Lacrimal drainage system inflammatory masses from retained silicone tubing

Bony nasolacrimal duct size and outcomes of nasolacrimal silicone intubation for incomplete primary acquired nasolacrimal duct obstruction

Purpose

To investigate the association between the bony nasolacrimal duct (NLD) size and outcomes of nasolacrimal silicone intubation for incomplete primary acquired nasolacrimal duct obstruction (PANDO).

Methods

Patients who underwent silicone intubation for incomplete PANDO and had undergone facial computed tomography (CT) were included. Surgical success was judged by both epiphora improvement and normalized tear meniscus height (TMH; < 300 μm) on anterior segment optical coherence tomography at 3 months after tube removal. The area, major axis diameter, and minor axis diameter of the elliptic bony NLD sections were measured in 1.0 mm-thick axial CT images. These bony NLD sizes were analyzed for associations with surgical success and TMH normalization.

Results

Eighty-one eyes of 48 patients were investigated. The smallest area and the smallest minor axis diameter were significantly larger in the success group (49 eyes), compared with those in the failure group (median smallest minor axis diameter: 4.7 mm vs. 3.8 mm, P = 0.008, Mann–Whitney U test). There was also a tendency for the TMH normalization rate to significantly increase as the smallest area and the smallest minor axis diameter increased (P = 0.028 and 0.037, respectively, Fisher’s 2 × 4 tests). Under multivariable logistic regression analysis using generalized estimating equation, a larger smallest minor axis diameter was associated with success of the nasolacrimal silicone intubation (odds ratio: 2.481, 95% confidence interval: 1.143–5.384).

Conclusion

Surgical success of the nasolacrimal silicone intubation in incomplete PANDO is associated with a larger smallest minor axis diameter of the bony NLD. This finding will help understand the pathophysiology of surgical failure after nasolacrimal silicone intubation.

Clinical Characteristics, Intraoperative Findings, and Surgical Outcomes of Canalicular Laceration Repair with Monocanalicular Stent in Asia

Purpose

To report the epidemiological and clinical data as well as surgical outcomes of canalicular lacerations with Mini-Monoka insertion at a tertiary center in Taiwan and to discuss differences in traumatic pattern, pathogenesis, and surgical outcomes between Taiwan and other countries.

Methods

From 2009 to 2018, all 48 patients who underwent canalicular laceration repair with Mini-Monoka stent at a tertiary center in Taiwan were retrospectively analyzed. Demographic and clinical data and surgical outcomes were recorded.

Results

The mean age of the 48 patients was 38 years. Single lower canaliculus was involved in 37 (77.1%) patients, upper canaliculus in 10 (20.8%) patients, and both in 1 (2.1%) patient. The most common etiology was motorcycle accident (41.7%), and all traffic accident injuries accounted for 68.75% of cases. Subgroup classification revealed 64.6% of patients (n=31) were categorized in the deep laceration group, and lower anatomical and functional outcomes were noted in deep laceration. The mean follow-up time was 14.5 months. Overall, the anatomical success rate was 87.5%, and the functional success rate was 91.7% after stent removal.

Conclusion

Canalicular laceration caused by traffic accidents occurred with a relatively high frequency in Taiwan. Affected patients tended to be middle-aged, and deep laceration accounted for 64.6% of patients. These were contributed by the avulsive eyelid injury mechanism caused by traffic accidents. Furthermore, the deeper lacerated site was located, and the lower anatomical and functional success rates were observed. Early repair after trauma with Mini-Monoka stents achieved good eyelid position (100%) as well as good anatomical (87.5%) and functional (91.7%) success without serious complication.

An unusual complication of crawford tube insertion

The authors describe an unusual and challenging complication of bicanalicular (Crawford) stent insertion that has previously never been reported. A 27-year-old man sustained multiple lacerations to the left (L) periocular and facial areas with a glass bottle. He was admitted under the care of the Plastic Surgical team at another institution and underwent repair of the facial, eyelid, and canalicular lacerations in the operating room. During the surgery, a Crawford stylet was guided in the L inferior canaliculus but was not retrieved nasally. Neuroimaging revealed that the metallic stylet of the Crawford tube was within the orbit, extending via the superior orbital fissure into the middle cranial fossa. The patient was then transferred under the care of the neurosurgical team and underwent a combined orbital/neurosurgical procedure to retrieve the stylet.

Nonsurgical retrieval of retained lacrimal stenting material

PURPOSE

The aim was to describe a novel technique to retrieve retained stenting material from the lacrimal system.

