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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 2  |  Page : 368-369

Double lacrimal puncta: Three cases


1 Department of Ophthalmology, Bolu Izzet Baysal State Hospital, Bolu, Turkey
2 Department of Ophthalmology, Hitit University Erol Olcok Education and Research Hospital, Corum, Turkey

Date of Submission02-May-2020
Date of Acceptance09-Sep-2020
Date of Web Publication01-Apr-2021

Correspondence Address:
Dr. Yonca Asfuroğlu
Sağlık, Şehitler Caddesi, No: 20 14300, Merkez, Bolu
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1246_20

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  Abstract 


Supernumerary puncta are uncommon lacrimal anomalies. Besides being a rare condition, it is usually overlooked. In this study, we report 3 cases of supernumerary lacrimal puncta. While two patients presented with epiphora; one patient was asymptomatic. In biomicroscopic examination, two lacrimal puncta on the lower lid were observed. A supernumerary punctum should be considered in patients with excessive tearing. Supernumerary puncta may alter the efficacy of topical medications, therefore, patients need to be informed about this rare anomaly.

Keywords: Double lacrimal puncta, lacrimation, tear film


How to cite this article:
Asfuroglu M, Üçer MB, Asfuroğlu Y. Double lacrimal puncta: Three cases. Indian J Ophthalmol Case Rep 2021;1:368-9

How to cite this URL:
Asfuroglu M, Üçer MB, Asfuroğlu Y. Double lacrimal puncta: Three cases. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jul 29];1:368-9. Available from: https://www.ijoreports.in/text.asp?2021/1/2/368/312321



The nasolacrimal system sustains a constant lubricated ocular surface to continue clear optics. After blinking, tear film moves along the menisci towards a single opening, named the punctum.[1],[2],[3] Each punctum is surrounded by a papilla and musculature that help drainage of the tears through the canaliculus, nasolacrimal sac, and into the nasal cavity, respectively.[4] During the closure of the eyelids, the canaliculi and sac are contracted to push the tears towards the nasal cavity.

The most common congenital anomaly of nasolacrimal duct in nature is obstruction. In this study, we report a case series of a rare condition: supernumerary lacrimal puncta.


  Case Reports Top


Case 1

A 45-year-old female patient was discovered during routine ophthalmologic examination to have two lacrimal puncta on the lower lid of the left eye [Figure 1]. She was unaware of this and she had no symptoms of intermittent or chronic tearing. Biomicroscopy revealed a normal-appearing round (1.0 mm) lateral punctum and another 1.0 mm medially positioned to the other. The lower punctum in the right eye was normal in size and anatomy (1.0 mm round). Dilatation of the double-punctum was performed.
Figure 1: Double lacrimal puncta on the lower lid of the left eye

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Case 2

A 55-year-old female patient presented with epiphora in the left eye. In biomicroscopic examination, two lacrimal puncta on the lower lid of the left eye were observed [Figure 2], a normal-appearing round (1.0 mm) lateral punctum and a 0.5-mm punctum medially positioned to the other. The lower punctum in the right eye appeared to be in normal size and anatomy (1.0 mm round). The patient had no systemic association or ocular surgery history. The lacrimal outflow system was evaluated by syringing both punctum and both were communicated to the lacrimal sac. The double-punctum was dilated, and there was no epiphora during the 6-month follow-up.
Figure 2: Double lacrimal puncta on the lower lid of the left eye

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Case 3

A 40-year-old male patient presented with symptoms of epiphora in the right eye. In biomicroscopic examination, two lacrimal puncta on the lower lid of the right eye were observed [Figure 3], a normal-appearing round (1.0 mm) lateral punctum and a 1-mm punctum medially positioned to the other. In the left eye, the lower punctum in the left eye was normal (1.0 mm round). The patient had no systemic association or ocular surgery history. The lacrimal outflow system was evaluated by syringing in both punctum; both puncta were communicated to the lacrimal sac. The double-punctum was dilated and there was no epiphora during the 6-month follow-up.
Figure 3: Double lacrimal puncta on the lower lid of the right eye

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  Discussion Top


Supernumerary puncta are uncommon lacrimal anomalies. Besides being a rare condition, it is also under-diagnosed because this anomaly is usually overlooked. First documented by Mackenzie in 1854,[5] abnormal epithelial budding from the upper end of the lacrimal cord or incomplete separation of the core from the surface epithelium in an embryo are presumed to cause this anomaly. The incidence of supernumerary puncta shows wide variability in different series. The punctum is the most proximal structure of the drainage system, so any anomaly may cause an imbalance in tear flow.

