This article is more than 5 years old. Information may no longer be current.
Surgeons explain how to perform canaliculo-canalicular intubation
A surgical technique for intubating an avulsed proximal canalicular defect at the level of common canaliculus is discussed.
Click Here to Manage Email Alerts
Canalicular lacerations are most common among young adults with a mean age range of 18 to 30 years. In toddlers, dog bites are commonly responsible for canalicular lacerations. Although males are more often victims of lacrimal system injury, there is no racial predilection for such injuries.
These injuries may be classified as either direct penetrating or avulsive blunt injuries. In one study of 236 patients, penetrating injuries accounted for 55.2%, whereas avulsive blunt injuries represented 45.7% of the canalicular lacerations. Direct trauma causing canalicular laceration includes injury with objects, such as knives, coat hangers or glass, dog bites, cat claws or fingernail injury. Indirect trauma can be caused by facial blows, accidental falls onto blunt objects or impact with blunt weapons.
The eyelid margin can be divided into a larger, flat, palpebral part that is lined with lashes anteriorly and meibomian gland orifices posteriorly, and a smaller lacrimal part that is round and devoid of lashes. Eyelid canalicular lacerations usually represent the most common cause of injury to the lacrimal system. This is partly due to the canalicular system being superficially located in the medial aspect of the eyelid.
Anatomically, the lacrimal drainage system consists of a 2-mm vertical portion originating from the punctum, followed by an 8-mm horizontal portion located in the lacrimal segment of the lid, about 2 mm from the lid margin — hence its vulnerability to traumatic injuries. The medial canthal ligament is often disrupted, as well, secondary to trauma. If this occurs, it should also be repaired in order to facilitate lid function and restore appropriate anatomic position for overall optimal postsurgical results.
In more than 50% to 75% of such cases, the inferior canaliculus is involved. It is often said that in any lid laceration medial to the pupil, the canaliculus is involved until proven otherwise. However, in any acute traumatic injury, life-threatening injuries take priority.
It is also important to mention that while attending to a canalicular lid laceration, one should ensure there are no vision-threatening injuries, such as an open globe, and explore the possibility of an associated orbital injury. Ocular injury, including corneal abrasion, traumatic hyphema and an open globe, may coexist with eyelid laceration in up to two-thirds of cases. A comprehensive management approach consists of a good history; a detailed examination, including recording the visual acuity; and appropriate imaging studies. Each component is important to achieving an optimal postsurgical outcome for the patient and better medico-legal coverage for the surgeon.
Beyond the actual eyelid injury, the degree of tissue contamination and the possibility of retained foreign bodies should be kept in focus. Furthermore, projecting objects from a traumatic wound may be associated with possible intracranial injury and, as such, should not be removed until proper imaging studies indicate it is safe to do so. Postoperatively, broad-spectrum systemic antibiotics should be administered along with topical ophthalmic antibiotic coverage.
Although an early repair within 48 hours of injury may be optimal in most cases, a waiting period of up to 5 days after injury often does not compromise the postoperative success in a high percentage of these cases.
In this column, Drs. Carey, Snyder and Slonim describe their surgical technique for the management of canalicular laceration repair.
Thomas “TJ” John, MD
OSN Surgical Maneuvers Editor
The purpose of this article is to describe a surgical technique for intubating an avulsed proximal canalicular defect at the level of the common canaliculus, where direct suture anastomosis is not possible and the uninvolved canalicular system is anatomically intact.
Canalicular lacerations are typically the result of direct trauma to the face, eyes and/or orbits. One-half to two-thirds of canalicular injuries occur in the lower system, and only about 10% to 12% involve both the upper and lower systems. Without repair, approximately 50% of patients will experience epiphora, with only one patent canalicular system.
Traumatic loss of either the upper or lower system may result in epiphora, as it appears that the task of draining tears is divided in most individuals, although one system may be dominant. Some surgeons will not attempt a repair of the upper canalicular system, whereas the vast majority will make every attempt to repair a lower canalicular laceration.
