Journal of Pediatric Ophthalmology and Strabismus

Original Article 

Pattern of Presentation and Surgical Outcomes of Canalicular Laceration Repair in a Pediatric Population

Rajul Agarwal, MBBS, DOMS; Narendra Patidar, MBBS, DOMS; Amit Mohan, MS; Rukmendra Singh, MBBS, MS; Pradhnya Sen, MBBS, MS

Abstract

Purpose:

To evaluate demographic data, clinical profile, and factors responsible for the success of anatomical and functional outcomes of canalicular laceration repair with the Mini Monoka stent (FCI Ophthalmics) in children younger than 10 years.

Methods:

This was a retrospective cohort observational study involving children younger than 10 years who underwent canalicular tear repair with the Mini Monoka stent with a minimum follow-up of 6 months.

Results:

A total of 18 patients (9 boys and 9 girls) with a mean age of 5.39 ± 3.05 years were included. Twelve and 6 patients had lower and upper canalicular tear, respectively. Six (33.4%) patients had associated ocular comorbidity. The common mode of trauma was direct injury in 77.8% of the patients. The blouse hook of the mother was noted as the most common object causing canalicular laceration. Early repair (< 48 hours) and delayed repair were done in 7 (38.9%) and 11 (61.1%) patients, respectively. Anatomical and functional success was achieved in 88.9% and 94.4% of patients, respectively. The odds ratio (95% CI) for anatomical and functional success with the time since injury was 0.6 (CI: 0.03 to 11.47) and 0.19 (CI: 0.01 to 5.33), respectively. There was no significant difference between the early and delayed repair groups in terms of the distribution of anatomical (P = 1.000) and functional (P = .389) success. There was no significant difference between the various groups in terms of the distribution of complications (P = .224).

Conclusions:

Canalicular laceration repair with the Mini Monoka stent in children younger than 10 years has shown good outcomes in terms of anatomical and functional success irrespective of time lag since injury to repair.

[J Pediatr Ophthalmol Strabismus. 2021;58(1):42–47.]

Abstract

Purpose:

To evaluate demographic data, clinical profile, and factors responsible for the success of anatomical and functional outcomes of canalicular laceration repair with the Mini Monoka stent (FCI Ophthalmics) in children younger than 10 years.

Methods:

This was a retrospective cohort observational study involving children younger than 10 years who underwent canalicular tear repair with the Mini Monoka stent with a minimum follow-up of 6 months.

Results:

A total of 18 patients (9 boys and 9 girls) with a mean age of 5.39 ± 3.05 years were included. Twelve and 6 patients had lower and upper canalicular tear, respectively. Six (33.4%) patients had associated ocular comorbidity. The common mode of trauma was direct injury in 77.8% of the patients. The blouse hook of the mother was noted as the most common object causing canalicular laceration. Early repair (< 48 hours) and delayed repair were done in 7 (38.9%) and 11 (61.1%) patients, respectively. Anatomical and functional success was achieved in 88.9% and 94.4% of patients, respectively. The odds ratio (95% CI) for anatomical and functional success with the time since injury was 0.6 (CI: 0.03 to 11.47) and 0.19 (CI: 0.01 to 5.33), respectively. There was no significant difference between the early and delayed repair groups in terms of the distribution of anatomical (P = 1.000) and functional (P = .389) success. There was no significant difference between the various groups in terms of the distribution of complications (P = .224).

Conclusions:

Canalicular laceration repair with the Mini Monoka stent in children younger than 10 years has shown good outcomes in terms of anatomical and functional success irrespective of time lag since injury to repair.

[J Pediatr Ophthalmol Strabismus. 2021;58(1):42–47.]

Introduction

Canalicular lacerations are commonly caused by trauma to the eyelids and periorbital area, and occur in 16% of eyelid lacerations.1 Other lacrimal tract injuries involving the lacrimal sac or the nasolacrimal duct are rare and commonly associated with blunt craniofacial trauma or iatrogenic cause after some surgical procedures.2 In lacrimal system lacerations, the canaliculi are involved in 70% of cases and the lacrimal sac and/or nasolacrimal duct in 30%.3 Canalicular laceration in eyelid injuries in the pediatric population can be caused due to direct injury with some sharp or blunt object and sometimes indirect accidental injuries. Lacrimal drainage system involvement in eyelid injuries requires an expert oculoplastic surgeon because any disturbance in the normal anatomy and function of the lacrimal drainage system can cause long-term epiphora and eyelid malposition. The main aim of treatment in these cases is to maintain the patency of the canalicular system by placing temporary stents and to avoid any eyelid malposition.

