The pathogenesis of canalicular laceration

Pediatric Eyelid and Canalicular Lacerations: Epidemiology and Outcomes

PURPOSE

To characterize the epidemiology of eyelid lacerations, identify risk factors for canalicular involvement, and describe postoperative complications following laceration repair.

METHODS

All patients undergoing eyelid laceration repair at a tertiary care, level I trauma center children's hospital from November 2010 to April 2021 were identified by a Current Procedural Terminology code search. Patient characteristics, surgical characteristics, and surgical outcomes were collected via chart review. Univariate analysis and multivariate logistic regression were performed to identify risk factors for canalicular involvement and postoperative complication.

RESULTS

A total of 165 patients were identified, of whom 136 had at least 1 week of follow-up and were further assessed for postoperative complications. The most common mechanisms of injury were dog bites (62, 38%), falls (33, 20%), and being struck by an object (22, 13%). Eyelid margin involvement was present in 108 patients (65%) and canalicular involvement in 77 patients (47%). Risk factors for canalicular involvement were hook-related injury, eyelid margin involvement, and lower eyelid injury. Thirty-three patients (24%) had postoperative complications, most commonly ptosis (7, 5%), premature stent loss (7, 5%), and eyelid margin notching (6, 4%). There was no association between postoperative complication and antibiotic use, delayed repair, or wound class.

CONCLUSIONS

Hook-related injury, eyelid margin involvement, and lower eyelid injury are risk factors for canalicular involvement. Postoperative complications of eyelid lacerations are generally minor and are not associated with perioperative factors. Close postoperative follow-up is needed to monitor for complication development. [J Pediatr Ophthalmol Strabismus. 2023;60(1):33-38.].

A case series study of lacrimal canalicular laceration repair with the bi-canalicular stent

BACKGROUND

Lacrimal canalicular laceration can be caused by trauma on the ocular adnexa, such as penetrating or blunt injuries, accounting for approximately 16% of eyelid lacerations and 20% of eye traumas. Historically, canalicular anastomosis combined with bi-canalicular or mono-canalicular stent intubation has been used for canalicular laceration repair. In this study, we analyzed the epidemiological characteristics of lacrimal canalicular laceration and evaluate the clinical outcomes of repair using the bi-canalicular stent in central China. It aims to provide a reference for clinical work.

METHODS

This is a review of 338 patients (338 eyes) with eyelid lacrimal canaliculus laceration undergoing reparative bi-canalicular stent intubation from January 1st 2017 to December 30th 2020. The analyzed data included demographics, the place of occurrence of the trauma, the mechanism of injury, additional injury, and surgical outcomes at follow-up. The outcomes included anatomic success, functional success, and complications.

RESULTS

The average age was 39.6±20.0 years (1 to 88 years). Of all the 338 patients, 254 (75.15%) patients were men. Upper and lower canalicular lacerations were seen in 68 (20.12%) and 256 (75.74%) patients, respectively. Also, 14 patients (4.14%) presented with both upper and lower canalicular lacerations. Most injuries occurred on the streets (146, 43.20%), followed by the home in 111 (32.84%) patients. Traffic accidents were the leading cause of injury (127, 37.57%), including 72 (21.30%) cases of electric bike-associated accidents, followed by fall-related trauma in 65 (19.23%) cases. During the follow-up, there were 6 (1.78%) patients with eyelid ectropion and 9 (2.66%) patients with stent extrusion and loss due to eye rubbing and pulling the sutures out. At the end of follow-up, the anatomical success rate was 95.86% and the functional success rate was 89.64%.

CONCLUSIONS

Electric bike-associated accidents occurring on the streets is the current leading cause of injury in central China. Lacrimal canalicular laceration repair with a bi-canalicular stent offers an effective surgical therapeutic strategy for traumatic canalicular lacerations. In addition, avoiding traffic accidents is also one way prevent lacrimal canalicular laceration.

Bicanalicular Annular Stent Compared with Bicanalicular Nasal Intubation in Management of Traumatic Lower Canalicular Laceration

Purpose

To report the functional and anatomical results of bicanalicular annular stent compared to bicanalicular nasal intubation in the management of traumatic lower canalicular laceration.

