|Year : 2014 | Volume
| Issue : 3 | Page : 160-165
Effects of an autostable bicanaliculus intubation stent in the management of acquired punctal stenosis
Mohamed Y Farag, Dikran Hovaghimian, Olfat A Hassanin, Ahmed Ismail
Department of Ophthalmology, Research Institute of Ophthalmology, Giza, Egypt
|Date of Submission||01-Apr-2014|
|Date of Acceptance||30-Jul-2014|
|Date of Web Publication||30-Dec-2014|
Mohamed Y Farag
107 elalameenst, Elawkaf Square, Elagoza, Giza
Source of Support: None, Conflict of Interest: None
To study the success rate of an autostable bicanaliculus intubation stent in the management of acquired punctal stenosis.
Patients and methods
Twenty-one eyes of 12 patients who underwent stent implantation using disposable sizers, from December 2012 till March 2013, were studied. In all patients, the superior and inferior puncti, with a 1 mm calibrated dilator supplied with the stent, was performed carefully to prevent damage to the ampulla; before the insertion of the stent, it was necessary to verify the absence of canalicular obstruction by probing and patency of the nasolacrimal duct by irrigation. An initial clinical examination indicated that tearing was not ocular in nature. For the management of acquired punctal stenosis and punctal obstruction, patients were evaluated retrospectively in terms of sex and age, the duration and severity of epiphora, associated blepharitis or trachoma, and the success of treatment. Stents were removed 2 months after insertion.
Twenty-one eyes had punctal stenosis, causing epiphora. The mean age of the patients was 55 (±20) years. The mean interval between the onset of epiphora and stent implantation was 18.4 (±12.7) months. Associated chronic blepharitis was detected in four eyes and trachoma complication in three eyes. The patients were examined on the first day postoperatively, and at 1 week, 1 month, and 2 months. Success was achieved in 19 eyes (90%). We encountered four cases of minor conjunctival irritation that was resolved in 1 week and two cases of diminished palpebral fissure; in one case, we replaced the stent. Spontaneous stent loss was noted in five eyes between the 1-week and the 2-month follow-up. One patient had residual epiphora.
Autostable bicanaliculus intubation stent implantation is very effective for the treatment of acquired punctal stenosis and obstruction. However, careful punctum dilation should be performed and patients should be provided with proper instructions to wear protective eyeglasses following the procedure to decrease spontaneous stent extrusion.
Keywords: autostable bicanaliculus intubation stent, punctual occlusion, epiphora
|How to cite this article:|
Farag MY, Hovaghimian D, Hassanin OA, Ismail A. Effects of an autostable bicanaliculus intubation stent in the management of acquired punctal stenosis. J Egypt Ophthalmol Soc 2014;107:160-5
|How to cite this URL:|
Farag MY, Hovaghimian D, Hassanin OA, Ismail A. Effects of an autostable bicanaliculus intubation stent in the management of acquired punctal stenosis. J Egypt Ophthalmol Soc [serial online] 2014 [cited 2020 Apr 7];107:160-5. Available from: http://www.jeos.eg.net/text.asp?2014/107/3/160/148128
| Introduction|| |
Acquired external punctal stenosis (AEPS) can be a devastating disease for a significant number of patients as a result of the resultant visual disturbance and the social embarrassment from constant epiphora, and AEPS is one of the most commonly encountered diseases that causes tearing [1,2]. Punctal anatomy and physiology studies have shown considerable variability in the normal size of the punctum among different individuals, but also as a result of the use of different measurement methods . Textbook measurements range from 0.2 to 0.5 mm [4,5]; a study using computerized measurements of the punctum size in normal adults showed that the normal upper punctum has a mean area of 0.264 mm and the lower punctum has a mean area of 0.321 mm. It also showed that the upper punctum tended to be smaller than the lower punctum and there is no size difference between men and women, or any size difference in the right and left sides .
The incidence of AEPS has not yet been studied, but there are two reports on the prevalence of the disease. Of 682 patients seen in a hospital-based population, 54.3% had an element of punctal stenosis with a statistically significant correlation with advancing age and concomitant chronic blepharitis . The other study showed a prevalence of 17.3% of punctal stenosis among 621 participants from the general population. It also showed a significant correlation with advancing age, but not with chronic blepharitis .
