadequate and based on empirical clinical findings. There is increasing evidence of the role of lymphocytes and myofibroblasts in the pathogenesis of punctal stenosis. There is a need for a uniform assessment of punctal stenosis and a uniform reporting of severity that would help standardize the several management options available in the lacrimal armamentarium.

Spectral domain OCT imaging of the lower punctum in cases with silicone tube implantation OBJECTIVE: To record the structural changes in the lower punctum by performing spectral domain anterior segment OCT imaging of dacryocystorhinostomy cases who underwent bicanalicular silicone tube implantation.
METHODS: Thirty eyes of 30 patients who underwent bicanalicular Crawford silicone tube implantation with dacryocystorhinostomy were included in the study. The mean age of the cases was 53 ± 13.96 (24-72). Of the cases, 19 were female and 11 were male, 18 of them were operated on the right eye and 12 on the left eye. The lower punctum images of the cases were recorded with spectral domain anterior segment OCT preoperatively and at the 1st day, 1st month and 6th month after explantation of the silicone tube. In the lower punctum, external punctal width(EPW) and canaliculi depth (CD) were measured.
RESULTS: The mean EPW and CD measurements of the cases in the preoperative period, respectively; 544.90±144.11 µm and 451.70±197.45 µm. First day after silicone tube explantation, EPW was 818.00±186.83 µm and CD was 735.35±337.15 µm, at 1st month EPW was 665.95±142.12 µm and CD was 619.30±212.11 µm and at 6th months EPW was 530±150.29 µm and CD was 558.45±254.37 µm, respectively. Mean EPW values were found to be higher on the first day after extubation than before surgery (p = 0.001). There was no significant difference in the mean EPW values at the first and sixth months after extubation compared to pre-implantation (p>0.05). The mean CD values were higher at the 1st day, 1st month and 6th month after tube explantation than preoperative CD values, they were not statistically significant.
CONCLUSIONS: According to the lower punctum OCT imaging data, silicone tube implantations applied to the canalicular system do not create a structurally significant difference in the lower punctum. The punctal opening gradually decreases after extubation. The decrease in EPW values is more pronounced than the decrease in CD values. Silicone tube implantation was more effective in maintaining canaliculi depth compared to external punctal diameter.

UNASSIGNED: The aim of the study was to evaluate etiological and demographic characteristics of the adult patients referred to the oculoplastic surgery clinic of the tertiary care center with the complaint of epiphora.
UNASSIGNED: The medical records of the patients who applied to the oculoplastic surgery clinic with a complaint of epiphora between January 2014 and July 2021 were reviewed retrospectively. Etiology of epiphora, age, gender, duration of symptom, and follow-up period were evaluated. According to the etiological factors, nasolacrimal system disorders such as punctal stenosis, canalicular stenosis, canaliculitis, and acquired nasolacrimal system obstruction, respectively; the causes of epiphora were grouped as eyelid abnormalities such as entropion and ectropion, and hypersecretory tear secretion due to causes such as dry eye, allergy, and inflammation. The patients with epiphora over the age of 18 with at least 6 months of follow-up were included in the study. Patients with congenital or tumor-related nasolacrimal duct obstruction (NLDO) and epiphora due to trauma-related eyelid or canaliculi injury were not included.
UNASSIGNED: A total of 595 medical fields were evaluated. Epiphora was present in 747 eyes of 595 patients. Of the patients, 221 (37%) were male and 376 (63%) were female. According to etiological evaluation of frequency, 372 (62.5%, 432 eyes) patients with NLDO, 63 (10.5%, 123 eyes) patients with punctal stenosis, 44 (7.3%) patients with ectropion, 38 (6.3%) patients with entropion, 37 (6.2%, 69 eyes) patients hypersecretory causes (dry eye, allergy, inflammation, etc.), 24 (4%) patients had primary canaliculitis, and 17 (2.8%) patients had epiphora due to canalicular occlusion.
UNASSIGNED: Epiphora is an important complaint that may occur due to different etiologies. A detailed examination of the anterior segment, lacrimal system and eyelids, and taking a history are the most important steps in the management of the patient.

3p deletion syndrome or deletion 3p25-pter syndrome is an exceptionally rare genetic disorder characterized by deletion of the distal segment of the short arm of chromosome 3. There are less than a hundred reported cases worldwide. Clinical characteristics include severe physical and mental retardation, trigonocephaly, micrognathia, and diffuse hypotonia. The common ocular manifestations include congenital ptosis and canthal anomalies. To the best of the authors\' knowledge, no lacrimal drainage anomalies have been reported earlier. The present case describes proximal lacrimal drainage anomalies in a patient with 3p deletion syndrome. The patient was successfully managed with membranotomy and punctal and canalicular dilatation, resulting in a complete resolution of epiphora.

Peripunctal squamous cell carcinomas with canalicular infiltration are a rare clinical entity. Although there are universal guidelines on achieving margin clearance for excision of an eyelid tumor, literature is scarce on achieving the same while dealing with the lacrimal drainage system. The present case describes the management of a rare case of squamous cell carcinoma with secondary extension into the proximal lacrimal system. The surgery was performed with intraoperative frozen section guidance.

Punctoplasty is a common procedure in the management of punctal stenosis and was first described by Sir William Bowman in 1853. Several types of punctoplasty are described, and include 1-snip, 2-snip, triangular 3-snip, rectangular 3-snip and 4-snip procedures. The understanding of the anatomy and physiology of the punctum has greatly improved in the last decade aided by electron microscopic and molecular techniques. The use of minimally invasive modalities for primary cases is on the rise with successful preservation of the physiological functions of the punctum and canaliculus. The paper reviews the current anatomical and physiological evidence to present an alternative perspective. Given our evolving understanding, it may be time to debate the practice of performing routine punctoplasty.

暂无摘要。