Canalicular Stenosis Research Articles

The Treatment of Punctal and Canalicular Stenosis in Patients on Systemic 5-FU

5-FU administered systemically for cancer treatment can cause punctal and canalicular stenosis leading to symptoms of tearing. While some patients receiving 5-FU have resolution of their tearing with cessation of the drug, many patients require surgical treatment of their lacrimal outflow system. We studied the severity of punctal and canalicular stenosis in patients on 5-FU and the various treatments required to correct symptoms of tearing. Nineteen patients (16 with colon cancer and 3 with breast cancer) who were treated with systemic 5-FU with complaints of tearing were studied retrospectively. Treatment modalities were based on punctal stenosis evaluated by slit lamp exam, and probing and irrigation of the lacrimal outflow system. All patients demonstrated bilateral punctal and canalicular stenosis on exam. Fifteen of the 19 patients underwent surgery with 4 declining any surgical intervention. Of those 15 patients who underwent surgery; 5 had bilateral silicone tube intubation, 3 had bilateral conjunctivodacryocystorhinostomies (CDCR), 1 had a silicone tube on one side and a CDCR on the other side, 1 had a bilateral DCR, 4 had bilateral punctal 3-snip procedures, and 1 failed bilateral silicone tube intubation and will require bilateral CDCR. This is the largest single study in the literature evaluating patients on systemic 5-FU for the sequela and treatment of tearing. Although we found varying degrees of punctal and canalicular stenosis among our 19 patients, almost all had stenosis severe enough to warrant surgical intervention with either silicone tubes or CDCR. In our study 4 of 15 patients who elected surgery (26.7%) required CDCR, because of the permanent, severe stenosis of the lacrimal outflow system. Physicians should be aware that early recognition and treatment of tearing in patients on 5-FU with silicone tubes may salvage the canalicular system and prevent the need for CDCR.

Opening of lacrimal stenosis with endoscope and laser

Since the development of lacrimal endoscopes with which the mucosa and disorders of the lacrimal drainage system can be examined directly, the choice of surgical technique has changed decisively. Flexible miniendoscopes can be combined with a laser for the first time, allowing for exact localization of the stenosis and subsequent therapy. Between January 1996 and February 1997, 12 patients with acquired lacrimal stenosis were treated with an Hyb:erbium-YAG laser. After endoscopic localization, the stenosis or stricture was opened using the laser. Bicanicular intubation into the nose was performed and was left for at least 3 months. Five patients were treated for stenosis of the lower canaliculus and seven patients for postsaccal stenosis. The longest follow-up period was 22 months and the shortest 9 months. Treatment was successful in 4 cases with a canalicular stenosis, but restenosis occurred in all cases of postaccal stenosis and in 1 case of canalicular stenosis, and required a DCR. At this time we conclude that disorders of the canaliculi can be successfully treated with endoscopic localization, opening with a laser and subsequent silicone tube intubation. A high rate of restenosis may be expected in cases of postsaccal stenosis.

Microsurgical endonasal dacryocystorhinostomy with long-term insertion of bicanalicular silicone tubes.

To assess the results of microsurgical endonasal dacryocystorhinostomy with long-term insertion of single or double bicanalicular silicone tubes in canalicular (presaccal) and ductal (postsaccal) stenosis of the nasolacrimal duct system. Retrospective follow-up of case series between 1992 and 1996. Thirty-eight patients were included in the study: 19 with ductal stenosis; 28 with canalicular stenosis; and 1 (a 6-month-old girl) with congenital agenesis of the lacrimal duct system. Forty-seven endonasal microscopic dacryocystorhinostomies were performed on 38 patients. Bicanalicular silicone tubes were inserted, fixed in the nasal cavity, and left in place as long-term space holders. In patients with canalicular stenosis, a specially designed double bicanalicular tube was inserted for maximal dilatation of the lacrimal canals. The tubes are left in place as long as possible, ie, for months to several years. In cases in which there was recurrent obstruction following accidental tube extrusion, we simply inserted new tubes using a short-acting anesthesia. With 1 procedure, 17 (91%) of the eyes that were surgically treated for ductal stenosis became symptom free. The success rate in the cases of canalicular stenosis was 72%. In the remaining 28% of patients with recurrent obstruction, endonasal revision surgery was performed with new insertion of bicanalicular tubes. With the new tubes in place, these remaining patients have also stayed largely symptom free (length of follow-up, 8 months to 5 years [average, 3 years]). The routine insertion of bicanalicular tubes as long-term spacers has proved effective and has been tolerated without problems. A new aspect of our study is that in cases of canalicular stenosis or congenital agenesis of the lacrimal duct, which generally have a poor prognosis, the patients also benefit when our specially designed long-term double bicanalicular tubes are inserted in the lacrimal ducts.

