title: Double lacrimal puncta: clinical presentation and potential mechanisms of epiphora.
abstract: OBJECTIVE
  Congenital supernumerary lacrimal puncta and canaliculi are rarely reported. Our purpose is to present the largest series of patients with supernumerary puncta and to describe the clinical presentation and associated lacrimal anomalies.
  
  
  METHODS
  Observational retrospective case series.
  
  
  METHODS
  All patients diagnosed with supernumerary puncta by a single surgeon between 1988 and 2008.
  
  
  METHODS
  Retrospective case note review.
  
  
  METHODS
  Patient demographics, clinical presentation, lacrimal and systemic examination findings, management, and surgical outcomes.
  
  
  RESULTS
  Twenty-three patients (12 female, 11 male) with a median presenting age of 54 years (range, 1-88 years) had unilateral double lower lid puncta. In 5 patients the presence of a double punctum was an incidental examination finding. Eighteen patients had unilateral tearing on the same side as the double punctum. In 6 children presenting with tearing, associated congenital lacrimal anomalies included nasolacrimal duct obstruction, a lacrimal fistula, a lacrimal sac diverticulum, and absence of the upper canaliculus. Associated systemic findings in 3 children included Down syndrome (1 patient) and preauricular sinuses (2 patients). Of 12 adult patients presenting with ipsilateral tearing, 5 had complete nasolacrimal duct obstruction and 6 had either partial nasolacrimal duct obstruction or functional epiphora. Dacryocystorhinostomy was performed in 12 patients and resulted in improvement or resolution of symptoms in 11 patients (92%).
  
  
  CONCLUSIONS
  Double lower lacrimal puncta may be associated with epiphora. In younger patients, tearing may be due to associated congenital anomalies of the nasolacrimal system. A proportion of patients presenting with onset of tearing in adulthood have patent lacrimal systems and otherwise normal adnexal examination results, suggesting that the presence of double puncta may be associated with compromised canalicular function. Reflux of tears through the accessory canaliculus is a potential mechanism and would be consistent with a recently proposed 2-compartment model of lacrimal canalicular drainage.
  
  
  BACKGROUND
  The authors have no proprietary or commercial interest in any materials discussed in this article.
authors.affiliation: Orbital Plastic and Lacrimal Clinic, Royal Victorian Eye and Ear Hospital, Melbourne, Australia.
authors.forename: Khami
authors.initials: K
authors.lastname: Satchi
authors.forename: Alan A
authors.initials: AA
authors.lastname: McNab
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002675:Child, Preschool; D003608:Dacryocystorhinostomy; D005124:Eye Abnormalities / Q000175:diagnosis* / Q000378:metabolism / Q000503:physiopathology; D005143:Eyelids / Q000002:abnormalities*; D005260:Female; D006801:Humans; D007223:Infant; D007766:Lacrimal Apparatus Diseases / Q000175:diagnosis* / Q000503:physiopathology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013666:Tears / Q000378:metabolism