Charles B. Slonim
Normally, canalicular lacerations are repaired by approximating the proximal and distal ends of the lacerated canaliculus around a stent of silicone tubing. When utilizing silicone tubing stents, both ends of the lacerated canaliculus must be identified and isolated. On occasion, the proximal end of the canaliculus is avulsed at or near the common canaliculus/lacrimal sac junction. This makes performing a suture anastomosis of the two canalicular ends virtually impossible. The technique described below approximates the proximal end of the traumatized canaliculus to the patent canalicular system of the uninvolved eyelid without sutures but with a silicone tubing stent in place.
Patency of the uninvolved canaliculus must be confirmed by irrigation. Our technique is an attempt to re- establish canalicular patency of the involved canaliculus when suture anastomosis is not possible by using the patency of the uninvolved canaliculus as a guide to successful intubation. It is an attempt to prevent the need for future conjunctivodacryocystorhinostomy with Jones tube placement due to obstruction at the level of the common canaliculus, especially in a lower lid canalicular avulsion.
Surgical procedure
This procedure can be performed under regional anesthesia with monitored anesthesia care or under general anesthesia. Local infiltration may distort the involved anatomy. Regional periorbital blocks of the infraorbital and infratrochlear nerves are performed using a 50/50 mixture of 0.75% bupivacaine and 2% lidocaine with epinephrine. Additional local anesthesia may be required. Topical anesthetic drops are instilled into the conjunctival sac before the regional blocks.
Figure 1. A pigtail probe with a suture eyelet at its tip is introduced into the uninvolved canaliculus and advanced until it becomes visible in the wound.
Images: Slonim CB
Figure 2. A 7-0 silk suture is threaded through the eyelet hole of the pigtail probe using its needle and then passed through the lumen of the loose end of the silicone tubing of the pre-placed Mini Monoka from the involved canaliculus. The needle is passed out of the tubing lumen approximately 3 mm to 4 mm beyond the lumen entrance. The suture is tied securely, which draws the silicone tubing lumen against the end of the pigtail probe.
Figure 3. The 7-0 silk is cut to release the tubing from the pigtail probe. The tubing is then trimmed flush to the uninvolved punctum.
The punctum of the traumatized lid is dilated with punctal dilators and probed with a 00-Bowman canalicular probe. The proximal end of the horizontal canaliculus is identified. In the case shown, it has already been determined that a suture repair of the end is not possible due to anatomic position of the laceration (ie, at or near the common canaliculus). All attempts to intubate the proximal end of the common canaliculus had failed.
The punctum and remaining canaliculus of the involved eyelid are intubated using a Mini Monoka (FCI Ophthalmics). The Mini Monoka punctal plug is seated into the punctum and vertical canaliculus, and the loose end of the tubing is pulled through the cut end of the traumatized canaliculus. A pigtail probe with a suture eyelet at its tip is introduced into the uninvolved canaliculus and advanced until it becomes visible in the wound (Figure 1).
A 7-0 silk suture is threaded through the eyelet hole of the pigtail probe using its needle and passed through the lumen of the loose end of the silicone tubing of the preplaced Mini Monoka from the involved canaliculus. The needle is passed out of the tubing lumen approximately 3 mm to 4 mm beyond the lumen entrance. The suture is tied securely, which draws the silicone tubing lumen against the end of the pigtail probe (Figure 2).
The pigtail probe is then briskly reversed and removed from the uninvolved canaliculus, which pulls the silicone tubing into the uninvolved canalicular system at the common canaliculus, through the uninvolved canaliculus and out the punctum.
The 7-0 silk is cut to release the tubing from the pigtail probe. The tubing is then trimmed flush to the uninvolved punctum (Figure 3).
Conclusions
This technique re-establishes patency of the lacerated canalicular system by placing a silicone tubing stent through the proximal end of the lacerated canaliculus and into the distal end of the lacerated canaliculus at or near the common canaliculus/lacrimal sac junction to join the patent canalicular system of the uninvolved canaliculus. The goal is to allow tears to wick along the silicone tubing into the common canaliculus using the patency of the uninvolved canalicular system.
The benefit of this technique is that the patient is offered a chance at reanastomosis before considering a conjunctivodacryocystorhinostomy. This procedure provides an attempt at a closer approximation to the natural lacrimal drainage system. The technique is not appropriate for patients who have lacerated both the upper and lower canalicular systems.