Many local and systemic diseases [2,7] have been linked to the development of AEPS by induction of a chronic inflammatory reaction either as part of the inflammatory condition or in response to irritant exposure. Chronic inflammation leads to activation of macrophages and lymphocytes, inducing the release of cytokines and growth factors, namely, tumor necrosis factor, interleukin-1, interlukin-4, fibroblast growth factor, and transforming growth factor-b. These factors induce the proliferation of fibroblasts and an increase in collagen synthesis. At the same time, chronic inflammation inhibits matrix metalloproteinase activity, leading to decreased collagen degradation  ([Table 1]).
In this study, we present the techniques, results, complications, and the success rate of the use of an autostable bicanaliculus intubation stent in the management of AEPS.
| Patients and methods|| |
This was a prospective noncomparative study that included a total of 12 consecutive patients (21 eyelids) who were operated by one surgeon (first author), with severe (grade 1 punctal opening) and less severe (grade 2 punctal opening) having AEPS [Figure 1].
In clinical settings, ophthalmologists tend to diagnose punctum stenosis when the punctum diameter is less than 0.3 mm on slit-lamp biomicroscopic examination or when they cannot introduce a 25-G cannula without punctual dilatation, although false results can be obtained by stretching the punctal walls during cannula insertion [8,10].
Although precise estimations of the grade of punctal stenosis have enabled the development of standardized terms to compare the outcome of different studies, there is still no universal consensus on a grading method. Kashkouli et al.  ([Table 2]) proposed a clinical grading method in 2003 and confirmed its level of interobserver reliability in 2008 [3,11]. This method seems to be the most clinically applicable method as it is based on punctal shape and size on slit-lamp examination as well as the ease of introduction of a punctal dilator.
Punctal stenosis can be detected on slit-lamp examination and a diagnostic probing is necessary to verify the absence of canalicular obstruction by probing and by assessment of patency of the nasolacrimal duct by irrigation. Irrigation was performed using a 2-ml syringe filled with a balanced saline solution and a 25-G lacrimal cannula to evaluate the patency of the lower lacrimal system. An informed consent was obtained.
After instillation of a topical anesthetic drop (Benoxinate 0.4%) and injection of ~0.5 ml local anesthetic (lidocaine 2% with adrenaline 1/100 000) around the puncta, a verticalone snip was performed using a sharp-tip Westcott scissor from the area of the ampulla vertical to the lid margin. In all patients, the superior and inferior puncta, 1 mm calibrated dilator supplied with the stent was used carefully to prevent damage to the ampulla before the insertion of the stent.
The Self-Retaining Bicanaliculus Intubation Set (SRS) (FCI Ophthalmics, 20 Winter St. Pembroke, MA 02359, United States) [Figure 2] consists of a silicone tube 25, 30, or 35 mm long and 0.64 mm wide (18 eyes used 30 mm, two eyes used 25 mm, one eye used 35 mm) using disposable izers, from December 2012 till March 2013. At each end is an anchor-shaped head to allow fixation. Each head consists of two flexible winglets that fold inwards during insertion through the punctum and spread back out after passage through the junction of the common canaliculus and lacrimal sac, thus securing the stent's fixation. A centrally placed marking on the tube acts as a reference point and allows verification of proper stent positioning following insertion. The stent is introduced first through the superior punctum and then through the inferior punctum. Following insertion, it is necessary to verify good positioning of the stent, by ensuring that the central reference marking is situated in between both puncta and by ensuring good stent mobility during each blink. A safe criterion for decent intubation and correct size selection is to avoid contact of the stents with the cornea when the eye is in adduction. This is done in the operation room using the microscope; the stent remains in place for 2 months. A corticosteroid antibiotic drop is prescribed for 1 week [Figure 3]. However, careful punctum dilation should be performed and patients should be provided with proper instructions to wear protective eyeglasses, bandage, or eye shield at night and use special care when washing and administering drops, following the procedure, to decrease spontaneous stent extrusion.
The stent was removed under topical anesthesia (Benoxinate 0.4%) with a forceps. The patients were reviewed at least 3 months following this, with the exception of any recurrence.
Success was defined as restoration of anatomical and physiological functioning of the punctum without any residual symptom in the patient at least 3 months postoperatively. 'Functional success' was defined as the complete disappearance of the symptoms. 'Anatomical success' was defined as a punctal opening grade 3 (normal-size punctum), 4 (<2 mm slit punctum), or 5 (≥2 mm slit punctum) [Figure 4].
A recurrence was defined as a return of symptoms of epiphora and clinical evidence of further punctual stenosis resulting in watering of the eye 3 months postoperatively.