Holmium laser canaliculoplasty.

Thirty canaliculi of 18 patients with complete or nearly complete canalicular obstruction were subjected to laser canaliculoplasty as a substitute for the standard Jones-type bypass conduct. Etiologies for the obstruction included congenital lacrimal system atresia, eyelid trauma, scarring following previous lacrimal surgery, and chronic inflammatory fibrosis. The procedure utilized a holmium laser delivered via a 1,000 mu optical fiber to cut a 1-mm channel from the punctum into the lacrimal sac. In nine eyes, this procedure was combined with a surgical dacryocystorhinostomy (DCR) for concurrent lower nasolacrimal duct obstruction. Silicone stents were left in place for 6 months postoperatively. Follow-up data were available for 28 canaliculi of 17 patients. Moderate or better improvement in symptomatic epiphora and evidence of canalicular patency to drainage was seen in 16 of 28 (57%) treated canaliculi, and significant improvement was recorded in 12 of 28 (43%). Although these figures are lower than those obtainable after repair of small areas of focal canalicular stenosis or obstruction, the procedure is superior to any previous attempts at reconstruction of extensive obstructions, short of placement of a Jones tube. When successful, this procedure offers re-establishment of a near normal physiologic system, and avoids the complications of and patient dissatisfaction associated with a Jones tube.

Management of canalicular injury associated with eyelid burns.

To develop a protocol for treatment of injuries to the puncta and canaliculi associated with eyelid burns. We retrospectively reviewed the records of seven patients who required treatment of punctal and canalicular stenosis caused by burns to the medial eyelids. Seven patients were treated within 5 days of injury: one by punctal dilation and six by surgical debridement, punctoplasty or canaliculoplasty, and silicone intubation. All remained free of epiphora. Early evaluation and treatment of punctal and canalicular burn injuries are beneficial. If the puncta are only slightly stenotic, close observation with serial lacrimal testing and punctal dilation is recommended. If the puncta and lateral canaliculi are severely stenotic or obliterated, surgical débridement and punctoplasty or canaliculoplasty followed by placement of a silicone stent effectively prevents permanent lacrimal stenosis and epiphora.

Punctal and canalicular stenosis associated with systemic fluorouracil therapy

Ocular side effects of systemic fluorouracil include excessive lacrimation, due to punctal and canalicular stenosis and fibrosis. Obstruction of the tear ducts after systemic therapy with fluorouracil is more frequent than is assumed. Five patients with breast cancer and punctal or canalicular stenosis are presented. Although complaints of epiphora usually resolve two weeks after cessation of systemic therapy, local antibiotics and steroids may be indicated. In patients with persisting complaints, and patients treated with fluorouracil for a prolonged period of time, prophylactic intubation of the tear ducts with silastic tubes has been advocated. (Conjunctivo)dacryocystorhinostomy may be unavoidable.

Die endonasale Dacryocystorhinostomie mit Transillumination des Tränensackes: Durchführung und Resultate

Since Mai 1991 we performed a total of 17 endonasal dacryocystorhinostomies under transillumination of the lacrimal sac on 15 patients with lacrimal obstruction aged 11 to 88 years. 11 patients with 12 operations were followed up between 40 and 393 days (mean of 5.6 months). In all cases the connection between the lacrimal sac and the nasal cavity remained functionally open. One patient developed a secondary canalicular stenosis which made silicon tubing necessary. We consider the operation an elegant and as far as our experience goes reliable method to recanalize the lacrimal drainage system avoiding a cutaneous incision. It is simplified by the transillumination of the lacrimal sac under videoendoscopic conditions.

Secondary Dye Testing of the Lacrimal System

ABSTRACT Using the Olympus PF-22 angioscope to examine the inferior meatus during secondary dye testing of the lacrimal system, I evaluated the efficacy of the secondary dye test to localize partial or functional obstruction of the upper or lower lacrimal excretory system. Secondary dye testing was positive (dye present in the nose) in 12 of 13 lacrimal systems (92%) with functional nasolacrimal duct obstruction, in 7 of 8 (89%) with involutional ectropion, and in 4 of 5 (80%) with facial nerve palsy. Secondary dye testing was negative in the 1 lacrimal system w'rth canalicular stenosis and in 5 of the 6 (83%) with punctal stenosis. Secondary dye testing is helpful in differentiating punctal or canalicular stenosis from functional nasolacrimal duct obstruction; however, it cannot help differentiate ectropion or facial nerve palsy from functional nasolacrimal duct obstruction.

