Long-term outcome of lacrimal stent intubation for complete acquired lacrimal drainage obstructions

A major review on punctal stenosis: Part II: Updated therapeutic interventions, complications, and outcomes

We continue our review of on punctal stenosis by providing a detailed discussion of management modalities, their complications, and outcomes. There is a significant change in the understanding of punctal and peripunctal anatomy, puncto-canalicular junction, and the lacrimal pump mechanisms. While the snip punctoplasty procedures are still practiced, there is an increasing trend toward nonincisional procedures. The nonincisional procedures in select cases appear to be equally effective as the incisional ones. Although simple to use, punctal plugs never became the mainstay of treatment because of design issues and the inability to address the coexisting canalicular stenosis. Placing stents only in the lower punctum in cases of upper and lower punctal stenosis should be discouraged, and management needs to address punctal stenosis and not which punctum is involved. Several types of stents are used in the management of punctal stenosis, mostly based on surgeon's preference. The benefits of adjuvant mitomycin C are uncertain. In view of literature on how stent biofilms can themselves cause chronic inflammation, placing them for prolonged periods should be reviewed and debated. Enhanced understanding of the molecular pathogenesis of punctal stenosis and addressing the current controversies in management would help standardize the therapeutic interventions available in the lacrimal armamentarium.

First-Onset Dacryocystitis: Characterization, Treatment, and Prognosis

INTRODUCTION

To assess the risk of recurrent dacryocystitis after first-onset dacryocystitis and to obtain a demographic profile and treatment characteristic for patients with first-onset dacryocystitis.

METHODS

A retrospective study was performed on patients who had first-onset dacryocystitis during the years 2010-2013. Patients were followed up for 3 years. The analysis focused on the recurrence of dacryocystitis, demographics, medical treatment, and choice of lacrimal surgery.

RESULTS

The inclusion criteria were met by 52 patients. Of these 15 (29%) had one or more recurrence of dacryocystitis, and 18 patients (34.6%) underwent lacrimal surgery. The mean age was 51.6 years (median 55.5, range 0-93). The female-to-male ratio was slightly under 3:1 (73.1%). The most frequent medical treatment was flucloxacillin capsules combined with chloramphenicol eye drops or ointment.

CONCLUSIONS

The majority of patients with first-onset dacryocystitis had no further episodes of dacryocystitis. Some patients experienced recurrent and complicated infections requiring surgery and were thus a significant burden on the healthcare services. Various surgical options were used to clear the nasolacrimal obstruction causing dacryocystitis. Dacryocystorhinostomy was the most common procedure and showed excellent success rate.

Management of proximal lacrimal obstructions: a rationale

PURPOSE

To identify a rationale for correct surgical treatment of proximal lacrimal obstructions.

METHODS

Retrospective review of 775 consecutive patients (974 eyes) with proximal lacrimal obstructions, operated on with customized surgery by a senior surgeon (FMQL) from January 2003 to December 2018.

RESULTS

In case of punctal stenosis, punctoplasty was as effective as punctal dilatation with monocanalicular or bicanalicular stent (p > 0.05). In proximal canalicular obstructions, failure rate of dacrocystorhinostomy with retrograde intubation (R-DCR) was significantly higher in case of false inferior passage creation than in case of no false passage creation (p = 0.02). In mid-canalicular obstructions failure rate of R-DCR was 41.3%, and bypass surgery with Jones tube at second stage was likely. Trephination and monocanalicular intubation, performed in selected cases, had a failure rate respectively of 16.6% and 21.7% in mid and distal canalicular obstructions. Canaliculodacryocystorhinostomy (CDCR) was successful in 77% of cases of proximal common canalicular obstruction. Bypass surgery is the treatment of choice in case of no residual patency, and rates of tube extrusion were significantly reduced with the use of StopLoss Jones tubes (SLJT) (1.7%) with respect to standard tubes (12%), (p = 0.04, Fisher's exact test).

CONCLUSION

Patient history and accurate diagnosis of the site of obstruction are essential for a correct surgical choice. Less invasive techniques as trephination and intubation may be effective, but should be reserved to patients with no associated lower lacrimal obstruction. Further studies require specific randomized clinical trials, and a standardized protocol adopted by different clinical centres.