Primary Lacrimal Canaliculitis with clinically detected concretions: One-snip punctoplasty with lateral canaliculotomy vs. punctum sparing canalicular curettage.

PURPOSE: To compare two distinct surgical techniques in the management of chronic Primary Lacrimal Canaliculitis (PLC) with clinically detectable concretions. MATERIALS AND METHODS: Inclusion criteria: Patients presenting with symptoms consistent with the diagnosis of primary lacrimal canaliculitis (PLC) with ocular involvement were gathered. Gomori-Grocott Methenamine Silver test was used for concretion staining. Two groups were identified based on the surgical technique. Group A consisted of patients who underwent a punctum sparing canalicular curettage using a chalazion curette, while the patients in Group B underwent one-snip punctoplasty with lateral canaliculotomy. Failure was defined as recurrence of the initial symptoms at any time (ocular and canalicular inflammation with purulent discharge and pouting punctum). The results were analyzed by comparisons using a Fisher's exact test. RESULTS: Ninety-six consecutive patients (96) with a confirmed diagnosis of PLC underwent surgical treatment between 1987 and 2017. Data were collected and divided based on the surgical technique discussed above (Group A and B). Group A: 51 cases with a mean follow-up time of 22 months [1-224] presented with a mean age of 51.5 [25-83] and a surgical failure rate of 19.6%. Group B: 45 patients with a mean follow-up time of 27 months [1-176], a mean age of 68 [17-87] years and a surgical failure rate of 4.4%. Statistical significance was demonstrated, with a p-value of 0.033, odds ratio (OR) of 0.1936 and Standard Deviation (SD) at a 95% confidence interval of [0.0195-0.9885]. CONCLUSIONS: One-snip punctoplasty with lateral canaliculotomy is a simple, fast and effective procedure that allows better anatomical visualization intraoperatively and is thus shown to be statistically superior to punctum sparing canalicular curettage using a chalazion curette.

Preloaded Monoka (Lacrijet) and congenital nasolacrimal duct obstruction: Initial results.

STUDY OBJECTIVE: To study the performance of a pre-loaded Monoka stent in the management of congenital nasolacrimal duct obstruction (CNLDO). STUDY DESIGN: Non-randomized study of consecutive cases. MATERIALS AND METHODS: A preloaded classic Monoka silicone stent contained entirely inside its introducer (Lacrijet) was used to treat a consecutive series of subjects with CNLDO over an 11-month period (May 2019-March 2020). Only subjects with chronic symptomatic CNLDO were included. Subjects with intermittent tearing, canalicular pathology, trisomy 21, facial cleft, or history of lacrimal surgery were excluded. Intraoperative findings were recorded, including the degree and location of the nasolacrimal obstruction, successful metal to metal contact with the probe, any difficulties encountered by the Lacrijet device itself, procedure duration, tolerability of the fixation punctal plug, and finally, inspection of the stent after withdrawal of the inserter. Functional success was defined as disappearance of all symptoms of epiphora. RESULTS: A total of 45 preloaded Monoka Lacrijet stents (Lcj) were placed consecutively in 38 children. The mean age was 27.9 months (12-78 months). The mean procedural duration was 2.8minutes (range: 1-10min). The overall success with disappearance of all symptoms of epiphora was 88.8% (40/45). Surgery in cases of simple mucosal stenosis was successful in 92.2% (35/38) of cases, with a mean follow-up time of 7.9 months (range: 1 to 12 months). The duration of stent intubation was for this group was 32 days (range: 1-103). The surgical outcomes for the other 7 cases with more complex intraoperative findings are summarized in the publication. All withdrawn probes were intact. CONCLUSIONS: The Lacrijet stent system is a simple and reliable pushed intubation device for CNLDO in appropriately selected cases where bony stenosis of the canal is minimal.

Pediatric endonasal dacryocystorhinostomy and operative standardization.

