Lacrimal Punctum Research Articles

Prevalence, Clinical Characteristics, and Relative Factors of Acquired Punctal Stenosis in Adult Allergic Conjunctivitis Patients

Plain Language SummaryThis study aimed to examine the prevalence of acquired punctal stenosis (APS) among adults with allergic conjunctivitis (AC), describe its characteristics, and identify associated risk factors. We reviewed the medical data of 210 adult patients with AC at Zhongshan Ophthalmic Center. We gathered demographic data and evaluated ocular symptoms. Using slit-lamp microscopy, we assessed and graded the morphology of the lacrimal puncta (lacrimal duct openings) according to a modified grading system. The study results revealed that 69% of the adult patients with AC had APS. Stenotic lacrimal puncta were present in 49.3%, with grade IIa being the most common. The narrowing was most frequently observed in the upper lacrimal puncta compared to the lower ones. Older age and a higher tear meniscus height (TMH) were significantly associated with the presence of APS. Therefore, this study demonstrates that APS is commonly observed in adults with AC, which is associated with the increased age and widened TMH, indicating a possible link between chronic and recurrent AC and the development of APS.

Simplified medial canthoplasty: Technique and early postoperative complications in 601 dogs (1180 eyes).

To present a novel modified medial canthoplasty (MCP) technique, the application in 601 dogs (1180 eyes), and a review of the early postoperative complications related to the technique. Macroblepharon and nasal entropion is a common presentation in many brachycephalic dog breeds promoting chronic keratitis. The previously described MCP techniques limit the medial shortening of the eyelids to the location of the lacrimal puncta. A novel technique was developed allowing for a more extensive eyelid shortening nasally. The modification of the here described technique includes the longitudinal splitting of the lacrimal canaliculi allowing for an extensive shortening of the lids beyond the lacrimal puncta. Records of 601 dogs which underwent the modified MCP were reviewed regarding breed, indications for surgery, follow-up, and early postoperative surgical complications. Descriptive statistics were applied. Six hundred one dogs (1180 eyes) were included in this study. Twenty-four different breeds underwent the simplified MCP with the Pug (n = 403) being the most represented breed. Indications were macropalpebral fissure, medial entropion, pigmentary keratitis, trichiasis by haired caruncle, strabismus after globe prolapse, and facial nerve paralysis. The overall complication rate was 1.01% (12/1180) and consisted of wound dehiscence 0.59% (7/1180), corneal ulceration caused by suture material 0.25% (3/1180), and wound infection (2/1180). None of the 601 operated dogs developed serious complications related to the surgical technique. The simplified MCP is a novel technique with a very low complication rate.

Peripunctal melanocytic nevus involving the lacrimal canaliculus: A case report

A 56-year-old woman complained of a mass in the right eye’s lower eyelid. Slit-lamp examination revealed a dark mass with pigment in the inner canthus of the right lower eyelid involving the lacrimal punctum. The mass was removed and confirmed to be peripunctal melanocytic nevus. We have presented the first case of peripunctal melanocytic nevus involving the lacrimal canaliculus with histologic evidence. No recurrence occurred.

Prosedur Pemeriksaan Dacryocystografi Pada Kasus Dacryosistitis Kronis Di Instalasi Radiologi RSUP. Dr.Wahidin Sudirohusodo Makassar

Dacryocystography examination is the examination of the radiologist to show the nasolacrimal duct by using a positive contrast medium. The purpose of this examination is to describe the system of tear duct blockage and the level of blockage. This research method is descriptive with aproachcase study conducted in RSUP. Dr. WahidinSudirohusodo Makassar on Juni 2019. The inspection technique is done by using the projection Antero Posterior (AP), which contrast material is inserted throught the tear duct in the lacrimal punctum which empties into the concha nasalis inferior. From the result of the examination has been done, it can be concluded that the contrast as much as 1 cc inserted throught the superior lacrimal punctum, contrast restrained and spilled out. Contrast as much as 1 cc inserted throught the inferior lacrimal punctum, the contrast seems to fill out the inferior palpebra area. From the research, lacrimal duct obstruction impression superior and inferior.

