Lacrimal Drainage System Obstruction

The lacrimal drainage system consists of the lacrimal puncta, inferior and superior canaliculi, common canaliculus, lacrimal sac, and nasolacrimal duct. It is classically divided into upper and lower portions. Obstruction of the drainage system can be congenital or acquired, and may result in persistent epiphora and mucopurulent discharge. This paper discusses the etiology, clinical picture, diagnosis, and surgical treatment of lacrimal drainage system obstruction.     

Diagnosis of lacrimal canalicular diseases using ultrasound biomicroscopy:a preliminary study

AIM: To evaluate the application of ultrasound biomicroscopy (UBM) in the examination of lacrimal canalicular diseases, and to investigate UBM image characteristics of lacrimal canaliculi in disease states.METHODS:Sixty cases (63 eyes, 69 canaliculi) of lacrimal canalicular diseases were enrolled that included 32 patients (32 eyes, 32 canaliculi) with chronic lacrimal canaliculitis, 18 patients (18 eyes, 18 canaliculi) with previous lacrimal canalicular laceration, 9 patients (12 eyes, 18 canaliculi) with congenital absence of lacrimal puncta and canaliculi, and 1 case (1 eye, 1 canaliculus) of canalicular mass. The patients were examined using UBM, and disease-specific features of the UBM images were noted.RESULTS:UBM imaging of lacrimal canaliculi in chronic canaliculitis patients showed obvious ectasia of the lacrimal canalicular lumen. Dot-like moderate echoic signals were detected on some ectatic lumina of the lacrimal canaliculus. Some lumen-like structures of the lower lacrimal canaliculus were observed in 2 (2 eyes, 2 canaliculi) of the 9 patients (12 eyes, 18 canaliculi) with congenital absence of the lacrimal canaliculus. Of the 18 patients (18 eyes, 18 canaliculi) with previous lacrimal canalicular laceration, the lacerated end on the nasal side of the lacrimal canaliculus was detected only in 14 patients (14 eyes, 14 canaliculi).CONCLUSION:UBM can be used to evaluate lacrimal canalicular diseases and can provide an imaging basis for the diagnosis of lacrimal canalicular diseases.     

Functional dominance in the lacrimal canaliculi

Past reports ignored the functional relationship between the upper and lower lacrimal canaliculi. The authors measured the lacrimal function in 50 normal eyes of 27 subjects and found that the drainage was more rapid in the lower lacrimal canaliculi of 25 eyes and in the upper canaliculi of 22 eyes, while the drainage time was equal in 3 eyes. The drainage in 25 eyes with both the upper and lower canaliculi open was more rapid than with any one canaliculus occluded. The authors suggested that the function of the lacrimal canaliculi might be classified into three types: the dominating, the dominated and the balanced. There was no statistical difference (P greater than 0.05) between the numbers of dominating upper or lower canaliculi in this series. The function of the upper and lower canaliculi operated synergically and complete drainage was not accomplished by any one canaliculus alone.     

Two cases of lacrimal gland agenesis in the same family--clinicoradiologic findings and management

BACKGROUND: Lacrimal gland agenesis is extremely rare. This condition is occasionally associated with salivary gland agenesis and abnormalities in the lacrimal drainage system, particularly occlusions of the lacrimal puncta and canaliculi. The detailed presentation of clinicoradiologic findings and treatment modality has not been previously reported. METHODS: A 6-year-old boy was presented to our department complaining of severe foreign-body sensations in both eyes. Punctate epithelial erosions and mucous filaments were noted in both eyes. His tear break-up time (TBUT) was less than 1 second, and a Schirmer's test (both eyes) detected less than 1 mm of wetting in 5 minutes. His mother had similar complaints dating back to childhood. RESULTS: Orbital computed tomography (CT) scan and magnetic resonance imaging (MRI) revealed the absence of both lacrimal glands and all major salivary glands. After the insertion of a lacrimal punctal plug, punctate epithelial erosions and mucous filaments decreased remarkably within 2 weeks. MRI scans of the patient's mother confirmed the absence of both lacrimal glands and salivary glands. She had been using artificial tears for a long time. INTERPRETATION: The absence of lacrimal glands can be confirmed by clinicoradiologic findings, and the punctal plug may be an effective tool for the treatment of patients who retain a patent lacrimal drainage system.     

