Placement of Three Interrupted Sutures After Triangular Three-snip Punctoplasty

A Comparison Between Placement of Three Interrupted Sutures After Triangular Three-snip Punctoplasty vs Conventional Triangular Three-snip Punctoplasty for Treatment of Lower Punctal Stenosis

a prospective randomized study conducted upon 40 eyes of 24 patients with lower punctual stenosis (grade 1 or 2 according to Kashkouli scale) attending at Menoufia University hospitals and Kafr Elsheikh ophthalmic eye center. The upper punctum and canaliculus were patent. All patients were complaining of epiphora and had a thorough ophthalmological examination including dye disappearance test, and slit-lamp examination. A Nettelship dilator is used to enlarge the stenotic lacrimal punctum. A single blade of a small Westcott spring scissor or Vannus scissor is placed within the ampulla of the lacrimal canaliculus, with the remaining blade placed on the conjunctival surface of the posterior aspect of the eyelid. The first vertical snip is made at the vertical canaliculus. The second vertical snip is made from the edge of the first snip to create a flap. The final horizontal snip was made at the base. The triangular flap is removed and three sutures are placed, in an interrupted manner, at the posterior wall of the ampulla using 10-0 nylon. The sutures are removed 1 week after the surgery. Topical moxifloxacin 0.5% eye drops and fluorometholone 0.1% eye drops were used four times daily for one week.Patients were then followed up for 6 months after the surgery.

Study Overview

• Status: Unknown
• Conditions: Epiphora
• Intervention / Treatment: Procedure: Placement of three interrupted sutures after Triangular Three-snip Punctoplasty of the lower punctum; Procedure: Conventional Triangular Three-snip Punctoplasty of the lower punctum

Detailed Description

This is a prospective non-randomized study which includes 40 eyelids of 24 patients with acquired lower punctal stenosis grade 1 or grade 2 according to Kashkouli scale attending at Menoufia University hospitals and Kafr Elsheikh ophthalmic eye center in the period from January 2019 to June 2020. Ethics approval from the institutional review board was obtained, and a written informed consent was taken from every patient according to the Declaration of Helsinki.

A full history and examination were done for patients for evaluation of proximal lacrimal drainage system and exclusion of other causes of epiphora rather than punctal stenosis, Inspection of face and periorbital region for position of the eyelids and puncta, Gross nasal deformity, Facial symmetry, presence of any swelling or fistula in the lacrimal sac area , palpation of lacrimal sac for regurge test , slitlamp examination of lid margin for coaptation with the globe , blepharitis or rubbing lashes , skin for laceration or eczema , conjunctiva for papillae , follicles, hyperemia or discharge , cornea for punctate keratitis, filaments or abrasions , lower Tear meniscus height (TMH) using a 1 mm slit beam , punctal orifices position, shape , grading of stenosis according to Kashkouli et al.

Fluorescein dye disappearance test (FDDT) where the fluorescence of the tear meniscus was observed with the help of cobalt-blue filter. FDDT was graded according to Ozgur et al., scale according the time of dye clearance.

Diagnostic probing and syringing were done to ensure anatomically patent nasolacrimal system and to detect any obstruction distal to the punctum.

Patients were examined for results in visits at one week, 1month, 3 months and 6 months.

Satisfactory surgical outcome was defined as postoperative patent lower eyelid punctum and improved Epiphora and FDDT grade at 6 months after surgery.

Surgical procedure

Surgery was performed using an operating microscope under local anaesthesia. We transconjunctivally infiltrate 2% (w/v) lidocaine (with epinephrine in a 1:100,000 weight ratio) from the posterior aspect of the eyelid into the region of the lacrimal canaliculus and punctum.A Nettelship dilator is used to enlarge the stenotic lacrimal punctum. A single blade of a small Westcott spring scissor or Vannus scissor is placed within the ampulla of the lacrimal canaliculus, with the remaining blade placed on the conjunctival surface of the posterior aspect of the eyelid. The first vertical snip is made at the vertical canaliculus. The second vertical snip is made from the edge of the first snip to create a flap. The final horizontal snip was made at the base. The triangular flap is removed and three sutures are placed, in an interrupted manner, at the posterior wall of the ampulla using 10-0 nylon. The sutures are removed 1 week after the surgery. Topical moxifloxacin 0.5% eye drops and fluorometholone 0.1% eye drops were used four times daily for one week.Patients were then followed up in 1 week , 1 month , 3 months , 6 months period.

