Canalicular laceration repair using a viscoelastic injection to locate and dilate the proximal torn edge € Faruk H. Orge, MD, and Suhail A. Dar, MD BACKGROUND
Canalicular lacerations are common complications of eyelid trauma in the pediatric population. Irrigating air, water, and colored or viscous agents through the intact canaliculus have been suggested to identify the torn proximal edge. We report our experience in repairing canalicular lacerations using a novel viscoelastic injection technique with a Monoka monocanalicular stent.
METHODS
The medical records of patients \18 years of age who underwent repair of a canalicular laceration with a monocanalicular stent using superficial viscoelastic deployment to locate the torn canaliculus were retrospectively reviewed. Demographics, cause of eyelid injury, surgical management using our novel viscoelastic injection technique, and outcome were analyzed.
RESULTS
A total of 38 children with lid lacerations were identified, of whom the 17 with canalicular involvement were included (mean age, 6.27 years). Canalicular injury in these 17 was due to dog bite (9 patients) and shearing trauma (8 patients). In 11 patients, the injury was located in the lower lid; in 4, the upper lid; and in 2, combined upper and lower lids. All patients had good anatomic repair and on follow-up had negative dye disappearance tests and were free of tearing.
CONCLUSIONS
Deploying viscoelastic superficially near, and injecting into the injured canaliculus can improve visualization of the operative field by retracting the surrounding tissue and tamponading any bleeding, which aids in location and dilation of the torn canaliculus initially and in subsequent steps, eases intubation into the lubricated torn canaliculus and nasolacrimal duct, and avoids iatrogenic injury to an uninjured canaliculus. ( J AAPOS 2015;19:217-219)
C
analicular lacerations are common complications of eyelid trauma in children. Without proper repair, lacerations can lead to scarring and stenosis and subsequently epiphora, a complication more common in bicanalicular injuries or when no canalicular stent is placed at time of surgical repair.1-4 Successful canalicular repair requires approximation of the divided canaliculus around a stent in order to provide patency for the lacrimal drainage system and closure of the surrounding eyelid soft tissue.4,5 Locating the injured canaliculus requires a thorough understanding of medial canthal anatomy, especially in lacerations close to the lacrimal sac, because different portions of the orbicularis muscle insert on the lacrimal fascia and anterior and posterior lacrimal crests to form the
Author affiliations: Department of Ophthalmology, Case Western Reserve Medical Center University Hospitals, Cleveland, Ohio Submitted August 1, 2014. Revision accepted February 13, 2015. € Correspondence: Faruk H. Orge, MD, Department of Ophthalmology, Case Medical Center University Hospitals, 11100 Euclid Ave, Cleveland, OH 44106 (email: farukorge@ gmail.com). Copyright Ó 2015 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2015.02.013
Journal of AAPOS
lacrimal pump.4,6 Placement of the stent can be challenging in canalicular repairs, especially in patients with a narrow canaliculus, sunken eye sockets, severe eyelid edema, and persistent bleeding.7 Irrigating air, water, and colored or viscous agents through the intact canaliculus have been suggested to facilitate locating the torn canaliculus.6,8 We have found that deploying viscoelastic superficially in the vicinity of the injured canaliculus and then injecting it into the proximal torn end when the canaliculus is visible helps to retract the surrounding tissue and tamponade any slow, persistent bleeding for improved visualization. This also dilates the torn canaliculus, allowing for easier intubation and avoids any risk of iatrogenic injury of the intact canaliculus during repair. We report our experience in repairing pediatric canalicular lacerations using the viscoelasticassisted technique with a Monoka monocanalicular stent (FCI Ophthalmics, Marshfield Hills, MA).
Subjects and Methods The medical records of pediatric patients with canalicular trauma who presented to the emergency department at Rainbow Babies & Children’s Hospital, Cleveland, Ohio, or were referred to the pediatric ophthalmology service for treatment from January 2008 to December 2014 were retrospectively reviewed. The
217
218
€ Orge and Dar
Volume 19 Number 3 / June 2015
FIG 1. Identification of the proximal torn canaliculus (arrow).
