Canalicular Stenosis Research Articles

Radiation-Induced Acquired Lacrimal Drainage Obstructions: Management and Outcomes

ABSTRACT Objective To describe the management and outcomes of patients with radiation-induced acquired lacrimal duct obstructions (RALDO). Methods A retrospective chart review from July 2018 to December 2023 of all cases undergoing surgical intervention for RALDO by a single surgeon. Data collected included demographics, tumor type and anatomic location, radiation treatment (including radiation type, dosage, and duration), interval between radiation and reported onset of epiphora, oculoplastic clinical examination, management, and outcomes. Lacrimal irrigation was done prior to surgery in all patients. Results Seventeen eyes of 16 patients with a mean age at presentation of 63.3 years and over half the patients being females (56.3%) were included in the study. The right lacrimal drainage system (LDS) was involved in 4 (23.6%), and the left side was involved in 13 (76.4%). The mean onset of epiphora symptoms after radiation was 9.5 months. The underlying tumor type were intraocular having uveal melanoma in four, cutaneous squamous cell carcinoma in 2, basal cell carcinoma involving forehead and nose in one and sino-nasal indications present in 8 patients. One patient had metastasis to the orbit and eyelid. Four patients (25%) received external beam radiotherapy (XRT) (one case had bilateral LDS involvement), 6 patients (37.5%) received intensity-modulated radiation therapy (IMRT), 5 patients (31.25%) received proton beam irradiation (PBI), and one (6.25%) received stereotactic body radiotherapy (SBRT). Mean radiation dosage was 61.31 Gy in 15 patients (data was missing in 1 patient). Punctum was effaced in 3, canalicular stenosis in 1, proximal canalicular obstruction in 8, distal canalicular obstruction in 2, and nasolacrimal duct obstruction (NLDO) in 3. Treatment was based on the site and nature of obstruction and varied from minimally invasive techniques like serial dilatation with bicanalicular silicone tube or Guibor tube to surgical interventions like dacryocystorhinostomy (DCR) or conjunctivo-dacryocystorhinostomy (C-DCR). Only 10% with primary lacrimal intubation had good response. Of the six cases that underwent C-DCR with Jones tube either as primary or secondary procedure, four cases showed improvement in epiphora (67%). Three with NLDO did well after external DCR. In total, four patients had a secondary procedure after the first failed while 7 with failed initial surgery elected against secondary surgery. The mean follow-up was 9.6 months (range 2–24 months). Conclusions In patients with RALDO, salvage treatment with silicone lacrimal intubation has poor results, CDCR with Jones tube has better results, although imperfect and in cases with NLDO, DCR has good outcomes.

Retrospective study in 1020 cases on the rate of surgical site infections after lacrimal surgery without prophylactic systemic antibiotics.

Data regarding the effectiveness of prophylactic systemic antibiotics (PSA) in lacrimal surgery is scarce. Therefore, we determined the postoperative surgical site infection (SSI) rate in lacrimal surgery without PSA. We retrospectively analysed files of patients who underwent external (extDCR) or endoscopic endonasal dacryocystorhinostomy (endoDCR). We excluded patients with incomplete data (n = 68), acute a priori infection with the need for antibiotics (n = 15) and PSA post-operatively for other reasons (n = 28). Indications for surgery were canalicular stenosis (n = 51, 18.6% endoDCR vs n = 131, 19.5% extDCR), nasolacrimal duct obstruction (n = 118, 43.2% endoDCR vs n = 480, 64.3% extDCR) and mucocele/chronic dacryocystitis (n = 52, 19.0% endoDCR vs n = 187, 25.0% extDCR). In this study, 1020 DCR surgeries were performed in 899 patients. Postoperative SSI was diagnosed in eight patients (0.8%); exclusively after extDCR (1.1% of all extDCR). No SSIs were found in endoDCR cases. The prevalence between SSI in extDCR versus endoDCR did not prove significant (n = 8/747 0.8% vs n = 0/273 0%, p = 0.13). All patients diagnosed with SSI were successfully treated with systemic oral antibiotics. The prevalence of SSI after DCR is low and was effectively treated with oral antibiotics. In our study, SSI occurred rarely after extDCR and was not observed after endoDCR. We conclude that lacrimal surgery is safe without the routine administration of PSA.

Lacrimal Drainage Anomalies in Goldenhar, Rubinstein-Taybi, and Ectodermal-Ectrodactyly-Clefting Syndromes.