Various stents and factors affecting the outcomes of canalicular laceration repair in both adults and children have been described in the literature.4–9 However, there is little in the literature exclusively for the pediatric population. Adults and children are different because they are exposed to different modes of trauma and regenerative capacity of skin also varies with age. The Mini Monoka stent (FCI Ophthalmics) is easy to insert and remove and is securely anchored at the punctum by the collarette. No knots or sutures are necessary, making it the ideal choice in the pediatric age group. With this background in mind, we have attempted to study canalicular laceration in a pediatric population.

The aim of this study was to evaluate demographic data, clinical profile, and factors responsible for success of anatomical and functional outcome of canalicular laceration repair with the Mini Monoka stent in children younger than 10 years.

Patients and Methods

This was a retrospective cohort observational study. A retrospective review of medical records of all pediatric patients who underwent canalicular laceration repair with a Mini Monoka stent at a tertiary eye care center from July 2017 to July 2019 was done. The study was approved by the institutional review board of Sadguru Netra Chikitsalaya, Chitrakoot, India, and in accordance with the tenets of the Declaration of Helsinki.

Patients younger than 10 years who underwent canalicular laceration repair with the Mini Monoka stent and had a minimum follow-up of 6 months were included in the study. The data collection included age, gender, mode of injury, time lag from injury to repair, location of tear, associated ocular comorbidities, complications related to tear repair, duration of follow-up, and presence or absence of epiphora after stent removal. Anatomical success was defined as negative fluorescein dye disappearance test and tear meniscus height within the normal range. Functional success was taken as epiphora with a Munk score of grade 0 or 1 at the last follow-up visit. On the basis of the time lag between the injury and surgical repair, we subdivided the patients into early repair (less than 2 days) and delayed repair (2 to 15 days) groups.

The statistical analysis was done using SPSS software version 23 (SPSS, Inc). Continuous variables were presented as mean ± standard deviation. Frequency and percentage were calculated for demographic variables. Comparative and descriptive analysis of different variables was done. Association of success rate and complications was analyzed in relation to time lag since injury. A contingency data table was generated and the odds ratio was calculated. The success and failure rates were compared using the Fisher's exact test and a P value of less than .05 was considered statistically significant.

Surgical Technique

All children had general anesthesia. Under the operating microscope, the proximal portion of the canaliculus was identified by probing through the puncta. By giving traction to the surrounding soft tissue, a circular whitish ring of the distal cut end of the canaliculus was identified corroborative with the Calamari ring sign. In case of poor visualization, other methods were used, such as injecting saline through the normal opposite punctum while maintaining pressure over the lacrimal sac or use of a pigtail probe. After identifying the distal cut end, a Bowman 0000 lacrimal probe was used to pass through both cut ends and reach the lacrimal sac to feel the hard stop. Then the punctum was dilated. The Mini Monoka stent was cut to approximately 15 to 20 mm length with the beveled edge and inserted into the punctum to follow the canalicular path. The proximal end was secured over the punctum with its collarette. The distal portion of the stent was introduced into the distal cut end of the canaliculus and then into the lacrimal sac or nasolacrimal duct. Pericanalicular 5-0 polyglactin horizontal interrupted sutures were applied to maintain the lacerated canaliculus in a proper anastomosis, and finally the eyelid skin tear was repaired with 6-0 silk suture. Figure 1 shows the preoperative appearance of a child with a canalicular laceration. Figure 2 shows the postoperative appearance of the same child with the Mini Monoka stent in situ and Figure 3 shows the Mini Monoka stent removal. The Mini Monoka stent was planned to be removed 6 months after the operation. The patients were followed up at 1 week and 1, 3, and 6 months postoperatively.

The preoperative appearance of a child with canalicular laceration.

Figure 1.

The preoperative appearance of a child with canalicular laceration.

The postoperative appearance of the same child as in Figure 1 with the Mini Monoka stent (FCI Ophthalmics) in situ.

Figure 2.

The postoperative appearance of the same child as in Figure 1 with the Mini Monoka stent (FCI Ophthalmics) in situ.

Removal of the Mini Monoka stent (FCI Ophthalmics).

Figure 3.

Removal of the Mini Monoka stent (FCI Ophthalmics).

