A comparison of two methods of punctal occlusion

A Simple Step-by-Step Guide to Permanent Punctal Occlusion with the Ophthalmic Burr and Suture Technique

The medical treatment of dry eye disease usually follows a step-wise approach to achieve clinical improvement, ranging from non-surgical interventions with intensive lubrication to permanent surgical punctal occlusion. While frequent lubrication is essential, the intense regime is often too burdensome and difficult to maintain at the required frequency. Punctal plugs are an invaluable alternative approach, but also have limitations, especially in conscious children, in whom inserting and re-inserting punctum plugs in clinic can be challenging. If a patient has permanent and severe dry eye disease and responded well to a trial of temporary punctal plugging, a permanent surgical solution should be considered next. Liu et al showed that a more successful, yet simple technique to achieve permanent occlusion is to combine de-epithelialising the punctum and ampulla with the immediate firm apposition of the de-epithelialised surface using a self-absorbable suture - with a success rate of 92% in a prospective study. This article demonstrates this technique step-by-step in an 8-year-old child with severe chronic dry eye disease following proton beam therapy for orbital rhabdomyosarcoma. She underwent this procedure with excellent results.

Long-term Outcomes of Punctal Cauterization in the Management of Ocular Surface Diseases

PURPOSE

To evaluate the long-term outcomes of surgical occlusion of lacrimal puncta using thermal cautery in the management of ocular surface diseases.

METHODS

We reviewed medical records of 80 consecutive patients from a single academic center who underwent punctal cauterization. Patient demographics, ocular history, symptoms, and signs of ocular surface diseases pre- and post-cauterization were recorded.

RESULTS

A total of 80 patients (171 puncta) were included, with an average age of 59 years and a follow-up duration of 27 months. The most common ocular morbidity was ocular graft-versus-host disease (n = 36), followed by primary keratoconjunctivitis sicca (n = 15). Indications for punctal cauterization included plug loss (n = 51), difficulty in plug fitting (n = 11), plug-related complications (n = 6), recanalization of previous cauterization (n = 7), and severe ocular surface disease requiring permanent punctal closure (n = 4). After punctal cauterization, the percentage of eyes with severe (21%) and moderate (25%) dry eye decreased significantly (8% and 19% at 3 months and 6% and 17% at 12 months, P = 0.0006). Fifty-four percent of patients reported improvement in their symptoms. The rate of recanalization was 21% during the follow-up period. The use of topical corticosteroids was associated with higher recanalization rate. Associated complications were limited to temporary pain and swelling.

CONCLUSIONS

Punctal cauterization is an effective modality in treating severe ocular surface diseases in patients who repeatedly lose punctal plugs, and it can be easily performed in a clinic setting without major complications. However, cauterization may need to be repeated in up to a quarter of cases because of recanalization.

A new surgical approach for punctal occlusion using fibrous tissue from under the lacrimal caruncle

Purpose

Surgical punctal occlusion is indispensable for the treatment of severe dry eye in cases where punctal-plug insertion is not applicable due to an enlarged or deformed punctum. However, permanent punctal occlusion is difficult in some cases. In our aim to establish a more reliable punctal occlusion, we have devised a new surgical approach for punctal occlusion.

Patients and methods

This study involved 20 puncta of 12 eyes of 12 patients (1 male and 11 females; mean age: 65.2 years) with severe aqueous-tear-deficient dry eye. A new surgical procedure for punctal occlusion using fibrous tissue from under the lacrimal caruncle into the diathermy-induced deepithelialized canaliculus as supporting tissue for punctal closure was performed. In all patients, the assessment of eye symptoms, as well as the condition of punctal occlusion by slit-lamp biomicroscopy, tear volume (tear-meniscus radius [TMR] measurement by meniscometry), the condition of precorneal tear film (graded by interferometry [IG]), measurement of fluorescein breakup time (FBUT), and scoring of ocular surface staining (fluorescein score of area [FSA] and density [FSD], and lissamine green score [LGS]) were performed, and the preoperative and 6-month-postoperative values were compared.