To describe in detail the lacrimal drainage system anomalies and review of literature in patients with Goldenhar syndrome, Rubinstein-Taybi syndrome (RTS), and Ectodermal-Ectrodactyly-Clefting syndrome (EECS), their management and outcomes. A retrospective chart review from January 2011-June 2023 of all cases presenting to the Dacryology clinic with Goldenhar syndrome, RTS, and EECS was obtained. Data collected included demographics, laterality, clinical presentations, proximal and distal lacrimal drainage anomalies, associated systemic features, management, and outcomes. Eight children with Goldenhar syndrome (n = 13), three with RTS (n = 5) and three with EECS (n = 5) presented with lacrimal drainage system involvement. Cases with Goldenhar syndrome showed male predominance (5/8), and the mean age at presentation was 14.75 months. Four cases had simple CNLDO, seven cases with complex CNLDO (4 - buried probe and 3 - atonic sacs) and a single neonate presented with bilateral dacryocele. Patients with RTS presented with mean age of 36.33 months with male predominance. Probing under endoscopic guidance explored the anatomy thoroughly and those with altered nasal anatomy increased the probability of complex CNLDO. Those with EECS (n = 5) presented with a greater involvement of proximal lacrimal drainage system compared with Goldenhar syndrome and RTS, including anomalies like punctal agenesis, incomplete punctal canalization (IPC), ectopic puncta, canalicular stenosis, and complex CNLDO. A step-wise approach to assessing the proximal and lacrimal drainage system in those affected with craniofacial malformations and addressing them can result in satisfactory outcomes for the majority of patients.

Long-term Results of Punctoplasty With Canalicular Triangular Flap in Punctal Stenosis.

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. 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. 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. 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.

Punctal and Canalicular Stenosis Following Topical 1% 5-Fluorouracil Eye Drop Therapy for Ocular Surface Squamous Neoplasia.

To present the first known cases of punctal and canalicular stenosis following topical 5-fluorouracil (5-FU) eye drops for ocular surface squamous neoplasia (OSSN). A retrospective chart review of patients with OSSN receiving topical 1% 5-FU eye drops as a primary or adjuvant treatment between 2013 and 2021 was performed. Individuals diagnosed with punctal or canalicular stenosis during or after topical 5-FU use were included in this study. Four individuals met these criteria; we report clinical findings and treatment course for each patient. We reviewed 303 patients (316 eyes) with OSSN. All patients were treated with topical 1% 5-FU eye drops in cycles, given 4 times daily for 1 week with 3 weeks off. Four patients (5 eyes) developed punctal stenosis, for a frequency of 1.3%. The mean age at 5-FU initiation in the 4 individuals was 61 years (range 53-69). Most individuals were male (75%), White (75%), and non-Hispanic (100%). The most common presenting symptom of stenosis was epiphora, noted 4.6 ± 3 months after initiating topical 5-FU (after 4.9 ± 2.0 cycles). This occurred in 4 eyes while on therapy (3, 2, 4, and 4 months since 5-FU initiation) and in 1 eye after stopping therapy (10.3 months since 5-FU initiation). In 1 eye, punctal stenosis and epiphora resolved spontaneously after stopping 5-FU. Punctal dilation led to symptom resolution in 2 eyes. Surgical intervention (punctoplasty and external dacryocystorhinostomy) was needed in 2 eyes for punctal and canalicular stenosis, respectively. Punctal or canalicular stenosis is a rare and previously unreported adverse effect of topical 5-FU that may require surgical treatment.

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.

Outcomes of 8 × 8 mm osteotomy in powered external dacryocystorhinostomy.