Patients and Methods

A retrospective comparative, non-randomized interventional study. The study included consecutive patients suffering from traumatic lower canalicular laceration attended to ophthalmology department causality at Al Azhar University hospital Damietta branch, between December 2018 and August 2020.

Results

The study recruited eighty-five eyes of eighty-five patients admitted for treatment of traumatic lower canalicular laceration. In thirty-three patients, canalicular integrity was restored by bicanalicular annular stent (group 1) and in twenty five patients by bicanalicular lacrimal intubation (group 2). The affected patients were predominantly males (78.8% in the first group and 80% in the second group). Etiology of trauma was due to occupational hazards; 48.5% in the first group and 36% in the second group. Anatomical success in the first group was 93.9%, and 92% in the second group. Canalicular patency was achieved in 90.9% in the first group and in 80% in the second group.

Conclusion

There was no statistically significant difference between bicanalicular annular stent and bicanalicular nasal intubation regarding both anatomical and functional success. Both techniques represent a successful alternative to monocanalicular stent.

Traction Applying Technique on Bicanalicular Crawford Silicone Tube to Overcome the Notching Deformity After Lacrimal Canalicular Repair

ABSTRACT

Lower eyelid avulsion injury with lower canalicular laceration generally occur just medial to the punctum with insufficient skin remnant for repair causing tension on repair margins. The inevitable blinking force, along with the tension widens the repair margin, resulting in an aesthetically challenging notch at the medial lower lid. The authors attempted to minimize this notching deformity with a traction applying technique on bicanalicular silicone tube.Fifteen patients were enrolled and divided into 2 groups: the experimental group with 10 patients which received the traction technique, and the control group with 5 patients which the traction technique was omitted. Each end of the bicanalicular silicone tube was intubated through both puncta and the lacerated canaliculus. No canalicular anastomosis was performed. The tube ends were retrieved through the nostril, followed by medial canthal tendon, orbicularis oculi muscle, and skin repair. The tube ends were pulled to create a tension on the loop, until upper and lower puncta apposed each other, creating a dimple in the medial canthal area. The tube ends were tied and anchored at internal valve of the nostril to maintain the traction tension. Medial lower lid notching (>2 mm width), epiphora, and conjunctival injection were evaluated and compared in the 2 groups.Patients with traction technique showed symmetric medial canthal angle and minimized lower lid notching deformity when compared with the control group (P = 0.025). No conjunctival injections and epiphora were observed in either group. Symmetric and aesthetically satisfactory results were achieved by traction applying technique on bicanalicular silicone tube.

Periorbital Soft Tissue Trauma

Eyelid trauma occurs across a broad spectrum of pathology, ranging from simple periorbital lacerations to severe, vision-threatening injuries requiring expert oculoplastic consultation. Any injury, no matter how benign, is also inherently cosmetically sensitive, further adding to the reconstructive challenge. In this review, we discuss the anatomy of the eyelid and develop an understanding of evaluating for signs of more serious, potentially occult, trauma. A framework is developed for approaching the patient with periorbital trauma to assess for injury and triage necessary treatments. Damage to the lacrimal drainage system, which can be particularly difficult to detect and repair, is specifically emphasized and explored.

Berberine hydrochloride inhibits inflammation and fibrosis after canalicular laceration repair in rabbits

AIMS

This study was designed to investigate the molecular mechanisms underlying the anti-inflammatory and anti-fibrosis effects of Berberine hydrochloride (BBR) following canalicular laceration (CL) surgical repair.

MAIN METHODS

We used a rabbit CL model in this study. BBR and the control medicine were administered during and after the surgical operation. The degree of fibrosis in the canaliculi was evaluated using hematoxylin and eosin and Masson's trichrome staining 7 days after the operation. Inflammation inside the canaliculi was observed using a transcanalicular endoscope. Expression levels of inflammatory cell cytokines [tumor growth factor-β1 (TGF-β1), connective tissue growth factor (CTGF), intracellular adhesion molecule-I (ICAM-1), and interleukin-β1 (IL-1β)] were detected using immunohistochemistry. P38 and ERK1 phosphorylation and activation were determined using western blot analysis.

