introducing myself

[zuzu70]

Hello, I'm in my early 40s and have one dry eye due to the stupidest reason ever: I had my punctum snipped because of intermittent watery eye. I had even had worries about overcorrecting the problem, and now indeed it is the case. I am having extreme depression because I caused this problem myself. Well, the oculoplastic surgeon is not fault-free either, as I was scheduled for a "one-snip" procedure and he did a three-snip instead without telling me in advance. But, I place the majority of blame on myself. I wake every morning with a dry eye, and wearing contacts has been problematic as my vision out of that eye is blurry. I've been using OTC preserved eye drops 4-5 times a day until I can get some unpreserved ones. Right now I need to wait until it's fully healed (it's been a month so it's mostly healed and I doubt I will get much improvement though) but I don't know if I can deal with being angry at myself for the rest of my life. I am in a crazy state of mind right now. I don't know if a procedure to reverse it is possible...I'm scared.

[Rebecca Petris]

Welcome to DEZ. So sorry to hear what happened.

I am having extreme depression because I caused this problem myself. Well, the oculoplastic surgeon is not fault-free either, as I was scheduled for a "one-snip" procedure and he did a three-snip instead without telling me in advance. But, I place the majority of blame on myself.

Whoa!!!

Surgeon did something he did NOT have your consent to do. From what you have described, ethically and legally and medically, he screwed up. NOT YOU.

We have a lot of people here who can relate to the guilt/self-blame because of dry eye caused by elective LASIK, blepharoplasty or other surgeries but the fact is none of us are eye surgeons, none of us "caused" this to happen to ourselves, and we pretty much all made reasonable decisions about our surgeries based on the information presented to us.

I wake every morning with a dry eye, and wearing contacts has been problematic as my vision out of that eye is blurry.

If you are healed enough, consider some of the common remedies people here use to keep the eyes moister overnight... even a bit of plastic wrap over the eye at night can help.

I've been using OTC preserved eye drops 4-5 times a day until I can get some unpreserved ones.

I'd make that a pretty high priority. Make sure what you're using does NOT contain benzalkonium chloride (look at its list of inactive ingredients) - if it does, you may be better off using nothing till you get some unpreserved drops.

I don't know if I can deal with being angry at myself for the rest of my life. I am in a crazy state of mind right now.

You won't be. First of all it's so soon after the surgery - you need some time to heal and see what the actual outcome will be, and in the meantime you can baby your eye lots. Don't assume that at one month it is what it is. It can take a long time after some surgeries before things really settle down to a 'new normal'. And in the meantime you can focus on taking really good care of the eye.

Can you stick with glasses for awhile?

[DCRdryeye]

Zuzu, I had a procedure done by an oculoplastic surgeon for a watery eye too. He also snipped my two punctas. The procedure is called a DCR, is that what you had? I'm extremely dry now as a result of the procedure. The DCR involves more than just snipping the punctas, they also drill through nasal bone and create an artificial alternate route for tears to flow down...but it's an enormous hole and results in too much tears draining through, thus resulting in dry eye.

I was not told any of this would occur. I was not told a hole will be drilled into my skull, nor informed about the punctas being snipped. My punctas are so large that external plugs won't fit in them.

[zuzu70]

to DCRdryeye

Hi DCR,

No, I did not have a DCR too, just three-snip punctoplasty. In a one-snip, the doctor puts one blade of the scissors inside the dilated puncta and then snips 1-2mm. But in a 3-snip, he does two parallel snips on the side of the puncta and then one horizontal snip to cut off the rectangular flap. The first I discovered it was when he was finishing my second puncta and he said, "now I just need to get this flap out of there." He says that hardly anyone does one-snips anymore because the adjacent edges just heal back up, but regardless I don't think it was right that he called it something different. He says that "it's called a one-snip even though there's three cuts," but after extensive (read 40+ hours) of online research I know that is not correct. I was initially told that if the one-snip grew back together, the next step would be a DCR, and I had already decided that my watering problem was not significant enough to endure a DCR. I should have decided the same thing about the "simple" snip procedure.

