Punctal stenosis: definition, diagnosis, and treatment

Effects of Cyclosporine Eye Drop Use on the Success of Punctoplasty in Acquired Punctal Stenosis

PURPOSE

To evaluate the effect of cyclosporine-A (CsA) 0.05% eye drops for management of acquired punctal stenosis, either alone or in combination with punctoplasty.

METHODS

In this prospective study patients referred to the oculoplastics clinic with acquired punctal stenosis (APS) were divided into three groups. Group A consisted of patients treated with CsA, Group B consisted of patients who underwent punctoplasty, and Group C included patients treated with both CsA and punctoplasty. Munk score, fluorescein dye disappearence test (FDDT), punctal opening grading were evaluated at baseline, and at the 1st and 6th month follow-ups.

RESULTS

One hundred-eleven eyes of 80 patients were included in the study. While the punctum grade was significantly higher, the FDDT grade and Munk scores were significantly lower in group C compared to groups A and B at the 1st and 6th month follow-ups. The functional success rate was 69%, 79%, and 88% (p = .01), and the anatomical success rate was 77%, 77%, and 90% (p = .03) in Group A, B, and C, respectively, at the 6th month follow-up.

CONCLUSIONS

In the treatment of APS, the use of CsA alone and the punctoplasty procedure demonstrated comparable anatomical and functional success rates at the 6th month follow-up. However, combining CsA with punctoplasty enhances both anatomical and functional success rates.

Topical Cyclosporine and Steroid Treatments: A Comparative Approach to Membranous Punctal Stenosis

Purpose: To compare the efficacy of topical cyclosporine A (CsA) and steroid treatment in the membranous punctal stenosis (PS). Methods: Forty-eight patients with membranous PS were divided into 2 groups: 23 eyes of 13 patients received topical CsA for 6 months as Group CsA and 25 eyes of 14 patients received topical steroid for 3 months as Group S. Examinations were performed before and at 1, 3, 6, and 9 months after treatment. Clinical evaluations involved the Munk score and the fluorescein dye disappearance test (FDDT). Anterior segment optical coherence tomography was employed to measure tear meniscus height (TMH), tear meniscus area (TMA), and outer punctum diameter (OPD). TMH was also examined with biomicroscopy (TMH-Bio). A questionnaire was administered to assess patient satisfaction. Results: Munk score and FDDT grade decreased in both groups at all follow-ups compared with the pre-treatment. TMH-Bio was lower in the Group CsA at all follow-up visits compared with baseline (P < 0.001). TMA and TMH decreased in the Group CsA compared with pre-treatment at 6 months after treatment, whereas there were no changes in the Group S. OPD was larger at 9 months in both groups compared with baseline. The patients' satisfaction was higher in Group CsA at the 6th month compared with Group S. Conclusions: CsA has demonstrated the potential to be a more effective treatment option for the management of PS, with additional advantages compared with topical steroid, such as higher patient satisfaction and favorable functional outcomes.

Could ocular demodicosis be a risk factor for punctal stenosis, dry eye, and blepharitis?

PURPOSE

Demodex, an ectoparasite, can threaten eye health by settling into different eyelash bases. It is particularly suggested to cause dysfunction in the Meibomian glands. This cross-sectional study aimed to investigate the relationships between ocular demodicosis, punctal stenosis, dry eye, and blepharitis.

METHODS

A total of 144 patients who presented to the Ophthalmology Clinic and volunteered to participate in the study were included. The demographic characteristics of the patients, presence of blepharitis, tear breakup time, eye-watering according to Munk's epiphora scoring, and punctal structures according to Kashkouli classification were recorded. Eyelash epilation was performed while preserving the root structure, and the eyelashes were examined under a light microscope. The relationship between Demodex presence and severity with punctal structure, dry eye status, and blepharitis was evaluated.

RESULTS

No significant relationship was found between punctal stenosis and Demodexspp. infestation in both eyes (P > 0.05). Overall, there was a statistical relationship between the presence of Demodexspp. settled in the eyelashes (right lower and upper, left upper eyelid lashes) and dry eye (P < 0.05), but there was no relationship with Demodex density (>3/eyelid). In eyes with blepharitis, especially in patients with anterior blepharitis, the presence and density of Demodexspp. were higher than in patients without blepharitis (P < 0.001 for the right upper, left lower, and upper eyelids, P = 0.001 for the right lower eyelid).

CONCLUSION

Demodex infestations may be associated with blepharitis and dryness of eyes, but there is no association with punctal stenosis.

Evaluation of the lacrimal punctum parameters in Turkish population with anterior segment optic coherence tomography

PURPOSE

To determine the anatomical parameters of puncta in Turkish population without any complaint of epiphora, using anterior segment optic coherence tomography (AS-OCT).

MATERIALS AND METHODS

The healthy participants between 26 and 83 years old who applied to our outpatient clinic from May 2022 to June 2022 for spectacle prescription or the accompanying person of the patients were included in the study. All participants underwent AS-OCT (Revo 60, OPTOPOL Technology, Zawiercie, Poland).

