Original Investigation
Canalicular Laceration Repair: An Analysis of Variables Affecting Success Ann P. Murchison, M.D., M.P.H.*† and Jurij R. Bilyk, M.D.† *Wills Eye Emergency Department, and †Skull Base Division, Neuro-Ophthalmology Service, Wills Eye Hospital, Philadelphia, Pennsylvania, U.S.A.
Purpose: To evaluate the outcomes of all canalicular lacerations at a high-volume urban tertiary eye care center and calculate the impact of variables of repair on success. Methods: A retrospective review over a 10-year span of all primary canalicular laceration repairs was performed. Variables included patient demographics, repair setting, surgeon level of training, mechanism of injury, associated injuries, type of stent used, and success of repair. Results: One hundred thirty-seven patients met the inclusion criteria and were used for analysis. The mechanism of injury was primarily due to altercations (31.4%), followed by accidents (21.9%). Most repairs were performed in the operating room (72.3%) with an overall success rate of 85.9% compared with 36.8% in the minor procedure room. The success rate varied significantly by level of training, with a fellowship-trained oculoplastic surgery attending physician attaining the highest success rate of 84.0%. The success by primary surgeon training level was statistically significant (p < 0.0001). The efficacy of a monocanalicular stent was also studied and was not significantly different from bicanalicular stenting when other variables were accounted for (p = 0.1186). Conclusion: The overall success of canalicular laceration repair is good. However, the setting of repair and level of training greatly affect the success of repair. In a tertiary care setting, an attending surgeon with subspecialty training in oculoplastic surgery should participate in the canalicular laceration repair to maximize the success rate. Performing the repair in the operating room rather than a minor procedure room setting may further improve the patient outcomes. (Ophthal Plast Reconstr Surg 2014;30:410–414)
100%.4–9 However, the variables of surgeon level of training and the setting of repair (operating room [OR] vs. minor procedure room [MPR]) have not been studied in relation to outcome.
METHODS After institutional review board approval, a retrospective study of all patients with primary CL repair spanning 10 years was performed. Records of all patients repaired at a single urban tertiary eye care/postgraduate training institution with a dedicated eye emergency room were included in the initial review. Exclusion criteria included noncanalicular injury, no canalicular stent placed, secondary canalicular repair, lack of adequate follow up (3 months after stent removal. All data were analyzed in SPSS version 21.0 (SPSS Inc., Chicago, IL). Two-tailed Fisher exact tests were calculated for determining significance unless otherwise specified. This study is compliant with the Health Insurance Portability and Accountability Act.
RESULTS
C
analicular lacerations (CL) occur in 16% of all eyelid lacerations from either penetrating or blunt trauma.1 The epidemiology, diagnosis, and surgical management of CL has been reported extensively in the literature, along with the use of either bicanalicular or monocanalicular stenting.1–13 Most investigators agree that even mono CLs warrant repair with stenting to minimize the risk of posttraumatic epiphora.11,12,14,15 Most studies also show a high success rate of over 80% in avoiding posttraumatic epiphora with either mono- or bicanalicular stenting, with more recent reports demonstrating a success of 58% to Accepted for publication January 8, 2014. Funded by a Wills Eye Innovation Grant (no. 11–014). The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Ann P. Murchison, M.D., M.P.H., Department of Research Suite 802, Wills Eye Hospital, 840 Walnut Street, Philadelphia, PA 19107. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000133
410
Of the 210 patient records identified, 137 met the inclusion criteria and were included in the analysis. Details on the demographics including mechanism of injury and associated injuries are listed in Table 1. Most patients were white (54.0%), male (72.3%), and young adults. The mechanism of injury was primarily due to altercations (31.4%), followed by accidents (21.9%), dog bites (16.1%), falls (14.6%), and sports-related activities (11.7%). The setting of accidents and falls primarily occurred at home (44.8% and 70.0%, respectively). Nearly 30% of patients had isolated CLs, while 12.4% had mild, self-limited ocular injuries such as subconjunctival hemorrhage. However, over half of the patients sustained additional significant injuries requiring monitoring and/or surgical repair; these were most commonly other facial lacerations (24.8%), followed by intraocular injuries (19.7%), including commotio retinae or hyphema, and/or facial fractures (13.9%). Most repairs (72.3%) were performed in the OR under general anesthesia rather than the emergency department’s MPR with local anesthesia injection (Table 2). Most repairs (86.1%) were performed using a monocanalicular stent (Mini-Monoka, FCI Ophthalmics, Marshfield Hills, MA,
Ophthal Plast Reconstr Surg, Vol. 30, No. 5, 2014
Ophthal Plast Reconstr Surg, Vol. 30, No. 5, 2014
Variables of Canalicular Laceration Repair Success
TABLE 1. Demographics, mechanisms, and associated injuries Total patients, N Male gender, n (%) Race, n (%) White Black Hispanic Asian Other Mean age in years (median, range) Right side (%) Involved eyelid(s), n (%) Upper Lower Upper and lower Mechanism of injury, n (%) Altercations Dog bites* Falls Sports-related Motor vehicle accidents Self-inflicted Other accidents† Associated injuries, n (%) None Other facial lacerations Intraocular injuries‡ Orbital fracture Ocular surface injury (corneal abrasion or subconjunctival hemorrhage)
137 99 (72.3) 74 (54.0) 46 (33.6) 11 (8.0) 4 (2.9) 2 (1.5) 29.6 (25.7, 1.1–74.4) 68 (49.6) 32 (23.4) 98 (71.5) 7 (5.1) 43 (31.4) 22 (16.1) 20 (14.6) 16 (11.7) 5 (3.6) 1 (0.7) 30 (21.9) 40 (29.2) 34 (24.8) 27 (19.7) 19 (13.9) 17 (12.4)
*12 (54.5%) were male, mean age 14.8 years, and median age 11.9 years. †13 at home (44.8%), 7 while playing, 4 at work, 6 miscellaneous (shopping, etc.). Most home injuries were secondary to home repair/yard work. ‡Including 1 optic nerve head avulsion and 2 ruptured globes.
