Ali, Mohammad Javed
Purpose: The objective of this perspective is to present a separate disease description of “idiopathic canalicular inflammatory disease” and outline the diagnostic criteria and early experiences with its investigations and management.
Methods: Retrospective case series of 44 canaliculi of 22 eyes of 11 patients presenting at a tertiary care Dacryology service over a period of 2 years with typical clinical patterns of inflammatory canaliculitis and its outcomes were studied. All the patients underwent microbiological work-up with culture and sensitivity, dacryoendoscopy imaging, serial Fourier domain ocular coherence tomography, and collagen vascular profiles. Stages in the evolution of the disease were studied. All patients were treated initially with topical steroids followed by punctal dilatation and placement of mini-monoka stents. Five patients in addition had a small biopsy from the inflamed portion of the vertical canaliculus. Stents were extubated at 6 weeks.
Results: Forty-four canaliculi were diagnosed to have idiopathic canalicular inflammatory disease during the study period. There was a female preponderance (81.8%, 9/11) and the mean age at presentation was 57 years. All patients presented with unilateral epiphora without any discharge, pain, or swelling. Collagen vascular profiles and screening for autoimmune diseases were negative. Clinical picture ranged from stages 1 to 5, consisting of edema, progressive centripetal vascularization, pouting of vascularized mucosa, membrane formation, and progressive scarring. The presentation begins in 1 eye and usually involves the other eye at a mean of 6 months. Ocular coherence tomography and dacryoendoscopy were of adjunctive value in the diagnosis. Histopathological examination was suggestive of a chronic inflammation. All patients had relentless progression to end-stage disease, although delayed significantly by steroids and monoka intubation.
Conclusion: Idiopathic canalicular inflammatory disease has a distinct and typical clinical behavior and the current study proposed diagnostic features and disease staging. The use of topical and systemic immunosuppressive agents needs to be explored to formulate effective protocols for its management.
Singh, Swati; Ali, Mohammad Javed; Mohamed, Ashik
Purpose: To evaluate and compare the outcomes of invasive (rectangular 3-snip punctoplasty) versus minimally invasive (punctal dilatation with monocanalicular intubation) treatment modalities for the management of acquired punctal stenosis.
Methods: A retrospective, comparative, interventional case series was performed on 60 eyes of 36 patients with acquired punctal stenosis. Patients were categorized in 2 groups based on the intervention as 3-snip punctoplasty (group A) and punctal dilatation with monocanalicular intubation (group B). Qualitative and quantitative assessment for epiphora and punctal stenosis grading were performed preoperatively and postoperatively. Patients with associated canalicular and nasolacrimal duct obstructions, congenital punctal disorders, eyelid malpositions, and less than 6 months’ follow up were excluded. Anatomical and functional successes were recorded following stent extubation and at 6-month follow up. Statistical analyses were performed using the chi-square, Fisher exact, and the Mann–Whitney tests. A p value of <0.05 was considered significant.
Results: Ninety-nine puncta of 62 eyes of 36 patients were analyzed. Mean age at presentation was 49 and 50 years in groups A and B, respectively. Bilaterality was noted in 67% (24/36) of the patients. Epiphora was the most common presentation. Involvement of upper punctum was noted in 6% (4/62), lower punctum in 34% (21/62), and both in 60% (35/62) of eyes. At 6-month follow up, the anatomical success rate was 84% (47 out of 56 puncta) in group A, whereas 93% (40 out of 43 puncta) in group B (p = 0.29). At 6-month follow up, restenosis occurred in more number of puncta (n = 9) in group A and only in 3 puncta in group B; however, this was not statistically significant (p = 0.21). No stent-related complications were noted.
Conclusion: Punctal dilatation with monocanalicular intubation achieves comparable outcomes as that of 3-snip punctoplasty in patients with acquired punctal stenosis.
Md. Shahid Alam
Punctal stenosis is an elusive disorder with most of the cases being idiopathic. Antiglaucoma medications, chronic blepharitis, involutional changes, and cicatricial disorders are however some of the recognized causes. It is really disheartening to notice that while there is a plethora of literature on the management of obstruction of the distant lacrimal system, there is a paucity for that of the proximal lacrimal system, including punctal stenosis. Management of punctal stenosis along with other proximal lacrimal system obstruction is challenging, and so far, there is no clear guideline or management protocol…..
Shweta Gupta, Mohammad Javed Ali, Mohammad Hasnat Ali, Milind N Naik
Purpose: The objective of this study was to assess the quality of outcomes of mini-Monoka stent dilatation for punctal stenosis using the lacrimal symptom (Lac-Q) questionnaire. Methods: Prospective interventional case series of 45 eyes of 25 consecutive patients who underwent mini-Monoka stent dilatation for primary punctal stenosis were included in the study. The stents were extubated at 4 weeks. The Lac-Q questionnaire was administered preoperatively and at 12 weeks and 24 weeks following the intervention. Outcomes assessed were anatomical success, functional success, and changes in the questionnaire scores including total, social impact, and lacrimal symptom scores. Statistical analysis was performed using the Wilcoxon signed-rank test, and the probability of obtaining a certain score was calculated using the multinomial log-linear model. P < 0.05 was considered as significant. Results: Monoka stents were performed for 45 eyes. A total of 75 questionnaire responses were analyzed. At the last follow-up of 24 weeks, the anatomical and functional success rates were 93.3% (42/45). The changes in the mean total score (7.68 preoperatively to 0.82 at 24-week follow-up) were statistically significant (P ≤ 0.001). The mean social impact scores showed significant improvement postoperatively from 4.06 to 0.53 (P ≤ 0.001). The mean lacrimal symptom score changed from a preoperative value of 3.62 to 0.28 (P ≤ 0.001) at the last follow-up. Postoperative scoring correlated well with the anatomical and functional success rates. The symptom scores corroborated with changes in the clinical outcomes. Conclusion: Mini-Monoka stent dilatation is a very effective intervention for the management of primary punctal stenosis, and Lac-Q questionnaire is a simple and useful tool to evaluate the quality of outcomes in such cases.
Md. Shahid Alam, Neha Shrirao Mehta, Bipasha Mukherjee
To evaluate the anatomical and functional outcomes of canalicular laceration repair with self retaining monocanalicular intubation system (Mini-MONOKA).
Materials and methods
The data of 29 patients undergoing canalicular laceration repair from 2010 to 2014 were retrospectively analyzed. Operative details and complications were noted. The stent was removed earliest at 3 months. Anatomical and functional success was defined by a patent syringing and the absence of epiphora respectively.
Out of 29 patients, 23 (79.3%) were males. Mean age at presentation was 19.3 ± 13.8 years. Lower canaliculus was involved in 19 (65.5%), upper in 8 (27.5%) and both canaliculi in 2 (6.8%). Ten patients presented later than 11 days after trauma (range 12–168 days), and repair was attempted successfully in all.
Fourteen (48.2%) cases reported for stent removal, at a mean follow-up period of 4.64 ± 2.12 months. Anatomical success was noted in 12 (85.71%) and functional success in 13 (92.85%) cases. Four patients had stent related complications.