Geometric morphometric anatomy of the lacrimal punctum in normal population: Punctum update (PUP) study – Paper 5

BackgroundTo investigate the geometric morphological differences of the lacrimal punctum by analyzing its shape in relation to age and sex in a normal population. Methods960 high-magnification slit-lamp images were obtained from 320 puncta of normal asymptomatic Indian individuals across eight decades of life. Using advanced geometric morphometric techniques, including Elliptic Fourier Analysis and Principal Component Analysis, the intricate details of the lacrimal punctum's shape in a diverse population sample were categorized by age and sex. High-resolution images of the lacrimal punctum underwent standardization for scale and orientation, followed by precise landmark identification and coordinate data extraction. ResultsThe geometric morphometry of the lacrimal punctum shows significant changes as one ages. However, the gender differences, in isolation, without consideration of age, remain subtle and are not pronounced. Interestingly, detailed Principal Component scores analysis revealed potential sex- and age-related variations specifically for the left and right lower puncta, which warrant further investigation. These changes could reflect unique aging changes in the proximal lacrimal drainage system. ConclusionThe study is a starting point for geometric morphometric analysis of the lacrimal punctum and provides valuable insights into the punctal changes in size, orientation, and overall morphology across different age groups and between sexes. These findings highlight the significance of considering individual age-wise anatomical variations to better understand the lacrimal punctum.

Treatment of Cicatricial Lower Eyelid Ectropion with Suture of Horner Muscle Combined with Fascia Transplantation.

This case series aimed to describe a new technique for correcting contractures and deformities that reliably addresses lacrimal punctum deviation and severe cicatricial lower eyelid ectropion. This was a technical description and a retrospective interventional case series. Eyelid ectropion and lacrimal punctum deviation were treated surgically by grafting the fascia lata and suturing the tarsus-Horner muscle. In total, three patients underwent this surgery: one for burns, one for lower eyelid tumor resection, and the other for an orbital floor fracture following a motorcycle accident, all resulting in ectropion. All patients previously had failed ectropion correction procedures, including scar revision, skin grafting, auricular cartilage grafting, and lateral tarsal strips. The mean follow-up was 15.8 (12.5-18.5) months. Furthermore, all patients showed resolution of lower eyelid ectropion and significant improvement in lower eyelid contracture, with a mean increase of 4.0 (2.5-5) mm. No severe complications were observed, and they reported a significant improvement in ocular surface symptoms. Our study shows that tacking of the tarsus and Horner muscles in combination with fascia lata grafting is effective in correcting refractory cicatricial lower eyelid ectropion with deviation of the tear punctum.

Nasolacrimal sac foreign body extraction using vitreoretinal forceps in 28 dogs.

To describe a novel technique of nasolacrimal foreign body extraction in dogs by using a 20G vitreoretinal forceps introduced through the superior lacrimal punctum. A retrospective review of the medical records of dogs with dacryocystitis due to nasolacrimal foreign bodies between the years 2001 and 2022 was performed. We recorded the breed, age, affected eye, type and number of foreign bodies, concomitant diseases, and the use of imaging techniques. All animals underwent the same procedure of a 20G vitreoretinal forceps insertion through the upper canaliculus reaching the lacrimal sac and retrograde extraction of the foreign bodies. A total of 28 dogs were included, 16 males and 12 females, with a mean (±SD) age of 4.7 (±3.2) years. The most common breeds were Wire-Haired Dachshund (4/28; 14.29%) and Labrador Retriever (3/28; 10.71%). Additional imaging techniques were used, such as orbital ultrasound in 13 cases (13/28; 46.43%) and computed tomography in one case (1/28; 3.57%). The most common type of foreign body retrieved was grass awns, although seeds and plant debris were also found. Dacryocystitis resolved after removal of the foreign body and appropriate medical therapy was ensured in all cases in the 1-month postprocedure follow-up. Extraction of nasolacrimal foreign bodies with vitreoretinal forceps is a novel, noninvasive, and easily applicable technique that, although not successful in all cases, can be attempted before performing more aggressive surgery.

