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

Retrograde circular intubation for the failed passage of a pigtail lacrimal probe in the management of non-specific inflammatory punctum occlusion

PURPOSE

to describe the role of Retrograde Circular Intubation (RCI) technique in the management of non-specific inflammatory punctum occlusion (NIPO).

METHODS

patients with NIPO who failed conservative treatment underwent 3-snip mini rectangular punctoplasty with adjunctive use of circular canalicular intubation. When the use of the pigtail lacrimal probe was not safely possible, circular intubation was accomplished by the RCI technique. A loop of 6/0 polypropylene suture was introduced into the upper lacrimal drainage system in a retrograde manner from the nose by pulling its two ends up from the puncta with 2/0 polypropylene sutures. The latter were placed between the punctum and the nose by a canulated probe or a Ritleng lacrimal probe (https://youtu.be/n31NKdWIUJM).

RESULTS

Thirty-two patients (64 eyes) underwent circular intubation as an adjunct to the 3-snip mini rectangular punctoplasty. In 9 eyes (14%) the pigtail lacrimal probe couldn't pass safely across the upper lacrimal drainage system. Circular tube insertion was still possible with the RCI technique. Circular tubes were removed after two months. Over two years of follow-up, 27 patients (84%) maintained a patent punctum.

CONCLUSION

NIPO not responding to conservative measures can be managed surgically under an umbrella of medications. Circular canalicular intubation with its excellent stability and low morbidity is a valuable adjunctive to the 3-snip mini rectangular punctoplasty. When the passage of the pigtail lacrimal probe fails, circular tubes can be inserted with the RCI technique.

Long-term Results of Punctoplasty With Canalicular Triangular Flap in Punctal Stenosis

PURPOSE

The aim was to describe the punctoplasty technique with canalicular triangular flap, and present the long-term results of the technique in patients with inferior punctal stenosis.

METHODS

The files of the patients who were diagnosed with punctal stenosis grade 0, 1, and 2 and underwent a canalicular triangular flap were evaluated retrospectively. The study was approved by the local ethical committee of the University of Health Sciences, Prof. Dr. Cemil Tascioglu City Hospital, Istanbul. The demographic data, symptoms, prior interventions, punctal stenosis grading, associated eye pathologies, fluorescein clearance test, Munk score, and follow-up time were recorded. The puncta were evaluated biomicroscopically, and photographs were taken at each visit. The patients with at least 6 months of follow-up were included in the study. The loss of epiphora symptom, positive dye disappearance, and puncti ≥grade 3 opening were accepted as a success.

RESULTS

A hundred and nine inferior puncti of 64 patients with symptoms of epiphora and punctal stenosis diagnosis were included in the study. Thirteen eyes were excluded as they were diagnosed to have punctal atresia or canalicular stenosis of a variable degree beyond punctum. The rest 96 eyes of 55 patients-65 eyes of 36 females and 31 eyes of 19 males-were included in the study as having pure punctal stenosis. The mean age of the patients was 64.3 ± 9.01 years (40-88 years). Forty-one patients had bilateral and 14 patients had unilateral punctal stenosis. Sixty-six were grade 1, and 30 were grade 2. Epiphora was the most commonly reported symptom.The mean follow-up time was 21.17 ± 10.5 months (6-46 months). In 76 (79.1%) eyes of 96, Munk score was 0 and in 15 (15.6%) eyes, Munk score was 1. Anatomical success as having puncta larger than grade 2 was recorded in 97.9%, and functional success was recorded in 94.6% of anatomically successful eyes. No restenosis was recorded in any punctum.

CONCLUSION

Although the techniques of 1-snip, 2-snip, 3-snip, and 4-snip punctoplasty are performed with variable success rates in punctal stenosis patients, there is always a risk of restenosis due to the incision of the flap and unpredictability of the way the tissues will epithelize. In the canalicular triangular flap technique, the canalicular mucosal flap is preserved, and the continuity of the lacrimal mucosa with conjunctiva is provided, which utilizes appropriate re-epithelization of the wound edges, resulting in a wide punctal opening for the upper lacrimal system in the long term.

A major review on punctal stenosis: Part II: Updated therapeutic interventions, complications, and outcomes

We continue our review of on punctal stenosis by providing a detailed discussion of management modalities, their complications, and outcomes. There is a significant change in the understanding of punctal and peripunctal anatomy, puncto-canalicular junction, and the lacrimal pump mechanisms. While the snip punctoplasty procedures are still practiced, there is an increasing trend toward nonincisional procedures. The nonincisional procedures in select cases appear to be equally effective as the incisional ones. Although simple to use, punctal plugs never became the mainstay of treatment because of design issues and the inability to address the coexisting canalicular stenosis. Placing stents only in the lower punctum in cases of upper and lower punctal stenosis should be discouraged, and management needs to address punctal stenosis and not which punctum is involved. Several types of stents are used in the management of punctal stenosis, mostly based on surgeon's preference. The benefits of adjuvant mitomycin C are uncertain. In view of literature on how stent biofilms can themselves cause chronic inflammation, placing them for prolonged periods should be reviewed and debated. Enhanced understanding of the molecular pathogenesis of punctal stenosis and addressing the current controversies in management would help standardize the therapeutic interventions available in the lacrimal armamentarium.