KEY FINDINGS

The degree of inflammation and fibrosis were less in the BBR groups compared to Surgery group. The anti-inflammatory and anti-fibrosis effects of BBR were concentration-dependent. The levels of TGF-β1, CTGF, ICAM-1, and IL-1β were significantly lower in the BBR groups compared to Surgery group. BBR reduced the phosphorylation of P38 compared to Surgery group.

SIGNIFICANCE

In conclusion, this study shows that BBR can reduce local fibrosis after CL surgical repair via its anti-inflammatory and anti-fibrosis effects.

Eiology and prognosis of canalicular laceration repair using canalicular anastomosis combined with bicanalicular stent intubation

BACKGROUND

To evaluate the etiology of lacrimal canalicular laceration and explore the possible risk factors influencing prognosis.

METHODS

The data of 142 patients (142 eyes) with lacrimal canalicular lacerations who were surgically treated using canalicular anastomosis combined with bicanalicular stent intubation between March 2017 and March 2018 were reviewed. The analyzed data contained demographic information, types of trauma, injury locations, associated additional ocular injuries, and surgical outcomes at follow-up. The main outcome measures were anatomic success rate, functional success rate, and complications of surgery.

RESULTS

The mean patient age was 42.07 years (ranging from 1 to 75 years). Among the 142 patients, 112 (78.87%) were males. Upper and lower canalicular lacerations were found in 14 (9.86%) and 112 (78.87%) patients, respectively. Meanwhile, both upper and lower canalicular lacerations were found in 16 (11.27%) patients. Electric bike accidents comprised the leading cause of injury, accounting for 76 (53.52%) cases. There were 100 (70.42%) patients who had lid lacerations without tarsal plate fracture and 42 (29.58%) patients who had lid lacerations with tarsal plate fractures. The anatomic success rate was 98.59% and the functional success rate was 83.8%. The functional reconstruction failure rates were higher in patients with indirect injuries, lid lacerations with tarsal plate fractures, and those with punctum splitting (P < 0.05). Surgical complications were detected in the form of lacrimal punctum ectropion in 3 (2.11%) patients, punctum splitting in 2 (1.41%) patients, and stent extrusion and loss in 2 (1.41%) patients.

CONCLUSIONS

Electric bike accidents have become the leading cause of injury instead of motor vehicle accidents because of the changes in the lifestyles of people. Indirect injuries, lid lacerations with tarsal plate fractures, and those with punctum splitting were significantly more likely to lead to poor prognosis, as confirmed by the lower functional success rate of surgery.

Canalicular laceration repair using a self-retaining, bicanalicular, hydrophilic nasolacrimal stent

Purpose: To evaluate outcomes of primary eyelid and canalicular laceration repair using a self-retaining bicanalicular hydrophilic nasolacrimal stent.Methods: This study is a retrospective review of seven patients with canalicular laceration primarily repaired with a self-retaining bicanalicular nasolacrimal stent within 72 hours of initial injury. After lacrimal intubation, repair was performed by reapproximation of the lacerated tissues. Data collection included ophthalmic examination, mechanism of injury, involvement of upper/lower/common canaliculi, symptoms of epiphora, operative time, stent extrusion and canalicular irrigation.Results: Seven patients with monocanalicular laceration were repaired using the self-retaining bicanalicular nasolacrimal stent. The stent was left in place an average of 5 months. The average operative time was 29.3 minutes. None of the stents extruded prior to removal. After 5 months, the stent was removed successfully without difficulty. All patients reported subjective improvement in epiphora, with complete resolution of symptoms. Anatomic success was confirmed with irrigation in all cases. There were no complications associated with usage of the self-retaining bicanalicular nasolacrimal stent.Conclusions: Primary repair of canalicular lacerations can be successfully performed with a self-retaining bicanalicular nasolacrimal stent. This stent has several advantages, including potentially faster operative times, no need for intranasal fixation or retrieval, easier intubation in the lacrimal system, and improved anatomic reapproximation of lacerated tissues.

A New Way of Managing Canalicular Injury Associated With Late Eyelid Burns

PURPOSE

This study aimed to introduce a new way to rebuild the canalicular system of patients with occluded punctums after long-time burns.

