Monocanalicular lesions: To reconstruct or not

doi:10.1016/S0161-6420(99)00715-0

Ophthalmology

Volume 106, Issue 7, 1 July 1999, Pages 1310-1312

https://doi.org/10.1016/S0161-6420(99)00715-0 Get rights and content

Abstract

Objective

To evaluate the success rate of a simple surgical method for the treatment of a monocanalicular lacrimal lesion.

Design

Retrospective noncomparative case series.

Participants

Thirteen consecutive patients with monocanalicular trauma who were seen from August 1995 to March 1998. In six patients, the canaliculus was lacerated as a result of an external injury and in seven patients as a result of tumor removal (iatrogenic injury).

Intervention

Reapproximation of the orbicularis muscle and skin overlying the torn canaliculus without reanastomosis of the lacerated canaliculus. In those patients in whom the canaliculus was sacrificed as part of the removal of an eyelid tumor, no attempt was made to reconstruct the canaliculus.

Main outcome measures

Symptomatology, patency of the lacrimal passage, fluorescein dye disappearance test, and patient satisfaction.

Results

In all patients the injured canaliculus was totally blocked, but despite this none of the patients complained of inconvenient tearing either indoors or outdoors. The ipsilateral unharmed canaliculus was functioning normally in such a way that the fluorescein dye instillation test showed residual dye in six patients after 2 minutes and in none of the patients after 5 minutes. All patients were satisfied with the functional and cosmetic result.

Conclusion

Nonrepair of a monocanalicular lesion is a valid approach that results in little or no morbidity.

Section snippets

Patients and methods

Since August 1995 all patients with a monocanalicular trauma who were referred to the Orbital Center Utrecht were treated merely by reapproximation of the orbicularis muscle and meticulous closure of the skin. In those patients in whom the canaliculus was sacrificed as part of the removal of an eyelid tumor (iatrogenic trauma), no attempt was made to reconstruct the canaliculus.

From August 1995 to March 1998, 13 consecutive patients were treated this way. All 13 patients were re-examined in a

Results

Patient characteristics are shown in Table 1. The median age at trauma for all patients was 50 years. Seven patients had been treated for a basal cell carcinoma in the medial canthal area. In these patients the canaliculus, or a part of it, was sacrificed to ensure complete tumor removal at surgery. Wound healing occurred by secondary intention (“laissez-faire” method).

None of the 13 patients complained of inconvenient tearing either indoors or outdoors, although 3 patients experienced tearing

Discussion

None of the patients in our study group demonstrated bothersome symptoms of tearing, although the involved canaliculus was totally blocked in all. Apparently a single functioning canaliculus provides sufficient lacrimal drainage to prevent epiphora.

In this study, all consecutive patients with a monocanalicular injury who were seen at our department were treated only by reapproximation of the orbicularis muscle and skin overlying the torn canaliculus without any attempt to realize reanastomosis