Pigtail with self-retaining bicanalicular intubation combined with Mitomycin C for the treatment of acquired lower punctal stenosis

BACKGROUND

The pigtail was used to create an opening at the lower punctal site in grade 0 stenosis with insertion of self-retaining tube and Mitomycin C (MMC).

METHODS

The patients with acquired lower punctal stenosis (grade 0) were divided randomly into equal groups, Group A: were treated with pigtail and MMC 0.02% and Group B: were treated with pigtail alone. The pigtail was inserted through the upper punctum until its tip reached the occluded punctum, this site was incised with a scalpel (No. 11). A self-retaining bicanalicular tube was then placed.

RESULTS

Results of 36 eyes from 26 patients were included. No differences were observed between both groups regarding epiphora score, FDD test and punctal size preoperatively. The postoperative epiphora score, there were significant differences at 1 month (P = 0.035), 3 months (P = 0.005), and 6 months after removal (P < 0.001). The FDD test, there were significant differences at 6 months (P = 0.045), 1 month (P = 0.021), 3 months (P = 0.012), and 6 months post tube removal (P = 0.005). The punctal size, both groups differed at 1 month (P = 0.045), 3 months (P = 0.03), and 6 months post tube removal (P = 0.005). Only one case (5.5%) at each group showed extrusion of the tube.

CONCLUSION

The pigtail probe, bicanalicular stent and MMC can be an effective method in treatment of severe punctal stenosis.

A major review of punctal stenosis: Updated anatomy, epidemiology, etiology, and clinical presentation

We aim to provide a detailed and updated literature review on the epidemiology, etiology, clinical presentations, histopathology, and ultrastructural features of punctal stenosis. There are inconsistencies in the definition and staging of punctal stenosis. While advanced optical coherence tomography imaging techniques have revolutionized the way the punctum and vertical canaliculi are assessed or monitored following treatment, the planes of measurement to characterize punctum anatomy need to evolve further. The current criteria for diagnosing and grading punctal stenosis are inadequate and based on empirical clinical findings. There is increasing evidence of the role of lymphocytes and myofibroblasts in the pathogenesis of punctal stenosis. There is a need for a uniform assessment of punctal stenosis and a uniform reporting of severity that would help standardize the several management options available in the lacrimal armamentarium.

Topical cyclosporin A 0.05% eye drops for management of symptomatic acquired punctal stenosis: a prospective, controlled clinical study

PURPOSE

To study the efficacy of cyclosporin 0.05% eye drops in the management of grade 1 and 2 acquired punctal stenosis and to compare the results with the clinical outcomes of mini-Monoka insertion.

METHODS

A prospective, controlled, interventional clinical study includes all patients (16 years and older) with symptomatic epiphora and diagnosed with grade 1 or grade 2 acquired punctal stenosis. All patients undergo punctal dilatation, canalicular probing, and nasolacrimal duct irrigation. Afterwards, patients are divided into two groups: Group A: patients receive only medical treatment in the form of topical 0.05% cyclosporin (Restasis®, Allergan Inc.) twice daily for 6 months. Group B: patients receive mini-Monoka stent insertion in the lower canaliculus for 6 weeks. Outcome measures are changes in Munk scoring, grading of the punctum, and functional and anatomical success. Functional success is defined as Munk score 0 to 1 and FDDT grade 0-2. Anatomical success is defined as grade 3 punctum.

RESULTS

Forty-two patients are included in the study, with 21 patients in each group. There were no significant differences in the Munk score between the two groups before treatment; however, group B had a significantly higher mean rank at 6 months after treatment. After treatment, the punctal size was significantly larger in group B at 4 weeks and 3 months. However, no significant difference in punctal size was detected at 6 months after treatment between the two groups.

CONCLUSION

Application of cyclosporin 0.05% eye drops is a simple and efficient non-interventional method in the management of grade 1 and 2 acquired punctal stenosis.

An effective approach for the treatment of severe punctal stenosis: Bicanalicular silicone tube intubation with pigtail probe

PURPOSE

To evaluate the results of using a pigtail probe to open the inferior punctum followed by bicanalicular silicone tube intubation in patients with severe acquired punctal stenosis.

METHODS

Forty-one eyes of 25 patients with severe inferior punctal stenosis admitted to our tertiary care center were included in the study. The degree of epiphora was determined using the Munk score and the fluorescein disappearance test. The inferior punctum was located and opened by entering the superior punctum with a pigtail probe. Then, bicanalicular silicone tube intubation was performed. The silicone tube was removed after six months. A Munk score of 0 or 1 and a fluorescein disappearance test score of 1 and 2 were considered a complete success.

RESULTS

Ten (40%) patients were male, and 15 (60%) were female. The mean age was 60.4±15.5years. One year after the surgery, epiphora was absent in 18 eyes (43.9%) (Munk score grade 0) and rarely seen in 9 eyes (22%) (Munk score grade 1). At the one-year follow-up, the fluorescein disappearance test score was stage 1 (<3min) in 21 eyes (51.2%) and stage 2 (3-5min) in 13 eyes (31.7%). There was a statistically significant difference between the preoperative and one-year postoperative test results (P<0.001).