RESULTS

This study included 105 eyes of 53 healthy participants, 27 (54 eyes) of the patients were male and 26 (51 eyes) of them were female with a mean age of 55.6 years (SD: 14.8, Range: 26-83 years). The mean external punctum width and internal punctum width values were 509.1 ± 101.5 μm (222-788 μm) and 229.2 ± 69.2 μm (108-459 μm), respectively. The mean value for vertical canaliculi depth was 637.8 ± 167 μm (337-1045 μm).

CONCLUSIONS

OCT is a non-invasive and objective diagnostic method in the clinical diagnosis and treatment of punctal lesions and provides useful information in terms of visualizing the punctum and vertical canaliculus supplying anatomical data.

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.

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.

Lacrimal Canalicular Wall Dehiscence/Thinning Found in Adults: A Case Series

We retrospectively reviewed the medical records of all patients diagnosed with lacrimal canalicular wall dehiscence/thinning from January 2020 to January 2024 and found three patients. Two patients were male, and the other patient was female. Patient ages ranged from 53 to 82 years. None of the patients had a history of ocular trauma, congenital anomaly, or other ocular diseases except for cataract. All patients complained of epiphora, and the duration of symptom ranged from 15 months to 10 years. Unilateral involvement of the lower canaliculus and isolated single wall involvement affecting only the canalicular roof were observed in all patients. The roof was dehiscent in one case and thinned out in the other two cases. The dehiscent canaliculus was closed by sutures, and the thinned-out canalicular wall of one patient was covered using a conjunctival flap. However, recurrences were noted at two and five months after surgery.

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.

Overview of Epiphora Referred to Oculoplastic Surgery Clinic in Adults

Objectives

The aim of the study was to evaluate etiological and demographic characteristics of the adult patients referred to the oculoplastic surgery clinic of the tertiary care center with the complaint of epiphora.

Methods

The medical records of the patients who applied to the oculoplastic surgery clinic with a complaint of epiphora between January 2014 and July 2021 were reviewed retrospectively. Etiology of epiphora, age, gender, duration of symptom, and follow-up period were evaluated. According to the etiological factors, nasolacrimal system disorders such as punctal stenosis, canalicular stenosis, canaliculitis, and acquired nasolacrimal system obstruction, respectively; the causes of epiphora were grouped as eyelid abnormalities such as entropion and ectropion, and hypersecretory tear secretion due to causes such as dry eye, allergy, and inflammation. The patients with epiphora over the age of 18 with at least 6 months of follow-up were included in the study. Patients with congenital or tumor-related nasolacrimal duct obstruction (NLDO) and epiphora due to trauma-related eyelid or canaliculi injury were not included.

Results

A total of 595 medical fields were evaluated. Epiphora was present in 747 eyes of 595 patients. Of the patients, 221 (37%) were male and 376 (63%) were female. According to etiological evaluation of frequency, 372 (62.5%, 432 eyes) patients with NLDO, 63 (10.5%, 123 eyes) patients with punctal stenosis, 44 (7.3%) patients with ectropion, 38 (6.3%) patients with entropion, 37 (6.2%, 69 eyes) patients hypersecretory causes (dry eye, allergy, inflammation, etc.), 24 (4%) patients had primary canaliculitis, and 17 (2.8%) patients had epiphora due to canalicular occlusion.

Conclusion

Epiphora is an important complaint that may occur due to different etiologies. A detailed examination of the anterior segment, lacrimal system and eyelids, and taking a history are the most important steps in the management of the patient.

Holding back the tears: is there a role for marsupialisation?

Objective

Medial eyelid tumours may result in the loss of the proximal lacrimal system during staged excision and delayed reconstruction, to achieve tumour margin clearance. The remnant canaliculus was marsupialised during reconstruction. The aim was to understand how many patients experienced symptomatic epiphora as a consequence of this.

Methods and analysis

A retrospective study including patients over a 15-year period with medial eyelid tumours, where the proximal lacrimal system was sacrificed to achieve tumour margin clearance. Included were all who had marsupialisation of the remnant distal stump as part of their delayed reconstruction. All who had pre-existing epiphora were excluded. The primary objective was the rate of epiphora following the procedure. A systematic literature review of postoperative epiphora occurring in patients with lid tumours requiring lacrimal system injury/sacrifice during tumour excision.

Results

There were 22 eyes (22 patients). All were basal cell carcinomas except for 1 (4.5%) tarsal conjunctival squamous cell carcinoma. All cases involved the lower lid. There were two (9.1%) patients who developed epiphora. One patient underwent a superior three-snip punctoplasty, botulinum toxin to the lacrimal gland and conjunctivodacryocystorhinostomy with Lester Jones tube insertion. The other patient was not overly troubled and did not require further treatment. The literature review showed the median postoperative rate of epiphora in these patients was 12.5% (range 0%–100%).

Conclusion

Marsupialisation of the remnant canaliculus during delayed reconstruction is a straightforward and effective surgical option, which may help prevent postreconstruction epiphora when the proximal lacrimal system is sacrificed for tumour margin clearance.

Trial registration number

10391.

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.