METHODS

Cases with eyelid burns associated canalicular injury presented at Eye Hospital of Wenzhou Medical University from June 1st, 2015 to September 30th 2017 were referred to department of Orbital & Oculoplastic Surgery. Cases with occluded both superior and inferior punctuns were recommended to surgery. Twenty-seven cases were enrolled in our study. Patients were followed up at 1, 2, and 4 weeks and 3, 4, 6, and 12 months postoperatively. Success of the surgery was defined as being free of epiphora and purulence postoperatively, a normal functional endoscopic dye test, free-flowing irrigation through the lacrimal system, and the presence of upper and lower punctum ostium.

RESULTS

With a follow-up of 12 months postoperative, there were 22 cases that showed surgical success outcome according to the set criteria. The success rate of our surgery is 81.48%.

CONCLUSION

The surgical procedure used in our study is an effective and easy way to treat patiens with occluded punctum after long-time burns. The utility of silicone intubation is necessary and delayed tubing removal maybe meaningful in these kinds of patients.

Dog bite injuries of the eye and ocular adnexa

Dog bites result in a diverse range of injuries and complications in the periocular region, particularly in school aged children. It is therefore incumbent on the oculoplastic surgeon to be well versed in both acute and long-term management. The intent of this review is to provide a systematic evaluation of the epidemiology, principles of dog bite wound care, and specific considerations related to common patterns of ophthalmic injury. Review of clinical literature from 1976 to 2014. The majority of periocular injuries result from seemingly benign interactions between young children and familiar dogs. Aggressive saline lavage combined with selective debridement of devitalized tissue is essential. High-risk wounds and vulnerable patient groups may benefit from preventive antibiotic coverage as well as appropriate rabies and tetanus prophylaxis. While the nuances of surgical repair are variable given the heterogeneity of presentation, systematic examination and an algorithm-driven approach underlie the optimal management of these complex injuries.

[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.

Is the distance from punctum a factor in the anatomical and functional success of canalicular laceration repairs?

PURPOSE

The aim is to analyze the influence of the location of lacrimal canalicular laceration over the eventual anatomical and functional success after surgery.

METHODS

Retrospective, observational study of proximal canalicular laceration (PCL) and distal canalicular laceration (DCL) repairs by a single surgeon (MS). The distance between lacrimal punctum and the lateral canalicular lacerated end was defined as proximal (<6 mm) and distal (≥6 mm). The operation theater setup, microscopic magnified view, local adrenaline, and pigtail probe were used to locate the medial canalicular lacerated end. All patients underwent lacrimal stenting and the stents were removed after 3 months (12th week visit). After stent removal, a fluorescein dye disappearance test and lacrimal irrigation were performed to assess the anatomical and functional success of the operation.

RESULTS

Of 36 canalicular lacerations, 30 (83.33%) were monocanalicular lacerations which were repaired using monocanalicular stents. Of 6 (16.67%) bicanalicular lacerations, three were repaired using bicanalicular stents while in the remaining three, one monocanalicular stent was placed in each lacerated canaliculi. The medial cut end was identified by magnified visualization in 27 (75%), with adjunctive local adrenaline in four (11.11%) and pigtail probe in five (13.89%) patients. The mean post stent removal follow-up was 44 weeks. The DCL (n = 24, 66.67%) showed better functional and complete success as compared to PCL (75% vs. 33.33%, P = 0.03). Eight (22.22%) had spontaneous stent extrusion, two (5.56%) had loop prolapse, four (11.11%) had punctum granuloma, and three (8.33%) had medial canthus dystopia.

CONCLUSION

The location of canalicular laceration may help to prognosticate the functional and qualified success rate. We experienced better-qualified success in the distal canalicular laceration group.