To study the endoscopic ostium characteristics and outcome of 8 × 8 mm osteotomy in external dacryocystorhinostomy (DCR) using the microdrill system. This prospective interventional pilot study was performed on 40 eyes of 40 patients with primary acquired nasolacrimal duct obstruction (NLDO) from June 2021 to September 2021 in patients undergoing external DCR. An 8 × 8 mm osteotomy was performed using round, cutting burr attached to a microdrill system. Success was defined as patent ostium on lacrimal syringing (anatomical) and a Munk score <3 (functional) at 12 months. Postoperative endoscopic ostium evaluation was done using a modified DCR ostium (DOS) scoring system at 12 months. The mean age of the study participants was 42.41 ± 11.77 years and the male-to-female ratio was 1:4. The mean duration of surgery was 34.15 ± 1.66 minutes and that for osteotomy creation was 2.5 ± 0.69 minutes. The mean intraoperative blood loss was 83.37 ± 11.89 ml. Anatomical and functional success rates were 95% and 85%, respectively. The mean modified DOS score was "excellent" in 34 patients (85%), "good" in 1 patient (2.5%), "fair" in 4 patients (10%), and "poor" in 1 patient (2.5%). Complications included nasal mucosal injury in 10% (4/40) of patients, complete cicatricial closure of ostium in 2.5% (1/40), incomplete cicatricial closure in 10% (4/40), nasal synechiae in 5% (2/40), and canalicular stenosis in 2.5% (1/40). An 8 × 8 mm-sized osteotomy created by powered drill and covered by lacrimal sac-nasal mucosal flap anastomosis in external DCR is an effective technique that has minimal complications and shorter surgical time.

Overview of Epiphora Referred to Oculoplastic Surgery Clinic in Adults.

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. 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. 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. 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.

Effect of Topical 5-Fluorouracil on Lacrimal Drainage System: Histopathological Evidence From Animal Experiments and Potential Clinical Implications.

The purpose of this study is to investigate the histopathological changes in the lacrimal drainage system of rabbits following the application of 1% topical 5-fluorouracil (5-FU) for 4 weeks. Ten eyes of 10 healthy New Zealand white rabbits were subjected to topical instillation of 1% (10 mg/mL) 5-FU, 1 drop 4 times a day for 4 weeks. Rabbits underwent a detailed ocular examination including eyelids, ocular surface, punctal, peri-punctal changes, and nasolacrimal duct patency at baseline and after 4 weeks of 5-FU. The rabbits were then sacrificed, and the eyelid, conjunctiva, lacrimal gland, and the entire lacrimal drainage system were retrieved for histopathological analysis as per standard protocols. Clinically demonstrable peripunctal changes and canalicular stenosis were noted in 6 (60%, 6/10) rabbits. Two of these (20%, 2/10) had additional complete regurgitation of clear fluid, indicating a nasolacrimal duct obstruction. The remaining 4 (40%, 4/10) clinically did not demonstrate lacrimal drainage changes and were patent on irrigation. The conjunctiva showed focal loss of goblet cells in several areas. Significant changes were noted in the canalicular, lacrimal sac, and the nasolacrimal duct tissues in the form of epithelial hyperplasia, subepithelial inflammation, edema, dilated and congested vessels, and fibrosis. The lacrimal gland, eyelid tissue (excluding tarsal conjunctiva), and cornea showed no significant histopathological changes. Clinical and histopathological changes were noted in the lacrimal drainage system of rabbits subjected to topical 5-FU application. These findings can have potential clinical implications for patients receiving 5-FU therapy.

Soft stop on syringing and probing may have a high false-positive rate in diagnosing pre-sac obstruction

PurposeTo determine the diagnostic value of 'soft stops' encountered during lacrimal syringing and probing.MethodsSingle-center retrospective review. Adult patients with epiphora attending a tertiary lacrimal clinic from May 2010 to April 2021 were reviewed. Cases with evidence of soft stop encountered during lacrimal syringing/probing were included, and patients with possible canaliculitis or a history of lacrimal surgery were excluded. Findings of syringing/probing consistent with pre-sac obstruction were correlated with dacryocystography (DCG) and surgical findings.Results53 (10.2%) canalicular systems had soft stops on syringing/probing and were included in the analysis. The mean age of the patients was 63.8 ± 15.6 (range 28–87) years, and 27 (65.9%) were females. Intraoperative examination findings were available for 27 of 30 cases that underwent lacrimal surgery and DCG was available for 40 systems. Pre-sac obstruction found on syringing/probing was confirmed in 40% and 37% of cases on DCG and surgery, respectively. The correlation between syringing/probing and DCG was stronger for canalicular than for common canalicular location (p = 0.016). Canalicular stenosis on syringing/probing manifested as pre-sac abnormality on DCG in 5/7 (71.4%) compared to 0/6 common canalicular stenosis cases (p = 0.021). Based on the surgical findings, the false-positive rate of a soft stop on syringing/probing was highest for common canalicular ‘stenosis’ (100%) and lowest for canalicular ‘block’ (45.5%; p = 0.093). Findings of pre-sac obstructions on DCG were confirmed in 85.7% of the cases intraoperatively (p = 0.035 compared to syringing/probing alone).ConclusionsSoft stops on probing showed poor correlation with DCG and surgical findings, particularly in common canalicular location.

