Three_ Snip Punctoplasty versus Perforated Plug for Management of Lacrimal Punctal Stenosis

 INTRODUCTION

The lacrimal punctum is a 0.3-mm opening on the medial side of the eyelid. It is rounded or ovoid in young persons and usually collapses into fish-mouth with aging. The punctum sits on a raised mound called "papilla lacrimalis" and is encircled with a fibrous ring ¹.

Punctal stenosis is frequently associated with epiphora. This condition is either congenital or acquired.The plugs was first introduced by ² with a 0.6 mm central perforation to allow tear drainage. Because of the hydrophilic nature, the punctum either undergoes narrowing or stenosis. It is defined as a punctal diameter 3.

Management includes frequent mechanical and balloon dilation, punctum snip surgeries, and various stenting techniques ⁴.

Silicon material, collected secretions might occlude punctal lumen. Coating of PPP with polyvinylpyrrolidone (PVP) increases their

hydrophobicity and permits the drainage of tears and debris through the perforation ⁵.

A variety of punctoplasty procedures have been used in treating punctal stenosis including one-snip procedure, two-snip procedure, and TSP. The latter could be further divided into a rectangular and triangular surgeries ⁶.

In the current work, polyvinylpyrrolidone PPP and TSP were compared in terms of anatomic and functional outcomes as a treatment for epiphora linked with punctal stenosis.

PATIENTS AND METHODS

This study is a non-randomized, interventional, prospective, comparative investigation, carried out on 20 eyes of 10 cases complaining of bilateral punctal stenosis and epiphora, divided into 2 groups. Group A was managed by rectangular TSP of the inferior punctum while group B was managed by PVP-coated PPP inserted in the inferior punctum. The study was performed in Egypt's Al-Azhar University Hospitals' ophthalmology department. Inclusion criteria: All patients have epiphora caused by punctal stenosis.

Exclusion criteria: Include congenital and allergic punctal stenoses, canalicular, lacrimal sac or naso-lacrimal duct occlusion, malpositions and inflammation of the eyelid, ocular surface diseases, and keratoconjunctivitis sicca. Furthermore, cases with a history of irradiation therapy, prior lid or lacrimal surgeries was also ruled out.

Table 1: Munk classification for epiphora 7.

Pre-procedural assessment: Patients were selected randomly from those coming to Al-Azhar University hospitals. All participants in this study were subjected to the following:

History taking in terms of age, sex, main symptoms, onset of epiphora and its grade based on Munk scale (Table 1) (Dudeja et al., 2015)7, history of any topical or systemic medications and history of any surgeries or trauma.

Tear meniscus height measured (according to munk score).

Table 2: Punctal stenosis grading based on Kashkouli et al.’s score8 (Kashkouli et al., 2018)9.

Ophthalmological evaluation: Best corrected visual acuity, slit lamp examination to determine any ocular disease and punctal occlusion grade based on Kashkouli scale8 (Kashkouli et al., 20189) (Table 2).

Grade Clinical findings

2% fluorescein dye disappearance (FDD) test was performed and scored. The test underwent grading based on 5. scale that rely on with time needed for dye clearance where Grade 1 is 5 min.

Syringing and probing to rule out any lacrimal pathway obstruction.

Procedures: Operations were done under local or general anesthesia according to the patient cooperativity and age.

As regard the first procedure;

Perforated punctal plug: The plug consists of silicone and coated with a polyvinylpyrrolidone layer to make the surface smooth; thus avoiding collection of debris on surface and to increase drainage with a 0.6 mm central hole. The plug underwent preloading on a disposable plug inserter to promote the insertion. Insertion procedure: Benoxinate HCL 0.4% was utilized to achieve surface anaesthesia. Nettle ship dilator was utilized to perforate any membrane that covers the inferior punctum, then underwent vertical introduction for punctal dilatation. Further dilation was achieved by utilizing the insertor's dilator end. Plugs were then placed in the proper plane (the high end of the collar is directed towards the punctum's lateral side). The plug was introduced gently in a vertical and gradual way. After that, it was released from the inserter by pressing its lever until its entire end passed into the punctum. Patients applied moxifloxacin 0.5% and fluorometholone 0.1% eye drops 4 times a day for 7 days. Removal of the plug was performed with topical anaesthesia by fine-toothed forceps while the case was on slit lamp

As regard the second procedure:

3-Snip Operation: Punctoplasty was performed with 2% lignocaine and 1:200 000 adrenaline under general or local anesthesia. The punctal sites were found with a punctum seeker and marked. A 25/27-G needle was used to perforate the membranes protecting the punctum location as needed. The punctum was sufficiently dilated to enable toothed microforceps to grab the ampulla's posterior wall. Throughout the operation, the microforceps must keep their grasp on the posterior wall. With three snips, the posterior wall of the ampulla was excised with Vannas scissors, the first two downward on every side of the forceps and the third across the bottom. Remove any punctal tissue that extends 2–3 mm behind the canaliculus's vertical component. To reduce inflammation and potential scarring, cautery has been avoided during the operation. Compression and cold saline alone were sufficient to establish hemostasis in the majority of patients; the usage of a cotton tip applicator dipped in 2.5 % phenylephrine eye drops may further minimize hemorrhage. At the end of the operation, syringing and probing have been conducted to verify the lacrimal drainage system's patency and to look for any related common canaliculus or nasolacrimal duct blockage. For two weeks after surgery, all patients were given a combination of steroid and antibiotic eye drops.