Epistaxis-related hemolacria in a 6-year-old female after midfacial trauma: Epistaxis-related hemolacria

Hemolacria (HL) is a rare condition characterized by the presence of blood in the tears. Bleeding associated with tears can occur in the context of infection, inflammation, trauma to the eye or surrounding structures, vascular tumors of the eye or surrounding structures, or retrograde epistaxis. We herein present a pediatric case with HL in the setting of epistaxis due to post-traumatic vessel injury without fracture, along with a literature review. Bleeding from the inferior lacrimal punctum was controlled by successful cauterization of damaged vessels and follow-up has remained uneventful for over a year. Bleeding from the eye is an alarming symptom, especially if it developed after facial trauma. However, physicians should be more aware that, in the absence of a fracture, HL due to retrograde epistaxis resulting from facial trauma can be a self-limited condition that is easily treated by controlling nasal hemorrhage.

Therapeutic management of akissing nevus of the eyelid

Congenital divided melanocytic nevi of the upper and lower eyelid are rare pigmented changes of the eyelids. These processes are also known as "kissing nevi," "panda nevi," and "split ocular nevi," and were first described by Fuchs in 1919. About 120cases have been described in the literature so far. Congenital melanocytic nevi are either present at birth (small nevi are already found in about 1% of neonates) or manifest predominantly during the first decade of life. These rare melanocytic changes of the eyelids should be controlled regularly, as malignant transformation can occur. The actual incidence of malignant transformation is highly variable in the literature, ranging from 2 to 40% depending on the duration of follow-up, with an average of 14% for the whole lifetime. Moreover, nevi of the eyelids may be considered cosmetically disturbing and cause functional problems. Therapeutic removal (dermabrasion, cryotherapy, laser therapy, and surgical excision with ophthalmoplastic reconstruction) is rarely medically indicated due to the low risk of malignant transformation. Removal can be performed in cases of secondary amblyopia in ptosis, compression of the lacrimal point, epiphora, or cosmetic desire. Treatment becomes necessary not only in case of suspicious manifestation or impairment of eyelid function, but it also helps to avoid possible bullying at school among children and is recommended at age4 to6 (before school age).

A rare case of ocular pterygium in a young boy with congenital lamellar ichthyosis

Congenital lamellar ichthyosis is a rare dermato-ocular disease occurring in 1:300,000 population and is autosomal recessive. The most common ocular manifestation reported is cicatricial ectropion. Other symptoms include exposure keratopathy (secondary to ectropion), trichiasis, madarosis, deficit of the meibomian glands, and absence of lacrimal punctum. There are no reports of primary conjunctival involvement. We report a case of grade 3 pterygium in a young boy with congenital lamellar ichthyosis probably secondary to limbal stem cell deficiency.

Alterations in clinical parameters in cicatrising conjunctivitis secondary to GvHD

Cicatricial conjunctivitis is part of a well‐known complication of graft versus host disease (GVHD) resulting from the tissue fibrosis that affects different body organs. It results from inflammatory reactions determined by recognition of recipient antigens as foreign by donor cells. The main target tissues in ocular GVHD are the conjunctiva and the lacrimal gland, and conjunctival involvement is usually associated with more severe systemic disease. Clinical manifestations of cicatricial conjunctivitis includes conjunctival fibrosis, conjunctival shortening, conjunctival scarring and keratinization, and symblepharon and/or ankyloblepharon. Such scarring may even lead to cicatricial lagophthalmos, ectropion, entropion, and stenosis or closure of the lacrimal puncta. In fact, the degree of palpebral conjunctival changes has been used as a criterion to classify conjunctival involvement in chronic GVHD.Conjunctival epithelial cells and myofibroblasts may have donor origin, though with a very small proportion. These donor‐derived fibroblasts may play a role in the pathogenesis of conjunctival fibrosis. In addition, it has been shown that the ocular surface of patients with chronic GVHD may show epithelial‐mesenchymal transition, in which the epithelium may gain the mesenchymal phenotype and the ability to migrate into the subepithelial stroma, resulting in conjunctival fibrosis.Our group showed that a significant proportion of patients with ocular GHVD had subtarsal fibrosis, that was non evident in non‐GHVD dry eye disease (DED) patients, even with the same degree of clinical severity. Extent of involvement varied from one eye to another; on average, more than a quarter of the visible tarsal area was affected by the fibrosis. Such fibrosis was significantly associated with ocular surface epitheliopathy and conjunctival staining. In contrast, densities of epithelial and stromal immune cells in the conjunctiva were comparable between GVHD and non GVHD DED patients after adjustment for severity of DED. We also showed that spontaneous extrusion of punctal plugs occurs in a majority of ocular GVHD‐associated DED patients within 90 days of plug placement, and this lower retention rate of punctal plugs has been attributed to punctal subepithelial fibrosis.In all patients with ocular GVHD, the eye care provider should evaluate the presence of conjunctival fibrosis and associated ocular surface complications. If present, the therapeutic strategy should attempt to address this scarring process.