硅胶管置入行下泪小管断裂吻合术的体会

目的　探讨下泪小管断裂吻合的方法。方法　对 18例 (18眼 )下泪小管断裂采用螺旋状猪尾探针从上泪小管穿入 ,在手术显微镜下寻找下泪小管断端。上下泪小管均置入硅胶管 ,吻合下泪小管断端后 ,将硅胶管环形结扎于内眦部。结果　 18例均吻合成功 ,其中 16例 (88.89%)冲洗泪道通畅 ,2例 (11 .11%)冲洗泪道通而不畅。结论　采用螺旋状猪尾探针从上泪小管穿入寻找下泪小管断端方法简便易行 ,硅胶管置入行下泪小管断裂吻合疗效良好。     

Lacrimal drainage following repair of inferior canaliculus.

Eight cases of surgically repaired lower canaliculi were studied to ascertain whether the lower canaliculus is necessary for normal lacrimal drainage and whether it is advisable to probe the superior canaliculus during inferior canalicular repair. Six of 8 patients sutdied had no epiphora despite unsuccessful surgery and a normal Schirmer"1 test. Surgery was successful on 2 pateints. These results indicate that only cosmetic repair is necessary for lacerated lower canaliculi. It is suggested that the upper canalliculus alone provides sufficient lacrimal drainage to prevent epiphora.     

比较两种泪道置管治疗儿童泪小管断裂的临床研究

目的：比较RS管泪道再通管(RS-type lacrimal intubation，RS管)和环形泪管在儿童泪小管断裂吻合术中的临床疗效。

方法：回顾性分析2016-08/2018-07我院收治的泪小管断裂患儿37例37眼的临床资料。治疗组20例20眼行RS管置入术，对照组17例17眼行环形泪管置入术，比较分析两种泪道置管术的临床效果和并发症情况。

结果：治疗组和对照组术中鼻黏膜出血率分别为0和100%。治疗组和对照组治疗有效率分别为95%和88%(P=0.584)。治疗组和对照组术后并发症率分别为5%和12%(P=0.584)。

结论：RS管置入术可有效避免鼻黏膜出血情况发生，操作简便、易拔管、并发症少、安全性高、效果好，适宜在基层医院广泛推行。     

泪小管断裂吻合置管术的疗效分析

目的:观察显微镜下用直接发现法行泪小管断裂吻合置管术的临床效果。方法:在手术显微镜下沿泪小管断端在复原伤口后找泪小管断离鼻侧断端,以硬膜外麻醉导管作为泪小管内支撑,吻合泪小管断端。结果:患者60例其中1例术后因置管部分脱出,自行还纳时致泪小点及远端泪小管豁开,经手术修复治愈,1例拔管后随访泪道不通畅,其余均痊愈。结论:显微镜下直接发现法找到泪小管鼻侧断端的成功率较高,且行吻合修复术后恢复泪道排泪功能效果肯定。     

