Introduction
Intracanalicular lacrimal plugs can provide an effective treatment modality for dry eyes. We report an unusual case of left common canalicular obstruction following insertion of a lacrimal plug which required endoscopic dacryocystorhinostomy, and we present the first intra-operative photographs demonstrating retention and removal of the plug within the common canaliculus.
Case report
A 40-year-old woman initially presented four years previously with bilateral keratoconjunctivitis sicca which did not improve despite copious application of lubricants. Herrick lacrimal plugs were inserted into the horizontal canaliculus of both lower lids, which led to a significant improvement in the patient's symptoms.
The patient represented two years later with right epiphora. Sac washout of the right nasolacrimal duct indicated initial resistance, which was overcome. Again, the patient's symptoms improved, considered to be secondary to a reversible right canalicular obstruction; presumably, the plug had washed through during this investigation.
The patient presented a further two years later with bilateral epiphora. Sac washouts revealed obstruction at the level of the common canaliculus. The patient underwent bilateral endoscopic dacryocystorhinostomy. The right procedure was uneventful. However, the left endoscopic dacryocystorhinostomy revealed the presence of a lacrimal plug occluding the common canaliculus (Figure 1).
Retrieval of lacrimal plug from left common canaliculus during endoscopic dacryocystorhinostomy.
The procedure was performed under general anaesthetic. Following preparation of the nasal cavity with topical local anaesthetic and vasoconstrictors, the surgery was performed using a 0º, 4-mm nasendoscope. Mucoperiosteal flaps were elevated over the agger nasi and the lacrimal crest of the maxilla was widely exposed. The lacrimal crest was taken down using a combination of Hajeks forceps and a Xomed drill. Lacrimal bone covering the lacrimal sac was removed, facilitating wide exposure of the medial sac wall. The sac was probed from above and then opened widely with a phaco knife anteriorly, creating a posterior-based sac wall flap which was reflected posteriorly. The patency of the dacryocystorhinostomy was re-checked with a lacrimal probe and, as Figure 1 clearly illustrates, the presence of a Herrick lacrimal plug occluding the common canaliculus was detected. Following removal of the plug, silicone tubing was passed down both the upper and lower canaliculi into the nose in order to prevent fibrous closure of the nasolacrimal system.
The silicone tubing was left in situ for three months. The patient experienced symptomatic improvement of her epiphora post-operatively.
Discussion
Herrick lacrimal plugs are silicone, funnel-shaped, intra-canalicular plugs designed for implantation in the horizontal canaliculus. As in the above case, the main indication for their use is dry eye disease. The effects of this device can usually be reversed by a simple perfusion technique.Reference Jones, Anklesaria, Gordon, Prouty, Rashid and Singla1 However, adverse effects of their use have been reported, related to difficulty removing the plugs and permanent nasolacrimal duct obstruction.Reference White, Bartley, Hawes, Linberg and Leventer2 Specific side effects include epiphora,Reference Jones, Anklesaria, Gordon, Prouty, Rashid and Singla1, Reference Gerding, Küppers and Busse3, Reference Lee and Flanagan4 plug migration,Reference Jones, Anklesaria, Gordon, Prouty, Rashid and Singla1, Reference Lee and Flanagan4 irritation,Reference Jones, Anklesaria, Gordon, Prouty, Rashid and Singla1, Reference Lee and Flanagan4 canaliculitis,Reference Lee and Flanagan4 pyogenic granuloma,Reference White, Bartley, Hawes, Linberg and Leventer2 dacryocystitis,Reference Lee and Flanagan4 and pre-septal and orbital cellulitis.Reference Lee and Flanagan4 Additionally, nasolacrimal irrigation does not always reliably flush plugs from the lacrimal system, and these devices may act as a potential source of inflammation or infection.Reference Lee and Flanagan4 Management of these complications may include the use of systemic antibiotics,Reference Lee and Flanagan4 canaliculotomy,Reference Lee and Flanagan4 nasolacrimal probing with irrigation,Reference White, Bartley, Hawes, Linberg and Leventer2 probing and stenting with silicone tubing,Reference White, Bartley, Hawes, Linberg and Leventer2 eyelid margin cutdown,Reference White, Bartley, Hawes, Linberg and Leventer2 balloon dacryoplasty,Reference White, Bartley, Hawes, Linberg and Leventer2 dacryocystorhinostomy,Reference White, Bartley, Hawes, Linberg and Leventer2, Reference Lee and Flanagan4 and conjunctivodacryocystorhinostomy.Reference White, Bartley, Hawes, Linberg and Leventer2
The above cse highlights the potential side effects of the use of Herrick lacrimal plugs. While the presence of epiphora suggests that the primary diagnosis may have been in doubt, the patient did remain asymptomatic for at least two years following initial plug insertion. Also, the intra-operative photographs clearly demonstrate that nasolacrimal irrigation failed to flush the plug from the nasolacrimal system.
• Intracanalicular lacrimal plugs can provide an effective treatment modality for dry eyes
• This paper describes an unusual case of left common canalicular obstruction following insertion of a lacrimal plug, which required endoscopic dacryocystorhinostomy
• Intracanalicular lacrimal plugs should be used with caution and an awareness of potential adverse effects
Intracanalicular lacrimal plugs can provide an effective treatment modality for dry eyes. However, as this case demonstrates, they should be used with caution and an awareness of potential adverse effects.
