Primary surgical repair of traumatic lacerations of the lacrimal canaliculi

Primary surgical repair of traumatic lacerations of the lacrimal canaliculi Raymond F. MacGillivray, DDS, a and Mark R. Stevens, DDS, Miami, Fla. UNIVERSITYOF MIAMI SCHOOLOF MEDICINE/JACKSONMEMORIALHOSPITAL 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 pertinent 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. (Oral Sure ORALMEO ORALPat~ot O ~ t IIAOLOtEnooo

1996;81:157-63)

The purpose of this article is to describe the anatomy of the nasolacrimal system and to outline the common techniques for the primary repair of injuries specific to the canaliculi. Traumatic injuries to the lacrimal canaliculi are occasional sequelae to maxillofacial trauma. Causative factors include motor vehicle accidents, stab wounds, assaults, dog bites, and sports injuries), 2 The inferior canaliculus is more frequently lacerated than the superior canaliculus.l-4 Suspicion of canalicular injury should be high with any injury to the medial aspect of the orbit (Fig. 1). Diagnosis of canalicular injury is made by direct examination of the injured tissues under magnification and the use of injection techniques described in this article. ANATOMY Anatomically, the lacrimal system is divided into three component parts (Fig. 2): the secretory, distributory, and excretory systems. 5 The tears are composed of secretions from the lacrimal, conjunctival, and minor glands of the lid margin. The tear film consists of three layers. The goblet cells of the conjunctiva create the layer closest to the corneum. It is a thin mucinous layer approximately 7 jam thick and contributes to the wettability of the corneal epithelium by the aqueous layer. The aqueous layer forms the central layer of the tear film. It is 98% water and contains minor amounts of inorganic salts, proteins, mucopolysaccharides, and lipids that enhance the stability of the tear film. The outer surface layer is

aChief Resident, Division of Oral and Maxillofacial Surgery, Department of Surgery. bAssociate Professor of Surgery, Director of Graduate Training and Academic Affairs, Division of Oral and Maxillofacial Surgery, Department of Surgery. Received for publication Feb. 22, 1995;returned for revision May 4, 1995; accepted for publication July 25, 1995. Copyright 9 1996 by Mosby-Year Book, Inc. 1079-2104/96/$5.00 + 0 7112/69324

Fig. 1. Extensive facial laceration as a result of a motor vehicle accident.

produced by the meibomian and silosebaceous glands. It is O. 1 ~m thick. This layer prevents evaporation of the aqueous layer and keeps the tears from spilling over the palpebral margin. The tears are distributed primarily by the action of the eyelids as a result of pressure changes beneath the upper lid during function. 5 With the eyes open the tear film is subjected to the forces of surface tension and is spread over the 157

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Fig. 2. Anatomy and dimensions of lacrimal system.

Fig. 3. Fluorescein dye (2%) injected into inferior canaliculus to assess disruption of system as a result of laceration of medial orbit. Note outflow from the nares without extravasation into the wound. This canaliculus was intact. globe. Blinking of the eyelids directs the flow of tears medial toward the excretory system. The excretory system is composed of the following: (1) upper and lower canaliculi, (2) common

canaliculus, (3) lacrimal sac, and (4) nasolacrimal duct. The canaliculi are the most significant components of the excretory system and are at greatest risk to injury. The origin of the excretory system is the punctae of the superior and inferior lid. The punctae are positioned tangential to the globe to enhance evacuation of the tear secretions. Alterations in normal anatomic position as a result of traumatic injury or congenital malformation will compromise their function and result in epiphora. The puncta initially courses vertically for 2 ram, then turns medially for 8 m m beneath the medial canthal ligament. At the point of direction change, a small dilatation of the system occurs, the ampulla of the canaliculus. The canaliculi generally unite (90%) to form a common canaliculus before entering the lateral wall of the lacrimal sac. The canaliculi varies in diameter from 0.3 m m at the puncta to 2 to 3 m m at the ampulla and again to 0.5 m m within the horizontal limb. Multiple infoldings of the canalicular mucosa occur and these may be impediments to probing the system depending on their size and direction. Congenital anomalies of the canaliculi occur in a variety of forms and must be considered during diagnostic and therapeutic manipulations of the excretory system. They include the absence of puncta, supernumerary puncta, duplicated canaliculi, and fistulas. 6 PRINCIPLES OF REPAIR The basic tenets of surgical repair for lacerated canaliculi are (1) early direct anastamosis, (2) use of internal stents, and (3) magnification. 3 This is best accomplished with the patient under general anesthesia with the use of the operating microscope. Early repairs are preferable to avoid the stenosis associated

