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Primary anterior punctal malposition presenting as Centurion syndrome
Saudi Journal of Ophthalmology (2017) xxx, xxx–xxx
Photo Essay
Primary anterior punctal malposition presenting as Centurion syndrome Md Shahid Alam a,⇑; Jayshree a; Mohammad Javed Ali b
An 18-year-old girl presented with complaints of epiphora from both eyes since childhood, right more than left. On examination tear meniscus height was raised in both eyes. Slit lamp examination showed bilateral inferior puncta to be out of lacus lacrimalis (Fig. 1A and B). Both puncta were visible without any manual eversion and were directed vertically up and not in proper apposition with the globe. However both the eyelids were well apposed to the globe. A presumptive diagnosis of Centurion was thought of; however there were no other features (e.g. anterior medial canthal tendon insertion and prominent nasal bridge) suggestive of Centurion syndrome.1 On pulling the puncta further away from the globe it was found to be placed anterior to the summit of lacrimal papilla in both eyes (Fig 1C). A fine row of misdi-
rected eye lashes was also seen just behind the puncta in the left eye. Regurgitation on pressure over lacrimal sac (ROPLAS) was positive in right eye while left eye lacrimal sac irrigation was patent. A diagnosis of bilateral anterior punctal malposition with right sided primary acquired nasolacrimal duct obstruction was made. Patient was advised bilateral medial spindle conjunctivoplasty with a right sided dacryocystorhinostomy.
Comment Lacrimal puncta are situated over an elevated structure, 0.2–0.3 mm in diameter, known as lacrimal papilla which is itself surrounded by a fibrous ring.2 The papillae are
Figure 1. A and B: Slit lamp photographs of the right and left puncta, without any manual eversion, suggesting punctal malposition. Note that both the puncta are directed vertically up and not apposed to the globe (Arrows). C: Close-up view of the right punctum, with lid being stretched showing the puncta to be lying just anterior to the lacrimal papilla. (Arrow: lacrimal papillae, Arrow head: punctum).
Received 21 April 2017; received in revised form 17 May 2017; accepted 18 May 2017; available online xxxx. Ó 2017 The Authors. Production and hosting by Elsevier B.V. on behalf of Saudi Ophthalmological Society, King Saud University.This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). http://dx.doi.org/10.1016/j.sjopt.2017.05.011 a b
Department of Orbit Oculoplasty Reconstructive and Aesthetic Services, Sankara Nethralya, Medical Research Foundation, Chennai, India Govindram Seksaria Institute of Dacryology, L.V. Prasad Eye Institute, Hyderabad, India
⇑ Corresponding author at: 18. College Road, Nungambakkam, Chennai 600006, India. e-mail address: [email protected] (M.S. Alam). Peer review under responsibility of Saudi Ophthalmological Society, King Saud University
Production and hosting by Elsevier
Access this article online: www.saudiophthaljournal.com www.sciencedirect.com
Please cite this article in press as: Alam M.S., et al. Primary anterior punctal malposition presenting as Centurion syndrome. Saudi J Ophthalmol (2017), http:// dx.doi.org/10.1016/j.sjopt.2017.05.011
2 surrounded by the muscle of Riolan which pulls it postero medially.3 Both puncta are apposed to the globe and open near the plica semilunaris. Normally the punctum is placed directly over the summit of lacrimal papilla and hence it is well apposed to the globe. Primary punctal malposition is an extremely rare entity. Secondary punctal malpositions are usually noted in eyelid malpositions such as entropion and ectropion or secondary to anterior placement of medial canthal tendon as in the Centurion syndrome, and in all these cases the puncta lies directly over the summit of lacrimal papilla. The anterior malposition in the present case was a contributing factor to the epiphora. It is important to differentiate this condition from secondary punctal malpositions, most importantly Centurion syndrome since the later can be managed successfully by procedures such as medial canthal tendon release and medial conjunctivoplasty.4
M.S. Alam et al.
Conflict of Interest The authors declared that there is no conflict of interest.
References 1. Sullivan TJ, Welham RA, Collin JR. Centurion syndrome. Idiopathic anterior displacement of the medial canthus. Ophthalmology 1993;100:328–33. 2. Kakizaki H, Takahashi Y, Iwaki M, Nakano T, Asamoto K, Ikeda H, et al. Punctal and canalicular anatomy: implications for canalicular occlusion in severe dry eye. Am J Ophthalmol 2012;153(2), 229–37.e1. 3. Olver J, Part A. Colour atlas of lacrimal surgery. London (UK): Butterworth-Heinemann; 2001. 4. Murthy R, Hoavar SG, Naik M, Menon V, Bhaduri A, Das S. Centurion syndrome: clinical presentation and surgical outcome. Orbit 2009;28:269–74.
