Purpose To compare rectangular three-snip punctoplasty and polyvinylpyrrolidone-coated perforated punctal plugs for treatment of acquired lacrimal punctal stenosis. Patients and methods In a prospective comparative non-randomized interventional study, 80 eyes with acquired lacrimal punctal stenosis were classified into two groups. Group A was treated by insertion of polyvinylpyrrolidone-coated perforated punctal plugs (FCI ophthalmics)™ and Group B was treated by rectangular three-snip punctoplasty. The study was done in Minia University Hospital between January 2018 and April 2019. Exclusion criteria included allergic punctal stenosis, lid malposition, and lacrimal obstruction distal to the punctum. All patients were subjected to complete history taking, slit lamp examination of tear meniscus height, fluorescein dye disappearance test, punctal position, shape, size, grading of stenosis, and grading of epiphora. Results The mean age of the patients was 43.85 ± 14.93 years. They were 30 females and 10 males. Eepiphora Grade 3 or 4, improved postoperatively to Grade 0 or 1 in 97.5% of eyes in Group A versus 55% of eyes in Group B. All eyes (100%) in Group A versus 21 eyes (52.5%) in Group B improved regarding fluorescein dye disappearance test grade ( p < 0.001). Restenosis did not occur after plug removal, while it occurred in 10% of eyes subjected to three-snip punctoplasty. Conclusion Perforated punctal plugs and three-snip punctoplasty are safe and effective in treatment of punctal stenosis. However, perforated plugs are less invasive, better tolerated, and have more stable results compared to three-snip punctoplasty.