获得性泪点阻塞病因分析及手术治疗
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摘要
目的分析获得性泪点狭窄或阻塞的病因并评价手术治疗效果。设计前瞻性病例系列。研究对象2016年1月至2017年3月确诊为获得性泪点狭窄或阻塞并有溢泪症状接受手术治疗的患者40例(61眼),女性占83%,平均年龄(54±13.3)岁。方法术前根据Kashkouli方法进行裂隙灯下泪点开放程度分级,0级为无泪点及泪乳头,1级为泪乳头膜闭或纤维化,2级为泪点可辨认但小于正常,3级为正常大小。0级和1级泪点用25G针头穿刺造口再用直径由细到粗的泪点扩张器逐渐扩张泪点,泪点重建后行Ritleng人工泪管置人术。人工泪管取出后6个月分别从解剖和功能学评价手术效果,解剖成功为泪点3级及以上,功能成功为Munk溢泪症状评分0或1分且荧光染料消失试验阴性。主要指标泪点分级,Munk评分和荧光染料消失试验。结果双眼发病者21例(53%),上下泪点同时受累40眼(66%),病因不明的特发性病例31例(78%)。泪点平均分级术前为1.3±0.7,术后明显提高,为3.0±0.4(P<0.001)。术后泪点≥3级者95个,解剖成功率94%。Munk评分≤1分且FDDT阴性者56眼,功能成功率92%。仅2眼发生轻度泪点撕裂,其余无明显手术并发症。结论获得性泪点阻塞的病因以特发退行性改变为主,渐进式泪点扩张成形联合Ritleng人工泪管置入术安全有效,是治疗获得性泪点阻塞的理想术式。
Objective To assess the etiology and surgery effectiveness of the acquired punctal stenosis. Design Prospective case series. Participants Sixty-one eyes of 40 patients presenting with epiphora who were diagnosed as acquired punctal stenosis and underwent surgical management from January 2016 to March 2017 were assessed. Female accounted for 83% and the mean age was 54 ± 13. 3 years.Methods The severity of the stenosis was graded based on slit-lamp examination according to Kashkouli's method. Grade 0 is no papilla and punctum, Grade 1 is papilla covered by a membrane or fibrosis and difficult to recognize, Grade 2 is less than normal size but recognizable, and Grade 3 is normal. Sequential punctal dilation combined with Ritleng silicone intubation was performed in grading 0～2 of punctal opening size. A 25-G needle was used to open the papilla and then progressively larger dilators were used to dilate the ampulla to introduce a Ritleng probe. Anatomical success was defined as a well-patent puncta( Grade 3-5) and functional success as Munk epiphora scoring ≤1 and negative fluorescein dye disappearance test(FDDT) at 6 months after removal of silicone stents. Main Outcome Measures Punctal grading, Munk scoring, and FDDT. Results Twenty-one cases(53%) were bilateral and both upper and lower puncta were involved in 40 eyes(66%). Thirty-one cases(78%) were idiopathic without any known causes. The mean pre-operative and post-operative punctal grading was 1. 3 ±0. 7 and 3. 0 ±0. 4 respectively with statistically significance(p <0. 001). Anatomical success rate was 94%(95/101) and functional success rate was92%(56/61). No serious complication was noted except for mild punctal laceration in 2 eyes. Conclusion The most common underlying cause for acquired punctual stenosis was idiopathic involutional change in this series. Sequential punctal dilation with Ritleng intubation is a safe and efficient technique in the management of acquired punctal stenosis.
Objective To assess the etiology and surgery effectiveness of the acquired punctal stenosis. Design Prospective case series. Participants Sixty-one eyes of 40 patients presenting with epiphora who were diagnosed as acquired punctal stenosis and underwent surgical management from January 2016 to March 2017 were assessed. Female accounted for 83% and the mean age was 54 ± 13. 3 years.Methods The severity of the stenosis was graded based on slit-lamp examination according to Kashkouli's method. Grade 0 is no papilla and punctum, Grade 1 is papilla covered by a membrane or fibrosis and difficult to recognize, Grade 2 is less than normal size but recognizable, and Grade 3 is normal. Sequential punctal dilation combined with Ritleng silicone intubation was performed in grading 0～2 of punctal opening size. A 25-G needle was used to open the papilla and then progressively larger dilators were used to dilate the ampulla to introduce a Ritleng probe. Anatomical success was defined as a well-patent puncta( Grade 3-5) and functional success as Munk epiphora scoring ≤1 and negative fluorescein dye disappearance test(FDDT) at 6 months after removal of silicone stents. Main Outcome Measures Punctal grading, Munk scoring, and FDDT. Results Twenty-one cases(53%) were bilateral and both upper and lower puncta were involved in 40 eyes(66%). Thirty-one cases(78%) were idiopathic without any known causes. The mean pre-operative and post-operative punctal grading was 1. 3 ±0. 7 and 3. 0 ±0. 4 respectively with statistically significance(p <0. 001). Anatomical success rate was 94%(95/101) and functional success rate was92%(56/61). No serious complication was noted except for mild punctal laceration in 2 eyes. Conclusion The most common underlying cause for acquired punctual stenosis was idiopathic involutional change in this series. Sequential punctal dilation with Ritleng intubation is a safe and efficient technique in the management of acquired punctal stenosis.
引文
[1]Soiberman U,Kakizaki H,Selva D.et al.Punctal stenosis:definition,diagnosis,and treatment.Clin Ophthalmol,2012,6(7):1011-1018.
[2]Kashkouli MB,Beigi B,Murthy R,et al.Acquired external punctal stenosis:etiology and associated findings.Am J Ophthalmol,2003,136(6):1079-1084.