CONCLUSION

In cases with severe punctal stenosis, a pigtail probe is an effective method for locating and opening the punctum, and punctal opening and prevention of restenosis were achieved by a bicanalicular stent.

Age-Related Changes in the Lacrimal Punctum Morphology in a Normal Population: Punctum Update (PUP) Study-Paper 1

PURPOSE

To define the clinical and optical coherence tomography (OCT) morphology of the lacrimal punctum and assess the age-related changes across 8 decades of life in a normal population.

METHODS

A total of 1310 high-magnification slit-lamp, Fourier-domain OCT (FD-OCT), and optical coherence tomography angiography (OCTA) images were obtained from 320 puncta of normal asymptomatic individuals representing the Indian population. The punctum and peri-punctal area were defined with the help of 2 rims (inner punctal rim and outer punctal rim ) and 3 zones (white zone [Wz], separation zone [Sz], and peri-punctal vascularity). FD-OCT images were used to measure the external punctal diameters and internal lacrimal punctal diameters and the reflectivity patterns of the 3 punctal layers. OCTA was used to assess the branching and extent of vascular networks.

RESULTS

The upper puncta were narrower and more circular than the lower puncta across the decades. The elevation of the punctal papilla began in the upper puncta in the fifth decade, involved the lower puncta in the sixth decade, and gradually became exaggerated by the eighth decade. A typical punctal narrowing in previously wide puncta began to appear in the sixth decade of life, peaks in the seventh decade, and reverses gradually and spontaneously by the end of the eighth decade of life. The third and fourth decades saw a narrowing of the Sz with prominent vascularity crossing the Sz to reach the Wz. The Sz became indistinct in the fifth and sixth decades of life. The FD-OCT showed gradual thickening and dominance of the fibrous layer from the fifth to eighth decade of life. The clinical vascularity in the peri-punctal region increases from the third decade onwards, with vascular networks becoming increasingly dense, intricate, and branched as the age progresses.

CONCLUSION

The present study defined and characterized the involutional changes in a normal population's first-eighth decades of life. Significant morphological changes were noticed across the different age groups with several clinical implications.

Management of Bi-Punctal Stenosis by One-Snip Punctoplasty Combined with Silicone Intubation

PURPOSE

Assessment of the efficacy of upper and lower one-snip punctoplasty combined with silicone tube stenting for the management of bi-punctal stenosis.

METHODS

Prospective interventional case series of 20 patients (33 eyes, 66 puncta) with epiphora due to bi-punctal stenosis. All the patients were subjected to bi-punctal 1-snip punctoplasty with silicone intubation, and the tube was kept for 3 months. The follow-up was extended for 6 months after tube removal. The resolution of epiphora with patent puncta was considered as a complete functional success, while patent puncta with residual epiphora were considered as an anatomical success.

RESULTS

The mean patients' age was 41.3 years and 55% were females. Grade 0 puncta were found in 9.1%, and grade 1 represented 39.4%, while 51.5% had grade 2 puncta. Silicone tube was removed after an average period of 12.1 ± 2.7 weeks. Complete functional success was reported in 90.9% while anatomical success was noticed in 97%.

CONCLUSION

One-snip punctoplasty combined with 3 months of silicone intubation can be considered in the management of bi-punctal stenosis achieving high success rates with a minor discrepancy between functional and anatomical outcomes.

Routine punctoplasty: isn't it time we preserved the integrity of the punctum?

Punctoplasty is a common procedure in the management of punctal stenosis and was first described by Sir William Bowman in 1853. Several types of punctoplasty are described, and include 1-snip, 2-snip, triangular 3-snip, rectangular 3-snip and 4-snip procedures. The understanding of the anatomy and physiology of the punctum has greatly improved in the last decade aided by electron microscopic and molecular techniques. The use of minimally invasive modalities for primary cases is on the rise with successful preservation of the physiological functions of the punctum and canaliculus. The paper reviews the current anatomical and physiological evidence to present an alternative perspective. Given our evolving understanding, it may be time to debate the practice of performing routine punctoplasty.

Proximal lacrimal obstructions: a review

PURPOSE

The aims of the review are to summarize the aethiopathogenesis, management and outcomes of different treatments of proximal lacrimal obstructions.

METHODS

An electronic database (PubMed, MEDLINE and Google Scholar) search of all articles written in English and non-English language with abstract translated to English on proximal lacrimal obstructions was performed. The articles were reviewed along with their relevant cross references. Data reviewed included demographics, presentations, investigations, management, complications and outcomes.

RESULTS

Punctoplasty is as effective as punctal dilatation with monocanalicular or bicanalicular stent in case of punctal stenosis. Dacryocystorhinostomy with retrograde intubation is more effective in case of proximal canalicular obstructions than in case of mid-canalicular obstructions. Trephination and intubation is effective in both mid and distal canalicular obstructions in patients with no associated nasolacrimal duct obstruction. Canaliculodacryocystorhinostomy has a specific indication in case of proximal common canalicular obstruction. Bypass surgery is the preferred treatment if there is no residual patency, however surgical success may not match patient satisfaction.

CONCLUSION

Optimal choice of surgical method depends on identification of the site of obstruction. Mini-invasive techniques should be avoided in cases that would only benefit from standard surgical treatment.

