Balloon catheter dilation in common canalicular obstruction of the lacrimal system: safety and long-term effectiveness

The Use of Venous Catheter and Irrigation with Povidone-Iodine 0.6% in Patients with Punctal and Proximal Canalicular Stenosis: Preliminary Report

Background: This study aimed to evaluate the safety and efficacy of povidone-iodine 0.6% (PVI) irrigation for preventing recurrence of stenosis after punctoplasty in patients with punctal and proximal canalicular stenosis treated using a venous catheter as a stent. Methods: Twenty patients were enrolled and divided into two groups. Group 1 received irrigation of 1 mL 0.6% PVI, while Group 2 received 1 mL of balanced salt solution (BSS). The patients underwent baseline, 15-, 30-, and 90-day assessments using the Ocular Surface Disease Index (OSDI) questionnaire, Symptoms Assessment in Dry Eye (SANDE), Schirmer I test, tear meniscus height (TMH), bulbar redness, meibography, and non-invasive breakup time (NIKBUT) through Keratograph 5M (Oculus, Germany). Results: At three months, both groups demonstrated statistically significant improvements in symptoms and ocular surface parameters. However, Group 1 showed statistically significant improvements in OSDI, SANDE scores, bulbar redness, and NIKBUT compared to Group 2. Additionally, no patients in Group 1 presented a recurrence of stenosis, while three patients in Group 2 demonstrated stenosis relapse at the end of the follow-up period. Conclusions: The application of a venous catheter and PVI 0.6% irrigations proved to be effective in treating proximal lacrimal duct stenosis, reducing the risk of recurrence and improving tear film stability, ocular discomfort symptoms, and ocular surface parameters.

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.

Endoscopic transnasal canaliculorhinostomy for refractory common canalicular obstruction with an unidentifiable lacrimal sac

AIM

To describe the role of endoscopic transnasal canaliculorhinostomy (ETC) in refractory common canalicular obstruction (CCO) associated with an absent or unidentifiable lacrimal sac.

METHODS

The records of patients with refractory CCO who underwent ETC at the Eye Hospital of Wenzhou Medical University from October 2007 to December 2016 were retrospectively reviewed.

RESULTS

Fifty-six patients (56 eyes) with refractory CCO were recruited into the study. Eight patients were excluded due to the presence of a residual lacrimal sac or failure to complete the follow-up duration. The anatomic and functional success rates were both 85.4% (41/48) at a mean follow-up of 18.6mo. Five cases failed as a result of ostial synechia and two failed because of ostial obstruction by granulation. Postoperative complications included mild nasal bleeding in 5 cases, dried nasal feeling in 8 cases, and olfactory dysfunction in 4 cases.

CONCLUSION

Although being surgically challenging, ETC has comparable findings to its external approach counterpart or conjunctivodacryocystorhinostomy (CDCR) with Jones tube. And it may prove to be a novel alternate surgical technique for patients with refractory CCO without identifiable lacrimal sac.

The role of interventional radiology in the treatment of epiphora

Epiphora is a relatively common ophthalmologic affection representing almost 5% of clinical consultations in ophthalmology and it consists in the complete or partial obstruction of nasolacrimal duct, leading to insufficient drainage of tears. The traditional treatment is represented by surgery namely, external dacryocystorhinostomy (DCR). Despite the high success rate DCR has many disadvantages and limitations since it requires general anesthesia, it may arise in a permanent facial scar and it is often affected by the reobstruction of the anastomotic tract by fibrotic scars and osteogenic activity. Fluoroscopically guided interventional procedures are a therapeutic alternative to surgery for lacrimal duct system obstructions that can consist either in balloon dacryocystoplasty or in nasolacrimal stent placement. In both cases, a pre-operative imaging characterization of the occlusion is needed for a correct treatment planning. In this review, we propose to highlight the role of interventional radiology in the treatment of epiphora and the role of computed tomography dacryocystography (CTD) in depiction and the pre-interventional planning.

Long-Term Success of Modified External Dacryocystorhinostomy for the Treatment of Distal Common Canalicular Block

PURPOSE

Epiphora caused by common canalicular obstruction is difficult to manage. Distal common canalicular block caused by membranous obstruction near its junction with the lacrimal sac can be managed by modified dacryocystorhinostomy (DCR) consisting of internal membranectomy. We report our experience with this technique during long-term follow-up.

DESIGN

A prospective interventional case series was performed at a tertiary care center including 15 patients with a diagnosis of distal common canalicular obstruction.

