Inferior Canaliculus Research Articles

Mini Monoka Stent Insertion for the Management of Epiphora Secondary to Canalicular Obstruction or Stenosis

Background/Aims: To assess the outcomes of Mini monoka lacrimal stent insertion in the management of epiphora in adults caused by inferior or common canalicular duct obstruction or stenosis.Methods: A retrospective study was performed selecting consecutive patients at Hobart Eye Surgeons, from Oct 2007 to Mar ’08 who had Mini Monoka stents inserted for epiphora secondary to confirmed obstruction/stenosis in either inferior or common canaliculus. These patients had their stents routinely removed after six weeks.Results: There were a total of 36 eyes (31 patients) included in the study and 31 eyes (83.7%) showed subjective improvement in epiphora. One patient was lost to follow up and 5 eyes showed no improvement.Conclusion: In this first case series which used Mini Monoka stents to treat epiphora, there was a high success rate in improvement of epiphora. Further research is warranted to further validate its use into routine clinical practice.

Sustained-release dexamethasone for the treatment of ocular inflammation and pain after cataract surgery

To evaluate the safety and efficacy of dexamethasone as a sustained-release drug depot when placed in the canaliculus for the treatment of ocular inflammation and pain in cataract surgery patients. Four private practice sites in the United States. Multicenter randomized double-masked clinical trial. Patients were randomized (1:1) to receive either the sustained-release dexamethasone or a placebo vehicle punctum plug inserted into the inferior distal canaliculus of the operated eye intraoperatively during cataract surgery. The primary endpoints were the proportions of patients with absence of cells or pain in the anterior chamber at 8 days. Secondary endpoints included cells, flare, pain, and the presence of the device at various timepoints through 30 days. Approximately one fifth (20.7%) of patients in the sustained-release dexamethasone group had an absence of anterior chamber cells at 8 days compared with 10.0% in the placebo group (P = .1495). A higher proportion of patients in the sustained-release dexamethasone group (79.3%) than in the placebo group (30.0%) had an absence of ocular pain at 8 days (P < .0001) and at all other timepoints (P < .0002). There were significantly higher proportions of patients in the sustained-release dexamethasone group than in the placebo group with an absence of anterior chamber cells, anterior chamber flare, and pain at several timepoints through 30 days (P ≤ .0251). Sustained-release dexamethasone provided elution of drug for up to 1 month after cataract surgery, providing clinically significant reductions in inflammation and pain. Dr. Masket is a consultant to and shareholder in Ocular Therapeutix, Inc. No other author has a financial or proprietary interest in any material or method mentioned.

Eyelid Lacerations Due to Dog Bite in Children.

To evaluate the nature and extent of lacrimal apparatus injury in children after eyelid laceration from a dog bite. A retrospective chart review of all eyelid lacerations treated between 1990 and 2012 at Boston Children's Hospital, Boston, Massachusetts, was conducted. Seventy-three patients who sustained an eyelid laceration due to dog bite were identified and were matched 5:1 with a randomly selected cohort of 365 patients from the group of 1,177 patients who had sustained eyelid lacerations from other causes during the same time period. Of the 73 patients who sustained an eyelid laceration due to a dog bite, 26 (35.62%) had damage to the lacrimal apparatus. This was statistically significant when compared to patients who sustained eyelid lacerations from other causes, in which 13 (3.56%) patients had damage to the lacrimal apparatus (P < .000001). The inferior canaliculus was the most commonly involved site of lacrimal apparatus trauma as a result of a dog bite. Success was defined as lack of epiphora at the time of the last follow-up. Early surgical management of eyelid lacerations with lacrimal apparatus involvement had a success rate of 82%. Eyelid lacerations due to dog bites have a greater prevalence of involvement of the lacrimal apparatus and especially the inferior canaliculus than lacerations due to other causes in children. Clinicians should have a high index of suspicion for lacrimal apparatus involvement and be prepared for surgical repair, if indicated.