The Teknik Pemeriksaan Dacryocystography Dengan Klinis Obstruksi Ductus Nasolacrimal

Background: One examination using contrast media that is rarely encountered is the Dacryocystography examination. At one type A hospital in Jakarta only 34 examinations were carried out in 2019, while at another type A hospital this examination was not carried out at all. Dacryocystography examination is a radiological examination of the nasolacrimal system by filling the luminal canal with radiopaque contrast. This examination will not be visible well without using contrast. Based on the experience that the author found during practice at one of the type A hospitals in Jakarta, the Dacryocystography examination with clinical Nasolacrimal Ductus Obstruction only uses 1 (one) projection, namely AP (Anteroposterior). In contrast, according to Ballinger (2011), this examination uses 3 (three) projections—namely PA Caldwell, PA Waters, and Lateral.
 Methods: This research is descriptive and qualitative in nature, namely by conducting observations, interviews, and documentation at the KIARA radiology installation, RSUPN Dr. Cipto Mangunkusumo. With 1 (one) sample, interviews with 3 (three) radiographers and 3 (three) radiology specialists. Dacryocystography technique: the patient without preparation is then taken on a plain AP photo, then contrast media is injected into the lacrimal punctum of both eyes of the patient and a post-contrast photo with AP projection. Then the patient's eyes are dripped with NaCl to reduce the concentration of the contrast medium.
 Results: The results of the study showed that the Nasolacrimal Ductus was blocked because the contrast medium stopped at the location of the nasolacrimal duct blockage.
 Conclusions: In the Dacryocystography examination with clinical Nasolacrimal Ductus Obstruction, contrast media is injected using a special syringe that has been modified in the form of a bent and blunt needle. For projections, only 1 projection is used, namely Antero Posterior (AP) for preliminary photos and post-contrast photos which will depict the image of the Nasolacrimal Ductus having obstruction or blockage.

Proportion and characteristics of lacrimal drainage pathway disease and keratopathy in non-infectious corneal perforation using lacrimal syringing test

AbstractLacrimal drainage pathway disease-associated keratopathy (LDAK) has been associated with corneal perforation, which arises from both infectious and non-infectious corneal disorders. However, patients with corneal perforation are often not routinely tested for LDAK, and the potential risk posed by LDAK in the development of corneal ulcers has not been investigated in detail. This study aimed to assess the proportion and characteristics of LDAK in patients with non-infectious corneal perforation using lacrimal syringing test. This study enrolled 56 patients with corneal perforation treated at Saitama Medical University Hospital between January 2016 and September 2022. The causes of corneal perforation were trauma (n = 17, 30%), infection (n = 19, 34%), non-infection (n = 16, 29%), and unknown (n = 4, 7%). A lacrimal syringing test was performed on 12 patients with non-infectious corneal perforation and 4 with an unknown diagnosis. Among the 16 patients with non-infectious corneal perforation, 13 (81%) had lacrimal drainage disease, but only 3 (19%) patients had lacrimal puncta, as revealed by slit-lamp examinations. The primary bacterial species identified in lacrimal obstructive disease and lacrimal canaliculitis were Staphylococcus spp. and Actinomycetes spp. respectively. Lower temporal and peripheral corneal perforations were common. All patients underwent lacrimal surgery, and 6 (38%) were treated for corneal perforation without corneal surgery. Interestingly, several patients with LDAK who did not exhibit any lacrimal duct obstruction on slit-lamp examination. The study findings demonstrate the significance of the lacrimal syringing test for assessing LDAK in patients with corneal perforation, indicating LDAK as a potential cause of corneal perforation.

Horizontal shortening of the lower eyelid margin in facial nerve palsy.

