Flow Control Punctal Cautery: A Novel Approach to Occlusion

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Flow Control Punctal Cautery: A Novel Approach to Occlusion

Partial Flow Cautery

To cauterize or not to cauterize, that is the question. The big concern with punctal cautery as mentioned in a previous blog (“to plug or not to plug that is the question”) is that cautery is considered an irreversible and permanent solution. Moreover, cautery is thought of as an “all-or-none” flow, with nothing in between. Both assumptions are not necessarily accurate.

In this video snippet, Dr. Fishman demonstrates flow control punctal cautery where he lightly cauterizes just adjacent to the punctum to effectively shrink the orifice but not fully occlude the opening and to help preserve the punctal anatomy. Holzchuh et. al. (ref 1) published a nice paper where they described partial punctal occlusion by slightly touching the tip of the cautery to the inner border of the puncta for 1 or 2 sec.

The reality is that the permanence of occlusion is really technique dependent. In other words, depending on whether deep “heavy” cautery or superficial “light” cautery is performed, the results are quite different as shown in the Holzchuh paper (ref 1) where puncta diameter can be titratable to some extent. Even with heavy cautery, recanalization can be as high as 26% (ref 2).


  1. Ricardo Holzchuh, Marcos Bottene Villa Albers, Tammy Hentona Osaki, Thais Zamudio Igami, Ruth Miyuki Santo, Newton Kara-Jose, Nilo Holzchuh & Richard Y. Hida (2011) Two-Year Outcome of Partial Lacrimal Punctal Occlusion in the Management of Dry Eye Related to Sjögren Syndrome, Current Eye Research, 36:6, 507-512, DOI: 10.3109/02713683.2011.569870
  2. 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 47, 1465–1469 (2012). https://doi.org/10.1038/bmt.2012.50


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