Punctal Cauterization - Restoring Moisture and Brighter Vision

What Is Punctal Cauterization?

Cauterization or Cautery generally refers to a medical procedure in which a small and specific region is cauterized (sealed) using electrocautery (a form of heat). This approach is typically done to close the wound or stop the bleeding.

Punctal cauterization is one of the permanent methods of punctal occlusion, where the eyelid punctum is sealed or closed surgically using thermocautery or electrocautery. This method helps occlude the punctual to increase the volume of fear film and its retention on the ocular surface of the eye. So, it is indicated in the treatment of various ocular surface diseases. Punctal cauterization was first introduced in 1934, while the principle approach and techniques have been improved with modern cauterization devices.

What Are the Other Forms of Punctal Occlusion?

The punctum refers to any sharp tip of the parts in the human body. Here, the punctum signifies the small funnel-like draining holes in the corner of each of the upper and lower eyelids within the eye. This punctum is a valve draining the utilized tears from the eye for every blinking action. Punctal occlusion is a kind of mechanical intervention done to block the tear drainage system to preserve the natural tears on the ocular surface. This is a go-to treatment for dry eye syndrome.

The other forms of punctual occlusion treatment than punctual cauterization include the following:

• Punctal Plugs: These are the tiny plugs inserted into the opening of the tear drainage duct called the punctum. It blocks the puncta and slows down the tear drainage while allowing the moisture to retain on the ocular surface for a prolonged period.

• Punctal Inserts: Punctal inserts are similar to the plugs. They are generally dissolvable. This also helps retain the moisture for a longer period.

• Photocoagulation: The laser beam or certain intense light coagulates or blocks the punctum.

• Surgery: A surgical approach is used for the destruction or occlusion of the punctum or canaliculus (a short channel approximating the inner corner of the eyelids).

What Are the Indications of Punctal Cauterization?

Punctal cauterization is commonly used for ocular surface disorders accompanied by aqueous-insufficient (insufficient tear) dry eye syndrome. The conditions that benefit from punctal cauterization include the following.

• Primary Dry Eye Syndrome: This condition results when the tears cannot provide sufficient eye lubrication for many reasons.

• Sjogren Syndrome: Sjogren syndrome is an immune system disorder characterized by two significant manifestations. This includes dry eyes and dry mouth.

• Mucous Membrane Pemphigoid: This condition is a rare, chronic, and autoimmune disease of subepithelial blisters and erosions affecting the mucous membrane of the eyes.

• Stevens-Johnson Syndrome: Stevens-Johnson syndrome is a rare and serious condition affecting the skin and muscle membranes. It can also present several serious ocular manifestations, including conjunctival ulcers, corneal ulceration, and anterior uveitis (inflammatory condition of the eye's front surface).

• Ocular Graft Versus Host Disease: This condition involves both types of immunity called the humoral and cell-mediated. This is typically manifested as inflammation of the conjunctiva, lacrimal gland (tear-secreting gland), and the ocular surface of the eye.

Punctal cauterization can also be prescribed for several other pathologies that might be improved by increased tear volume and surface lubrication. Such conditions are listed below.

• Radiation Keratitis: This is an acute condition that results from UV radiation exposure of the eyes.

• Herpetic Keratitis: Herpes simplex keratitis or herpetic keratitis occurs due to recurrent cornea infection by a herpes simplex virus.

• Microbial Keratitis: Microbial keratitis is a serious condition that begins with abrupt redness and pain in the eyes.

• Recurrent Corneal Erosions: Recurrent corneal erosion generally manifests as redness, blurred vision, excessive tearing, and photophobia (photosensitivity).

What Is the Technique of Punctal Cauterization?

Punctal cauterization does not usually require intensive units. It can be readily done in the normal outpatient setting. Additionally, it is sometimes performed in conjugation with other ocular surface procedures in the minor or major operative rooms. The punctual cauterization procedure can vary depending on certain factors.

One common approach is discussed below.

• Firstly, the healthcare provider impregnates a drop of Tetracaine or Propatacaine on the ocular surface.

• This is followed by applying Lidocaine to the punctum using an appropriate applicator.

• Then, the doctors cleanse the eye and eyelid with betadine solution in an ophthalmic formulation.

• Then, a subcutaneous injection of Lidocaine is administered, allowing marked time for anesthesia.

• A low-intensity and disposable electrocautery device is now prepared with the required adjustments.

• A cotton tip applicator is used to inverse the punctum while inserting the tip of the cautery device through the punctum. This is done under slit lamp magnification.

• Then, the healthcare professionals induce short pulses from cautery, slowly retracting the device from the site. The pulses usually last for a second.

• The entire punctal cauterization procedure usually takes less than 15 to 20 seconds.

• Caution should be considered during the retraction of the cautery tip to prevent contact with the face or the ocular surface. Such contact could lead to thermal burns.

• Following the procedure, an erythromycin ointment is applied to the treated area.

• Subsequently, the patient is advised to apply the particular ointment for the succeeding days.

What Are the Contraindications of Punctal Cauterization?

The procedure of closing or narrowing the tear duct openings in the eyelids is contraindicated in the following conditions.

• Active infections.

• Recent eye surgery.

• Eye allergies.

• Sensitivity to light (photosensitivity).

• Severe ocular conditions.

• Pregnancy.

Outcomes and Pitfall: Punctal cauterization is an effective treatment for improving dry eye syndrome's moisture and other symptoms. Over-treatment of punctal cauterization should not be done since it might lead to trauma or debridement of the punctum. This treatment is well-tolerated by many, showing fewer consequences. But, in some cases, self-limited pain and swelling might occur.

Conclusion

Punctum cauterization is a medical procedure used to partially or completely close the tiny opening in the eye corners that drains tears called the punctum. Here, low-intensity heat is applied for the treatment. This procedure is highly recommended for dry eye conditions or excessive tearing. It is essential to consult an ophthalmologist and discuss this approach's potential benefits and risks based on individual concerns.