Functional Versus Anatomical Nasolacrimal Obstruction: Are There Differences in Epiphora Severity, Symptoms, or Effects on Quality of Life?

To elucidate whether the specific cause of nasolacrimal duct drainage impairment impacts the severity, symptoms, and implications on visual tasks and quality of life (QOL) in epiphora. A retrospective review of consecutive adult patients with epiphora attending a tertiary lacrimal clinic from June 2011 to March 2021 was conducted. Cases with evidence of canalicular stenosis, a mucocele, or other identifiable causes of epiphora were excluded. A structured interview assessed the epiphora severity (Munk), symptomatology, precipitating factors, and effects on visual tasks and QOL. Following lacrimal syringing, all eyes were investigated with dacryocystography and dacryoscintigraphy. The domains of the interview were compared between nasolacrimal duct obstruction (NLDO), stenosis (NLDS), and nonanatomical functional delay (FNLDO). One hundred twenty-two symptomatic eyes (63 patients; mean age 63.3 ± 17.2 years; 59% females) were included. There was no difference in Munk score between the groups (NLDO = 3.71 ± 0.18, NLDS = 3.79 ± 2.0, FNLDO = 3.85 ± 0.15; p = 0.82). In all 3 groups, most cases had a Munk >2 (86.8%, 75.9%, and 89.1%, respectively; p = 0.25). Discharge was more common in NLDO (65.7%) compared with NLDS (30.0%) and FNLDO (36.4%, p = 0.006). Worsening in the cold/wind was more frequent in FNLDO (77.1%) compared with NLDO (48.5%, p = 0.029). Effects on visual tasks and QOL were not significantly different. FNLDO patients experience a high severity of epiphora, comparable to patients with NLDS and those with complete NLDO. The distinction between FNLDO and NLDS had little consequence on reported symptoms, precipitating factors, visual tasks, and QOL. Discharge may be more specific to NLDO, whereas precipitating cold or wind is more specific to FNLDO.

Syringing has limited reliability in differentiating nasolacrimal duct stenosis from functional delay

PurposeTo elucidate the role of syringing in assessing nasolacrimal duct (NLD) stenosis and non-anatomical functional NLD delay.MethodsConsecutive adult patients with epiphora attending a tertiary lacrimal clinic from June 2011 to March 2021 were reviewed. Cases with evidence of canalicular stenosis or other identifiable causes of epiphora were excluded. Following syringing, patients were investigated with dacryocystography (DCG) and dacryoscintigraphy (DSG). The sensitivity and specificity of syringing were evaluated using the combined findings on DCG and DSG.ResultsA total of 289 symptomatic lacrimal systems (197 patients; mean age 65.5 ± 14.9 years, 66% females) were included. More than one-third of cases with both normal DCG and DSG were noted to have some degree of reflux on syringing (specificity = 65.1%, 95% CI 50.2–77.6%). The sensitivities were considerably low for NLD stenosis (i.e., stenosis on DCG and delay on DSG) and for functional NLD delay (i.e., normal DCG and delay on DSG), of which 43.7% (95% CI 32.2–55.9%) and 54.3% (95% CI 45.7–62.7%) had full patency on syringing, respectively (p = 0.17).ConclusionsFull patency on syringing was unreliable for ruling out NLD stenosis and functional delay. Furthermore, a positive syringing may be associated with functional NLD delay and cannot reliably differentiate it from stenosis.

DCR for nasolacrimal duct stenosis may be less effective than for complete obstruction