TABLE 2. Setting of repair, type of stent, time from injury to repair, and functional success by stent type Location of repair, n (%) Operating room Minor procedure room Type of stent, n (%) Mini-Monoka tube Crawford tube into nasolacrimal duct Circular silicone tube into lacrimal sac Suture Mean time of injury to repair in days (median, range) Overall functional success, n (%) Mini-Monoka tube Crawford tube
99 (72.3) 38 (27.7)* 118 (86.1) 17 (12.4) 1 (0.7) 1 (0.7) 1.1 (1.1, 0–5) 99 (72.3) 80 (67.8) 19 (100)
*All repaired with monocanalicular stenting; 8 of 38 were repaired by an unsupervised resident physician.
TABLE 3. Success rates in operating room vs. minor procedure room
Overall success, n (%) Mini-Monoka tube success, n (%) Crawford tube success, n (%)
Operating room
Minor procedure room
p Value
85 (85.9) 66 (82.5) 19 (100)
14 (36.8) 14 (36.8) N/A
Canalicular Laceration Repair: An Analysis of Variables Affecting Success Ann P. Murchison, M.D., M.P.H.*† and Jurij R. Bilyk, M.D.† *Wills Eye Emergency Department, and †Skull Base Division, Neuro-Ophthalmology Service, Wills Eye Hospital, Philadelphia, Pennsylvania, U.S.A.
Purpose: To evaluate the outcomes of all canalicular lacerations at a high-volume urban tertiary eye care center and calculate the impact of variables of repair on success. Methods: A retrospective review over a 10-year span of all primary canalicular laceration repairs was performed. Variables included patient demographics, repair setting, surgeon level of training, mechanism of injury, associated injuries, type of stent used, and success of repair. Results: One hundred thirty-seven patients met the inclusion criteria and were used for analysis. The mechanism of injury was primarily due to altercations (31.4%), followed by accidents (21.9%). Most repairs were performed in the operating room (72.3%) with an overall success rate of 85.9% compared with 36.8% in the minor procedure room. The success rate varied significantly by level of training, with a fellowship-trained oculoplastic surgery attending physician attaining the highest success rate of 84.0%. The success by primary surgeon training level was statistically significant (p < 0.0001). The efficacy of a monocanalicular stent was also studied and was not significantly different from bicanalicular stenting when other variables were accounted for (p = 0.1186). Conclusion: The overall success of canalicular laceration repair is good. However, the setting of repair and level of training greatly affect the success of repair. In a tertiary care setting, an attending surgeon with subspecialty training in oculoplastic surgery should participate in the canalicular laceration repair to maximize the success rate. Performing the repair in the operating room rather than a minor procedure room setting may further improve the patient outcomes. (Ophthal Plast Reconstr Surg 2014;30:410–414)
100%.4–9 However, the variables of surgeon level of training and the setting of repair (operating room [OR] vs. minor procedure room [MPR]) have not been studied in relation to outcome.
METHODS After institutional review board approval, a retrospective study of all patients with primary CL repair spanning 10 years was performed. Records of all patients repaired at a single urban tertiary eye care/postgraduate training institution with a dedicated eye emergency room were included in the initial review. Exclusion criteria included noncanalicular injury, no canalicular stent placed, secondary canalicular repair, lack of adequate follow up (3 months after stent removal. All data were analyzed in SPSS version 21.0 (SPSS Inc., Chicago, IL). Two-tailed Fisher exact tests were calculated for determining significance unless otherwise specified. This study is compliant with the Health Insurance Portability and Accountability Act.