METHODS

In this consecutive case series, the authors reviewed charts of 4 children with retained silicone material in their lacrimal sac following intubation. In 2 children, the presence of the retained material was well documented. The other 2 children were examined for the following clinical triad: history of lacrimal intubation, obstructive symptoms characterized by mucopurulent discharge, and a patent nasolacrimal system on irrigation, highly suggesting retained stenting material in the lacrimal system. Retrieval of the foreign body is achieved by performing an intubation of the superior canaliculus with both arms of a Crawford silicone tube. This forms a loop of silicone tubing that can be retrieved from the nose. As the loop passes through the lacrimal sac and duct, the foreign body material is retrieved and extracted through the nose.

RESULTS

In the 4 children on whom this procedure was attempted, it was successful in retrieving the retained piece of silicone on every occasion. In all children, there was complete resolution of the epiphora and chronic dacryocystitis without need for dacryocystorhinostomy.

CONCLUSIONS

Retained stenting material can be responsible for persistent obstructive symptoms and chronic dacryocystitis. Patients examined for the clinical triad described should raise suspicion of the possibility of a foreign body in the lacrimal system. This technique should be considered in patients where a retained foreign body is known or suspected, prior to considering dacryocystorhinostomy. When successful, it will be both a diagnostic and therapeutic procedure, and will additionally serve to avoid unnecessary dacryocystorhinostomy.

Effect of mitomycin C on success rate in dacryocystorhinostomy with silicone tube intubation and improper flaps

PURPOSE

To assess the effect of mitomycin C on surgical success rate of dacryocystorhinostomy and silicone intubation in patients with improper flaps.

METHODS

The study was a randomized clinical trial. The patients with indication for dacryocystorhinostomy surgery with silicone intubation (inappropriate lacrimal sac or nasal mucosal flaps during surgery and/or history of dacryocystitis in the past 3 months) were randomly assigned to application of mitomycin C (0.02%) on surgical flaps (group A) or a control group without mitomycin C application (group B). Main outcome measures were subjective symptomatic improvement and result of irrigation test at last follow-up visit.

RESULTS

The study enrolled 88 patients (88 eyes); there were 42 patients in group A and 46 patients in group B. There was an average follow-up of 10 months (range 6-15 months) following surgery. Significant improvement (no tearing with patent lacrimal system in irrigation) was observed in 31 patients (73.8%) in group A and 32 patients (69.6%) in group B. There was no statistically significant difference in no improvement (no change in tearing state and obstruction in irrigation test), relative improvement (decreased tearing and passage of fluid with force in irrigation test), and significant improvement rate between the 2 groups of study (p>0.05).

CONCLUSIONS

Application of mitomycin C on surgical flaps during dacryocystorhinostomy surgery with silicone intubation in patients with improper flaps has no proven beneficial effect on success rate of surgery.

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.

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.

Selective non-intubation of a silicone tube in external dacryocystorhinostomy

PURPOSE

To evaluate whether silicone tube insertion is always necessary in external dacryocystorhinostomy (DCR).

METHODS

During external DCR for primary nasolacrimal duct obstruction carried out between January 2001 and October 2004, silicone intubation was not performed selectively if the lacrimal sac was large and the nasal cavity was not severely narrowed.

RESULTS

Of a total of 166 DCR cases in 153 patients, no silicone tube was placed in 74 eyes of 69 patients (44.6%). Anatomic patency of rhinostomy was achieved in all non-intubation group eyes. However, four (6.7%) of these 69 eyes showed persistent epiphora even with anatomic patency.

CONCLUSIONS

Silicone tubing can be avoided in about 50% of cases of external DCR without detrimentally affecting the success rate. Cases in which intubation was avoided had a large lacrimal sac and a wide nasal cavity.

Pyogenic granulomas after silicone punctal plugs: a clinical and histopathologic study

PURPOSE

To describe clinical findings, histopathologic changes, and risk factors for pyogenic granuloma formation complicating silicone punctal plug therapy.

DESIGN

Retrospective observational case series.

METHODS

Between November 2000 and April 2004, 903 silicone punctal plugs of the same brand were inserted in 404 subjects. Cases associated with pyogenic granuloma formation were identified and reviewed. Granulation tissue was obtained from 10 patients for histopathologic examination. Multiple risk regression analyses identified factors related to pyogenic granuloma development and factors associated with histologic patterns.

RESULTS

Pyogenic granuloma development led to the extrusion of 4.2% of all plugs placed in a median time period of 141 days. All patients presented with varying degrees of plug extrusion. Similar distributions of partial and complete plug extrusions, as well as bilateral and unilateral plug extrusions, were seen. Findings at presentation ranged from a subclinical pyogenic granuloma causing partial plug extrusion to a pyogenic granuloma in the punctum with a ring of fibrovascular tissue retaining a completely extruded plug. Histopathologic examination revealed two patterns, representing either acute pyogenic granuloma or involuting pyogenic granuloma. Pyogenic granulomas resolved after 3.1 +/- 1.3 weeks in all patients after plug removal. Multiple regression analysis revealed that large plug size was associated with increased pyogenic granuloma formation (P < .0001). Partial or complete plug extrusion was associated with active or involuting pyogenic granuloma, respectively (P = .023).