Lodged intracanalicular plugs as a cause of lacrimal obstruction

PURPOSE: To evaluate the complications and success of treatment of migrated or lodged intracanalicular and punctal plugs. METHODS: A retrospective chart review of all cases having either a dacryocystorhinostomy or surgical removal of an intracanalicular or punctal plug from 1992 to 2006, in a single physician referral oculoplastics practice, was performed to identify cases in which a retained lacrimal plug required surgical intervention. Patients presented with symptoms of tearing, infection, or granuloma formation. The charts of 998 surgical cases were reviewed, from which 66 eyes (6.6%) were determined to have had lodged lacrimal plugs that required surgical removal, thus qualifying them for inclusion in this study. Patients were followed after surgery until reconstructive silicone tubing was removed (range, 6 weeks to 6 months), and each patient was questioned regarding symptoms. A comparison group of 336 eyes that had collared punctal plugs placed served as the control group. RESULTS: All cases were noted to have complications from intracanalicular plugs. No complications were noted from other forms of lacrimal plugs. All eyes in this series required a canaliculotomy or a dacryocystorhinostomy after office irrigation failed to dislodge the plug. Five eyes presented with canaliculitis, 28 eyes presented with epiphora, and 29 eyes presented with dacryocystitis. Four of 66 eyes (6%) in this cohort presented with a pyogenic granuloma. Five eyes (8%) presented with canaliculitis. Forty-nine of 66 eyes (74%) were asymptomatic following treatment, with no observable infection or epiphora. Seven of 66 eyes (11%) had some improvement in symptoms and another 10 of 66 eyes (15%) had no change in symptoms after treatment. No complications requiring surgical intervention were encountered in the control group of collared punctal plugs. CONCLUSIONS: Intracanalicular-type plugs may lodge in the lacrimal outflow system. This may result in epiphora, canaliculitis, or dacryocystitis that may require major reconstructive surgery. Despite surgical intervention, these symptoms do not always resolve (26% of eyes in this study had persistent epiphora). Intracanalicular plugs were observed to be associated with a higher rate of granulation tissue formation in the lacrimal outflow tract when compared with other forms of punctal plugs. As a result of the increased number of complications seen with intracanalicular plugs, caution is advised with respect to use of these devices. The relative infrequency of complications seen with collared punctal plugs suggests a safer alternative. Data from this study lead the authors to advocate the consideration of other forms of lacrimal occlusion due to the high number of complications noted with intracanalicular plugs, and the availability of other reversible forms of punctal occlusion.     

Management of acquired punctal stenosis with perforated punctal plugs

Purpose

To evaluate the efficiency of perforated punctal plug in acquired punctal stenosis.

Materials and methods

Forty-five eyes of 33 patients who had epiphora due to punctal stenosis were included in this study. After biomicroscopic examination and lacrimal dilatation punctal stenosis was managed with the perforated punctal plugs in all patients. In the following period epiphora, plug tolerance, lacrimal drainage were evaluated and graded. Lacrimal drainage was evaluated with fluorescein dye disappearing test.

Results

The age of the patients ranged between 31 and 80 (mean 55.78 ± 13.11). Preoperatively punctal dilatation and lacrimal system irrigations were performed on all patients. Lacrimal system irrigation was positive in all patients. Perforated punctal plugs were placed in the inferior puncti in all patients. The plugs were explanted 6 months after operation. The follow-up period ranged between 6 and 24 months. Plug tolerance was good in 97.8% of the eyes in the 1st month visit. Epiphora decreased remarkably in 88.9% of the patients 1 month after plug implantation, except one whose plug dropped off spontaneously in 2 weeks. Fluorescein disappearing times were found under 3 min in 97.8% of the eyes after plug explanations.

Conclusion

Punctum stenosis is one of the several disorders that cause lacrimal drainage obstruction. Perforated punctal plugs are found convenient and effective in managing punctal stenosis.     

硅胶泪导管双头双路插管法在外伤性泪小管断裂吻合术中的应用

目的探讨硅胶泪导管为内置管的双头双路插管在治疗外伤性下泪小管断裂的手术方法及术后效果。方法 23例（23眼）在手术显微镜直视下寻找下泪小管鼻侧断端,并以双头硅胶泪导管为支撑物插管,插管的另一端从上泪小管插入,两端从下鼻道内拉出后留适当长度置于下鼻道内。结果 23例术后泪道冲洗均通畅,患者对外观均满意,都能完成治疗周期顺利拔管。结论双头双路泪道插管法在外伤性泪小管断裂吻合术中因其手术方法简单,外固定牢效果好,不影响患者外观。     

深部泪小管断裂改良环形支撑管置管术的效果

目的:评价改良环形支撑管置管术治疗深部泪小管断裂的临床效果。方法:回顾性分析福建省立医院2008年1月至2019年6月深部泪小管断裂58例(58眼)的临床资料,患者均接受泪小管逆向置管联合远端支撑管缝线固定的改良环形硅胶支撑管置管术。术后随访(53.36±27.43)个月。观察其效果。结果:患者年龄9～76(39.52...     