RESULTS
C
analicular lacerations (CL) occur in 16% of all eyelid lacerations from either penetrating or blunt trauma.1 The epidemiology, diagnosis, and surgical management of CL has been reported extensively in the literature, along with the use of either bicanalicular or monocanalicular stenting.1–13 Most investigators agree that even mono CLs warrant repair with stenting to minimize the risk of posttraumatic epiphora.11,12,14,15 Most studies also show a high success rate of over 80% in avoiding posttraumatic epiphora with either mono- or bicanalicular stenting, with more recent reports demonstrating a success of 58% to Accepted for publication January 8, 2014. Funded by a Wills Eye Innovation Grant (no. 11–014). The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Ann P. Murchison, M.D., M.P.H., Department of Research Suite 802, Wills Eye Hospital, 840 Walnut Street, Philadelphia, PA 19107. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000133
410
Of the 210 patient records identified, 137 met the inclusion criteria and were included in the analysis. Details on the demographics including mechanism of injury and associated injuries are listed in Table 1. Most patients were white (54.0%), male (72.3%), and young adults. The mechanism of injury was primarily due to altercations (31.4%), followed by accidents (21.9%), dog bites (16.1%), falls (14.6%), and sports-related activities (11.7%). The setting of accidents and falls primarily occurred at home (44.8% and 70.0%, respectively). Nearly 30% of patients had isolated CLs, while 12.4% had mild, self-limited ocular injuries such as subconjunctival hemorrhage. However, over half of the patients sustained additional significant injuries requiring monitoring and/or surgical repair; these were most commonly other facial lacerations (24.8%), followed by intraocular injuries (19.7%), including commotio retinae or hyphema, and/or facial fractures (13.9%). Most repairs (72.3%) were performed in the OR under general anesthesia rather than the emergency department’s MPR with local anesthesia injection (Table 2). Most repairs (86.1%) were performed using a monocanalicular stent (Mini-Monoka, FCI Ophthalmics, Marshfield Hills, MA,
Ophthal Plast Reconstr Surg, Vol. 30, No. 5, 2014
Ophthal Plast Reconstr Surg, Vol. 30, No. 5, 2014
Variables of Canalicular Laceration Repair Success
TABLE 1. Demographics, mechanisms, and associated injuries Total patients, N Male gender, n (%) Race, n (%) White Black Hispanic Asian Other Mean age in years (median, range) Right side (%) Involved eyelid(s), n (%) Upper Lower Upper and lower Mechanism of injury, n (%) Altercations Dog bites* Falls Sports-related Motor vehicle accidents Self-inflicted Other accidents† Associated injuries, n (%) None Other facial lacerations Intraocular injuries‡ Orbital fracture Ocular surface injury (corneal abrasion or subconjunctival hemorrhage)
137 99 (72.3) 74 (54.0) 46 (33.6) 11 (8.0) 4 (2.9) 2 (1.5) 29.6 (25.7, 1.1–74.4) 68 (49.6) 32 (23.4) 98 (71.5) 7 (5.1) 43 (31.4) 22 (16.1) 20 (14.6) 16 (11.7) 5 (3.6) 1 (0.7) 30 (21.9) 40 (29.2) 34 (24.8) 27 (19.7) 19 (13.9) 17 (12.4)
*12 (54.5%) were male, mean age 14.8 years, and median age 11.9 years. †13 at home (44.8%), 7 while playing, 4 at work, 6 miscellaneous (shopping, etc.). Most home injuries were secondary to home repair/yard work. ‡Including 1 optic nerve head avulsion and 2 ruptured globes.
TABLE 2. Setting of repair, type of stent, time from injury to repair, and functional success by stent type Location of repair, n (%) Operating room Minor procedure room Type of stent, n (%) Mini-Monoka tube Crawford tube into nasolacrimal duct Circular silicone tube into lacrimal sac Suture Mean time of injury to repair in days (median, range) Overall functional success, n (%) Mini-Monoka tube Crawford tube
99 (72.3) 38 (27.7)* 118 (86.1) 17 (12.4) 1 (0.7) 1 (0.7) 1.1 (1.1, 0–5) 99 (72.3) 80 (67.8) 19 (100)
*All repaired with monocanalicular stenting; 8 of 38 were repaired by an unsupervised resident physician.
TABLE 3. Success rates in operating room vs. minor procedure room
Overall success, n (%) Mini-Monoka tube success, n (%) Crawford tube success, n (%)
Operating room
Minor procedure room
p Value
85 (85.9) 66 (82.5) 19 (100)
14 (36.8) 14 (36.8) N/A
