Punctal recanalization with retrograde canaliculotomy ·Brief Report· Treatment of upper and lower lacrimal punctal occlusion using retrograde canaliculotomy and punctoplasty Ai Zhuang1,2, Jing Sun1,2, Wo-Dong Shi1,2 1Department of Ophthalmology, Shanghai Ninth People’s INTRODUCTION Hospital, Shanghai Jiao Tong University School of Medicine, acrimal punctal occlusion can be caused by trauma, Shanghai 200011, China L inflammation, congenital anomalies, or surgical 2Shanghai Key Laboratory of Orbital Diseases and Ocular intervention[1-3]. Soft tissues or scars close the punctum, Oncology, Shanghai 200011, China obstructing tear drainage through the canaliculus into the Co-first authors: Ai Zhuang and Jing Sun nasal cavity[4]. Thus, patients may experience severe epiphora Correspondence to: Wo-Dong Shi. Department of and report low quality of life. For patients with punctal Ophthalmology, Shanghai Ninth People’s Hospital, Shanghai stenosis alone or minimal and superficial punctal scars, Jiao Tong University School of Medicine, Shanghai Key direct punctoplasty and silicone tube intubation can be used Laboratory of Orbital Diseases and Ocular Oncology, 639 Zhi for treatment[5-6]. For patients with complete upper or lower Zao Ju Road, Shanghai 200011, China. [email protected] punctal occlusion, some clinicians have reported the use of a Received: 2018-09-04 Accepted: 2019-02-26 pigtail probe from the normal punctum through the canalicular system to identify and repair the occluded punctum[7]. For those Abstract with simultaneous upper and lower lacrimal punctal occlusion, ● This is a retrospective, noncomparative analysis of a lacrimal bypass with a conjunctivodacryocystorhinostomy case series to explore the safety and effectiveness of (CDCR) may be an option, although it carries the known risks retrograde canaliculotomy and punctoplasty for treating of displacement, recurrent stenosis, conjunctival granuloma, epiphora due to upper and lower lacrimal punctal and backflow from the nasal cavity to the eye[8]. Here, we occlusion. During the procedure, the horizontal portion chose retrograde canaliculotomy and punctoplasty to treat of the normal lower canaliculus was identified; the simultaneous upper and lower lacrimal punctal occlusion. By corresponding punctum was reconstructed via retrograde incising the canaliculus from the grey line and the conjunctival canaliculotomy and punctoplasty. Intubation was surface, then travelling backwards to reconstruct the punctal performed to prevent postoperative reocclusion. Patients opening, we achieved satisfactory outcomes in sixteen patients. were followed up for 12 to 24mo. A total of 16 patients SUBJECTS AND METHODS with unilateral upper and lower lacrimal punctal occlusion Ethical Approval The study followed the tenets of the were included. Satisfactory outcomes were achieved: Declaration of Helsinki and was approved by the Ethics all 16 patients exhibited improvement of epiphora; Committee of Shanghai Ninth People’s Hospital, Shanghai 31 rebuilt punctal openings and canaliculi achieved Jiao Tong University School of Medicine. Written informed recanalization. Only one upper punctal opening could not consent for participation in the study was obtained from be reconstructed because the corresponding canaliculus participants or their guardians. Permission was obtained for the exhibited severe injury. No significant complications use of patients’ images. occurred as a result of the treatments. Retrograde Overview This is a retrospective, non-comparative analysis canaliculotomy and punctoplasty appears to effective, of a case series. We included patients who presented to the safe, and minimally invasive for treatment of upper and hospital between September 2015 and September 2016 for lower punctal occlusion. treatment of upper and lower lacrimal punctal occlusion. We ● KEYWORDS: punctal occlusion; retrograde canaliculotomy; reviewed patient records, including outpatient and inpatient punctoplasty; intubation medical records, as well as follow-up data and photos recorded DOI:10.18240/ijo.2019.09.20 by the surgeon (Shi WD). In the affected eyes, normal punctal structures could not be found with the naked eye and via slit Citation: Zhuang A, Sun J, Shi WD. Treatment of upper and lower lamp examination (Figure 1). In accordance with Kashkouli lacrimal punctal occlusion using retrograde canaliculotomy and et al’s[9] visual grading system, punctal occlusion was scored punctoplasty. Int J Ophthalmol 2019;12(9):1498-1502 as Grade 0. All patients presented with prominent epiphora 1498 Int J Ophthalmol, Vol. 12, No. 9, Sep.18, 2019 www.ijo.cn Tel: 8629-82245172 8629-82210956 Email: [email protected] Figure 1 Upper and lower punctal occlusion in a single patient A: The original upper punctal