Bicanalicular Silicone Intubation for the Management of Punctal Stenosis and Obstruction in Patients With Allergic Conjunctivitis

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.

Prevalence, Clinical Characteristics, and Relative Factors of Acquired Punctal Stenosis in Adult Allergic Conjunctivitis Patients

INTRODUCTION

The objective of this study was to investigate the prevalence, characteristics, and risk factors of acquired punctal stenosis (APS) in adult patients with allergic conjunctivitis (AC).

METHODS

This observational case series study included 210 adult AC patients at Zhongshan Ophthalmic Center. The demographic data were collected, and the ocular manifestations were assessed. Morphologies of AC patients' lacrimal puncta were evaluated and graded using the modified grading system by slit-lamp microscopy.

RESULTS

There was 69.0% (145/210) of adult AC participants suffering from APS. Stenotic lacrimal puncta were present in 49.3% (414/840), with grade IIa being the most common (54.6%). Abnormal upper lacrimal puncta were more frequent than lower ones (89.0% vs. 73.1%, p = 0.001). AC patients with APS were significantly older than those without APS (p < 0.001). The percentage of patients with tear meniscus height (TMH) >0.3 mm was 40% in the APS group, compared to 12.5% in the non-APS group (p < 0.001). The age (OR = 1.589, 95% CI: 1.109-2.276, p = 0.012) and TMH (OR = 3.449, 95% CI: 1.224-9.719, p = 0.019) were positively associated with the occurrence of APS.

CONCLUSION

APS, especially the stenosis of upper lacrimal punctum, is frequently observed in the AC patients. Increased age and widened TMH are associated with the prevalence of APS in adult AC patients, suggesting a potential relationship between the long-term and recurrent course of AC and the development of APS.

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.

Clinical features and management of keratoconjunctivitis associated with inadequate tear drainage

OBJECTIVE

To describe clinical features and management of toxic keratoconjunctivitis associated with punctal and (or) canaliculus stenosis (toxic soup syndrome).

DESIGN

Retrospective observational case series.

METHODS

Electronic medical record database search for the keywords "toxic soup syndrome" and retrospective chart review were performed. Thirty-five eyes of 25 patients were seen at a tertiary cornea clinic between January 2017 and December 2021. Sex, age, distance-corrected visual acuity, topical medications, symptoms, clinical signs, and outcomes after medical and surgical interventions were analyzed. The main outcome measured was improvement in ocular surface signs and symptoms after interventions.

RESULTS

Overall, 35 eyes of 25 patients with a mean age of 66.8 ± 12.8 years, of which 72% were female, were included. The primary complaint was hyperemia and epiphora in all patients. Rosacea or meibomian gland disease were present in all patients, 7 (28%) had glaucoma, and 7 (28%) developed limbal stem cell deficiency. Twenty-two patients (88%) were using topical medications on presentation. All eyes had either punctal plugs, cauterized puncta, or punctal and (or) canaliculus stenosis. Management of all patients consisted of suspension of all preserved topical medications and institution of some type of anti-inflammatory therapy. Nineteen patients (76%) improved after improvement of lacrimal drainage. One patient with severe resistance in the canaliculus required ongoing preservative-free topical steroids.

CONCLUSIONS

Chronic drug-induced or pooled inflammatory mediators causing toxic conjunctivitis may be aggravated by punctal and (or) canaliculus stenosis, leading to toxic soup syndrome. Clearance of punctal obstruction leads to improvement in most patients.

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.

Optimisation of reduction for prolapsed silicone tube after lacrimal intubation

BACKGROUND

A common complication of bicanalicular intubation is dislocation of the silicone tube.

METHODS

Eleven patients with prolapsed silicone tubes who had undergone bicanalicular nasal intubation were injected with a 2 per cent lidocaine solution to infiltrate the lacrimal duct mucosa. A memory wire probe was used to pull a 4-0 suture through the lacrimal passage retrogradely, allowing the suture to grab the silicone tube. Paraffin oil was applied to the contact part of the rope and the silicone tube, then the distal end of the silk thread was removed from the nostril until the tube was pulled into place.

RESULTS

The prolapsed silicone tubes were restored by surgery in nine patients, with the drainage tube in the correct position in the eye and the lacrimal duct irrigation unobstructed.

CONCLUSION

The optimisations made in this study are considered effective adjustments of reduction surgery for a prolapsed silicone tube.

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.

[Punctal stenosis: etiology, diagnosis, treatment]

This article reviews etiological factors in the development of lacrimal punctal stenosis, modern diagnostic techniques, as well as both conservative and surgical treatment methods. The presented analysis is based on data from 67 literary sources, which provide information on conventional and high-tech examination and treatment methods of patients with lacrimal punctal stenosis. Particular attention is paid to various aspects of punctoplasty - the most common surgical intervention used to treat this pathology.

Endoscopic dacryocystorhinostomy for refractory nasolacrimal duct obstruction with a small lacrimal sac (≤ 5 mm in diameter)

BACKGROUND

Although endoscopic dacryocystorhinostomy (DCR) is a standard procedure for nasolacrimal duct obstruction (NLDO), the failure rate remains approximately 10%. A small lacrimal sac is considered the main reason for surgical failure. We explored the efficacy of endoscopic DCR for the treatment of NLDO with a small lacrimal sac.