To determine whether horizontal lower eyelid margin length shortens following facial nerve palsy (FNP). A single-centre retrospective audit of lower eyelid margin horizontal length, measuring from the lower lacrimal punctum to lateral canthal angle with a straight plastic ruler, with the eyelid on gentle stretch ('punctum-to-canthus (PC) distance'), recorded in all FNP patients reviewed in July-September 2021. Affected and fellow eyes were compared using parametric testing. Forty-one patients were reviewed. Seventeen were excluded due to previous surgery that would lengthen (e.g., periosteal flap) or shorten (e.g., lateral tarsal strip) the lower eyelid margin. Of the remaining 24, mean age was 52.5 years (range, 27-79) and 54% were female. Mean PC distance was significantly shorter in affected eyes (26.0 mm, range: 22-34 mm) compared to fellow eyes (27.5 mm, 24-35 mm) (paired t-test, T(23) = 6.06, p < 0.00001). Mean difference between both eyes' PC distance was 1.5 mm (0-4 mm). Only three patients were still in the 'paralytic phase' (i.e., <1 year since FNP onset), and difference in PC distance was 0 mm in all three. A reduction in lower eyelid PC distance was weakly associated with a reduction in upper eyelid lid-margin-to-brow distance (R = 0.4775, p = 0.0286). The lower eyelid margin appears to shorten horizontally following FNP. This study provides proof-of-concept for the use of measuring PC distance in patients with FNP as an additional tool for the overall assessment of soft tissue contraction following FNP. It may help identify patients in whom further lower eyelid margin shortening should be avoided and in whom eyelid lengthening may be required.

Mini-invasive Therapy for Primary Chronic Canaliculitis without Damaging Lacrimal Punctum.

This study aimed to introduce a mini-invasive surgical approach without damaging lacrimal punctum for treating primary chronic canaliculitis (PCC). A retrospective analysis of 35 patients (35 eyes) suffering from PCC were recruited in the study. The surgery method is described briefly below: After making a conjunctival incision about 3-mm in length along the horizontal canaliculus at about 3-mm to the nasal of punctum, a curette of 2-mm diameter was used to evacuate the concretions through the incision of canaliculus. After evacuating all concretions, a silicon tube was inserted into the lacrimal duct through canaliculus to nasal cavity. With a follow-up of 12 months, all patients had resolution of symptoms of inflammation and no recurrent case was found. The anatomical success was achieved in 34 cases (97.1%). The functional success was achieved in 32 cases (91.4%). Key Words: Primary chronic canaliculitis, Mini-invasive, Silicone tube.

Angeborene Fehlbildungen der ableitenden Tränenwege

Congenital dacryostenosis is the most common reason for ophthalmic consultation in childhood. It is most often caused by persisting of Hasner's membrane. However, congenital malformations of the lacrimal drainage system can also occur in rare cases. In the area of the proximal lacrimal drainage system, supernumerary lacrimal puncta and canaliculi can arise as well as diverticula, fistula, and atresia. The distal lacrimal drainage system can be affected by fistulas, amniotoceles, and cysts. Association of lacrimal malformations with congenital systemic diseases is reported in about 10% of cases. Depending on the severity of the symptoms, surgical rehabilitation can be performed, and endoscopic procedures and modern lacrimal drainage intubation systems may be employed.

Perforated Punctal Plugs for the Management of Acquired External Punctal Stenosis

The study presents the results of treating patients with pathological tearing caused by acquired external punctal stenosis.&#x0D; Method: 61 eyes of 34 individuals with an average age of 67 were enrolled in the study. A perforated silicone implants were inserted into the narrowed lacrimal punctums, after pathological tearing had been diagnosed using the Munk test, fluorescein disappearance test, and other parameters. Implants has been removed after 3 months.&#x0D; Results: Overall, a statistically significant (p &lt; 0.001%) reduction in the fluorescein disappearance test was observed in 93.2% of eyes (n = 55). None of the patients experienced an exacerbation of excessive tearing. The average score on the fluorescein disappearance test decreased from 3.64 before the procedure to 1.42 after the procedure.&#x0D; Conclusions: Intubation of the lacrimal punctum with perforated silicone implants is a quick, effective, and safe method for treating pathological tearing in cases of acquired narrowing of the lacrimal punctum.

Surgical Punctal Occlusion; Combined Lacrimal Canaliculi Cauterization and Punctal Suturing for Severe Dry Eye.