FIG 2. Proximal torn edge with injected viscoelastic (arrow).
author (FO) repaired all cases. Case Medical Center University Hospitals Institutional Review Board approval was obtained for this study. All patients underwent repair under general anesthesia. The surgical site was prepared with betadine 5% solution after which an examination was performed to confirm a canalicular tear. An attempt was made to locate the proximal torn canaliculus by deploying viscoelastic over the tissue in the vicinity of the canalicular laceration. At no time was viscoelastic injected into the intact canaliculus. The viscoelastic helped to retract the surrounding tissue and tamponade any slow, persistent bleeding, aiding in magnification and visualization of the torn proximal edge. As soon as it was identified viscoelastic was then injected directly into the injured canaliculus, both dilating and lubricating it for easier intubation (Figure 1). Using a dilator, the lacrimal punctum was then dilated and the Ritleng stent introducer was passed through the punctum and distal lacerated canaliculus into the proximal canaliculus (Figure 2). Caution was taken not to injure the punctum. The introducer was then passed through the nasolacrimal duct into the nasal cavity. The polypropylene suture attached to the end of the monocanalicular stent was passed through the introducer and retrieved with the Ritleng hook in the nasal cavity (Figure 3). A separate monocanalicular stent was used for each torn system if both were injured to avoid the risk of failure to both systems if a bicanalicular stent came out earlier than expected. The canaliculus was reapproximated around the silicone stent and sutured with 7-0 polyglactin 910 sutures to help secure the edges and prevent formation of a gap.. The skin was closed with either 7-0 polyglactin 910 or 6-0 plain gut sutures. Without using a seating device, the stent was then pulled from the nasal cavity such that the colarette fit into the punctum and was cut at the level of the inferior turbinate. It was left in place for up to 6 months and was removed in the clinic. Dye disappearance tests were performed to confirm patency of the lacrimal system.
cases, the injury was located in the lower lid; in 4 cases, in the upper lid; and in 2 cases, in both the upper and lower lids. Mechanisms of injury included dog bite (9 patients) and shearing trauma (8 patients). All patients had good anatomic repair, without iatrogenic injury to the intact canaliculus, when present, and the punctum. In 1 patient the injured superior canaliculus could not be located because of severe damage by a dog bite. However, the patient was asymptomatic, because the lower canalicular system was successfully repaired. All patients had negative dye disappearance tests and were free of tearing on follow-up.
Results A total of 38 cases of lid lacerations were reviewed, of which the 17 with canalicular involvement were included. Mean patient age was 6.27 years (range, 1-12 years). In 11
Discussion Repair of canalicular tears can often be complicated by an inability to locate the proximal end of the torn canaliculus.3,4,6,7 This step may be complicated by an injury altering the anatomy or profuse bleeding, making the canaliculus more difficult to locate. The viscoelastic method described here provides several benefits. It helps retract the surrounding tissue and tamponade any bleeding, aids in both dilating and lubricating the torn canaliculus for easier intubation, and avoids iatrogenic injury to the unaffected canaliculus, because we do not probe and introduce a pigtail or directly inject into it. Instead, we only superficially deploy the viscoelastic in the vicinity of the affected location and into the proximal torn end. The viscoelastic’s high viscosity, which makes it tend to linger at the cusp of the cut end of the lumen,6,9 also makes relocating the proximal canalicular edge easier after the surgeon’s attention is drawn away from the torn edge during dilation and passage of an introducer through the lacrimal punctum. The use of viscous substances has previously been reported in the literature, although reports are limited to injection of the intact canaliculus as an aid in location and intubation,6,9 whereas our method can also improve visualization of the operative field. Several disadvantages in the traditional method include the inability to inject air, water, or a viscous substance into an intact canaliculus when both systems are injured and the
Journal of AAPOS
Volume 19 Number 3 / June 2015
FIG 3. Introducer being passed through the punctum into the dilated torn canaliculus (arrow).
