Management of canalicular laceration

Comparing pericanalicular sutures with direct canalicular wall sutures for canalicular laceration

PURPOSE

To determine whether a statistically significant difference exists between direct canalicular wall sutures (DCs) and pericanalicular sutures (PCs) in the repair of traumatic canalicular lacerations.

METHODS

The medical records of 63 patients who underwent primary repairs for traumatic canalicular lacerations were retrospectively reviewed. Patients were divided in 2 groups according to the suturing techniques used: the DC group (n = 41) and the PC group (n = 22). Anatomic results were compared between these 2 groups. A successful result was determined by attempted irrigation and probing of the injured canaliculus at the last follow-up visit.

RESULTS

There were 6 failed procedures among the patients who underwent pericanalicular repair and 1 failed procedure among the patients who underwent direct canalicular wall repair (p = 0.024).

CONCLUSIONS

These data support the higher success rates in patients treated with direct canalicular repair compared with pericanalicular repair.

Effectiveness of canalicular laceration repair using monocanalicular intubation with Monoka tubes

PURPOSE

 This study aimed to evaluate the clinical efficacy of canalicular laceration repair using monocanalicular intubation with Monoka tubes.

METHODS

A total of 36 single lacerated canaliculi were repaired using monocanalicular intubation with Monoka tubes, without mucosal anastomosis of the canaliculi, and were retrospectively reviewed. Demographic information, injury locations, associated ocular injuries, complications and outcomes were analysed.

RESULTS

Mean patient age was 34 years (range 1-64 years). Tubes were removed at a mean of 4.2 months (range 3-6 months). There were 26 lower canalicular lacerations (72%) and 10 upper canalicular lacerations (28%). Overall, 34 of 36 cases (92%) showed improvement in symptoms and exhibited positivity on the dye disappearance test at 4-12 months after the procedure (mean 7.8 months). In total, 21 patients (58%) achieved complete success, 13 patients (36%) achieved partial success and two patients (6%) suffered surgical failure. Complications were seen in five cases and included two early tube protrusions, two punctal slits and one punctal granuloma.

CONCLUSIONS

Monocanalicular intubation with Monoka tubes leads to successful outcomes without significant complications and offers an alternative to bicanalicular intubation in the treatment of monocanalicular lacerations.

Therapeutic effects of two anastomoses of lacrimal passage on canalicular laceration

OBJECTIVE

To evaluate the therapeutic effects of two anastomoses (canaliculus-to-lacrimal sac anastomosis and end-to-end anastomosis) on nasolacrimal laceration for over 7 mm from the broken end to the dacryon.

METHODS

A total of 71 patients (44 males and 27 females, aged 16-55 years, mean equal to 34.32 years) with fresh canalicular laceration were treated in our hospital from March 2003 to April 2008. Under a microscope, 37 patients were treated with lacrimal sac anastomosis (the treatment group) and 34 with end-to-end anastomosis (the control group), detaining silicone tubes till 3 months later.

RESULTS

The cure rate of the treatment group (89.19%) was significantly higher than that of the control group (55.56%). Class I cure rates were 70.27% in the treatment group and 47.06 % in the control group, and the difference between the two groups was significant (P less than 0.05). Postoperative inflammatory reactions had significant influences on the two kinds of anastomosing methods, but no significant difference was found between the two groups (P larger than 0.05).

CONCLUSIONS

When the distance from the broken end to the dacryon is over 7 mm, especially when it is necessary to find the paranasal broken end of the lacrimal canaliculus with dacryocystotomy, canaliculus-to-lacrimal sac anastomosis is a better treatment method than end-to-end anastomosis for laceration of lacrimal canaliculus.

A simple new method for identifying the proximal cut end in lower canalicular laceration

Purpose

We report a simple and effective method of identifying the medial cut end of lower canalicular laceration cases.

Methods

Twenty-seven eyes with lower canalicular lacerations as a result of trauma were involved in the study. Surgery was performed within 48 hours after injury for canalicular reconstruction. Upper canalicular probing was utilized to identify the medial cut end of deep canalicular lacerations when difficulties were encountered. Total time from the initiation of the probing procedure to the identification of the medial cut end of the lower canaliculus was measured.