Dupilumab-associated ocular manifestations: A review of clinical presentations and management

Dupilumab is a first-in-class biologic approved by the European Medicines Agency (EMA) and the US Food and Drug Administration (US FDA) for the treatment of multiple atopic diseases, including atopic dermatitis, asthma, and chronic rhinosinusitis with nasal polyposis. Since gaining traction as an effective treatment modality, multiple reports have highlighted the many ocular side effects associated with dupilumab usage. These range from mild diseases such as conjunctivitis, dry eyes, and blepharitis, to more severe manifestations such as intraocular inflammation and cicatrising conjunctivitis. The pathogenesis behind these manifestations remains controversial but are likely multi-factorial. We review the current evidence surrounding ocular manifestations of dupilumab-associated disease and proposed treatments to provide an overview of this unique disease entity. With increasing usage of dupilumab, formal recommendations regarding the treatment of dupilumab-associated ocular disease are warranted to provide standardised clinical guidance. Furthermore, it is important for healthcare practitioners to remain abreast with existing literature to adequately counsel and empower patients with the knowledge surrounding contemporary treatments for atopic diseases and their associated side-effects.

Changes of Lacrimal Puncta by Anterior Segment Optical Coherence Tomography after Topical Combined Antibiotic and Steroid Treatment in Cases of Inflammatory Punctual Stenosis

Purpose

To evaluate the role of medical treatment and assessing its effect on resolving epiphora and improving punctum size by high resolution AS-OCT imaging comparing punctal parameters in patients before and after treatment with topical combined antibiotic and steroid treatment in cases of inflammatory punctual stenosis. Patients and Methods. Double-blinded controlled randomized study which was conducted on two groups of patients who had acquired punctal stenosis and epiphora presented to Ophthalmology Clinics of Sohag University Hospitals in the period between Jan 2021 and April 2021. The study included 44 eyes of 50 subjects complaining of epiphora. They were divided into two groups, the epiphora group one (EG1) received eye drops containing combination of antibiotics and steroids (orchadexoline eye drops, each ml contains 5 mg chloramphenicol, 1 mg dexamethasone sodium phosphate, 0.25 mg tetryzoline hydrochloride, 2 mg hydroxypropyl methyl cellulose, 10 mg α-tocopherol acetate (vitamin E), and 8 mg macrogol 400), 5 times daily for the first week, three times daily for the next two weeks, and one time daily for another one week. The second epiphora group (EG2) received preservative-free artificial tears (sodium hyaluronate-, polyethylene-, and propylene glycol-based), three times daily for four weeks. The patients were examined before treatment, one week, one month, and one and half months later.

Results

Both groups were comparable regarding mean age (49 ± 13 vs 53 ± 11 years, P value = 0.2) and sex (males were 38.6% vs 31.8%, female were 61.4% vs 68.2%, P value = 0.6), respectively, with no statistically significant difference between both groups. Both groups were comparable regarding outer punctual diameter and length between the puncti before treatment. Outer punctal diameters were (EG1 228 ± 113 um, EG2 241 ± 115 um, P value = 0.5). Length between the puncti were (EG1 129 ± 73 um, EG2 137 ± 72 um, P value = 0.6). There was marked improvement of the outer punctual diameter (EG1 373 um ± 92 um, EG2 240 ± 109 um, (P value < 0.0001) and length between the puncti (EG1 217 ± 109 um, 136 ± 71 um (P value < 0.0002)) during the follow-up period. EG1 showed more improvement than EG2 when compared during the follow-up period.

Conclusions

Topical combined antibiotic and steroid treatment was an effective method in treating cases of inflammatory punctual stenosis as found by monitoring of punctal parameter changes by AS-OCT. AS-OCT was found to be a useful method for evaluation of the lacrimal punctal parameters especially with different treatment modalities in epiphora cases.

Adjunctive Punctal Re-Dilation for Early Postoperative Cicatrization after One-Snip Punctoplasty

OBJECTIVES

This was an assessment of one-snip punctoplasty outcomes in patients for whom adjunctive punctal re-dilatation was performed in-office for early postoperative cicatricial changes.

METHODS

A retrospective analysis was conducted of patients who underwent one-snip punctoplasty between March 2019 and February 2020 due to acquired punctal stenosis. Patients were followed up on the first, third, and seventh postoperative day, then weekly for the remainder of the first month, every 2 weeks over the next month, and then monthly. Punctal re-dilatation was performed if patients showed early clinical signs of re-stenosis. Demographic details, the number and timing of re-dilatation procedures, the timing of re-stenosis, and anatomical and functional success rates were analyzed.

RESULTS

The medical records of 148 eyes of 86 patients were evaluated. A re-dilation procedure was performed in a total of 57 (38.5%) puncta showing signs of early cicatrization. The first punctal re-dilatation was performed at a mean of 17.2±11.3 days (range: 3-57 days). Re-stenosis was observed in 25 puncta (16.9%) at a mean of 5.6±3.1 weeks (range: 2-16 weeks). The anatomical success rate was 83.1% and the functional success rate was 79.1%. There were no significant differences in the anatomical and functional success rates between the patients who did and did not need adjunctive re-dilatation.