OBJECTIVE: The objective of this study was to confirm that the standardized endonasal dacryocystorhinostomy (DCR) technique routinely performed in adults can be used in children. MATERIALS AND METHODS: A consecutive series of children undergoing endonasal DCR between 2003 and 2017 was analysed. The surgical procedure consisted of: preoperative CT scan, anatomical localization of the ideal surgical zone, access to the nasal cavity via an optional planned enlargement, creation of a mucoperiosteal flap, osteotomy with rongeurs and equatorial resection of the medial wall of the lacrimal sac. This pediatric series was compared to a series of adult patients operated according to the same standardized technique. RESULTS: A total of 20 DCRs (17 patients, with a mean age of 8 years (range: 4-16)) were included. Anatomical localization was effective in 100% of cases without the need for transillumination. With a mean follow-up of 4 years, the success rate was 95%, and no major complications were observed. Comparison with the same surgical technique in adults revealed similar results. DISCUSSION: Our experience suggests that standardized endonasal DCR can be adapted to the nasal cavities of children. Anatomical localization is effective. The physiologically narrow nasal cavity does not constitute a major obstacle with the use of slightly smaller instruments. The results and complications are similar to those observed in adults. CONCLUSION: The same standardized endoscopic endonasal DCR surgical technique can be used in adults and children with a similar good success rate.

Insertion of a preloaded Monoka™ stent for congenital nasolacrimal obstruction: Intraoperative observations. A preliminary study.

STUDY OBJECTIVE: To study the intraoperative deployment of a pre-loaded probe for a "pushed" monocanalicular nasolacrimal intubation. STUDY DESIGN: Non-randomized study of consecutive cases. MATERIALS AND METHODS: Description: A classical Monoka™ silicone stent with the silicone tube attached at right angles to the punctal plug is contained entirely inside an introducer connected to a piston. Insertion: The procedure begins with intubation of the nasolacrimal duct with the metallic introducer. Traction on the piston retracts the metallic introducer inside the handpiece. This relative shortening progressively ejects the stent, starting with its free end at the bottom of the introducer. The operation was observed endoscopically under single-blind conditions. RESULTS: Twenty-eight preloaded Monoka™ stents were placed consecutively, in 28 congenital nasolacrimal duct intubations in 22 patients (28 sides). Endoscopic examination showed that the free part of the stent was progressively ejected from the introducer during retraction of the piston. Insertion of this pushed stent into the nasal cavity was effective in 23/28 cases (82.1%). A total of 28 preloaded stent insertions were attempted and 23 were correctly deployed. DIFFICULTIES ENCOUNTERED: At the end of nasolacrimal duct intubation, contact between the punctal plug and the lacrimal punctum was problematic in four cases (4/28=14.2%). At the beginning of stent placement, premature ejection of the punctal plug within the end of the introducer occurred in five cases (5/28=17.8%). These five stents failed to insert properly into the nasal cavity. At the end of insertion, retention of the punctal plug in the introducer occurred in two cases (2/28=7.1%). COMPLICATIONS: No cases of intraoperative or postoperative epistaxis were observed. CONCLUSIONS: Intraoperative nasal endoscopy validated the concept of the preloaded Monoka stent and its deployment. Reproducibility and improved reliability may require a change in stenting technique and a design modification.

Intralacrimal migration of Masterka® stents.

BACKGROUND: Tearing and conjunctivitis in children are commonly due to lacrimal drainage system obstruction. Congenital nasolacrimal obstruction is a common pathology treated by probing with or without silicone stent insertion, depending upon the age of the child. The silicone stent is self-retaining and placed for at least one month. Masterka® is a recent version of Monoka®, which may lead to the same surgical complications, such as intralacrimal migration. SUBJECTS AND METHODS: The medical records of two patients surgically treated with the Masterka® probe for nasolacrimal duct obstruction, who developed intralacrimal migration of the stent, were retrospectively reviewed and analyzed. A 41-month-old child and an 18-month-old child presented with disappearance of the silicone tube after 7 days and 2 years respectively. In the first case, the tube migrated completely within the lacrimal system and became externalized through the nose at 2 years, while in the second case, the Masterka® was retrieved through a canalicular approach. In both cases, infants had no further tearing. DISCUSSION: The frequency self-retaining stent disappearance is estimated at 15%. Among these cases, intralacrimal migration is only reported in 0.5% of cases. To prevent intralacrimal migration, the surgical technique must follow a certain number of rules. Management, based on residual epiphora, is discussed. CONCLUSION: Prevention of intralacrimal migration of self-retaining stents involves a rigorous analysis of the relationship between the meatus and the fixation head at the time of placement. After lacrimal intubation, scheduled monitoring is necessary to screen for stent disappearance. Management is based on clinical findings, anterior rhinoscopy and even exploratory canaliculotomy.

