Abstract
Purpose
To evaluate the efficiency of perforated punctal plug in acquired punctal stenosis.
Materials and methods
Forty-five eyes of 33 patients who had epiphora due to punctal stenosis were included in this study. After biomicroscopic examination and lacrimal dilatation punctal stenosis was managed with the perforated punctal plugs in all patients. In the following period epiphora, plug tolerance, lacrimal drainage were evaluated and graded. Lacrimal drainage was evaluated with fluorescein dye disappearing test.
Results
The age of the patients ranged between 31 and 80 (mean 55.78 ± 13.11). Preoperatively punctal dilatation and lacrimal system irrigations were performed on all patients. Lacrimal system irrigation was positive in all patients. Perforated punctal plugs were placed in the inferior puncti in all patients. The plugs were explanted 6 months after operation. The follow-up period ranged between 6 and 24 months. Plug tolerance was good in 97.8% of the eyes in the 1st month visit. Epiphora decreased remarkably in 88.9% of the patients 1 month after plug implantation, except one whose plug dropped off spontaneously in 2 weeks. Fluorescein disappearing times were found under 3 min in 97.8% of the eyes after plug explanations.
Conclusion
Punctum stenosis is one of the several disorders that cause lacrimal drainage obstruction. Perforated punctal plugs are found convenient and effective in managing punctal stenosis.
Keywords: Epiphora, Punctal stenosis, Perforated plug
Introduction
Punctum stenosis is one of the frequent causes of epiphora besides canalicular or nasolacrimal duct obstruction. It can be congenital or acquired. Acquired punctum stenosis may result from inflammatory or infectious eye disease, systemic or topical drug toxicity, lid malposition, different forms of trauma, tumours or ageing changes. Chronic inflammation and subsequent fibrosis appear to be the basic ultrastructural response to various noxious stimuli. Associated canalicular and nasolacrimal sac or duct stenosis or obstruction might be present in some cases.1–7
Pure punctum stenosis treatment relies on punctum dilatation, surgical opening or punctum stenting with canalicular tubes or punctum plugs. However canalicular tubing is unnecessary if there is no intracanalicular pathology.5,6,8–12
The purpose of this study was to investigate the clinical outcomes and tolerances of polyvinylpyrrolidone (PVP) coated perforated punctum plugs (PPP) in punctum stenosis and agenesis.
Materials and methods
Forty-five eyes of 33 patients with punctal stenosis who received perforated punctal plug implants were included in the study. The study conforms to the provisions of the Declaration of Helsinki in 1995. Proper informed consent for both the treatment and participation in the study was obtained from the patients.
Patients with lid malposition, canalicular or nasolacrimal sac or duct obstruction, previous eyelid or lacrimal drainage surgery, untreated conjunctivitis or blepharitis were excluded.
Diagnosis was based in order on a history of tearing, biomicroscopic examination, fluorescein dye disappearance test, punctal dilatation and diagnostic canaliculi probing, nasolacrimal duct irrigation, and if passage is patent after irrigation fluorescein dye disappearance test repetition. Epiphora was scored using the combination of Munk score and epiphora score used by Malet et al. (Table 1).8,12
Table 1.
Score scale of epiphora.
| Score | Description | Clinical findings |
|---|---|---|
| 0 | No epiphora | No tearing |
| 1 | Mild epiphora | Tearing sometimes in windy days |
| 2 | Moderate epiphora | Always tearing, but sometimes need to wipe |
| 3 | Permanent epiphora | Always tearing and need to wipe |
In biomicroscopic examination special attention was given to tear meniscus, lid margin, conjunctiva and punctal orifice. Associated conjunctivitis or blepharitis was treated. Punctal orifice was graded based on biomicroscopic examination which was examined before punctal dilatation (Table 2).
Table 2.
Grading of punctal orifice.
| Grade | Clinical findings |
|---|---|
| 0 | No punctum(agenesis) |
| 1 | Papilla is covered with a membrane(difficult to recognise) |
| 2 | Less than normal size but recognisable |
| 3 | Normal (easily recognised) |
After biomicroscopic examination fluorescein dye disappearance test was performed with a drop of 2% fluorescein and assessment after 3 and 5 min of the remaining dye in the tear meniscus. All patients had over 5 min dye disappearance time. Fluorescein dye disappearance test was graded (Table 3).
Table 3.
Grading of fluorescein dye disappearance test.
| Grade | Fluorescein dye disappearance time |
|---|---|
| 1 | <3 min |
| 2 | 3–5 min |
| 3 | >5 min |
Punctal dilatation, canaliculi probing and nasolacrimal duct irrigation were performed in the office or operating room under surgical microscope. After instillation of a topical anaesthetic drop (proparacaine hydrochloride ophthalmic solution), a punctal finder was used to open the papilla and pushed forward to dilate the lower punctum. Afterwards a canaliculi probe was introduced. A soft stop that could not be overcome was defined as canalicular obstruction. A soft stop that could be overcome was defined as canalicular membranous stenosis. A hard stop was defined as patent upper canalicular system. Irrigation was performed with a 5 ml syringe filled with serum saline and a 26 gauge lacrimal cannula through the lower punctum and canaliculi. A normal system was defined as free passage of saline into nose or nasopharynx without any reflux through the upper or lower punctum. Patients with any associated canalicular or nasolacrimal duct pathology were not included in the study.