CONCLUSION

In-office punctal re-dilatation may improve functional and anatomical success rates after one-snip punctoplasty by preventing recurrent punctal cicatrization.

Kelly Punch Punctoplasty and Simple Punctal Dilatation Are Equally Effective for Punctal Stenosis: A Prospective Study

PURPOSE

To examine the clinical, imaging, and histopathologic differences between Kelly punch punctoplasty and punctal dilatation, both with mini Monoka stent insertion.

METHODS

This is a prospective, comparative clinical study. Patients with bilateral punctal stenosis and for whom surgery was advised participated in the study. The right eye underwent Kelly punch punctoplasty and the left eye simple punctal dilatation, both with mini Monoka stents were participated. Data were collected and analyzed before and 3 months following the procedure and included the degree of epiphora (Munk score) and punctal size as measured by anterior segment optical coherence tomography (AC- OCT). All specimens removed by the Kelly punch punctoplasty were sent for histopathologic evaluation, including Masson's trichome muscle staining.

RESULTS

The study included 46 eyes of 23 patients (4 males and 19 females) whose mean age at presentation was 60.43 ± 14.81 years (range 19-84 years). There was a significant decrease in the Munk score after both punctoplasties compared with baseline values (P < 0.01, matched pairs). There were no significant differences between groups in the delta Munk score. There was a significant increase in punctal size after both procedures compared with baseline values as measured by AS-OCT. Horner-Duverney's muscle was visible in only 3 of the 23 (13.04%) specimens from patients who underwent the Kelly punch punctoplasty.

CONCLUSIONS

The Kelly punch punctoplasty and the simple dilator punctoplasty, both with stents, are equally effective treatments for epiphora due to acquired punctal stenosis. Only a few specimens removed during the Kelly punch method show muscle fibers.

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.

Investigation of the Lower Punctum Parameters: A Spectral Domain Anterior Segment Optical Coherence Tomography Study

Purpose:

To evaluate the dimensions of lower punctum in a sample of Iranian normal population using spectral domain anterior segment optical coherence tomography (OCT).

Methods:

In this cross-sectional study, 102 eyes of 102 healthy volunteers were enrolled. All participants underwent a detailed history and complete ophthalmic examination. Lower punctum metrics were measured using OCT (Spectralis, Heidelberg) with the anterior segment module. External punctal diameter was defined as the largest diameter at the surface of the punctum. Internal punctal diameter was measured at two different depths of 100 μm and 500 μm from the external surface. Measurements were repeated for 30% of data by another grader. The agreement was measured using intraclass correlation coefficient (ICC).

Results:

The mean age of the participants was 61.5 ± 7.9 years. The mean external punctal diameter was 425.6 ± 124.3 μm. The mean internal punctal diameter at 100 μm and 500 μm was 183 ± 97.5 μm and 77.7 ± 51.4 μm, respectively. The agreement between the graders was high in assessing all punctal characteristics (ICC >0.9 for all measurements).

Conclusion:

The spectral domain OCT can be used for measuring lower punctum diameter with acceptable reproducibility.

The relationship between histopathological features and surgical success in primary acquired punctal stenosis

PURPOSE

To investigate the pathophysiology of punctal stenosis based on histopathological features, and to assess the correlation between histopathological findings and treatment outcomes in primary punctal stenosis.

METHODS

A total of 43 eyes of 34 consecutive patients with primary punctal stenosis were included in this prospective study. Punctum specimens obtained by rectangular three-snip punctoplasty (TSP) were examined based on the multilayered structure of the epithelium and subepithelial histopathology. The correlation between the histopathological findings and treatment outcomes was evaluated.

RESULTS

A total of 61.8% of the patients were female and had an average age of 62.4 (41-81) years. Based on the histopathological examination, all 43 puncta consisted of non-keratinized stratified squamous epithelia. Subepithelial pathology demonstrated inflammation in 10 puncta (23.3%), fibrosis in 19 puncta (44.2%) and both inflammation and fibrosis in 11 puncta (25.6%). There was a moderate relationship between the presence of subepithelial fibrosis and symptom duration (r = 0.4, p = 0.03). The surgical success was 88.4% at the mean of 12.4 ± 3.5 months follow-up. The surgical success was clinically lower in the puncta with exhibited fibrosis, although it was not statistically significant (p = 0.6).

CONCLUSION

Although the findings for almost all punctum specimens were consistent with fibrosis, inflammation or both, subepithelial fibrosis was detected as the most common histopathological feature. Clinically lower surgical success rates in puncta exhibiting fibrosis may be associated with a longer duration of symptoms and excessive postoperative healing response.

Lacrimal stenting versus three-snip punctoplasty for treatment of punctal stenosis or occlusion: an open- label, randomized clinical trial

Background

To compare the short-term anatomical and functional outcomes of, as well as patient satisfaction with, lacrimal stenting and three-snip punctoplasty for the treatment of punctal stenosis or occlusion.

