Perforated punctal plugs with adjuvant use of mitomycin-C in management of acquired external punctal stenosis grades 0 and 1.

OBJECTIVE: To evaluate the use of perforated punctal plugs with adjuvant application of mitomycin-C in the management of acquired external punctal stenosis grades 0 and 1. METHODS: This is a prospective interventional case series including 30 eyes of 30 patients with acquired external punctal stenosis of the lower punctum of grades 0 and 1 presenting with epiphora. They were examined to exclude other causes of lacrimation and epiphora: Slit-lamp assessment of the stenosed punctum and grading was done, probing was done to exclude associated canalicular stenosis, and syringing was done to exclude nasolacrimal duct obstruction. For all cases, dilatation was done, followed by application of mitomycin-C, and perforated punctal plugs were then inserted. Plugs were removed after 6 months, and anatomical and functional success were assessed and followed during and for 6 months after removal of the plugs. RESULTS: The study included 30 patients with acquired external punctal stenosis: 9 males (30%) and 21 females (70%) with a mean age of 62.83 ± 8.3 years. Punctal stenosis grade 0 (no punctum) occurred in 9 cases (30%), and grade 1 (the punctum is covered by a membrane) occurred in 21 cases (70%). Six months after removal of the plugs, epiphora improved in 93.3% of patients, and fluorescein dye disappearance test results improved in 90% of patients; 6.7% of cases had early extrusion of the plug, and 3.3% had granuloma formation. CONCLUSIONS: Application of perforated punctal plugs combined with mitomycin-C is a simple and efficient technique in the management of tight acquired external punctal stenosis.

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.

[Comparison of balloon catheter dilatation and silicon intubation as the secondary treatment for congenital nasolacrimal duct obstruction after failed primary probing].

OBJECTIVE: To determine the success rates and compare the results of balloon catheter dilation and nasolacrimal intubation as treatment for congenital nasolacrimal duct obstruction after failed probing, stratified by category of age and type of obstruction. METHODS: It was a prospective, randomized, clinical trial that enrolled 189 children (245 eyes) aged between 6 months to 48 months who had a history of failed nasolacrimal duct probing. All eyes underwent either balloon catheter nasolacrimal duct dilation or nasolacrimal duct intubation randomly. The eyes were divided into 2 age categories: category 1 (6-24 months) and category 2 (>24 months) and into 2 types of obstructions: simple obstruction and complex obstruction. Treatment success was defined as absence of epiphora, mucous discharge, or increased lacrimal lake at the outcome visit 6 months after surgery. Complications were also compared. RESULTS: In 124 eyes treated with balloon catheter dilatation, 112 were successful (90.3%) comparing with 106 successful eyes (87.6%) in 121 eyes treated with nasolacrimal duct intubation. The risk ratio for success between intubation and balloon dilation was 0.971, and the 95% confidence interval was 0.95-1.22. Within each age category, the success rate varied but did not show significant difference: In those under 24 months, success rate was 89.7% in 97 eyes treated with intubation, and 91.9% in 99 eyes treated with balloon dilation (RR, 0.976; 95% CI, 0.590-0.956). In those above 24 months, success rate was 79.1% in 24 eyes treated with intubation, and 84.0% in 25 eyes treated with balloon dilation (RR, 0.942; 95%CI, 0.813-1.387). In the group of simple obstruction, success rate was 96.5% in 87 eyes treated with intubation, and 93.1% in 88 eyes treated with balloon dilation (RR, 1.036; 95% CI, 0.967-1.105). In the group of complex obstruction, Success rate was 64.7% in 34 eyes treated with intubation, and 86.1% in 36 eyes treated with balloon dilation. The success rate of balloon dilatation showed slightly higher than that of intubation (RR, 0.751; 95% CI, 0.590-0.956). There were 59 eyes showed complications in intubation group, while only 2 eyes in balloon dilation group. CONCLUSIONS: Both balloon catheter dilation and nasolacrimal duct intubation could alleviate the clinical signs of persistent nasolacrimal duct obstruction with a similar percentage of patients. In the complex obstruction group, balloon catheter dilation showed better efficacy than nasolacrimal duct intubation.

