Trauma to the Lacrimal System in Children

To evaluate the success rate of a simple surgical method for the treatment of a monocanalicular lacrimal lesion.

Retrospective noncomparative case series.

Thirteen consecutive patients with monocanalicular trauma who were seen from August 1995 to March 1998. In six patients, the canaliculus was lacerated as a result of an external injury and in seven patients as a result of tumor removal (iatrogenic injury).

Reapproximation of the orbicularis muscle and skin overlying the torn canaliculus without reanastomosis of the lacerated canaliculus. In those patients in whom the canaliculus was sacrificed as part of the removal of an eyelid tumor, no attempt was made to reconstruct the canaliculus.

Symptomatology, patency of the lacrimal passage, fluorescein dye disappearance test, and patient satisfaction.

In all patients the injured canaliculus was totally blocked, but despite this none of the patients complained of inconvenient tearing either indoors or outdoors. The ipsilateral unharmed canaliculus was functioning normally in such a way that the fluorescein dye instillation test showed residual dye in six patients after 2 minutes and in none of the patients after 5 minutes. All patients were satisfied with the functional and cosmetic result.

Nonrepair of a monocanalicular lesion is a valid approach that results in little or no morbidity.

Injuries of the lacrimal system are occasionally associated with maxillofacial trauma. Detailed knowledge of the anatomy of the lacrimal apparatus is essential for optimal treatment of these injuries. The partinent anatomy is reviewed. Techniques for the diagnoses and repair of lacrimal injuries specific to the canaliculi are presented and discussed with emphasis on early detection and intervention.

Background: It has been widely believed that direct microsurgical re-anastomosis of the canalicular epithelium is necessary for satisfactory repair of canalicular lacerations. However, because repair is carried out in conjunction with placement of an indwelling silicone stent, this stent should keep the canalicular edges adequately approximated without the need for suturing. The authors report their results in repairing canalicular lacerations using a single, fine, horizontal, mattress suture to re-approximate the overlying pericanalicular orbicularis muscle and eliminate direct microsurgical re-anastomosis of the canalicular epithelium.

Methods: The authors retrospectively reviewed the charts of 67 patients who underwent repair of lacerated canaliculi with one-stitch re-approximation of the overlying orbicularis muscle in conjunction with bicanalicular silicone tube intubation. Stents were left in place for 3 months postoperatively and then removed. Probing across the lacerated portion of the canaliculus was carried out at the time of stent removal to ensure patency. Dye disappearance testing with 2% fluorescein and irrigation through the canaliculus then was performed 6 weeks to 3 months after stent removal.

Results: Of the 67 patients, 59 were followed to stent removal. Probing with a 00 probe showed canalicular patency in all 59 patients. Irrigation resulted in reflux in two patients, indicating unrelated nasolacrimal duct obstruction. Of these 59 patients, 45 complied with scheduled follow-up 6 weeks to 3 months after stent removal. Dye disappearance testing using 2% fluorescein demonstrated delay in lacrimal outflow in 6 of the 45 patients. Only two patients had symptomatic epiphora, and in both patients there was an underlying nasolacrimal duct obstruction confirmed by irrigation.

Conclusions: Simple re-approximation of the lacerated overlying soft tissue combined with bicanalicular silicone intubation proved highly successful in managing canalicular lacerations. Probing through the lacerated canaliculus demonstrated patency in 100% of the 59 patients followed to stent removal. Only 4% of patients had symptomatic epiphora postoperatively, and 13% demonstrated some delay in outflow with dye disappearance testing. This compares very favorably with previous reported series in which lacerated canaliculi were microsurgically re-anastomoed.

Although canalicular injuries are relatively common, controversy persists regarding indications for repair and the surgical methods that should be employed. In this review, these various treatment philosophies and techniques are analyzed in an historical and a contemporary context. The surgical anatomy, epidemiology and clinical presentation of canalicular injuries are discussed. Inconsistencies in current nomenclature regarding the surgical anatomy of canalicular lacerations are analyzed. Recent studies of lacrimal drainage in systems with monocanalicular obstruction are cited. Various surgical techniques in the repair of canalicular injuries are reviewed, including methods of identifying the medial lacerated lacrimal passages and the various lacrimal stents that have been used. The current popularity of silicone tubing as a lacrimal stent is reviewed. The various methods of stent placement and fixation are systematically categorized. Case series of canalicular repair reported in the literature are reviewed, and the results and complications are compared.