Methods

In this open-label, randomized clinical trial, we included 50 eyes of 30 patients diagnosed with punctal stenosis or occlusion. They were randomly allocated to two groups of 25 eyes each, using central telephone randomization. Group A underwent a lacrimal stenting procedure and was subdivided into two subgroups: Group A1 (13 eyes) received polyvinylpyrrolidone-coated perforated punctal plugs, and Group A2 (12 eyes) received closed intubation using a bicanalicular silicon tube. Group B included 25 eyes that underwent three- snip punctoplasty. All eyes were examined after 1 day, 1 week, 1 month, 3 months, and 6 months. Postoperative anatomical success assessing the punctum size, functional success using the fluorescein disappearance test (FDT), and patient satisfaction based on epiphora scoring were recorded.

Results

Both study groups were comparable in terms of sex and age distribution. Compared to Group B, Group A had a significantly larger punctum size at one, three, and 6-month postoperatively (P = 0.009, 0.01, and 0.02, respectively). The difference in FDT results was significant between the two groups at all follow-up visits (P = 0.008, 0.0001, 0.003, and 0.002, at postoperative one week, one-months, three-month, and si-month, respectively). Likewise, patient satisfaction was significantly different between both groups at all follow-up visits (P = 0.007, 0.001, 0.005, and 0.002, at postoperative one week, one-months, three-month, and si-month, respectively).

Conclusions

Lacrimal stenting is an effective method for the treatment of punctal stenosis or occlusion. Overall, the FDT results and patient satisfaction outcomes were significantly better.

Acquired symptomatic external punctal stenosis: a tertiary referral center study

Background

To report the prevalence of acquired symptomatic external punctal stenosis (EPS) in a tertiary referral center in Kuwait, and to study the associated risk factors, etiologies, and management outcomes.

Methods

This prospective interventional hospital-based study was performed at the Farwaniya governmental hospital in Kuwait between November 2018 and November 2019. All patients were referred to the oculoplastic clinic with symptomatic epiphora, age > 18 years, epiphora Munk score ≥ 0, tear film meniscus ≥ 2 mm, and punctum with grade ≤ 2 (smaller than normal size, but recognizable) were included. Eclusion criteria were congenital causes of epiphora, previous eyelid surgeries, and traumatic or neoplastic causes of punctal or canalicular obstruction.

Results

A total of 418 patients with symptomatic epiphora, who were referred to our oculoplastic clinic, were enrolled in our study. The prevalence of EPS was 70.3%. Eamination of the puncta revealed different shapes, including tangential, pinpoint, elevated, slit-shaped, horse shoe-shaped, and membranous puncta, with the tangential type accounting for the greatest proportion (65.3%). Bilateral punctal stenosis was observed in 206 patients (70.1%) and unilateral involvement in 88 patients (29.9%). Dilatation and syringing were performed for all puncta upon diagnosis, and repeated dilatation was performed for 225 puncta (32.7%). Placement of a Mini-Monoka tube was performed in 11 puncta (1.6%).

Conclusions

EPS was a common cause of symptomatic epiphora in our study. Aging and female sex were identified as common risk factors. Most etiological factors of EPS were associated with a pathophysiological inflammatory mechanism. For exact estimates of its prevalence, a population-based study is necessary in future.

Imaging and anatomical parameters of the lacrimal punctum and vertical canaliculus using optical coherence tomography

Purpose: The anatomical parameters of normal lacrimal puncta and vertical canaliculus using optical coherence tomography (OCT) and the OCT imaging features of punctal lesions were analyzed to provide a basis for clinical diagnosis and treatment. Methods: From June to September 2019, 40 volunteers (80 eyes) from Tongji Hospital were enrolled. The external punctal diameter (ELP) was measured using slit-lamp microscopy and OCT. The internal lacrimal punctal diameter (ILP) at 100 μm, vertical canalicular length (VCL), and tear meniscus depth were measured by OCT with open eyes. Twenty-eight volunteers (56 eyes) underwent the same examinations with their eyes closed. The OCT imaging features of 26 patients (27 eyes) with lacrimal lesions were examined. Results: The ELP of the right and left healthy eyes under slit-lamp microscopy were 564.40 and 555.40 µm respectively. Under OCT, the ELP, ILP, and VCL of the right and left eyes were 628.20 um and 616.85 µm, 343.40 µm and 346.95 µm, 731.95 um and 709.20 µm respectively. The ELP was larger when measured by OCT than slit-lamp microscopy (p<0.05). Twenty-eight volunteers (56 eyes) had measurements taken under different conditions. The ELP, ILP, and VCL of the open and closed right eyes were 667.54 and 567.21 µm, 369.18 and 303.18 µm, 715.00 and 417.14 µm, respectively. The ELP, ILP, and VCL of the open and closed left eyes were 655.86 um and 551.68 µm, 369.25 um and 313.54 µm, 719.96 um and 433.89 µm respectively. The anatomical parameters of the open eyes were greater than those of the closed eyes (p<0.05). Thus, we identified the imaging features of lacrimal stenosis, punctal obstruction, punctal tear, lacrimal atresia, and lacrimal mass using OCT. Conclusions: OCT can be used to measure the anatomical parameters of lacrimal puncta and vertical canaliculus in vivo. In addition, OCT can detect punctal lesions in vivo and provide an objective basis for the clinical diagnosis and treatment of punctal lesions.

