Laceração de canalículo lacrimal em centro de referência do centro-oeste paulista / Lacrimal canaliculus laceration in a reference center in the Center-West of the state of São Paulo

RESUMO Objetivo: Descrever as características clínico-epidemiológicas, técnicas cirúrgicas e resultado do tratamento das lacerações canaliculares operadas em nosso serviço. Métodos: Estudo retrospectivo, realizado de janeiro de 2012 a junho de 2020, considerando-se as lesões de canalículo lacrimal operadas em um serviço de referência. Dados demográficos, características das lesões, detalhes das cirurgias e resultado do tratamento foram obtidos de prontuários eletrônicos e analisados estatisticamente. Resultados: Foram incluídos 26 portadores de lesões canaliculares, com idade entre 2 e 71 anos, sendo 73,1% homens. A lesão acometia o canalículo superior em 53,9%; 80,8% pacientes procuraram pelo serviço nas primeiras 24 horas, e 46,2% tiveram a cirurgia realizada entre 24 e 72 horas após o traumatismo. Todos os pacientes tiveram intubação mono ou bicanalicular, e o tempo transcorrido entre a cirurgia e a retirada do silicone, variou de zero a 183 dias. Após a cirurgia, 21 pacientes (80,8%; p<0,05) não apresentaram complicações, 2 (7,7%) evoluíram com obstrução canalicular, 2 (7,7%) com granuloma e 1 (3,8%) com ectrópio de ponto lacrimal. Conclusão: As lesões de canalículo encontradas em nossa prática são mais comuns em crianças ou homens jovens, acometem mais o canalículo superior e as nossas condutas levam a sucesso no tratamento na maior parte dos casos. As grandes controvérsias no assunto persistem, como o tipo e o tempo de permanência do tubo de silicone na via lacrimal. Somente estudos com grandes amostras podem consolidar esses conceitos.

ABSTRACT Objective: To describe the clinical and epidemiological characteristics, surgical techniques, and results of the canalicular laceration treatment at our service. Methods: A retrospective study was carried out from January 2012 to June 2020, considering canalicular injuries operated at a reference center. Demographic data, lesion characteristics, surgical details, and treatment outcomes were obtained from electronic medical records and were statistically analyzed. Results: Twenty-six cases of people with canalicular lesions aged between 2 to 71 years old were included, of whom 73.1% were men. The superior canaliculus was affected in 53.9%; 80.8% of patients searched for care within the first 24 hours, and 46.2% had the surgery performed between 24-72 hours after trauma. All patients had mono or bicanalicular intubation and the time elapsed between surgery and silicone removal ranged from 0 to 183 days. After surgery, 21 patients (80.8%, p<0.05) did not present any complications, two (7.7%) evolved with canalicular obstruction, two (7.7%) with granuloma, and one (3.8 %) with lacrimal puncta ectropion. Conclusion: In our practice, canalicular injuries are more common in children or young men, affecting mainly the superior canaliculus, and treatment success using our approach can be achieved in most of the cases. However, great controversies remain on the subject, such as type of intubation and when to remove the silicone tube from the lacrimal pathway. Larger series are required to consolidate controversial concepts.

Intraorbital Wooden Foreign Body in a Soldier.

The authors report a case of an intraorbital wooden foreign body that was misinterpreted as a radiolucent area of retained air on a computed tomography (CT) scan. A 20-year-old soldier presented to an outpatient clinic following an impingement with a bough while cutting down a tree. He had a 1-cm-deep laceration on the inner canthal area of his right eye. A military surgeon explored the wound and suspected a foreign body, but could not find or extract anything. Thereafter, the wound was sutured and the patient was transferred. An examination revealed an acutely ill-looking man with distressing pain in the medial canthal and supraorbital area associated with ipsilateral ptosis and periorbital edema. A CT scan showed a radiolucent area suspected to be retained air in the medial periorbital area. The wound was explored. Upon removal of the stitch, yellowish pus was drained. An intraorbital piece of wood measuring 1.5 cm×0.7 cm was extracted. The patient's hospital course was uneventful. Pus culture revealed growth of Staphylococcus epidermidis . Wood has a density similar to air and fat and can be difficult to distinguish from soft tissue both on plain x-ray films and CT. In this case, the CT scan showed a radiolucent area resembling retained air. Magnetic resonance imaging is a better method of investigation in cases of a suspected organic intraorbital foreign body. Clinicians should be aware of the possibility of retention of an intraorbital foreign body in patients presenting with periorbital trauma, especially those with even a small open wound.

