Retrospective Comparative Analysis Of Monopolar Diathermy Versus Handheld Cautery For Punctal Occlusion Over A Two-Year Period (2024–2025)

Punctal occlusion plays a key role in aqueous deficient dry eye disease (DED) by reducing tear outflow, thereby increasing tear film retention time and enhancing the therapeutic effect of lubricants on the ocular surface. Thermal punctal cautery is widely adopted for permanent occlusion because it is minimally invasive and easily repeatable. Despite its common use, there is limited comparative data evaluating different cautery modalities. 

This study aims to compare the anatomical closure rates, symptom improvement, recanalisation rates, procedural efficiency, complication profile, and relative cost-effectiveness of monopolar diathermy versus handheld cautery for permanent punctal occlusion in patients with aqueous-deficient DED.

Department of Ophthalmology, Frimley Park Hospital (FPH), a district general hospital in Surrey, United Kingdom. All procedures were conducted between Jan 2021 and December 2026.

We conducted a retrospective, non-randomised comparative analysis of all patients undergoing permanent punctal occlusion procedures performed between January 2024 and December 2025 who had a minimum 3 months follow-up post procedure at a single center Frimley Park Hospital, United Kingdom. Treatment modality was determined by surgeon preference and temporal practice pattern undergoing monopolar diathermy using the Ellman long-loop electrode or thermal occlusion with the Accu-Temp Variable Low-Temp handheld cautery device. Primary outcome was anatomical recanalisation requiring repeat intervention. Secondary outcomes included subjective symptom improvement, clinical signs, theatre efficiency, cost effectiveness and procedural complications.

23 patients met inclusion criteria (13 monopolar diathermy & 10 handheld cautery). The mean age was 63.8yrs, with 86.9% female predominance. The most common aetiology was autoimmune disease (56.5% Sjögren’s syndrome), followed by aqueous deficiency without systemic association (26.1%). Recanalisation occurred in 38.5% of monopolar diathermy cases, requiring repeat intervention. No recanalisation was observed in the handheld cautery group, giving anatomical success rates of 61.5% vs 100%.

Mean follow-up duration was longer in the monopolar group (≥1 year) compared with 3–6 months in the handheld cautery group.

Mean procedure time was similar (10.8 vs 9.5 minutes). Cost per case was ~£100 vs £18.60. No complications were observed.

Handheld cautery demonstrated superior short-term anatomical durability compared with monopolar diathermy, with a 38.5% absolute reduction in recanalisation and greater patient satisfaction. Procedural time was comparable, but handheld cautery had markedly lower per-case cost and required no capital equipment servicing.

Monopolar diathermy may pose theoretical risks in patients with pacemakers or implantable devices due to electromagnetic interference.

Despite small sample size and unequal follow-up, findings support handheld cautery as a clinically effective and cost-efficient option for permanent punctal occlusion.