Medical anti-glaucoma therapy: Beyond the drop

Barriers to effective medical therapy are numerous and include difficulties with effective and sustained control of intraocular pressure (IOP) and adherence to prescribed anti-glaucoma drop regimens. In an effort to circumvent these challenges, a number of new anti-glaucoma therapies with sustained effects have emerged. Methods for sustained delivery of prostaglandin analogs are being intensely investigated and many are in human clinical trials. Intracameral devices include the following: Allergan's Durysta^™ Bimatoprost SR, Envisia Therapeutics' ENV515 travoprost implant, Glaukos' iDose^™ , Ocular Therapeutix's OTX-TIC travoprost implant, and Santen's polycaprolactone implant with PGE2-derivative DE-117. Other prostaglandin-based technologies include Allergan's bimatoprost ring (placed in the conjunctival fornix), Ocular Therapeutics' OTX-TP intracanalicular travoprost implant, subconjunctival latanoprost in a liposomal formulation, and the PGE2 derivative PGN 9856-isopropyl ester that is applied to the periorbital skin. Exciting breakthroughs in gene therapy include using viral vectors to correct defective genes such as MYOC or to modulate gonioimplant fibrosis, CRISPR technology to edit MYOC or to alter aquaporin to reduce aqueous humor production, and siRNA technology to silence specific genes. Stem cell technology can repopulate depleted tissues or, in the case of Neurotech's Renexus® NT-501 intravitreal implant, serve as a living drug delivery device that continuously secretes neurotrophic factors. Other unique approaches involve nanotechnology, nasal sprays that deliver drug directly to the optic nerve and noninvasive alternating current stimulation of surviving cells in the optic nerve. Over time these modalities are likely to challenge the preeminent role that drops currently play in the medical treatment of glaucoma in animals.

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.

Anterior Segment Optical Coherence Tomography (AS-OCT) Guided Reversal of Edematous Punctal Occlusion

Aim

To evaluate the role of anterior segment–optical coherence tomography (AS-OCT) in the diagnosis of punctal stenosis and to compare punctal parameters before and after medical treatment.

Patients and Methods

The study was conducted on 40 eyes of 24 patients who had acquired inflammatory punctal stenosis and had persistent epiphora (persistent epiphora group – PEG), and 20 eyes of 10 subjects with normal punctal openings as a control group (control group – CG). We measured the outer punctal diameter (OPD), recorded the visibility of the internal punctum and punctal depth (PD) using AS-OCT, before and 1 month after treatment with preservative free methylprednisolone 5% eye drops. Punctal diameter, tear meniscus height (TMH) and Munk’s score were compared to the control group before and after treatment.

Results

The mean OPD of the PEG before treatment (455.5 ± 174 µm) was significantly smaller than that of the CG (590.9 ± 106.6 µm) (P= 0.002). The mean OPD of the PEG significantly increased to 484.6 ± 175.5 µm after treatment (P <0.001). Also, the visibility of vertical canaliculus lumen and PD were restored in 70% of eyes. The TMH was much higher in the PEG than in the CG before treatment (P<0.05). However, after treatment the difference was not statistically significant.

Conclusion

AS-OCT parameters were useful in monitoring and measuring the efficacy of medical treatment in relieving punctal edema, which subsequently resulted in reducing the epiphora symptoms.

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.

The clinical and histopathological characteristics of Kelly punch punctoplasty

PURPOSE

To examine the clinical presentation, histopathological characteristics and surgical success of patients that underwent Kelly punch punctoplasty.

METHODS

A retrospective consecutive case series of all patients diagnosed with punctal stenosis and referred to Kelly punch punctoplasty and mini-monoka insertion between January 2017 and December 2017. The demographic, clinical and prognosis parameters were retrieved and analyzed. Moreover, a histopathological examination was performed on the tissue retrieved from the Kelly punch at the end of the procedure in order to evaluate the presence of muscle in the tissue, as well as chronic inflammation.

RESULTS

The series was composed of 44 eyes of 28 patients. All patients' complaints prior to surgery were epiphora: 18 patients had bilateral epiphora, 5 presented with right-eye epiphora and 5 with left-eye epiphora. The average Munk degree of epiphora before surgery was 3 and at least 3 months after surgery 1.04 (matched pairs, p < 0.0001). Two patients underwent the second punctoplasty. In haematoxylin and eosin staining, the Riolan muscle was not visible in the mucosal layer in 40 specimens. In four specimens, the muscle was observed. A Masson's trichrome staining ensured that the Riolan muscle existed only in those four specimens.

DISCUSSION

Kelly punch punctoplasty is a simple and minimally invasive procedure for punctal dilation with high functional success rate. Moreover, in histopathological specimens, in all but four of the cases there was no muscle indicated. Intact Riolan muscle enables the punctum to stay in the right circular shape and position, and the lacrimal pump to maintain its pressure gradient.

