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ABSTRACT _PURPOSE_ To determine when and how to perform punctoplasty, review the history, and determine the efficacy of posterior ampullectomy. _METHOD_ Retrospective analysis of 53 cases of

punctal stenosis, operated by a single surgeon by means of posterior ampullectomy via 3-snips. A review of the history of the procedure from papers found with a Medline search for 1-snip,

2-snip, 3-snip, and punctoplasty. _RESULTS_ In all, 102 sets of notes were reviewed. The age range was from 9 to 89 years with a mean age of 56 years. A total of 74% of patients were female.

We excluded 22 patients who had additional surgery and 16 patients who elected not to have surgery. There was no comment as to success or failure in four sets of notes and seven notes could

not be found; these cases were also excluded. Of the remaining 53 patients, success was documented in 49 cases, or 92%. _CONCLUSIONS_ The historical review helps explain the debate about

the procedure. The retrospective review confirms that posterior ampullectomy via 3-snips is an effective procedure. SIMILAR CONTENT BEING VIEWED BY OTHERS LONG-TERM OUTCOMES AFTER ENDOSCOPIC

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CHOLANGIOPANCREATOGRAPHY Article Open access 10 August 2022 INTRODUCTION Stenosis of the lacrimal punctum has numerous causes, including infection with herpes simplex, herpes zoster,

chlamydia, actinomyces, and human papilloma virus. It can be caused by rare systemic conditions such as porphyria cutanea tarda and acrodermatitis enteropathica, direct and thermal trauma or

be secondary to topical or systemic chemotherapy, and irradiation. Despite this long list it remains an uncommon condition. The anatomy of the punctum, ampulla, and canaliculus is

consistent and straightforward. The surgery involved in attempting to resolve the stenosis is now commonly described as a 1-, 2-, or 3-snip procedure. As these descriptions would imply the

exact number of cuts required to perform the procedure, it is not surprising that there remains, especially among general ophthalmologists, debate about how best to perform the surgery, and

therefore uncertainty as to whether the operation is effective or not. The historical review explains these procedures. HISTORY In 1853, Bowman1 presented a 1-snip procedure, supported in

1873 by Arlit.2 The procedure involved an incision of the entire length of the canaliculus with a canaliculus knife. This had the significant disadvantage of destroying the capillary action

of the canaliculus. In 1926, Graves3 described his posterior ampullectomy, refined into the modern 3-snip by Thomas in 19514 and Viers in 1955.5 In 1962, Jones6 re-popularised the 1-snip

with a single vertical snip down the ampulla. The obvious problem was failure through re-approximation of the adjacent raw cut ends of the ampulla. In recognition of this, Jones suggested

punctal dilatation if the punctum was starting to re-close and eventual 2-snip procedure if needed (the first snip down the ampulla and the second along the canaliculus from the lower edge

of the first). As an alternative to 3-snips, Hughes and Maris in 1967 used a punch to perform the ampullectomy,7 revisited in 1991 and 1992 by Edelstein and Reiss.8 Undeterred, the

proponents of 1-snip suggested increased success by preventing the reunion of the cut ends. Dolin and Hecht9 in 1986 suggested placing the lid under tension with a 4:0 suture passed through

the tarsus and anchored laterally over sterile buttons. In 1993, Lam and Tessler10 went further, suggesting the use of mitomycin C as adjunctive therapy in iatrogenic punctal stenosis.

Perhaps sensing a trend to make a simple procedure more complex, in 1993 Offutt and Cowen11 suggested an altogether new microsurgical approach to punctoplasty involving excision of the

stenotic puncta followed by microscopic externalisation of the vertical canaliculus. We present a retrospective review of 3-snip punctoplasty. All cases were performed by a single surgeon

(AAM), and consisted of a posterior ampullectomy by means of three snips. METHODS The patient notes were pulled from the surgical database by searching for punctal stenosis in the diagnosis

and/or punctoplasty in the surgery. The surgery involved ½ of 2% lignocaine with 1 : 10 0000 epinephrine injected subcutaneously below the lower punctum. The punctum would be found with a

punctum seeker and dilated sufficiently to allow the posterior wall of the ampulla to be grasped with toothed microforceps. The microforceps then should maintain their grip on the posterior

wall throughout the procedure. Vannas scissors are then used to excise the posterior wall of the ampulla with three snips, the first two downwards on each side of the forceps and the third

across the bottom. Chloramphenicol ointment was applied to the lower conjunctival fornix four times each day, and the patient was reviewed after 1 week. Success was defined as a subjective

improvement in symptoms. RESULTS In all, 102 sets of notes were reviewed. The age range was from 9 to 89 years with a mean of 56 years. A total of 74% of patients were female. Of the initial