The analysis of 54 cases of anastomasis for traumatic lacrimal canaliculus lacerations

Objective To investigate the effective methods of anastomosis for traumatic lacrimal canaliculus lacerations. Methods The appropriate surgical methods of broken ends finding and anastomosis were performed in 54 eyes of 54 cases with traumatic lacrimal canaliculus lacerations according to their specific injuries. Results Of 54 eyes after treatment 4 cases of 48 eyes with inferior lacrimal canaliculus laceration were obstructed in early time postoperatively, 4 cases obstructed 6 months later. One case of 3 patients with superior lacrimal canaliculus laceration appeared epiphora. 3 cases with both superior and inferior laceration of lacrimal canaliculus flushed smoothly when the pipes were put out. Conclusion Appropriate surgical method according to injury condition is effective for traumatic lacrimal canaliculus laceration. Key words: Lacrimal canalicular, lacerations, traumatic; Anastomosis

Retrograde intubation for inferior lacrimal canaliculus laceration

Objective To investigate the clinical effect of lacrimal duct retrograde intubation for traumatic inferior lacrimal canaliculus laceration. Methods Forty-five eyes of forty-five cases with inferior lacrimal canaliculus laceration were retrospectively analysed. The operation was performed under operating microscope. The probing needle of lacrimal passage was inserted from the nasal broken end,Ytype nasolacrimal stent with lacrimal canaliculus was implanted retrogradely and lacrimal canaliculus was anastomosed. Results Canalicular nasal ends of all the 45 patients could be successfully found under microscope and be anastomozed. No stent slippage or formation of granulation occurred, 43 cases were cured, and lacrimal canaliculus was obstructed again in 2 cases after extubation. Conclusion Retrograde intubation for traumatic inferior lacrimal canaliculus laceration has high success rate, less injury, and less pain. Key words: Lacrimal disease; Laceration, lacrimal canaliculus; Anastomosis, lacrimal canalicular; Intubation, lacrimal duct, retrograde

Clinical analysis of surgical technique in 41 cases of inferior lacrimal canaliculus laceration

Objective To analyze the surgical techniques of lacrimal canaliculus laceration. Methods 41 cases of inferior lacrimal canaliculus laceration received the anastomosis. The data of patients were analysed retrospectively. There are three key steps during the operation： searching the nasal broken end, supporting with the silicone stent tube and anastomosing by the way of ＂one-stich anastomosis through the skin＂. Results All cases were followed up for 3 months to 1 year after the operation. The 38 cases of inferior lacrimal canaliculus laceration were cured, accounting for 92.7%. The surgery was effective in 3 cases （7.3%） , and was invalid in no cases. Conclusion Finding the broken end, appropriate supporting, and anastomosis accurate are keys to repair lacrimal canaliculus laceration. Key words: Laceration, inferior lacrimal canaliculus; Stent, silicon; Anastomosis, one-stich, through the skin

Comparaison de la dacryoIRM 3 T par instillation au dacryoscanner dans le cadre du larmoiement chronique

Epiphora is frequently related to stenosis of the lacrimal drainage pathways. In the evaluation of stenosis, dacryo-CT scan remains the gold standard, despite the need for radiation and catheterization of the lacrimal passages. Evaluation by high field 3T MRI compared to the gold standard in the morphological study of the lacrimal passages and quantification of the stenosis is attractive considering the lack of radiation and non-invasive nature of the technique. Twenty-four patients were included, including 9 with bilateral epiphora, representing 33 pathological drainage systems out of 48. Twenty-three drainage systems underwent subsequent surgery (18 patients, 5 patients bilaterally). The average diameter on CT scan images of the superior canaliculus was 0.70 mm (± 0.46), of the inferior canaliculus 0.69 (±0.42), the common canaliculus 0.68 (± 0.58), the lacrimal sac 4.32 (± 2.10), and the nasolacrimal duct 1.15 mm (±1.42). 3T dacryo-MRI overestimated the diameters by 0.35 to 1mm (up to 20 % of the lacrimal sac size), and the concordance between dacryo-CT scan and 3T dacryo-MRI was of average value (kappa 0.5, P<0.05) concerning the diagnosis of stenosis. Furthermore, dacryo-CT scan demonstrated higher sensitivity (72.7 %) than 3T dacryo-MRI (42.4 %). The two techniques are not equivalent in the diagnosis of stenosis. An optimization of protocols and an evaluation on a larger cohort remain necessary before dacryo-CT scan can be replaced by dacryo-MRI in routine practice.

