Corneal abrasions are a known complication of lacrimal intubation. The authors describe two consecutive patients in which this occurred using the JEDMED (St. Louis, MO) mono-canalicular tube, and propose a mechanism, based on the flange design, as an explanation.
Corneal Abrasions Associated With Crawford Mono-Canalicular Tubes
From the Department of Ophthalmology, Ochsner Clinic Foundation, New Orleans, Louisiana.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to H. Sprague Eustis, MD, Department of Ophthalmology, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121. Email: firstname.lastname@example.org
Received: May 23, 2011
Accepted: September 01, 2011
Posted Online: October 11, 2011
We present two patients who developed corneal abrasions after placement of Crawford Mono-Canalicular tubes (JEDMED, St. Louis, MO). The pattern of abrasions was consistent with mechanical trauma from the Crawford tubes. The design of the JEDMED Crawford tubes likely explains this complication: the shape and size of the punctual cuff is circular and wider than the eyelid margin. When placed, the posterior aspect of the cuff extends beyond the eyelid margin and abuts the globe, resulting in a mechanical corneal abrasion. To our knowledge, this is the first report of complications with these particular tubes.
The first patient was a 13-month-old girl with a history of a nasolacrimal duct obstruction since birth. She was brought to surgery where she underwent probing and intubation of her right nasolacrimal system. The probing revealed stenosis of the nasolacrimal duct and a JEDMED Mono-Canalicular Crawford tube was inserted into the lower canalicular system without complication. On the following day, the patient returned with redness, tearing, and irritation to her right eye. Examination revealed injected conjunctiva in the nasal aspect of the eye, two linear corneal abrasions adjacent to the limbus, and a moderate punctate corneal epithelialopathy surrounding the linear abrasion (Fig. 1).
Figure 1. Case 1, with injected conjunctiva in the nasal aspect of the eye, two linear corneal abrasions adjacent to the limbus, and a moderate punctate corneal epithelialopathy surrounding the linear abrasion.
The Crawford tube was securely in place in the inferior punctum. The tube was removed in the office without difficulty and the patient was prescribed neomycin/polymyxin B/dexamethasone ointment and ketorolac. Within 24 hours, the abrasions healed without sequelae.
A 3-year-old girl had a history of nasolacrimal duct obstruction in the left eye since birth. She had previously undergone probing and placement of Bi-Canalicular Crawford tubes, which spontaneously extruded after approximately 3 weeks; the nasolacrimal duct obstruction recurred. Further surgical treatment consisted of probing and irrigation of the left nasolacrimal system, a balloon dilation using the LacriCATH (Quest Medical, Allen, TX), and placement of a JEDMED Mono-Canalicular Crawford tube into the lower canalicular system. The patient’s mother noted that several hours after surgery the patient’s eye was irritated and she was in obvious pain. The patient presented to the clinic the following morning, where we identified an inferior nasal corneal abrasion. The nasal conjunctiva was also irritated and injected. The tube was correctly positioned in the lower punctum without evidence of extrusion. The tube was removed without difficulty in the office, and the patient was prescribed tobramycin/dexamethasone ointment and ketorolac. Within 24 hours, the abrasion healed without sequelae.
Nasolacrimal duct obstructions are a common pediatric eye problem.1–4 In children who present after 1 year of age or have recurrent obstructions following previous treatment, most physicians would recommend the insertion of lacrimal tubes to improve the surgical success rate.
Many different types of lacrimal tubes are available in both mono-canalicular and bi-canalicular designs. In the mono-canalicular design, the upper end of the tube contains a hub flange, which is secured into the lacrimal punctum to prevent extrusion. The JEDMED Crawford Mono-Canalicular tube is designed with a circular hub, which is round in configuration and measures 2 mm in horizontal diameter (Fig. 2). This larger diameter and non-oval configuration allows the posterior aspect of the tube to extend posterior to the eyelid margin, resulting in contact with the globe. We believe this mechanical contact over time was responsible for the corneal abrasions seen in these two patients. Although corneal abrasions are a recognized but uncommon complication of lacrimal tubes, we suggest they will occur more often when a JEDMED Mono-Canalicular tube is used because of its hub flange design. We have contacted JEDMED concerning this complication in hopes that a redesign in configuration will be considered.
Figure 2. On the left is the Crawford Mono-Canalicular tube (JEDMED, St. Louis, MO), with a round circular hub that is 2 mm in horizontal diameter. On the right is the Crawford Mono-canalicular tube (FCI, Marshfield Hills, MA), with an oval hub measuring 1 mm in horizontal diameter.
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