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Clin Ophthalmol. 2018 Mar 6;12:463-472. doi: 10.2147/OPTH.S155209. eCollection 2018.

A new surgical approach for punctal occlusion using fibrous tissue from under the lacrimal caruncle.

Author information

Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan.
Department of Frontier Medical Science and Technology for Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan.



Surgical punctal occlusion is indispensable for the treatment of severe dry eye in cases where punctal-plug insertion is not applicable due to an enlarged or deformed punctum. However, permanent punctal occlusion is difficult in some cases. In our aim to establish a more reliable punctal occlusion, we have devised a new surgical approach for punctal occlusion.

Patients and methods:

This study involved 20 puncta of 12 eyes of 12 patients (1 male and 11 females; mean age: 65.2 years) with severe aqueous-tear-deficient dry eye. A new surgical procedure for punctal occlusion using fibrous tissue from under the lacrimal caruncle into the diathermy-induced deepithelialized canaliculus as supporting tissue for punctal closure was performed. In all patients, the assessment of eye symptoms, as well as the condition of punctal occlusion by slit-lamp biomicroscopy, tear volume (tear-meniscus radius [TMR] measurement by meniscometry), the condition of precorneal tear film (graded by interferometry [IG]), measurement of fluorescein breakup time (FBUT), and scoring of ocular surface staining (fluorescein score of area [FSA] and density [FSD], and lissamine green score [LGS]) were performed, and the preoperative and 6-month-postoperative values were compared.


In regard to the postoperative improvement of symptoms, 11 patients showed remarkable improvement, 1 patient showed improvement, and no reopening of the closed punctum was found in any patient. Test values were all significantly improved post surgery (all: P<0.05) as compared to those prior to surgery (respective values [mean ± SD], and the pre- and postoperative P-values were: TMR (mm) [0.18±0.08; 0.56±0.28, P=0.002], IG [4.3±0.9; 2.7±0.8, P=0.009], FBUT [0.4±0.6; 4.1±2.9, P=0.004], FSA [1.6±0.7; 0.7±0.9, P=0.03], FSD [2.7±0.7; 0.6±0.7, P=0.003], and LGS [5.1±2.7; 1.1±2.1, P=0.005]). Moreover, no postoperative complications were observed.


The findings of this study showed that our novel surgical procedure for punctal occlusion is highly successful and that it results in improved and more complete punctal occlusion.


aqueous-tear-deficient dry eye; lacrimal caruncle; surgical punctal occlusion

Conflict of interest statement

Disclosure Norihiko Yokoi is a consultant for Kissei Co. Ltd., Nagano, Japan and Rohto Co. Ltd, Osaka, Japan. Shigeru Kinoshita is a consultant for Santen Pharmaceutical Co. Ltd, Osaka, Japan and Otsuka Pharmaceutical Co. Ltd., Tokyo, Japan. Aoi Komuro and Chie Sotozono report no conflicts of interest in this work.

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