Results

A total of 27 eyes with lower canalicular lacerations were reconstructed. In 20 eyes, the medial lacerated end was located by upper canalicular probing. The mean time from initiation of the probing procedure to identification of the medial cut end of the lacerated canaliculus was 2 minutes.

Conclusions

We conclude that upper canalicular probing in patients with lower canalicular lacerations significantly reduces the time from the initiation of the operation to the identification of the medial cut end of the lower canaliculus.

The round-tipped, eyed pigtail probe for canalicular intubation: a review of 228 patients

PURPOSE

To assess the effectiveness and outcomes of canalicular intubation with the use of a round-tipped, eyed pigtail probe.

METHODS

Retrospective interventional case series of 228 patients requiring intubation of the canalicular system. Patients were treated surgically with attempted repair of the canalicular system with the round-tipped, eyed pigtail probe. The main outcome measures were successful intubation of the lacrimal system, symptoms of tearing, clinical functional evaluation of lacrimal system, complications, and need for further lacrimal surgery.

RESULTS

Of 228 patients, 222 (97.4%) had their canalicular systems successfully intubated with silicone tubing using the round-tipped, eyed pigtail probe. Follow-up was obtained in 191 (86%) of the 222 patients. One-hundred sixty of 191 (83.8%) patients were irrigated and found to be anatomically patent (of the remainder, one was blocked whereas 30 were too young to be irrigated). One hundred fifty-two of the 191 (79.6%) patients had no tearing by history. Thirty-two (16.7%) had occasional tearing on some days that was not bothersome. Seven (3.7%) had intermittent or persistent tearing on a daily basis. Sixty-seven of the 191 (35%) had their lacrimal system more extensively assessed using the dye disappearance test, Jones I test, Jones II test, and canalicular probing. Anatomic patency in this subgroup was demonstrated in 66 of 67 (98.5%) of patients. The dye disappearance test, however, revealed slight asymmetry in 24 of 53 patients (45%) with canalicular lacerations yet only 14 of these 24 (58%) had any symptoms of tearing, indicating some discrepancy between subjective and objective assessment of tearing postcanalicular repair. Fifty-three of the repaired trauma patients underwent probing of the involved and uninvolved canalicular systems. In no patient was a stricture or blockage involving the uninvolved canaliculus identified. Additional lacrimal surgery (dacryocystorhinostomy) was performed on 2 of 191 (1%) patients with greater than 3 months follow-up.

CONCLUSION

The round-tipped, eyed pigtail probe can help safely and effectively identify and repair canalicular lacerations. Symptomatic tearing was infrequent; the lacrimal systems showed complete anatomic patency in the majority of patients tested, and need for further lacrimal surgery was rare following pigtail probe intubation.

Management of canalicular lacerations: epidemiological aspects and experience with Mini-Monoka monocanalicular stent

PURPOSE

To report the epidemiological data, clinical profile, and surgical outcome of canalicular lacerations in an Indian population.

DESIGN

Retrospective interventional case series.

METHODS

All patients who underwent canalicular laceration repair from July 1, 2002 to June 30, 2005 at a tertiary eye care center were retrospectively reviewed. Demographics, cause of eyelid injury, associated ocular injury, surgical management with Mini-Monoka monocanalicular stent, and its outcome were analyzed.

RESULTS

Sixty-six patients underwent eyelid laceration repair, of which 24 (36%) had involvement of the canalicular system. The mean age at presentation was 16 years (range, 10 months to 52 years); 20 (83.3%) patients were males. Mode of injury included the blouse-hook fastener in five (20.8%) breast-feeding infants, bicycle handle injury in four (16.7%) children, and metal rod injury in five (20.8%) adults. Lower canaliculus was involved in 13 (54.1%), upper in eight (33.3%), and both in three (12.5%) patients. Simultaneous globe injury was noted in six (25%) patients, five (83.3%) of which had upper canalicular involvement. Twenty-seven canalicular lacerations (24 patients) underwent stenting with the Mini-Monoka monocanalicular stent. Three (11.1%) stents extruded within one month. At the final follow-up (mean, 18.5 months), canalicular block was noted in two (10%) out of 20 patients; none had epiphora.