Use of Lacrimal Symptoms Questionnaire After Punctoplasty Surgery: Retrospective Data of Technical Strategy

ABSTRACT

The goal of this study is to evaluate postpunctoplasty symptoms with lacrimal symptoms questionnaire (Lac-Q). A retrospective study was conducted on 31 patients (14 men and 17 woman) with a diagnosis of canalicular stenosis: 26 patients with unilateral occlusion and 5 patients with bilateral occlusion. The Lac-Q was administered preoperative and at 1, at 3, and at 6 months following the surgery. Moreover, the Lac-Q questionnaire was administered by an independent observer (SI). The mono-lateral and bilateral postoperative Lac-Q score showed a significant improvement of symptoms at 1, 3, and 6 months than the preoperative results. The Lac-Q questionnaire is a way to evaluate the quality of outcomes after punctoplasty surgery. In this study, all patients showed a significant improvement of symptoms after surgery.

Management of proximal lacrimal obstructions: a rationale

PURPOSE

To identify a rationale for correct surgical treatment of proximal lacrimal obstructions.

METHODS

Retrospective review of 775 consecutive patients (974 eyes) with proximal lacrimal obstructions, operated on with customized surgery by a senior surgeon (FMQL) from January 2003 to December 2018.

RESULTS

In case of punctal stenosis, punctoplasty was as effective as punctal dilatation with monocanalicular or bicanalicular stent (p > 0.05). In proximal canalicular obstructions, failure rate of dacrocystorhinostomy with retrograde intubation (R-DCR) was significantly higher in case of false inferior passage creation than in case of no false passage creation (p = 0.02). In mid-canalicular obstructions failure rate of R-DCR was 41.3%, and bypass surgery with Jones tube at second stage was likely. Trephination and monocanalicular intubation, performed in selected cases, had a failure rate respectively of 16.6% and 21.7% in mid and distal canalicular obstructions. Canaliculodacryocystorhinostomy (CDCR) was successful in 77% of cases of proximal common canalicular obstruction. Bypass surgery is the treatment of choice in case of no residual patency, and rates of tube extrusion were significantly reduced with the use of StopLoss Jones tubes (SLJT) (1.7%) with respect to standard tubes (12%), (p = 0.04, Fisher's exact test).

CONCLUSION

Patient history and accurate diagnosis of the site of obstruction are essential for a correct surgical choice. Less invasive techniques as trephination and intubation may be effective, but should be reserved to patients with no associated lower lacrimal obstruction. Further studies require specific randomized clinical trials, and a standardized protocol adopted by different clinical centres.

Medical treatment of inflammatory punctual stenosis monitored by anterior segment optical coherence tomography

AIM

To evaluate the role of medical treatment in the management of inflammatory punctum stenosis guided by spectral domain anterior segment optical coherence tomography (OCT).

METHODS

This prospective study included 60 patients complaining of epiphora due to inflammatory punctual stenosis. They were divided into two groups: Group A (30 patients) treated with a combination of preservative free hydrocortisone sodium phosphate 3.35 mg/mL eye drops, and preservative free artificial tears based on sodium hyaluronate, polyethylene and propylene Glycol; Group B (30 patients) treated with the same preservative free artificial tears only. Thirty normal subjects were included for comparison of pre-treatment anatomical parameters. Before starting treatment, all patients underwent anterior segment assessment including slit lamp examination, measurement of intraocular pressure (IOP), fluorescein dye disappearance test, and measurement of the outer punctum diameter (OPD) by Spectral domain anterior segment OCT. All assessments were repeated at each follow up done at 1 and 3mo later, together with subjective evaluation of patient's satisfaction of the treatment outcome by simple rating questionnaire.

RESULTS

Punctual diameter increased significantly with treatment in both groups (P<0.0001); although the widening was more in Group A as compared to group B (16.2% vs 8% of the original punctual size, mean difference of 28.933 µm, P=0.0076). Subjective satisfaction with treatment outcome was also better in group A (70% vs 40%, Chi-square P=0.0397).

CONCLUSION

A combination of preservative free steroid eye drops and artificial tears causes significant widening of inflammed stenotic punctae and improvement of the associated epiphora.

Kelly punch punctoplasty vs. simple punctal dilation, both with mini-monoka silicone stent intubation, for punctal stenosis related epiphora

OBJECTIVES

To compare the outcomes of stenotic punctal dilation by means of a punctal dilator alone vs. a Kelly punch punctoplasty, both followed by insertion of a mini-monoka stent, for treatment of symptomatic punctal stenosis.

METHODS

A retrospective, comparative study. The participants were patients with punctal stenosis related epiphora treated at the Goldschleger Eye Institute, Sheba Medical Center. All patients were treated either by simple punctal dilation (group 1) or Kelly punch-assisted punctoplasty (group 2), both followed by mini-monoka stent insertion. Symptoms relief and subjective epiphora scoring (Munk score) were compared and analysed.

RESULTS

Fifty patients were included in the study; Mean age (+SD) of the participants was 60 years (±12, range 30-86 years). Baseline characteristics (age, gender distribution, and visual acuity) were similar in both groups. The mini-monoka stent was placed for an average period of 2 weeks, and all patients received postoperative steroids and antibiotic treatment for 1 week. The Munk score decreased significantly in both groups following the procedure, dropping from 4.9 to 1.9 in group 1 and from 4.3 to 1.2 in group 2 (P < 0.005 for both groups). There was no difference in the delta Munk score between the two groups.

