Management of proximal lacrimal obstructions: a rationale

Abstract

Purpose To identify a rationale for correct surgical treatment of proximal lacrimal obstructions. Methods Retrospective review of 775 consecutive patients (974 eyes) with proximal lacrimal obstructions, operated on with customized surgery by a senior surgeon (FMQL) from January 2003 to December 2018. Results In case of punctal stenosis, punctoplasty was as effective as punctal dilatation with monocanalicular or bicanalicular stent (p > 0.05). In proximal canalicular obstructions, failure rate of dacrocystorhinostomy with retrograde intubation (R‐DCR) was significantly higher in case of false inferior passage creation than in case of no false passage creation (p = 0.02). In mid‐canalicular obstructions failure rate of R‐DCR was 41.3%, and bypass surgery with Jones tube at second stage was likely. Trephination and monocanalicular intubation, performed in selected cases, had a failure rate respectively of 16.6% and 21.7% in mid and distal canalicular obstructions. Canaliculodacryocystorhinostomy (CDCR) was successful in 77% of cases of proximal common canalicular obstruction. Bypass surgery is the treatment of choice in case of no residual patency, and rates of tube extrusion were significantly reduced with the use of StopLoss Jones tubes (SLJT) (1.7%) with respect to standard tubes (12%), (p = 0.04, Fisher’s exact test). Conclusion Patient history and accurate diagnosis of the site of obstruction are essential for a correct surgical choice. Less invasive techniques as trephination and intubation may be effective, but should be reserved to patients with no associated lower lacrimal obstruction. Further studies require specific randomized clinical trials, and a standardized protocol adopted by different clinical centres.

Proximal lacrimal obstructions: a review

“…The obliterated canaliculus is resected and the surgical anastomosis is shaped between the medial ends of the patent canaliculi or the common canaliculus and the nasal mucosa, which is used to fashion a large anterior flap; the sac mucosa is used for the posterior flap. In case of common canalicular obstruction success rate is approximately 80%, but it is lower in case of distal canalicular obstructions (Doucet & Hurwitz 1982;Quaranta-Leoni et al 2020).…”

“…Proximal lacrimal obstructions can be classified into punctal stenosis, proximal canalicular obstructions, midcanalicular obstructions, distal canalicular obstructions and common canalicular obstructions (Liarakos et al 2009;Quaranta-Leoni et al 2020) • Punctal stenosis is defined as congenital or acquired narrowing or occlusion of the external entrance of the lacrimal drainage system (Kashkouli et al 2003;Matew & Olver 2011). Punctal obliteration indicates that the puncta are completely obliterated, with no punctal opening clinically detectable (Starks & Yoon 2019).…”

“…Trephination and positioning of LacriJet -a single use injector handpiece into which a silicone tube is preloaded inside a metallic probe used for trephination -appears to be effective in patients with no previous history of discharge (Fig. 2), and no nasolacrimal duct obstruction associated to the canalicular block (Quaranta-Leoni et al 2020), and trephination and intubation is successful in patients with mid-canalicular block developed after DCR (Vahdani & Rose 2019).…”

“…Dacryocystorhinostomy with retrograde intubation (R-DCR) may be considered in patients with associated nasolacrimal obstruction, but postoperative failure appears to be more frequent in mid-canalicular obstructions than in proximal canalicular obstructions (Wearne et al 1999;Quaranta-Leoni et al 2020), and patients should by advised that the need of bypassage surgery at a second stage is likely.…”

“…However, mini-invasive positioning of LJT does not exclude the possibility of a dacryocystitis and should be carefully evaluated (Quaranta-Leoni et al 2020).…”