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#Bose pinpoint free#
In a normal system, there is the passage of free fluid into the nose or nasopharynx without reflux.įluorescein dye disappearance after dilation is then performed.
Irrigation is performed with a 5ml normal saline syringe. A soft stop indicates canalicular obstruction, and a hard stop against the lacrimal bone indicates a patent canalicular system. A punctal finder is used to dilate the punctum, and a canalicular probe is inserted. Diagnostic canalicular probing and nasolacrimal duct irrigation are performed under topical anesthesia. Punctal dilation of the stenotic punctum with a Nettleship dilater is performed after the dilater is lubricated with ointment (Fig 5). Usually, in punctal stenosis, there is a dye disappearance time of over 5 minutes. The tear meniscus is examined after 3 to 5 minutes of insertion of 2% fluorescein to check for the presence of the remaining dye. The fluorescein dye disappearance test is done prior to dilation. Laboratory testing is generally not needed. The diagnosis is usually made on the basis of history, the dye disappearance test, and slit-lamp examination. Uncorrected, these early medial ectropions will lead to progressive stenosis of the punctum. Early lower eyelid laxity and ectropion will only be detectable with examination under the biomicroscope when the lower punctum is seen to be pointing upwards or outwards, even if the lower eyelid position seems to be normal on examination. The normal punctum sits, pointing backward in the medial tear lake. It should not normally be visible to examination under the biomicroscope.
When assessing a patient for punctal stenosis, it is important to determine the resting position of the lower punctum in particular. A normal patent lacrimal system will have no reflux of normal saline, whereas any obstruction will be evident through regurgitation of normal saline through the punctum. In order to assess the lower lacrimal system, irrigation is done with normal saline and an irrigating lacrimal cannula (23 G).
Obstruction in the canalicular system is defined as a soft resistance to probing. Probing and irrigation are performed to confirm the diagnosis. Based on the shape of the external punctum, punctal stenosis is of four types: One study determined the criteria for punctal stenosis: the punctum is less than 0.3mm, or there is an inability to cannulate the punctum with a 26G cannula without dilation. Normal punctal size ranges from approximately 0.2-0.5mm. The papillae containing the puncta are surrounded by the Riolan muscle fibers and a fibrous ring. The puncta open into the tear layer and lead into the lacrimal duct, lacrimal sac, and nasolacrimal duct. Upper and lower puncta approximate each other when the eyelids are closed. The upper punctum is located 1mm medial to the lower punctum. Īnatomically, lacrimal puncta are located at the nasal end of the palpebral margin. The incidence of this condition is variable, ranging from 8% to 54.3%. Patients usually present with symptoms of excessive tearing. It may also be associated with occlusion of the common canalicular duct. This should be distinguished from punctal agenesis, which is a congenital condition (Fig 1). The narrowing or occlusion of the external opening of the lacrimal canaliculus leads to punctal stenosis.
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