Exclusion criteria were as follows:
(a) Previous operation (eyelid and/or lacrimal surgery).
(b) An initial clinical examination verified that tearing was not ocular in nature; severe ocular surface disease and lid malposition.
(c) Complete upper or lower lacrimal system obstruction (canaliculi and common canaliculus) on diagnostic probing, nasolacrimal duct stenosis or obstruction on the irrigation test,
(d) And less than 3 months of follow-up.
Clinical demographic patient data were evaluated in terms of age, sex, laterality, underlying causes associated with blepharitis or trachoma, duration of epiphora, preoperative and last follow-up of punctal grading, improvement in symptoms at the time of the SRS removal, complications of the surgery such as infection and irritation, last follow-up time point, recurrence rate, and success rate; these data were stored in a sheet database for analysis. Photographs were taken preoperatively and 3 month(s) postoperatively.
| Results|| |
Twenty-one eyes showed punctal stenosis, causing epiphora. The mean age of the patients was 55 (±20) years. The presenting symptom was tearing in all the eyes (100%) and tearing with eye discomfort in 11 eyes (52%). The mean interval between the onset of epiphora and stent implantation was 18.4 (±12.7) months; there was a fairly equal sex distribution, with six men and six women.
The bilateral puncti were involved in nine patients (75%), grade 1 in seven patients (58%) and grade 2 in five patients (42%). The underlying cause of AEPS was chronic blepharitis (infectious, seborrheic) (eight eyes, 39%), unknown (nine eyes, 47%), and trachoma complication (three eyes, 14%).
On preoperative diagnostic probing, there were normal canaliculi in all 21 eyes (100%); the patients were examined on the first day postoperatively, and at 1 week, 1 month, and 2 months. Postoperative follow-up was performed at 3-6 months.
After removal of the stent or premature stent loss, anatomical success was observed in 19 eyes (90%) and functional success in 20 eyes (95%). Anatomical success was grade 3, 71% in 15 eyes; grade 4, 19% in four eyes; grade 2, 5% in one eye; and grade 1, 5% in one eye ([Figure 5] and [Figure 6]).
Four patients (19%) reported temporary ocular surface discomfort (conjunctival irritation) after the operation, which was managed with a topical lubricant in a few days, and two patients had diminished palpebral fissure. We replaced the stent in the office setting with no inconvenience in one patient. Premature spontaneous stent loss occurred in five (24%) eyes between the first week and the 2-month follow-up. No other complications related to the SRS were encountered. One patient (5%) developed residual epiphora.
| Discussion|| |
The main aims of the treatment of AEPS include creating an adequate opening, maintaining the punctal position against the lacrimal lake, enhancing tear access from the lacrimal lake to the punctal opening, and preserving the function of the lacrimal pump.
As all surgical procedures for the treatment of punctual stenosis have the risk of fibrosis during the healing phase with resultant restenosis, the use of prosthetic devices has been suggested to keep the punctum dilated during healing. This study incorporates the use of SRS as an adjunct to standard one-snip punctoplasty to prevent fibrosis and, subsequently, restenosis of puncti.
Historically, the one-snip procedure was introduced by Bowman  in 1853 and by Arlet  in 1874. Both advocated incision of the horizontal canaliculus rather than the ampulla because that technique can damage the capillary attraction of the canaliculus. Later, Jones  popularized the one-snip procedure involving vertical incision of the ampulla.
Triangular three-snip punctoplasty was first described in the 1950s [15,16] as an attempt to overcome the reapproximation of cut edges after one-snip punctoplasty by making a vertical cut incision along the posterior wall of the ampulla using vannus scissors, a horizontal cut along the roof of the canaliculus to create a flap, and then removing the base of the flap. Later, modification of the shape of the three snips from triangular to rectangular was suggested to avoid disruption of the horizontal canaliculus, [17-19] which is vital for the proper function of the lacrimal pump mechanism.
Four-snip punctoplasty was proposed recently to overcome severe punctal stenosis that cannot accommodate the two vertical incisions needed for rectangular three-snip punctoplasty by making a small vertical incision down to the ampulla, a second 2-mm horizontal cut along the roof of the canaliculus, followed by a third vertical cut from the edge of the second and a horizontal cut from the edge of the first cut to create a flap, which can then be removed by cutting the base .
Wedge punctoplasty involves a punch incision in the posterior wall of the punctum and vertical canaliculus to create a funnel effect in which tears are drawn toward the open punctum. The wedge shape of the resultant incision is supposed to prevent apposition of the cut edges without disturbing the lacrimal pump. This procedure can be performed using a Kelly punch .