opening was undetectable (white arrow); B: The lower punctal opening was replaced by white scar tissues (black arrow). Figure 2 Graphic drawings of the surgical procedure A: After exposing the horizontal canaliculus, a Bowman probe was inserted backward to tent the occluded punctal area, and then a punctal opening was made; B: A silicone stent was intubated through the new opening and lacrimal canaliculus, eventually reaching the nasal cavity; C: The incision was closed with 8-0 absorbable sutures; D: Bicanalicular nasolacrimal duct intubation with the silicone stent was done. either indoor or outdoor, and suffered inconvenience from was explored under the assumption that the canaliculus might wiping away tears from time to time. Patients with any of the have been pushed deeper by fibrous tissues after trauma. When following concomitant conditions were excluded: additional the canaliculus was identified, the following procedures were lacerations or obstructions involving the lacrimal sac and/ performed. or nasolacrimal duct, craniofacial fractures, injuries of the If the identified canaliculus was unobstructed, lacrimal optic nerve or the globe, prior surgery involving the lacrimal irrigation was performed to ensure that the distal lacrimal system, or a combination thereof. All patients underwent system was patent. A Vannas scissor was used to incise the retrograde canaliculotomy and punctoplasty to reconstruct the canaliculus, and a Bowman probe was inserted backward punctal opening and canaliculus. We recorded patient age, sex, into the proximal canaliculus, such that the tip of the probe etiology (congenital/acquired), affected side, duration of time tented the occluded punctal area. Then a punctal opening was from onset to surgery, and concomitant conditions. Epiphora made, approximately 1 mm in diameter; this was intubated (frequency and indoor/outdoor characteristics), tear drainage through the new opening with a silicone tube that was 1 mm in function, punctal opening shape, and complications were diameter, 20 cm in length, with a probe at both heads (FREDA, assessed in the retrospective analysis. Shandong, China). The silicone tube was then passed through Surgical Procedure The patients underwent general or local the lacrimal canaliculus and nasolacrimal duct, eventually anesthesia. Each patient was placed in the supine position. reaching the nasal cavity. An identical procedure was then The surgery was performed under the OPMI Visu 150 surgical performed on the corresponding upper punctal area. Both microscope (ZEISS, Germany, 5× magnification). Direct heads of the silicone tube were extracted from the nasal cavity probing and dilation of potential upper and lower punctal to form square knots. The canaliculus incision was then closed sites was attempted to ensure that they were imperforate. A with 8-0 absorbable sutures (Vicryl, Johnson & Johnson, New small incision of the gray line perpendicular to the lid margin Brunswick, NJ, USA) (Figure 2). was made approximately 4 mm medial to the typical location If the identified canaliculus was occluded, an incision was of normal lower punctum. Sharp dissection was carefully made in a more medial location, in order to identify the performed from the palpebral conjunctival incision to deep soft canaliculus lumen. If a single canaliculus was completely tissues; this exposed the horizontal canaliculus, which lay 2-3 mm occluded, the corresponding upper or lower punctum and deep from the grey line, between the palpebral conjunctiva and canaliculus was reconstructed. Thus, only one head of the the tarsus. Occasionally, the canaliculus could not be found silicone tube was extracted from the nasal cavity; together within 3 mm from the grey line; therefore, an additional 1-2 mm with the other head from the reconstructed punctal opening, it 1499 Punctal recanalization with retrograde canaliculotomy Figure 3 Retrograde canaliculotomy and punctoplasty A: The lower punctal opening (white triangle) was reconstructed, and a silicone stent was inserted from the reconstructed punctum, through the canaliculus (white arrow) and nasolacrimal duct, eventually reaching the nasal cavity; B: The horizontal part of the upper canaliculus (black arrow) was identified; C: A silicone stent was intubated from both the reconstructed upper and lower punctal openings to prevent postoperative reocclusion. was used to form square knots and was then fixed in the nasal All patients underwent retrograde canaliculotomy and cavity. The incisions were repaired with 8-0 absorbable sutures. punctoplasty to reconstruct the puncta and canaliculi. In 15 If both upper and lower canaliculi were completely occluded, of 16 patients (93.75%), successful reconstruction of both lacrimal bypass with a CDCR was performed