[3]Munk PL,Lin DT,Morris DC.Epiphora:treatment by menas of dacryocystoplasty with balloon dilation of the nasolacrimal drainage apparatus.Radiology,1990,177(3):687-690.
[4]Ali MJ.Principle and practice of lacrimal surgery.India:Springer,2015:17.
[5]Viso E,Rodriguez-Ares MT,Gude F.Prevalence and associationsof external punctal stenosis in a general population in Spain.Cornea,2012,31(11):1240-1245.
[6]Ali MJ,Mishra DK,Baig F,et al.Punctal stenosis:histopathology,immunology,and electron microscopic features?a step toward unraveling the mysterious etiopathogenesis.Ophthal Plast Reconstr Surg,2015,31(2):98-102.
[7]Hur MC,Jin SW,Roh MS,et al.Classification of lacrimal punctal stenosis and its related histopathological feature in patients with epiphora.Korean J Ophthalmol.2017,31(5):375-382.
[8]Kashkouli MB,Nilforushan N,Nojomi M,et al.External lacirmal punctum grading:reliability and interobserver variation.Eur J Ophthalmol,2008,18(4):507-511.
[9]孙红梅,张宁,韩毳,等.应用小梁咬切器行泪点咬切成形术治疗泪点膜.中华眼外伤职业眼病杂志,2014,36(3):219-222.
[10]于静,高明宏,年春志,等.激光联合泪点塞在泪小点狭窄或阻塞疾病中的应用.眼科新进展,2008,28(5):379-383.
[11]Wong ES,Li EY,Yuen HK.Long-term outcomes of punch punctoplasty with Kelly punch and review of literature.Eye,2017,31(4):560-565.
[12]Singh S,Ali MJ,Mohamed A.Comparison of outcomes of 3-snip punctoplasty versus simple punctal dilation with monocanalicular intubation for acquired punctal stenosis.Ophthal Plast Reconstr Surg,2017[epub ahead of print]
[13]王朋,陶海,白芳.泪道置管术后治疗泪道阻塞性疾病的研究现状.中国中医眼科杂志,2016,26(1):50-54.
[14]Abd El Ghafar AS,El-Kannishy AM,Elwan MM,et al.Perforated punctal plugs with adjuvant use of mitomycin-C in management of acquired external punctal stenosis grades 0 and 1.Can J Ophthalmol,2017,52(6):606-610.
[15]Kim BM,Osmanovic SS,Edward DP.Pyogenic granulomas after silicone punctal plugs:a clinical and histopathololgic study.Am J Ophthalmol,2005,139(4):678-684.
[16]Timlin HM,Keane PA,Rose GE,et al.The application of infrared imaging and optical coherence tomography of the lacrimal punctum in patients undergoing punctoplasty for epiphora.Ophthalmology,2017,124(6):910-917.
[2]Kashkouli MB,Beigi B,Murthy R,et al.Acquired external punctal stenosis:etiology and associated findings.Am J Ophthalmol,2003,136(6):1079-1084.
[3]Munk PL,Lin DT,Morris DC.Epiphora:treatment by menas of dacryocystoplasty with balloon dilation of the nasolacrimal drainage apparatus.Radiology,1990,177(3):687-690.
[4]Ali MJ.Principle and practice of lacrimal surgery.India:Springer,2015:17.
[5]Viso E,Rodriguez-Ares MT,Gude F.Prevalence and associationsof external punctal stenosis in a general population in Spain.Cornea,2012,31(11):1240-1245.
[6]Ali MJ,Mishra DK,Baig F,et al.Punctal stenosis:histopathology,immunology,and electron microscopic features?a step toward unraveling the mysterious etiopathogenesis.Ophthal Plast Reconstr Surg,2015,31(2):98-102.
[7]Hur MC,Jin SW,Roh MS,et al.Classification of lacrimal punctal stenosis and its related histopathological feature in patients with epiphora.Korean J Ophthalmol.2017,31(5):375-382.
[8]Kashkouli MB,Nilforushan N,Nojomi M,et al.External lacirmal punctum grading:reliability and interobserver variation.Eur J Ophthalmol,2008,18(4):507-511.
[9]孙红梅,张宁,韩毳,等.应用小梁咬切器行泪点咬切成形术治疗泪点膜.中华眼外伤职业眼病杂志,2014,36(3):219-222.
[10]于静,高明宏,年春志,等.激光联合泪点塞在泪小点狭窄或阻塞疾病中的应用.眼科新进展,2008,28(5):379-383.
[11]Wong ES,Li EY,Yuen HK.Long-term outcomes of punch punctoplasty with Kelly punch and review of literature.Eye,2017,31(4):560-565.
[12]Singh S,Ali MJ,Mohamed A.Comparison of outcomes of 3-snip punctoplasty versus simple punctal dilation with monocanalicular intubation for acquired punctal stenosis.Ophthal Plast Reconstr Surg,2017[epub ahead of print]
[13]王朋,陶海,白芳.泪道置管术后治疗泪道阻塞性疾病的研究现状.中国中医眼科杂志,2016,26(1):50-54.
[14]Abd El Ghafar AS,El-Kannishy AM,Elwan MM,et al.Perforated punctal plugs with adjuvant use of mitomycin-C in management of acquired external punctal stenosis grades 0 and 1.Can J Ophthalmol,2017,52(6):606-610.
[15]Kim BM,Osmanovic SS,Edward DP.Pyogenic granulomas after silicone punctal plugs:a clinical and histopathololgic study.Am J Ophthalmol,2005,139(4):678-684.
[16]Timlin HM,Keane PA,Rose GE,et al.The application of infrared imaging and optical coherence tomography of the lacrimal punctum in patients undergoing punctoplasty for epiphora.Ophthalmology,2017,124(6):910-917.