An effective approach for the treatment of severe punctal stenosis: Bicanalicular silicone tube intubation with pigtail probe

PURPOSE

To evaluate the results of using a pigtail probe to open the inferior punctum followed by bicanalicular silicone tube intubation in patients with severe acquired punctal stenosis.

METHODS

Forty-one eyes of 25 patients with severe inferior punctal stenosis admitted to our tertiary care center were included in the study. The degree of epiphora was determined using the Munk score and the fluorescein disappearance test. The inferior punctum was located and opened by entering the superior punctum with a pigtail probe. Then, bicanalicular silicone tube intubation was performed. The silicone tube was removed after six months. A Munk score of 0 or 1 and a fluorescein disappearance test score of 1 and 2 were considered a complete success.

RESULTS

Ten (40%) patients were male, and 15 (60%) were female. The mean age was 60.4±15.5years. One year after the surgery, epiphora was absent in 18 eyes (43.9%) (Munk score grade 0) and rarely seen in 9 eyes (22%) (Munk score grade 1). At the one-year follow-up, the fluorescein disappearance test score was stage 1 (<3min) in 21 eyes (51.2%) and stage 2 (3-5min) in 13 eyes (31.7%). There was a statistically significant difference between the preoperative and one-year postoperative test results (P<0.001).

CONCLUSION

In cases with severe punctal stenosis, a pigtail probe is an effective method for locating and opening the punctum, and punctal opening and prevention of restenosis were achieved by a bicanalicular stent.

Three-snip punctoplasty versus perforated plugs for management of lacrimal punctal stenosis

PURPOSE

To compare rectangular three-snip punctoplasty and polyvinylpyrrolidone-coated perforated punctal plugs for treatment of acquired lacrimal punctal stenosis.

PATIENTS AND METHODS

In a prospective comparative non-randomized interventional study, 80 eyes with acquired lacrimal punctal stenosis were classified into two groups. Group A was treated by insertion of polyvinylpyrrolidone-coated perforated punctal plugs (FCI ophthalmics)™ and Group B was treated by rectangular three-snip punctoplasty. The study was done in Minia University Hospital between January 2018 and April 2019. Exclusion criteria included allergic punctal stenosis, lid malposition, and lacrimal obstruction distal to the punctum. All patients were subjected to complete history taking, slit lamp examination of tear meniscus height, fluorescein dye disappearance test, punctal position, shape, size, grading of stenosis, and grading of epiphora.

RESULTS

The mean age of the patients was 43.85 ± 14.93 years. They were 30 females and 10 males. Eepiphora Grade 3 or 4, improved postoperatively to Grade 0 or 1 in 97.5% of eyes in Group A versus 55% of eyes in Group B. All eyes (100%) in Group A versus 21 eyes (52.5%) in Group B improved regarding fluorescein dye disappearance test grade (p < 0.001). Restenosis did not occur after plug removal, while it occurred in 10% of eyes subjected to three-snip punctoplasty.

CONCLUSION

Perforated punctal plugs and three-snip punctoplasty are safe and effective in treatment of punctal stenosis. However, perforated plugs are less invasive, better tolerated, and have more stable results compared to three-snip punctoplasty.

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.

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.

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.

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.

Assessment and management of proximal and incomplete symptomatic obstruction of the lacrimal drainage system

Epiphora is a common complaint of patients who present to an Ophthalmology Clinic. In many cases, epiphora is due to an obstruction in the lacrimal drainage system. However, a subgroup of symptomatic patients with epiphora has a patent lacrimal drainage system. Such cases are usually termed ‘functional obstruction’ and / or ‘stenosis of the lacrimal drainage system’. Various etiologies and diagnostic and therapeutic approaches have been described in literature, which implies the lack of a standardized approach. This article will review the evolving diagnostic and therapeutic approaches in literature, and in the end, propose a paradigm in approaching this group of patients.