• Study Type: Interventional
• Enrollment (Anticipated): 24
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Egypt
  • Shibīn Al Kawm, Egypt
    • MenoufiaU

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 17 years and older (ADULT, OLDER_ADULT, CHILD)
• Accepts Healthy Volunteers: Yes
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• primary acquired lower punctal stenosis grade 1 or 2 according to Kashkouli et al. , patent upper punctum and both canaliculi as well as patent nasolacrimal duct , normal lower eyelid margin position

Exclusion Criteria:

• Patients with Congenital punctal stenosis, Acute conjunctival allergic punctal stenosis, Punctal stenosis associated with radiotherapy, Lid malposition, Canalicular, lacrimal sac and nasolacrimal duct obstruction revealed after syringing , Previous eyelid or lacrimal drainage system surgery, Blepharitis and ocular surface disorders, Patients with dry eye were excluded.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: TREATMENT
• Allocation: RANDOMIZED
• Interventional Model: PARALLEL
• Masking: NONE

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
ACTIVE_COMPARATOR: Placement of three interrupted sutures after Triangular Three-snip Punctoplasty of the lower punctum; After instillation of topical benoxinate hydrochloride 0.4%, subconjunctival injection of 2% lidocaine was done beneath the lower punctum, then Nettleship dilator was used to dilate the punctum. A single blade of a small Westcott spring scissor or Vannus scissor is placed within the ampulla of the lacrimal canaliculus, with the remaining blade placed on the conjunctival surface of the posterior aspect of the eyelid. The first vertical snip is made at the vertical canaliculus. The second vertical snip is made from the edge of the first snip to create a flap. The final horizontal snip was made at the base. The triangular flap is removed and three sutures are placed, in an interrupted manner, at the posterior wall of the ampulla using 10-0 nylon. Hemostasis was done by compression with a cotton tip for one minute until bleeding stop. The sutures are removed 1 week after the surgery.	Procedure: Placement of three interrupted sutures after Triangular Three-snip Punctoplasty of the lower punctum; A Nettelship dilator is used to enlarge the stenotic lacrimal punctum. A single blade of a small Westcott spring scissor or Vannus scissor is placed within the ampulla of the lacrimal canaliculus, with the remaining blade placed on the conjunctival surface of the posterior aspect of the eyelid. The first vertical snip is made at the vertical canaliculus. The second vertical snip is made from the edge of the first snip to create a flap. The final horizontal snip was made at the base. The triangular flap is removed and three sutures are placed, in an interrupted manner, at the posterior wall of the ampulla using 10-0 nylon. The sutures are removed 1 week after the surgery.
ACTIVE_COMPARATOR: Conventional Triangular Three-snip Punctoplasty of the lower punctum; After instillation of topical benoxinate hydrochloride 0.4%, subconjunctival injection of 2% lidocaine was done beneath the lower punctum, then Nettleship dilator was used to dilate the punctum. A single blade of a small Westcott spring scissor or Vannus scissor is placed within the ampulla of the lacrimal canaliculus, with the remaining blade placed on the conjunctival surface of the posterior aspect of the eyelid. The first vertical snip is made at the vertical canaliculus. The second vertical snip is made from the edge of the first snip to create a flap. The final horizontal snip was made at the base. Hemostasis was done by compression with a cotton tip for one minute until bleeding stop.	Procedure: Conventional Triangular Three-snip Punctoplasty of the lower punctum; A Nettelship dilator is used to enlarge the stenotic lacrimal punctum. A single blade of a small Westcott spring scissor or Vannus scissor is placed within the ampulla of the lacrimal canaliculus, with the remaining blade placed on the conjunctival surface of the posterior aspect of the eyelid. The first vertical snip is made at the vertical canaliculus. The second vertical snip is made from the edge of the first snip to create a flap. The final horizontal snip was made at the base. The triangular flap is then removed .

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Degree of improvement of epiphora by Munk score	Measurement of improvement of epiphora by use of Munk score as follow : Grade 0 : No Epiphora. Grade 1 : Occasional epiphora requiring drying or dabbing less than twice a day. Grade 2 : Epiphora requiring dabbing two to four times per day. Grade 3 : Epiphora requiring dabbing five to ten times per day. Grade 4 : Epiphora requiring dabbing more than ten times daily or constant tearing.	6 months
Degree of improvement of lacrimal drainage by Dye disappearance test	Performed by putting a drop of 2% fluorescein sodium in the conjunctival sac followed by assessment after 5 minutes of the remaining dye in the tear meniscus. Results were graded according to the following scale Grade 1 : <3 minutes Grade 2 : 3-5 minutes Grade 3 : >5 minutes	6 months
Slit lamp assesment of the state of the lower punctum	Slit lamp examination of the lower punctum and its grading according to Kashkouli scale as follows: Grade 0 : No punctum (agenesis) Grade 1 : Papilla is covered with a membrane (difficult to recognize) Grade 2 : Less than normal size, but recognizable Grade 3 : Normal Grade 4 : Small slit (<2 mm) Grade 5 : Large slit (≥2 mm)	6 months

Collaborators and Investigators

• Sponsor: Menoufia University
• Investigators: Principal Investigator: sameh s mandour, MD, Menoufia University

Study record dates

Study Major Dates

• Study Start (ACTUAL): January 1, 2019
• Primary Completion (ANTICIPATED): December 20, 2020
• Study Completion (ANTICIPATED): December 23, 2020

Study Registration Dates

• First Submitted: December 17, 2020
• First Submitted That Met QC Criteria: December 17, 2020
• First Posted (ACTUAL): December 22, 2020

Study Record Updates

• Last Update Posted (ACTUAL): December 22, 2020
• Last Update Submitted That Met QC Criteria: December 17, 2020
• Last Verified: December 1, 2020

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Eye Diseases; Lacrimal Apparatus Diseases
• Other Study ID Numbers: MenoufiaU112019

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No