What is punctal stenosis?

A narrowing of the tear drain openings

Punctal stenosis is a narrowing of the puncta, the tiny openings at the inner corner of each eyelid through which tears drain. There are normally two puncta in each eye, one on the upper eyelid and one on the lower. They are the entry points of the tear drainage system, the equivalent of the plughole in a sink.

When the puncta become narrowed or partially blocked, tears cannot drain efficiently. They build up on the eye surface and overflow on to the cheek, producing a persistently watery eye.

Age is the most common reason

The most common cause is simply age. As the tissues of the eyelid change over time, the punctal opening can gradually narrow. Chronic inflammation of the eyelid margins, such as that caused by long-term blepharitis, is the next most frequent contributor.

Less commonly, certain medications can be responsible. Glaucoma eye drops used over many years are known to cause progressive narrowing of the puncta, and chemotherapy agents and some other systemic medications can have a similar effect. Repeated episodes of conjunctivitis may also be a contributing factor.

Very rarely, some people are born with punctal openings that are unusually small or effectively absent, a congenital variant that can cause watering from early life.

A persistently watery eye, often worse in certain conditions

The main symptom is a persistently watery eye, often worse in cold or windy conditions, and when reading or using a screen. Because tears cannot drain normally, they overflow on to the cheek. The eye may also feel sticky, particularly in the mornings, and some people notice a slight blurring of vision that clears with blinking, caused by an excess of tears on the eye surface.

A straightforward examination with specialist equipment

An optometrist or ophthalmologist can examine the puncta with a slit lamp, a specialist microscope used to examine the eye in detail. The puncta are normally visible as small dots at the inner corner of the eyelids. In punctal stenosis, they appear smaller than usual, or in some cases almost invisible.

A simple procedure called syringing, in which a fine cannula is passed into the punctum and saline is flushed through the drainage system, can confirm whether drainage is restricted and help identify where the narrowing or blockage lies.

A minor surgical procedure with a good success rate

The main treatment for a narrowed punctum is a minor surgical procedure called punctoplasty. Performed under local anaesthetic, punctoplasty permanently widens the punctal opening to restore normal tear drainage. It is a straightforward procedure with a good success rate and a rapid recovery.

If the narrowing has extended to the deeper drainage channels, the canaliculi, further treatment may be needed. In some cases, a small silicone tube is inserted to keep the drainage channel open while it heals.