Canalicular lacerations: Factors predicting outcome at a tertiary eye care centre

To determine the factors predictive of outcome in canalicular laceration repair at a tertiary eye care centre. A retrospective review of the medical records of all primary canalicular laceration repairs managed at a tertiary eye care centre between the years 2006 and 2014 was done. Thirty-nine patients were included and majority were male (79.5%) with a mean age of 30.05 + 16.2 years (range 2-65). Most (n = 34) had monocanalicular laceration and 5 had bicanalicular laceration. All surgeries were done in the operating room setting. Overall patency by irrigation was seen in 74.4% at a median follow-up of 19.89 weeks (range 21-910). Anatomical outcome was different among the stents and best after Mini-Monoka monocanalicular stent (17/19; 89.5%) followed by bicanalicular annular stents (n = 6; 60%) and 20G Silicone rod (8/14, 57%). The factors predictive of poor outcome were related to the mode of injury [road traffic accidents; Hazard ratio (HR)19.57; p = 0.048] and the type of stent [20G silicone rod (HR 35.7; C.I 3.04 - 419.14; p = 0.004)] by multivariate analysis. Skill of the surgeon was critical as the outcome for fellows-in-training showed a trend towards failure (HR 6.66, p = 0.07). Complications included stent extrusion (n = 28.2%), punctal granuloma (n = 5.1%) and stent exposure (n = 2.5%). The mode of injury - road traffic accidents and type of stent - 20 G silicone rod were risk factors predictive of poorer outcome after canalicular laceration repair. Individual skill of operating surgeon may be a critical factor suggesting a review of training protocols.

Eyelid Lacerations Due to Dog Bite in Children

PURPOSE

To evaluate the nature and extent of lacrimal apparatus injury in children after eyelid laceration from a dog bite.

METHODS

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.

RESULTS

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%.

CONCLUSIONS

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.

Pediatric canalicular lacerations: epidemiology and variables affecting repair success

PURPOSE

To evaluate the epidemiology and outcomes of all pediatric canalicular lacerations at a high-volume urban tertiary eye care center. Variables of repair were evaluated in relation to age and success of repair.

METHODS

A retrospective review over a 10-year span of all primary pediatric canalicular laceration repairs was performed. Variables included patient demographics, repair setting, mechanism of injury, associated injuries, type of stent used, and success of repair.

RESULTS

Of 137 canalicular lacerations evaluated, 27.7% occurred in patients younger than 18 years. The majority of the children were male (73.7%) and white (68.4%), with a mean age of 10.8 years (range: 1.1 to 17.9 years). The mechanism of injury was significantly more likely to be due to dog bites in children when compared to adults (P < .0001), particularly those younger than 10 years (P = .0068). Repair was significantly more successful in the operating room than the minor procedure room, regardless of type of stent used (P = .0247). The majority of children did not have other injuries (60.5%). However, of the other injuries sustained, 52.6% required further monitoring or repair.

CONCLUSIONS

Pediatric canalicular lacerations are most common in young boys and dog bites are the most common etiology. Although many children may not have other injuries, full examination is warranted because other injuries may require intervention or more frequent monitoring.

Tear drainage in traumatic canalicular fistula

PURPOSE

To evaluate the function of the canaliculus with fistula after canalicular laceration repair.

METHODS

Patients with monocanalicular fistula following canalicular laceration repair were evaluated with dye disappearance test (DDT). Temporary collagen plugs were used to occlude the uninvolved canaliculus in the ipsilateral eye and the corresponding canaliculus in the contralateral eye. After 24 hours of placement of the temporary plugs, the same evaluation was repeated.

RESULTS

Ten patients with unilateral monocanalicular fistulas were evaluated. None of the patients had epiphora before and after placement of temporary plugs and DDT, and tear meniscus continued to be normal both in the affected and the unaffected eyes after temporary plug placement.

CONCLUSIONS

In this series, the presence of canalicular fistula at the site of repair did not affect tear drainage.

A modified bicanalicular intubation procedure to repair canalicular lacerations using silicone tubes

PURPOSE

To explore a modified technique for silicone intubation for the repair of canalicular lacerations.

METHODS

The surgery was performed on 35 eyes in 35 adult patients from October 2007 to September 2009. Using a modified soft probe, silicone tubes were inserted through the lacrimal punctum and left in the bicanaliculi for 3-10 months.

RESULTS

The surgery was performed successfully in all cases. The tubes were removed after 3-10 months (mean 5.3±1.8 months). The mean follow-up time after tube removal was 13.8 months (range, 6-22 months). Lower punctum splitting occurred in one case (2.86%) after the surgery. No other complications associated with the silicone tubes occurred. All the tubes were removed successfully without any difficulty. No iatrogenic injuries occurred during tube removal.