CONCLUSIONS

Simple punctal dilation followed by insertion of a mini-monoka stent is effective in alleviating the symptoms of punctal stenosis-related epiphora. There was no added benefit when the more invasive Kelly punch-assisted punctoplasty was used, raising some doubt about its justification in these cases.

The use of anterior segment optical coherence tomography in evaluation of punctal stenosis

PURPOSE

To evaluate the applicability of anterior segment optical coherence tomography (AS-OCT) for objective diagnosis of punctal stenosis.

METHODS

We report the use of AS-OCT in 3 cases of epiphora related to punctal stenosis. We followed the methodology described in previous studies. The examination was performed by a single technician using a single Spectralis OCT with the AS-OCT module. Three patients with complaints of epiphora (mean age=80 years) were examined. The external punctal diameter was measured on both infrared (IR) and OCT images. The internal diameter was measured on OCT images at a depth of 500μm. The diagnosis was confirmed by clinical examination.

RESULTS

The external punctal diameters were 159μm in the right eye (Cases 1 and 2) and 195μm in the left eye (case 2; mean: 171μm). All measurements were lower than cadaveric measurements (200-500μm), as well as previously described average diameters, thus confirming the diagnosis of punctal stenosis. The AS-OCT diameter correlated moderately with the punctal diameter estimate on the IR photos (mean: 183μm). In addition, the mean internal diameter of the punctum at 500μm (cases 1 and 2) was 58μm, which is consistent with the mean diameter at 500μm described in previous studies. Case 3 involved an 88-year-old man who complained of chronic epiphora. Slit lamp examination showed total punctal stenosis associated with cicatricial ectropion in the left eye due to a cutaneous tumor treated with radiotherapy. AS-OCT confirmed the presence of total punctual stenosis and the absence of associated canalicular stenosis.

LIMITATIONS

Our study is obviously limited by its small study population. The decision to resort to surgery was made by 2 different surgeons. There was thus no homogeneity in terms of stenosis. There is difficulty in everting the lid without applying pressure to the globe or changing the punctal or canalicular morphology. This maneuver was difficult in the postoperative setting after ectropion repair.

CONCLUSION

Our study shows that AS-OCT can be a rapid, non-invasive method in diagnosing punctal stenosis. Further studies are necessary to assess the use of AS-OCT in punctal stenosis.

Treatment of upper and lower lacrimal punctal occlusion using retrograde canaliculotomy and punctoplasty

This is a retrospective, noncomparative analysis of a case series to explore the safety and effectiveness of retrograde canaliculotomy and punctoplasty for treating epiphora due to upper and lower lacrimal punctal occlusion. During the procedure, the horizontal portion of the normal lower canaliculus was identified; the corresponding punctum was reconstructed via retrograde canaliculotomy and punctoplasty. Intubation was performed to prevent postoperative reocclusion. Patients were followed up for 12 to 24mo. A total of 16 patients with unilateral upper and lower lacrimal punctal occlusion were included. Satisfactory outcomes were achieved: all 16 patients exhibited improvement of epiphora; 31 rebuilt punctal openings and canaliculi achieved recanalization. Only one upper punctal opening could not be reconstructed because the corresponding canaliculus exhibited severe injury. No significant complications occurred as a result of the treatments. Retrograde canaliculotomy and punctoplasty appears to effective, safe, and minimally invasive for treatment of upper and lower punctal occlusion.

Evaluation of acquired punctal stenosis using anterior segment optical coherence tomography

BACKGROUND/OBJECTIVES

The aim of this article was to study the lower punctum parameters in patients with acquired punctal stenosis using spectral-domain anterior segment optical coherence tomography.

SUBJECTS/METHODS

This was a prospective nonrandomized study that included two groups. Group 1 was composed of 32 puncta from 32 subjects (11 males and 21 females, aged 40-62 years) with epiphora and clinically diagnosed punctal stenosis. Group 2 (control group) included 30 puncta from 30 normal subjects (10 males and 20 females, aged 43-63 years). Anterior segment optical coherence tomography was employed to evaluate lower punctum parameters in all subjects; the inner and outer punctal diameters as well as punctal depth were measured.

RESULTS

External punctal diameter (mean: 466.1 ± 120.3 μm), internal punctal diameter (mean: 173.4 ± 55.6 μm) and punctal depth (mean: 188.4 ± 67 μm) values in Group 1 were statistically significantly lower than those in Group 2 (mean: 745.7 ± 156.9 μm, mean: 384 ± 119.1 μm, and mean: 284.9 ± 57.7 μm, respectively).

CONCLUSION

Anterior segment optical coherence tomography could possibly be used as a noncontact and noninvasive diagnostic modality for evaluating and measuring the lower punctum in patients with punctal stenosis. Further research is required to develop a normative database and grading system for stenosed puncta and to correlate the degree of stenosis with the severity of epiphora.

A Simple Surgical Approach for the Management of Acquired Severe Lower Punctal Stenosis

Purpose

Evaluation of using pigtail probe to detect and open severely stenosed lower lacrimal punctum followed by self-retaining bicanalicular intubation.