Results

In regard to the postoperative improvement of symptoms, 11 patients showed remarkable improvement, 1 patient showed improvement, and no reopening of the closed punctum was found in any patient. Test values were all significantly improved post surgery (all: P<0.05) as compared to those prior to surgery (respective values [mean ± SD], and the pre- and postoperative P-values were: TMR (mm) [0.18±0.08; 0.56±0.28, P=0.002], IG [4.3±0.9; 2.7±0.8, P=0.009], FBUT [0.4±0.6; 4.1±2.9, P=0.004], FSA [1.6±0.7; 0.7±0.9, P=0.03], FSD [2.7±0.7; 0.6±0.7, P=0.003], and LGS [5.1±2.7; 1.1±2.1, P=0.005]). Moreover, no postoperative complications were observed.

Conclusion

The findings of this study showed that our novel surgical procedure for punctal occlusion is highly successful and that it results in improved and more complete punctal occlusion.

Current concepts of ocular adnexal surgery

Ophthalmic Plastic and Reconstructive Surgery is a specialized area of ophthalmology that deals with the management of deformities and abnormalities of the eyelids, lacrimal system and the orbit. An ophthalmoplastic surgeon is able to identify and correct abnormalities of the ocular adnexae such as ectropion, lid retraction, conjunctival scarring with severe entropion, that can cause secondary ocular surface disorders; manage patients with watering eye, and when needed intervene with a dacryocystorhinostomy by external or endonasal approach and moreover minimize disfigurement following enucleation or evisceration and prevent further corneal damage, alleviate complains of tearing and grittiness, but also cosmetic complaints in patients with Graves' orbitopathy. Aim of this manuscript was to review current established and recently evolving surgical procedures.

Punctal and canalicular anatomy: implications for canalicular occlusion in severe dry eye

PURPOSE

To characterize the microscopic anatomy of the lacrimal punctum and canaliculi in relation to the tarsal plate, muscle of Riolan, and Horner muscle; and to report a novel technique to excise the horizontal canaliculus in severe dry eye patients.

DESIGN

Observational anatomic study and a retrospective case series.

METHODS

The microscopic anatomy was studied in 86 eyelids of 25 cadavers (age range: 45-96 years, mean: 79.5 years). Surgery was performed on 18 canaliculi of 7 patients with dry eyes (age range: 37-69 years, mean: 59.9 years). In the microscopic study, 32 eyelids were incised sagittally, 38 eyelids were incised horizontally (1 mm from the eyelid margin), and 16 eyelids were incised parallel to the tarsal plate. All specimens were stained with Masson trichrome. In the surgical group, probe-guided horizontal canalicular excision with incision of the Horner muscle to the lateral edge of the lacrimal caruncle was performed. Both canalicular stumps were cauterized.

RESULTS

In the microscopic anatomic study, the punctum and the vertical canaliculus were part of the tarsal plate with the muscle of Riolan, whereas the horizontal canaliculus was surrounded by the Horner muscle. In the surgical group, all the operated canaliculi were completely occluded without recanalization 12 months postoperatively. No complications were recorded.

CONCLUSIONS

Based on microscopic anatomic findings that the lacrimal punctum and the vertical canaliculus are part of the tarsal plate, and that the horizontal canaliculus is surrounded by the Horner muscle, excision of the horizontal canaliculus may be an effective technique to treat patients with severe dry eyes.

[Surgical treatment of paralytic lagophthalmos]

Impairment of the peripheral or central part of the facial nerve causes an ipsilateral peripheral facial nerve paresis. It is quite a common syndrome and affects 20-35 persons per 100,000 per year in Western Europe and the United States. A possible complication of facial palsy is paralytic lagophthalmos with aesthetic and functional impairment for the patient. Beside primary nerve reconstructive procedures plastic-reconstructive procedures play a major role in correcting paralytic lagophthalmos. The eyebrow, upper and lower lids, medial and lateral lid angle as well as the lacrimal system need to be seen as functional units and can be corrected with local surgical procedures. Restoration of eye closure is the most important goal in treating the affected eye. Due to the significant aesthetic limitations and resultant psychological stress for the patient cosmetic aspects must be included in the surgical concept.

Science and Strategy for Preventing and Managing Corneal Ulceration

ABSTRACT Corneal ulcers can cause significant loss of vision from scarring and astigmatism, but rapid management can limit the destruction and improve outcomes. Infectious ulcers usually resolve with antimicrobial treatment. Noninfectious ulcers, however, present a diagnostic and therapeutic challenge. They can often be resolved by eliminating toxic medications and providing surface support with lubrication and collagenase inhibitors, but resistant ulcers may need more aggressive therapy with bandage contact lenses, tarsorrhaphy, or autologous serum. Ulcers impending perforation require urgent surgical management (e.g., tissue glue, conjunctival flaps, or keratoplasty). Topical steroids are useful when the ulceration is secondary to inflammatory mediators, but they are contraindicated in corneal melts with minimal inflammation, such as those associated with Sjogren syndrome. Systemic immunomodulation is required in addition to topical therapy in the presence of autoimmune disease. Understanding of the pathological processes that occur in different types of corneal ulcers is essential to formulation of a logical and effective treatment plan. Newer, more targeted treatment modalities may offer treatment options that have greater efficacy and fewer adverse effects.