CONCLUSION

Pyogenic granuloma-related spontaneous plug extrusions may be more common than previously thought and can present with a range of clinical findings. The degree of plug extrusion correlates with the histopathologic pattern. Larger plug size and sharp edges in plug geometry may be responsible for pyogenic granuloma formation.

Histopathologic changes in the lacrimal sac of dacryocystorhinostomy patients with and without silicone intubation

PURPOSE

To evaluate the histopathologic impact of dacryocystorhinostomy (DCR) and silicone intubation on the lacrimal sac.

METHODS

Biopsy materials were taken from the sac wall and fixed (primary biopsy) in 224 patients undergoing DCR between 1995 and 2003 in our institution. A total of 23 patients underwent a second operation as the result of restenosis, and a secondary biopsy specimen was taken from the sac wall. During the initial operation, DCR and silicone intubation were combined in 13 patients (group 1), and only DCR without silicone intubation was performed in 10% patients (group 2). The histopathologic findings of the primary and secondary biopsy specimens were compared in these 23 recurrent cases. In addition, the secondary biopsy findings in the intubation and nonintubation groups were compared to determine the possible effects of the silicone intubation on the sac mucosa.

RESULTS

Endonasal examination of restenosis cases revealed macroscopic cicatrization. One of the cases with silicone intubation had pyogenic granuloma and two had polypoid granulation tissue at the site of anastomosis. Inflammatory polypoid development at the site of anastomosis was also observed in one case without intubation. The primary biopsy specimens of those 23 patients undergoing a second operation revealed the following findings: chronic inflammatory changes, mild fibrosis, focal ulceration in the epithelium, and a decrease in the number of goblet cells. In the secondary biopsy specimens, 2 patients in group 1 had polypoid granulation tissue, 1 patient had pyogenic granuloma, and 3 patients had exudate reflecting acute inflammation. In group 2, granulation tissue was observed in 1 case, and 2 patients had acute inflammation. There were no differences in the primary and secondary biopsy specimens of the two groups with respect to chronic inflammatory changes, focal ulceration, and the number of goblet cells (p = 0.31; 0.31, 0.65). A marked increase in fibrosis was observed in the secondary biopsy specimens of all cases (p < 0.0001). There were no significant differences between the intubation and the nonintubation groups in terms of secondary biopsy specimens (p > 0.05).

CONCLUSIONS

The marked increase in the intensity of fibrosis observed in the secondary biopsy specimens of all cases was the result of the tissue repair reaction against surgical manipulation rather than the effect of the silicone tube.

Endoscopic endonasal management of prolapsed silicone tubes after dacryocystorhinostomy

BACKGROUND

Loss or prolapse of silicone tubes at the medial canthus may occur after dacryocystorhinostomy (DCR) surgery. Repositioning of the prolapsed tubes is often difficult and can necessitate early removal of tubes. The goal of this study was to determine the incidence of tube prolapse after DCR, review the methods used to reposition them, and identify the optimum management.

DESIGN

Retrospective, noncomparative, interventional case series.

PARTICIPANTS

A total of 205 adults patients who had DCR with intubation by a specialist lacrimal service in West London over a 3-year period.

METHODS

Patients with spontaneous tube loss or prolapse were identified from clinic attendance and case note review.

MAIN OUTCOME MEASURES

Incidence and timing of prolapse, techniques used for repositioning and success, whether prolapse recurred, and further intervention necessary.

RESULTS

Five (2.5%) had tube loss or prolapse or both, all within the first month after surgery. The tubes were repositioned initially in four patients, but prolapse recurred in two patients necessitating further intervention. Only nasal endoscopy enabled precise tube visualization and endonasal manipulation with eventual tube stability.

CONCLUSIONS

Tube prolapse is rare after DCR surgery. The tubes can be pushed back in, but prolapse may recur unless the endonasal aspect is addressed. The position of the tie or knots should be inspected endonasally and the tubes further secured if indicated. Repositioning is best managed with endoscopic assistance, which is a simple office procedure.