Acquired fistula of the lacrimal sac and laisser-faire approach. Description of the natural history of acquired fistulas between the lacrimal sac and the skin occurring before planned endonasal dacryocystorhinostomy (DCR) and without any treatment of the fistula.

INTRODUCTION: The formation of a fistula between the lacrimal sac and the skin is a classic outcome of resistant lacrimal sac abscesses. There is currently no consensus about treatment in such cases. The goal of this study was to describe the natural history of acquired fistulas between the lacrimal sac and the skin, occurring before planned endonasal dacryocystorhinostomy (DCR) and without any treatment of the fistula. MATERIALS AND METHODS: This prospective study was only descriptive and included patients between 1999 and 2012. The patients included were adults with a nasolacrimal duct (NLD) obstruction that was planned to be treated with endonasal DCR. A resistant lacrimal sac abscess appeared a few days before the planned surgery, and fistulized spontaneously despite medical treatment. The surgery was not delayed. The DCR was endoscopic. Nothing was done for the fistula. Its healing was spontaneous. The exclusion criteria were the following: congenital fistulas, post-traumatic and/or iatrogenic fistulas, fistulas which had regressed by the day of the surgery, postoperative follow-up less than 5 months, post-traumatic and/or iatrogenic fistulas, any history of previous DCR or any other lacrimal surgery, children. RESULTS: Twenty adults (25 cases) were included in the analysis. Mean age was 79 years old (from 41 to 90). The mean follow-up was 41 months (from 5 to 108 months). The fistula spontaneously disappeared in all cases, less than one month after it had appeared and in a permanent fashion. No unsightly scar developed. DISCUSSION: Spontaneously acquired fistulas between the lacrimal sac and the skin may occur in the natural course of abscessed acute dacryocystitis. Our study showed spontaneous healing of the fistula post-endoscopic DCR. CONCLUSION: Fistula excision in fistulous acute dacryocystitis does not seem essential to its healing. The laisser-faire approach appears adequate for aesthetic outcomes as well as for functional outcomes of DCR.

[Mastering endonasal dacryocystorhinostomy]. / Comprendre la dacryocystorhinostomie par voie endonasale.

A persistent, symptomatic lacrimal duct stenosis is treated by dacryocystorhinostomy (DCR), with external (EX) or endonasal (EN) access. The basic indication is the same in all cases and either route can be used. The EX route seems better in terms of speed of surgery, learning curve and cost. It is logical to use the external route to treat the disorder when it is associated with a lacrimal sac diverticulum, an irreducible stenosis of the union canal, or a canthopexy. The EN route has been shown to be worth consideration whenever there is a nasal sinus disorder that can be repaired at the same time. Moreover, it is indicated in a rare case of lacrimal abscess that cannot be treated medically, where the risk of scarring would contraindicate standard surgery, or when DCR is recurrent. A series of prospective randomized studies is needed to determine whether the route materially influences the outcome. Until then, it is best to have both methods available for an unbiased case-by-case decision.

[Value of mono-canalicular probes fixated to the meatus]. / Intérét des sondes monocanaliculaires à fixation méatique autostable.

Description of monocanaliculonasal and true monocanalicular intubation. The authors describe the advantages and indications of these methods.

[Is the uncinate process resection the key to endonasal dacryocystorhinostomy?]. / L'unciformectomie est-elle la clef de la dacryocystorhinostomie par voie endonasale ?

Endonasal dacryocystorhinostomy is technically more difficult than the classic method and apparently less rational. The nasal fossa is a variable and potentially dangerous anatomic region. The uncinate process "opens the door" to the middle meatus and covers, in almost all cases, the junction between the lacrymal bone and maxillary concha. A marker almost always found. Uncinate process resection is a natural way to access the lacrymal apparatus. Associated with transillumination of the lacrymal duct, uncinate process resection, is in our opinion, a reliable and, most importantly, reproducible method for an endonasal approach to the lacrymal sac. With resection, endonasal dacryocystorhinostomy becomes a simple, safe and rapid procedure.