To evaluate the treatment outcome of surgical punctal occlusion with combined canaliculi ablation and punctal suturing in patients with severe dry eye. Eleven eyes of seven patients were diagnosed with severe dry eye with decreased lacrimal secretion and were refractory to treatment with various eye drops and/or had repeatedly experienced loss of punctal plugs, and continued to experience subjective symptoms received surgical punctal occlusion. In 20 puncta, lacrimal canaliculi ablation was performed along the entire length of the lacrimal canaliculus where a diathermy needle could be inserted. After resection of the annulus fibrosus in the peri-punctal area, tight cross-stitch suturing of the puncta was performed with 8-0 absorbent thread. Visual acuity, corneal staining score according to the area (A) and density (D) classification, and Schirmer tear test (STT); tear break up time (tBUT); and subjective symptoms assessed by the University of North Carolina (UNC) and Dry Eye Management Scale were compared before and one year after surgery. Recanalization occurred in 1/20 puncta (5.0% at month 5) in 1/11 eyes. Student's t-test showed significant improvement at one year compared with preoperative values for LogMAR value (P = 0.019), corneal staining score A (P = 0.00003) and D (P = 0.0003), STT (P = 0.004), and subjective symptoms (P = 0.015). No change was shown in tBUT and no serious adverse event occurred. This improved, minimally invasive surgical procedure has a low recanalization rate and achieves both objective and subjective improvements at one year.

Identification of a novel mutation in the FGF10 gene in a Chinese family with obvious congenital lacrimal duct dysplasia in lacrimo-auriculo-dento-digital syndrome.

To identify the pathogenic gene variant in a family with lacrimo-auriculo-dento-digital syndrome [LADD (MIM 149730)] showing congenital lacrimal duct dysplasia as the main clinical manifestation and lay the foundation for future research on the pathogenic gene. Ophthalmological examinations, including slit-lamp biomicroscopy and lacrimal duct probing, and computed tomography dacryocystography (CT-DCG) were performed for all participants. The family pedigree was drawn, genetic features were analyzed, and the genomic DNA of the subjects was extracted. Pathogenic genes were screened via whole exome sequencing (WES) and confirmed using Sanger sequencing. Six patients belonged to this three-generation family, and their clinical manifestations included congenital nasolacrimal duct obstruction, congenital absence of lacrimal puncta and canaliculi, lacrimal fistulae, and limb deformities. This pattern indicates autosomal dominant inheritance. Diagnosis was based on the clinical characteristics of LADD syndrome, which presented in all the patients in this family. A novel frameshift mutation in the FGF10 gene (NM_004465.1), c.234dupC (p.Trp79Leus*15), was identified in all patients via WES. The variant was confirmed by Sanger sequencing and classified as a "pathogenic mutation" according to the American College of Medical Genetics and Genomics (ACMG) variant interpretation guidelines. A novel frameshift mutation in the FGF10 gene is found in all patients. This finding helps this family with LADD syndrome receiving a more accurate clinical diagnosis and genetic counseling by extending the mutation range of the FGF10 gene.

Novel findings on the anatomy of medial canthus in dogs.

Severe entropion of the medial canthus results in ocular surface diseases and tear staining syndrome. However, detailed anatomical structures of the medial canthus and lacrimal ducts in dogs are poorly understood. We aimed to understand the anatomical structures of the medial canthus by analyzing the distances from the medial palpebral commissure to the superior lacrimal punctum (DSP) and to the inferior lacrimal punctum (DIP) and by histological examinations of the medial canthal anatomy. Dogs that underwent modified medial canthoplasty (MMC) between April 2017 and March 2021 were studied. As a reference, non-brachycephalic dogs that underwent other surgeries were also examined. DSP and DIP were measured preoperatively in all dogs in both the non-everted and everted positions. Histological examinations of the medial canthal anatomy were performed in four eyes isolated from beagles. The ratios of DIP to DSP (mean ± SD) at the non-everted and everted positions in 242 MMC eyes of 126 dogs were 2.05 ± 0.46 and 1.05 ± 0.13, respectively (p < .01). The ratios of everted to non-everted positions for DIP and DSP were 0.98 ± 0.21 and 1.93 ± 0.49, respectively (p < .01). Histological findings indicated that the orbicularis oculi muscle (OOM) circumjacent lacrimal canaliculus transformed into collagen fibers and were attached to the lacrimal bone. Histological studies revealed that the OOM circumjacent lacrimal canaliculus transformed into collagen fibers and these collagen fibers may be related to the difference between DSP and DIP.