Study design

A prospective nonrandomized clinical study.

Methods

The study included 24 patients with severe lower punctal stenosis (grade 0 according to Kashkouli scale) attending at Menoufia University Hospitals. The upper punctum and canaliculus were patent. All patients were complaining of epiphora and had a thorough ophthalmological examination including dye disappearance test and slit-lamp examination. Pigtail probe was used from patent upper punctum to detect the lower stenosed punctum which was opened with a scalpel. Syringing of the lower lacrimal passages was done to confirm its patency, and self-retaining silicone bicanalicular stent was inserted. The silicone tube was left in place for 6 months before it was removed. Patients were then followed-up for 1 year after the surgery.

Results

One year after surgery, epiphora was absent (grade 0) in 16 eyes (66.7%) and was present only occasionally (grade 1) in 4 eyes (16.7%). The difference from preoperative epiphora was statistically significant. One year after surgery, fluorescein dye disappearance time was grade 1 (<3 minutes) in 20 cases (83.3%), and grade 2 (3–5 minutes) in 4 cases (16.7%). There was a statistically significant difference compared with preoperative results.

Conclusion

Using the pigtail probe is effective in treatment of severe punctal stenosis. Maintaining the punctal opening and prevention of restenosis can be achieved by using self-retaining bicanalicular stent after confirmation of nasolacrimal duct patency. This trial is registered with NCT03731143.

Punctal stenosis in 6 dogs following the long-term use of topical neomycin-polymyxin B-dexamethasone

Six dogs were diagnosed with punctal stenosis following the long-term use of topical neomycin-polymyxin B-dexamethasone (NPD). All patients were initially presented for ophthalmic diseases requiring ongoing anti-inflammatory therapy. Five of the 6 dogs had previously or concurrently been treated with topical anti-inflammatory medications other than NPD. One patient exclusively received topical NPD prior to the diagnosis of punctal stenosis. The onset of punctal stenosis following therapy with NPD was variable among patients, ranging from 4 months to over 1 year. Diagnosis of punctal stenosis was made based upon the presence of epiphora and visualization of fibrotic tissue over the nasolacrimal puncta.

A novel surgical technique for punctal stenosis: placement of three interrupted sutures after rectangular three-snip punctoplasty

Background

We developed a novel surgical technique to treat punctal stenosis involving the placement of three interrupted sutures after rectangular three-snip punctoplasty (TSP).

Methods

Retrospective chart review of forty-eight eyes of 44 patients who underwent rectangular TSP with three interrupted sutures was performed. We investigated whether anatomical recurrences (re-stenosis) occurred during the follow-up period. The subjective symptoms of patients were surveyed.

Results

The mean patient age was 64.1 years, and the mean follow-up time was 17.4 months. The placement of three interrupted sutures after rectangular TSP afforded satisfactory outcomes. Regarding subjective symptoms, 91.7% of the eyes (44/48) were reported as improved. Among 4 eyes determined as symptomatic failure, anatomical recurrence (re-stenosis of the punctum) was observed in only one eye. The other three (6.25%, 3/48 eyes) showed functional nasolacrimal obstruction, namely epiphora with patent tear duct.

Conclusions

Placement of three interrupted sutures after rectangular TSP to treat punctal stenosis showed promising results. Notably anatomical success rate was about 98%. Further comparisons between the novel surgical technique and conventional techniques are required.

Suture-assisted punctoplasty

Purpose

To describe a surgical technique in which a suture, instead of forceps, is used to improve access for the introduction of scissors and more easily achieve an appropriately-sized punctoplasty.

Materials and Methods

In this technique, a new modification of the 2-snip punctoplasty, a 6-0 polyglactin 910 suture is passed through the posterior wall of the punctum to apply traction. A video of the technique is provided.

Results

This technique improves the surgical field of view and eases access for introduction of Vannas scissors into the punctum to perform the punctoplasty.

Conclusions

This simple and practical modification of the 2-snip punctoplasty improves instrument access so that an appropriately-sized punctoplasty can be performed with ease.

Classification of Lacrimal Punctal Stenosis and Its Related Histopathological Feature in Patients with Epiphora

Purpose

To evaluate the classification of punctal stenosis based on the shape of the external punctum, clinical characteristics and histopathologic features.

Methods

Patients who experienced tearing and were diagnosed with punctal stenosis were evaluated in this study. Punctal stenosis was classified according to the shape of the lower external punctum, which included membranous type, slit type, horseshoe type, and pinpoint type. Tear meniscus height, 2% fluorescein dye disappearance test and lacrimal pathway irrigation were measured or performed. For treatment, a punctal snip operation and silicone tube placement were performed, and the peripunctal histopathological findings were evaluated.

Results

Punctal stenosis was classified into four types: membranous type (17 eyes, 21.5%), slit type (11 eyes, 13.9%), horseshoe type (25 eyes, 31.6%), and pinpoint type (26 eyes, 32.9%). The tear meniscus was significantly higher, and the 2% fluorescein dye disappeared significantly more slowly in the punctal stenosis group. However, correlation of the tear meniscus height and 2% fluorescein dye disappearance test with the punctum shape was not statistically significant. A history of previous chemotherapy was significantly associated with the occurrence of punctal stenosis, especially the membranous type (p < 0.05). Histopathologic evaluation of the punctum showed differences between the punctum types. Pinpoint puncta exhibited a high density of muscle fibers, while they were faintly visible in the membranous type.

