In the current study, we placed three interrupted sutures in the posterior wall of the ampulla after rectangular TSP; both the subjective and objective surgical outcomes were satisfactory; 91.7% of eyes were reported improved over about 17.4 months of follow-up. TMH is significantly correlated with the volume of the tear film, of which 75–90% is contained in the tear meniscus [13,14,15,16,17,18]. We used TMH to measure changes in tear film volumes after surgery. The mean TMH decreased significantly (p < 0.001).
Punctal stenosis is the cause of 8% of all epiphora encountered in tertiary care institutions [19]. Punctoplasty is a simple surgical procedure that resolves punctal stenosis. The history of punctoplasty contains many surgical modifications and developments [2]. One-snip punctoplasty was the first modality to be introduced. Problems included deterioration of the capillarity of the lacrimal canaliculus and difficulties in re-approximation of the raw cut ends. Thus, one-snip punctoplasty was replaced by two-snip punctoplasty and TSP [2]. Currently, TSP is the most successful surgical technique used to enlarge a stenosed punctum [3]. There are two types of TSP: triangular TSP and rectangular TSP, the latter is believed to afford better symptom resolution [2, 3]. However, rectangular TSP is still associated with a high recurrence rate of functional epiphora (10.3%) [1]. Thus, efforts towards an optimal surgical procedure for resolution of punctal stenosis continue.
The anatomical recurrence rate of this study was about 2.1% with an average follow-up time of 17.4 months. Chak and Irvine reported that the anatomical recurrence rate was about 6% (3/49 eyes) after conventional rectangular TSP and about 3% (2/50 eyes) after conventional triangular TSP [3]. Ali et al. [1] recently reported an anatomical recurrence rate of 5.7% after conventional rectangular TSP; this value was similar to that of Chak and Irvine [3]. Our anatomical recurrence rate was lower and our average follow-up time was 17.4 months, which was longer compared with 8.2 months in the study of Chak and Irvine [3] and 4.2 months in the study by Ali et al. [1]. It is promising that our new technique shows a lower recurrence rate than conventional rectangular TSP of the two cited studies, despite having a longer follow-up period. In this study, the functional recurrence rate was about 6.25%, which was higher than the anatomical recurrence rate. Recently, long-term outcomes of punch punctoplasty using a Kelly punch have been reported with promising results [8]. In this report, the anatomical success was 94% and the functional success rate 92%.
Our rationale to explain the promising results of the three sutures after rectangular TSP was that the interrupted sutures helped to decrease the raw surface of the dilated punctum and making restenosis of the dilated punctum less likely.
Although the invasiveness of the new procedure still remains a concern, our new technique involving the placement of three sutures after rectangular TSP has shown promising results. Physiological preservation of the lacrimal system should be further reviewed in comparison with that provided by conventional rectangular or triangular TSP as control groups. A limitation of this study was a lack of preoperative grading of stenosed puncta.