The value of nasal endoscopy after dacryocystorhinostomy

PURPOSE To determine the value of office nasal endoscopy after dacryocystorhinostomy (DCR). METHODS A prospective clinical observational study of consecutive adult patients after primary external or endonasal surgical DCR, both with intubation for nasolacrimal duct obstruction. Nasal endoscopy was used at the time of tube retrieval and six months after surgery to evaluate nasal pathology and ostium function. RESULTS Sixteen patients were examined. 5/16 (31%) had surgically induced nasal synaechiae; in 2/5 patients transnasal synaechiae occluded the ostium. Granuloma adjacent to the ostia in 2/16 (12.5%) did not impair function. There was no difference in the incidence of synaechiae or granuloma after endonasal compared to external DCR. In 3/16 (19%) endoscopy aided retrieval of tubes concealed by transnasal synaechiae or a narrow nasal space. Six months after surgery ostium function was positive in 12/16 (75%) using the functional endoscopic dye test; 13/16 (81%) patients had relief of epiphora with patent syringing; one had an alternative drainage route. CONCLUSIONS Nasal endoscopy after DCR i) identifies surgically induced nasal mucosal pathology, ii) assists in difficult retrieval of tubes and iii) assesses ostium function using the functional endoscopic dye test. The information obtained is adding much to our understanding of the effects of DCR at the lacrimal / sinus / nasal interface.

Pyogenic granuloma

A retrospective review of cases of pyogenic granuloma seen at the King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia between 1984-1991 is described. Epidemiology and the factors that led to the granuloma formation were examined and only cases documented histopathologically were included in the review. Of the 110 cases, 80% developed the granuloma at the site of the previous surgery (especially entropion repair, and dacryocystorhinostomy with a stent tube or with a Jones tube) while 20% did not have a prior surgery. Recurrence occurred in 7% and these patients were in the group who had a prior surgery. Surgical procedures lead to an increased tendency for the formation of pyogenic granuloma due to different mechanisms acting via a mechanical or chemical irritation and an inhibition of re-epithelialization.

A report of 131 cases of endoscopic laser lacrimal surgery

BACKGROUND

Despite the many advantages of endoscopic laser dacryocystorhinostomy, clinical data have been sparse, and the effectiveness of this procedure has not been fully evaluated.

METHODS

Among 127 patients (131 procedures) who underwent endoscopic laser lacrimal surgery, 92 procedures with longer than 3 months of follow-up were evaluated. The authors used endoscopic sinus surgery equipment, radiosurgical instruments, otodrill, microrongeur, holmium:YAG and contact neodymium:YAG lasers.

RESULTS

After the primary operation, 71 (77.2%) of 92 cases were symptom-free and had positive results on primary Jones dye test. With simple revision of failed cases, 88 (95.7%) of 92 cases were treated successfully.

CONCLUSION

Improvement of surgical technique and use of adequate surgical instruments were essential in increasing the rate of success. Endoscopic laser surgery is useful in treating patients with lacrimal passage obstruction, but a longer period of observation is necessary to confirm its effectiveness.

Pyogenic granulomas of the lacrimal sac

Eight cases of pyogenic granulomas of the lacrimal sac are reported. The clinical symptoms were consistent with chronic dacryocystitis which was unresponsive to previous probing and antibiotics. Extirpation of the sacs was done because of dacryocystocoele, pyocoele, or fistula formation through the skin. Trauma and inflammation were thought to have contributed to the growth of the pyogenic granulomas. The histopathological examination revealed nonspecific granulomas consisting of well vascularised, friable tissue of a myxomatous nature containing an infiltration of lymphocytes, plasma cells, and a few eosinophils. Over the granulomas an epithelial layer of cells is stretched showing no signs of dysplasia or neoplastic growth. The term 'lobular capillary hemangioma' has been suggested to describe lesions morphologically similar to those observed in the study. These masses made up 53.3% of a total of 15 lacrimal sac tumour biopsy specimens examined over a period of 10 years (1979-1989). The few reported cases of primary lacrimal sac tumour of non-epithelial origin suggest that they make up a large minority of the lacrimal sac tumours. A review shows that relatively few of these lesions have been described in recent English literature but these growths are probably not being as consistently reported as primary epithelial tumours.

Management of canalicular laceration

Although canalicular injuries are relatively common, controversy persists regarding indications for repair and the surgical methods that should be employed. In this review, these various treatment philosophies and techniques are analyzed in an historical and a contemporary context. The surgical anatomy, epidemiology and clinical presentation of canalicular injuries are discussed. Inconsistencies in current nomenclature regarding the surgical anatomy of canalicular lacerations are analyzed. Recent studies of lacrimal drainage in systems with monocanalicular obstruction are cited. Various surgical techniques in the repair of canalicular injuries are reviewed, including methods of identifying the medial lacerated lacrimal passages and the various lacrimal stents that have been used. The current popularity of silicone tubing as a lacrimal stent is reviewed. The various methods of stent placement and fixation are systematically categorized. Case series of canalicular repair reported in the literature are reviewed, and the results and complications are compared.