亚甲兰透明质酸钠在下泪小管断裂吻合术中的应用

目的:探讨寻找泪小管断端方法,提高吻合泪小管成功率。方法:从上泪小点注入亚甲兰透明质酸钠,在显微镜下寻找下泪小管鼻侧断端,行泪小管吻合术。结果:本组患者22例(22眼),经泪小管鼻侧断端亚甲兰透明质酸钠标记明显,寻找断端的成功率100%。术后随访6~12mo,19例患者治愈(86%),3例未愈(14%)。结论:注入亚甲兰透明质酸钠,寻找泪小管断端,方法简便易行,容易成功,值得推荐。     

Two Types of the Sinus of Maier: An Anatomic Study

Purpose: To show the morphological characteristics of two different types of the sinus of Maier, one with a lacrimal sac diverticulum supplied by separate canalicular openings, and the other with a terminal dilatation of the common lacrimal canaliculus.

Methods: Twelve coronal specimens (6 right and 6 left) from 6 Japanese cadavers (age range, 70–90 years at death) and 15 axial specimens of 11 Japanese cadavers (8 right, 7 left; age range, 45–89 years at death), fixed in 10% buffered formalin, were used. All specimens were stained with Masson’s trichrome.

Results: The sinus of Maier, with a lacrimal sac diverticulum supplied by separate canalicular openings, was shown in one coronally sectioned group, with a diameter of 1.29?mm. The mucosa between both openings (0.282?mm length) comprised stratified squamous epithelia, which was characteristic of the lacrimal canaliculi. The diverticular mucosa was lined by a stratified columnar epithelium, which corresponded to the lacrimal sac. The sinus of Maier, with a terminal dilatation of the common lacrimal canaliculus and with a diameter of 0.51?mm, was demonstrated in one axially sectioned group.

Conclusions: The morphological characteristics of two types of the sinus of Maier were described in this study. One type was the lacrimal sac diverticulum supplied by separate canalicular openings, and the other was the terminal dilatation of the common lacrimal canaliculus.     

硅胶泪道引流管治疗泪道阻塞性疾病的临床观察

目的:探讨运用硅胶泪道引流管逆行泪道插管术治疗泪道阻塞性疾病的手术效果.方法:对68例83眼鼻泪管阻塞患者选用球头型硅胶管逆行插管术,对26例37眼泪小管或泪总管阻塞患者选用引线型硅胶管逆行插管术.结果:术后随访6～12mo,球头型硅胶管治疗组有效率87%,引线型硅胶管治疗组有效率73%.结论:逆行泪道插入硅胶泪道引流管治疗泪道阻塞性疾病,办法简便,效果良好,适合基层医院临床推广.     

鼻内窥镜下crawford管置管治疗下泪小管阻塞的临床分析

目的观察鼻内窥镜下crawford管治疗泪小管阻塞的临床疗效。方法在门诊治疗的下泪小管阻塞共42例(53眼),在局麻下行crawford管治疗。根据病情平均3-6个月拔管,拔出泪道硅胶管后,泪道冲洗通畅且无症状为治愈;泪道冲洗通畅,但有一定阻力且偶有流泪为好转;泪道冲洗不通畅为无效;拔管两个月以上再次流泪冲洗不通畅为复发。结果拔管后,治愈41眼(77.36%);好转6眼(11.32%);无效2眼(3.77%);复发4眼(7.55%)。结论鼻内窥镜下crawford管置管是一种有效的治疗下泪小管阻塞的办法。     

鼻泪管填塞联合黏弹剂注入在复杂泪小管断端定位中的应用

目的：探讨鼻泪管填塞联合黏弹剂注入在不易寻找断端的复杂泪小管吻合术中定位鼻侧断端的应用效果。

方法：对我院收治13例13眼不易寻找断端的外伤性单根泪小管断裂患者,采用RS泪道引流管自完整的泪小管插入泪道填塞鼻泪管,再注入黏弹剂,使黏弹剂自断裂泪小管的鼻侧断端溢出,用于定位不易寻找鼻侧断端,并完成泪小管吻合手术。

