Thermal Punctal Cautery for Chronic Ocular Surface Disease

Procedure: This video demonstrates permanent punctal occlusion with high-temperature thermal cautery for the treatment of severe ocular surface disease, in this case due to graft-versus-host disease. Introduction: Ocular surface dryness can be caused by primary tear insufficiency or occur secondarily in the setting of various underlying ocular or systemic conditions. Treatment generally requires a multimodal approach to improve ocular surface lubrication and tear film quality. Punctal occlusion allows prolonged retention of tears on the ocular surface, and thus is a mainstay of therapy in dry eye disease. This can be done reversibly with punctal plugs or can be made permanent using thermal cautery to induce scarring at this entry point to the lacrimal drainage system. Indications: Permanent punctal occlusion with thermal cautery is indicated in patients with chronic, severe or refractory dry eye disease who have previously demonstrated benefit with temporary/reversible punctal occlusion, such as punctal plugs. Contraindications: Patients who are unable to tolerate prior attempts at temporary punctal occlusion due to symptomatic epiphora or patients with mild or temporary causes of dry eye disease are not appropriate candidates for permanent thermal punctal cautery. Materials and Methods: A fine-tip high-temp cautery pen is used. Results: Permanent occlusion of the lacrimal puncta inhibits tear drainage, thereby improving the signs and symptoms of ocular surface dryness. Conclusion: Thermal punctal cautery is a safe, efficient, and effective method of preventing tear drainage to treat chronic, severe dry eye disease.

Ocular surface dryness can occur primarily or can be secondary to other ocular or systemic pathology, such as Sjogren syndrome, Stevens-Johnson syndrome, ocular graft-versus-host disease, and corneal exposure, among many others. Treatment for dry eye disease relies on supplementation and augmentation of the patient’s natural tear production with artificial tears and other topical therapies, in conjunction with occlusion of the lacrimal puncta.¹ Most commonly, punctal occlusion is accomplished with punctal plugs, made from temporary, dissolvable collagen or semi-permanent silicone. However, semi-permanent silicone punctal plugs can be extruded or lost, with plug loss observed in up to 27% of patients within 6 months, thus requiring frequent replacement.² Some patients can also experience ocular surface irritation from the presence of the plug.  In these cases, surgical permanent punctal occlusion is the definitive therapy. Permanent punctal occlusion with diathermy was first described by Dohlman in 1978, and a similar approach with diathermy, thermal cautery, or argon laser has since become a mainstay in the long-term management of ocular surface disease.³ The goal of this procedure is to induce scarring of the lacrimal puncta, thereby inhibiting tear drainage. In doing so, the ocular surface is bathed in a more continuous supply of tears. The procedure can be performed quickly and safely in an operating room or outpatient procedure room setting. Numerous studies have demonstrated the efficacy of permanent punctal occlusion in the treatment of severe ocular surface disease of any etiology.^4,5

Preoperative workup: A thorough history and complete eye exam with slit lamp biomicroscopy should be performed. Particular attention should be directed to the ocular surface to assess for signs of dryness, including epithelial irregularity and fluorescein staining, as well as the tear break up time and size of the tear lake. The eyelids should also be inspected, with detailed examination of the bilateral upper and lower lacrimal puncta, checking for patency and appropriate lid margin positioning with apposition to the globe. Instrumentation/Setup: A fine-tip high-temp cautery pen is used to perform the thermal punctal occlusion. This device is battery-powered and disposable, and the tip reaches temperatures as high as 1300 degrees Fahrenheit. Anatomy and landmarks: There are four lacrimal puncta, one at the medial margin of each upper and lower eyelid. The puncta are the entry point to the lacrimal drainage system. Procedure steps: Local anesthetic is infiltrated subcutaneously in all four lids near the puncta, and corneal shields are then placed over both eyes. The eyelid margin is held away from the globe with forceps and the tip of the high-temp cautery pen is placed into the punctum, just within the most proximal lumen of the canaliculus, and then heat is applied. The external aspect of the punctum is also cauterized by passing the high-temp cautery pen over the opening of the punctum in a linear fashion. This is repeated for all four puncta. The corneal shields are then removed, and antibiotic ointment is placed on both eyes.

The intended outcome of permanent punctal occlusion is to prevent drainage of tears, both natural secretions and artificial tear drops, down the lacrimal drainage system, thereby prolonging their effect on the ocular surface. Complications are uncommon and generally mild, including short-term pain and swelling. After permanent punctal occlusion with thermal cautery, there should be improvement in the signs and symptoms of dry eye disease, with improvement in keratopathy and decreased patient discomfort. Follow-up examinations should demonstrate scarred or epithelialized lid margin at the site of punctal cautery. In some cases, recanalization of the puncta can be observed after thermal cautery treatment. In a study of permanent punctal occlusion for treatment of ocular surface disease of any etiology, recanalization requiring repeat treatment was observed in 21% of cases after thermal cautery, with a median time of 12 months from treatment to recanalization.⁵ The rate of recanalization may vary depending on the underlying ocular surface diagnosis, as well as the procedure technique.

Punctal occlusion prevents the drainage of tears and allows preservation of tear volume on the ocular surface, thereby effectively improving the signs and symptoms of dry eye disease. Silicone punctal plugs are a reversible option for occlusion, but in many cases such plugs are recurrently lost and require frequent replacement.¹ This beneficial effect can be achieved permanently by using thermal cautery to induce scarring of the lacrimal puncta, as described above. This technique has been extensively studied with demonstrated efficacy in severe ocular surface disease of many etiologies, including but not limited to refractory primary keratoconjunctivitis sicca, graft-versus-host disease, Stevens-Johnson syndrome, and Sjogren syndrome.^4–7 Patients should be carefully selected for permanent punctal occlusion, as those with milder dry eye disease may experience chronic epiphora. Patients should be aware that this is generally not reversible, even with additional surgery. Patients should also be aware that additional treatments may be required, given the possibility of recanalization. The procedure is generally well tolerated and adverse events are uncommon.

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1. Ervin A-M, Law A, Pucker AD. Punctal occlusion for dry eye syndrome. Cochrane Database Syst Rev 2017;6:CD006775. 2. Balaram M, Schaumberg DA, Dana MR. Efficacy and tolerability outcomes after punctal occlusion with silicone plugs in dry eye syndrome. Am J Ophthalmol 2001;131:30–36. 3. Dohlman CH. Punctal occlusion in keratoconjunctivitis sicca. Ophthalmology 1978;85:1277–1281. 4. Yaguchi S, Ogawa Y, Kamoi M, et al. Surgical management of lacrimal punctal cauterization in chronic GVHD-related dry eye with recurrent punctal plug extrusion. Bone Marrow Transplant 2012;47:1465–1469. 5. Wang Y, Carreno-Galeano JT, Singh RB, et al. Long-term Outcomes of Punctal Cauterization in the Management of Ocular Surface Diseases. Cornea 2021;40:168–171. 6. Ohba E, Dogru M, Hosaka E, et al. Surgical Punctal Occlusion With a High Heat-Energy Releasing Cautery Device for Severe Dry Eye With Recurrent Punctal Plug Extrusion. American Journal of Ophthalmology 2011;151:483-487.e1. 7. Kaido M, Goto E, Dogru M, Tsubota K. Punctal occlusion in the management of chronic Stevens–Johnson syndrome. Ophthalmology 2004;111:895–900.