CONCLUSIONS

The modified bicanalicular intubation procedure described here is an effective and atraumatic procedure for the management of canalicular lacerations in adults, and it is associated with fewer complications than the traditional sutures of canalicular lacerations.

Clinical characteristics and treatment of blow-out fracture accompanied by canalicular laceration

BACKGROUNDS

Blow-out fracture and canalicular laceration can occur simultaneously as a result of the same trauma. Despite its importance, little research has been conducted to identify clinical characteristics or surgical techniques for repair of a blow-out fracture accompanied by canalicular laceration. The aim of this study was to evaluate the clinical characteristics, the surgical approach, and the outcomes.

METHODS

Thirty-four eyes of 34 patients who underwent simultaneous repair of canalicular laceration using silicone tube intubation and reconstruction of blow-out fracture were included. Medical records were retrospectively reviewed for patient demographics, nature of injury, affected canaliculus, location, and severity of blow-out fracture, associated facial bone fracture, ophthalmic diagnosis, length of follow-up period, and surgical outcome.

RESULTS

Mean patient age was 40.0 years (range, 17-71 y). The mean follow-up was 7.3 months. Fist to the orbital area (10 patients, 29.4%) was the most common cause. There were 24 lower canalicular lacerations (70.6%), 6 upper canalicular lacerations (17.6%), and 4 upper and lower canalicular lacerations (11.8%). Isolated medial wall fractures were most common (area A4: 20/34, 58.8%). Fractures involving both the floor and medial wall and maxillo-ethmoidal strut (areas A1, A2, A3, and A4) were the second most common (6/34, 17.6%), and floor and medial wall with intact strut (areas A1, A2, and A4) were injured in 6 patients (17.6%). Pure inferior wall fractures were least frequent (areas A1 and A2: 2/34, 5.9%). The severity of the fracture was severe in most patients except for 1 linear fracture with tissue entrapment and 1 moderate medial wall fracture (32/34, 94.1%). There was lid laceration in 20 patients (58.8%). Nasal bone fracture (5/34, 14.7%) was the most common facial bone fracture. Tubes were removed at a mean of 3.3 months (range, 3-4 mo). In total, 31 patients (91.2%) achieved complete success in canalicular laceration and blow-out fracture repair. No significant complications were encountered.

CONCLUSION

Fractures involving the medial wall with a lower canalicular laceration were the most common among concomitant blow-out fractures and canalicular lacerations. The severity of the fracture was most often classified as severe. Computed tomographic scan of the orbit and facial bones for identification of any additional injuries such as orbital wall and facial bone fractures should be performed in patients with canalicular laceration. To avoid disruption of the medial canthal area, repair of the canalicular laceration with silicone tube intubation was performed before reconstruction of the blow-out fracture through transconjunctival and transcaruncular approaches. Finally, the tube was fixed after blow-out fracture surgery, and these surgical orders yielded good surgical outcomes without complications.

Comparing pericanalicular sutures with direct canalicular wall sutures for canalicular laceration

PURPOSE

To determine whether a statistically significant difference exists between direct canalicular wall sutures (DCs) and pericanalicular sutures (PCs) in the repair of traumatic canalicular lacerations.

METHODS

The medical records of 63 patients who underwent primary repairs for traumatic canalicular lacerations were retrospectively reviewed. Patients were divided in 2 groups according to the suturing techniques used: the DC group (n = 41) and the PC group (n = 22). Anatomic results were compared between these 2 groups. A successful result was determined by attempted irrigation and probing of the injured canaliculus at the last follow-up visit.

RESULTS

There were 6 failed procedures among the patients who underwent pericanalicular repair and 1 failed procedure among the patients who underwent direct canalicular wall repair (p = 0.024).

CONCLUSIONS

These data support the higher success rates in patients treated with direct canalicular repair compared with pericanalicular repair.

Effectiveness of canalicular laceration repair using monocanalicular intubation with Monoka tubes

PURPOSE

 This study aimed to evaluate the clinical efficacy of canalicular laceration repair using monocanalicular intubation with Monoka tubes.