CONCLUSION

Canalicular involvement occurs in 36% of eyelid injuries. Injury by the "blouse-hook fastener" is unique to infants in the Indian context. Simultaneous globe injury is present in 25% of cases, especially when the upper canaliculus is involved. Mini-Monoka stent extrusions occur within one month. With an 11.1% extrusion rate, Mini-Monoka stents achieved good anatomical (90%) and functional (100%) success in the management of canalicular injury.

Bicanalicular laceration managed with two Mini-Monoka monocanalicular stents

Bicanalicular lacerations have been traditionally managed using bicanalicular nasal intubation or annular stents. The Mini Monoka monocanalicular stent has been described for the management of monocanalicular lacerations. A bicanalicular laceration can also be successfully managed using two Mini Monoka monocanalicular stents, and this technique has several advantages. We report this simple and minimally invasive alternative in the management of bicanalicular laceration.

National survey on the management of lacrimal canalicular injury in the United Kingdom

PURPOSE

The management of lacrimal canalicular injury is controversial. It is believed that practice varies widely among surgeons.

METHODS

One hundred and twenty National Health Service-based Consultant Ophthalmologists with oculoplastic interest across the United Kingdom (UK) were identified via the website http://www.specialistinfo.com, which is a website that asks UK consultants to identify their areas of subspecialty interests. Questionnaires were sent out to them to determine caseload, intraoperative techniques (magnification, suture and stents) and postoperative management (antibiotic use, stent placement and replacement and secondary lacrimal surgery) of patients with canalicular injuries.

RESULTS

Eighty-nine (74%) completed questionnaires were returned and analysed. Most (63%) of the respondents treated between one and five canalicular injuries over the past year. Thirty-eight (43%) of them would repair a monocanalicular injury only if the lower canaliculus was involved and 36 (40%) respondents would always repair a monocanalicular injury. Eighty-two (92%) respondents used magnification during surgery. Fifty-one (57%) respondents would never consider using the pigtail probe. Eighty-five (96%) would use the bubble test and/or fluorescein dye to locate the severed medial canalicular end. Vicryl or dexon was the suture of choice for 76 (85%) and 63 (71%) respondents for repairing pericanalicular and canalicular tissues, respectively. Thirteen (14.6%) respondents did not stent their canalicular repairs. Forty-seven (53%) routinely used prophylactic antibiotics. Sixty-eight (76%) respondents would wait between 3 and 12 months before undertaking further lacrimal surgery.

CONCLUSION

This study confirmed that management of lacrimal canalicular injury varies widely among surgeons in the UK.

Acquired external punctal stenosis: surgical management and long-term follow-up

PURPOSE

To introduce and assess the results of a long-term follow-up of a one-snip punctoplasty with monocanalicular stent (Mini Monoka) for acquired external punctal stenosis (AEPS) with and without associated internal punctal and canalicular stenosis.

DESIGN

Prospective non-comparative interventional case series.

METHODS

Thirty-five eligible patients (53 eyes) with AEPS underwent a horizontal one-snip punctoplasty and Mini Monoka tube insertion by or under supervision of a consultant Oculoplastic surgeon from June 1999 to May 2002. Diagnostic probing and irrigation were performed before operation and after operation at the last follow-up. Patients with canalicular obstruction, nasolacrimal duct stenosis and obstruction, and those with less than 6 months' follow-up were excluded. The Chi-square (X(2)), Fisher's exact, Pearson correlation, and multiple logistic regression analysis tests, with 95% confidence interval when appropriate, were used for statistical analysis.