I am scared to try plugs because of everything I hear about them getting stuck inside the nasal cavity and causing infection, etc. But to be honest, I'm concerned about foreign matter getting inside these huge puncta too. And I'm so sorry that your puncta are so large that plugs don't fit. I was wondering that about myself, too. If things don't improve, I suppose my only alternative would be cautery, but the permanence of that (and messing with my eye again) scares me too.

I was so neurotic today I called the optometrist who had initially referred me to the oculoplastic. I thought the optometrist knew what he was talking about, but today he actually said, "I'm sure there's something the oculo can do to shrink the puncta. It probably involves a single stitch or something like that." Ugh, nice conjecture.

[zuzu70]

DCRdryeye,

Just curious, have you ever tried punctal cautery? Or have the docs recommended against it? I'm wondering about my situation with the snipped puncta...if cautery would be the answer someday should I need it. I know you said the docs snipped your puncta as well.

[DCRdryeye]

Hi zuzu,
I can relate to your wanting to avoid getting anything else done to your eyes. I've been recommended cautery too by various specialists and they don't seem to 'get' that I would rather avoid anyone messing with my eyes, especially if it cannot be reversed. In terms of reducing the size of the punta's after the snipping, I had a procedure to have a 'mini-monaka stent' placed into both lower punta's. The two punctas on my left eye are those that are enlarged, and unfortunately I developed proud flesh under the stent on the large puncta and it pushed the stent out. However, the surgeon used micro sutures to stitch the puncta tighter, thus reducing it's size...so it can be done!

[zuzu70]

Hey DCRdryeye, you give me hope! If you would be so kind, please tell me about the micro sutures procedure. Was it a simple office procedure? Did he inject a local anaesthetic, or do pressure (topical) anaesthetic? Approximately how big was your puncta to start with, and how small did the sutures make it? Did you/do you have any foreign body sensation from the sutures? Dissolvable sutures or did they have to be removed? Did he suture both puncta, or just upper or lower? Did the suturing do anything in terms of pulling your lid farther away from your eyeball (I have a bit of a "crater" where my punctas used to be, especially the upper, and I would think that deepening the crater would not be a good thing.) Thank you in advance for your reply...I feel like your case is most similar to mine that I've seen on here yet.

[DCRdryeye]

Hi zuzu, you can read about my procedure with mini-monaka stents here: http://www.dryeyezone.com/talk/showt...ugs&highlight=

Okay, it's only my left eye that has the very large puncta's. I believe my oculoplastic surgeon said they were 6mm wide. I had one stent put into each left and right lower punctas. The left puncta developed proud flesh and pushed the stent out. I still have the stent in my right eye where the punctas have never been tampered with. I have two very dry eyes (left is worse), thus having stents put into both eyes.
To allow the stent to sit in place, my surgeon had to suture the large puncta because it was too large for the stent. She sutured 'around' the stent so there was an air tight seal against it to stop tears draining into my nose. Obviously, it wasn't completely sutured shut because the stent was there. When the stent was pushed out by the proud flesh, there was a 3mm hole. Thus, the sutures had closed 50% of my puncta (from 6mm to 3mm). My surgeon said she could shut them completely if I wanted them shut. Or you can simply have them reduced so they are smaller. Zuzu, I believe you simply want your punctas smaller, is that correct?
I was under general anaesthetic during the procedure mostly because I have gone into a panic attack during attempted surgery under local anaesthetic. I didn't feel the sutures against my eyeball, nor did they pull my lid further from the eyeball (they are microscopic size, hardly visible to the naked eye). The sutures were disolvable.
I would suggest you consult a few occuloplastic surgeons. See at least three of them before making a decision. In fact, I had consulted about four of them and found them all to be incredibly different in their techniques and approach. Attitude is also a big deal to me. I do not respond well to arrogant surgeons who couldn't be bothered answering my questions and having no heart for my concerns. So my chosen surgeon was a very compassionate female oculoplastic surgeon. She was wonderful and did whatever she could to help. In fact, she even began to dream of new ways to block my puncta's without using plugs or cautery (by removing conjunctiva and placing it over the punctas). When a surgeon is willing to pioneer new surgical techniques to accomodate your needs, then you have struck gold. They are out there zuzu...don't stop at the first surgeon you consult