Surgery of acquired canalicular stenosis

Between January 1984 and May 1991 sixty eyes of 58 patients underwent canalicular surgery. According to the intraoperative findings, the canaliculi were either dilated and intubated (group I: 27 cases) or the medial canthus was opened, the stenosis excised and the canaliculi intubated (group II: 33 cases). Two patients were lost for follow-up. The results were good in group I in 20 cases (74.1%) and in group II in 17 cases (54.9%). After revision surgery and including moderate results, the final success rate in group I was 24 (88.9%) and in group II 23 (75.5%).

Canalicular Stenosis Following Probing for Congenital Nasolacrimal Duct Obstruction

A canalicular stenosis was identified in 29 of 66 (44%) children and 35 of 80 (44%) lacrimal drainage systems undergoing silicone intubation for congenital nasolacrimal duct obstruction, having previously had unsuccessful probings. The stenoses were equally divided between boys and girls and between right and left sides. There was no significant difference in age at the time of probing, number of prior probings, or age at intubation between children with and without canalicular stenosis. Stenoses may be congenital or acquired as a result of faulty probing. Any child undergoing a second lacrimal procedure after a failed probing should be evaluated for evidence of a canalicular stenosis. If a stenosis is present, a silicone stent should be placed to try to salvage the canaliculus.

Canalicular Stenosis Following Probing for Congenital Nasolacrimal Duct Obstruction

A canalicular stenosis was identified in 29 of 66 (44%) children and 35 of 80 (44%) lacrimal drainage systems undergoing silicone intubation for congenital nasolacrimal duct obstruction, having previously had unsuccessful probings. The stenoses were equally divided between boys and girls and between right and left sides. There was no significant difference in age at the time of probing, number of prior probings, or age at intubation between children with and without canalicular stenosis. Stenoses may be congenital or acquired as a result of faulty probing. Any child undergoing a second lacrimal procedure after a failed probing should be evaluated for evidence of a canalicular stenosis. If a stenosis is present, a silicone stent should be placed to try to salvage the canaliculus.

Stevens-Johnson Syndrome with Associated Nasolacrimal Duct Obstruction Treated with Dacryocystorhinostomy and Crawford Silicone Tube Insertion

Although Stevens-Johnson syndrome (SJS) has long been recognized as a cause of punctal and canalicular obstruction, nasolacrimal duct obstruction secondary to SJS is rare and has not been reported in the ophthalmologic literature. Keratoconjunctivitis sicca, entropion, and trichiasis are well-known complications of SJS that may require measures to supplement or preserve tears. Lacrimal drainage system obstruction may occasionally occur in the face of relatively normal tearing, resulting in clinically significant epiphora. We report two cases of SJS, one associated with epidemic keratoconjunctivitis, that led to nasolacrimal duct obstruction and canalicular obstruction or stenosis. Epiphora and, in one case, dacryocystitis, necessitated dacryocystorhinostomy and Crawford tube insertion.

Modified Kinosian Dacryocystorhinostomy: A Review of 122 Cases

A consecutive series of 122 dacryocystorhinostomies is reviewed, and a surgical technique which preserves the anterior lacrimal crest and eliminates the need to create mucosal flaps is described. The success rate of this simplified technique is 89%. The success rate rises to 94% following secondary revisions. This is comparable to more complicated procedures. Canalicular and common punctal stenosis are not found to be contraindications to dacryocystorhinostomy for obstruction of the nasolacrimal duct but do lower the success rate. Eighty-one percent of patients with concomitant canalicular disease and nasolacrimal duct obstruction were cured by dacryocystorhinostomy with silicone intubation. A success rate of 98% was achieved in patients without preoperative canalicular disease.

Phospholine Iodide Toxicity and Jones' Tubes

A 72-year-old man with epiphora secondary to bilateral canalicular stenosis resulting from long-term treatment with 0.125% to 0.25% echothiophate iodide (phospholine iodide) drops for glaucoma underwent bilateral conjunctivodacryocystorhinostomies with Jones' tubes. Within days after undergoing this surgery, he experienced severe unexplained diarrhea, fatigue, weight loss, and prostration. He cancelled his postoperative ophthalmic appointment because of “medical illness.” He required admission to his local hospital where extensive studies were done in an attempt to establish the cause of this life-threatening condition. After stopping the echothiophate iodide drops, all symptoms disappeared within two days. Drug toxicity is a previously unreported complication of conjunctivodacryocystorhinostomy, and this case demonstrates that topical medications have enhanced systemic absorption after lacrimal surgery with placement of fistulizing prosthetic devices. One must be aware of this possible complication, not only with long-acting anticholinesterases, but with topical sympathomimetic drugs (especially in cardiac patients) as well as cycloplegic agents in children.