A Permanent and Reversible Procedure to Block Tear Drainage for the Treatment of Dry Eye

PURPOSE

To describe a technique of canalicular ligation and report observations on 59 consecutive surgeries.

METHODS

Retrospective, non-comparative case series of canalicular ligation by 3 surgeons over a 7-year period.

RESULTS

Fifty-nine eyelids of 29 patients (2 men and 27 women) underwent canalicular ligation for the treatment of severe dry eyes. Patient age ranged from 34 to 90 years. Average length of follow-up was 20 months. There were no complications. Ninety-one percent of patients noted an improvement in their symptoms. Two patients developed symptomatic epiphora more than 1 year postoperatively and both underwent successful reversal.

CONCLUSIONS

Canalicular ligation is an effective technique for punctal occlusion in patients with severe dry eyes. It combines surgical ease with excellent cosmetic outcomes.

Preventive effect of lacrimal occlusion on topical timolol-induced bronchoconstriction in asthmatics

AIM

To evaluate the potential preventive role of lacrimal occlusion on the topical timolol-induced bronchoconstriction in asthmatics.

METHODS

This was a prospective and single-masked study. Fourteen volunteer subjects with asthma were included. Collagen plugs were inserted into both canaliculi on one side to inhibit lacrimal drainage. The effect of lacrimal occlusion on lung function tests was measured before and 60 min after the instillation of a timolol drop in unplugged and plugged eyes. The spirometric measurements include forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC, and mid expiratory flow-rate (FEF25-75).

RESULTS

The timolol (0.5%) drop administration into the eye caused a significant decrease in pulmonary functions in patients with asthma in whom the lacrimal punctae had not been occluded by collagen plug. P values were 0.008 for FVC and 0.001 for FEV1 and FEF25-75. The occlusion of the lacrimal duct by intracanalicular plugs significantly reduced this decrease in pulmonary function. P values were 0.6 for FVC, 0.8 for FEV1, and 0.5 for FEF25-75. The lacrimal occlusion did not affect heart rate and blood pressures. Three subjects complained of epiphora.

CONCLUSIONS

Lacrimal occlusion with intracanalicular collagen plugs may almost completely prevent the bronchoconstriction caused by topical timolol in asthmatics by inhibiting or decreasing systemic absorption of the medication.

Surgical punctal occlusion: a prospective study

AIMS

To assess the outcome of a surgical punctal occlusion technique.

METHOD

Prospectively, 11 consecutive patients (26 puncta) with severe dry eyes recalcitrant to maximal medical therapy underwent permanent punctal occlusion at a tertiary eye care centre between January 1999 and December 2000. The epithelium of the punctum and the vertical portion of the canaliculus was removed with a corneal rust ring burr. The bared punctum-canaliculus complex was closed with a 6-0 chromic suture. Success was measured by the complete functional occlusion of the punctum, tear function tests, and patients' response.

RESULT

Five males and nine females, aged 26-77 enrolled in the study with three patients later excluded. As of November 2001, the remaining 11 patients had follow up ranging from 14 to 34 months (mean 24 months; median 24 months). 24 puncta (or 92%) remained occluded, including four puncta which showed anatomical reopening. Seven out of 11 patients (63.6%) stated they had symptomatic improvement regardless of their objective findings.

CONCLUSION

This technique resulted in a 92% permanent occlusion of the puncta and compared favourably with other reported techniques. Punctal occlusion does not appear to correlate well with Schirmer tests, the frequency of lubrication, and/or subjective feelings in these patients.

The clinical efficacy of silicone punctal plug therapy

PURPOSE

To evaluate the clinical efficacy and safety of silicone punctal plugs in various ocular surface disorders.