[zuzu70]

Yes, I just want my punctas smaller...back to where they were when I started would be great, in fact! (Stupid me, stupid decision, stupid surgeon) 6 mm wide (or even 3 mm wide) sounds like HUGE puncta. I would estimate mine were 0.2 mm diameter before my punctoplasty, and about 1 mm diameter now. (which, if you do the math, is 25 times the surface area. I was told the punctoplasty would make the puncta "a little" bigger...hey doc, doesn't "a little" bigger mean maybe twice the size, not 25 times?!?)

When you say in your original post the "She had to cut some of the puncta and use micro stitches," do you mean that she cut away more tissue (like cut it out or cut it off), or just that she made cuts into the puncta without removing tissue? I'm a little freaked out about removing more tissue, unless it's a microscopic amount.

I have read at least one study about 11 patients who had the conjunctival tissue transplant to block the puncta. Sounds like it's a fairly new technique, (and it sounds horribly painful!) but if that was what I needed to do, I'd do it.

[zuzu70]

Oh, and I also read on one site that the puncta can also be covered by amniotic tissue. It didn't elaborate, and I wonder what they mean...an amniotic sac from a pregnancy? Weird.

[DCRdryeye]

The puncta's in my left eye are HUGE after they were snipped for DCR surgery. The surgeon did not tell me he would snip them, nor did he tell me the surgery involved drilling a hole into my skull. May-be he was afraid I'd refuse the surgery? Well, the damage is done now and us victims are left to pick up the pieces. Zuzu, your puncta's are small in comparison to mine and to be honest, it's not much to worry about. If you asked a surgeon to return your puncta's to their original size (from 1mm to 0.2mm) they may look at you in a strange way. Some people naturally have larger puncta's and 1mm is very small. What is your reason for wanting to go back to your original sized puncta's? How will it benefit you? How is the slightly more larger puncta's a problem for you?
My surgeon had to cut some of the puncta to enable a tight fit around the stent. They also need to file some of the flesh on the puncta to create a rough surface to allow a join to occur, otherwise when the stitches dissolve, the flesh will just separate again.

[zuzu70]

If you asked a surgeon to return your puncta's to their original size (from 1mm to 0.2mm) they may look at you in a strange way. Some people naturally have larger puncta's and 1mm is very small. What is your reason for wanting to go back to your original sized puncta's? How will it benefit you? How is the slightly more larger puncta's a problem for you?
.

Yes, you're right, I may get looked at funny. The bigger punctas are a problem because my eye is too dry. But you're right that a surgeon may look at me and say it's not a big enough problem to do anything about. My big goal, though, is I'd like to be able to wear my contacts the whole day again, instead of every other day just 7 hours or so. I was wearing them the whole day before the surgery, and I just wish I could un-do my punctal snip and live with the occasional watery eye I had been getting (maybe 2-3 months out of the year). I wish I had found this site before my punctal snip.

I did a little online sleuthing, and this is what I found in regard to average punctal size:

Textbook parameters for punctal diameter range from 0.2 mm to 0.5 mm. A prospective study of 50 asymptomatic patients found the lower puncti to be significantly larger in diameter than the upper puncti. No difference between genders was found. The mean area of the upper puncti was 0.264 ± 0.141 mm2. The mean area of the lower puncti was 0.321 ± 0.155 mm2, and the variation was substantial (0.1–0.7 mm2 for the upper puncti and 0.1–0.8 mm2 for the lower puncti).

So, it seems like 1 mm diameter is twice as big as the biggest "normal" size, and gosh I'm not sure what to call 6 mm. I feel so bad for you.