ORIGINAL ARTICLE Prevalence and associated factors of external punctal stenosis among elderly patients in Turkey Prevalência e fatores associados à estenose externa do ponto lacrimal em pacientes idosos na Turquia MahMut Oğuz ulusOy1, MEHMET ATAKAN2, sertaç argun Kıvanç3 ABSTRACT RESUMO Purpose: To estimate the prevalence of external punctal stenosis (EPS) in the Objetivo: Estimar a prevalência de estenose externa do ponto lacrimal (EEPL) na po- elderly population and investigate associated factors. pulação idosa e investigar os fatores associados. Methods: A total of 278 patients ≥65 years of age were evaluated for evidence Métodos: Foram avaliados 278 pacientes ≥65 anos com estenose externa do ponto of EPS from January to July 2016. Associated systemic, ocular, demographic, lacrimal de janeiro a julho de 2016. Todos os fatores sistêmicos, oculares, demográ- and lifestyle factors were investigated. Multiple logistic regression analyses ficos e de estilo de vida associados foram investigados. Foram utilizadas análises de were applied to evaluate the factors related to having EPS. P values <0.05 were regressão logística múltipla para avaliar os fatores relacionados a estenose externa do considered statistically significant. ponto lacrimal, valores de p<0,05 foram considerados estatisticamente significativos. Results: The prevalence of EPS in this study population was 63.3%, with a mean Resultados: A prevalência de estenose externa do ponto lacrimal foi de 63,3%, com age of 70.67 ± 7.85 (65-92 years). The ocular factor that was most commonly idade média de 70,67 ± 7,85 (65-92 anos). O fator ocular mais relacionado com related to EPS was chronic blepharitis (48.9%). EPS was also associated with estenose externa do ponto lacrimal foi blefarite crônica. (IC de 95%, 0,08-0,96, taking glaucoma medications (95% CI, 0.08-0.96, p=0.043), smoking history (95% p=0,043), história de tabagismo (IC 95%, 0,13-0,84, p=0,021), ectrópio (IC 95%, 0,004- CI, 0.13-0.84, p=0.021), ectropion (95% CI, 0.004-0.26, p=0.001), complaints of 0,26, p=0,001), queixa de lacrimejamento (95% IC, 1,11-3,52, p=0,02) e atividade tearing (95% CI, 1.11-3.52, p=0.02), and outdoor occupational activity (95% CI, ocupacional ao ar livre (IC 95%, 3,42-9,97, p<0,05). 3.42-9.97, p<0.05). Conclusão: A estenose externa do ponto lacrimal é um distúrbio mais comum em Conclusions: EPS is more common in elderly patients than in the general popu- pacientes idosos do que na população em geral. Atividade ocupacional ao ar livre, lation. Outdoor occupational activity, taking antiglaucomatous medications, medicação antiglaucomatosa, ectrópio e tabagismo foram significativamente associados ectropion, and smoking are significantly associated with EPS. In addition, com estenose externa do ponto lacrimal. A decisão sobre tratamento cirúrgico deve surgical treatment decisions should be made after complete evaluation and ser dada após a avaliação completas dos fatores associados em cada paciente. interviewing the patients. Keywords: Lacrimal apparatus; Lacrimal duct obstruction; Blepharitis; Dry eye Descritores: Aparelho lacrimal; Obstrução dos ductos lacrimais; Blefarite; Síndromes syndromes; Aged; Turkey/epidemiology do olho seco; Idoso; Turquia/epidemiologia INTRODUCTION patient population that visited our general ophthalmology clinic External punctal stenosis (EPS) is a common disorder of the from January to July 2016. The participants were questioned about punctum. Regardless of the cause of EPS, this condition, which basic demographic data, complaints of epiphora, systemic disease, can be congenital or acquired, can cause epiphora as a result of glaucoma therapy, smoking history (patients were categorized accor- blockage of the lacrimal passage. The acquired form can originate ding to their smoking habits into three groups as follows: (1) current from topical or systemic medication use, various infections, lid smokers (people who smoke any tobacco product occasionally), (2) malposition, or different forms of trauma and tumors(1-3). Changes nonsmokers, and (3) ex-smokers (people who had smoked regularly caused by aging are also a risk factor for EPS(4). The prevalence of in the past and had quit smoking at least 1 year before the study), and EPS increases with age, and has been reported to be between 17.3% occupational history (grouped as outdoor or indoor activity). and 54.3%(5,6). A slit-lamp biomicroscopy was used to evaluate the external Because of the lack of research in this field, we aimed to evaluate punctum. EPS was visually graded according to the criteria used by the prevalence of EPS and associated factors in elderly patients in Kashkouli et al.