PATIENTS AND METHODS

Medical records of patients who underwent silicone punctal plug insertion from January 1996 to November 2000 were retrospectively reviewed. The clinical data collected included sex and age of the patients, indications for plug insertion, symptoms, corneal fluorescein staining and frequency of lubricant use at baseline and at 4 +/- 2 weeks after the insertion, location (upper versus lower punctum), initial versus replacement plug, spontaneous extrusion or removal of the plug, and percentage of complications and punctum cauterization.

RESULTS

There were 203 eyes of 153 patients (126 women and 27 men) in the study group. The total number of silicone punctal plug procedures was 312. Dry eye syndrome was the most common indication for punctal plug treatment (127 eyes, 62.5%), followed by epitheliopathy after penetrating keratoplasty (32 eyes, 15.8%). The symptoms improved in 150 (73.9%) of 203 eyes at 4 +/- 2 weeks' follow-up. The mean score of the fluorescein staining of the cornea was reduced from 2.7 +/- 0.1 to 1.3 +/- 0.1 with silicone punctal plug treatment at 4 +/- 2 weeks' follow-up. This reduction was statistically significant (p< 0.01). The overall success rate at 4 +/- 2 weeks follow up was 76.8%. The frequency of the lubricant use was significantly decreased with punctal plug treatment (p< 0.001). Considering all plugs, the estimated probability of plug retention was 49.4% with 85.1 +/- 7.3 weeks as the mean survival time. There was no statistical difference in plug retention rates between lower (49.6%) and upper (48.7%) plugs (p= 0.15). Retention rate of first plugs (53.5%) was significantly higher than that of second plugs (32.0%) (p= 0.05). The spontaneous total extrusion of silicone punctal plug was the most common complication in our study (158 plugs, 50.7%). The plug was removed in 14 eyes (14 plugs, 6.9%) because of epiphora in 11 eyes and conjunctival erosion in three eyes. The percentage of punctum cauterization performed in our population was 10.8%.

CONCLUSIONS

Punctal plug insertion is a simple, effective, safe, and reversible method to treat aqueous tear deficiency and other ocular surface diseases, such as epitheliopathy after penetrating keratoplasty, superior limbic keratoconjunctivitis, neurotrophic keratitis, recurrent corneal erosions, and toxic epitheliopathy not controlled by lubrication with preservative-free tears. However, spontaneous extrusion of silicone plug occurs commonly. Careful choosing of the optimal plug size and close follow-up are recommended to ensure the success of the treatment.

Corneal topographical study of the effect of lacrimal punctum occlusion on corneal surface regularity in dry eye patients

PURPOSE

To compare topographic indices of surface regularity in dry eye patients and in normal subjects (controls) and to investigate the short-term effect of lacrimal punctal plugs on these indices in dry eye patients.

METHODS

The surface regularity index (SRI) and surface asymmetry index (SAI) of the TMS-2 corneal topographic modelling system were used to evaluate corneal surface regularity in 20 eyes of 10 dry eye patients before and after the insertion of Herrick silicon lacrimal plugs (Lacrimedics, Rialto, CA, USA) and in 24 eyes of 12 normal subjects as controls.

RESULTS

SRI and SAI were significantly lower in controls than dry eye patients (p=0.00). Median SRI was 1.72 in dry eye patients before punctal occlusion and 0.525 in the control group. Median SAI was 1.305 in dry eye patients and 0.240 in controls. After lacrimal punctal occlusion, Schirmer test results and fluorescein breakup time increased in nine patients and remained the same in one patient. After occlusion, the SRI decreased in 9 eyes, and increased in 11 (p=0.970); SAI decreased in 13 eyes and increased in 7 (p=0.135).

CONCLUSIONS

No significant change in topographic indices of corneal surface irregularity could be detected in severe dry eye patients with lacrimal punctal plugs in the short-term follow-up.

The value of tear film breakup and Schirmer's tests in preoperative blepharoplasty evaluation

The authors published their article on the value of tear film breakup and Schirmer's tests in preoperative blepharoplasty evaluation in 1989. The purpose of this update is to expand the original article in light of refinements and experiences in subsequent years. It was concluded in the 1989 article that the abnormal tear film breakup and Schirmer's tests were not good predictors of possible postblepharoplasty dry eye complications. It was concluded in the review that the anatomy and the history including scleral show, lagophtholmus, negative vector, snap test, previous surgery, increased blinking, dryness, grittiness and pain were more important predictors of postoperative dry eye problems than the ocular tests. The authors' opinion remains so, and they do less preoperative tear film testing and place more emphasis on the history and the anatomy as predictors of potential problems. In this follow-up to the 1989 article, the authors include a survey from several surgeons as to how they evaluate their patients for elective aesthetic blepharoplasty, which in large measure confirms the authors' practice.

