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a b
Fig.16.3 Mucocoele expression. a place a finger against the side of the nose medially to the
mucocoele. b While maintaining firm pressure against bone, roll the finger slowly onto the swelling
towards the medial canthus
life without other intervention. Perform sac expression by placing a finger against
the side of the nose just medially to the mucocoele (Fig. 16.3a). While maintaining firm pressure against bone, roll the finger slowly onto the swelling towards
the medial canthus (Fig. 16.3b). Successful expression causes the mucocoele to
disappear temporarily.
16.4.2 Lacrimal Probing (± Silicone Intubation)
16.4.2.1 Paediatric Probing
Lacrimal probing is indicated in symptomatic children whose mucocoele and
watering have not resolved on expression alone during the first year or two of
life. It requires a general anaesthetic but has a high success rate. Should the first
probing fail to cure the child the second attempt should include nasal endoscopic
control to confirm that the probe enters into the nose below the inferior turbinate.
The second probing may be combined with the insertion of temporary silicone
stents which are left in place for about two months (e.g., Nunchaku tubes®, FCI
info@fci-ophthalmics.com).
Principle
Pass a smooth, blunt ended, probe through the lacrimal drainage passages to
establish the site of any obstruction and possibly overcome it.
Steps
This technique is similar to lacrimal syringing up to the point of lacrimal sac entry.
1. Pull the lid laterally to straighten the canaliculus. Dilate the lacrimal punctum
with a punctum finder-seeker, twirling it between your fingers as you push
(Fig. 16.4a). The lid margin tension provides counter pressure to the punctal
dilator.
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a
c
b
00
d
00
e
00
Fig.16.4 Lacrimal Probing. a Pull the lid laterally to straighten the canaliculus. Dilate the
lacrimal punctum with a punctum finder-seeker. b Keeping the lid on lateral stretch insert a Bowman 00-gauge lacrimal probe into the punctum perpendicularly. c Keeping the tip of the probe
in the canaliculus rotate the probe laterally through 90°. d Advance the probe gently along the
canaliculus until you reach a firm stop. e While maintaining gentle forward pressure on the probe,
release the lid traction and rotate the probe’s axis 90° nasally to advance it into the nasolacrimal
duct. Continue pushing the probe downwards until you reach an obstruction or encounter the floor
of the nose (another ‘hard stop’)
2. Keeping the lid on lateral stretch insert a Bowman 00-gauge lacrimal probe into
the punctum perpendicularly (Fig. 16.4b).
3. Keeping the tip of the probe in the canaliculus rotate the probe laterally through
°
(Fig. 16.4c).
90
4. Advance the probe gently along the canaliculus until you reach a firm stop
(Fig. 16.4d). A so called ‘hard stop’ confirms that the tip has entered the
lacrimal sac and is hitting the medial sac wall which lies on nasal bone. A ‘soft
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stop’ is when the probe springs back slightly when you release it. It means
that the probe tip has encountered a fibrous obstruction within the canaliculus
and has yet to enter the sac. If you encounter a soft stop abandon further probing. You have localized a pre-sac obstruction, though it may not be the only
obstruction in the drainage system.
5. While maintaining gentle forward pressure on the probe to keep it against the
medial sac wall, release the lateral lid traction and rotate the probe’s axis 90
nasally to advance it into the nasolacrimal duct (Fig. 16.4e). Do this gently to
avoid creating a false passage.
6. Continue pushing the probe downwards until you reach an obstruction or
encounter the floor of the nose (another ‘hard stop’). A novice may find it
difficult to distinguish between the two. Now apply more force to the probe. A
membranous obstruction will give, and you will feel the probe tip advance to
the nasal floor.
Note: Probing may be combined with nasal endoscopy to confirm nasal entry of
the probe. However, nasal endoscopy requires skill and should not be undertaken
without training.
