Tränenwegsverletzungen und ihre chirurgische Versorgung

Congenital Nasolacrimal Duct Obstruction - Early Diagnosis and Graded Therapeutic Approach as Key Points for Successful Management

PURPOSE

Epiphora in childhood is a frequent symptom that is typically associated with Congenital nasolacrimal duct obstruction (CNLDO). Nevertheless, inflammatory pathologies of the ocular surface as well as inside the eye, or even congenital glaucoma, must be considered in the differential diagnosis.

METHODS

A comprehensive literature review concerning CNLDO was conducted. Different therapeutic steps are categorized and summarized in order to reflect the existing staged therapeutic concept.

RESULTS

For CNLDO, a staged therapeutic concept is applicable, resulting in a cure rate of approximately 95% with only conservative or minimally invasive intervention. This concept includes five steps that encompass therapeutic interventions with increasing complexity. It includes conservative techniques, followed by probing and syringing, transcanalicular approaches without or with lacrimal intubation, and dacryocystorhinostomy which is the ultima ratio.

CONCLUSION

To preserve the topographic anatomy as much as possible, therapeutic recommendations enable stepwise and individualized management of children with CNLDO.

[Deep periocular trauma with affection of the lacrimal ducts during Caesarean section]

Periokuläre Verletzungen im Rahmen einer Kaiserschnittentbindung sind extrem selten. Anhand einer Kasuistik eines 5 h alten Neugeborenen soll das Trauma-Management in Hinblick auf Diagnostik, Therapie und Nachsorge einer tiefen periokulären Weichteilwunde dargestellt werden. Das Verletzungsmuster umfasste durchgreifende Wunden des medialen und lateralen Lidwinkels mit Eröffnung der Bindehautumschlagsfalte, der Tenonkapsel und Durchtrennung des oberen Tränenröhrchens. Der schichtweise Wundverschluss beinhaltete eine autostabile monokanalikulonasale Intubation der ableitenden Tränenwege.

Application Possibilities of a New Preloaded Nasolacrimal Duct Intubation System

INTRODUCTION

The LacriJet (FCI S. A. S. - France Chirurgie Instrumentation, Paris, France) represents a novel, simplified and preloaded system for monocanalicular or monocanaliculonasal nasolacrimal duct intubation. It is a further development of the Masterka and shall reduce the intubation time during the surgical procedure. The aim of the present study was to present first experiences with this system for different indications.

MATERIAL AND METHODS

All patients who underwent nasolacrimal duct intubation with the LacriJet at the University of Muenster Medical Center in the period from March to November 2019 were included. The postoperative outcome was evaluated 3 to 6 months later.

RESULTS

In total, 12 nasolacrimal duct intubations with the LacriJet were performed at our center in the above-mentioned period. The main indication for intubation was congenital nasolacrimal duct obstruction (CNLDO). In addition, intubation was performed in cases with eye lid tumors involving the nasolacrimal duct, in a case of canalicular laceration and in a case of canaliculitis. In 3 cases, there was an early dislocation or a complete loss of intubation. Of these, 2 were cases with CNLDO and the third dislocation was due to manipulation by the patient. All in all, the functional results were satisfying.

SUMMARY

The use of the LacriJet is highly suitable for the treatment of CNLDO, stenting in canalicular laceration or lid tumours involving the lacrimal drainage system. However, the known disadvantages of monocanalicular intubation (dislocation, early loss of intubation) also occur with this type of system and a system briefing seems useful. The LacriJet therefore represents a modern and simple method for nasolacrimal duct intubation and can be used for various indications.

Pattern of Presentation and Surgical Outcomes of Canalicular Laceration Repair in a Pediatric Population

PURPOSE

To evaluate demographic data, clinical profile, and factors responsible for the success of anatomical and functional outcomes of canalicular laceration repair with the Mini Monoka stent (FCI Ophthalmics) in children younger than 10 years.

METHODS

This was a retrospective cohort observational study involving children younger than 10 years who underwent canalicular tear repair with the Mini Monoka stent with a minimum follow-up of 6 months.

RESULTS

A total of 18 patients (9 boys and 9 girls) with a mean age of 5.39 ± 3.05 years were included. Twelve and 6 patients had lower and upper canalicular tear, respectively. Six (33.4%) patients had associated ocular comorbidity. The common mode of trauma was direct injury in 77.8% of the patients. The blouse hook of the mother was noted as the most common object causing canalicular laceration. Early repair (< 48 hours) and delayed repair were done in 7 (38.9%) and 11 (61.1%) patients, respectively. Anatomical and functional success was achieved in 88.9% and 94.4% of patients, respectively. The odds ratio (95% CI) for anatomical and functional success with the time since injury was 0.6 (CI: 0.03 to 11.47) and 0.19 (CI: 0.01 to 5.33), respectively. There was no significant difference between the early and delayed repair groups in terms of the distribution of anatomical (P = 1.000) and functional (P = .389) success. There was no significant difference between the various groups in terms of the distribution of complications (P = .224).