€ Orge and Dar
219
injects filtered air through the intact canaliculus while the medial canthus is submerged under normal saline, proving as efficacious as the traditional air-injection method. Unlike both of these methods, ours does not run the risk of injuring the intact canaliculus and is not cumbersome. In conclusion, in our experience deploying viscoelastic superficially in the vicinity of and injecting into the injured canaliculus makes repair easier, more efficient, and avoids the risk of iatrogenic injury to an intact canaliculus. It improves visualization of the operative field, aids in location and dilation of the torn canaliculus initially and in subsequent steps, and eases intubation into the torn canaliculus and nasolacrimal duct. References
occasional need to use a colored substance with the viscoelastic for improved identification, because the dye tends to paint and cloud target areas as and may enter the eye in cases of concurrent globe injury.6,7 Viscoelastic offers several advantages over other methods: it can create a closed system by itself, is innocuous to the body, and can be easily rinsed out on completion of the procedure.9 As a cost saving alternative, hypromellose can be employed with similar results. The air-injection method is commonly employed by experienced lacrimal surgeons: it is safe, easy, and does not obscure the operative field. Originally described by Morrison,10 the technique requires submersion of the medial canthus under saline and injecting air through the intact canaliculus. The exit can be identified where the bubbles escape. Morrison emphasized that in order to form a closed system so the air can only escape from the laceration, the nasolacrimal ostium must be blocked.10 If regional block or local anesthesia is used, the patient can blow air through the nose to facilitate the surgeon’s identifying the location of the torn edge.10 Liu and colleagues7 also described a novel air-injection method utilizing a side port stainless steel probe with a closed round tip that
Journal of AAPOS
1. Kennedy RH, May J, Dailey J, Flanagan JC. Canalicular laceration. An 11-year epidemiologic and clinical study. Ophthal Plast Reconstr Surg 1990;6:46-53. 2. Kersten RC, Kulwin DR. “One-stitch” canalicular repair. A simplified approach for repair of canalicular laceration. Ophthalmology 1996; 103:785-9. 3. Naik MN, Kelapure A, Rath S, Honavar SG. Management of canalicular lacerations: epidemiological aspects and experience with MiniMonoka monocanalicular stent. Am J Ophthalmol 2008;145:375-80. 4. Wu SY, Ma L, Chen RJ, Tsai YJ, Chu YC. Analysis of bicanalicular nasal intubation in the repair of canalicular lacerations. Jpn J Ophthalmol 2010;54:24-31. 5. Eo S, Park J, Cho S, Azari KK. Microsurgical reconstruction for canalicular laceration using Monostent and Mini-Monoka. Ann Plast Surg 2010;64:421-7. 6. Reifler DM. Management of canalicular laceration. Surv Ophthalmol 1991;36:113-32. 7. Liu B, Li Y, Long C, et al. Novel air-injection technique to locate the medial cut end of lacerated canaliculus. Br J Ophthalmol 2013;97: 1508-9. 8. Kwitny A, Baker JD. Functional results of the surgical repair of a lacerated canaliculus in children. J Pediatr Ophthalmol Strabismus 2011;48:117-19. 9. Liang X, Liu Z, Li F, et al. A novel modified soft probe for identifying the distal cut end in single canalicular laceration. Br J Opthalmol 2013;97:665-6. 10. Morrison FD. An aid to repair of lacerated tear ducts. Arch Ophthalmol 1964;72:341-2.
Canalicular lacerations are common complications of eyelid trauma in the pediatric population. Irrigating air, water, and colored or viscous agents through the intact canaliculus have been suggested to identify the torn proximal edge. We report our experience in repairing canalicular lacerations using a novel viscoelastic injection technique with a Monoka monocanalicular stent.
METHODS
The medical records of patients \18 years of age who underwent repair of a canalicular laceration with a monocanalicular stent using superficial viscoelastic deployment to locate the torn canaliculus were retrospectively reviewed. Demographics, cause of eyelid injury, surgical management using our novel viscoelastic injection technique, and outcome were analyzed.
RESULTS
A total of 38 children with lid lacerations were identified, of whom the 17 with canalicular involvement were included (mean age, 6.27 years). Canalicular injury in these 17 was due to dog bite (9 patients) and shearing trauma (8 patients). In 11 patients, the injury was located in the lower lid; in 4, the upper lid; and in 2, combined upper and lower lids. All patients had good anatomic repair and on follow-up had negative dye disappearance tests and were free of tearing.
