The lacrimal drainage system is made up of an upper and lower canaliculus that join to form a common canaliculus. Each canaliculus has a 2-mm vertical part that leads into an 8-mm horizontal part. "If a lacrimal probe is placed at anything less than 10 mm, it is usually before the common canaliculus," Dr. Kikkawa explained.
Several tools are available for treating obstructions associated with canalicular disease. The pigtail probe, he explained, can be utilized with an apposing intact canaliculus. One side of the probe is used for the right upper and left lower eyelids and the other side for the left upper and right lower eyelids. Dr. Kikkawa is professor of clinical ophthalmology, and chief of Division of Ophthalmic Plastic and Reconstructive Surgery, Shiley Eye Center, University of California, San Diego, in La Jolla.
A recently introduced device is the monocanalicular stent (MiniMonica, FCI). This is a punctual plug with a monocanalicular long stent that can be placed in the canalicular system.
The inflatable balloon and pump have been used primarily for nasal lacrimal duct disease, but Dr. Kikkawa reported that he finds them useful for canalicular disease for certain indications.
A microtrephine, composed of a 0.81-mm cutting tip and an easily removable stylet, can be used for some obstructions of the canaliculus.
"The diseases of the canaliculus are broadly defined as developmental and acquired. Regarding the former, atresia, an absence of the upper system including the canaliculus and the puncta, is typically seen," Dr. Kikkawa said.
Occasionally, in young children, he said, he has tried to re-establish a mucosal line drainage using multiple silicone stents with a mucosal line track. The prognosis is poor for maintaining a mucosal line conduit, Dr. Kikkawa said. "The gold standard for these patients continues to be the conjunctival dacryocystorhinostomy (DCR), and we typically use the endoscopic approach," he said.
The presentation of canaliculitis can vary from a broad spectrum of a pyogenic granuloma exuding from the puncta or the classic "pouting puncta" presentation. Complete curettage is usually curative without antibiotic administration.
Canalicular trauma can be divided into two categories, the avulsion type involving medial canthal degloving or a laceration that is typically from a penetrating injury, Dr. Kikkawa said.
Bicanalicular intubation remains the gold standard; the monocanalicular stents, however, are ideal for isolated, single lid lacerations, he said. These stents can be used in the office with local anesthesia. One complication associated with the stents is extrusion; also, the tip of the stent can rise and cause a foreign body sensation. In addition, Dr. Kikkawa said, when the plug is in place, there is no flow through the segment that was repaired.
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