Factors affecting outcome of punctoplasty surgery: a review of 205 cases

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.

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.

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.

[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.

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.

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.

A Systematic Review of Patient-Reported Outcomes for Surgically Amenable Epiphora

PURPOSE

In evaluating epiphora and its management, the bottom line for all stakeholders is whether an intervention confers any real benefit on quality of life. A review was conducted to identify and appraise patient-reported outcome measures (PROMs) in surgically amenable epiphora.

METHODS

A systematic search was conducted of studies relating to surgical intervention for epiphora. Patient-reported outcome measures were identified and assessed against standard criteria.

RESULTS

Of 30,544 identified articles, 227 were eligible for data extraction. Of these, 69% reported a PROM as the primary outcome. PROMs identified included single-item symptom scores (48% of primary outcome PROMs), single-item reports of improvement (30%), the Glasgow Benefit Inventory (3%), Lacrimal Symptom Questionnaire (0.5%), Nasolacrimal Duct Obstruction Symptom Score (0.5%), Ocular Surface Disease Index (0.5%), Visual Function Questionnaire-25, the Short Form-36 Health Survey, and 3 other symptom scores. None were developed through consultation with the target population, and there was inadequate testing of content validity. The strengths and limitations of each PROM are presented, with regard to interpretation, responsiveness, reliability, and validity.

DISCUSSION

The importance of robust and psychometrically sound PROMs is essential if the under-reporting of quality of life improvement in patients treated for epiphora is to change. Recommendations for the use of each identified PROM are discussed.

CONCLUSIONS

Several PROMs have been used in the recent literature to evaluate patients undergoing surgery to treat epiphora. Assessed against standard criteria, no PROM has proven to be both psychometrically robust and clinically meaningful for use in this population. Future PROM development should be guided by this standard framework.

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.

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.

Optical coherence tomography imaging of the proximal lacrimal system

INTRODUCTION

There are currently no routinely used imaging modalities for the proximal lacrimal system. Optical Coherence Tomography (OCT) is a safe and non-invasive method of high resolution cross-sectional imaging of tissue microstructures using infra-red radiation. In this study we investigate whether OCT may be used to image the punctum and proximal canaliculus.

METHODS

A cohort of healthy subjects with normal ocular anatomy and no symptoms of epiphora were prospectively invited to enrol. Spectral OCT images of the lower punctae were captured with a Topcon 3D Optical Coherence Tomography 2000 machine. Measurements were made of the maximal punctal diameter, canalicular diameter and canalicular depth. Our data for depth of the vertical canaliculus was compared to the widely quoted figure of 2 mm using a two-tailed t-test to check for a statistically significant difference at p < 0.05.

RESULTS

Thirty-six punctae of 18 subjects were scanned. The punctum was recognisable on the OCT image in all cases. The mean depth, width and cross- sectional area of the visualised canaliculi were 0.753 mm (SD 0.216), 0.110 mm (SD 0.067) and 9.49 × 10(-3)mm(2), respectively. The mean width of the punctum was 0.247 mm (SD 0.078).

DISCUSSION

We have demonstrated the first in-vivo high resolution images of normal punctal and vertical canalicular anatomy using spectral OCT. There is currently no other practical way to accurately image punctal and proximal canalicular morphology in vivo. OCT is a convenient and readily available tool in most eye clinics with resolution ideally suited for imaging of the punctum and proximal canaliculus.

Presumed Virus-Induced Punctal Occlusion

Purpose. To investigate viral infection as a cause of punctal stenosis in individuals without any ocular or systemic risk factors. Methods. The study group comprised patients with no known cause for punctal occlusion who underwent surgery at one medical center during a one-year period. Excised tissue was subjected to histological examination, PCR, and nested PCR testing for common viruses (adenovirus, influenza A and B, enterovirus, varicella-zoster, CMV, herpes simplex types 1 and 2, Epstein-Barr virus, and parainfluenza type 1). Results. All nine patients identified were female, 20-38 years of age. The three-snip-procedure resolved tearing in eight of them. All excised samples showed chronic mononuclear inflammation compatible with viral infection or with viral infection immune inflammatory reaction. PCR testing was negative for all the viruses examined; however, nested PCR was positive in three patients. Conclusion. This study supports the proposition that punctal occlusion in young healthy females may be due to viral infection.

Adjunctive re-dilation for early cicatrization after punctoplasty

PURPOSE

To evaluate punctoplasty outcomes with adjunctive in-office probing of early post-procedure cicatricial changes.

METHOD

Retrospective analysis of all eyes undergoing 3-snip punctoplasty by a single surgeon between August 1,2008 and June 30, 2011.

RESULTS

Twenty-two patients were eligible for this study. Twenty-eight eyes (15 right, 13 left) underwent punctoplasty. Twenty-three eyes underwent in-office post-procedure dilation for early cicatricial changes. Anatomical success was achieved in 22 patients (100%). Twenty-one patients (95.5%) reported improvement in epiphora.

CONCLUSIONS

Functional and anatomical success rates after punctoplasty may be improved by close post-procedure follow-up with in-office re-dilation for recurrent punctal cicatrization.

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.