Long-term outcomes of monocanalicular lacrimal stenting in punctum and canalicular stenosis or obstruction

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.

Long-term outcomes of labial mucosal graft in conjunctivo-rhinostomy surgery

OBJECTIVE

To report the long-term outcomes of the conjunctivo-rhinostomy surgery with labial mucosal graft performed for the patients of proximal lacrimal drainage system disorders.

METHODS

Retrospective, single surgeon (KB), non-comparative study including patients having complete obstruction of the superior and inferior proximal lacrimal drainage system. All patients underwent conjunctivo-rhinostomy with labial mucosal graft insertion. Preoperatively, tear film break-up time and a fluorescein dye disappearance test was performed for each patient. A phaco aspiration tubing segment was used for supporting the mucosal graft for first 4 weeks followed by its removal. Minimum follow-up was 12 months. fluorescein dye disappearance test and nasal endoscopy were performed at each follow-up visit. Total resolution of epiphora and negative fluorescein dye disappearance test was defined as complete success.

RESULTS

Eighteen patients (12 males, 6 females) with a mean age of 39.94 years (range 7-76 years) all had a unilateral presentation. The indication for surgery was trauma (n = 11), failed dacryocystorhinostomy (DCR) with canalicular obstruction (n = 4), chronic ocular inflammation with complete punctal occlusion (n = 2), and post-radiotherapy (n = 1). At a mean follow-up of 5.38 years, complete success was observed in 12 (66.67%), partial success in 4 (22.22%) while in 2 (11.11%) patients, the procedure failed.

CONCLUSION

Labial mucosal graft in conjunctivo-rhinostomy is a successful adjunct which provides satisfactory long-term outcomes. Our surgical technique of directly suturing the mucosal graft to surrounding muscle provides better functionality to the system with eyelid blinking.