Question

Describe techniques for repair of a canalicular injury.

Hint:

Timely repair within 24 hours and the use of silicone stents are critical for optimal functional and cosmetic outcomes in canalicular injury repair.

Answer 1

Canalicular injuries are commonly caused by trauma, such as blunt or sharp objects impacting the eye or surrounding areas. These injuries involve the lacrimal drainage system, which includes the punctum, canaliculus, and lacrimal sac. The repair of canalicular injuries is essential to restore normal tear drainage and prevent complications such as epiphora (excessive tearing) or chronic dacryocystitis (infection of the lacrimal sa.
Techniques for Canalicular Injury Repair:
1. Primary Repair:
- Indications: Primary repair is performed within 24 hours of the injury to prevent scarring and preserve the normal anatomical structure of the canaliculus.
- Procedure: The canalicular laceration is identified, and the injured ends are re-approximated using a fine suture, such as 6-0 Vicryl or 7-0 Prolene, through the canalicular lumen. The ends of the canaliculus are carefully sutured together without tension to ensure patency.
- Surgical Approach: The punctum is dilated, and the canaliculus is carefully sutured with the use of a canalicular stent or intubation for stabilization.
2. Canalicular Intubation (Stenting):
- In cases where there is a significant gap or a delay in presentation, canalicular intubation is required. A small, flexible tube (such as silicone stents) is passed through the canaliculus to maintain patency and ensure proper healing.
- Stenting Duration: The stents are left in place for several months, with periodic follow-up to monitor the success of the repair and the removal of the stents once healing is complete.
3. Monocaudal and Bicanalicular Intubation:
- In complex canalicular injuries involving both the upper and lower canaliculi, bicanalicular intubation is preferred. A double-lumen stent is placed through both canaliculi, with the ends of the stent exiting through the puncta and securing the canaliculi together.
4. Flap Repair with Mucosal Graft:
- If the canalicular injury is extensive or has caused significant tissue loss, a mucosal graft from the buccal mucosa or nasal mucosa can be used to bridge the gap between the two canalicular ends.
5. Canalicular Reconstruction:
- In cases of severe trauma or large defects, more advanced techniques, such as canalicular reimplantation or canalicular reconstruction using a bony or synthetic graft, may be necessary.
6. Dacryocystorhinostomy (DCR):
- If the injury involves the lacrimal sac or if there is a complete canalicular loss, a DCR procedure may be required in conjunction with other techniques to restore tear drainage.