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.

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.

Characterizing the Occluded Lacrimal Punctum Using Anterior Segment Optical Coherence Tomography

PURPOSE

Epiphora is sometimes associated with an absent or occluded lacrimal drainage punctum (or puncta). This study uses noninvasive "enhanced depth" anterior segment optical coherence tomography (OCT) to give improved characterization and understanding of absent or fully occluded puncta and the underlying canaliculus.

METHODS

Anterior segment spectral domain OCT images were collected prospectively from 9 lower puncta of 6 patients with epiphora and absent or fully occluded puncta, not amenable to dilation in clinic, to see if a canaliculus was visible on OCT imaging below the occluded punctum.

RESULTS

An epithelial lined canalicular lumen was visible on OCT in 4 lower eyelid puncta from 2 patients and OCT identified 80% (4/5) of the canaliculi that were located on microscope-assisted punctal exploration. These lumens were seen within 580 μm depth from the eyelid margin surface. A half of the eyes in which a canaliculus was identified on OCT (the 2 eyes in a single patient) had resolution of epiphora following punctoplasty, and the other patient was found to have coexisting nasolacrimal duct stenosis and required later dacryocystorhinostomy. The positive predictive value for identifying a canaliculus on lower eyelid punctal exploration in acquired complete punctal occlusion (excluding the congenital case) was 1, with a negative predictive value of 1.

CONCLUSIONS

This study demonstrates that canaliculi can be imaged with OCT where formal access is precluded by an occluded punctum. This noninvasive investigation might help predict the likelihood of successful retrieval of a canaliculus at surgical exploration.

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.

Scaling the punctum and canaliculus in patients undergoing punctoplasty surgery: A prospective cohort study

Optical Coherence Tomography (OCT) is a safe and non-invasive method of high-resolution cross-sectional imaging of tissue microstructures using infrared radiation. This study investigates how the appearance of the punctum and proximal canaliculus differs pre- and post-operatively in patients undergoing punctoplasty surgery. Patients with symptomatic punctal stenosis warranting punctoplasty surgery were prospectively invited to enrol from a single centre. Spectral OCT images of the lower punctae were captured with a Topcon 3D OCT 2000 machine pre- and post-operatively (at their follow-up appointment). Measurements were made of the maximal punctal diameter, canalicular diameter and canalicular depth. Pre- and post-operative measurements were compared using a paired t-test. Twenty-three punctae of 18 patients with punctal stenosis were included in the study. They were 10 males and 8 females with a median age 71.0 (SD 12.1). Mean canalicular cross-sectional area was 56.9 × 10-3 mm² pre-operatively and 267.2 × 10-3 mm² post-operatively, showing a statistically significant increase (p = 0.0004). There was an increase in both mean canalicular width (0.253 to 0.524mm (p = 0.0001)) and depth (0.433 to 0.852mm (p = 0.0001)) from pre- to post-operatively. There was a significant improvement in symptoms from pre- to post-operatively, as measured subjectively by the Lac-Q questionnaire (p = 0.021). This study describes the change in the appearance of the punctum and proximal canaliculus in patients undergoing punctoplasty operations, by using spectral OCT to capture in vivo high-resolution images. It demonstrates that punctal OCT can be successfully applied to quantify the morphological changes of the punctum and canaliculus pre- and post-punctoplasty.

Changes of meibomian glands in the early stage of post hematopoietic stem cell transplantation

Hematopoietic stem cell transplantation (HSCT) is the most effective cure for hematologic malignancies. Graft-versus-host disease (GVHD) is a major complication following allogeneic HSCT, which significantly affects non-relapse mortality. And ocular manifestations of GVHD are known to occurin 60-90% of patients with chronic GVHD. Although the pathogenesis of ocular GVHD is not clearly known, it is known to progress into inflammation and fibrosis through presentation of antigens on CD4 and CD8 T cells. There is much evidence that the ocular surface and meibomian glands are severely damaged in ocular GVHD patients, and there are few observational studies on the early changes. In this review, we will discuss the various changes in the meibomian glands and ocular surface, and tear dynamics in the early stage following HSCT. These results show that tear film break-up time (TFBUT) decreased and the corneal staining score was significantly higher 2-3 months after HSCT. The upper eyelid and total eyelid meiboscore increased after 3 months following HSCT. The information of the early changes of meibomian glands morphology would be helpful to further examine the pathogenesis of meibomian gland dysfunction.