16.4.2.2 Adult Probing
Lacrimal probing in adults has a low success rate as a treatment. It has been
reported to succeed in 50% of cases when combined with silicone intubation,
but only where no bony resistance is encountered in the nasolacrimal duct during probing. However, probing is sometimes helpful in confirming the site of an
obstruction. Carry it out under general anaesthesia as adequate local anaesthesia
of the entire drainage pathway is difficult to achieve.
o
16.4.3 Punctal Stenosis
A stenosed punctum is one that will not admit a 26 G lacrimal canula without
dilatation. As dilatation with a punctum dilator/seeker has only a very temporary
effect on patency use one of the more effective remedies below.
16.4.3.1 Perforated Punctum Plug (Fig. 16.5)
The most elegant solution for enlarging a stenosed punctum is to stent it for two
months with a perforated punctum plug (FCI S.A.S.–Chirurgie Instrumentation,
20–22 rue Louis Armand, 75,015 PARIS–France). This is done under topical
anaesthesia alone, does not damage the integrity of the punctal fibroelastic ring
and allows some passage of tears while in place to discourage post-plug membrane
formation.
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Fig.16.5 Perforated
punctum plug.
Polyvinylpyrrolidone surface
modified silicone stent (to
improve wettability)
Steps
1. Anaesthetise the eye with a drop of Proxymetacaine Hydrochloride 0.5%.
2. Place a small cotton wool pledget on the medial canthus, soak it with proxymetacaine and push it into the lower fornix behind the lower punctum, using
the tip of the Minims® container. Wait several minutes for complete anaesthesia
before removing the pledget.
3. Get the plug ready for insertion by opening its sterile packet.
4. Dilate the punctum with a punctum dilator/seeker, entering perpendicularly and
then angling the dilator laterally while twisting and pushing it medially. Do this
slowly to avoid tearing the fibrous ring.
Note: The punctum plug introducer has a punctum dilator at the other end.
However, the taper on this is too short to make it useful.
5. Remove the dilator and insert the plug without delay as the fibrous ring will
contract again rapidly.
6. After confirming correct insertion of the plug, remove the plug introducer by
squeezing it. The plug should sit flush with the lid margin.
7. Remove the plug after 2–3 months under topical anaesthesia by pulling it out
with Moorfields forceps. The punctum remains enlarged.
Note: The punctal stenosis may return after several years. The stenting treatment
can be repeated if this happens.
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Fig.16.6 Nunchaku
Lacrimal intubation. Silicone
stenting tubing on introducer
stylets
16.4.3.2 Lacrimal Intubation (Fig. 16.6)
Lacrimal intubation with a silicone tube is also an effective form of stenting for
punctal stenosis but is more invasive and requires a general anaesthetic. Several
types of tubes are available. The self-retaining Nunchaku® tubes (FCI) are particularly easy to place and remove and are self-adjusting. The technique for inserting
these tubes is the same as for lacrimal probing (above) with one added step. Once
the tube on its introducer stylet is correctly positioned, grasp the stylet loosely
with Moorfields forceps, just above the silicone tube. Use the forceps to prevent
the tube from coming out as you withdraw the stylet.
An alternative form of intubation is to insert a self-retaining monocanalicu-
lar stent (e.g., LacriJet® FCI S.A.S.–Chirurgie Instrumentation, 20–22 rue Louis
Armand, 75,015 PARIS–France). However, such punctum plug retained stents do
not allow tear drainage while in place.
16.4.3.3 Punch Punctoplasty (Fig. 16.7)
This procedure is simpler and safer to perform than the previously popular, now
hopefully obsolete, ‘three snip punctoplasty’ which it replaces. The latter is nolonger recommended as it damages the capillary action of the canaliculus. But
even a punch punctoplasty causes damage to the punctal fibroelastic ring. It has
not been shown to be superior to stenting alone.
Steps
1. Anaesthetise the eye with a drop of Proxymetacaine Hydrochloride 0.5%.
2. Place a small cotton wool pledget over the medial canthus and push it in
place just behind the punctum and soak it using the tip of the proxymetacaine
Minims® container. Wait a few minutes for complete anaesthesia.