Conclusions

Acquired punctal stenosis has various shapes, and the major types of stenotic puncta exhibited unique histopathologic features. Punctal stenosis and its pathophysiology may be related to multiple factors, such as age and systemic 5-fluorouracil chemotherapy history.

Long-term outcomes of punch punctoplasty with Kelly punch and review of literature

PurposeTo report long-term outcomes of punch punctoplasty utilizing the Kelly punch and to compare the results with other described methods of punctoplasty in literature.Patients and methodsA retrospective, non-comparative interventional case series of patients who underwent punch punctoplasty at the Hong Kong Eye Hospital over an 8-year period. A standard Kelly Descemet's membrane punch was utilized for punctal enlargement in all cases. Patient records and their operative records were reviewed. Anatomical success was defined by well-patent puncta on follow-up. Functional success was considered complete if tearing resolved completely postop and partial if residual tearing remained despite patent puncta and nasolacrimal drainage system. An OVID MEDLINE review was performed to compare success rates of various punctoplasty surgeries in literature.ResultsIn all, 101 punch punctoplasties from 50 patients were performed between January 2008 to January 2016. At a mean follow-up of 34 months (range: 6-86 months), the anatomical success rate was 94% (95 out of 101 puncta), whereas functional success was 92% (54 out of 59 eyes). Two cases experienced postop dry eyes; otherwise no major complication was observed.ConclusionPunch punctoplasty via the readily available Kelly punch is a simple, minimally invasive procedure that demonstrates high anatomical and functional success as a sole primary treatment for simple punctal stenosis.

Three-Snip Punctoplasty Outcome Rates and Follow-Up Treatments

PURPOSE

To demonstrate the success rate of three-snip punctoplasty (TSP) for the treatment of punctual stenosis and to evaluate the need for additional treatment after TSP.

METHODS

A retrospective chart review was conducted of all patients undergoing TSP by a single surgeon at Bascom Palmer Eye Institute from January 1, 2006 to January 1, 2010. Outcome measures include the persistence of symptomatic epiphora, the need for additional surgical interventions, and postoperative time required until complete resolution of symptoms achieved.

RESULTS

Primary TSP resulted in an 86% success rate with resolution of symptomatic epiphora without further surgical intervention. Seven eyes (14%) required secondary TSP with or without stent placement. All 6 eyes with TSP with stent placement achieved functional success within an average of 6.8 months (stdev 6.83) from the first TSP. The one eye that was not stented during secondary TSP required a tertiary TSP with stenting and achieved functional success within the 1 month of the final procedure.

CONCLUSION

Primary TSP showed an 86% success rate with the resolution of tearing by an average of 1.2 months post-operatively. Membrane formation or scarring over the surgical site required an additional TSP with stenting in 14% of patients. All 50 eyes eventually achieved functional success. TSP alone as a primary procedure is a safe, relatively simple, and effective treatment of epiphora caused by punctual stenosis. Stenting should be explored as an adjunct to this procedure if primary TSP alone does not produce resolution of symptoms.

Evaluation of the Lower Punctum Parameters and Morphology Using Spectral Domain Anterior Segment Optical Coherence Tomography

Purpose. To study features of the lower punctum in normal subjects using spectral domain anterior segment optical coherence tomography (SD AS-OCT). Methods. Observational cross-sectional study that included 147 punctae (76 subjects). Punctae were evaluated clinically for appearance, position, and size. AS-OCT was used to evaluate the punctal shape, contents, and junction with the vertical canaliculus. Inner and outer diameters as well as depth were measured. Results. 24 males and 52 females (mean age 44 ± 14.35 y) were included. Lower punctum was perceived by OCT to be an area with an outer diameter (mean 412.16 ± 163 μm), inner diameter (mean 233.67 ± 138.73 μm), and depth (mean 251.7 ± 126.58 μm). The OCT measured outer punctum diameter was significantly less than that measured clinically (P: 0.000). Seven major shapes were identified. The junction with the vertical canaliculus was detectable in 44%. Fluid was detected in 34%, one of which had an air bubble; however, 63% of punctae showed no contents and 4% had debris. Conclusions. AS-OCT can be a useful tool in understanding the anatomy of the punctum and distal lacrimal system as well as tear drainage physiology. Measuring the punctum size may play a role in plugs fitting.

Outcomes of rectangular 3-snip punctoplasty in acquired punctal stenosis: is there a need to be minimally invasive?

AIM

To report the clinical profiles of acquired punctal stenosis and outcomes with rectangular 3-snip punctoplasty.

METHODS

Retrospective chart review of all patients who underwent rectangular 3-snip punctoplasty, over a 3-year period from a single surgeon's (MJA) database was performed. Data retrieved include demographics, symptomatology, prior interventions, grades of punctal stenosis, associated ocular findings, and outcomes. A minimum follow-up of 6 months following punctoplasty was considered for analysis. Success was defined as clearance of dye on functional dye disappearance test and resolution of symptoms.