METHODS

External DCR was performed, and after lacrimal sac opening, membranous obstruction at the distal end of the common canaliculus was identified and managed successfully in all cases. Mitomycin C was applied, and silicone intubation was done for 2 months. The main outcome measures were anatomical success (patent syringing) and functional success (complete relief of epiphora) at a minimum follow-up period of 1 year.

RESULTS

Fourteen (93%) cases were completely relieved of epiphora with patent lacrimal syringing at a mean follow-up of 15.4 months (P = 0.0001, McNemar test). The postoperative complications occurred in 4 cases and included nasal bleeding, lateral displacement of silicone tube at medial canthus, complete extrusion of silicone tube (at 4 weeks), and noticeable incisional scar.

CONCLUSIONS

Distal common canalicular obstruction can be successfully managed with DCR with internal membranectomy and silicone intubation with mitomycin C. It avoids excision of common canaliculus as compared with canaliculo-DCR. The procedure is safe and effective with minor complications.

Randomized study comparing the efficacy of a self-retaining bicanaliculus intubation stent with Crawford intubation in patients with canalicular obstruction

Background

The purpose of this study was to compare the efficacy of self-retaining stent (SRS) bicanalicular intubation with bicanalicular silicone (Crawford) intubation in patients with canalicular and punctal obstruction.

Methods

In this prospective, randomized clinical trial, 38 patients with canalicular or punctal obstruction (25 partial, 13 complete) and epiphora were randomized into two groups. Twenty-one patients (14 with partial and seven with complete obstruction) underwent SRS intubation and 17 patients underwent bicanalicular silicon intubation in a randomized fashion.

Results

After a mean follow-up of 6 months following tube removal, 16 (76%, 12 partial, four complete) of the 21 eyes in the SRS intubation group and 13 (76%, 10 partial, three complete) in the bicanalicular silicon intubation group had a successful outcome and remained symptom-free. For partial obstructions, the success rate was 85% and 90% for the SRS and bicanalicular silicon intubation groups, respectively. The corresponding values for complete obstruction were 63% and 50% for the SRS and bicanalicular silicon intubation groups, respectively.

Conclusion

SRS could effectively substitute for a more extensive procedure such as bicanalicular silicon intubation in patients with canalicular obstruction, particularly those with partial obstruction. The newly developed SRS intubation procedure has the advantages of simple, easy implementation and extubation, low cost, and a lower rate of trauma when compared with bicanalicular silicon intubation.

[CT dacryocystography: normal findings and pathology]

CT dacryocystography, performed under sterile technique and following local anesthesia, is well tolerated by patients. It is the imaging technique of choice in patients with persistent tearing following clinical examination with non-invasive procedures when patency of the lacrimal drainage system remains uncertain, when a dacryolith or tumor is suspected or following unsuccessful dacryocystorhinostomy. Two techniques are available: instillation or direct cannulation, either initially or after non-visualization of the nasolacrimal system after contrast instillation. Non-specific idiopathic stenosis at the mid portion of the nasolacrimal duct is the most frequent etiology in patients over 50 years old; dacryoliths are present in 5 to 20% of cases of nasolacrimal duct stenosis. CT dacryocystography also allows evaluation of surrounding structures (medicolegal) to identify variants and anomalies when surgery is contemplated to avoid potential complications.

Ballooning canaliculoplasty after lacrimal trephination in monocanalicular and common canalicular obstruction

PURPOSE

To evaluate the clinical effect of balloon canaliculoplasty with LacriCATH after lacrimal trephination in monocanalicular and common canalicular obstruction.

METHODS

Silicone intubation following ballooning dilation with a 2-mm-diameter catheter after lacrimal trephination was attempted in 66 eyes of 62 patients (10 men, 52 women; mean age, 67.3 years; age range, 34-77 years) with epiphora due to monocanalicular or common canalicular obstruction between January 2003 and February 2005. A total of 56 of the 66 eyes had common canalicular obstruction, and ten had monocanalicular obstruction.

RESULTS

The cause of obstruction in 54 (81.8%) eyes was idiopathic. Overall initial technical improvement was achieved in 64 (97.0%) eyes (common canalicular obstruction, 56/56, 100%; monocanalicular obstruction, 8/10, 80.0%) Immediate clinical improvement was achieved in 54 eyes (81.8%). The cumulative patency rates at the last clinic visit were 53.6% in cases of common canalicular obstruction and 25.0% in cases of monocanalicular obstruction. Causes of failure were combined nasolacrimal duct obstruction, recurrent monocanalicular obstruction, and acute canaliculitis.