Please cite this article in press as: Alam M.S., et al. Primary anterior punctal malposition presenting as Centurion syndrome. Saudi J Ophthalmol (2017), http:// dx.doi.org/10.1016/j.sjopt.2017.05.011
Photo Essay
Primary anterior punctal malposition presenting as Centurion syndrome Md Shahid Alam a,⇑; Jayshree a; Mohammad Javed Ali b
An 18-year-old girl presented with complaints of epiphora from both eyes since childhood, right more than left. On examination tear meniscus height was raised in both eyes. Slit lamp examination showed bilateral inferior puncta to be out of lacus lacrimalis (Fig. 1A and B). Both puncta were visible without any manual eversion and were directed vertically up and not in proper apposition with the globe. However both the eyelids were well apposed to the globe. A presumptive diagnosis of Centurion was thought of; however there were no other features (e.g. anterior medial canthal tendon insertion and prominent nasal bridge) suggestive of Centurion syndrome.1 On pulling the puncta further away from the globe it was found to be placed anterior to the summit of lacrimal papilla in both eyes (Fig 1C). A fine row of misdi-
rected eye lashes was also seen just behind the puncta in the left eye. Regurgitation on pressure over lacrimal sac (ROPLAS) was positive in right eye while left eye lacrimal sac irrigation was patent. A diagnosis of bilateral anterior punctal malposition with right sided primary acquired nasolacrimal duct obstruction was made. Patient was advised bilateral medial spindle conjunctivoplasty with a right sided dacryocystorhinostomy.
Comment Lacrimal puncta are situated over an elevated structure, 0.2–0.3 mm in diameter, known as lacrimal papilla which is itself surrounded by a fibrous ring.2 The papillae are
Figure 1. A and B: Slit lamp photographs of the right and left puncta, without any manual eversion, suggesting punctal malposition. Note that both the puncta are directed vertically up and not apposed to the globe (Arrows). C: Close-up view of the right punctum, with lid being stretched showing the puncta to be lying just anterior to the lacrimal papilla. (Arrow: lacrimal papillae, Arrow head: punctum).
Received 21 April 2017; received in revised form 17 May 2017; accepted 18 May 2017; available online xxxx. Ó 2017 The Authors. Production and hosting by Elsevier B.V. on behalf of Saudi Ophthalmological Society, King Saud University.This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). http://dx.doi.org/10.1016/j.sjopt.2017.05.011 a b
Department of Orbit Oculoplasty Reconstructive and Aesthetic Services, Sankara Nethralya, Medical Research Foundation, Chennai, India Govindram Seksaria Institute of Dacryology, L.V. Prasad Eye Institute, Hyderabad, India
⇑ Corresponding author at: 18. College Road, Nungambakkam, Chennai 600006, India. e-mail address: [email protected] (M.S. Alam). Peer review under responsibility of Saudi Ophthalmological Society, King Saud University
Production and hosting by Elsevier
Access this article online: www.saudiophthaljournal.com www.sciencedirect.com
Please cite this article in press as: Alam M.S., et al. Primary anterior punctal malposition presenting as Centurion syndrome. Saudi J Ophthalmol (2017), http:// dx.doi.org/10.1016/j.sjopt.2017.05.011
2 surrounded by the muscle of Riolan which pulls it postero medially.3 Both puncta are apposed to the globe and open near the plica semilunaris. Normally the punctum is placed directly over the summit of lacrimal papilla and hence it is well apposed to the globe. Primary punctal malposition is an extremely rare entity. Secondary punctal malpositions are usually noted in eyelid malpositions such as entropion and ectropion or secondary to anterior placement of medial canthal tendon as in the Centurion syndrome, and in all these cases the puncta lies directly over the summit of lacrimal papilla. The anterior malposition in the present case was a contributing factor to the epiphora. It is important to differentiate this condition from secondary punctal malpositions, most importantly Centurion syndrome since the later can be managed successfully by procedures such as medial canthal tendon release and medial conjunctivoplasty.4
M.S. Alam et al.
Conflict of Interest The authors declared that there is no conflict of interest.
References 1. Sullivan TJ, Welham RA, Collin JR. Centurion syndrome. Idiopathic anterior displacement of the medial canthus. Ophthalmology 1993;100:328–33. 2. Kakizaki H, Takahashi Y, Iwaki M, Nakano T, Asamoto K, Ikeda H, et al. Punctal and canalicular anatomy: implications for canalicular occlusion in severe dry eye. Am J Ophthalmol 2012;153(2), 229–37.e1. 3. Olver J, Part A. Colour atlas of lacrimal surgery. London (UK): Butterworth-Heinemann; 2001. 4. Murthy R, Hoavar SG, Naik M, Menon V, Bhaduri A, Das S. Centurion syndrome: clinical presentation and surgical outcome. Orbit 2009;28:269–74.
Please cite this article in press as: Alam M.S., et al. Primary anterior punctal malposition presenting as Centurion syndrome. Saudi J Ophthalmol (2017), http:// dx.doi.org/10.1016/j.sjopt.2017.05.011