Accessory puncta are typically located on the lower lid medial to the normal punctum with a slit-like appearance.[6],[7] Mostly, there is one accessory punctum, yet up to four supernumerary puncta have been reported.[8] A supernumerary punctum may be associated with systemic findings, may have a shared canaliculus or the canaliculi may be replicated for each punctum.

Some individuals with a double-puncta and canaliculus have tearing, whereas others are asymptomatic. The site of origin of the accessory canaliculus and the relationship with the lacrimal part of the orbicularis oculi muscle are presumed to determine the direction of the tear flow within the accessory canaliculus, and thus the effect of its presence on canalicular function and symptoms.[9] If the accessory canaliculus originates from the common canaliculus, tears drain back from the common canaliculus to the tear lake during relaxation of the lacrimal part of the orbicularis oculi muscle, resulting with excessive tearing.

Satchi et al.[6] published the largest case report series regarding double-lacrimal puncta, which consisted of 23 patients. They reported that all patients had unilateral accessory punctum in the lower lid and medial to the main punctum. The effect of supernumerary punctum is not well known; several studies reported cases with epiphora, and others reported patients with dry eye.[10] Bair et al.[10] attributed increased severity of dry eye on the side of a duplicated upper canaliculus in a patient due to enhanced outflow.


  Conclusion Top


Supernumerary puncta are rare congenital anomalies whose incidence is not known. In the majority of publications, they have been described as incidental examination findings in asymptomatic individuals. Even though it may be asymptomatic, a supernumerary punctum should be considered in the examination of a patient with excessive tearing. Patients with supernumerary puncta can be identified with lid eversion during biomicroscopic examinations. Supernumerary puncta may alter the efficacy of topical medications, therefore, patients need to be informed about this rare anomaly.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflicts of interest

There is no conflict of interest to disclose.



 
  References Top

1.
Oyster C. The eyelids and the lacrimal system. In: Oyster C, editor. The Human Eye Structure and Function. Sunderland, Massachusetts: Sinauer Associates Inc; 1999. p. 291-320.  Back to cited text no. 1
    
2.
Olver J. Chirurgie des Voies Lacrimales. France: Elsevier SAS; 2003.  Back to cited text no. 2
    
3.
Hurwitz J. Physiology of the lacrimal drainage system. In: Hurtwitz J, editor. The Lacrimal System. Philadelphia, Pennsylvania: Lippincott-Raven Publishers; 1996. p. 23-7.  Back to cited text no. 3
    
4.
Katowitz W, Katowitz J. Congenital etiologies of lacrimal system obstructions. In: Cohen A, Mercandetti M, Brazzo B, editors. The Lacrimal System: Diagnosis, Management and Surgery. New York, New York: Springer; 2006. p. 35-42.  Back to cited text no. 4
    
5.
Mackenzie W. A Practical Treatise on the Disease of the Eye. 4th ed.. London: Boston; Carter, Hendee; 1854.  Back to cited text no. 5
    
6.
Satchi K, McNab AA. Double lacrimal puncta: Clinical presentation and potential mechanism of epiphora. Ophthalmology 2010;117:180-3.  Back to cited text no. 6
    
7.
Hurwitz J, Pashby R. Pediatric lacrimal disease. In: Hurwitz J, editors. The Lacrimal System. Philadelphia, Pennsylvania: Lippincott-Raven Publishers; 1996. p. 242.  Back to cited text no. 7
    
8.
Verma AK, Wapa A, Dogra A, Tuli R, Chauhan A. Double lower lid lacrimal puncta: A case report. Adv Ophthalmol Vis Syst 2018;8:1-2.  Back to cited text no. 8
    
9.
Sevel D. Development and congenital abnormalities of the nasolacrimal apparatus. J Pediatr Ophthalmol Strabismus 1981;18:13-9.  Back to cited text no. 9
    
10.
Bair PJ, Tsai YY, Lin JM. Congenital reduplication of the lacrimal punctum and canaliculus in a patient with dry eye. Ophthalmic Surg Lasers Imaging Retina 2004;35:156-8.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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