Radiological evaluation of lacrimal apparatus injury after functional endoscopic sinus surgery.

OBJECTIVE: To determine the incidence of nasolacrimal duct injury after functional endoscopic sinus surgery radiologically, using computed tomography. METHODS: Fifty patients of either sex who underwent functional endoscopic sinus surgery were evaluated for nasolacrimal duct injury by computed tomography. Computed tomography was conducted pre-operatively, and post-operatively at the end of four weeks, and nasolacrimal duct injury was analysed. RESULTS: The prevalence of nasolacrimal duct injury dehiscence was 1.16 per cent, with a similar incidence of 1.16 per cent for nasolacrimal duct injury post-operatively. However, no cases of symptomatic nasolacrimal duct injury were recorded. CONCLUSION: Computed tomography scan is an effective, non-invasive method to evaluate nasolacrimal duct injury following functional endoscopic sinus surgery, in accordance with evidence-based medicine.

Pattern of Presentation and Surgical Outcomes of Canalicular Laceration Repair in a Pediatric Population.

PURPOSE: To evaluate demographic data, clinical profile, and factors responsible for the success of anatomical and functional outcomes of canalicular laceration repair with the Mini Monoka stent (FCI Ophthalmics) in children younger than 10 years. METHODS: This was a retrospective cohort observational study involving children younger than 10 years who underwent canalicular tear repair with the Mini Monoka stent with a minimum follow-up of 6 months. RESULTS: A total of 18 patients (9 boys and 9 girls) with a mean age of 5.39 ± 3.05 years were included. Twelve and 6 patients had lower and upper canalicular tear, respectively. Six (33.4%) patients had associated ocular comorbidity. The common mode of trauma was direct injury in 77.8% of the patients. The blouse hook of the mother was noted as the most common object causing canalicular laceration. Early repair (< 48 hours) and delayed repair were done in 7 (38.9%) and 11 (61.1%) patients, respectively. Anatomical and functional success was achieved in 88.9% and 94.4% of patients, respectively. The odds ratio (95% CI) for anatomical and functional success with the time since injury was 0.6 (CI: 0.03 to 11.47) and 0.19 (CI: 0.01 to 5.33), respectively. There was no significant difference between the early and delayed repair groups in terms of the distribution of anatomical (P = 1.000) and functional (P = .389) success. There was no significant difference between the various groups in terms of the distribution of complications (P = .224). CONCLUSIONS: Canalicular laceration repair with the Mini Monoka stent in children younger than 10 years has shown good outcomes in terms of anatomical and functional success irrespective of time lag since injury to repair. [J Pediatr Ophthalmol Strabismus. 2021;58(1):42-47.].

Canalicular laceration repair using a self-retaining, bicanalicular, hydrophilic nasolacrimal stent.

Purpose: To evaluate outcomes of primary eyelid and canalicular laceration repair using a self-retaining bicanalicular hydrophilic nasolacrimal stent.Methods: This study is a retrospective review of seven patients with canalicular laceration primarily repaired with a self-retaining bicanalicular nasolacrimal stent within 72 hours of initial injury. After lacrimal intubation, repair was performed by reapproximation of the lacerated tissues. Data collection included ophthalmic examination, mechanism of injury, involvement of upper/lower/common canaliculi, symptoms of epiphora, operative time, stent extrusion and canalicular irrigation.Results: Seven patients with monocanalicular laceration were repaired using the self-retaining bicanalicular nasolacrimal stent. The stent was left in place an average of 5 months. The average operative time was 29.3 minutes. None of the stents extruded prior to removal. After 5 months, the stent was removed successfully without difficulty. All patients reported subjective improvement in epiphora, with complete resolution of symptoms. Anatomic success was confirmed with irrigation in all cases. There were no complications associated with usage of the self-retaining bicanalicular nasolacrimal stent.Conclusions: Primary repair of canalicular lacerations can be successfully performed with a self-retaining bicanalicular nasolacrimal stent. This stent has several advantages, including potentially faster operative times, no need for intranasal fixation or retrieval, easier intubation in the lacrimal system, and improved anatomic reapproximation of lacerated tissues.