METHODS

A total of 36 single lacerated canaliculi were repaired using monocanalicular intubation with Monoka tubes, without mucosal anastomosis of the canaliculi, and were retrospectively reviewed. Demographic information, injury locations, associated ocular injuries, complications and outcomes were analysed.

RESULTS

Mean patient age was 34 years (range 1-64 years). Tubes were removed at a mean of 4.2 months (range 3-6 months). There were 26 lower canalicular lacerations (72%) and 10 upper canalicular lacerations (28%). Overall, 34 of 36 cases (92%) showed improvement in symptoms and exhibited positivity on the dye disappearance test at 4-12 months after the procedure (mean 7.8 months). In total, 21 patients (58%) achieved complete success, 13 patients (36%) achieved partial success and two patients (6%) suffered surgical failure. Complications were seen in five cases and included two early tube protrusions, two punctal slits and one punctal granuloma.

CONCLUSIONS

Monocanalicular intubation with Monoka tubes leads to successful outcomes without significant complications and offers an alternative to bicanalicular intubation in the treatment of monocanalicular lacerations.

Management of canalicular lacerations: epidemiological aspects and experience with Mini-Monoka monocanalicular stent

PURPOSE

To report the epidemiological data, clinical profile, and surgical outcome of canalicular lacerations in an Indian population.

DESIGN

Retrospective interventional case series.

METHODS

All patients who underwent canalicular laceration repair from July 1, 2002 to June 30, 2005 at a tertiary eye care center were retrospectively reviewed. Demographics, cause of eyelid injury, associated ocular injury, surgical management with Mini-Monoka monocanalicular stent, and its outcome were analyzed.

RESULTS

Sixty-six patients underwent eyelid laceration repair, of which 24 (36%) had involvement of the canalicular system. The mean age at presentation was 16 years (range, 10 months to 52 years); 20 (83.3%) patients were males. Mode of injury included the blouse-hook fastener in five (20.8%) breast-feeding infants, bicycle handle injury in four (16.7%) children, and metal rod injury in five (20.8%) adults. Lower canaliculus was involved in 13 (54.1%), upper in eight (33.3%), and both in three (12.5%) patients. Simultaneous globe injury was noted in six (25%) patients, five (83.3%) of which had upper canalicular involvement. Twenty-seven canalicular lacerations (24 patients) underwent stenting with the Mini-Monoka monocanalicular stent. Three (11.1%) stents extruded within one month. At the final follow-up (mean, 18.5 months), canalicular block was noted in two (10%) out of 20 patients; none had epiphora.

CONCLUSION

Canalicular involvement occurs in 36% of eyelid injuries. Injury by the "blouse-hook fastener" is unique to infants in the Indian context. Simultaneous globe injury is present in 25% of cases, especially when the upper canaliculus is involved. Mini-Monoka stent extrusions occur within one month. With an 11.1% extrusion rate, Mini-Monoka stents achieved good anatomical (90%) and functional (100%) success in the management of canalicular injury.

Repair of a canalicular laceration in a neonate

A neonate with lower eyelid and corresponding canalicular laceration of the left eye was examined 2 hours after birth. The eyelid and canalicular laceration were repaired with a short, 24-gauge catheter as the stent. The laceration healed with minimal scarring, and the epiphora had disappeared by the 12-month follow-up visit.

Medial Upper Eyelid Shortening to Correct Medial Eyelid Laxity in Floppy Eyelid Syndrome: A New Surgical Approach

PURPOSE

To describe and present the results of a new surgical technique for patients with floppy eyelid syndrome, based on the medial upper eyelid stretching encountered in this condition.

METHODS

A case series of 24 patients with floppy eyelid syndrome who where found to have symptomatic predominately medial upper eyelid laxity was analyzed. The history, clinical features, histopathology, and outcome were reviewed after patients underwent medial upper eyelid shortening with or without upper eyelid skin reduction as the first surgical procedure.

