DUPLICATION OF THE LOWER LACRIMAL puncta and canaliculi is rare and it has been estimated that this occurs once in every 60,000 people.1 It is the purpose of this paper to present another isolated occurrence of this rare congenital anomaly and to remind the clinician of its significance.
This 32 year-old female has a negative family history except for duplication of the inferior canine tooth in one niece. Her own history revealed normal delivery at full term, a cyst in the root of the left inferior incisive tooth removed at age 28 and a small adenoma removed from her right breast at age 25. Her eye examination was negative on both sides except for the following findings in the left lower lid. There was a reduplication of the left lower lacrimal punctum. The two puncta appeared entirely normal and were located next to each other in back of the gray line and about \Vz mm apart (Fig. 1). Both puncta were normal in size and they both filled promptly with Targesin or Fluorescein instilled into the lower cul-de-sac. Examination with probes showed that two probes could be passed through into the lacrimal sac without making contact on the way. This proved that two independent lower lacrimal canaliculi were present - one for each punctum - and that they had separate entrances into the lacrimal sac. The upper lid exhibited only one entirely normalappearing punctum with normal function.
Duplication of the lower lacrimal punctum and duct has been observed as an isolated occurrence as well as in association with other congenital defects.2 Such associated defects reported in the earlier literature were: atresia of the upper punctum,3'4 anomalies in shape and position of puncta,3,4'5 narrowing of the lacrimal system causing epiphora,6 duplication of the plica semilunaris,1 fistula of the lacrimal sac,* diverticulum-formation in the lacrimal system,4 teratoma,4 cyst of the lacrimal gland,T coloboma of the upper lid and congenital bone defects around the orbit.3 Three or four puncta of the lower lid have also rarely been seen.3'4 Familial occurrence of double lower puncta and other related anomalies has been recorded once in five members of a family.8
Cases of simple duplication of the lower puncta with patent ducts and normal function certainly need no treatment. The present patient is a good example of such an entirely harmless anomaly. However, this anomaly is of great interest to the embryologist since this must be due to an unexplained duplication of that minute rod of cells that grows upward from the surface ectoderm between the lateral nasal and maxillary processes at about the 10 mm stage to form the canalieuli in normal development.
1. Wicherkiewicz, B.: Zur congenitalen Anomalie der oberen Tränenwege. Atti d, XI Internat. Cong. Med. 1894, Rome, 6:49, 1895.
2. Duke-Elder, Sm St.: System of Ophthalmology. C. V. Mosby Co., St. Louis, 1963, Vol. III, Part 2, p. 930
3. Krax, R. C: Developmental anomalies of the lacrimal passages, a review of the literature and presentation of three unusual cases. Am. J. Ophth., 42:227, 1956.
4. von Bacskuxjn, J.: Punctum lacrimale duplex, triplex und quadruplex. Klin. Mbl. f. Augenheilk., 144:418, 1964.
5. von Fazakas, A.: Ueber doppelte Tränen - kanälchen und Tränenabfiuss, Klin. Mbl. f. Augenheilk., 9Í:395, 1933.
6. Greeves, R. ?.: Case of supernumerary punctum lachrymale and canaliculus. Proc. Roy. Soc. Med. London 1913-14, VU, Ophthalmol. Sect., 141.
7. Flom, L. and Levitt, J. M.: Double lacrimal puncta and dacryops. A. M. A. Arch. Ophth., 54:760, 1955.
8. Sedan, J.: Supernumerary lacrimal canaliculj and congenital fistulas of lacrimal sac in 5 members of same family. Annales, o'oculistique, 252:855,…