Double puncta, endless tears: A rare anatomical twist

Supernumerary lacrimal puncta, a rare and frequently overlooked congenital anomaly of the lacrimal drainage apparatus, can present subtle yet significant clinical challenges. We report the case of a 9-year-old boy with chronic unilateral epiphora, manifesting as tearing and ocular discomfort. Slit-lamp biomicroscopy unveiled an unusual anatomical variation: two distinct, well-formed puncta located on the lower eyelid of the right eye, disrupting the physiological tear outflow. Diagnostic probing through the lower puncta revealed notable resistance and an absence of free passage into the nasal cavity, and dacryocystography confirmed segmental narrowing of the nasolacrimal duct, pointing towards an underlying nasolacrimal duct obstruction. This anatomical anomaly, compounded by a functional outflow compromise, offered a clear explanation for the patient’s symptoms. Beyond its diagnostic intrigue, this condition may also affect the pharmacodynamics of topical ocular medications. The case highlights the importance of recognizing such variants in patients with unexplained epiphora and reinforces the need for tailored management strategies and patient education.