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Fig. 4. A, Ring intubation. B, Nasal intubation, loop. C, Nasal intubation. I), Nasal intubation, prefabricated system.

with increased scar formation. Repairs performed from 24 to 48 hours after injury have been equally successful to repairs performed within the first 6 hours. 4 Excellent results are reported with repairs up to 5 days after injury. 7

EVALUATION OF INJURIES Injury to the lacrimal canaliculi is best determined by injecting visible fluid into the canaliculus and observing for extravasation into the wound (Fig. 3). This is accomplished in the emergency department with topical anesthesia. A 22-gauge angiocatheter is used to intubate the verticle portion of the canaliculus, and the fluid is injected. It is seldom necessary to dilate the punctum with lacrimal probes to achieve intubation of the canaliculus for this purpose. Sterile milk, methylene blue, and 2% fluorescein dye are commonly injected fluids and are easily visible in the wound. The nasal mucosa should be adequately treated with topical agents to enhance the visibility of the injected fluid as it exits Hasner's valve in the intact system.

INDICATIONS FOR REPAIR Primary repair of lacrimal canalicular injuries is indicated for all transections of the inferior canalic-

ulus when the severed ends are identifiable in the wound. Severed ends may be unidentifiable with crush injuries or avulsion of tissue and thus prevent primary repair. Injuries to the superior canaliculi seldom cause symptoms of lacrimal system obstruction as the inferior canaliculus is the excretory pathway for the bulk of the tear flow.

SURGICAL TECHNIQUES Several techniques are commonly advocated for the repair of canalicular injuries (Fig. 4). The ring intubation is probably the most frequently used. 8-1~Its main advantage is that the proximal stump of the lacerated canaliculus is found within the wound bed with a minimum of difficulty or delay. The punctum is first dilated with blunt conical lacrimal probes that sequentially increase in size. On dilation of the canaliculus, retrograde probing is initiated. Standard lacrimal probes can be modified for this purpose, 11 although the development of true retrograde probes obviate this need. The Kellman 4 and pigtail probe of Worst 8 are examples. A retrograde probe is first introduced into the nontraumatized canaliculus. At the level of the common canaliculus, it is carefully advanced into the proximal end of the cut canaliculus. It may be difficult to ne-

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Fig. 5. Retrograde probing in ring intubation.

Fig. 6. Anastamosis of canaliculus over internal stent. Sutures in place and as yet united.

gotiate the acute curvature at the junction of the comm o n canaliculus, or advancement may be prohibited because of large mucosal foldings. Careful technique usually overcomes these problems, and the probe becomes visible in the wound bed (Fig. 5). A monofilament suture of sufficient size (2-0 to 4-0) engages the eye of the probe, and the probe and sutures are withdrawn, The distal end of the traumatized canaliculus is also probed, and when the tip of the probe becomes visible in the wound the opposite end of the suture is threaded and withdrawn. Silicone tubing is then passed over the suture to serve as a stent. Anastamosis of the cut ends of the canaliculus is achieved with three 9-0 monofilament sutures (Fig. 6) whenever possible, and the laceration is closed in the standard fashion. Practically speaking this is often difficult, and one or two sutures may have to suffice. The paracanicular connective tissue is engaged with these sutures. A bolster dressing is secured to protect the anastamosis from forces associated with facial movement. The free ends of the silicone tubing are trimmed and joined over a thick monofilament suture to form a ring. The ends are secured with a single 9-0 monofilament suture, and the complex is rotated to place this junction within the nontraumatized canaliculus (Fig. 7). When retrograde probing is unsuccessful, loop intubation is attempted (Fig. 4, B). The principles of repair remain the same. A 6-cm length of tubing of adequate external diameter, greater than 0.6 ram, is ad-