3. Dilate the stenosed punctum and select the punctal wall to be removed. Choose
the posterior wall if there is a slight punctal ectropion. If there is punctal entropion remove the anterior wall instead. A normally positioned punctum can be
enlarged medially.
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a
c
Fig.16.7 Punch punctoplasty. a Open the punctum with a finder/seeker probe. b Use a punctum
dilator to enlarge the punctum. c Use a Kelly’s punch to punch out one of the walls of the vertical
portion of the canaliculus
b
4. Withdraw the punctum dilator and immediately insert the tip of a Kelly trabeculectomy punch into the canalicular ampulla before the fibroelastic ring has
time to contract again. Punch out the chosen punctal wall.
16.4.4 Punctal Inversion Surgery (Fig. 16.8)
Age related punctal ectropion is common. It used to be corrected by retropunctal cautery or ‘tarsoconjunctival diamond excision’. To achieve correction
using cautery an effective symblepharon must be created. This is undesirable as it
limits independent movement between the eye and lid. Tarsoconjunctival diamond
excision is futile for two reasons. Firstly, there is next to no tarsal plate below the
punctum worth excising. Secondly, excising conjunctiva achieves nothing as it is
too elastic to add inward traction.
Lower lid retractor plication to the sub-punctal tarsal plate on the other hand is
an effective alternative. It provides an active inward pull and is the mechanism by
which retro-punctal cautery and diamond excision work on the occasions that they
do.
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16.4.4.1 Steps
1. Make a short horizontal conjunctival incision 3–4 mm below the punctum, just
inferior to the medial end of the tarsal plate (Fig. 16.8b).
2. Grasp and pull on the inferior conjunctival incision edge with Moorfields forceps. Insert closed scissors immediately under the conjunctiva and advance
them infero-laterally by 10 mm. Open the scissors and withdraw to bluntly
dissect a subconjunctival pocket from the incision to the middle of the inferior
fornix (Fig. 16.8c).
a b
c
e
Fig.16.8 Punctal inversion surgery. a Punctal ectropion. b Make a horizontal conjunctival inci-
sion below the punctum. c Bluntly dissect a subconjunctival pocket. d Engage the retractors with an
absorbable suture, bring the needle out through the inferior edge of the tarsal plate below the punctum and re-insert it through the lower conjunctival edge. e Tie the suture tightly in the wound to
bury the knot. f The retractors pull the punctum inwards on down-gaze. The suture knot is burried
d
f
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3. While still holding and gently stretching the conjunctiva, insert a pair of Jayles
forceps into the pocket and grasp the lower lid retractors (found just anterior
to the conjunctiva). Confirm that you have grasped the retractors by asking the
patient to look down as far as possible. You should feel a tug on your forceps.
4. Ask the patient to look up while you pull the retractor aponeurosis out of the
wound sufficiently to engage it with a 6/0 absorbable suture (Fig. 16.8d).
5. Bring the retractor suture needle out through the inferior edge of the tarsal
plate below the punctum (Fig. 16.8e). Then re-insert the needle through the
lower conjunctival edge, so that when tied the knot is buried.
6. Tie the suture tightly in the wound to bury the knot (Fig. 16.8f). This plicates
the retractor directly to the posterior lamella below the punctum. From now on
every time the patient looks down the retractors pull the punctum inwards.
16.4.5 Lid Margin Tightening
Watering from mild punctal ectropion may simply be a result of lower lid laxity. In
this case (and after other possible explanations have been excluded) full thickness
lid margin shortening (lateral Bick resection—Chap. 8) can cure the watering.
16.4.6 Lacrimal Drainage Surgery
Full surgical details of lacrimal drainage surgery are beyond this book’s remit and
can be found in other texts. Here I shall only outline the factors that promote
success.
