Outcomes of 4-Snip Punctoplasty for Severe Punctal Stenosis: Measurement of Tear Meniscus Height by Optical Coherence Tomography SUNG EUN KIM, SUNG JUN LEE, SANG YEUL LEE, AND JIN SOOK YOON ● PURPOSE: To investigate the surgical outcome of rect- angular 4-snip punctoplasty, a modification of rectangu- lar 3-snip procedures, using objective measurements. ● DESIGN: Noncomparative case series. ● METHODS: The medical charts of patients who un- derwent rectangular 4-snip punctoplasty for severe punctal stenosis with at least 6 months follow-up were reviewed. Before surgery and at 1 and 6 months after surgery, subjective evaluation of tearing was assessed using Munk scores. The size of the punctum was graded based on slit-lamp examination, and measure- ment of tear meniscus height was done using Fourier- domain optical coherence tomography. ● RESULTS: A total of 45 eyes (26 patients) were stud- ied. The subjective epiphora score was significantly reduced after surgery and maintained until 6 months after the surgery ( 2 for trend test, P < .001). The grade of the punctum size was also significantly enlarged after surgery and the enlarged punctum was maintained until 6 months after the surgery ( 2 for trend test, P < .001). The mean preoperative tear height (452.4  249.3 m) was significantly reduced both at 1 month after surgery (341.6  207.9 m; P  .003, paired t test) and at 6 months after surgery (362.1  212.6 m; P  .004, paired t test). The functional success rate was 93.3% and anatomic success rate was 88.9% at 6 months after surgery. ● CONCLUSIONS: Rectangular 4-snip punctoplasty was an anatomically and functionally effective procedure for severe punctal stenosis patients, maintaining large puncta for fairly long periods. (Am J Ophthalmol 2012;153: 769 –773. © 2012 by Elsevier Inc. All rights reserved.) P UNCTAL STENOSIS CAN BE EASILY TREATED BY punctoplasty, namely the snip procedures. The sur- gery for stenosis involves a 1-, 2-, or 3-snip puncto- plasty. There are debates as to the number of cuts or the direction of the snip(s) that is best to prevent recurrence of epiphora and achieve anatomic and functional success. The 1-snip procedure refers to a single vertical snip down to the ampulla, which produces a high rate of failure attributable to reapproximation of the adjacent raw cut ends. 1,2 To solve this problem, a 2-snip variation of the surgery was suggested by Jones. 3 This procedure consists of removing a V-shaped wedge from the vertical portion of the canaliculus on the conjunctival surface. More recently, the 3-snip procedure has become more widely adopted than the 1-snip or 2-snip procedure. 4,5 The traditional 3-snip, specifically the triangular 3-snip proce- dure, is a posterior ampullectomy, which removes the triangular-shaped ampulla by a first cut at the vertical canaliculus, followed by a second cut along the horizontal canaliculus and a final snip at the base. 6 A rectangular 3-snip punctoplasty, which involves 2 vertical snips at either side of the ampulla and a cut at the base, was recently reported to have high functional and anatomic success rates. 4,7 The higher success rates are thought to be attributable to the preservation of physiology, as only the vertical portion of posterior ampulla is excised, and the anatomy and physiological functions of the lacrimal system are preserved. At our institute, we have performed the traditional triangular 3-snip procedure and experienced relatively high rates of reapproximation, which led to more recent adoption of rectangular 3-snip punctoplasty. However, we observed that in cases of severe punctal stenosis, the punctum could not be sufficiently dilated to allow 2 vertical cuts. In addition, the size of the rectangular punctum left by this procedure was not large enough to resolve the epiphora found in severe stenotic cases. Therefore, we modified the rectangular 3-snip procedure to create a rectangular 4-snip to maximize the punctum size, and prevent re-stenosis in cases of severe punctal stenosis. This procedure includes a small portion of the horizontal canaliculus in the rectangular flap. In this study, we retro- spectively reviewed the outcomes of this new procedure. METHODS THE MEDICAL CHARTS OF THE PATIENTS WHO UNDERWENT rectangular 4-snip procedure for severe punctal stenosis Accepted for publication Sept 21, 2011. From the Department of Ophthalmology, Myongji Hospital, Kwan- dong University College of Medicine, Koyang, Korea (S.E.K.); Depart- ment of Ophthalmology, Dongguk University Ilsan Hospital, Dongguk University, Seoul, Korea (S.J.L.); and Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, Korea (S.Y.L., J.S.Y.). Inquiries to Jin Sook Yoon, Department of Ophthalmology, Yonsei University College of Medicine, 134 Shinchondong Seodaemungu, Seoul, Korea, 120-752; e-mail: yoonjs@yuhs.ac © 2012 BY ELSEVIER INC.ALL RIGHTS RESERVED. 0002-9394/$36.00 769 doi:10.1016/j.ajo.2011.09.026