vanced into the dilated punctum of the injured canaliculus. The tubing is retrieved within the wound. The proximal end of the injured canaliculus is identified at this time. This can be difficult in a macerated wound. Identification is greatly facilitated by the injection of sterile milk, methylene blue, or 2% fluorescein dye that will render the torn end highly visible in the wound. Magnification remains essential. The tubing is passed into the proximal canaliculus and enters the lacrimal sac. The anastamosis is completed, and the free end of the tubing is passed through the uninjured canaliculus, into the lacrimal sac, to complete the loop. The stent is secured with a single skin suture. Nasal intubation is another alternative ~2-14 (Fig. 4, C). The injured canaliculus is intubated with monofilament from punctum to nasal cavity. The free end is retrieved as it exits Hasner's Valve in the inferior meatus. Silicone tubing is threaded over the suture, and both ends are secured externally on the skin (Fig. 8). Anastamosis is then performed. Prefabricated systems are available for nasal intubations and simplify the technique 12, 14, 15 (Fig. 4, D). The silicone tubing is attached to thin metal probes. The probes are passed sequentially through the injured canaliculus, then the intact canaliculus, each in turn is retrieved from the nasal cavity (Fig. 9). A loop of silicone remains at the medial canthus. The probes are easily removed, and the tubing ends are secured within the nose. Anastamosis is then performed.

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Fig. 7. Loop intubation with silicone tubing at medial canthus.

Fig. 8. Nasal intubation with silicone tubing.

DISCUSSION Several areas of controversy exist in the repair of traumatic canalicular injury: (1) probing and intubation of the uninjured canaliculus, (2) types of stent material, and (3) duration of stent placement. Several authors recommend against probing or intubating the uninjured canaliculus. 17' 16, 17 They cite the potential for iatrogenic injury from manipulation of the intact system as the major contraindication. An incidence of 10% is reported for 30 cases. Recently, retrograde probing with ring, loop, or nasal intubation of the canaliculi has been advocated.Z, 10-15,18, 19 Ease of technique, low incidence of

iatrogenic canalicular injury, predictability of results, and patient acceptability are indications that favor this method of canalicular reconstruction. Iatrogenic injuries to intact canaliculi are attributed to probing technique errors and are avoidable with patience and careful technique. Various materials have been described for use as internal stents. These include doubled sutures of silk or monofilament, 4, 8, 9 malleable rods, 2~ polyethylene tubing,4, 8 and more recently silicone tubing. 7, 12, 13, 18 Polyethylene tubes are rigid and can cause tissue erosion.15 Malleable rods of Veirs are problematic if the swaged silk suture becomes loose with migration of

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Fig. 9. A, Nasal intubation with prefabricated system. B, Disruption of canaliculus at junction with lacrimal sac.

the rod. Silicone has become the recommended stent material today. Its properties and indications for use in ophthalmic plastic and reconstructive surgery are reviewed, e~ Advantages over polyethylene are its softness and flexibility. It rarely causes tissue erosion or corneal abrasions and it is well tolerated by patients. The smooth surface of silicone tubing allows for unimpeded epithelialization along its length to bridge traumatic defects as seen with lacerations. 22 Minor complications with its use are reported. 16' 19 These include erosions, granulation formation, and fibrous band formation. The duration of stent placement varies greatly depending on the material used and the experience of the clinician. Recommendations range from a few days to 6 months with monofilament, 3 3 to 9 weeks with polyethylene tubes or double silk thread, 4 3 to 6 weeks for the malleable rod Of Veir, 2~ 23 and 2 to 6 months for silicone tubing. 12' 13 Determination of the optimal duration of stent placement is further complicated by the lack of standardization of canalicular repair techniques used. The canine model demonstrates histologically that 3 months may be the ideal time for stent removal, z2 At 3 months after repair of iatrogenic lacerations to the eanaliculi, there is com-

plete continuity of the epithelium and no pericanalicular inflammation. The principle of direct anastamosis over a silicone stent was used. Reports on the successful repair of canalicular injuries are clouded by the variability of techniques used and the definition of success applied to the obtained results. Reports range from a low of 20% 16 to a high of 94%, 7 but Often within a given series of different stents are used, anastamosis is not achieved, or wound closure is performed without any attempt at canalicular repair. 3 In a study that defined a successful result as that of a patent system to gentle probing and irrigation without fistula postoperatively, a rate of 36.6% was achieved. The surgical technique was suture intubation without anastamosis. Interestingly, 73.6% of all "failures" in this series were asymptomatic. CONCLUSION The anatomy of the nasolacrimal system has been reviewed, and several methods to achieve primary repair of traumatic lacerations of the canaliculi have been outlined. These techniques are indicated for all transections of the inferior canaliculus in which the severed ends are identifiable. Adherence to sound