[Impact of lacrimal obstruction type on the efficacy of probing for congenital nasolacrimal duct obstruction].

OBJECTIVE: To explore the impact of lacrimal obstruction type on the efficacy of lacrimal probing in the treatment of congenital nasolacrimal duct obstruction. METHODS: We conducted a retrospective study in which 872 eyes of 741 children with congenital nasolacrimal duct obstruction underwent nasolacrimal duct probing under superficial anesthesia. Two types of obstructions were encountered during probing, i.e. simple and complex. They were divided into early (4 - 12 months) and late (1 - 4 years) groups based upon the age at the time of initial probing. Those refractory to the first probing underwent a second probing 4 weeks later. The main observation criterion was the success rate of probing. RESULTS: The success rate was 90.0% in early group versus 70.4% in late group (χ(2) = 38.527, P < 0.01). No significant difference existed in the cure rate of simple or complex obstruction between two groups (χ(2) simple = 0.054, P = 0.815, χ(2) complex = 1.705, P = 0.192). The proportion of simple obstruction was 94.4% in early group versus 62.2% in late group. Difference was statistically significant (χ(2) = 125.471, P < 0.01). The success rate of a second probing of simple obstruction was 61.9% in early group versus 68.2% in late group (χ(2) = 0.324, P = 0.569). The success rate of a second probing of complex obstruction was 19.2% in early group versus 5.7% in late group (Fisher's exact test, P = 0.125). For either group, the success rate of a second probing of simple obstruction was higher than that of complex obstruction (χ(2) early group = 16.100, P < 0.01; χ(2) late group = 25.186, P < 0.01). CONCLUSION: Unsuccessful probing may result from the selection of complex obstructions. Probing should remain the first-line treatment in children above 1 year of age. The success rate with a second probing was significantly lower in patients of complex obstruction. Other surgical interventions, such as silicone tube intubation or balloon dacryocystoplasty, should be recommended instead of repeated probing for the patients of complex obstruction if an initial probing fails.

Perspective: what does the term functional mean in the context of epiphora?

The term 'functional block' is used to encompass the concept of lacrimal drainage dysfunction in the presence of anatomical patency. There is significant variability in the nomenclature, clinical and investigative criteria used in the literature to define this entity. This has led to confusion and lack of comparability of studies looking at this group. The clinical features, investigative findings and treatment options in this group of patients are described. In addition, the need to differentiate between nasolacrimal stenosis and 'functional block' is emphasized, as evidence suggest patients with nasolacrimal duct stenosis have better outcomes with dacryocystorhinostomy. To better define the disease entity and enable comparability of future studies, it was proposed that this entity be replaced by the term functional epiphora with no delay, pre- or post-sac delay.

External lacrimal punctum grading: reliability and interobserver variation.

PURPOSE: To test the reliability and interobserver variation of external lacrimal punctum (ELP) grading. METHODS: In a population-based epidemiologic study, ELP was visually graded based on slit lamp examination (grade 0 to 5), as described previously. Grades 0, 1, and 2 are for closed or stenotic ELP and grade 3 is for normal ELP (subjective grades). Grades 4 and 5 are for larger than normal (slit) ELP measured in millimeters by slit lamp beam (objective grades). Upper and lower ELP were graded by an oculoplastic surgeon and a senior ophthalmology resident. Both observers were masked to the reading of the other. Both observers were familiar to the grading system for past few years, although the oculoplastic surgeon had more experience in this regard. Patients with previous periocular surgery, medial lid mass obscuring the ELP, anatomically distorted punctum, and subjects with grade 4 and 5 ELP (objective grades) were excluded. The intraclass correlation coefficient test was used for the statistical analysis. RESULTS: There were 632 eyes from 174 (55.10%) male and 142 (44.90%) female subjects. Subjects' ages ranged from 7 to 87 years (mean +/- SD = 54+/-17.56). The intraclass correlation coeficient test showed a positive and strong correlation between two observers for grading the upper (value=+0.87, 95% CI: 0.84 and 0.88, p=0.000) and lower (value=+0.91, 95% CI: 0.90 and 0.92, p=0.000) ELP. In general, the less experienced observer tended to overestimate both upper and lower ELP grading. CONCLUSIONS: Reliability of the new ELP grading makes it a recommendable option for use in the clinic and comparing reports on ELP pathologies.