The comparison of three different methods to localize nasal broken end of lacerated inferior lacrimal canaliculus

Objective To compare the clinical efficacy of three different methods to localize nasal broken end of lacerated inferior lacrimal canaliculus.Methods 24 cases of lacerated inferior lacrimal canaliculus due to trauma were treated by three different methods (pushing water into the superior punctum,finding directly under operating microscope,probing needle)to localize nasal breakage.The clinical effects were analyzed.Results The searching method of pushing water into the superior punctum was performed in 24 cases and only 7 nasal breakages were localized successfully accounting for 29.17％.The searching method of finding directly under microscope was performed in 24 cases and the nasal breakages were found in all cases and the success rate was 100％.The searching method of probing needle was performed in 24 cases.The nasal broken ends were localized in 12 cases,but 4 cases were not successful because of iatrogenic false passage.The success rate was 50％.Conclusion For the patients with lacerated inferior lacrimal canaliculus due to trauma,searching nasal broken ends directly under microscope is the preferred method.If the searching time is more than 30 minutes,pushing water into the superior punctum can be tried.Using probing needle is the last choice,but not be performed when the trauma tissue is edema. Key words: Laceration,canalicular, lacrimal; Ends, broken, nasal

New TASER injuries: lacrimal canaliculus laceration and ethmoid bone fracture

The TASER is a non-lethal conducted electrical weapon intended to incapacitate a person. The growing use of the TASER has resulted in an increased risk of injuries, including those to the face. We report a case of lacrimal canaliculus laceration and ethmoid bone fracture caused by an extra penetration (XP) TASER X26 dart. A 35-year-old was subdued with a TASER head shot; the probe was discharged into the left medial canthus without causing any ocular lesions. A computed tomography scan revealed the probe to be embedded in the left nasolacrimal duct and showed a displaced ethmoid fracture. The barbed dart had sectioned the inferior lacrimal canaliculus without electrifying the lesion. This case expands the knowledge of injuries that may occur as a result of the use of this device and the management of peri-ocular TASER injuries.

Acquired canaliculocele with intranasal extension in a dog

AbstractTo describe a case of a nasolacrimal canaliculocele with intranasal extension in a dog. A 6‐year‐old neutered female Jack Russell Terrier was referred to the Centre Hospitalier Vétérinaire des Cordeliers for a slowly enlarging mass adjacent to the medial canthus of the right eye of 5 months duration. Ophthalmic exam, ultrasound, fine needle aspiration, dacryocystorhinography and computerized tomography examinations were performed. Rhinoendoscopic treatment with marsupialisation of the endonasal canaliculocele was performed. Physical examination revealed a 3 cm diameter, subcutaneous mass beneath the medial canthus of the right eye, with a defect in the maxillary bone below. Dacryocystorhinography demonstrated blockage at the level of the nasolacrimal duct. Fine needle aspiration confirmed the cavitary nature of the lesion. During rhinoendoscopy, a mass containing watery fluid was found. Following marsupialisation with a large mass wall resection, the lacrimal drainage system irrigated freely in the nasal chamber. The communication of the lumen of the diverticulum with the lumen of the superior but not the inferior canaliculus was clearly demonstrated during endoscopy. Given negative immunohistochemical staining for smooth muscle actin and desmin, nasolacrimal dacryocele appears to be the most likely diagnosis. Histological examination confirmed that no goblet cells were present in the wall of the diverticulum, which is consistent with the canaliculus rather than the lacrimal sac. Complete resolution was observed without recurrence one year after surgery. Despite its rarity, a canaliculocele should be considered in adult dogs with nasolacrimal duct obstruction. Marsupialisation seems to be the appropriate therapy.

Rhinotillexomania

The authors report a rare case of medial orbital wall erosion with an orbital inflammatory mass and resultant lacrimal obstruction secondary to rhinotillexomania. A 67-year-old male with known history of compulsive nose picking (rhinotillexomania) sought treatment for complaints of watering in his OD. Examination revealed a blocked right inferior canaliculus. Nasal endoscopy showed a large nasal septal defect with multiple areas of crusting and bleeding. Hematologic investigations were normal. CT scan confirmed a large nasal septal and right medial orbital wall defect with an adjacent soft tissue mass in the medial orbit. Investigations ruled out systemic pathology. Histologic examination of medial orbital mass, sinus, and nasal mucosa revealed a reactive inflammatory infiltrate with surface Gram-positive cocci. The authors hypothesized that the patient had enlarged an existing nasal septal defect due to repetitive nose picking resulting in recurrent infection and inflammation of sinuses, leading to erosion of his medial orbital wall.