(7). All patients with EPS had a grade 1 (severe punctal Turkey. stenosis) or grade 2 (less severe punctal stenosis) punctal opening (Table 1). In addition, the presence of pterygium, eyelid malposi- tions (ectropion, entropium, trichiasis, and distichiasis), chronic da­­ METHODS cryocystitis, cataract, and age-related macular degeneration were This cross-sectional study was performed in Konya, Turkey. also documented. Chronic dacryocystitis was revealed by performing Patients who were older than 65 years were recruited from the nasolacrimal duct irrigation. A dilated biomicroscopic examination Submitted for publication: February 14, 2017 Funding: No specific financial support was available for this study. Accepted for publication: April 6, 2017 Disclosure of potential conflicts of interest: None of the authors have any potential conflict of 1 Department of Ophthalmology, School of Medicine, Konya Research Hospital, Başkent University, interest to disclose. Konya, Turkey. 2 Corresponding author: Mahmut Oğuz Ulusoy. Başkent Üniversitesi Tıp Fakültesi. Konya Uygulama ve Department of Ophthalmology, Aksaray State Hospital, Aksaray, Turkey. Araştırma Hastanesi - E-mail: [email protected] 3 Department of Ophthalmology, School of Medicine, Uludağ University, Bursa, Turkey. Approved by the following research ethics committee: Başkent University Institutional Review Board and Ethics Committee (#94603339-604.01.02/2131). 296 Arq Bras Oftalmol. 2017;80(5):296-9 http://dx.doi.org/10.5935/0004-2749.20170072 ULUSOY MO, ET AL . of the fundus with a +78 diopters lens was performed to detect hundred twelve (40.3%) patients had bilateral EPS. The presence of age-related macular degeneration. epiphora was consistent with the EPS ratio (p=0.004). No sex domi- Suspected dry eye was also evaluated with tear film breakup nance was observed for EPS (p=0.45). time (BUT), fluorescein and rose bengal staining, and Schirmer’s Chronic blepharitis was found in 45.5% (80/176) of the patients test. The BUT was also measured by touching the inferotemporal with EPS (95% CI, 0.58-1.72, p=0.13), and this was the most common bulbar conjunctiva with a fluorescein sodium strip wetted with a ocular factor associated with EPS. The associations between the preservative-free isotonic saline. Patients were asked to blink, and presence of EPS and other demographic, occupational, ocular, and the precorneal tear film was examined under blue light illumination systemic factors are presented in table 2. using a slit-lamp biomicroscope. The mean value of three measu- rements was recorded. The BUT was considered low when it was less than 10 seconds. The corneal surface was then examined for Table 2. Demographic, lifestyle, ocular, and systemic factors associa- fluorescein staining, and its presence or absence was recorded. The ted with external punctal stenosis cases were labeled as asymptomatic if they did not complain of EPS (+) EPS (-) OR epiphora and their tear meniscus height was less than 2 mm. The a patients were labeled as having dry eye if they had a BUT less than Age (years) 72.77 ± 7.8 67.03 ± 6.54 0.89 (3.93-7.54) 10 s and positive corneal staining with fluorescein. Schirmer’s test Sex was performed in both eyes. Five minutes after the instillation of Male 88 (65.2%) 047 (34.8%) 0.95 (0.56-1.63) one drop of oxybuprocaine hydrochloride 0.4%, the inferior fornix Female 88 (61.5%) 055 (38.5%) Reference was gently blotted, and a precalibrated standard filter strip was Complaints of tearing placed in the lower temporal fornix for 5 min. During this time, the participants were instructed to look slightly upward and blink Yes 121 (69.5%) 053 (30.5%) 1.97 (1.12-3.52) normally. After removing the strip, the length of the strip that was No 055 (52.9%) 049 (47.1%) Reference wet was measured. The test result was considered positive if this Dry eye measurement was ≤5 mm. Yes 017 (50.0%) 017 (50.0%) 0.72 (0.33-1.56) This study was approved by Baskent University Institutional Review Board and Ethics Committee (Project no: 94603339-604.01.02/2131) No 159 (65.2%) 085 (34.8%) Reference and supported by the Baskent University Research Fund. Informed Blepharitis consent was obtained from all participants. The study adhered to the Yes 080 (58.8%) 056 (41.2%) 1.00 (0.58-1.72) tenets of the Declaration of Helsinki. No 096 (67.6%) 046 (32.4%) Reference Pterygium STATISTICAL ANALYSIS Yes 006 (40.0%) 009 (60.0%) 0.37 (0.11-1.23) Statistical data were analyzed using SPSS version 21.0 (IBM Corp., Armonk, NY, USA). Values were expressed as the mean ± standard No 170 (64.6%) 093 (35.4%) Reference deviation. The chi-square test with 95% confidence intervals (CIs) and Ectropion Fisher’s exact test were used to assess the effects of sex, systemic Yes 033 (97.1%) 001 (2.90%) 0.03 (0.004-0.26) disease, topical or systemic medication, smoking, and occupational No 143 (58.6%) 101(41.4%) Reference activity. Multiple logistic regression analyses were used to evaluate Hypertension the independent factors related to having EPS. P values <0.05 were considered statistically significant. Yes 067 (59.8%) 045 (40.2%) 0.71 (0.41-1.24) No 109 (65.7%) 057 (34.3%) Reference RESULTS Diabetes mellitus Yes 043 (58.1%) 031 (41.9%) 0.57 (0.31-1.05) A total of 278 patients were recruited, with a mean age of 70.67 ± 7.85 (65-92 years).