CONCLUSIONS

Balloon canaliculoplasty after lacrimal trephination is a simple and safe method that may be a good alternative treatment for common canalicular and distal canalicular obstructions, before resorting to conjunctivodacryorhinostomy with Jones tube insertion.

Long-term results of balloon dacryocystoplasty: success rates according to the site and severity of the obstruction

PURPOSE

To evaluate the long-term patency of lacrimal drainage system (LDS) after balloon dacryocystoplasty (BD) and to give the long-term success rates according to the severity and localization of the obstruction.

METHODS

Between May 1993 and December 2003, BD was attempted in 117 eyes of 108 patients with idiopathic-acquired LDS obstruction. Patients with active dacryocystitis, dacryolithiasis, traumatic obstruction or lacrimal mass, obstructions at the superior or inferior canaliculi lateral to the common canaliculus, and follow-up period less than 36 months were excluded from the study.

RESULTS

The results of BD were evaluated in 99 eyes of 94 cases. The obstruction was seen at the common canaliculus in seven eyes, proximal nasolacrimal duct in 70 eyes, and distal nasolacrimal duct in 22 eyes. The mean follow-up period was 100.0+/-38.4 months (range: 36-142 months). The long-term overall success rate was 40.8% (20/49 eyes) in complete obstruction and 68% (34/50 eyes) in partial obstruction. The clinical success rate was 57.1% in common canalicular (complete: 33.3%, partial: 75%), 50% in proximal nasolacrimal duct (complete: 38.5%, partial: 64.5%), and 68.2% in distal nasolacrimal duct (complete: 57.1%, partial: 73.3%) obstructions. The overall success was 54.5% (54/99 eyes) for the entire series at the last clinical follow-up visit.

CONCLUSION

The long-tem success rate of BD for the treatment of epiphora is low and is not comparable to conventional dacryocystorhinostomy. More predictable results can only be achieved in carefully selected patients and this procedure can be recommended in cases demonstrating partial obstruction of the distal nasolacrimal duct.

Interventional radiology in the lacrimal drainage system

This article presents a review of the interventional radiological procedures in the lacrimal drainage system. Balloon dacryocystoplasty and nasolacrimal polyurethane stent placement are the main fluoroscopically guided interventions for the treatment of epiphora by recanalizing the obstructed LDS. These procedures can also be used for dacryolith removal and lacrimal sac abscess treatment.

Long-term outcome after Reny canaliculoplasty for extended canalicular stenosis

PURPOSE

To evaluate the long-term functional outcome in patients undergoing a canaliculoplasty that turns the lacrimal sac inside out for extended canalicular stenosis, and to determine the place of this technique in comparison with other surgical techniques proposed for this difficult condition.

METHODS

A retrospective study was conducted over a ten-year period (1990-2000). Thirty-eight patients (21 men and 17 women) were included. Mean age was 48.8 years, range 11-81 years. We evaluated the long-term outcome in 25 patients. Among these patients, canalicular stenosis had developed after infection in 16 and after trauma in 9.

RESULTS

The rate of success was 52% at nine years. Success appeared to be more frequent in trauma victims (75%) than after infection (43%). The rate of success was better for patients with monocanalicular (60%) than for those with bicanalicular stenosis (40%). Digital dacryography demonstrated good flow of the contrast product through the neocanaliculus into the nasal fossa in eight of ten patients explored.

CONCLUSION

We were able to achieve complete cure in many patients with an overall success rate of 50%. Digital dacryography with dye flow provides good opacification of the neocanaliculus, demonstrating its nearly physiological morphology. Our study demonstrated the usefulness of this method and has encouraged us to continue proposing this canaliculoplasty technique for selected patients.

Obstruction of the lacrimal system: treatment with a covered, retrievable, expandable nitinol stent versus a lacrimal polyurethane stent

PURPOSE

To compare the clinical effectiveness of a covered nitinol stent with that of a polyurethane stent for treatment of lacrimal system obstructions.