Blind canalicular marsupialization in complete punctal absence as part of a systematic approach for classification and treatment of lacrimal system obstructions.

The procedure of choice for epiphora caused by bipunctal and canalicular obstruction is conjunctivodacryocystorhinostomy. Despite its high success rate, it may result in multiple complications, such as extrusion, migration, and secondary obstruction. The author describes a simple alternative procedure to conjunctivodacryocystorhinostomy for patients with epiphora caused by bipunctal and proximal canaliculus complete occlusion and a systematic approach to treat lacrimal system obstructions. Ten instances of bipunctal and proximal canaliculus absence in five consecutive patients, caused in four patients by ocular surface disorders (topical drug toxicity, herpetic keratoconjunctivitis, and trachoma), were treated by blunt dissection of the presumed lower punctal site under a surgical microscope. The punctal site was determined by several landmarks, the peaked medial lid margin, a dimple at that site, or an area of relative avascularity. The canaliculus was exposed and expanded to create a pocket. After the procedure, the lacrimal drainage system was found patent in nine of the 10 procedures. After one additional procedure, irrigation of the lacrimal drainage system revealed a nasolacrimal duct obstruction that was treated with dacryocystorhinostomy and silicone tube insertion. After these procedures, an objective resolution of the epiphora was noted in all patients. Epiphora resulting from lack of punctal and proximal canaliculus caused by ocular surface diseases may be treated with blind exposure and marsupialization of the proximal canaliculus instead of conjunctivodacryocystorhinostomy. If, in addition, the nasolacrimal duct is obstructed, a dacryocystorhinostomy may be performed. If this proposed procedure fails, the patient can still undergo conjunctivodacryocystorhinostomy or other procedures. The procedure may be part of a systematic approach to treat lacrimal drainage obstructions that is based on an association between the location and the cause of the obstruction.

Obstruçäo primária do ducto nasolacrimal: proposta de classificaçäo histopatológica / Primary acquired nasolacrimal duct obstruction: proposal of histopathological classifiction

Com o objetivo de determinar e classificar as alteraçöes histológicas que ocorrem na obstruçäo primária do ducto nasolacrimal, realizou-se estudo prospectivo de 51 espécimens biopsiados durante a dacriocistorrinostomia via externa, de 50 indivíduos portadores de obstruçäo primária do ducto nasolacrimal. Os ductos foram classificados em três padröes histopatológicos: inflamável crônico sem obliteraçäo fibrosa ductal (31,4 por cento). Houve associaçäo positiva entre o padräo inflamatório crônico com obliteraçäo fibrosa ductal e ausência de epitélio da mucosa. Os três padröes histopatológicos näo mostraram diferença quando comparados em relaçäo ao tempo de evoluçäo dos sintomas

Acquired lacrimal drainage obstruction: an etiologic classification system, case reports, and a review of the literature. Part 1.

The cause of acquired lacrimal drainage obstruction may be primary or secondary. Primary acquired nasolacrimal duct obstruction results from inflammation of unknown cause that eventually leads to occlusive fibrosis. Secondary acquired lacrimal drainage obstruction, the theme of this report, may result from a wide variety of infectious, inflammatory, neoplastic, traumatic, or mechanical causes. An etiologic classification system for acquired lacrimal drainage obstruction is proposed, and it is illustrated by representative patients from the author's practice and discussed with reference to published reports.