Normative dimensions and symmetry of the lacrimal drainage system on dacryocystography: statistical analysis of morphometric characteristics

Asymmetric lacrimal flow occurs in females more than males. We hypothesised that the normal lacrimal drainage system (LDS) may show subtle left-right asymmetry in morphometry when imaged on dacryocystography (DCG). We retrospectively reviewed 60 normal bilateral LDSs.Images were analysed for 7 parameters: (1) combined length of either the superior or inferior canaliculus plus common canaliculus, (2) angle of insertion of common canaliculus into lacrimal sac (LS), (3, 4) length and width of the LS, (5) length of the naso lacrimal duct (NLD), and (6, 7) width of proximal and distal NLD. We tested the effect of independent variables (age, gender, and side) on each dependent variable (length, width, or angle) using regression analysis. We used a Studentt-test for independent samples to statistically compare bilateral LDSs. Patient median age was 62 years, and male:female ratio was 27:73. Mean dimensions and angles for all LDSs were: (1) 14.5 mm, (2) 57°,(3) 11.6 mm, (4) 2.1 mm, (5) 20.7 mm, (6) 1.4 mm, and (7) 1.8 mm. No independent variable affected variation in length, width, or angle. No significant difference emerged between dimensions of right and left LDSs in both sexes. A degree of affective lateralisation in the brain is known to result in lacrimal flow asymmetry after mood manipulation. We show that this is not reflected in LDS anatomy. Moreover, our detailed morphometric data can aid in therapeutic planning of LDS luminal procedures, especially when DCG images of one LDS are used as a road map for contralateral interventions.

High-spatial-resolution isotropic three-dimensional fast-recovery fast spin-echo magnetic resonance dacryocystography combined with topical administration of sterile saline solution

ObjectiveThis study aims to investigate the clinical performance of three-dimensional (3D) fast-recovery fast spin-echo (FRFSE) magnetic resonance dacryocystography (MRD) with topical administration of sterile saline solution for the assessment of the lacrimal drainage system (LDS). MethodsA total of 13 healthy volunteers underwent both 3D-FRFSE MRD and two-dimensional (2D)-impulse recovery (IR)-single-shot fast spin-echo (SSFSE) MRD after topical administration of sterile saline solution, and 31 patients affected by primary LDS outflow impairment or postsurgical recurrent epiphora underwent 3D-FRFSE MRD and conventional T1- and T2-weighted sequences. All patients underwent lacrimal endoscopy or surgery, which served as a standard of reference for confirming the MRD findings. Results3D-FRFSE MRD detected more visualized superior and inferior canaliculi and nasolacrimal duct than 2D-IR-SSFSE MRD. Compared with 2D-IR-SSFSE MRD, 3D-FRFSE MRD showed more visualized segments per LDS, although the difference was not statistically significant. Significant improvements in the inferior canaliculus and nasolacrimal duct visibility grades were achieved using 3D-FRFSE MRD. 3D-FRFSE MRD had 100% sensitivity and 63.6% specificity for detecting LDS obstruction. In 51 out of the 62 LDSs that were assessed, a 90% agreement was noted between the findings of 3D-FRFSE MRD and lacrimal endoscopy in detecting the obstruction level. Conclusion3D-FRFSE MRD combined with topical administration of sterile saline solution is a simple and noninvasive method of obtaining detailed morphological and functional information on the LDS. Overall, 3D-FRFSE MRD could be used as a reliable diagnostic method in many patients with epiphora prior to surgery.

A Para-Canalicular Abscess Resembling an Inflamed Chalazion

Background. Lacrimal infections by Actinomyces are rare and commonly misdiagnosed for long periods of time. They account for 2% of all lacrimal diseases. Case Report. We report a case of a 70-year-old female patient suffering from a para-canalicular abscess in the medial canthus of the left eye, beside the lower punctum lacrimale, resembling a chalazion. Purulence exited from the punctum lacrimale due to inflammation of the inferior canaliculus (canaliculitis). When pressure was applied to the mass, a second exit of purulence was also observed under the palpebral conjunctiva below the lacrimal caruncle. A surgical excision was performed followed by administration of local antibiotic therapy. The histopathological examination of the extracted mass revealed the existence of actinomycosis. Conclusion. Persistent or recurrent infections and lumps of the eyelids should be thoroughly investigated. Actinomyces as a causative agent should be considered. Differential diagnosis is broad and should include canaliculitis, chalazion, and multiple types of neoplasias. For this reason, in nonconclusive cases, a histopathological examination should be performed.