CONCLUSIONS
Deploying viscoelastic superficially near, and injecting into the injured canaliculus can improve visualization of the operative field by retracting the surrounding tissue and tamponading any bleeding, which aids in location and dilation of the torn canaliculus initially and in subsequent steps, eases intubation into the lubricated torn canaliculus and nasolacrimal duct, and avoids iatrogenic injury to an uninjured canaliculus. ( J AAPOS 2015;19:217-219)
C
analicular lacerations are common complications of eyelid trauma in children. Without proper repair, lacerations can lead to scarring and stenosis and subsequently epiphora, a complication more common in bicanalicular injuries or when no canalicular stent is placed at time of surgical repair.1-4 Successful canalicular repair requires approximation of the divided canaliculus around a stent in order to provide patency for the lacrimal drainage system and closure of the surrounding eyelid soft tissue.4,5 Locating the injured canaliculus requires a thorough understanding of medial canthal anatomy, especially in lacerations close to the lacrimal sac, because different portions of the orbicularis muscle insert on the lacrimal fascia and anterior and posterior lacrimal crests to form the
Author affiliations: Department of Ophthalmology, Case Western Reserve Medical Center University Hospitals, Cleveland, Ohio Submitted August 1, 2014. Revision accepted February 13, 2015. € Correspondence: Faruk H. Orge, MD, Department of Ophthalmology, Case Medical Center University Hospitals, 11100 Euclid Ave, Cleveland, OH 44106 (email: farukorge@ gmail.com). Copyright Ó 2015 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2015.02.013
Journal of AAPOS
lacrimal pump.4,6 Placement of the stent can be challenging in canalicular repairs, especially in patients with a narrow canaliculus, sunken eye sockets, severe eyelid edema, and persistent bleeding.7 Irrigating air, water, and colored or viscous agents through the intact canaliculus have been suggested to facilitate locating the torn canaliculus.6,8 We have found that deploying viscoelastic superficially in the vicinity of the injured canaliculus and then injecting it into the proximal torn end when the canaliculus is visible helps to retract the surrounding tissue and tamponade any slow, persistent bleeding for improved visualization. This also dilates the torn canaliculus, allowing for easier intubation and avoids any risk of iatrogenic injury of the intact canaliculus during repair. We report our experience in repairing pediatric canalicular lacerations using the viscoelasticassisted technique with a Monoka monocanalicular stent (FCI Ophthalmics, Marshfield Hills, MA).
Subjects and Methods The medical records of pediatric patients with canalicular trauma who presented to the emergency department at Rainbow Babies & Children’s Hospital, Cleveland, Ohio, or were referred to the pediatric ophthalmology service for treatment from January 2008 to December 2014 were retrospectively reviewed. The
217
218
€ Orge and Dar
Volume 19 Number 3 / June 2015
FIG 1. Identification of the proximal torn canaliculus (arrow).
FIG 2. Proximal torn edge with injected viscoelastic (arrow).
author (FO) repaired all cases. Case Medical Center University Hospitals Institutional Review Board approval was obtained for this study. All patients underwent repair under general anesthesia. The surgical site was prepared with betadine 5% solution after which an examination was performed to confirm a canalicular tear. An attempt was made to locate the proximal torn canaliculus by deploying viscoelastic over the tissue in the vicinity of the canalicular laceration. At no time was viscoelastic injected into the intact canaliculus. The viscoelastic helped to retract the surrounding tissue and tamponade any slow, persistent bleeding, aiding in magnification and visualization of the torn proximal edge. As soon as it was identified viscoelastic was then injected directly into the injured canaliculus, both dilating and lubricating it for easier intubation (Figure 1). Using a dilator, the lacrimal punctum was then dilated and the Ritleng stent introducer was passed through the punctum and distal lacerated canaliculus into the proximal canaliculus (Figure 2). Caution was taken not to injure the punctum. The introducer was then passed through the nasolacrimal duct into the nasal cavity. The polypropylene suture attached to the end of the monocanalicular stent was passed through the introducer and retrieved with the Ritleng hook in the nasal cavity (Figure 3). A separate monocanalicular stent was used for each torn system if both were injured to avoid the risk of failure to both systems if a bicanalicular stent came out earlier than expected. The canaliculus was reapproximated around the silicone stent and sutured with 7-0 polyglactin 910 sutures to help secure the edges and prevent formation of a gap.. The skin was closed with either 7-0 polyglactin 910 or 6-0 plain gut sutures. Without using a seating device, the stent was then pulled from the nasal cavity such that the colarette fit into the punctum and was cut at the level of the inferior turbinate. It was left in place for up to 6 months and was removed in the clinic. Dye disappearance tests were performed to confirm patency of the lacrimal system.
cases, the injury was located in the lower lid; in 4 cases, in the upper lid; and in 2 cases, in both the upper and lower lids. Mechanisms of injury included dog bite (9 patients) and shearing trauma (8 patients). All patients had good anatomic repair, without iatrogenic injury to the intact canaliculus, when present, and the punctum. In 1 patient the injured superior canaliculus could not be located because of severe damage by a dog bite. However, the patient was asymptomatic, because the lower canalicular system was successfully repaired. All patients had negative dye disappearance tests and were free of tearing on follow-up.