ObjectivesTo ascertain the success of endo-DCR in nasolacrimal duct stenosis (NLDS) versus nasolacrimal duct obstruction (NLDO).MethodsConsecutive adult patients with epiphora attending a tertiary lacrimal clinic from February 2012 to February 2021 were reviewed. NLDS was diagnosed by patent lacrimal syringing and combined dacryocystography (NLD stenosis) and dacryoscintigraphy (post-sac delay) findings in all eyes. Cases with evidence of canalicular stenosis or other identifiable causes of epiphora were excluded. The epiphora resolution and improvement rates following endo-DCR were compared between NLDS and complete NLDO cases.ResultsDCRs in 24 NLDS (23 patients, 69.6% females, mean age 61.0 ± 17.07) and 58 NLDO (56 patients, 69.6% females, mean age 61.9 ± 17.4) were included. Resolution of epiphora was achieved in 10 (41.7% [95% CI 0.24–0.61]) of the NLDS cases compared to 40 (69.0% [95% CI 0.56–0.79]) in NLDO (p = 0.021). Improvement of epiphora (i.e., either improvement or resolution) was noted in 17 (70.8% [95% CI 0.51–0.85]) of NLDS and 53 (91.4% [95% CI 0.81–0.96]) of NLDO cases (p = 0.034). Three patients (12.5%) with NLDS had subsequent lacrimal procedures (one DCR revision, two Jones tube) at a median of 14 (range 11–21) months. 71.4% of the NLDS patients responded to a phone questionnaire at a median of 93 months postoperatively. Of these, 46.7% reported resolution or significant improvement, and 33.3% reported slight improvement. 64.3% said they would recommend DCR to others suffering from epiphora.ConclusionEndo-DCR may benefit approximately 70% of patients with NLDS. The success of endo-DCR in complete NLDO may be higher.

Tränenwegsbefunde von 143 Kindern mit Mikrophthalmus-Anophthalmus-Komplex

Report of clinical findings relating to the lacrimal system in congenital clinical anophthalmos and severe blind microphthalmos (MAC-complex patients). A retrospective study of the notes of 207 consecutive patients treated surgically at least once with highly hydrophilic self-inflating expanders for MAC between 1998 and 2021. The lacrimal drainage system was always probed and irrigated under general anaesthesia before any other procedure was started. 64 patients were excluded due to possible misdiagnosis because of previous lid or orbit surgery elsewhere or due to missing data. The analysis therefore included 67 girls and 76 boys aged between 1 and 126 months (median age: 5 months). 72 patients presented with unilateral and 42 with bilateral anophthalmos, and 24 had unilateral and 5 bilateral microphthalmos; consequently, 286 orbits (of which, 190with probable pathology) were available for assessment. In unilateral cases the lacrimal system on the normal side was never affected. On the anophthalmic or microphthalmic side the lacrimal system was normal in 68 orbits only (35.8%). The most frequent finding was canalicular stenosis (91 orbits; 48%). Common canaliculus stenosis was observed in 12 orbits (6.3%) and nasolacrimal duct obstruction in 9 orbits (4.7%). There were four cases of punctal aplasia, but no other anomalies. In unilateral MAC pathologic findings during lacrimal probing were found to be associated with anatomical malformation of the contralateral fellow eye. Only in unilateral anophthalmos there was a significant association with cleft lip and palate, which was not found in the three other groups. In congenital clinical anophthalmos the lacrimal system is affected in up to 66.5% of cases, mostly due to canalicular stenosis. Even if there is no clear evidence of an embryological connection, this association is certainly not a random finding.

Evaluation of lacrimal drainage system in Pseudoexfoliation syndrome.

PurposeTo evaluate the prevalence of the obstruction of lacrimal drainage system (LDS) in patients with pseudoexfoliation (PXF) syndrome.Materials and MethodsThis cross-sectional study included 152 eyes of 76 consecutive patients with bilateral PXF syndrome and 170 eyes of 85 age and gender-matched controls. The LDS evaluation was performed based on dye disappearance test, slit-lamp examination, diagnostic probing, and irrigation test. The presence of punctal stenosis and canalicular obstruction were considered as the obstruction of proximal LDS; and complete or incomplete nasolacrimal duct obstruction was considered as obstruction of distal LDS. Demographic characteristics, ophthalmologic findings, and prevalence and site of obstruction of LDS were compared among the groups.ResultsThe prevalence of obstruction of LDS was higher in the PXF syndrome group when compared to controls (21.1% vs 12.2%), but the difference was not statistically significant (p = 0.061). The obstruction of proximal LDS was found to be more frequent in the PXF syndrome (17.7%) group when compared to controls (10.0%), and this difference was statistically significant (p = 0.041). There was significantly more punctal stenosis in the PXF syndrome group when compared to controls (15.1% vs 7.6%, p = 0.033). The prevalence of canalicular stenosis and obstruction of distal LDS was similar in the PXF and the control groups (p = 0.596 and p = 0.741, respectively).ConclusionThe prevalence of punctal stenosis was statistically significantly higher in the PXF syndrome group when compared to the controls. This association is probably related to increased local ocular surface inflammation which is triggered by the accumulation of PXF material.