Caruncular Dacryops After Cataract Surgery With Histopathological Characterization.

ABSTRACT: Caruncular dacryops is a rare cyst of lacrimal tissue most commonly found in the palpebral lobe of the lacrimal gland. The exact cause of dacryops is unclear, although it may be congenital or associated with trauma, infection, or inflammation. The pathophysiology and histology of a caruncular dacryops of the left lacrimal gland in a 68-year-old woman is reported. The patient presented 3 months after a cataract surgery with symptoms of irritation and pruritus of the left eye. A 6- × 6-mm clear cyst of the lacrimal gland prolapsing into the lateral fornix was noted on physical exam. Histological examination of the cyst showed a double layer of flat cuboidal epithelium surrounded by fibrous tissue with minor lacrimal glands present. Periodic acid Schiff-diastase and mucicarmine staining showed the presence of goblet cells dispersed in the epithelial cells. Complete excision of the cyst is the treatment of choice for most caruncular dacryops, and our case remains without recurrence after excision. This case highlights the clinical and histological presentation of caruncular dacryops and raises awareness of their incidence following presumed trauma during cataract surgery.

Anatomic Danger Zones of the Head and Neck.

BACKGROUND: Dermatologic procedures require a detailed understanding of surface anatomy to avoid complications. The head and neck region has prominent danger zones including nerves and vasculature that may be at risk during cutaneous surgery. A thorough understanding of these danger zones can help avoid complications that may lead to functional or cosmetic impairment. METHODS: The anatomic literature regarding the course of high-risk structures of the head and neck was reviewed. Structures deemed at risk during dermatologic procedures were included in the analysis. The final analysis focused on branches of the facial nerve, parotid duct, spinal accessory nerve, trigeminal nerve, and the lacrimal system. Anatomical information was compiled regarding each high-risk structure to develop a "danger zone" at which each respective structure is at risk. RESULTS: The danger zone for each structure was compiled based on the review of the literature and depicted in the figures. CONCLUSION: With careful attention to anatomy and the meticulous surgical technique, there is great potential for reduction in surgical injury to danger zones of the head and neck.

Annular intubation with pigtail probe for canalicular lacerations.

PURPOSE: Pigtail probe as a procedure of choice for canalicular laceration. METHODS: Retrospective, consecutive interventional case series of patients with eyelid laceration involving the canaliculus undergoing repair. All patients were subjected to repair with pigtail probe as first choice and only if this was not possible, they were repaired by other method. Outcome was analyzed in terms of cosmetic, functional, and anatomic success. RESULTS: A total of 35 patients (mean age, 10.88 years) underwent eyelid and canaliculus repair by a single surgeon (RM). In all, 32 (91.42%) canalicular lacerations were repaired by annular intubation using a pigtail probe, while the remaining 3 (8.58%) lacerations in which pigtail probe intubation was not possible, were repaired by an alternative method. Upper canaliculus was involved in 6 (17.14%) and lower canaliculus in 29 (82.86%) eyes. Mean follow-up was 8.2 months (range 3-13 months). Intubation tubes were removed after at least 3 months (range 12-20 weeks). None of the patients had complaints of epiphora. All the patients had good cosmesis, anatomic alignment and functional success as assessed by dye disappearance test in younger children and lacrimal irrigation in older children and adults. CONCLUSION: Bicanalicular annular repair with pigtail probe achieved excellent functional and cosmetic results. The loop minimizes the chances of extrusion of the tube, maintains natural anatomic alignment of the cut ends of the canaliculus and thus retains the integrity of the delicate canalicular system. Pigtail probe intubation can be considered as the first choice in canalicular lacerations.

