Delhi Journal of Ophthalmology

Accessory Lower Lid Lacrimal Puncta

Smriti Sharma, Mandeep Tomar, Rajeev Tuli, Richa Dhiman, Maninder Singh, Ankush Sharma
Department of Ophthalmology Dr. Rajendra Prasad Government Medical College, Tanda Kangra, Himachal Pradesh, India

Corresponding Author:

Smriti Sharma MBBS, MS (3rd Year)
Department of Ophthalmology
Dr. Rajendra Prasad Government Medical
College, Tanda Kangra,
Himachal Pradesh-176001, India
Email id: simi.taurus30@gmail.com

Received: 28-AUG-2018

Accepted: 20-JAN-2019

Published Online: 05-MAY-2019

DOI:http://dx.doi.org/10.7869/djo.459

Abstract
A 40 year old female presented with a history of watering in her left eye for the last 6 months. Her visual acuity was 6/6 bilaterally. On slit lamp examination there were presence of 2 puncta on the left lower lid. One of the punctum was slit like and the other punctum was round. On syringing, it was found that both the puncta were patent. Fluorescence dye disappearance test was done which revealed early disappearance of dye from the left eye as compared to the right eye. Dacrocystography was done which showed single patent nasolacrimal duct.

Keywords :Double puncta, Watering, Syringing



The lacrimal drainage pathway arises embryologically at day 32 from a thickening of the ectoderm in the nasooptic fissure. The ectoderm embeds itself into the surrounding mesenchyme and forms an epithelial cord. The cord extends cephalad and caudad to reach the ocular and nasal ends of the pathway.1
Congenital supernumerary lacrimal puncta and canaliculus are rarely reported. It has been estimated that it affects one in every 60000 people.2 Obstruction or any anomaly in the nasolacrimal duct system may cause epiphora.
A 40 year old female presented with a history of watering in her left eye for the last 6 months. 
Her visual acuity was 6/6 bilaterally. Ocular movements were full and pupils were reactive bilaterally. On slit lamp examination there were presence of 2 puncta on the left lower lid (Figure 1). 



One of the punctum was slit like (Figure 2) and was close to medial canthus. The other punctum was round. Rest of the ocular examination was normal. There was no history of any trauma or any lid surgery in the past.
On syringing, it was found that both the puncta were patent and allowed free passage of fluid.



Fluorescence dye disappearance test was done which revealed early disappearance of the dye from the left eye as compared to the right eye.
Dacrocystography was done which showed single patent nasolacrimal duct.
Duplication of the lower lacrimal puncta and duct has been observed as an isolated occurrence as well as in association with other congenital defects.3 Abnormal anterior budding of the portion of the epithelial rod from which canaliculus and punctum develop is regarded as the cause of these anomalies.4
Accessory puncta are typically located on the lower lid medial to the normal puncta with a slit like appearance.4 In some cases the condition is discovered accidentally, in others the patients complained of epiphora.5
Cases of simple duplication of lower puncta with patent ducts and normal function certainly need no treatment.2 Since our patient presented with watering for last 6 months, only dilatation of punctum and canaliculi with syringing was done. The patient was prescribed topical antibiotic for 2 weeks and was kept for follow up for 2 months. Symptoms of epiphora were relieved.


References

1. Vivian S, Torbet JK, Lenke BN. Jakobiec’s principle and practice of ophthalmology, 3:3212.
2. Uzcategui C. Double lacrimal puncta and canaliculi. Journal of pediatric ophthalmology and strabismus 1967; 4:44-5.
3. Mosby CV, St. Louis. Duke-Elder, Sm St. System of Ophthalmology 1963; 3:930.
4. Osorio RF. Congenital supernumerary lacrimal puncta and canaliculus on the caruncle. J Clin Ophthal Optan 2017; 1:101.
5. Greeves R. Case of supernumerary punctum lachrymale and canaliculus. Proc Roy Med London, VU 1913; 14:141.


CITE THIS ARTICLE

Smriti Sharma, Mandeep Tomar, Rajeev Tuli, Richa Dhiman, Maninder Singh, Ankush SharmaAccessory Lower Lid Lacrimal Puncta.DJO 2019;29:104-105

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Smriti Sharma, Mandeep Tomar, Rajeev Tuli, Richa Dhiman, Maninder Singh, Ankush SharmaAccessory Lower Lid Lacrimal Puncta.DJO [serial online] 2019[cited 2019 Nov 13];29:104-105. Available from: http://www.djo.org.in/articles/29/4/Accessory-Lower-Lid-Lacrimal-Puncta.html