Author Block: Harleen Bedi

Author Disclosure Block: H. Bedi: None.

Title:The Kissing Puncta: an underreported cause of epiphora and presentation of a three-pronged approach to improving tear clearance

Abstract Body:

Purpose: ‘Kissing puncta’ (KP) or punctal apposition is an anatomical phenomenon that is sparsely reported as a cause of epiphora in the ophthalmic literature. We review our three-pronged approach to managing the three distinct components implicated in contributing to chronic epiphora in patients with medial canthal crowding.
Study Design: A prospective review of seven patients (fourteen eyes) with KP associated with epiphora was conducted.
Methods: Each patient’s presenting symptoms, eye examination, and surgical outcomes were collected. Pre- and post-intervention photos were collected with patient’s consent. An epiphora symptom questionnaire (MUNK scale) was completed at the time of initial consult and at post-operative follow-up visits.
Results: Seven patients aged with average age 74 years (+3.5) were reviewed. Megalocaruncle, medial orbital fat prolapse, and involutional eyelid laxity were noted to be common clinical features. Punctal narrowing was observed in four patients. All patients were free to nasolacrimal duct irrigation with a hard stop and absence of any strictures on lacrimal probing. Seven patients underwent our three-pronged approach to restore the medial canthal architecture. A combined carunculectomy, medial elliptical skin incision with transcutaneous orbital fat decompression and lateral tarsal strip procedure was performed to successfully alleviate punctal apposition. Additionally, four patients underwent puntoplasty as an adjunctive procedure for punctal narrowing. At three month follow-up, all patients reported improvement in their symptoms as denoted by a median MUNK score of 0 (median pre-intervention MUNK score of 4).
Conclusions: Our study illustrates the significance of a thorough medial canthal exam as an essential part of the workup and management of epiphora. Kissing puncta can cause poor tear propagation along the eyelid margin due to medial canthal crowing and mechanical obstruction of the upper and lower puncta during the entire blink cycle. Restoration of normal punctal position with our three-pronged approach conferred significant clinical improvement in epiphora.