Punctal Stenosis, Canalicular Obstructions, and Canaliculitis

The successful treatment of canalicular obstructions continues to represent a therapeutic challenge; management is still controversial and is usually related to the site and extent of the obstruction. Canalicular epithelial inflammation due to primary herpes simplex infection is a common cause of canalicular occlusion. Subepithelial canalicular inflammation due to lichen planus may lead to a more severe and extensive annular fibrosis and carries a poor prognosis. Systemic chemotherapeutic agents may damage the canalicular epithelium, the evidence suggesting active concentration of these agents by the lacrimal outflow structures. Microbial canaliculitis is frequently overlooked, leading to a delay in management and failure to adequately remove canalicular stones and debris. Punctoplasty is as effective as punctal dilation, dilatation with monocanalicular or bicanalicular stenting used in cases of punctal stenosis. Dacryocystorhinostomy with retrograde intubation is more effective in case of proximal canalicular obstructions than in case of mid-canalicular obstructions. Trephination and intubation is effective in both mid and distal canalicular obstructions in patients with no associated nasolacrimal duct obstruction. Bypass surgery is the preferred treatment if there is no residual patency. ‘Mini-invasive’ techniques should be avoided in patients with associated distal nasolacrimal duct obstruction.