结果：不易寻找断端的患眼13眼,使用RS泪道引流管填塞鼻泪管,在注入黏弹剂后,可在显微镜直视下发现凝胶自鼻侧断端溢出,并成功置入泪道引流管,断端寻找成功率为100%。13眼均置管3mo后拔管,随访6mo。其中治愈9眼,显效3眼,无效1眼。治愈率69%,总有效率92%。

结论：鼻泪管填塞联合黏弹剂注入操作简单,对术者的临床经验要求相对较低,适合不同程度的单根泪小管断裂患者,能够在较短的时间内完成不易寻找断端的复杂泪小管断裂吻合手术,是一种新的快速定位鼻侧断端的技术。     

Anatomical analysis of the human lacrimal drainage pathway under an operating microscope

Mesoscopic structures of the lacrimal drainage pathway were observed under an operating microscope in six cases of 5 adult cadavers. In all these cases the upper and lower canaliculi fused to form the common canaliculus. Two cases with a large common canaliculus showed large projections of mucosa which reduced the inner space of the common canaliculus. The remaining 4 cases with a small common canaliculus did not show any projections. These findings indicate that the human lacrimal system can function physiologically through a small narrow space of the common canaliculus.Abbreviation DSI direct silicone intubation     

下泪小管断裂吻合术55例临床观察

目的：探讨下泪小管断裂伤术中泪小管鼻侧断端的简单有效的寻找方法及下泪小管断裂吻合术后的疗效评价。

方法：下泪小管断裂伤患者55例55眼采用在手术显微镜直视下或自上泪小点注入生理盐水必要时注射玻璃酸钠的方法寻找断裂的下泪小管的鼻侧断端。以0.8mm外径空心硅胶软管作为支撑物吻合泪小管周围组织2～3针,硅胶软管留置2～3mo。术后随访6～24mo。

结果：下泪小管断裂患者55例55眼均吻合成功。其中治愈49例(89.1%),好转5例(9.1%),无效1例(1.8%)。

结论：该方法是一种行之有效操作简单疗效确切的泪小管断裂吻合方法,适合在有显微手术条件的医院采用。     

20-MHz ultrasound and its value in imaging of lacrimal plugs

BACKGROUND: High-frequency B scan ultrasonography is a proven method for the assessment of anterior segment diseases. Only few studies have used sonography to examine the lacrimal drainage system. We examined the proximal lacrimal drainage system by high-resolution 20-MHz ultrasound to verify the possibility to identify intracanalicular lacrimal plugs. METHODS: Eight patients who had received 12 lacrimal plug implants were examined by high-resolution ultrasound. A 20-MHz sector scanner was used for detection and localization of 2 types of intracanalicular plugs (Herrick) lacrimal silicone plug, Smart trade mark acrylic polymer plug) and 1 punctum plug. Ultrasound examinations were performed 1-24 months after plug placement. Cross-sections of the lacrimal canaliculi were obtained. RESULTS: The various intracanalicular implants were successfully viewed using the 20-MHz ultrasound sector scanner. Intracanalicular plugs were located at the appropriate position as intended. The silicone plugs could be seen as areas of higher reflectivity. In contrast, acrylic polymer plugs were seen as low-reflective inner structures. In a longitudinal echogram, the interface between the acrylic polymer plug and the lacrimal canaliculus produced a strong acoustic impedance. In patients with an intracanalicular acrylic polymer plug, the caliber of the plug could be ascertained and the diameter measured. CONCLUSION: High-resolution ultrasound with a 20-MHz sector scanner is helpful in detecting intracanalicular plugs and is a valuable tool to assess the migration of lacrimal plugs through lacrimal canaliculi. A 20-MHz sector scanner can be used to identify and locate lacrimal plugs in the proximal drainage system even if biomicroscopic signs or clinical data are absent.