RESULTS

The age range was 39 to 90 years (mean: 67.2, SD: 11.8, SE: 2). Twenty-seven patients (77.1%) were female. There was a normal canalicular system in 21 (39.6%), lower canalicular stenosis in 10 (18.8%), and internal punctal stenosis in 22 (41.5%) eyes. Postoperative follow-up was from 6 to 41 months (mean: 18.5, SD: 9.2, SE: 1.2). There was a 77.4% complete functional success, 7.5% partial functional success, and 96.2% anatomical success at the last follow-up. The success rate was not significantly different between the eyes with and without preoperative internal punctal and canalicular stenosis (p = 0.4). The lower success rate was significantly correlated with a final abnormal probing and irrigation (p < 0.01).

CONCLUSION

The use of a monocanalicular Mini Monoka stent together with a one-snip punctoplasty is helpful to prevent the recurrence of punctal stenosis in the healing phase and addresses the associated internal punctal and canalicular stenosis.

Determination of relative contribution of the superior and inferior canaliculi to the lacrimal drainage system in health using the drop test

PURPOSE

The aim of this study was to explore the use of the 'drop test' as a method of assessing maximal lacrimal outflow capacity, and to measure the relative contribution of the superior and inferior canaliculi to the drainage capacity in normal subjects.

METHOD

The drop test involves instilling measured aliquots of normal saline over 3-min periods to raise the tear lake medially. Both eyes were assessed; however, for the right lacrimal drainage system only, sequential insertion and then removal of silicone punctal plugs was performed. After each stage the maximal lacrimal drainage capacity was measured. no punctal plugs were placed in the puncta on the left side.

RESULTS

Complete data were collected from 20 subjects with a mean age of 35.6 years. The intraclass correlation coefficient for the five left eye readings was 0.98 (CI 0.96-0.99) and the limits of agreement of a single reading were -22.6 to +93.0 micro L/3 min. Without intervention, no statistically significant difference was found in the mean lacrimal outflow between the left and right eyes (P = 0.16). A statistically significant reduction in outflow resulted from punctal occlusion (P < 0.05). Presenting the proportion of lacrimal outflow as a percentage of the combined values of the superior and inferior canaliculi, 59.9% of outflow occurred through the inferior canaliculus.

CONCLUSION

The drop test was found to provide a simple and repeatable method of assessing lacrimal drainage in a minimally invasive manner in the clinical setting. In healthy volunteers in the supine position 60% of maximal lacrimal outflow capacity occurs through the inferior canaliculus.

Maloccurrence in oculoplastic surgery related to the managed care environment

Conflicts between specialties abound in problems of the periorbita with different specialties claiming expertise in this area. These conflicts include both the diagnosis and the treatment of oculoplastic problems. Cases are presented in which such conflicts have arisen leading to less than optimal care for the patients. Engendering these conflicts are the Managed Care fiats of both insurance companies and hospital territorial conflicts. Ideas are presented for the ethical resolution of both the physician conflicts and for the recognition that managed care induced conflicts lead ultimately to less than optimal care.

Mini Monoka silicone monocanalicular lacrimal stents: Subjective and objective outcomes

BACKGROUND. Canalicular injuries and anomalies are relatively common. Despite this, controversy still exists regarding the indications for surgery and best surgical methods. The most favourable intervention would be one that is simple, associated with a high level of subjective and objective outcome, and does not threaten the uninjured or unaffected part of the lacrimal drainage system. This study assesses outcomes of intervention with the Mini Monoka silicone monocanalicular lacrimal stent. METHOD. A single cohort, hospital-based study with retrospective and prospective components. Participants were all identifiable patients at Bristol Eye Hospital in whom the Mini Monoka silicone monocanalicular stent was used for any indication. Retrospective analysis of patient records for all related pre-operative, operative and postoperative data was performed. Prospective analysis of subjective outcome via confidential patient questionnaire and objective outcome via clinical examination was performed. RESULTS. Complete data were obtainable in 13 patients (14 canaliculi) of the identified 22 patients (23 canaliculi). Follow-up was from 12 to 70 months (mean 39 months). A high level of subjective outcome was noted with no patients experiencing significant or disabling symptoms. In terms of objective outcome, 79% achieved canalicular patency. The main complications with this technique were premature stent loss (29%) and stent migration (14%). CONCLUSIONS. The Mini Monoka monocanalicular stent is a safe, effective and simple surgical technique that, unlike bicanalicular procedures, does not threaten the uninjured / unaffected part of the lacrimal drainage system.