102 sets of notes, 49 had to be excluded. The reason for exclusion included 22 patients who had additional surgery, 16 patients who elected not to have surgery, no comment as to success or

failure in four sets of notes, and seven notes that could not be found. Of the remaining 53 eligible patients, success, measured as a subjective improvement in epiphora, was documented in 49

cases, or 92%. These subjective results were documented either at postoperative clinic review, or by postoperative telephone call. The patients were discharged after this postoperative

review. DISCUSSION Punctoplasty is one of the most straightforward surgical procedures. There has, however, remained debate as to how best to perform the procedure, and whether the procedure

is effective. There is also no commonly agreed definition of what constitutes punctal stenosis. We used the simple clinical test of whether or not the undilated punctum would admit a 26g

lacrimal cannula. If the punctum would not admit the cannula without prior dilatation, it was classified as stenosed. The indication for punctoplasty is a patient with both epiphora and a

stenosed punctum, patent to syringing once the punctum is dilated. With respect to the surgery, the instructional nomenclature of 1-, 2-, and 3-snip has not helped the debate. The anatomical

principle of punctoplasty is to enlarge permanently a stenosed punctum, bring the enlarged punctum closer to the tear meniscus, and preserve the canaliculus. By basic surgical principles,

it is clear that the posterior wall of the ampulla needs to be excised to achieve these aims. By using three-snips, the raw edges are not in contact and should not immediately heal and

re-stenose the punctum. As surgeons, we are always searching for improvements, and ideally simplification in all our surgical techniques. Historically, it would appear that the concept of an

effective ‘1-snip’ procedure was too attractive to ignore. The failure of 1-snip then led to more complicated surgery in trying to prevent re-approximation of the adjacent raw cut ends of

the ampulla. In her 2001 text on lacrimal surgery, Olver12 comments on the 1-snip ‘it is not an elegant procedure’. This paper is limited by being a retrospective review of a single

technique. We cannot therefore give any evidence to prove that 3-snip is more effective than 1- or 2-snip. While we accept these limitations, we would like to propose posterior ampullectomy

by either three-snips or one punch as the most anatomically and surgically logical procedure for effective punctoplasty. It is simple, quick, and in this series improved function in 92% of

patients. REFERENCES * Bowman W . Methode de traitement applicable a l'epiphora dependent du renversement en dehors ou de l'obliteration des points lacrymaux. _Ann Oculist_ 1853;

29: 52–55. Google Scholar  * Arlit F . Operationen an den Thranenwegen. In: Graefe A, Saemisch T (eds). _Handbuch der Gesammten Augenheilkunde_. Verlag Von Wilhelm Englemann: Leipzig, East

Germany, 1874, pp 479–480. Google Scholar  * Graves B . Making a new lacrimal punctum. _Am J Ophthalmol_ 1926; 9: 675–677. Article  Google Scholar  * Thomas JBT . A modification of

Graves' operation for epiphora due to stenosis of the lacrimal punctum. _Br J Ophthalmol_ 1951; 35: 306. Article  CAS  Google Scholar  * Viers ER . Disorders of the canaliculus. In:

_The Lacrimal System_. Grune & Stratton: New York, 1955, pp 46–47. Google Scholar  * Jones LT . The cure of epiphora due to canalicular disorders, trauma and surgical failures on the

lacrimal passages. _Trans Am Acad Ophthalmol Otolaryngol_ 1962; 66: 506–524. CAS  PubMed  Google Scholar  * Hughes WL, Maris CSG . A clip procedure for stenosis and eversion of the lacrimal

punctum. _Trans Am Acad Ophthalmol Otolaryngol_ 1967; 71: 653–655. CAS  PubMed  Google Scholar  * Edelstein J, Reiss G . The wedge punctoplasty for treatment of punctal stenosis. _Ophthalmic

Surg_ 1992; 23(12): 818–821. CAS  PubMed  Google Scholar  * Dolin SL, Hecht SD . The punctum pucker procedure for stenosis of the lacrimal punctum. _Arch Ophthalmol_ 1986; 104(7):

1086–1087. Article  CAS  Google Scholar  * Lam S, Tessler HH . Mitomycin as adjunct therapy in correcting iatrogenic punctal stenosis. _Ophthalmic Surg_ 1993; 24(2): 123–124. CAS  PubMed 

Google Scholar  * Offutt IV WN, Cowen DE . Stenotic puncta: microsurgical punctoplasty. _Ophthal Plast Reconstr Surg_ 1993; 9(3): 201–205. Article  Google Scholar  * Olver J . Localised

punctal and proximal canalicular problems. In: _Colour Atlas of Lacrimal Surgery_. Butterworth Heinemann: London, 2001, pp 146. Google Scholar  Download references AUTHOR INFORMATION AUTHORS

AND AFFILIATIONS * Orbital, Plastic and Lacrimal Clinic, The Royal Victorian Eye and Ear Hospital, Melbourne, UK R H Caesar & A A McNab Authors * R H Caesar View author publications You

can also search for this author inPubMed Google Scholar * A A McNab View author publications You can also search for this author inPubMed Google Scholar CORRESPONDING AUTHOR Correspondence

to R H Caesar. ADDITIONAL INFORMATION The authors have no proprietary interest in the paper RIGHTS AND PERMISSIONS Reprints and permissions ABOUT THIS ARTICLE CITE THIS ARTICLE Caesar, R.,

McNab, A. A brief history of punctoplasty: the 3-snip revisited. _Eye_ 19, 16–18 (2005). https://doi.org/10.1038/sj.eye.6701415 Download citation * Received: 19 May 2003 * Accepted: 29

December 2003 * Published: 30 April 2004 * Issue Date: 01 January 2005 * DOI: https://doi.org/10.1038/sj.eye.6701415 SHARE THIS ARTICLE Anyone you share the following link with will be able

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initiative KEYWORDS * 3-snip * punctoplasty * posterior ampullectomy