METHODS

The clinical data of 72 patients (88 eyes) diagnosed with NLDO and undergoing endoscopic DCR from 2012 to 2020, with at least 24 months of follow-up were retrospectively collected. Intraoperatively, the Rosenmüller valves were fully exposed, mucosal flaps were preserved to cover the naked bone, and a silicone tube was implanted if necessary. Postoperative intervention was performed if necessary. The main outcome measures were symptomatic improvement and objective ostium patency.

RESULTS

Eighty-eight eyes of 72 patients were divided into two groups: the refractory group (34 patients, 47 eyes), with a small lacrimal sac (≤ 5 mm in diameter), and the simple group (38 patients, 41 eyes). Patients with small lacrimal sacs were more prone to bilateral eye disease than those in the simple group (P = 0.014) and required a longer postoperative follow-up (P < 0.001). Refractory NLDO and simple NLDO had a success rate of 91.5% and 95.1%, respectively, with no significant difference.

CONCLUSION

Endoscopic DCR for refractory NLDO with a small lacrimal sac could achieve a beneficial result by exposing the Rosenmüller valves, preserving mucosal flaps, implanting necessary intubation, and intervening postoperatively. Thus, a small lacrimal sac should not be regarded as a contraindication to surgery.

Rectangular 3-snip punctoplasty versus punch punctoplasty with silicone intubation for acquired external punctal stenosis: a prospective randomized comparative study

AIM

To evaluate the effectiveness of rectangular 3-snip punctoplasty versus punch punctoplasty via Kelly punch with silicone intubation for the management of acquired external punctal stenosis (AEPS).

METHODS

A prospective, randomized, comparative study was performed on 123 eyes of 94 patients with AEPS. Patients were recruited into either group of rectangular 3-snip punctoplasty (group A) or group of punch punctoplasty with silicone intubation (group B). Outcomes measured were Munk score, grade of punctal stenosis, fluorescein dye disappearance time test (FDDT) and tear meniscus height (TMH) 6 and 12mo after surgery.

RESULTS

Twelve months after surgery, Munk score, FDDT and TMH significantly decreased in both groups compared with the baseline (all P<0.05), and grade of punctal stenosis increased significantly (P<0.05). The grade of punctal stenosis, Munk score, FDDT and TMH were better in group B compared with group A at 6 or 12mo (all P<0.05). There was a positive correlation between TMH and Munk score (R=0.655, P<0.001). At the last followed-up, anatomical success was noted in 96.7% eyes in group A and 98.4% eyes in group B (P=0.613).

CONCLUSION

Punch punctoplasty via Kelly punch with silicone intubation achieves better outcomes than rectangular 3-snip punctoplasty. The new technique is a simple, minimally invasive, with high anatomical and functional success in patients with AEPS.

The spectrum of allergic ocular diseases

OBJECTIVE

The purpose of this article is to review the pathophysiologic mechanisms, differential diagnosis, evaluation, and treatment of the various manifestations of ocular allergy, with an especial focus on immunoglobulin E (IgE)-mediated disease.

DATA SOURCES

A PubMed search was performed to include articles, using the search terms ocular allergy and allergic conjunctivitis.

STUDY SELECTIONS

Recent and relevant human studies in the English language pertaining to our topic of study were selected. Animal studies pertaining to pathophysiology of ocular allergy were also reviewed. We focused on clinical trials, practice guidelines, reviews, and systematic reviews. In addition, case reports were reviewed if they described rare clinical presentations, disease mechanisms, or novel therapies.

RESULTS

Ocular allergy encompasses both IgE- and non-IgE-mediated disease, and the clinical severity may range from mild to sight-threatening inflammation. A comprehensive treatment regimen including education, lifestyle measures, topical therapies, and even systemic interventions may be necessary for the effective management of ocular allergies, tailored according to symptom severity.

CONCLUSION

Ocular allergy is frequently encountered by allergists and eye-care specialists, and despite progressively increasing incidence, it often remains underdiagnosed and, hence, untreated.

The Role of Th17 Cells and IL-17 in Th2 Immune Responses of Allergic Conjunctivitis

Allergic conjunctivitis (AC) is a common allergic disease that is often associated with the onset of rhinitis or asthma. The incidence of AC has increased significantly in recent years possibly due to air pollution and climate warming. AC seriously affects patients' quality of life and work efficiency. Th (T-helper) 2 immune responses and type I hypersensitivity reactions are generally considered the basis of occurrence of AC. It has been found that new subpopulations of T-helper cells, Th17 cells that produce interleukin-17 (IL-17), play an important role in the Th2-mediated pathogenesis of conjunctivitis. Studies have shown that Th17 cells are involved in a variety of immune inflammation, including psoriasis, rheumatoid arthritis, inflammatory bowel disease, systemic lupus erythematosus, and asthma. However, the role of Th17 and IL-17 in AC is unclear. This paper will focus on how T-helper 17 cells and interleukin-17 are activated in the Th2 immune response of allergic conjunctivitis and how they promote the Th2 immune response of AC.