[Bilateral hidrocystoma of the median canthus. Apropos of a case]. / Hidrocystome bilatéral de l'angle interne des paupières. A propos d'une observation.

Cystic lesions of the eyelids are not uncommon and are variable in nature. A case report of a 42-year-old male patient is detailed. A bilateral cystic lesion was clearly visible at both medial canthuses. Surgical resection was performed under local anesthesia, followed by histopathological study of the specimens. This revealed that these lesions were hidrocystomas, of probable eccrine origin. As many different cystic lesions may be encountered on the eyelids (dermoid cysts, epidermic cysts, cystic basal cell carcinomas...), routine histopathological study of surgically removed cystic specimens is mandatory to obtain an accurate diagnosis.

[Transient internal palpebral inocclusion after dacryocystorhinostomy]. / Inocclusion palpébrale interne transitoire après dacryocystorhinostomie.

The authors report two cases of postoperative lagophthalmos immediately following ab externo dacryocystorhinostomy (DCR). Two female patients, aged 67 and 62 years, underwent under general analgesia for chronic dacryocystitis with mucocele. An inferior surgical approach, sparing the inner canthal ligament was chosen in both cases.

[Internal transient palpebral inclusion following dacryocystorhinostomy]. / Inocclusion palpébrale interne transitoire après dacryocystorhinostomie.

The authors report two cases of postoperative lagophthalmos immediately following ab externo dacrycystorhinostomy (DCR). Two female patients, aged 67 and 62 years, underwent under general analgesia for chronic dacryocystitis with mucocele. An inferior surgical approach, sparing the inner canthal ligament was chosen in both cases. Lagophthalmos was observed on the operated side on the first postoperative day. Normal lid occlusion was present on the contralateral side. Impairement of palpebral occlusion was predominant in the nasal portion of the lid fissure. Upon voluntary and reflex blinking, a reduction in the downward movement of the superior lid was observed. This reduction was not as apparent when the patients were asked to produce a forced blink. Lagophthalmos disappeared progressively over 3 postoperative months in both cases. Neither epiphora nor any corneal complications were observed. Lagophthalmos following DCR via an inferior approach is a previously unreported complication and may be related to the disinsertion of the nasal portion of the orbicularis muscle and periosteum at the time of periosteal cleavage. Recovery of normal lid function may be due to reattachment of the periosteum.

[Endonasal dacryocystorhinostomy (DCR) with protected drill]. / Forage osseux protégé lors des dacryocystorhinostomies (DCR) par voie endo-nasale.

PURPOSE: To analyze the interest of protected drills to perform endoscopic endonasal DCR. MATERIAL AND METHODS: [corrected] Fifty patients suffering from chronic epiphora were operated successively. None of those patients had had prior nasal surgery. The same surgeons (BF and ER) did the surgical procedure for all the cases. The technical steps were: endoscopic visualization of the middle meatus and evaluation of the anatomic variations of the nose; identification of the lacrymal bag with a 1 mm light in the canaliculus; unciformectomy; the maxillary bone was drilled with a 3.2 mm bit (straightshot Xomed), protected and irrigated; the lacrymal bag was opened by cissors and the flap was pushed in the ethmoid and coagulated. RESULTS: The suction-irrigation system was efficient to clean the surgical site, with a good endoscopic control. The protected bit didn't damage the 4-mm optics and the septal wall mucosa, even in narrow noses. The staightshot bit (Xomed) was tough enough to drill the maxillary bone in only 68 % of the surgical cases. In 28 % the drilling was unsatisfactory and in 4 % it was inefficient. The functional results at 6 month were good in 85 %. There was no difference between normal and narrow noses. CONCLUSION: The concept of protected bits perfectly matches the endoscopic endonasal DCR. The visual comfort and security of the surgical procedure are increased. Short term results are equivalent to external DCR, but are rather inefficient and expensive.

[Recent wounds of the lacrimal duct. Apropos of 262 cases treated as emergencies]. / Contribution à l'étude des plaies récentes des voies lacrymales. A propos de 262 cas traités en urgence.