The perils of permanent punctal plugs

PURPOSE

To describe previously unreported complications associated with permanent lacrimal punctal plugs.

METHOD

Five oculoplastic practices reviewed patients referred to them over the preceding 2 years for permanent lacrimal punctal plug complications.

RESULTS

In 12 patients, 14 lacrimal punctal plugs migrated distally within the lacrimal drainage system, causing symptoms and necessitating surgical removal.

CONCLUSION

Luxation of permanent punctal plugs into the distal lacrimal drainage system can occur, sometimes requiring complex surgical intervention.

Reversal of iatrogenic punctal and canalicular occlusion

PURPOSE

Significant epiphora occasionally develops after therapeutic punctal occlusion. When this complication occurs from combined scarring of the upper and lower proximal canaliculi, correction usually requires a conjunctivodacryocystorhinostomy.

METHODS

The authors describe a new microsurgical technique for reversing iatrogenic occlusion of both the upper and lower canaliculi. The relatively straightforward reconstruction uses the remaining canalicular system to create new tear outflow sites.

RESULTS

This procedure has been used successfully to repair eight of nine consecutive cases of iatrogenic canalicular occlusion, with an average follow-up of 2 years.

CONCLUSION

Iatrogenic canalicular occlusion can be reversed microsurgically without a conjunctivodacryocystorhinostomy.

The effects of nasolacrimal canal blockage on topical medications for glaucoma

Twenty patients with primary open angle glaucoma who have been treated with identical antiglaucoma eye drops in both eyes were examined. Silicone punctal plugs were used to occlude the inferior punctum of one eye, in order to block the nasolacrimal canal. The intraocular pressures and effects of the medical therapy before and after punctal occlusion were compared. Punctal occlusion significantly decreased the intraocular pressure with an average of 2.00 +/- 0.43 mmHg in the plugged eyes (p < 0.001). The intraocular pressure in the unplugged control eyes did not change significantly (p > 0.05) after punctal occlusion of the fellow treated eye.

Treatment of dry eye by blocking the lacrimal canaliculi

Occlusion of the lacrimal canaliculi improves the objective signs and subjective symptoms of dry eye. In this review, methods of occlusion are classified as surgical, thermal and tamponade. Surgical methods include dacryocystectomy, canalicular ligature, canalicular offset, canalicular excision, transfer of the punctum to dry dock, punctal tarsorrhaphy and punctal patch. Thermal methods include cautery, diathermy and laser burn. Tamponade methods use absorbable inserts of hydroxypropyl cellulose, gelatin, collagen and catgut, and nonabsorbable inserts of silicone (punctum plugs, canalicular plugs), polyethylene, cyanoacrylate, and others. The characteristics of all these methods are analyzed.

Cannalicular occlusion with cyanoacrylate adhesive: a new treatment for the dry eye

One hundred microlitres (0.1 ml) of N-butyl cyano-acrylate adhesive was injected into the inferior cannaliculus of 8 patients with dry eye. The adhesive induced total (upper and lower) cannalicular occlusion in each patient which has not resolved to date (mean follow-up 15.2 months, range 11-19 months). Complications were minor and not specific to use of this adhesive. It is hoped that its ultimate reversibility will make the technique suitable for younger patients with dry eye.

A prospective, randomized comparison of thermal cautery and argon laser for permanent punctal occlusion

Permanent punctal occlusion was performed by two techniques on 27 patients (73 puncta). Patients were randomly assigned to be treated with either thermal cautery or argon laser for keratitis sicca. Follow-up assessment disclosed that the puncta to which thermal cautery was applied remained closed significantly longer than those to which laser treatment was applied (P < .05, log-rank test). Using time to recanalization of a punctum as the end point, we found a long-term advantage of thermal cautery over argon laser treatment.

Rapid atraumatic nail plate removal using the cordless cautery unit

This article describes the use of a handy, battery-powered, thermocautery unit to cut through the nail plate when performing dermatologic surgery involving nail tissue. Thermocauterization of keratin is a simple, atraumatic method of removing portions of the nail plate, so that the underlying soft tissue may be biopsied or treated. The units are inexpensive and safe to operate.