RESULTS

Of the 24 patients, 18 were men (75%) with a mean age at referral of 56 years, having ocular discomfort and conjunctival irritation/papillary conjunctivitis as the main complaints at presentation. Obesity was present in 96% of cases, with lower eyelid laxity/ectropion (50%) and upper eyelid eyelash ptosis (29%) in conjunction with the upper eyelid laxity. The affected side was related to sleeping habits or recurrent mechanical eyelid trauma. Histologic studies showed a nonspecific inflammatory cell infiltrate and loss of elastin with loose dermal connective tissue. After surgery, complete relief of ocular symptoms and good functional and cosmetic results were present in all cases after 18 months of follow-up.

CONCLUSIONS

This new surgical approach is based on the presence of predominately medial upper laxity in patients with floppy eyelid syndrome. The excision of this stretched area stabilized the upper eyelid in an anatomic fashion, providing a good and stable long-term result. The possible mechanisms involved in the medial upper eyelid stretching are discussed.

Determination of relative contribution of the superior and inferior canaliculi to the lacrimal drainage system in health using the drop test

PURPOSE

The aim of this study was to explore the use of the 'drop test' as a method of assessing maximal lacrimal outflow capacity, and to measure the relative contribution of the superior and inferior canaliculi to the drainage capacity in normal subjects.

METHOD

The drop test involves instilling measured aliquots of normal saline over 3-min periods to raise the tear lake medially. Both eyes were assessed; however, for the right lacrimal drainage system only, sequential insertion and then removal of silicone punctal plugs was performed. After each stage the maximal lacrimal drainage capacity was measured. no punctal plugs were placed in the puncta on the left side.

RESULTS

Complete data were collected from 20 subjects with a mean age of 35.6 years. The intraclass correlation coefficient for the five left eye readings was 0.98 (CI 0.96-0.99) and the limits of agreement of a single reading were -22.6 to +93.0 micro L/3 min. Without intervention, no statistically significant difference was found in the mean lacrimal outflow between the left and right eyes (P = 0.16). A statistically significant reduction in outflow resulted from punctal occlusion (P < 0.05). Presenting the proportion of lacrimal outflow as a percentage of the combined values of the superior and inferior canaliculi, 59.9% of outflow occurred through the inferior canaliculus.

CONCLUSION

The drop test was found to provide a simple and repeatable method of assessing lacrimal drainage in a minimally invasive manner in the clinical setting. In healthy volunteers in the supine position 60% of maximal lacrimal outflow capacity occurs through the inferior canaliculus.

Posttraumatic obstruction of lacrimal pathways: a retrospective analysis of 58 consecutive naso-orbitoethmoid fractures

Posttraumatic dacryostenosis represent a troublesome sequela for patients who have sustained centrofacial trauma and can determine complexity in diagnosis and treatment. This article, based on a retrospective analysis of 58 patients with naso-orbitoethmoidal (NOE) trauma, reports the incidence of posttraumatic dacryostenosis and the evolution of such impairments in consideration of fracture type. Experience in diagnosis and treatment is illustrated, and surgical outcomes 6 months after external dacryocystorhinostomy (DCR) are reported. Posttraumatic epiphora was observed in 27 patients with NOE fractures (46.5%). In 10 cases, temporary epiphora was encountered and spontaneous recovery of lacrimal drainage within 5 months was observed. In the remaining 17 cases, permanent epiphora was registered and a frequent association with delayed treatment of facial fracture repair or bone loss in the lacrimal district was found. Surgical reconstruction of lacrimal pathways was performed 6 months after primary surgery, with external DCRs in all 17 patients with epiphora and the presence of nasolacrimal duct obstruction observed with dacryocystorhinography. External DCR with a large rhinostomy achieved a success rate of 94% in the reconstruction of lacrimal drainage. Such a technique proved to be effective in the treatment of posttraumatic dacryostenosis, although patients considered the temporary presence of external scars and stenting material to be a major problem.

Eye injuries from merchandise display hooks

PURPOSE/METHODS

Four patients had ocular or ocular adnexal injuries, which resulted from store merchandise display hooks.

RESULTS/CONCLUSIONS

Ocular and periocular injuries from display hooks include conjunctival, eyelid, and canalicular lacerations, as well as penetrating brain injury. Display hooks are commonly used in retail establishments and pose a high risk when placed below eye level.