Canalicular Obstruction

Etiology

(Liarakos, Curr Opin Ophthalmol 2009)

• Infectious
• Viral: Herpes, Adenovirus, Epstein Barr virus
• Bacterial: Prior canaliculitis, trachoma
• Medications
• 5-fluorouracil, docetaxel, paclitaxel (Esmaeli, Ophthalmology 2001)
• Idoxuridine
• Physostigmine
• Echothiophate iodide
• Trauma
• Canalicular laceration
• Chemical or thermal burns
• Iatrogenic
• Punctal or canalicular plugs
• Repeated probe and irrigation
• Surgery with accidental injury to the canaliculus
• Cautery (for example, for punctal occlusion)
• Congenital
• Agenesis
• Associated with anophthalmos or severe microphthalmos; usually causes canalicular stenosis
• Inflammatory
• Ocular cicatricial pemphigoid
• Stevens-Johnson syndrome
• Chronic blepharitis
• Chronic dacryocystitis
• Lichen planus
• IgG4-related disease (Silverman, OPRS 2017)
• Tumors
• Intrinsic canalicular tumors: papillomas
• Skin cancers: basal cell carcinoma, squamous cell carcinoma, melanoma, sebaceous cell carcinoma
• Radiation
• For invasive local skin cancers

History

• Length of symptoms
• History of medication use
• Prior eye infections, trauma, skin cancers

Clinical features

• Tearing
• Chronic discharge from the punctum

Testing

• External examination
• Active inflammation: erythema of the skin or conjunctiva, discharge from the punctum
• Masses or skin lesions in the medial lid region
• Evidence of prior inflammation (for example, symblepharon)
• Canalicular probe and irrigation
• May not be able to probe with punctal stenosis
• Probing may demonstrate a soft stop
• Irrigation: Fluid will reflux out the same punctum with a canalicular obstruction; may reflux out the opposite punctum with a common canalicular obstruction

Testing for staging, fundamental impairment

(Liarakos, Curr Opin Ophthalmol 2009)

• Canalicular probing can help to determine level of obstruction
• Proximal: Punctal stenosis or occlusion, malformations of the first 2–3 mm
• Mid-canalicular: Usually acquired, between 3 to 6-8 mm from the punctum
• Distal: Membrane at the common canaliculus (acquired from infection or congenital), stenosis 6–8 mm from the punctum

• Nasolacrimal duct obstruction
• Lacrimal sac mass
• Lacrimal dysgenesis (Allen, Curr Opin Ophthalmol 2014)

Natural history

In the presence of continued risk factors (inflammation, infection, medication use), stenosis/obstruction can worsen.

Without intervention, tearing generally remains constant.

Medical therapy

• Steroid drops or ointment for inflammatory conditions
• Discontinue causative medications.

Surgery

• Punctoplasty: Punctal stenosis
• One-snip, two-snip, or three-snip technique can be used to open the punctum.
• Can consider silicone intubation
• Chalvatzis et al. reported improved relief of epiphora with the use of bicanalicular stents after punctoplasty (Chalvatzis, OPRS 2013)
• Silicone intubation: Partial canalicular stenosis
• Often used as an adjunct to another procedure
• A variety of intubation systems can be used, including Crawford, Ritleng, Monoka, and so on
• If primarily intubating with a bicanalicular stent, the stent can be placed in the canaliculi and retrieved beneath the inferior turbinate.
• Hussain et al. reported 82% rate of significant improvement with the use of mini-monoka stents (Hussain, Br J Ophthalmol 2012).
• Balloon canaliculoplasty: Partial canalicular stenosis
• A guide wire is passed into the canaliculus and a balloon catheter is placed over it.
• The balloon is then inflated to 8–9 bar for 30 seconds to 5 minutes, deflated, then re-inflated for a shorter period.
• Can consider silicone intubation
• Zoumalan et al. found improvement in 76.2% of eyes with canaliculoplasty and silicone stenting (Zoumalan, OPRS 2010)
• Surgical excision of focal obstruction
• If focal obstruction is suspected, obstructed portion of the canalicular system can be excised followed by reapproximation of the patent system over a bicanalicular or monocanalicular stent
• Success has been described with double stent intubation
• Canalicular trephination: Proximal and distal obstructions
• Essentially, cuts through the obstruction
• Silicone stents may then be placed
• Most successful for distal obstructions
• Khoubian et al. (Khoubian, OPRS 2006)
• 41 eyes underwent trephination and stenting
• 49% experienced complete relief of epiphora, 38% had partial relief
• Among those with distal lower canalicular obstructions, 80% experienced complete relief
• Among patients with distal bicanalicular obstructions
• 66% complete resolution of symptoms
• 59% with common canalicular obstructions experienced complete relief
• 55% with proximal bicanalicular obstructions experienced partial relief (45% experienced no relief)
• Retrograde intubation dacryocystorhinostomy (DCR)
• External DCR approach is first accomplished without intubation
• Retrograde intubation is then performed through the lacrimal sac, and a pseudopunctum is made at the site of the obstruction
• Stent can then be passed through the patent canaliculus and then into the nose
• This procedure may eliminate the need for a conjunctivodacryocystorhinostomy
• Wearne et al. performed 123 such procedures, and reported a significant improvement in epiphora in 73% (Wearne, Ophthalmology 1999)
• DCR with membranectomy: Distal obstruction
• Membrane or obstruction can be incised during external DCR
• Probe is placed in the canaliculus and used to tent the membrane; membrane is then incised with a blade allowing the passage of stents
• Borboridis et al. reported a 92% anatomic success rate with this technique (Boboridis, Am J Ophthalmol 2005)
• Endocanalicular laser surgery (Liarakos, Curr Opin Ophthalmol 2009)
• Endocanalicular probe is placed in the canaliculus and a laser (holmium, erbium, or potassium-titanium phosphate) is used at the site of the obstruction
• Silicone intubation is then performed
• Conjunctivodacryocystorhinostomy (CDCR) (Lim, Am J Ophthalmol 2004)
• Final step in treatment of extensive canalicular obstruction
• External DCR or endoscopic DCR approach can be taken; osteotomy is performed and lacrimal sac is opened
• Jones tube is then placed through the conjunctiva/caruncle into the nasal passage
• Typically, the distal end is approximately 2 mm inside the nose, not touching the nasal septum

