Acquired symptomatic external punctal stenosis: A tertiary referral center study

Background: To report the prevalence of acquired symptomatic external punctal stenosis (EPS) in a tertiary referral center in Kuwait, and to study the associated risk factors, etiologies, and management outcomes. Methods: This prospective interventional hospital-based study was performed at the Farwaniya governmental hospital in Kuwait between November 2018 and November 2019. All patients were referred to the oculoplastic clinic with symptomatic epiphora, age > 18 years, epiphora Munk score ≥ 0, tear film meniscus ≥ 2 mm, and punctum with grade ≤ 2 (smaller than normal size, but recognizable EPS) were included. Exclusion criteria were congenital causes of epiphora, previous eyelid surgeries, and traumatic or neoplastic causes of punctal or canalicular obstruction. Results: A total of 418 patients with symptomatic epiphora, who were referred to our oculoplastic clinic, were enrolled in our study. The prevalence of EPS was 70.3%. Examination of the puncta revealed different shapes, including tangential, pinpoint, elevated, slit-shaped, horse shoe-shaped, and membranous puncta, with the tangential type accounting for the greatest proportion (65.3%). Bilateral punctal stenosis was observed in 206 patients (70.1%) and unilateral involvement in 88 patients (29.9%). Dilatation and syringing were performed for all puncta upon diagnosis, and repeated dilatation was performed for 225 puncta (32.7%). Placement of a Mini-Monoka tube was performed in 11 puncta (1.6%). Conclusions: EPS was a common cause of symptomatic epiphora in our study. Aging and female sex were identified as common risk factors. Most etiological factors of EPS were associated with a pathophysiological inflammatory mechanism. For exact estimates of its prevalence, a population-based study is necessary in future. Keywords: punctal stenosis, dry eye, chronic blepharitis, Mini Monoka, Kuwait, prevalence, epiphora