Laser punctoplasty was proposed in 1985  for punctal occlusions because of an overgrowth of the conjunctival epithelium that occurs with aging or scar tissue created by low-grade inflammation, but it was never used widely.
Cautery application was proposed in 1977 using retraction rather than dilatation to open a stenotic punctum in the lower lid, but it did not gain any popularity .
Punctum redilatation is an additional procedure that can be combined with any punctoplasty surgery by applying an office punctum redilatation if patients showed signs of cicatrization at their postoperative appointments. Punctum dilatation can be applied using a lacrimal dilator that is advanced into the proximal canaliculus to release cicatricial changes. This technique can be repeated at every follow-up visit if signs of fibrosis and reapproximation are noted .
The basis for the current treatment options for AEPS is surgical enlargement of the punctum with or without prosthetic material insertion, namely, perforated punctual plugs . The mini-Monoka stent has the advantage of addressing the issue of concomitant canalicular stenosis that may be found in 46% of patients with punctal stenosis . Adjuvant use of mitomycin-C has also been introduced to overcome fibrosis , and recently, the use of self-retaining bicanalicular stents in conjunction with rectangular three-snips punctoplasty has been suggested, showing a higher anatomical and functional success rate than that found with the use of quadrangular three-snips alone .
Perforated punctal plugs were first introduced by Fayet and Bernard . in France as a modification for the punctual plugs used for the treatment of dry eyes; a central perforation of 0.6 mm was made to allow tears to drain. The early versions of the perforated plugs were not successful because accumulated secretions soon blocked the perforated area because of the hydrophilic nature of the silicone material. This problem was solved by coating the plug with polyvinylpyrrolidone, a material that is hydrophobic and allows tears and debris to flow smoothly through the perforation .
Kashkouli et al.  reported 96.2% anatomical success and 84.9% functional success among 53 eyes with AEPS and different underlying causes. There were five (9.4%) premature stent losses and no other serious complications, such as persistent corneal erosion, bacterial keratitis, or lid infection .
Shahid et al.  reported, in a retrospective case study of 205 patients who underwent punctoplasty surgery with a similar mean follow-up, anatomical, functional, and patient satisfaction rates of 91, 64, and 71%, respectively.
Ma'luf et al.  reported functional success rates (symptom free and improvement) of 96% (anatomical success: 100%) and 76%(anatomical success: 81%) after a posterior punctectomy with and without adjunctive intra-operative mitomycin-C, respectively .
Edelstein and Reiss  performed a wedge punctoplasy (Reiss punctal punch) on 35 eyes with AEPS. They did not perform diagnostic probing and irrigation preoperatively and postoperatively. After a mean follow-up of 12 months, a 95% anatomical success and 92% symptomatic relief were achieved. They recommended a supporting stent (silicone intubation) to achieve a permanent opening .
Kristan  inserted a temporary punctal plug after a one-snip punctoplasty and observed a symptomatic improvement in all of 25 AEPS cases without associated canalicular or NLD stenosis.
We performed a one-snip punctoplasty with SRS tube insertion to prevent restenosis during the healing phase; anatomical success was achieved in 19 eyes (90%) and functional success was achieved in 20 eyes (95%).
Fein reported that nine (37%) recurrences in the patients in their series involved internal punctal stenosis. Stenosis might be expected at the beginning and at the end of each individual segment of the lacrimal excretory system. Stenosis at any junction point in the system may indicate future stenosis at other junction points .
Premature stent loss has been reported as often as 28% in one study .
In our results, premature spontaneous stent loss occurred in five (24%) eyes, between the 1-week and the 2-month follow-up, and we replaced the stent in the office setting with no inconvenience in one patient. No other complications related to the SRS were observed. One patient (5%) developed residual epiphora.
On the basis of the data available, recurrent epiphora because of fibrosis and restenosis is the most common cause of treatment failure in all treatment modalities. Despite the improvement in the success rate with the introduction of punctual prosthetics, another set of potential complications emerged including plug extrusion, canalicular stenosis, plug migration with resultant canaliculitis, and dacryocystitis [32,33]. The possibility of tumorigenesis, such as granuloma and papilloma, has also been noted .
| Conclusion|| |
Autostable bicanaliculus intubation stent implantation for the treatment of AEPS and obstruction is very effective, yielding 95%functional success. However, a larger study group is required to confirm these results, with longer follow-up periods.
| Acknowledgements|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2]