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REFERENCES 1. Saunders DH, Shannon GM, Flanagan JC. The effectiveness of the pigtail probe method of repairing canalicular lacerations. Ophthalmic Surg 1978;9:33-40. 2. Billson FA, Taylor HR, Hoyt CS. Trauma to the lacrimal system in children. Am J Ophthalmol 1978;86:828-33. 3. Canavan YM, Archer DB. Long-term review of injuries to the lacrimal drainage apparatus: Trans Ophthal Society UK 1979; 99:201-4. 4. Hanselmayer H. Prognosis of injured canaliculi in relation to elapsed time until primary operation. Ophthalmologica 1973; 166:175-9. 5. Bergin DJ. Anatomy of eyelids, lacrimal system, and orbit. In: McCord CD Jr, Tanenbaum M, eds. Occuloplastic surgery. 2nd ed. New York: Raven Press, 1987:63-6. 6. Goldberg A, Hurwitz JJ. Congenital abnormalities of lacrimal drainage: management of difficult cases. Can J Ophthal 1979; 14:106-9. 7. Dortzbach RK, Angrist RA. Silicone intubation for lacerated lacrimal canaliculi. Ophthalmic Surg 1985;16:639-42. 8. Worst JGK. Method for reconstructing torn lacrimal canaliculus. Am J Ophthalmol 1962;53:520-2. 9. Kartch MC. French-eye pigtail probe for lacrimal canaliculus repair. Am J Ophthalmol 1971 ;72:1145-6. 10. Sisler HA. Lacrimal canalicular repair. Arch Ophthalmol 1986;79:54-6. 11. Shannon GM, Hamdi TN. Repair of injuries of the lacrimal canaliculus. Am J Ophthalmol 1966;62:974-6. 12. Guibor P. Canaliculus intubation set. Trans Am Acad Ophthalm Otolaryngol 1975;79:419-20.

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13. Neuhaus RW. Silicone intubation of traumatic canalicular lacerations. Ophthalmic Plast Reconstr Surg 1989;5:256-60. 14. Crawford JS. Intubation of the lacrimal system. Ophthalmic Plast Reconstr Surg 1988;4:249-50. 15. Crawford JS. Intubation of obstructions in the lacrimal system. Can J Ophthal !977;12:289-92. 16. Anderson RL, Edwards JJ. Indications, complications, and results with silicone stents. Ophthalmology 1979;86:1474-87. 17. Jones LT, Wobig JL. Surgery of the eyelids and lacrimal system. Birmingham: Aesculapius Publishing, 1976:183. 18. Adams AD. Silicone-loop repair of the torn canaliculus. Arch Ophtbalmol 1976;94:1958-60. 19. Keith CG. Intubation of the lacrimal passages. Am J Ophthalmol i968;65:70-4. 20. Veirs ER. Malleable rods for immediate repair of the traumatically severed lacrimal canaliculus. Trans Am Acad Ophthalmol Otolaryngol 1962;66:263-5. 21. Stewart WB, Gelender H, Miller GR, Tenzel RR. Silicone in ophthalmic plastic and reconstructive surgery: a review and laboratory trial. Ophthalm Surg 1978;9:92-101. 22. Snead JW, Rathbun JE, Crawford JB. Effects of the silicone tube on the canaliculus. A m Acad Ophthalmol 1980;87: 1031-6. 23. Meacham CT. The hard to repair severed lacrimal canaliculus. Arch Ophthal 1972;87:406-11.

Reprint requests." Mark R. Stevens, DDS Associate Professor of Surgery Director of Graduate Training and Academic Affairs Division of Oral and Maxillofacial Surgery Department of Surgery University of Miami School of Medicine/ Jackson Memorial Hospital 1611 N.W. 12th Avenue, ACC-East Bldg. 2nd Floor Miami, FL 33101

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