In the presence of continued risk factors (inflammation, infection, medication use), stenosis/obstruction can worsen.
Without intervention, tearing generally remains constant.
- Steroid drops or ointment for inflammatory conditions
- Discontinue causative medications.
- Punctoplasty: Punctal stenosis
- One-snip, two-snip, or three-snip technique can be used to open the punctum.
- Can consider silicone intubation
- Chalvatzis et al. reported improved relief of epiphora with the use of bicanalicular stents after punctoplasty (Chalvatzis, OPRS 2013).
- Silicone intubation: Partial canalicular stenosis
- Often used as an adjunct to another procedure
- A variety of intubation systems can be used, including Crawford, Ritleng, Monoka, and so on
- If primarily intubating with a bicanalicular stent, the stent can be placed in the canaliculi and retrieved beneath the inferior turbinate.
- Hussain et al. reported 82% rate of significant improvement with the use of mini-monoka stents (Hussain, Br J Ophthalmol 2012).
- Balloon canaliculoplasty: Partial canalicular stenosis
- A guide wire is passed into the canaliculus and a balloon catheter is placed over it.
- The balloon is then inflated to 8–9 bar for 30 seconds to 5 minutes, deflated, then re-inflated for a shorter period.
- Can consider silicone intubation
- Zoumalan et al. found improvement in 76.2% of eyes with canaliculoplasty and silicone stenting (Zoumalan, OPRS 2010).
- Surgical excision of focal obstruction
- If focal obstruction is suspected, obstructed portion of the canalicular system can be excised followed by reapproximation of the patent system over a bicanalicular or monocanalicular stent.
- Success has been described with double stent intubation.
- Canalicular trephination: Proximal and distal obstructions
- Essentially, cuts through the obstruction
- Silicone stents may then be placed
- Most successful for distal obstructions
- Khoubian et al. (Khoubian, OPRS 2006)
- 41 eyes underwent trephination and stenting.
- 49% experienced complete relief of epiphora, 38% had partial relief.
- Among those with distal lower canalicular obstructions, 80% experienced complete relief.
- Among patients with distal bicanalicular obstructions,
- 66% complete resolution of symptoms
- 59% with common canalicular obstructions experienced complete relief.
- 55% with proximal bicanalicular obstructions experienced partial relief (45% experienced no relief).
- Retrograde intubation dacryocystorhinostomy (DCR)
- External DCR approach is first accomplished without intubation.
- Retrograde intubation is then performed through the lacrimal sac, and a pseudopunctum is made at the site of the obstruction.
- Stent can then be passed through the patent canaliculus and then into the nose.
- This procedure may eliminate the need for a conjunctivodacryocystorhinostomy.
- Wearne et al. performed 123 such procedures, and reported a significant improvement in epiphora in 73% (Wearne, Ophthalmology 1999).
- DCR with membranectomy: Distal obstruction
- Membrane or obstruction can be incised during external DCR.
- Probe is placed in the canaliculus and used to tent the membrane; membrane is then incised with a blade allowing the passage of stents.
- Borboridis et al. reported a 92% anatomic success rate with this technique (Boboridis, Am J Ophthalmol 2005).
- Endocanalicular laser surgery (Liarakos, Curr Opin Ophthalmol 2009)
- Endocanalicular probe is placed in the canaliculus and a laser (holmium, erbium, or potassium-titanium phosphate) is used at the site of the obstruction.
- Silicone intubation is then performed.
- Conjunctivodacryocystorhinostomy (CDCR) (Lim, Am J Ophthalmol 2004)
- Final step in treatment of extensive canalicular obstruction
- External DCR or endoscopic DCR approach can be taken; osteotomy is performed and lacrimal sac is opened.
- Jones tube is then placed through the conjunctiva/caruncle into the nasal passage.
- Typically, the distal end is approximately 2 mm inside the nose, not touching the nasal septum.
Other management considerations
In cases of chemical or thermal burns, one can consider placing silicone tubes preemptively to prevent canalicular stenosis (Meyer, Arch Ophthalmol 1995).
Control other medical conditions simultaneously (ensure resolution of pre-existing malignancy, medical management of OCP, and so on).
Common treatment responses, follow-up strategies
If stents are placed, they can be kept in position for 6 weeks to indefinitely — if patient has resolution of symptoms with stents in place.