Results

Of all 47 patients who had undergone canalicular laceration repair during the study period, 18 pediatric patients met the inclusion criteria and were enrolled. The study population comprised an equal proportion of boys and girls, with a mean age of 5.39 ± 3.05 years. Table 1 shows the demographic details and clinical profile of the patients. The time from injury to repair was delayed in 61.1% of patients and early in 38.9% of patients. Most of the patients (77.8%) sustained direct trauma. The blouse hook of the mother was noted to be the most common object (27.8%) causing canalicular laceration. None of the patients presented with bilateral canalicular tear. The lower eyelid (66.7%) was more commonly injured compared to the upper eyelid (33.4%). Subconjunctival hemorrhage was the most commonly associated ocular finding noted in 4 (22.2%) patients. Anatomical success was achieved in 88.9% of patients, with 2 (11.1%) patients showing delayed dye disappearance and slightly increased tear meniscus height. Both reported a Munk score of grade 1. Functional success was achieved in 94.4% of patients, and 1 (5.6%) patient had epiphora according to the caregiver. Table 2 shows the percentage of anatomical and functional success in our series.

Demographic Details and Clinical Profile of Children

Table 1:

Demographic Details and Clinical Profile of Children

Distribution of the Participants in Terms of Anatomical Recovery (N = 18) and Functional Recovery

Table 2:

Distribution of the Participants in Terms of Anatomical Recovery (N = 18) and Functional Recovery

There was no significant difference between the early and delayed groups in terms of distribution of anatomical success (chi-square = 0.117, P = 1.000). The odds ratio (95% CI) for time since injury and anatomical success was 0.6 (CI: 0.03 to 11.47). Table 3 shows the association between time since injury and anatomical recovery, functional recovery, and complications. There was also no significant difference between the early and delayed groups in terms of distribution of functional success (chi-square = 1.664, P = .389). The odds ratio (95% CI) for time since injury and functional success was 0.19 (CI: 0.01 to 5.33). Table 3 shows the association between time since injury and functional success. Ectropion was the most common postoperative complication noted in 4 (22.2%) patients. There was no significant difference between the early and delayed groups in terms of distribution of complications (chi-square = 3.273, P = .224).

Association Between Time Since Injury and Anatomical Recovery, Functional Recovery, and Complications

Table 3:

Association Between Time Since Injury and Anatomical Recovery, Functional Recovery, and Complications

Discussion

Our study included 18 pediatric patients with a mean age of 5.39 ± 3.05 years. Children younger than 10 years were included in the study because there are many studies reflecting differences in wound healing properties with increasing age. Every phase of healing undergoes age-related change. Skin composition and organization changes with age. Changes in the skin microstructure can affect its stiffness and alter the response of different cells involved in wound repair. A prolonged inflammatory response and delayed reepithelialization in the wounds of aged skin may be related to an altered mechanical environment.10 However, it has been widely observed that aged skin wounds heal differently than young wounds, and are associated with delayed rates of closure and mechanically weaker tissue following repair.11,12

Many studies have described success rates after canalicular laceration repair in both adults and children, but none of these studies are exclusive for a pediatric population. A few studies have described outcomes of canalicular laceration repair only in a pediatric population, but they used stents other than the Mini Monoka and included patients older than 10 years. Both Murchison and Bilyk6 and Alhammad et al7 included patients up to 17.96 years of age and used various stents with different techniques of repair. Our study is the only one describing outcomes in a pediatric population younger than 10 years with a pericanalicular suturing technique using the Mini Monoka stent. Direct trauma is the most common mode of injury and the blouse hook was noted to be the most common object of injury in our study, which is corroborative with the previous Indian study.13 Blouse hook injury is typical and unique to Indian ethnicity because the sari with blouse is the traditional dress commonly worn by Indian women. The blouse has metallic hooks in front that can be a potential source of injury to a child's eye while breast feeding because the metallic hook can become entangled in the punctum, resulting in canalicular laceration.

Dog bites, cow horn injuries, and injury by metallic bicycle wire were also noted among the pediatric population in our study. Dog bite and clothes hanger were the most common mode of injury in a study done by Murchison and Bilyk6 and Alhammad et al7, respectively.

Older theories regarding the timing of canalicular repair held that operative repair should be performed within 24 to 48 hours to ensure a good functional result.14 It was believed that stenosis occurs more frequently after repair beyond that time limit because of increased scar formation, thereby making it difficult to identify the distal canalicular end. Our study included patients with both early and delayed repair and found no significant difference between the two. This may be because most patients were repaired within 7 days and most of them sustained direct trauma that resulted in clean cut wounds with little scarring and fibrosis. Chu et al15 also reported that, for an experienced oculoplastic surgeon, there was no difference between early (within 48 hours) and late (after 48 hours) repair in success rate and operation time. Therefore, eyelid and canalicular repair can be delayed until associated systemic and ocular comorbidities have been managed.

