Timely repairs of canaliculus result in best outcomes

May 1, 2007

Canalicular injuries must be repaired in a timely fashion for the patients to achieve the best outcomes. Even seemingly small lacerations require careful examination because when the eyelid is everted and a laceration is noted medial to the punctum, the laceration can have an impact on the canaliculus.

Key Points

Baltimore-Canalicular injuries must be repaired in a timely fashion for patients to achieve the best outcomes. Daniel Garibaldi, MD, described how that is done at the Current Concepts in Ophthalmology meeting, Baltimore.

"Managing canalicular injuries is an important topic because the timing of repair is critical to the outcomes and may prevent epiphora," Dr. Garibaldi said.

Canalicular lacerations should be suspected when there are any lacerations medial to the puncta, the affected punctum is laterally displaced, or there is a distracting injury, such as with a fingernail, according to Dr. Garibaldi, who is the current assistant chief of service at The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore. The meeting was sponsored by Johns Hopkins University and Ophthalmology Times.

Canalicular repair

"Many techniques have been described for finding the cut ends of the canaliculus," Dr. Garibaldi said.

The techniques described in the literature to identify the proximal end of a lacerated canaliculus include the use of a pigtail probe and injection of a substance such as bubbles, milk, or dye into the intact canaliculus, which then can be seen to bubble out from the cut end, he said. Dr. Garibaldi, however, emphasized that direct observation with meticulous retraction of tissue can, in the vast majority of cases, be used to localize the cut end of the canaliculus without risking trauma to the unaffected canaliculus.

The fundamental technique of canalicular repair is intubation of the canaliculus with silicone tubing, according to Dr. Garibaldi. A mini-Monoka (FCI Ophthalmics, Marshfield Hills, MA) can be used for a simple laceration of one canaliculus, and a bicanalicular stent can be used if both canaliculi are involved or if there is a large avulsion.

The mini-Monoka is the material of choice for many canalicular injuries. "It is designed with a small elbow to prevent extrusion from the punctum and a flat footplate to minimize irritation. However, if the tubing is cut too long, it can be difficult to insert into the lacrimal sac," he advised. The silicone tubing is removed at 3 to 6 months, depending on the patient's clinical course.

The canthal ligament and tissue next to the canaliculus should be reapproximated with 6-0 Vicryl sutures. The margins can be reapproximated, if necessary, with 8-0 silk, 7-0 chromic, or 6-0 Vicryl sutures.

Injuries from dog bites are special situations. Many of those are facial injuries that involve the central target area consisting of the lip, nose, and cheek. Orbital and eyelid injuries are uncommon in that scenario, with only 4% to 8% of cases involving the orbit and lids. However, Dr. Garibaldi noted, when the orbit and eyelids are involved, most often the injuries are severe. Eyelid lacerations in these cases usually are associated with injury to the lacrimal system.

There are complications associated with canalicular repair. In some cases the deep closure can loosen, resulting in a dehiscence of the wound. This dehiscence, when recognized early, can be readily repaired and result in normal lid contour.