Discussion
The literature is heterogenous regarding the definitions of epiphora and of success. Some studies use the Munk grading scale to quantify the degree of epiphora,10 16 which includes minor degrees of epiphora.30 Others excluded epiphora if it was ‘not to excess’11 or conversely included it but quantified it by stating it was ‘not interfering with daily life’.13 Others did not quantify the degree of epiphora, making it difficult to compare to studies which did.12 14 15
It is well documented that both the upper and lower canaliculi are functionally important for tear drainage, and that one functioning canaliculus may be sufficient to prevent symptomatic epiphora, particularly in the absence of reflex tearing.10 31–35 In this series, all cases involved the lower canaliculus, with all upper canaliculi remaining intact. The lack of epiphora symptoms could be attributed to the intact upper canaliculus. Hence, a comparative series, where the remnant canaliculi were not marsupialised, would have been very valuable. This was not possible, as it is not the practice in this unit. However, the literature contains studies where a laissez-faire approach is used, and no canalicular or lacrimal system reconstruction is attempted.
The rate of epiphora in these cases using a laissez-faire approach ranged from 42.9% to 81.8%,10 14 18 26 27 if the reports where there was only one patient in the cohorts are excluded17 19 (table 2). The series by Morton11 and by Yazici et al27 also used the laissez-faire approach to lacrimal reconstruction in addition to marsupialisation11 and silicone intubation27 but did not specify which method of lacrimal reconstruction was used in their patients with epiphora.
Of these series using the laissez-faire approach, Smit and Mourits,10 (n=7) was comparable to this series, as none of the upper canaliculi were injured, and they reported on all epiphora, not only that which was problematic for the patient.10 Their rate of epiphora of 42.9%10 is higher than the rate found in this study of 9.1%. This suggests that marsupialisation of the remnant inferior canaliculus substantially aids in tear drainage, in addition to that which is drained by the intact upper canaliculus. Kesiktas et al,14 Motomura et al26 and Madge et al18 also reported high rates of epiphora. The patients in Madge et al18 underwent en bloc resection of the tumour, including the lacrimal sac, and Kesiktas et al14 and Motomura et al26 did not specify which parts of the lacrimal apparatus were removed during tumour excision but, based on the representative photos included, it is likely that both canaliculi were affected, if not much or all of the lacrimal apparatus. These may account for their much higher epiphora rates. Even in a more recent series (n=14), where the laissez faire approach was used in the majority of cases, with stenting in the others, the rate of epiphora was 21.4%, which was still higher than that in this series, and they only noted ‘persistent epiphora’ instead of all degrees of epiphora.27
For the most part, the epiphora reported in this context is mild (table 2), with a minority of patients requiring further surgery or intervention. In this study, one patient required extensive intervention for her epiphora symptoms. Perhaps this was due to her young age (46.1 years vs a mean of 77.6 years). It is well known that with increasing age, reflex tear secretion decreases.36 Malignant eyelid tumours are more common in older patients, with the mean age of incidence of basal cell carcinomas and squamous cell carcinomas peaking in the seventh decade, and in the seventh to eight decades for sebaceous gland carcinomas.37
Due to the retrospective nature of the study, it was not possible to apply a uniform grading system to quantify the degree of epiphora nor were the results of syringing of the lacrimal system postoperatively universally available. The authors acknowledge these are limitations. However, it has previously been found that the presence or absence of epiphora is a more important and sensitive marker of the success of treatment for canalicular laceration, rather than an anatomically intact canalicular system.10 38 Therefore, while anatomical success is academically interesting, using symptomatic epiphora as an endpoint is more useful pragmatically, particularly when considering the impact on the patient and on the health service.
No patients were lost to follow-up. In uncomplicated cases, those undergoing excision and reconstruction of lid tumours are routinely discharged from the unit 3–4 months afterwards. The authors acknowledge that 3–4 months is a relatively short amount of time. However, long-term patient outcomes were sought as much as feasibly possible within the limits of a retrospective study covering a large time frame and including the fact that half of the patients in the cohort were deceased by the time of data collection. It is unlikely that epiphora occurring after discharge from the unit was missed. The unit is one of four British ocular oncology centres. Hence, any subsequent ocular symptoms following treatment for ocular malignancy done in this unit, including epiphora, would be re-referred to the unit, irrespective of time elapsed. Furthermore, unrelated lid symptoms are typically re-referred to the unit, particularly as other care providers (primary care or local ophthalmology departments) prefer to have reassurance that the new symptom does not represent recurrence of the previously treated ocular malignancy.
Therefore, case notes were reviewed for reattendances or re-referrals following discharge. The nature of these was noted specifically for symptoms of epiphora, even if the patient had been referred or attended for something unrelated (eg, glaucoma screening). This was at a minimum review time of 2 years and 2 months but extending as long as 10.5 years. In the latter case, that patient is still under review due to the original malignancy being a tarsal conjunctival squamous cell carcinoma. A lack of reattendance or re-referral was taken to confirm a lack of symptomatic epiphora. The authors acknowledge that a lack of reattendance or re-referral does not equate to the absence of epiphora. However, the severity of epiphora is relevant when considering the impact on the patient. Mild or minor symptoms are tolerated by patients, without seeking further intervention.
The advantages of using marsupialisation in this setting are that it is a relatively straightforward procedure to add onto the reconstructive surgery without excessively extending surgical time or recovery for the patient. The patient does not need to undergo an additional procedure for this to be done and, in doing so, may help the patient avoid secondary nasolacrimal rehabilitative procedures, which may be extensive and involve longer patient recovery. There is also no additional cost, which would incur when using a stent. The current cost to the department for one unit each of Mini Monoka (FCI Ophthalmics, Pembroke, Masssachusetts, USA), bicanalicular Crawford tubes (FCI Ophthalmics) and monocanalicular Crawford tubes (FCI Ophthalmics) is £81.67, £47.50 and £98.33, respectively. Furthermore, there is no risk of iatrogenic damage to the intact upper canaliculus or the remnant healthy canaliculus, as may occur when using stents. Morton11 surmised his low rate of epiphora was due to leaving the remnant healthy canaliculus alone and therefore avoiding unnecessary trauma. There is also no upkeep required by the patient, as would be required if a Lester Jones tube was placed.39 Moreover, this option remains as a fall back if marsupialisation fails. Therefore, marsupialisation of the remnant canaliculus during delayed reconstruction is a straightforward and effective surgical option that may help prevent postoperative epiphora when the proximal lacrimal system is sacrificed for tumour margin clearance.