Canalicular lacerations in a tertiary eye hospital: our experience with monocanalicular stents.

Introduction: Canalicular injury is commonly encountered in lid trauma. A multitude of techniques and stents are available to manage canalicular lacerations. Monocanalicular stents offer a simple, technically easy and cost-effective solution for managing such cases. Objective: This is a retrospective review of the patients presenting with canalicular lacerations to a tertiary eye hospital from January 2014 to September 2017. We evaluated factors like time of surgery, cause of injury, time of stent removal and their association with the surgical outcome. Additionally, we also reviewed the current data available in literature on the exclusive use of monocanalicular stents for the management of all types of canalicular injuries. Methods: Retrospective patient file review. Results: We evaluated 30 cases of canalicular injuries in 30 patients. The majority of our patients were males (24, 80%), and the mean age was 32.11±15.09 (4-59) years. The mode of injury was road traffic accidents (RTA) in 20 (66.7%), assault with sharp edged weapons in 8 (26.7%) and dog bite in 2 (6.6%) cases. The mean time of repair was 17.2±9.37 (6-36) hours after injury and the mean time of stent removal/ extrusion was 3.5±0.99 (0.5-5) months. The cases were divided based on time of repair i.e., within 24 hours (21 cases) or after 24 hours (9 cases) from the onset of injury. The extrusion rates were 14.3% (3) and 44.4% (4) respectively in the two groups. Our overall anatomical success rate was 86.7% and functional success rate of 76.7%. Conclusions: Overall failure rate was 23.3% (7 out of 30). Delay in surgery (>24 hours) and dog bites were associated with a poorer prognosis of canalicular repair using monocanalicular stents. Abbreviations: FDDT = Fluorescein dye disappearance test, SPSS = Statistical Package for Social Sciences, RTA = Road Traffic Accident.

Laceración palpebral y canalicular asociada a trauma obstétrico. Descripción de un caso / Eye lid and canalicular laceration due to obstetric trauma. Case report

Las lesiones oculares por trauma obstétrico son poco frecuentes. Su incidencia aumenta cuando el parto es asistido con instrumental, cesárea urgente y presentación anómala del feto. Presentamos el caso clínico de un recién nacido pretérmino varón asiático de 33 + 2 semanas, 1.500 g y embarazo gemelar, que nació por cesárea urgente. Se observó una laceración palpebral inferior de 5mm de longitud horizontal en el canto interno del ojo izquierdo con sección del canalículo inferior. Al séptimo día de vida se realizó la intubación con stent monocanalicular Mini-Monoka® (FCI, Issy-Les Moulineaux, Francia), consiguiendo la anastomosis de los extremos proximal y distal de la laceración. La piel se suturó con poliglactínico de 8/0 (Vicryl 8/0, Ethicon, Johnson & Johnson S. A., Madrid, España). El tratamiento postoperatorio fue con colirio de tobramicina y dexametasona 4 veces al día durante 10 días. La evolución fue favorable, la posición del punto lagrimal inferior fue adecuada y la siringación, normal. A las 14 semanas se retiró el Mini-Monoka®

Ocular injuries associated with birth trauma are rare. Their incidence increases in cases of instrument-assisted delivery, emergency cesarean section, and abnormal presentation of the fetus. We present the clinical case of a premature Asian male baby, aged 33 + 2 weeks and weighing 1,500 g. The infant was born out of a twin pregnancy and was delivered by emergency cesarean section. Following delivery, a 5 mm long lower eyelid laceration was observed in the inner corner of the left eye, with injury to the inferior canaliculus. A Mini-Monoka® (FCI, Issy-Les Moulineaux, France) monocanalicular intubation stent was inserted on the seventh day with anastomosis of the proximal and distal ends of the canaliculus laceration. The skin was then sutured with a polyglactin 8/0 (Vicryl 8/0, Ethicon, Johnson & Johnson S. A., Madrid, Spain) suture. The postoperative treatment consisted of tobramycin and dexamethasone eye drops four times per day for 10 days. A good progression was observed, the position of the inferior lacrimal punctum was adequate, and syringation was normal. The Mini-Monoka® was removed after 14 weeks

Eye lid and canalicular laceration due to obstetric trauma. Case report. / Laceración palpebral y canalicular asociada a trauma obstétrico. Descripción de un caso.