Evaluation of planned bicanalicular nasolacrimal tube retention in treating punctal stenosis or occlusion secondary to trachoma

This article evaluates retaining bicanalicular silicone nasolacrimal tube in patients susceptible to restenosis after punctoplasty. Sixty-nine eyes (38 patients) suffering from epiphora due to stenosis or occlusion of both punctae were included in this prospective study. All had 3 snip punctoplasty and bicanalicular silicone nasolacrimal duct insertion. Cases associated with proximal canalicular stenosis or obstructions were excluded. Tolerance to tube presence until the time of loss or removal was evaluated using a score (0 to 2). Average age was 49.71 ± 11.09 years. Tachomatous lesions were detected in all cases of punctal stenosis (48 eyes/69.57%) and membranous occlusion (21 eyes/30.43%). Common canalicular obstruction was additionally found in 12 eyes (17.39%). Absolute improvement was detected in 85% of cases and mean time for tube retention was (29.6 ± 10.2 months) with no difference in presence of common canalicular obstruction (P value: 0.138). Isolated punctal affection favoured tube retention that was well tolerated throughout the follow-up period (P value <0.001). Silicone bicanalicular nasolacrimal tube is an available option for treating acquired punctal stenosis. It is tolerated especially in cases suffering from isolated punctal stenosis. Tube retention could be of value in patients who are at risk of re-occlusion following tube removal.

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.

How Important Is the Etiology in the Treatment of Epiphora?

Purpose. There are several etiological factors that cause epiphora, and treatment differs according to the cause. We aimed to evaluate the etiology of epiphora and the treatment modalities of the affected patients. Materials and Methods. Data of patients who were referred to ophthalmology clinics for epiphora were retrospectively analyzed. All patients were evaluated for epiphora etiology, treatment modalities, and duration of complaints, after complete ophthalmologic examination. Results. This study consisted of 163 patients with a mean age of 64.61 ± 16.52 years (range 1-92 years). Lacrimal system disease (48.4% [79/163]) was the most common cause, followed by ocular surface disease (dry eye/blepharitis) (38.7% [63/163]). Among the patients included in this study, 69% (113/163) did not receive any treatment, whereas only 1.8% (3/163) were treated surgically. About 4.3% of the patients (7/163) had a complaint for more than 5 years (p = 0.012) and six of these had chronic dacryocystitis and one had ectropion. Conclusion. Epiphora not only has a negative impact on patients' comfort, but also puts them at risk for probable intraocular operations in the future. Therefore, the wide range of its etiology must be taken into consideration and adequate etiology-specific treatment options must be applied.

Immunopathology and histopathology of conjunctival biopsies in patients with presumed idiopathic punctal stenosis

BACKGROUND/AIMS

Numerous processes have been implicated as causes of punctal stenosis. Recent studies have highlighted inflammation in punctoplasty specimens in patients with punctal stenosis. Conjunctival biopsy has been suggested as a means to determine underlying aetiologies, although little is known regarding what conjunctival pathologies are associated with punctal stenosis. Our objective is to examine the pathological and immunological findings in conjunctival biopsy specimens in patients with presumed idiopathic punctal stenosis.

METHODS

A retrospective chart review was performed at a single institution over a 5 year period of patients with presumed idiopathic punctal stenosis who underwent conjunctival biopsy for histopathological and/or direct immunofluorescence (DIF) examination. Patients with known aetiologies of punctal stenosis were excluded.

RESULTS

23 patients met inclusion criteria. Conjunctival biopsies (n=36) from all 23 patients underwent histological examination. 35 specimens (97.2%) showed lymphocytic infiltrates. Two patients (8.7%) had findings suggestive of sarcoidosis. Conjunctival biopsies from 18 of the 23 patients were also evaluated by DIF. Nine patients (50.0%) had fibrinogen characteristics suggestive of lichen planus. There were no complications related to the conjunctival biopsy procedures.

CONCLUSIONS

Conjunctiva appears to be an excellent proxy in evaluating patients with presumed idiopathic punctal stenosis. The biopsy is safe and provides ample tissue. Clinically, abnormal tissue should be targeted, if available. 11 of the 23 patients in this study demonstrated findings consistent with underlying immunological disorders, suggesting that conjunctival biopsy may play a role in identifying underlying aetiologies of punctal stenosis. Knowledge of these underlying conditions impacted treatments for several patients.

Management of acquired punctal stenosis with perforated punctal plugs

Purpose

To evaluate the efficiency of perforated punctal plug in acquired punctal stenosis.

Materials and methods

Forty-five eyes of 33 patients who had epiphora due to punctal stenosis were included in this study. After biomicroscopic examination and lacrimal dilatation punctal stenosis was managed with the perforated punctal plugs in all patients. In the following period epiphora, plug tolerance, lacrimal drainage were evaluated and graded. Lacrimal drainage was evaluated with fluorescein dye disappearing test.

Results

The age of the patients ranged between 31 and 80 (mean 55.78 ± 13.11). Preoperatively punctal dilatation and lacrimal system irrigations were performed on all patients. Lacrimal system irrigation was positive in all patients. Perforated punctal plugs were placed in the inferior puncti in all patients. The plugs were explanted 6 months after operation. The follow-up period ranged between 6 and 24 months. Plug tolerance was good in 97.8% of the eyes in the 1st month visit. Epiphora decreased remarkably in 88.9% of the patients 1 month after plug implantation, except one whose plug dropped off spontaneously in 2 weeks. Fluorescein disappearing times were found under 3 min in 97.8% of the eyes after plug explanations.

Conclusion

Punctum stenosis is one of the several disorders that cause lacrimal drainage obstruction. Perforated punctal plugs are found convenient and effective in managing punctal stenosis.