Fluorescein dye disappearance test was repeated after punctum dilatation and found to be under 3 min (grade 1 or 2) in all patients.
After punctum dilatation PVP coated PPP (FCI, S1-3512u) implantation was performed.
Demographic data, laterality, symptoms, findings of biomicroscopic examination and diagnostic probing and irrigation were recorded. Findings of biomicroscopic examination, fluorescein dye disappearance test and plug tolerance were investigated at postoperative 1st day, 1st month, 3rd month, 6th month, 1st year and 2nd year visits (Table 4). Plugs were explanted after 6 months.
Table 4.
Plug tolerance of patients.
| Tolerance | Clinical findings |
|---|---|
| Good | No irritation. No secretion |
| Mild | Secretion, mild irritation |
| Poor | Secretion and irritation |
Results
The age of the patients ranged between 31 and 80 (mean 55.78 ± 13.11). Twenty-one (63.6%) patients were female and 12 (36.4%) were male. The right lower punctum was involved in 11 (29.8%) patients, the left lower punctum was involved in 8 (27%) patients and bilateral lower puncti were involved in 13 (43.2%) patients. Upper punctum was involved in 5 eyes (11.1%).
In preoperative examination, thirty-five eyes (77.8%) had papilla covered with a membrane (grade 1) (Fig. 1), and 10 (22.2%) eyes had punctum less than normal size (grade 2). All eyes had moderate (grade 2, n:27) or permanent (grade 3, n:18) epiphora. Fluorescein dye disappearance test was over 5 min (grade 3) in all patients. Free passage into the nose was obtained in all patients with nasolacrimal system irrigation. Fluorescein dye disappearance test was repeated in eyes that had normal passage with irrigation and it was found to be under 3 min in all patients that could be evaluated in the office.
Figure 1.
Punctum stenosis grade 1 (punctum covered with a membrane).
Surgical procedure: After punctal dilatation, control irrigation was performed. Plugs were implanted with their own preloaded inserter after puncti were dilated with the inserters’ own dilatator. In Fig. 2 the punctum with an implanted perforated punctal plug is seen.
Figure 2.
Appearance of an implanted PVP coated perforated punctal plug.
Upper punctal dilatation was performed besides punctal plug implantation in patients having also upper punctum involvement.
Epiphora
The epiphora score was grade 0 or 1 in 30 eyes (66.7%) at 1st day postoperatively, and grade 0 or 1 epiphora score was present at the 1st month visit in 37 eyes (82.2%), in the 6th month visit (after plugs were explanted) in 41 eyes (91.1%), and in the 1st year visit in 37 (82.2%) eyes (Fig. 3).
Figure 3.
Postop epiphora grading changes.
Fluorescein dye disappearance test
It was under 5 min (grade 1 or 2) in 32 eyes (71.1%) after plug implantation day 1, and improved in all eyes at 1st and 3rd month visits [grade 1 in 37 eyes (82.2%), grade 2 in 8 eyes (17.8%)]. Fluorescein dye disappearance test was under 3 min in all eyes after plug explantation except 1 eye whose plug dropped off in the second week (97.8%). But the number of eyes with a fluorescein dye disappearance test under 5 min decreased to 37 (82.2%) at the 1st year visit. Puncti were observed stenotic again in the 8 eyes in which fluorescein dye disappearance test was over 5 min (grade 3).
Plug tolerance
Plug tolerance was found good in 84.4% (n = 38) of the eyes at 1st day postoperatively and remaind the same at 1st week, and improved to 93.3% (n = 42) at the 1st month visit (Fig. 4). Early plug drop off occured in 2 patients (one within 2 weeks, one within 3 months). In one patient pyogenic granuloma formation within the plug was observed 5 months after implantation (Fig. 5). The granuloma was excised, the plug was explanted and remaining piece of the granuloma was excised. The passage was found open after granuloma excision and plug explantation according to the fluorescein dye disappearance test and irrigation. No other serious complications were observed related to the plug.
Figure 4.
Plug tolerance of the patients.
Figure 5.
Granuloma formation in the perforated punctal plug.
Eleven of the puncti were observed at least for 2 years, and 2 of them (18.18%) were determined as stenotic according to fluorescein dye disappearance test (which was grade 3), epiphora score (which was 2 or 3) and biomicroscopic examination of the puncti (which was grade 1 or 2).
Discussion
Epiphora is caused by different obstruction levels in the lacrimal drainage system. In the first step, it is important to distinguish epiphora from lacrimation. Any ocular surface pathology causing lacrimation should be eliminated. If it is decided that it is epiphora, it is very important to determine the obstruction level of the lacrimal drainage system.