Pulled versus Pushed Monocanalicular Silicone Intubation in Adults with Lacrimal Drainage System Stenosis: A Comparative Case Series.

Purpose To compare the success rate and complications of pulled versus pushed monocanalicular intubation in adults with incomplete lacrimal drainage system obstruction (lacrimal drainage system stenosis). Methods Patients with lacrimal drainage system stenosis (Munk grade ≥3), including both nasolacrimal duct (NLD) stenosis and common canalicular stenosis, were recruited in this prospective comparative case series. Patients underwent probing and either Monoka (51 eyes) or Masterka (48 eyes) intubation under general or local anesthesia. Tubes were removed 4–14 weeks after the procedure. Six months after tube removal, Munk grades 0 and 1 were defined as a complete success, Munk grade 2 was defined as a partial success, and Munk grade ≥3 was defined as failure. All complications were recorded. Results Ninety-nine eyes from 89 patients with lacrimal drainage system stenosis who underwent either Monoka (51 eyes) or Masterka (48 eyes) intubation were included. The mean (SD) age of the patients was 55.4 (12) years in the Monoka group and 53.5 (12.9) in the Masterka group. Groups were matched on demographics. Masterka intubation could not be performed in one eye. Complete and partial successes were observed in 52.9% (27/51) and 17.6% (9/51) of eyes in the Monoka group and 42.6% (20/47) and 12.8% (6/47) of eyes in the Masterka group, respectively (p=0.29). There was a trend toward a higher total success rate in patients with NLD stenosis treated with Monoka 66.7% (26/39) than Masterka 45.5% (15/33) intubation (p=0.07). This trend also existed in patients with common canalicular stenosis (83.3% (10/12) vs. 76.6% (11/14), p=0.75). Age, sex, bilateral involvement, and duration of intubation did not have a significant impact on the success rate. Early tube loss, slit puncta, and temporary superficial punctate keratopathy were observed complications. Conclusion Intubation with the pulled monocanalicular silicone tube was associated with a slightly but not significantly higher success rate in adults with lacrimal drainage system stenosis. Patients with NLD stenosis may achieve better results with pulled silicone tubes.

Update on the Long-Term Outcomes Following the Management of Incomplete Punctal Canalization.

To study the clinical profile, associated lacrimal disorders, and long-term outcomes following a membranotomy, in patients with incomplete punctal canalization (IPC). Retrospective interventional study was performed of all the patients diagnosed with IPC during the study period over 5 years from January 2015 to December 2020. The diagnosis of IPC was made based on the earlier published guidelines. A combination of rapid and slow taper Nettleship's punctal dilators were used for an effective membranotomy, followed by further assessment of the lacrimal drainage passage. Appropriate interventions for associated lacrimal disorders were performed. Data collected on chart reviews include demographics, clinical presentation, laterality, type of IPC, associated lacrimal anomalies, management modalities, and long-term outcomes. Ninety-eight puncta of 62 eyes of 46 patients with IPC were examined in the clinic. Incomplete punctal canalization-external membrane variant was seen in 62% (61/98) and internal membrane variant in 38% (37/98). Seventy-eight puncta (78/98, 79.5%) in 39 patients underwent membranotomy using Nettleship's punctal dilator. Associated lacrimal drainage pathway deformities were seen in 31% of patients (12/39). Three puncta had mini-monoka insertion for associated canalicular stenosis and canalicular obstruction. Five patients with associated congenital nasolacrimal duct obstruction underwent probing, of which 3 patients needed dacryocystorhinostomy for complex congenital nasolacrimal duct obstruction. Associated punctal agenesis was noted in 3 patients involving the other punctum of the same eye. Canalicular wall hypoplasia involving 3 walls of the canaliculus was seen in 1 patient. At a mean follow up of 28 months, the anatomical and functional outcomes were noted in 100% and 97.4%, respectively. The long-term outcomes of membranotomy for IPC are excellent. Associated congenital lacrimal drainage anomalies are common with IPC.

Use of Lacrimal Symptoms Questionnaire After Punctoplasty Surgery: Retrospective Data of Technical Strategy.