CONCLUSIONS

Canalicular laceration repair with the Mini Monoka stent in children younger than 10 years has shown good outcomes in terms of anatomical and functional success irrespective of time lag since injury to repair. [J Pediatr Ophthalmol Strabismus. 2021;58(1):42-47.].

Tränenwegsstenosen im Erwachsenenalter

Zur Aufrechterhaltung der okulären Oberflächenhomöostase und damit den Erhalt der optischen Eigenschaften sind Tränenproduktion, -verteilung und -abtransport essenzielle physiologische Funktionen. Störungen dieser funktionellen Einheit gehen mit starken Beschwerden und einem hohen Leidensdruck bei den Patienten einher. Da etwa 3% unserer Patienten eine Tränenabflussstörung aufweisen, ist die Thematik von hohem klinischem Interesse.

[Lacrimal Duct Obstruction in Adults]

The tearing eye (epiphora) is the guiding symptome of nasolacrimal duct obstruction. Depending on the localization of stenosis, mucopurulent lacrimal discharge occurs additionally. These symptoms induce alterations of the optical system and can cause severe complications such as acute phlegmonous dacryocystitis. The grade of suffering in these patients is very high. For the diagnosis, patient's history, ocular surface conditions and inspection (macro-/microscopically) as well as palpation of the lacrimal region are essential examinations. Moreover, functional and anatomical tests enable a classification of nasolacrimal duct obstruction regarding grade of stenosis (incomplete vs. complete), type (functional vs. mechanical), and localization (pre-, intra-, postsaccal). ENT consultation prior to lacrimal surgery is obligate. Through this, a purposeful therapeutic intervention is warranted. Surgical methods consist of minimally invasive transcanalicular procedures or anastomosing surgeries. Dependent on the clinical findings, these treatment options can be applied in a patient centered therapeutic concept.

Treatment of upper and lower lacrimal punctal occlusion using retrograde canaliculotomy and punctoplasty

This is a retrospective, noncomparative analysis of a case series to explore the safety and effectiveness of retrograde canaliculotomy and punctoplasty for treating epiphora due to upper and lower lacrimal punctal occlusion. During the procedure, the horizontal portion of the normal lower canaliculus was identified; the corresponding punctum was reconstructed via retrograde canaliculotomy and punctoplasty. Intubation was performed to prevent postoperative reocclusion. Patients were followed up for 12 to 24mo. A total of 16 patients with unilateral upper and lower lacrimal punctal occlusion were included. Satisfactory outcomes were achieved: all 16 patients exhibited improvement of epiphora; 31 rebuilt punctal openings and canaliculi achieved recanalization. Only one upper punctal opening could not be reconstructed because the corresponding canaliculus exhibited severe injury. No significant complications occurred as a result of the treatments. Retrograde canaliculotomy and punctoplasty appears to effective, safe, and minimally invasive for treatment of upper and lower punctal occlusion.

Postoncological lacrimal duct reconstruction: A practical classification system for reconstructive planning and short-term results of a case series

BACKGROUND

Surgical resection of skin tumors in the medial canthal area may damage the lacrimal duct and can result in chronic epiphora. Postoncologic reconstruction of the lacrimal duct has not been studied extensively. The current study discusses the anatomical and functional features of the lacrimal duct. It describes short-term functional outcomes after monocanalicular reconstruction of the lacrimal duct in a case series of 10 patients.

METHODS

From February 2015 to October 2017, all patients with a postoncological lacrimal duct defect were analyzed to make an anatomical classification. The functional outcomes of patients after monocanalicular reconstruction were measured with the Munk scale up to 3 months after stent removal.

RESULTS

Twelve patients had lacrimal duct defects after Mohs resection. Anatomical characteristics were used to create a clinical classification for lacrimal duct defects. This classification divides the upper (U) and lower (L) proximal lacrimal duct into two sections which can be damaged: the punctum and pars verticalis (1), the canaliculus horizontalis (2), or combined (3). The Common lacrimal duct (C) is the distal part of the lacrimal duct and can also be affected. Ten patients were analyzed after lacrimal duct reconstruction. Three months after stent removal, none of the patients suffered from epiphora.

CONCLUSIONS

This article proposes an anatomical classification for lacrimal duct defects in the proximal lacrimal drainage system. The classification can be applied in comparing cases and determining reconstructive strategies after oncologic skin tumor resection. Short-term results are promising for future efforts to reconstruct the lacrimal duct.

[Diagnostics and treatment of lacrimal duct diseases : A structured patient-centred care concept]

BACKGROUND

The cardinal symptom of lacrimal stenosis is epiphora and a subjective high level of discomfort due to continuous dacryorrhea.

OBJECTIVE

The aim of the current paper is to present a structured review of common diagnostic and therapeutic strategies for lacrimal stenosis.

MATERIALS AND METHODS

The most important diagnostic and therapeutic approaches are analysed using the existing literature and by reporting the authors' own experiences.

