THE MANAGEMENT OF PUNCTAL AGENESIS

Background. Agenesis of one or more lacrimal puncta is a rare cause of presentation to ophthalmologists. Where normal canalicular tissue lie s within the lid, it may occasionally be successfully exteriorized to the conjunctival surface with relief of symptoms. The pattern of punct al agenesis, its relationship to the presence of underlying canalicula r tissue, and its management have not been defined previously in a lar ge cohort. Methods: The authors reviewed the pattern of agenesis, unde rlying anatomic abnormalities and patient symptomatology in 57 patient s seen over a 10-year period. A management plan was devised for eyes w ith no puncta and those with a single missing punctum. Results: Both p uncta were absent in 53 eyes, and a single punctum was missing in 41 e yes. In 86% of eyes with absence of both puncta, no canalicular tissue was identified when the lacrimal sac was opened at surgery. The under lying canaliculus also was absent in patients with one absent punctum. Nasolacrimal duct obstruction frequently accounted for the onset of s ymptoms in patients with a single punctum. Fifty-three (93%) of the 57 operated eyes were functionally cured at the completion of this repor t. Conclusion: Punctal agenesis usually is associated with the absence of underlying canalicular tissue. Where both puncta are absent, the a uthors recommend inspection of the internal opening of the common cana liculus at surgery and, if no canalicular tissue can be identified (86 % in this series), insertion of a Lester-Jones tube. Symptomatic patie nts with a single punctum frequently require surgery to relieve nasola crimal rather than canalicular obstruction.