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La traumatologie lacrymale en urgence est dominée par les plaies canaliculaires intéressant le canalicule inférieur, le supérieur ou les deux canalicules. Les sujets de sexe masculin, de tout âge, en particulier les enfants, voire les très jeunes enfants, sont les plus touchés. La cause dépend de l’âge : chez le jeune enfant, les morsures par animaux prédominent ; chez l’adulte jeune les rixes, les accidents de la voie publique étant devenus beaucoup moins fréquents ; chez le sujet âgé les chutes. Dans tous les cas, une prévention antitétanique est indispensable ainsi qu’une consultation antirabique en cas de morsure par animal. Le diagnostic est très simple : il repose sur l’inspection, voire sur le sondage réalisé en peropératoire. Il faut écarter les lésions vitales et/ou oculaires, en particulier une plaie du globe associée qui modifie le degré d’urgence. En l’absence de plaie oculaire, la réparation lacrymale doit être réalisée chirurgicalement sous microscope opératoire dans un délai de 48 heures : repérage des extrémités du ou des canalicules lésés, suture des berges canaliculaires sectionnées, avec ou sans intubation. Les autres atteintes traumatiques des voies lacrymales sont beaucoup plus rares : plaies du sac lacrymal ou sections traumatiques du conduit lacrymonasal.
Among lacrimal system injuries, canalicular lacerations are at the top of the list. Men are more affected than women, but children are most likely to experience such trauma. The cause depends on the patient's age: in young children, there is a higher prevalence of animal bites (dogs and cats); in young adults, fights predominate, since motor vehicle accidents have become less common; in the elderly, falls are among the most frequent causes. Tetanus vaccination is required in all cases, but assessment for rabies exposure is necessary in the case of dog or cat bites. Diagnosis is very simple: it is based on examination or wound probing. Other head, facial, or ocular injuries must be excluded; for example, an injury to the globe must take precedence over a canalicular laceration. In the absence of an ocular injury, the canalicular wound should be managed surgically within 48 hours under an operating microscope: identification of both severed ends of the injured canaliculus, suture of the severed canaliculus with monofilament suture, and appropriate lacrimal intubation if indicated. Other trauma to the lacrimal system, such as sharp or blunt trauma to the lacrimal sac or nasolacrimal duct, are much rarer.
Ocular Injury and Emergencies Around the Globe
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Citation Excerpt :
More importantly, the medial canthal ligament has an intricate relationship with the lacrimal drainage system, which is why periocular trauma and eyelid lacerations are relatively often associated with canalicular laceration. Literature shows that canalicular repair must be performed if both canaliculi are involved (Fig. 11); however, some investigators claim that in case of a single canalicular laceration, epiphora may not occur if one patent canaliculus remains.5 Even so, it must be said that if epiphora does occur, secondary repair of the canaliculus can be extremely challenging.
Controversies of the lacrimal system
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Given increased tear flow through the ipsilateral intact canaliculus, fewer than 10% of monocanalicular patients experience constant epiphora in basal tear settings.23,27,29,41 Smit and Mourits documented in a series of 13 patients with unrepaired monocanalicular lacerations that no patients complained of epiphora under basal tear conditions and that only 3 patients complained of epiphora under reflex-tearing conditions (cold or wind).34 In situations of reflex tearing, however, tear overflow symptoms such as watery eye, blurred vision, discomfort, and crusting occur in roughly 50% of patients with a single canaliculus.23
Numerous long-standing controversies influence the management of lacrimal sac abscesses, canalicular lacerations, and obstruction of the nasolacrimal duct. We examined the debatable beliefs that underline these controversies and concluded the following: drainage of a pointing lacrimal sac abscess can be well tolerated under local anesthesia, is associated with few adverse events, and should be performed regardless of whether systemic antibiotics have been administered. Reconstruction of monocanalicular lacerations should be considered in all cases, without distinction to whether the injury involves the upper or lower canaliculus. Finally, no firm evidence currently exists supporting intubation with routine dacryocystorhinostomy.
Management of Canalicular Lacerations: Epidemiological Aspects and Experience with Mini-Monoka Monocanalicular Stent
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Citation Excerpt :
Immediate repair of laceration with stenting of the canaliculus is currently the most preferred treatment approach for bicanalicular injuries.1 However, controversy still exists regarding the repair of a single-lacerated canaliculus.1,8,12–14 Considering the predominance of a younger population, the number of patient-years of morbidity, and the possibility of future injury or disease, it may be prudent to repair all canalicular lacerations even if a single canaliculus is involved.
To report the epidemiological data, clinical profile, and surgical outcome of canalicular lacerations in an Indian population.
Retrospective interventional case series.
All patients who underwent canalicular laceration repair from July 1, 2002 to June 30, 2005 at a tertiary eye care center were retrospectively reviewed. Demographics, cause of eyelid injury, associated ocular injury, surgical management with Mini-Monoka monocanalicular stent, and its outcome were analyzed.
Sixty-six patients underwent eyelid laceration repair, of which 24 (36%) had involvement of the canalicular system. The mean age at presentation was 16 years (range, 10 months to 52 years); 20 (83.3%) patients were males. Mode of injury included the blouse-hook fastener in five (20.8%) breast-feeding infants, bicycle handle injury in four (16.7%) children, and metal rod injury in five (20.8%) adults. Lower canaliculus was involved in 13 (54.1%), upper in eight (33.3%), and both in three (12.5%) patients. Simultaneous globe injury was noted in six (25%) patients, five (83.3%) of which had upper canalicular involvement. Twenty-seven canalicular lacerations (24 patients) underwent stenting with the Mini-Monoka monocanalicular stent. Three (11.1%) stents extruded within one month. At the final follow-up (mean, 18.5 months), canalicular block was noted in two (10%) out of 20 patients; none had epiphora.
Canalicular involvement occurs in 36% of eyelid injuries. Injury by the “blouse-hook fastener” is unique to infants in the Indian context. Simultaneous globe injury is present in 25% of cases, especially when the upper canaliculus is involved. Mini-Monoka stent extrusions occur within one month. With an 11.1% extrusion rate, Mini-Monoka stents achieved good anatomical (90%) and functional (100%) success in the management of canalicular injury.
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Monocanalicular lesions: To reconstruct or not

Abstract

Objective

Design

Participants

Intervention

Main outcome measures

Results

Conclusion

Section snippets

Patients and methods

Results

Discussion

Ophthalmology

Am J Ophthalmol

Ophthalmology

Am J Otolaryngol

Ophthalmology

Ophthalmology

Ophthalmology

Surv Ophthalmol

Oral Surg Oral Med Oral Pathol Oral Radiol Endod