Graefe’s Arch Clin Exp Ophthalmol
(2002) 240:960–961
L E T T E R T O T H E E D I T O R
DOI 10.1007/s00417-002-0565-9
tion through the lower punctum was at-
tempted, but failed. Congenital NLDO was
present. Therapeutic probing of the naso-
lacrimal duct was carried out. Right-sided
turbinate infracture was also performed be-
cause the inferior turbinate was in close
proximity to the lateral wall of the nose
(around the outlet of the nasolacrimal
duct). A silicone tube was passed from the
right lower punctum to the nasolacrimal
duct and out of the nose. The two ends
were tied beside the nose and the tube was
left in place for 6 months. Since removal of
the tube 1 year ago the patient has been
free of tearing.
Jia-Kang Wang
Pei-Ching Lai
Shu-Lang Liao
is to open the lacrimal sac and per-
form retrograde probing through the
common canalicular opening. We did
not, however, attempt any of these
means to explore the right upper
canaliculus of this patient, for four
reasons:
Punctal and canalicular
agenesis presented
with congenital
nasolacrimal duct
obstruction
1. The possibility of considerable
damage to the eyelid or lacrimal
excretory system
2. The patent lower punctum and
canaliculus
3. Punctal agenesis, which is often
associated with the absence of
underlying canalicular tissue
4. Lack of identification of upper
canalicular tissue by a pigtail
probe
Received: 23 August 2002
Published online: 2 October 2002
© Springer-Verlag 2002
Discussion
Punctal agenesis may be the result
of a defect during one of the stages
of differentiation of the lacrimal
passage. It usually is associated with
the absence of underlying canalicu-
lar tissue. In 86% of eyes with the
absence of both puncta, no canalicu-
lar tissue is identified when the lac-
rimal sac is opened surgically [2].
The underlying canaliculus is also
absent in patients who have one ab-
sent punctum. Our patient, however,
had absence of both puncta, but ab-
sence of only one canaliculus. Asso-
ciated NLDO was also discovered.
Therefore, we had to solve three
problems: punctal agenesis, canalic-
ular agenesis, and congenital
Introduction
For congenital NLDO, simple prob-
ing and irrigation were effective [2].
Still, additional silicone intubation
can improve the patency rate and
avoid the risk of additional surgery
[4]. Because only one punctum was
patent, we could not perform regular
intubation through both puncta, but
had to fix the ends of the silicone
tube beside the nose. Fortunately,
the tube did not dislodge for
6 months; this was due to the coop-
eration of the child. One patient re-
ported by Putterman also received
intubation through the lower punc-
tum only. The two ends of the tube
were tied over the cheek and left in
place for 1 month [3].
In summary, the patient had com-
plicated congenital anomaly of lacri-
mal excretory system. Treatment in-
cluded a modified Jones one-snip
procedure, nasolacrimal duct prob-
ing, turbinate infracture, and sili-
cone intubation. Management of
such complicated cases should be
adjusted on the basis of the results
of previous reports and the anatomi-
cal peculiarities of the individual pa-
tient.
Punctal and canalicular agenesis are
not common [2]. Punctal agenesis,
canalicular agenesis, and congenital
nasal lacrimal duct obstruction
(NLDO) can appear together or
separately. There are several means
of managing these conditions
[1, 2, 3, 4]. Herein we describe a
case of combined punctal agenesis,
canalicular agenesis, and congenital
NLDO.
Case report
NLDO.
The 2-year-old male patient had epiphora
of the right eye since birth. Medical and
family histories were unremarkable. The
ocular examination revealed the absence of
Punctal agenesis in this patient
was corrected by using a modified
Jones one-snip technique. Usually, a
both puncta on the right side. Under gener- partially occluded punctum can be
al anesthesia, the child underwent Jones
easily found and treated by the Jones
one-snip procedure on both puncta as mod-
one-snip method. However, the site
ified by Putterman [3]. A 27-gauge needle
of absent puncta should first be pre-
cisely located. The Putterman modi-
fication of the Jones technique utiliz-
es needles and dilators to solve this
problem [3].
was used to penetrate the site of absent
puncta, and a punctal dilator was then em-
ployed. One snip was made on each punc-
tum with Wescott scissors. Diagnostic
probing of both puncta was accomplished
using a Bowman probe. A “hard stop” on
the lower punctum and a “soft stop” with
short advancement on the upper punctum
were displayed. A pigtail probe was then
inserted into the lower punctum and cana-
liculus to locate the upper canaliculus; it
could not be found. The upper canalicular
agenesis, however, was identified. Irriga-
There are several ways to expose
canalicular tissue in patients with
canalicular agenesis. Exploratory
cut-down through the lid margin has
been advocated but has often failed.
Another generally accepted method