Punctal stenosis is one of the frequent causes of epiphora. Biomicroscopic examination is important in a patient with tearing. Besides ocular surface examination, the aspect of the punctum should be determined. If punctum dilatation and irrigation are performed without biomicroscopic examination or only dacryoscintigraphy is performed without any other diagnostic tests used for lacrimal system, the diagnosis might be mistaken. In this view, to diagnose punctum stenosis we performed a fluorescein dye disappearance test, punctum dilatation and diagnostic canaliculi probing, and nasolacrimal duct irrigation, if passage was patent after irrigation fluorescein dye disappearance test repetition.
The punctal orifice is normally 0.3 mm in diameter.5,10 We graded the punctal orifices from 0 to 3 according to the aspect and sizes of the punctal openings similar to Kashkouli et al. but we did not grade puncti any further according to their size measured with the slit of the lamp microscope.1 In our study, 77.8% of the eyes had papilla covered with a membrane preoperatively (grade 1) and 22.2% eyes had punctum less than normal size (grade 2). Kashkouli et al. found grade 1 punctal opening rate 86% and 57% in eyes with more than and less than 6 months duration of symptoms, respectively.
Female patients were significantly (63.6%) more in our study which is compatible with the literature. Postmenopausal hormonal changes may be the reason for this sex difference.1,10,14
There are various methods to treat punctal stenosis which are repeated dilatations (generally ineffective); surgical opening with one snip, two snips, three snips or punch punctoplasty; microsurgical punctoplasty with sutures; balloon dilatation; electrocautery; laser treatment or temporary stenting (canalicular tubing, punctal plugs). Despite the high success rate, microsurgery sections the fibrous ring of the punctum, with the subsequent risk of stricturotomy if bicanalicular intubation is later required.5,6,9,10,15
Perforated punctal plugs were first introduced by Bernard et al. to obtain an artificial punctum. The first ones were made of silicone but were not coated with hydrophilic polyvinylpyrrolidone, therefore secretions were obstructing the central orifice. For this reason, the FCI laboratories along with the Le Mans Centre for Technology Transfer (Dr. Legeay) modified the hydrophobic nature of plugs, making their surface hydrophilic by coating the silicone plugs with polyvinylpyrrolidone.9,12 In this study PVP coated PPP were used.
In a retrospective series of 44 eyes treated with the placement of a perforated punctal plug for acquired punctal stenosis, the success rate was 84.1% (37 of 44 eyes) for the improvement of epiphora.16 Chang et al. reported a success rate of 85% in their series of 20 eyes.17. Similarly, our results showed improvement in the epiphora and the fluorescein dye disappearance test. All eyes had grade 2 or 3 epiphora before plug implantation, and 82.2% of the eyes had grade 0 or 1 epiphora after 1 month following plug implantation. Although epiphora score was 0 or 1 in 91.1% of the eyes after plug explantation after 6 months it decreased to 82.2% after 1 year follow-up. Fluorescein dye disappearance test score was directly proportional to epiphora score which was grade 1 or 2 in 100% at 1st month postoperatively and decreased to 82.2% after 1 year follow-up. Some of the puncti became stenotic again during the follow-up period. The possible explanation for this drawback might be the ongoing of ageing changes, as all these patients were over 62 years old. Malet et al. compared 20 silicone PPP and 20 PVP coated silicone plugs. They removed all the silicone plugs and 10 of the PVP coated plugs after 2 months. They reported that all puncti with silicone plugs were stenotic after 6 months. But the 10 patients with PVP plugs did not have epiphora and tolerance was excellent.9 We left the plugs for 6 months in all of our patients and only 17.8% of them became stenotic again at 1 year. The big difference between Malet’s results and ours might be related to the timing of plug removing. Leaving the plug longer might be more effective.
The advantages of the perforated punctal plugs over surgery are that lacrimal sphincter is not disturbed and it is a less invasive procedure. However there are several complications of punctal plugs including pyogenic granuloma, expulsion, migration, local irritation, and the possibility of punctal laceration during insertion.9,13,16–22 Plug tolerance was good in 93.3% of our patients during the 1 and 6 months follow-up. The complications were early plug drop-off in 2 patients and pyogenic granuloma in 1 patient. Spontan plug loss was reported in 4 eyes in the study by Chung.17 In the study by Malet et al. they compared the tolerance of silicone and PVP coated silicone perforated plugs. They found PVP coated plugs superior to silicone plugs as plug tolerance was good in 75% of eyes and mild in 25% of eyes with PVP coated plugs, and it was only mild in 75% and poor in 25% of eyes with silicone plugs.9
In conclusion punctal stenosis without any additional ocular surface and lid problems or nasolacrimal system stenosis can be easily treated with PVP coated PPP. Although restenosis may develop in elderly patients, in long term it is a tolerable and effective procedure for isolated punctal stenosis.
Conflict of interest
The authors declared that there is no conflict of interest
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