Canine dacryolithiasis: a case description and mineral analysis

A 4-year-old, female, spayed, Labrador retriever was presented with a painless swelling of the left ventromedial eyelid and epiphora of 3 months duration. Bilateral patency of the nasolacrimal system was confirmed by the appearance of fluorescein dye at both nares. Ultrasonography revealed a well-demarcated fluid-filled structure containing echogenic ill-defined material in close proximity to the nasolacrimal system. A transconjunctival surgical approach confirmed the close anatomical proximity of the cyst and the absence of a communication with the inferior canaliculus. The cyst contained multiple intraluminal calculi (dacryoliths). Following surgical excision of the cyst, the epiphora resolved and no recurrence was noted over a 12-month follow-up period. On histopathology, the cystic structure was lined by stratified squamous epithelium, consistent with lacrimal canaliculus epithelium. Presumed progression of a canalicular diverticulum to a cyst with the formation of intraluminal dacryoliths was suspected. Mineral analysis of the dacryoliths revealed a calcium carbonate composition.

Measurement of canaliculus with ultrasound biomicroscopy

To study biometric measurements of normal canaliculus in vivo with ultrasound biomicroscope. Cross-sectional study. Eighty volunteers of normal lacrimal duct (80 eyes), including 40 men (40 eyes), 40 women (40 eyes), aged from 18 to 82 years old (average 41 years old). Eighty volunteers were divided into three stages, one eye of each volunteer was detected and measured with ultrasound biomicroscope in the goggle state and the imaging characteristics of canalicular ultrasound biomicroscopy were obtained. The length of the vertical canaliculus, the distal, middle, proximal anteroposterior diameter of the vertical canaliculus, the distal, middle, proximal anteroposterior diameter and vertical diameter of the horizontal canaliculus were measured. According to elliptical area formula S = πab (a = 1/2 anteroposterior diameter, b = 1/2 vertical diameter)the distal, middle, proximal transverse erea of the horizontal canaliculus were caculated. The differences among age groups and those among distal, middle, proximal measurements were compared by One-way ANOVA analysis. The measurements of canaliculus between male and female were analyzed using t test. Eighty volunteers (80 eyes) participated in the study, 6 eyes were failed to be imaged, the success rate was 92.5% (74/80). The length of vertical canaliculus of superior canaliculus were (2.10 ± 0.12) mm, of inferior canaliculus were (2.08 ± 0.10) mm. The proximal, middle, distal anteroposterior diameter of the vertical part of superior canaliculus respectively were (0.24 ± 0.05) mm, (0.28 ± 0.05) mm, (0.33 ± 0.04) mm (F = 16.315, P = 0.000), of inferior canaliculus were (0.23 ± 0.04) mm, (0.28 ± 0.06) mm, (0.32 ± 0.05) mm (F = 17.570, P = 0.000). The proximal, middle, distal transverse erea of the horizontal part of superior canaliculus respect were (0.77 ± 0.13) mm(2), (0.62 ± 0.13) mm(2), (0.48 ± 0.11) mm(2) (F = 22.970, P = 0.000), of inferior canaliculus were (0.79 ± 0.11) mm(2), (0.63 ± 0.08) mm(2), (0.48 ± 0.09) mm(2) (F = 21.45, P = 0.000). There was no significant difference of the canaliculus measurements between male and female (t = 0.105 - 0.487, P > 0.05). No significant differences were found among age groups (F = 0.142 - 3.954, P > 0.05). It is practicable to measure the normal canaliculus in vivo with UBM.