Postoperative follow up:

Recording data from 5 follow up visits within 6 months after the procedure in days 1,7 and after 1,3,6 months. Follow up assessment included the following: Assessment of symptoms (recurrence of epiphora, redness, vision), asking if there is improvement or not. Improvements in subjective epiphora symptoms as measured by the Munk score, the fluorescein disappearing test, the preservation of recently produced punctal openings, and the occurrence of complications.  Slit-lamp biomicroscopic examination was done to assess the punctum. The best corrected visual acuity.

Informed consent: All patients were informed about the details and were asked to provide a written informed consent. Also, any unanticipated dangers that arose over the course of the study were promptly communicated to the participants as well as the ethics committee.

Medical ethical committee: Ethical aspects of this study were checked by medical ethical committee.

Statistical analysis and data interpretation:

Data has been entered into the computer and evaluated by IBM SPSS Corp., which was released in 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. Numbers and percentages have been employed to describe qualitative data. After confirming normality with the Shapiro–Wilk test, quantitative data has been presented employing mean and standard deviation for parametric data. The significance of the obtained findings has been determined at the (0.05) level. Qualitative data: The Chi-Square test is performed to compare two or more groups. When more than 25% of cells in tables (>2*2) contain a count of < 5, the Monte Carlo test is employed as a correction for the Chi-Square test. When > 25% of cells in 2*2 tables had a count of < 5, the Fischer Exact test has been performed to correct the Chi-Square test. Marginal Homogeneity is used to compare more than 2 periods in same group. Quantitative data between groups: parametric tests: A student t-test has been employed to compare two independent groups.

RESULTS

Our study included 20 eyes of 10 cases having bilateral punctal stenosis with epiphora. The patients were classified in 2 groups. Group A underwent rectangular three-snip punctoplasty of the inferior punctum while Group B was managed by PVP coated PPP in the inferior punctum, aiming at comparison of Three_ Snip Punctoplasty and Perforated Plug for treatment of epiphora due to lacrimal punctal stenosis. Twenty-Six cases were examined for involvement in the study with exclusion of 6 patients (not met inclusion criteria) then 20 cases were divided into 2 groups (10 in each group).

t:Student t test, FET: Fischer exact test

Table 3: Comparison of socio-demographic features of the groups tested.

There are no statistically significant differences in age and sex between the tested groups, with the mean ±SD age of group A versus Group B (54.30±13.85 & 60.60±8.15, respectively). Among group A; 60% males versus 70% among group B (Table 3).

FET: Fischer exact test

Table 4: Comparison of Patient satisfaction of the groups tested.

There is no statistically significant difference of patient satisfaction between studied groups with 100% of patients at group B versus 80% of group A are satisfied (Table 4).

Table 5: Comparison of epiphora incidence of the groups tested.

There were no statistically significant differences in epiphora grade before and after surgery between the groups tested. In group A, there is a statistically significant enhancement of epiphora during follow-up; changed from 40% grade 4, grade 5 pre-operative to 80% no epiphora after 1 day, 70% no epiphora after 1 week, 1 month, 3 months and 6 months. Among group B, better improvement is detected as there is no epiphora is detected after 1 day & 1 week and after 1 month, 3 months and 6 months (90%, 80% &80% no epiphora) (Table 5).

MC: Monte Carlo test, FET: Fischer exact test,*Statistically significant

p1: difference between before and one day after surgery; p2: difference between before and one week after surgery; p3: difference between before and one month after surgery; p4: difference between before and three months after surgery; p5: difference between before and six months after surgery.

Grade 0=No epiphora, Grade 1: epiphora require dabbing 10 times/days, Grade5: constant epiphora

MC:Monte Carlo test,FDDT: Fluorescein dye disappearance test, FET: Fischer exact test,*Statistically significant

Table 6: Comparison of fluorescein dye disappearance test grading of the groups tested.

As detected by the fluorescein dye disappearance test, there are no statistically significant differences in grade before and after surgery between the studied groups. There is statistically significant improvement in grade among group A during follow-up; it changed from 20% grade 2, 80% grade 3 pre-operative to 90% grade after 1 day, 80% grade 1 after one week, one month, three months, and six months. Among group B, better improvement is detected as FDD grade 1 is detected after 1 day and 1 week. FDD grade 1 after one month, three months and six months (90% Each) (Table 6).

p1: difference between before and one day after surgery; p2: difference between before and one week after surgery; p3: difference between before and one month after surgery; p4: difference between before and three months after surgery; p5: difference between before and six months after surgery.

FET: Fischer exact test,*Statistically significant

 p1: difference between 1 day &1 week post-operative, p2: difference between 1 day &1 month post-operative, p3: difference between 1day &3 months post-operative, p4: difference between 3&6 months post-operative

Table 7: Comparison of the new punctum opening of the groups tested

There are no statistically significant differences in new punctum opening between the groups tested. Among group A; 30% of cases have closed punctum after 1 week and 20% closed after 1, 3 & 6 months. Among group B; 10% closed after 1, 3 & 6 months. No statistically significant change of new punctum opening during follow up is detected for either groups (Table 7).

FET: Fischer exact test,*Statistically significant

Table 8: Comparison of complications of the groups tested.

3 cases (30%) of group A shows complications without any complications detected for group B (Table 8).