Monocanalicular lesions: to reconstruct or not

OBJECTIVE

To evaluate the success rate of a simple surgical method for the treatment of a monocanalicular lacrimal lesion.

DESIGN

Retrospective noncomparative case series.

PARTICIPANTS

Thirteen consecutive patients with monocanalicular trauma who were seen from August 1995 to March 1998. In six patients, the canaliculus was lacerated as a result of an external injury and in seven patients as a result of tumor removal (iatrogenic injury).

INTERVENTION

Reapproximation of the orbicularis muscle and skin overlying the torn canaliculus without reanastomosis of the lacerated canaliculus. In those patients in whom the canaliculus was sacrificed as part of the removal of an eyelid tumor, no attempt was made to reconstruct the canaliculus.

MAIN OUTCOME MEASURES

Symptomatology, patency of the lacrimal passage, fluorescein dye disappearance test, and patient satisfaction.

RESULTS

In all patients the injured canaliculus was totally blocked, but despite this none of the patients complained of inconvenient tearing either indoors or outdoors. The ipsilateral unharmed canaliculus was functioning normally in such a way that the fluorescein dye instillation test showed residual dye in six patients after 2 minutes and in none of the patients after 5 minutes. All patients were satisfied with the functional and cosmetic result.

CONCLUSION

Nonrepair of a monocanalicular lesion is a valid approach that results in little or no morbidity.

"One-stitch" canalicular repair. A simplified approach for repair of canalicular laceration

BACKGROUND

It has been widely believed that direct microsurgical re-anastomosis of the canalicular epithelium is necessary for satisfactory repair of canalicular lacerations. However, because repair is carried out in conjunction with placement of an indwelling silicone stent, this stent should keep the canalicular edges adequately approximate without the need for suturing. The authors report their results in repairing canalicular lacerations using a single, fine, horizontal, mattress suture to re-approximate the overlying pericanalicular orbicularis muscle and eliminate direct microsurgical re-anastomosis of the canalicular epithelium.

METHODS

The authors retrospectively reviewed the charts of 67 patients who underwent repair of lacerated canaliculi with one-stitch re-approximation of the overlying orbicularis muscle in conjunction with bicanalicular silicone tube intubation. Stents were left in place for 3 months postoperatively and then removed. Probing across the lacerated portion of the canaliculus was carried out at the time of stent removal to ensure patency. Dye disappearance testing with 2% fluorescein and irrigation through the canaliculus then was performed 6 weeks to 3 months after stent removal.

RESULTS

Of the 67 patients, 59 were followed to stent removal. Probing with a 00 probe showed canalicular patency in all 59 patients. Irrigation resulted in reflux in two patients, indicating unrelated nasolacrimal duct obstruction. Of these 59 patients, 45 complied with scheduled follow-up 6 weeks to 3 months after stent removal. Dye disappearance testing using 2% fluorescein demonstrated delay in lacrimal outflow in 6 of the 45 patients. Only two patients had symptomatic epiphora, and in both patients there was an underlying nasolacrimal duct obstruction confirmed by irrigation.

CONCLUSIONS

Simple re-approximation of the lacerated overlying soft tissue combined with bicanalicular silicone intubation proved highly successful in managing canalicular lacerations. Probing through the lacerated canaliculus demonstrated patency in 100% of the 59 patients followed to stent removal. Only 4% of patients had symptomatic epiphora postoperatively, and 13% demonstrated some delay in outflow with dye disappearance testing. This compares very favorably with previous reported series in which lacerated canaliculi were microsurgically re-anastomosed.

Bilateral monocanalicular silicone loop: predictable home removal of nasolacrimal stents

Premature dislocation, a potential disadvantage of conventional, unilateral silicone intubation for lacrimal disease, can be alleviated with a firmly-tied, bilateral, superior canaliculus intubation. Since the looped silicone stent can be removed easily at home by parents, this technique is particularly beneficial for remote patients for whom postoperative, clinic removal is a financial burden.