Lateralized petrous internal carotid artery: imaging features and distinction from the aberrant internal carotid artery

This study aimed to describe the lateralized petrous internal carotid artery (ICA), a rare variant of the intratemporal course of the ICA, and distinguish it from aberrant ICA. A retrospective multi-institutional review of all patients diagnosed over a 10-year period with lateralized ICA was completed. Medical records were reviewed for demographic data as well as clinical information in all patients. Computerized tomography (CT) studies were reviewed in all patients. Magnetic resonance studies in this patient group were reviewed when available. In order to obtain normative data for the ICA, the intratemporal course of the ICA was evaluated on 50 consecutive high-resolution sinus CT scans. Sixteen cases of lateralized ICA were identified on CT scans in 12 patients. In each of these, the ICA entered the skull base in a position more lateral to the cochlea than normal and protruded into the anterior mesotympanum with dehiscent or thinned overlying bone. Magnetic resonance angiography was available in 5 of 12 patients and catheter angiography in 1 of 12. Lateralized petrous ICA can be identified on CT by its more posterolateral entrance to the skull base and protrusion into the anterior mesotympanum. It can be distinguished from the aberrant ICA which enters the posterior hypotympanum through an enlarged inferior tympanic canaliculus, then courses across the inferior cochlear promontory to connect with the normal horizontal petrous ICA. Lateralized ICA is best considered an incidental petrous ICA variant. Awareness of this entity is important in the presurgical evaluation of the temporal bone to avoid vascular injury and confusion with the congenital diagnosis of aberrant ICA.

Monocanalicular Intubation in External Dacryocystorhinostomy

To examine the feasibility of monocanalicular intubation in external dacryocystorhinostomy (EX-DCR).Monocanalicular intubation using the mini-Monoka tube (S1-1500u, FCI Ophthalmics, Marshfield Hills, MA, U.S.A.) was performed in 18 patients undergoing EX-DCR. The tube was placed at the superior canaliculus in 16 cases and at the inferior canaliculus in 2 cases and was removed 3 months postoperatively. All cases were followed for at least 6 months postoperatively.The mini-Monoka was well tolerated in all patients. One case of spontaneous tube dislocation and 2 cases of presumed tube migration were recorded on the 15-day interval. Success rates on the 6-month interval were 88.88% (16/18), 94.44% (17/18), and 66.66% (12/18), concerning patency upon irrigation, resolution of mucopurulent epiphora, and resolution of watery epiphora, respectively.Monocanalicular intubation using mini-Monoka in EX-DCR is safe and effective. The technique may have advantages over bicanalicular intubation, such as easier insertion and removal, easier probing and irrigation though the unintubated canaliculus and, more importantly, less risk of punctal or corneal damage.

Eyelid avulsion repair with bi-canalicular silicone stenting without medial canthal tendon reconstruction

AimsTo evaluate the functional and cosmetic success rate of combined canalicular laceration and eyelid avulsion repairs using the bi-canalicular Crawford stent, without the concomitant placement of a medial traction suture...

Clinical efficacy of the smartplug™ in the treatment of primary Sjogren’s syndrome with keratoconjunctivitis SICCA: one-year follow-up study

To evaluate the efficacy of a thermo-sensitive punctum plug, (SmartPlug™) in Primary Sjogren's Syndrome (pSS) patients with dry eyes, whose symptoms persist despite preservative-free artificial tear treatment. In this study, 22 Primary Sjögren's Syndrome (pSS), as defined by American-European Consensus Group Classification Criteria. All patients being followed up by Ege University Departments of Rheumatology and Ophthalmology. The patients had positive Schirmer test results (<5 mm without anesthesia). SmartPlug™ (Medennium, Irvine, California, USA) was inserted into the inferior lacrimal canaliculi of both eyes. Visual acuity measurements, Schirmer I test measurements, lissamine green staining scores, and tear-film breakup times (BUT) were noted before plug insertion and at the 1st, 6th, and 12th months following the procedure. Minimum follow-up period was 6 months for 19 patients and 12 months for 16 patients. Significant improvements were seen in the Schirmer I test scores (before insertion: 1.98 ± 2.67; 1st month: 5.68 ± 6.69; 6th month: 5.35 ± 5.38; 12th month 6.43 ± 5.14 P = 0.006), tear-film BUT in seconds (before insertion: 4.64 ± 3.7; 1st month: 5.80 ± 2.36; 6th month: 7.53 ± 2.92; 12th month 7.50 ± 2.52, P < 0.0001), respectively. Thermodynamic punctum plug insertion only in inferior canaliculus is a simple, effective, and comfortable option for treatment of severe aqueous tear deficiency that cannot be controlled using preservative-free tears.