RESULTS

One hundred and forty five puncta of 87 eyes of 56 patients were studied. The mean age at presentations was 52 years. Puncta (71.7%; 104/145) were of grade 2 size. Epiphora was the commonest presenting symptom noted in 94.3% (82/87) of the eyes. At a minimum follow-up of 6 months, complete resolution of symptoms was achieved in 74.7% (65/87) of eyes. Eight out of 87 eyes (9.1%) failed to show any improvement secondary to lacrimal obstructions distal to the puncta. Five out of 87 (5.7%) eyes showed punctal restenosis whereas 10.3% (9/87) of the eyes had functional epiphora post punctoplasty.

CONCLUSION

Puncta of grade 2 size were the most common in this series. Although rectangular 3-snip punctoplasty is an effective and safe procedure for majority of grades 1 and 2 of acquired punctal stenosis, a higher percentages of functional epiphora and punctal restenosis in the remaining patients should propel further investigations into developing nonincisional, minimally invasive alternatives.

Assessment and management of proximal and incomplete symptomatic obstruction of the lacrimal drainage system

Epiphora is a common complaint of patients who present to an Ophthalmology Clinic. In many cases, epiphora is due to an obstruction in the lacrimal drainage system. However, a subgroup of symptomatic patients with epiphora has a patent lacrimal drainage system. Such cases are usually termed ‘functional obstruction’ and / or ‘stenosis of the lacrimal drainage system’. Various etiologies and diagnostic and therapeutic approaches have been described in literature, which implies the lack of a standardized approach. This article will review the evolving diagnostic and therapeutic approaches in literature, and in the end, propose a paradigm in approaching this group of patients.

Punctal stenosis: definition, diagnosis, and treatment

Acquired punctal stenosis is a condition in which the external opening of the lacrimal canaliculus is narrowed or occluded. This condition is a rare cause of symptomatic epiphora, but its incidence may be higher in patients with chronic blepharitis, in those treated with various topical medications, including antihypertensive agents, and especially in patients treated with taxanes for cancer. The purpose of this review is to cover the medical literature, focusing in particular on definition, incidence, risk factors, etiology and treatment options.

Outcomes of 4-snip punctoplasty for severe punctal stenosis: measurement of tear meniscus height by optical coherence tomography

PURPOSE

To investigate the surgical outcome of rectangular 4-snip punctoplasty, a modification of rectangular 3-snip procedures, using objective measurements.

DESIGN

Noncomparative case series.

METHODS

The medical charts of patients who underwent rectangular 4-snip punctoplasty for severe punctal stenosis with at least 6 months follow-up were reviewed. Before surgery and at 1 and 6 months after surgery, subjective evaluation of tearing was assessed using Munk scores. The size of the punctum was graded based on slit-lamp examination, and measurement of tear meniscus height was done using Fourier-domain optical coherence tomography.

RESULTS

A total of 45 eyes (26 patients) were studied. The subjective epiphora score was significantly reduced after surgery and maintained until 6 months after the surgery (χ2 for trend test, P<.001). The grade of the punctum size was also significantly enlarged after surgery and the enlarged punctum was maintained until 6 months after the surgery (χ2 for trend test, P<.001). The mean preoperative tear height (452.4±249.3 μm) was significantly reduced both at 1 month after surgery (341.6±207.9 μm; P=.003, paired t test) and at 6 months after surgery (362.1±212.6 μm; P=.004, paired t test). The functional success rate was 93.3% and anatomic success rate was 88.9% at 6 months after surgery.

CONCLUSIONS

Rectangular 4-snip punctoplasty was an anatomically and functionally effective procedure for severe punctal stenosis patients, maintaining large puncta for fairly long periods.

Comparing anatomical pattern of topical anti-glaucoma medications associated lacrimal obstruction with a control group

PURPOSE

To compare the anatomical pattern of lacrimal drainage system obstruction (LDSO) associated with topical anti-glaucoma medications (AGM) with a control group.

METHODS

In a cross-sectional controlled study, case group included patients on topical anti-glaucoma medications and control group included patients with no history of glaucoma, free of ocular disease, and not using topical medications. Data recording, eye examination, and categorization of patients into case and control groups were performed by a senior ophthalmology resident. Diagnostic probing and irrigation test was performed by an oculoplastic surgeon who was masked to the patients' data. Chi-square (X(2)) and tests were used to assess the effect of sex and systemic diseases, as well as logistic regression analysis with intra-cluster correlation for the effect of topical anti-glaucoma medications on lacrimal drainage system, and then independent sample t-tests to compare the mean ages, plus the binary logistic regression test for the effect of increasing age on LDSO.

RESULTS

There were 128 eyes of 96 patients in the case and 277 eyes of 172 patients in the control group. Two groups were similar regarding to the age, sex, and associated systemic disorders (0.3<P<0.5). There was a significantly more LDSO in the case than control group (P = 0.008). Upper LDSO was observed in 76.92% (20/26) of the cases, and 37.5% (9/24) of the control group (P = 0.01). Nasolacrimal duct obstruction was also found in 19.23% of case group.

CONCLUSIONS

Although punctum and canaliculus are the main anatomical sites of LDSO associated with topical AGM, common canaliculus and nasolacrimal duct separately or in association with punctum and canaliculus may also be involved.