The goal of this study is to evaluate postpunctoplasty symptoms with lacrimal symptoms questionnaire (Lac-Q). A retrospective study was conducted on 31 patients (14 men and 17 woman) with a diagnosis of canalicular stenosis: 26 patients with unilateral occlusion and 5 patients with bilateral occlusion. The Lac-Q was administered preoperative and at 1, at 3, and at 6 months following the surgery. Moreover, the Lac-Q questionnaire was administered by an independent observer (SI). The mono-lateral and bilateral postoperative Lac-Q score showed a significant improvement of symptoms at 1, 3, and 6 months than the preoperative results. The Lac-Q questionnaire is a way to evaluate the quality of outcomes after punctoplasty surgery. In this study, all patients showed a significant improvement of symptoms after surgery.

Docetaxel for Breast Cancer Treatment-Side Effects on Ocular Surface, a Systematic Review

Docetaxel is a very effective chemotherapeutic agent for the treatment of metastatic or locally advanced breast cancer. Epiphora (hyperlacrimation) has been shown to be the most common eye condition in patients receiving docetaxel-based chemotherapy. This symptom does not decrease visual acuity, but decreases the quality of life. Daily activities (reading, working on the computer, watching TV, and so on) are affected, with patients complaining about an alteration of daily life with the appearance of this symptom. The mechanism by which epiphora occurs is considered to be the canalicular stenosis, but the trials on the subject failed to reach statistical significance. The objective of this scoping review is to determine whether there is a treatment regimen-dependent relationship between docetaxel administration and the presence of epiphora in women with breast cancer. The inclusion criteria were met by 10 trials, from which one was excluded owing to data selection biases. Accordingly, nine studies were evaluated quantitatively and qualitatively in the present review. We included subjects with docetaxel as single treatment or docetaxel in combination with other chemotherapy compounds. The occurrence of epiphora among subjects treated with docetaxel, regardless of the therapeutic regimen used, was statistically significant (p = 0.005). The proportion of patients with epiphora after weekly administration of docetaxel (54 out of 131 subjects, 41.22%) was different compared with that of those who received docetaxel at three week intervals (112 out of 325 subjects, 34.15%), but the difference between the two was not statistically significant (p = 0.732). The present study demonstrates that epiphora occurs more frequently in patients receiving weekly docetaxel-based chemotherapy than those taking the three-weekly regimen, but the difference is not statistically significant. Ophthalmologic assessment of all patients starting this treatment is recommended. The causal relationship between canalicular stenosis and epiphora is not fully elucidated as long as this ocular symptom occurs in women who do not have stenosis of the lacrimal system. Further well-designed trials are required to bring new insights into the mechanisms of epiphora pathogenesis in subjects treated with docetaxel.

Anatomical and Functional Outcome of Rectangular Three Snip Punctoplasty in Primary Acquired Punctal Stenosis in a Tertiary Care Hospital of Karachi

Purpose: To find out the anatomical and functional outcomes of rectangular three-snip punctoplasty in primary acquired punctal stenosis.&#x0D; Study Design: Quasi Experimental study.&#x0D; Place and Duration of Study: Isra Postgraduate Institute of Ophthalmology, Karachi, from July to December 2020.&#x0D; Methods: Patients of age 50 years and above, from either gender with primary acquired punctal stenosis of any grade (0-5) presenting with epiphora were recruited from Oculoplasty Outpatient department. Punctal stenosis with secondary causes like lesion on or around punctum or lacrimal drainage system and history of surgery or radiotherapy, lower canalicular or common canalicular stenosis were excluded from the study. Punctal stenosis was graded by Kashkouli scale and epiphora by the Munk score. After local anesthesia, two vertical cuts were given in the posterior wall of the punctum and a third cut was given horizontally to connect the vertical cuts. This resulted in a posterior ampullectomy. Syringing and probing was done to assess patency of the lower lacrimal drainage system. The patients were followed up for 6 months to assess for anatomical and functional success.&#x0D; Results: At the end of six month anatomical success was achieved in 85% cases and functional success in 70% patients. Fifteen percent patients suffered re-stenosis of punctum.&#x0D; Conclusion: Rectangular punctoplasty is a functionally successful procedure for treating primary acquired punctal stenosis. The anatomy is least distorted and long-term recurrence rate is also low.&#x0D; Key Words: Epiphora, Primary acquired punctual stenosis, Punctoplasty, Munk score.