16.4.6.1 Dacryocystorhinostomy (Fig. 16.9)
The gold standard lacrimal bypass surgery is an external dacryocystorhinostomy
[2] (DCR). Its success rate is upwards of 90% if the obstruction is beyond
the lacrimal sac (within the nasolacrimal duct). The role of concurrent silicone
intubation in DCR remains uncertain. Factors that promote DCR success are:
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a b
c d
Fig.16.9 Dacryocystorhinostomy (DCR). Crosshatched bone is removed a to connect the sac
directly to the nose b, making the lacrimal sac part of the nasal wall. This bypasses the blocked
nasolacrimal duct. c Additionally, the crosshatched scarred common canaliculus is excised to convert a DCR into a Canaliculo-DCR (CDCR). d When not enough functioning canaliculus is present
insert a glass bypass tube between the medial fornix and the nose
•
Adequate haemostasis
•
Creating a large bony ostium that spans the entire lacrimal sac bed
•
Complete opening of the lacrimal sac top to bottom
•
Suturing both the posterior lacrimal and nasal mucosal flaps to each other as
well as the anterior flaps.
The aim of the surgery is to lay fully open the lacrimal sac and make it part
of the lateral wall of the nose (Fig. 16.9b) so that the sac as such ceases to exist.
Surgical failures are usually due to not achieving the above aims. Mucosal scar
contraction can result in partial or complete reformation of the lacrimal sac. The
other cause of failure is pre-existing or surgically induced lacrimal canalicular
scarring resulting in pre-sac obstruction and persistent symptoms. Endonasal DCR
techniques are gaining popularity and in some hands the results equal those of the
external approach. However, achieving the goals outlined above is more difficult
via the limited endonasal access.
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16.4.6.2 Canaliculo-Dacryocystorhinostomy (CDCR)
Where the site of drainage obstruction is before the sac, and 8 mm of proximal canaliculus is patent, the stenosed portion of the canaliculus can be resected
(Fig. 16.9c). Perform a standard DCR but in addition probe the canaliculi and
excise the stenosed portion. Then anastomose the cut ends of the canaliculi to the
lateral sac wall and intubate the system.
16.4.6.3 Trans-Canalicular Endoscopic Surgery
The advent of ever smaller endoscopes has made trans-canalicular endoscopic
surgery possible. Its place in routine lacrimal surgery remains to be established.
16.4.6.4 Lester-Jones Lacrimal Bypass Tube
When the canaliculi are insufficiently long for a CDCR the only remaining option
is to bypass the drainage system completely with a Pyrex glass tube inserted
between the medial conjunctival fornix and the nose (Fig. 16.9d). This can give
very good symptomatic relief. However, it is an option of last resort as it commits
the patient to lifelong follow up and tube maintenance. These tubes are prone to
block with mucus and frequently become displaced (inwards or outwards).
16.4.6.5 Dacryocystectomy
Surgical removal of an infected lacrimal sac (dacryocystectomy) is an option for
patients suffering recurrent dacryocystitis who are unfit for a DCR as it may be performed under local anaesthesia. It prevents further infections but does not address
any watering issues. It is also indicated for the removal of lacrimal sac tumours.
16.5 Take Home Message
•
Watering of the eyes has multiple possible causes.
•
It significantly affects quality of life.
•
Accurate assessment is key to the correct management.
References
1. Kallarackal GU, Ansari EA, Amos N, Martin JC, Lane C, Camilleri JP (2002) A comparative
study to assess the clinical use of Fluorescein Meniscus Time (FMT) with Tear Break up Time
(TBUT) and Schirmer’s tests (ST) in the diagnosis of dry eyes. Eye (Lond) 16(5):594–600.
https://doi.org/10.1038/sj.eye.6700177. PMID: 12194075
2. McNab AA (1994) Manual of Orbital and Lacrimal Surgery Hardcover. Churchill Livingstone
ISBN 0–443–04791-x
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