MATERIALS AND METHODS

A nitinol stent was knit from a single thread of 0.1-mm nitinol wire in a tubular configuration and was covered by dipping the stent into a polyurethane solution. The stent was 4 mm in diameter and 30 or 35 mm long. With fluoroscopic guidance, a covered nitinol stent (n = 33, group A) or a polyurethane stent (n = 35, group B) was placed in 68 patients. The following items were evaluated retrospectively: technical success, procedure time, cumulative patency rate, and complications. An unpaired Student t test was used to analyze the difference between the procedure times. Kaplan-Meier survival curves and a log-rank test were used to compare the cumulative patency rates.

RESULTS

Stent placement was technically successful in 31 (94%) of 33 patients in group A and in all 35 (100%) patients in group B. After stent placement, all patients showed resolution of epiphora. Average procedure time was 400 seconds (range, 270-900 seconds) in group A and 260 seconds (range, 150-900 seconds) in group B. The difference between the procedure times was statistically significant (P =.0003). During the mean follow-up period of 40 months, there was recurrence of epiphora in 30 of 31 patients in group A and 26 of 35 patients in group B. The difference of the cumulative patency rates was statistically insignificant (P =.2).

CONCLUSION

Although the polyurethane stent used for treatment seemed to be more effective than the nitinol stent, selection of these stents for placement should be made with caution, because the long-term patency rates are not encouraging.

External dacryocystorhinostomy for the treatment of acquired partial nasolacrimal obstruction in adults

AIM

To determine the long term success of external dacryocystorhinostomy (DCR) in adults with acquired partial nasolacrimal obstruction.

METHODS

A retrospective study of 50 external dacryocystorhinostomies with silicone intubation performed for partial nasolacrimal obstruction, was undertaken. Preoperative lacrimal scintigraphy divided drainage abnormalities into presac or postsac delays. Postoperative success was determined by lacrimal patency to irrigation, a positive dye test on nasal endoscopy and subjective resolution of epiphora. Statistical analysis was performed using the Fisher exact test.

RESULTS

A patent DCR system to irrigation and a positive dye test was achieved in 90% of procedures. At an average of 3.6 months' follow up, subjective success was reported in 84% of cases-91% for postsac and 67% for presac delays. At 3 years' follow up success had declined to 70% overall and to 80% and 47% for postsac and presac occlusions respectively. There was a statistically significant association between a presac delay and postoperative recurrence of epiphora, p = 0.04.

CONCLUSION

External DCR with silicone intubation is an effective procedure for partial nasolacrimal obstruction. Presac delays do significantly less well and further studies are necessary to evaluate the best type of surgery for these patients.

Diseases of the lacrimal drainage system

We will refer to lacrimal system pathologies involving the outflow pathways, as well as to the recent advances in the management of canalicular and lacrimonasal duct anomalies, including modifications to dacrycystorhinostomy technique, treatment for congenital obstructions, and lacrimal intubations. Special emphasis will be placed on the usefulness of nasal and canalicular endoscopy for the examination and treatment of congenital obstructions and endonasal pathologies, as an aid for intubations and lacrimal surgery, as well as on reasons for failed procedures.

Balloon dacryocystoplasty: results and factors influencing outcome in 350 patients

PURPOSE

To evaluate the initial and long-term results of balloon dacryocystoplasty in the treatment of epiphora caused by obstruction of the lacrimal system with analysis of the procedure's favorable effects.

MATERIALS AND METHODS

Four hundred thirty eyes of 350 patients with obstructions of the lacrimal system were enrolled. Dacryocystoplasty was performed with use of a balloon catheter and a ball-tipped guide wire. The lesions were categorized according to cause, severity, site of the obstruction, and diameter and inflation time of the balloon. The technical success, initial success (improvement of symptoms after 1 week), and long-term patency rates were calculated. These rates in each group were compared with the chi(2) test and the Kaplan-Meier method.

RESULTS

The overall technical success rate was 95.3%. The overall initial success rate was 57.4%. There was no significant complication except for mild epistaxis in 12%. The 2-month, 1-year, and 5-year patency rates were 48.2%, 39.4%, and 36.9%, respectively. Initial success was influenced by the severity (P =.014) and the site (P <.001) of the obstruction, and the diameter of the balloon (P =.047). Long-term patency was affected by the site of the obstruction (P <.001) and the balloon inflation time (P <.001). Among the 183 initially ineffective and 88 recurrent cases, 62 underwent repeat balloon dacryocystoplasty, and the initial success rate was 38.7%.

CONCLUSIONS

The initial success rate of balloon dacryocystoplasty is relatively low. However, long-term patency can be expected in cases with initial success. Some additional factors also should be considered for better results.