Ocular injuries associated with birth trauma are rare. Their incidence increases in cases of instrument-assisted delivery, emergency cesarean section, and abnormal presentation of the fetus. We present the clinical case of a premature Asian male baby, aged 33+2 weeks and weighing 1,500g. The infant was born out of a twin pregnancy and was delivered by emergency cesarean section. Following delivery, a 5mm long lower eyelid laceration was observed in the inner corner of the left eye, with injury to the inferior canaliculus. A Mini-Monoka® (FCI, Issy-Les Moulineaux, France) monocanalicular intubation stent was inserted on the seventh day with anastomosis of the proximal and distal ends of the canaliculus laceration. The skin was then sutured with a polyglactin 8/0 (Vicryl 8/0, Ethicon, Johnson & Johnson S. A., Madrid, Spain) suture. The postoperative treatment consisted of tobramycin and dexamethasone eye drops four times per day for 10 days. A good progression was observed, the position of the inferior lacrimal punctum was adequate, and syringation was normal. The Mini-Monoka® was removed after 14 weeks.

A rabbit model for assessing symblepharon after alkali burn of the superior conjunctival sac.

Symblepharon due to chemical burns affects ocular surface health, and there are currently no satisfactory treatments. To improve our understanding of symblepharon, an appropriate animal model is urgently needed. We established a rabbit model of superior conjunctival sac alkaline burn to evaluate symblepharon severity. Alkali burns were induced in rabbits by contacting the superior conjunctival sac with 2 N NaOH-soaked semicircle filter paper (10 mm diameter) for 60 s, 90 s or 120 s. Clinical and histological features were examined, symblepharon severity was evaluated via conjunctival sac depth (grade I - IV) and volume measurements (grade a-d) post-injury at 4 weeks. With increasing alkali burn duration, corneal perforation and symblepharon severity increased. The 60 s group manifested a sub-conjunctiva scar. The 90 s group featured localized adhesion. The 120 s group was characterized by extensive scar hyperplasia and adhesion. The rabbit model exhibited stable and reliable symblepharon following an alkali burn of the superior conjunctival sac. For further research, 90 s is a suitable duration for conjunctival sac burn. The volume measured using conjunctival sac casting was considered when developing a successful evaluation system for symblepharon severity.

Monocanalicular Stents in Eyelid Lacerations: A Report by the American Academy of Ophthalmology.

PURPOSE: To determine the efficacy and complication rates of monocanalicular stents in the setting of canalicular lacerations. METHODS: A literature search was performed in May 2018 in the PubMed database to identify all English-language reports of monocanalicular stenting to address canalicular lacerations. Studies that did not include at least 10 patients with at least 3 months of follow-up evaluation after surgery were excluded. Ninety-nine articles were identified, and 15 of these met criteria for data abstraction and were included in this assessment. The panel methodologist (V.K.A.) evaluated the quality of evidence and assigned a level-of-evidence rating to each of these studies. RESULTS: All 15 studies were rated as level III evidence. Anatomic and functional success rates after surgery ranged from 68% to 100% and 79% to 100%, respectively. Stents were generally well tolerated, although extrusion rates varied from 0% to 29%. CONCLUSIONS: Only level III evidence was available, and studies were not powered to detect differences between groups for rare complications or failure. Monocanalicular stents seem to be efficacious and well tolerated in the management of canalicular lacerations. Potential complications include extrusion (most commonly), tube displacement, granuloma, ectropion, slit punctum, fistula, and infection. Further comparative studies would help to identify the optimal time for device removal and to directly compare monocanalicular with bicanalicular stents.

[Lacrimal Stenosis after Chemical and Thermal Ocular Burns]. / Tränenwegstenosen durch Verätzungen und Verbrennungen.