We found an anatomical success rate of 88.9% and a functional success rate of 94.4%, which is similar to previous studies except that they included both adult and pediatric patients.16–19 Alhammad et al7 achieved a functional success rate of 87.5% in their series of pediatric patients. There was no significant difference between the early and delayed repair group in terms of distribution of complications in our study, although ectropion was noted more in the delayed repair group. Tube extrusion was noted in 1 (14.3%) patient in the early repair group who showed delayed dye disappearance with a Munk score of grade 2, but patency could not be confirmed with syringing because the age was 1.33 years. Delayed dye disappearance was also seen in 1 (9.1%) patient in the delayed repair group who had a Munk score of grade 1. The time lag from injury to repair in this patient was 15 days and because the child was 9 years old and cooperative, syringing was performed and showed individual canalicular block. Previous studies have determined functional success by the absence of epiphora and anatomical success rate by irrigation of the lacrimal system.20

The limitations of our study are its retrospective nature, small sample size, and lack of diagnostic testing to confirm the anatomic patency of the lacrimal system because syringing could not be done in all patients due to the difficulty of doing these procedures in a pediatric age group. However, we tried to assess the anatomical success rate with the help of the fluorescein dye disappearance test and tear meniscus height and functional success by grading epiphora with the Munk score.

The emphasis should be placed on translating what has been learned from the epidemiology and demography of injury into effective interventions to prevent injuries or/and to improve outcomes from trauma, thereby applying research to practice. Direct trauma by some sharp or blunt object can be avoided by proper supervision of children and counselling of mothers about blouse hook injury post-natally during the hospital stay, thereby preventing functional and cosmetic morbidity.

Canalicular laceration repair with the Mini Monoka stent in children younger than 10 years has shown good outcomes in terms of anatomical and functional recovery irrespective of time lag from injury to repair.

References

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Demographic Details and Clinical Profile of Children

ParameterValue
Mean ± SD age (y)5.39 ± 3.05
Gender
  Male9 (50.0%)
  Female9 (50.0%)
Time since injury
  Early7 (38.9%)
  Delayed11 (61.1%)
Type of injury
  Direct14 (77.8%)
  Indirect4 (22.2%)
Mode of injury
  Blunt trauma2 (11.1%)
  Cow horn2 (11.1%)
  Dog bite3 (16.7%)
  Blouse hook5 (27.8%)
  Road traffic accident4 (22.2%)
  Bicycle wire2 (11.1%)
Location of tear
  Upper eyelid6 (33.4%)
  Lower eyelid12 (66.7%)
Associated ocular comorbidity
  None12 (66.7%)
  Subconjunctival hemorrhage4 (22.2%)
  Moderate ptosis1 (5.6%)
  Traumatic uveitis + glaucoma1 (5.6%)
Complications
  None12 (66.7%)
  Ectropion4 (22.2%)
  Delayed DDT2 (11.1%)
  Anatomical recovery (present)16 (88.9%)
  Functional recovery (present)17 (94.4%)

Distribution of the Participants in Terms of Anatomical Recovery (N = 18) and Functional Recovery

RecoveryFrequencyPercentage
Anatomical
  Present1688.9%
  Absent211.1%
  Total18100.0%
Functional
  Present1794.4%
  Absent15.6%
  Total18100%

Association Between Time Since Injury and Anatomical Recovery, Functional Recovery, and Complications

ParameterTime Since InjuryFisher's Exact Test


EarlyDelayedTotalChi-squareP
Anatomical recovery (n = 18)
  Present6 (85.7%)10 (90.9%)16 (88.9%).1171.000
  Absent1 (14.3%)1 (9.1%)2 (11.1%)
  Total7 (100.0%)11 (100.0%)18 (100.0%)
Functional recovery (n = 18)
  Present6 (85.7%)11 (100.0%)17 (94.4%)1.6640.389
  Absent1 (14.3%)0 (0.0%)1 (5.6%)
  Total7 (100.0%)11 (100.0%)18 (100.0%)
Complications (n = 18)
  None6 (85.7%)6 (54.5%)12 (66.7%)3.273.224
  Ectropion0 (0.0%)4 (36.4%)4 (22.2%)
  Delayed DDT1 (14.3%)1 (9.1%)2 (11.1%)
  Total7 (100.0%)11 (100.0%)18 (100.0%)
Authors

From the Departments of Orbit and Oculoplasty (NP, RS), Pediatric Ophthalmology & Strabismus (PS), and Children's Eye Care Center (AM), Sadguru Netra Chikitsalaya (RA), Chitrakoot, India.

The authors have no financial or proprietary interest in the materials presented herein.

Correspondence: Narendra Patidar, MBBS, DOMS, Sadguru Netra Chikitsalaya, Chitrakoot, Jankikund, District Satna, Madhya Pradesh-210204, India. Email: narendrapatidar59@gmail.com

Received: March 25, 2020
Accepted: July 13, 2020

10.3928/01913913-20201007-02

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