Other management considerations

In cases of chemical or thermal burns, one can consider placing silicone tubes preemptively to prevent canalicular stenosis (Meyer, Arch Ophthalmol 1995)

Control other medical conditions simultaneously (ensure resolution of pre-existing malignancy, medical management of OCP, and so on)

Common treatment responses, follow-up strategies

If stents are placed, they can be kept in position for 6 weeks to indefinitely — if patient has resolution of symptoms with stents in place

CDCR: Tubes can extrude or dislocate

• Tube modifications have been made to prevent extrusion or dislocation, including tubes with suture holes in the collar, frosted tubes, tubes with an extra flange, and porous-polyethylene coated tubes
• It is often recommended to secure the tube with a suture at least around the cuff of the tube
• Tubes can be replaced and resecured if needed

Canalicular trephination or stenting: False passages can be made

• Surgeons should take care to follow the direction of the canaliculus and nasolacrimal duct

(Liarakos, Curr Opin Ophthalmol 2009)

• CDCR: Lester Jones developed the Pyrex tube in 1960, variants of which are most commonly used today
• Retrograde intubation: Originally described by Lester Jones in 1962
• Canalicular trephination: First described by Sisler and Allarakhia in 1990

1. Allen RC. Hereditary disorders affecting the lacrimal system. Curr Opin Ophthalmol 2014;25:424-31.
2. Boboridis KG, Bunce C, and Rose GE. Outcome of external dacryocystorhinostomy combined with membranectomy of a distal canalicular obstruction. Am J Ophthalmol 2005. 139:1051-5.
3. Chalvatzis NT, Tzamalis AK, Mavrikakis I, et al. Self-retaining bicanaliculus stents as an adjunct to 3-snip punctoplasty in management of upper lacrimal duct stenosis: a comparison to standard 3-snip procedure. Ophthal Plast Reconstr Surg 2013;29:123-7.
4. Esmaeli B, Valero V, Ahmadi MA, et al. Canalicular stenosis secondary to docetaxel (taxotere): a newly recognized side effect. Ophthalmology 2001;108:994–995.
5. Hussain RN, Kanani H, McMullan T. Use of mini-monoka stents for punctal/canalicular stenosis. Br J Ophthalmol 2012;96:671-3.
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10. Meyer DR, Kersten RC, Kulwin DR, et al. Management of canalicular injury associated with eyelid burns. Arch Ophthalmol 1995;113:900-3.
11. Silverman N, Lanjewar S, Gupta R, Shinder R. IgG4-related disease of the punctum and canaliculus. Ophthal Plast Reconstr Surg 2017;33:S165-7.
12. Sisler HA, Allarakhia L. New minitrephine makes lacrimal canalicular rehabilitation an office procedure. Ophthal Plast Reconstr Surg 1990; 6:203–206.
13. Wearne MJ, Beigi B, Davis G, et al. Retrograde intubation dacryocystorhinostomy for proximal and midcanalicular obstruction. Ophthalmology 1999;106:2325-8.
14. Zoumalan CI, Maher EA, Lelli GJ, et al. Balloon canaliculoplasty for acquired canalicular stenosis. Ophthal Plast Reconstr Surg 2010;26:459-61.