BACKGROUND: Chemical or thermal burns of the ocular surface are an urgent ophthalmologic emergency. Consecutive epiphora causes a high level of suffering for affected patients. METHOD: Based on a review of current literature, and our own longstanding experiences, recommendations are given on the treatment of secondary lacrimal duct obstruction due to ocular surface damage after chemical or thermal burns. RESULTS: An initial evaluation of the tissue damage is crucial. Necrotic tissue should be removed. The patency of the lacrimal passage has to be proved in respect. In case of primary involvement of the lacrimal ducts, treatment is necessary. Here, recanalization can be achieved by using conical probes or lacrimal cannulas. Lacrimal intubation has to be performed. Scar formation should be completed if a secondary reconstruction is required. CONCLUSION: Lacrimal stenosis after chemical or thermal burns of the ocular surface is a rare complication. Initial surgical intervention should be performed if primary lacrimal involvement can be ensured. If possible, surgical reconstruction should not be performed prior to 6 months after the trauma.

Laceração palpebral e canalicular neonatal em parto cesárea / Neonatal eyelid and canalicular laceration in cesarean delivery

Resumo Na medicina moderna, lesões traumáticas neonatais durante o parto são raras. Mais raras ainda são as relatadas por ocasião de um parto cesárea. Reporta-se o primeiro caso descrito de laceração palpebral e canicular neonatal em parto cesáreo. Descreve-se o trabalho conjunto de diagnóstico oportuno por parte da equipe de pediatria e a pronta intervenção cirúrgica oftalmológica num caso bem conduzido de laceração palpebral e canalicular à direita. O lactente apresenta-se sem prejuízo funcional permanente durante seguimento pós-operatório.

Abstract In modern medicine, neonatal traumatic injuries during childbirth are rare. More rarely are those during a cesarean birth. That is the first reported case of palpebral laceration and neonatal canicular cesarean section. We describe the joint work of early diagnosis by the pediatric team and the prompt ophthalmologic surgical intervention in a well-conducted case of right palpebral and canalicular laceration. The infant presents without permanent functional impairment during postoperative follow-up.

Ocular Compartment Syndrome and Lateral Canthotomy Procedure.

BACKGROUND: Ocular compartment syndrome (OCS) is a serious ophthalmological emergency that should be diagnosed and treated immediately to prevent permanent loss of vision. It is usually caused by a retro-orbital bleed that will subsequently increase intra-orbital pressure and threaten the patient's vision. Lateral canthotomy and cantholysis is a minor bedside procedure using simple equipment that is readily available in emergency departments, and the aim of such a procedure is to free the eye globe from its lateral attachment to the bony orbital wall and allow more eye protrusion and hence reduce intra-orbital pressure and save the patient's sight. The case we present describes a 42-year-old man who presented with facial injuries following an alleged assault and in whom a computed tomography scan of the head showed a retro-orbital hemorrhage. The patient had subtle signs of increased intra-orbital pressure for which lateral canthotomy and cantholysis was indicated. DISCUSSION: OCS is an ophthalmological emergency that can present with subtle signs of increased intraocular pressure that can lead to irreversible loss of vision if not treated with a simple bedside operation called lateral canthotomy and cantholysis within a specific time frame. We explore the pathophysiology and presentation of OCS and how to perform the lateral canthotomy with cantholysis procedure. CONCLUSIONS: The aim of this case presentation is to highlight the importance of diagnosing OCS as an ophthalmological emergency and discuss how to perform the sight-saving procedure.

Lacrimal Injury After Rhinoplasty: Two Case Reports.

Lacrimal injury is very uncommon after osteotomy in rhinoplasty. We present 2 cases of lacrimal injury after osteotomy in rhinoplasty and present the steps to managing such an injury. These cases were finally treated with endoscopic dacryocystorhinostomy. We concluded that osteotomies must be at least 3 mm from the medial canthus or medial to the line from the medial canthus to the alar base. Also, it is recommended that osteotome blades be sharpened before each osteotomy.