This is a prospective randomized study which included 40 eyelids of 24 patients with acquired lower punctal stenosis grade 1 or grade 2 according to Kashkouli scale. Patients included in the study were recruited from Menoufia University hospitals in the period from January 2019 to June 2020. Informed consent was obtained from all patients, and the study was approved by the institutional review board. All measures were in accordance with the tenets of the Declaration of Helsinki.
All patients of the study were complaining of epiphora which was graded according to Munk score as follows; grade 0: no epiphora, grade1: occasional epiphora requiring drying or dabbing less than twice a day, grade3: epiphora requiring dabbing two to four times per day, grade4: epiphora requiring dabbing five to 10 times per day & grade 5: epiphora requiring dabbing more than ten times daily or constant tearing. [13]
Patients were classified in two groups. Group A patients were treated by triangular 3-snip punctoplasty of the lower punctum followed by three interrupted sutures at the ampulla. Group B patients were treated by conventional triangular 3-snip punctoplasty of the lower punctum.
Inclusion criteria included; primary acquired lower punctal stenosis grade 1 or 2 according to Kashkouli grading, with patent upper punctum and both canaliculi as well as patent nasolacrimal duct revealed after syringing, with normal lower eyelid margin position.
Exclusion criteria included; Patients with Congenital punctal stenosis, Acute conjunctival allergic punctal stenosis, Punctal stenosis associated with radiotherapy, Lid malposition, Canalicular, lacrimal sac and nasolacrimal duct obstruction revealed after syringing, Previous eyelid or lacrimal drainage system surgery, Blepharitis and ocular surface disorders, Patients with dry eye.
A full history was taken and thorough ophthalmological examination was done for all patients including evaluation of proximal lacrimal drainage system regarding punctal orifices position, shape, grading of stenosis according to Kashkouli et al and exclusion of other causes of epiphora rather than punctal stenos. Inspection of face and periorbital region for position of the eyelids and puncta, Gross nasal deformity, Facial symmetry, presence of any swelling or fistula in the lacrimal sac area , palpation of lacrimal sac for regurge test , slitlamp examination of eyelid margin for coaptation with the globe , blepharitis or rubbing lashes , skin for laceration or eczema , conjunctiva for papillae , follicles, hyperemia or discharge , cornea for punctate keratitis, filaments or abrasions , lower Tear meniscus height (TMH) using a 1 mm slit beam.
Fluorescein dye disappearance test (FDDT) where a drop of sterile 2% fluorescein solution or a moistened fluorescein strip is instilled into the conjunctival fornices and tear meniscus was observed after 5 minutes with the help of cobalt-blue filter and results were graded according to Ozgur et al., scale depending on the time of dye clearance as follows; grade1 (<3 minutes), grade2 (3-5 minutes) & grade3 (>5 minutes). [14]
Diagnostic probing and syringing were done to ensure anatomically patent nasolacrimal system and to detect any obstruction distal to the punctum.
Surgical technique
Surgery was performed using an operating microscope under local anaesthesia. We transconjunctivally infiltrate 2% (w/v) lidocaine (with epinephrine in a 1:100,000 weight ratio) from the posterior aspect of the eyelid into the region of the lacrimal canaliculus and punctum. A Nettelship dilator is used to enlarge the stenotic lacrimal punctum. A single blade of a small Westcott spring scissor or Vannus scissor is placed within the ampulla of the lacrimal canaliculus, with the remaining blade placed on the conjunctival surface of the posterior aspect of the eyelid. The first vertical snip is made at the vertical canaliculus. The second vertical snip is made from the edge of the first snip to create a flap. The final horizontal snip was made at the base. The triangular flap is removed and three sutures are placed, in an interrupted manner, at the posterior wall of the ampulla using 10–0 nylon. The sutures are removed 1 week after the surgery. Topical moxifloxacin 0.5% eye drops and fluorometholone 0.1% eye drops were used four times daily for one week.
Patients were examined in visits at one week, 1 month, 3 months and 6 months for patency of the lower eyelid punctum, FDDT grade and Munk score of epiphora.
Satisfactory surgical outcome was defined as postoperative patent lower eyelid punctum and improved Epiphora score and FDDT grade at 6 months after surgery.
Statisticalanalysis:
Data were collected, coded and entered PC for statistical analysis using the Statistical Package for the Social Sciences (SPSS: statistical package version 20. Armonk، NY، USA: IBM Corp). For descriptive statistics, mean and standard deviation (SD) were used for quantitative data, number (n) and percentage (%) were used for qualitative data and Kolmogorov- Smirnov for normality test was used to differentiate between parametric data and non-parametric data. For Analytical statistics, Independent sample t-test was used for analysis of quantitative data and paired sample t-test was used for analysis of paired quantitative data. For all tests, probability (p) was considered non-significant if it is ≥ 0.05, significant if it is < 0.05, highly significant if it is < 0.01 and very highly significant if it is <0.001. Bivariate correlation analysis was used for association analysis. Correlation (r) was considered weak or no correlation if it is 0.00 to 0.24, fair correlation if it is 0.25 to 0.49, moderate correlation if it is 0.50 to 0.74 and strong correlation if it is 0.75 more.