From 1982 to 1987, surgery was performed in emergency in 262 patients on lacrimal ducts at the Hotel Dieu Hospital in Paris. The retrospective study of these cases and the comparison with the conclusion of the report of the French Society of Ophthalmology about the lacrimal apparatus (1980) can allow us a few conclusions. The first cause is assault in a 30 year old man, with a left lower canaliculus wound, and 20% of the cases an eye-penetrating wound. With the current use of safety belts, car-related injuries have become the second cause. Children are often bitten by family dogs. Upper lacrimal drainage wounds are associated in 40% of the cases with eye-penetrating wound, and must be repaired. Complications of intubation are: disappearance of silicone tubing 5%; loop retraction: 8%; slit canaliculus: 16% of the cases. This last complication becomes rarer with surgical experience. Concerning nasolacrimal intubation versus pig-tail probe, statistical results lead us to prefer the first technique.

[Surgical treatment of eye wounds with retinochoroidal metal foreign bodies. Apropos of 6 cases]. / Traitement chirurgical des plaies du globe avec corps étrangers métalliques rétino-choroïdiens. A propos de six cas.

Six cases of intra-ocular metallic foreign bodies located into the retino-choroidal wall are presented. A surgical treatment was performed, and included a vitrectomy, a foreign body extraction with intraocular forceps, a primary or a secondary scleral buckling for the peripheral wound, and a retino-choroidectomy for one of the posteriorly located foreign bodies. In all the cases, we observed a cicatricial retraction of the retino-choroidal wound. When the wound was peripheral, the retina detached in the cases without buckling and it was necessary to do a secondary scleral buckling procedure. When the wound was located at the posterior pole, the retina remained flat in one case, with a 6 mm metallic body, probably because of the relaxing retinotomy performed to extract the foreign body. We think that it is better to perform a primary scleral buckle of the peripheral wounds. The various aspects of the treatment are discussed.

[Canalicular stenoses complicating the insertion of lacrimal plugs. Incidence and mechanisms]. / Sténoses canaliculaires compliquant la pose de bouchons lacrymaux. Incidence et mécanismes.

Changes in canalicular permeability following the insertion of punctum plugs was studied. This occlusive method was used to treat dry eye syndrome in 43 patients over a period of 32 months. All had normal canalicular patency, confirmed on the day of implantation. One hundred and five large plugs were used (2.4 plugs per patient). Twenty seven (25.7%) impassable acquired canalicular stenoses were seen in 15 patients. The canalicular site of the 27 stenoses was the same: junction between the vertical and horizontal portions. Among the 27 stenoses: 4 plugs had disappeared at an unknown time, with follow-up probing taking place after a mean interval of 7.5 (months range: 1 to 15 months); 17 plugs had been expelled after being in place for an average of 5 months (range: 1 to 12 months; standard deviation 3.47), with follow-up examination taking place on average 12 months after insertion (range: 6 to 17 months; standard deviation 3.4); and 6 plugs were still in place after a mean of 7 months (range: 2 to 15 months; standard deviation 4.73) and the stenosis was discovered when they were removed. They were intact. These 6 Cases eliminate any possibility of intra-canalicular migration of the prosthesis--of all or part--of the prosthesis. Stenoses appeared to develop rapidly: 45% of cases were discovered during the first 3 months. 16/27 (59%) of stenoses were investigated a second time, 6 months later on average (range: 2 to 12 months): these 16 canaliculi all remained impassable.

[Acanthamoeba keratitis. Clinical, histological and ultrastructural study]. / Kératite à Acanthamoeba. Etude clinique, histologique et ultrastructurale.

Acanthamoeba keratitis is a rare but very severe necrotizing stromal keratitis due to a non-parasitic free-living soil and freshwater amoeba. It affects more readily soft and hard lens wearers. It is often clinically mistaken for herpetic keratitis because of the similarity of the signs and the difficulty in performing the specific microbiological tests. This is the reason why the diagnosis is most often made at the time of penetrating keratoplasty and histological study of the buttons with special stains. Medical treatment is effective only when starting at the beginning of the disease.

[Excessive tearing in infants and young children. Questions? Answers]. / Le larmoiement du petit enfant. Questions? Réponses...

Tearing in infants and young children is a subject of controversy. A logical succession of questions and answers is helpful in developing a consensual attitude.