RESULTS

A detailed patient history is crucial for diagnosis of lacrimal disorders. Precise inspection and palpation of the lacrimal and lid region may confirm lacrimal stenosis. Examinations of tear production, tear quality and the properties of the ocular surface are helpful. The most important diagnostic tool is lacrimal duct probing and syringing. Therapy is guided by underlying pathologies. Treatment of congenital lacrimal stenosis follows a staged concept. Epiphora in adults without signs of dacryocystitis should be treated with dacryoendoscopy. Dacryoendoscopy is also a therapeutic option for chronic dacryocystitis, but dacryocystorhinostomy may also be required. Lacrimal trauma should be reconstructed rapidly after the incident by lacrimal intubation. Neoplasia of the lacrimal excretory system requires histological classification to enable multidisciplinary management.

CONCLUSION

Basic ophthalmologic diagnostics are complemented by special symptom-based examinations. Due to ongoing improvement of available diagnostic and therapeutic options, patients' care is becoming increasingly individualised.

A new method for locating the proximal lacerated bicanalicular ends in Chinese preschoolers and long-term outcomes after surgical repair

This report is to explore the long-term outcomes of surgical repair of bicanalicular lacerations in Chinese preschool patients. In this report, 12 patients with bicanalicular lacerations were studied between September 2010 and September 2015. The distance from the punctum to the distal canalicular lacerated end was recorded before surgery to classify different types of trauma. All patients underwent surgical repair of the lacerated canaliculi by 1 surgeon within 48 hours after the trauma occurred. After treatment, the lesions were divided into 3 types according to the distance from the punctum to the distal lacerated canalicular end as follows: lateral, medial, and the central. Based on this classification, each lacerated canaliculus was successfully repaired. Nearly half of the lesions (46%) were lateral, 42% were central, and 12% were medial. The average time for locating the proximal lacerated end of the canaliculus was 3.33 ± 1.52 minutes (range, 1.0-7.0 minutes). The follow-up time ranged from 6.0 months to 4.5 year (median, 25 months). Our study showed that 96% (23) of the canaliculi were completely patent. One lateral lesion presented with residual outdoor epiphora in cold weather secondary to left lower canalicular stenosis. All 12 patients had excellent cosmetic results. Our study displayed a surgical management based on the 3 types of lesions helped to find the proximal lacerated end of the canaliculus, and provided excellent long-term outcomes of drainage function.

[Prognostic value of lacrimal duct diagnostics after tube removal : Retrospective analysis of risk of relapse during the first postoperative year after transcanalicular lacrimal duct surgery with silicone tubing]

BACKGROUND

Transcanalicular lacrimal duct surgery has become more important over the past two decades.

OBJECTIVES

The aim of the study was to prove the prognostic value of postoperative lacrimal syringing and the testing of spontaneous drainage of lacrimal fluid immediately after tube removal.

METHODS

A total of 110 cases with postoperative lacrimal syringing and 183 cases with verification of the postoperative lacrimal fluid drainage performed between January 2001 and August 2008 were retrospectively evaluated. The indication for postoperative diagnostics was set by the investigator. The prognostic value of these two procedures was determined by using prognostic parameters (positive predictive value, PPV; negative predictive value, NPV) and analyzing recurrence nonexistence via Cox regression and Kaplan-Meier estimator. The observation period was limited to 12 months. Predominantly, recurrence was defined on the patient's satisfaction and absence of symptoms, which was determined with the help of a questionnaire.

RESULTS

Postoperative verification of the lacrimal syringing is a suitable instrument to estimate surgical success within the first year after lacrimal surgery with a PPV of 92.31%. Testing of the spontaneous drainage of lacrimal fluid after tube removal reached a PPV of 63.33%.

CONCLUSION

The proven prognostic value shows that syringing of the lacrimal duct and verification of spontaneous drainage should be integrated into postoperative care in a standardized manner. Hereby, early information for the patient about the expected result of the surgical procedure is enabled.

[Indications and techniques for intubation of the lacrimal ducts]

There are several well established methods to correct congenital and acquired lacrimal canalicular stenosis. The primary goal of all these surgical methods is the reopening and recanalization of a functional lacrimal pathway. Intubation by bicanalicular or monocanalicular silicone tubes has been established as a means of enhancing the redevelopment of a smooth epithelial surface and keeping the recanalized tear ducts continuously open. The use after endocanalicular surgery is mostly undisputed and unequivocally advocated after trauma but the use after either endonasal or transcutaneous dacryocystorhinostomy is still controversial as there is no clear evidence that it produces superior results. There are several systems available to place monocanalicular or bicanalicular silicone tubes. The decision to place an intubation depends mainly on the level and the type of stenosis.

[Possibilities in the surgical management of eyelid trauma]

The face plays a central role in interpersonal communication and aesthetic perception. Moreover, due to the heavy dependence of ocular function on lid anatomy, the treatment of periocular injuries, particularly those involving soft tissue loss, requires profound knowledge of both anatomy and reconstructive plastic surgery. Numerous surgical procedures are described in the literature. The aim of these procedures is to achieve an optimal functional and aesthetic result according to injury localization and extent. Against this background, treating eyelid injuries presents certain challenges. Close collaboration between all areas of head surgery is required particularly in the case of large defects.