Results A total of 38 cases of lid lacerations were reviewed, of which the 17 with canalicular involvement were included. Mean patient age was 6.27 years (range, 1-12 years). In 11
Discussion Repair of canalicular tears can often be complicated by an inability to locate the proximal end of the torn canaliculus.3,4,6,7 This step may be complicated by an injury altering the anatomy or profuse bleeding, making the canaliculus more difficult to locate. The viscoelastic method described here provides several benefits. It helps retract the surrounding tissue and tamponade any bleeding, aids in both dilating and lubricating the torn canaliculus for easier intubation, and avoids iatrogenic injury to the unaffected canaliculus, because we do not probe and introduce a pigtail or directly inject into it. Instead, we only superficially deploy the viscoelastic in the vicinity of the affected location and into the proximal torn end. The viscoelastic’s high viscosity, which makes it tend to linger at the cusp of the cut end of the lumen,6,9 also makes relocating the proximal canalicular edge easier after the surgeon’s attention is drawn away from the torn edge during dilation and passage of an introducer through the lacrimal punctum. The use of viscous substances has previously been reported in the literature, although reports are limited to injection of the intact canaliculus as an aid in location and intubation,6,9 whereas our method can also improve visualization of the operative field. Several disadvantages in the traditional method include the inability to inject air, water, or a viscous substance into an intact canaliculus when both systems are injured and the
Journal of AAPOS
Volume 19 Number 3 / June 2015
FIG 3. Introducer being passed through the punctum into the dilated torn canaliculus (arrow).
€ Orge and Dar
219
injects filtered air through the intact canaliculus while the medial canthus is submerged under normal saline, proving as efficacious as the traditional air-injection method. Unlike both of these methods, ours does not run the risk of injuring the intact canaliculus and is not cumbersome. In conclusion, in our experience deploying viscoelastic superficially in the vicinity of and injecting into the injured canaliculus makes repair easier, more efficient, and avoids the risk of iatrogenic injury to an intact canaliculus. It improves visualization of the operative field, aids in location and dilation of the torn canaliculus initially and in subsequent steps, and eases intubation into the torn canaliculus and nasolacrimal duct. References
occasional need to use a colored substance with the viscoelastic for improved identification, because the dye tends to paint and cloud target areas as and may enter the eye in cases of concurrent globe injury.6,7 Viscoelastic offers several advantages over other methods: it can create a closed system by itself, is innocuous to the body, and can be easily rinsed out on completion of the procedure.9 As a cost saving alternative, hypromellose can be employed with similar results. The air-injection method is commonly employed by experienced lacrimal surgeons: it is safe, easy, and does not obscure the operative field. Originally described by Morrison,10 the technique requires submersion of the medial canthus under saline and injecting air through the intact canaliculus. The exit can be identified where the bubbles escape. Morrison emphasized that in order to form a closed system so the air can only escape from the laceration, the nasolacrimal ostium must be blocked.10 If regional block or local anesthesia is used, the patient can blow air through the nose to facilitate the surgeon’s identifying the location of the torn edge.10 Liu and colleagues7 also described a novel air-injection method utilizing a side port stainless steel probe with a closed round tip that
Journal of AAPOS
1. Kennedy RH, May J, Dailey J, Flanagan JC. Canalicular laceration. An 11-year epidemiologic and clinical study. Ophthal Plast Reconstr Surg 1990;6:46-53. 2. Kersten RC, Kulwin DR. “One-stitch” canalicular repair. A simplified approach for repair of canalicular laceration. Ophthalmology 1996; 103:785-9. 3. Naik MN, Kelapure A, Rath S, Honavar SG. Management of canalicular lacerations: epidemiological aspects and experience with MiniMonoka monocanalicular stent. Am J Ophthalmol 2008;145:375-80. 4. Wu SY, Ma L, Chen RJ, Tsai YJ, Chu YC. Analysis of bicanalicular nasal intubation in the repair of canalicular lacerations. Jpn J Ophthalmol 2010;54:24-31. 5. Eo S, Park J, Cho S, Azari KK. Microsurgical reconstruction for canalicular laceration using Monostent and Mini-Monoka. Ann Plast Surg 2010;64:421-7. 6. Reifler DM. Management of canalicular laceration. Surv Ophthalmol 1991;36:113-32. 7. Liu B, Li Y, Long C, et al. Novel air-injection technique to locate the medial cut end of lacerated canaliculus. Br J Ophthalmol 2013;97: 1508-9. 8. Kwitny A, Baker JD. Functional results of the surgical repair of a lacerated canaliculus in children. J Pediatr Ophthalmol Strabismus 2011;48:117-19. 9. Liang X, Liu Z, Li F, et al. A novel modified soft probe for identifying the distal cut end in single canalicular laceration. Br J Opthalmol 2013;97:665-6. 10. Morrison FD. An aid to repair of lacerated tear ducts. Arch Ophthalmol 1964;72:341-2.
