Lecture: Lacrimal Trauma: A Systematic Approach to Canalicular Lacerations

DR PELTON: Hello. My name is Ron Pelton. I’m an oculoplastic surgeon in Colorado Springs, Colorado. We’re gonna be talking today about lacrimal trauma. So injuries around the eyes and eyelids are very common, and they can cause significant problems. In the United States, it’s been reported that about 5% of all serious trauma also incurs eyelid trauma. Specifically trauma to the lacrimal system. So the injuries to the lacrimal system — 80% of the time, it’s gonna involve the canaliculi. And of all lacrimal trauma, 25% of these injuries are gonna occur in children. So one study performed by the National Center for Health Statistics in the United States estimated that 2 million eye injuries occurred annually in the United States, and about 90% of these are considered preventable. So today we’re gonna be talking about lacrimal trauma and how to repair lacrimal trauma. And, of course, this is sponsored by Orbis. And I’m one of the physicians that has the privilege of working with Orbis. So our first question today is: What part of the lacrimal system is most commonly injured during trauma? Your choices are the punctum, canaliculus, the lacrimal sac, or the nasolacrimal duct. So most people said the canaliculus, and that is correct. So this is a typical type patient. This gentleman came to see me because he had tearing on the left. And on examination, it’s pretty obvious that he has had an injury at some time in the past to this left eye. If you look at his left medial canthus, you can see he has blunting of the angle of the left medial canthus, and obviously he has a divot just medial to the punctum. Here’s another type of injury that I see fairly commonly. I saw him from the emergency room because of this orbital fracture on the left side. And the injury is pretty obvious. He has an injury to the lower lid, which involves the canaliculus. Now, canalicular injuries are the most frequent cause of injury to the lacrimal system, and about half of the time, it’s because of penetrating injury, and half the time it’s because of blunt injury. Cadaver studies have shown that when force is applied to the lateral canthus, or the malar eminence, and this is the sort of injury that often happens when you get a fist to the face, lacerations will occur in the medial canthus. Because the medial canthal tendon complex, as it wraps around the lacrimal sac, is weakened. And so when the injury occurs laterally, it pulls on the medial canthus, and it tears this medial canthal tendon, and the lacrimal drainage system that’s associated with that. So any time you see a canalicular injury medial to the punctum, or, for example, associated with a dog bite, you should think about a canalicular injury. And as we said, it’s the inferior canaliculus. The lower one. That’s involved in about 80% of these cases. And most typically, it’s the horizontal limb of the lower canaliculus. So to remember, refresh your anatomy, we have the punctum, with the vertical portion, which is about 2 millimeters in length. And then the superior and inferior horizontal limb of the canaliculi. And these come together to form the common canaliculus. Now, in some people, the common canaliculus is absent. But in most people, you can find the common canaliculus as it moves into the lacrimal sac, which then moves into the lacrimal duct. And as you can see here, the medial canthal tendon splits into a posterior and an anterior leaf, which wraps around the lacrimal sac. So when you see an injury like this, the first question you’re gonna ask yourself is: Am I gonna repair the canaliculus or not? And if you decide not to, you’ve got to ask yourself: Do I feel lucky? Now, the reason I bring that up is: There was a paper published in 1999 in Ophthalmology. And the paper had to do with monocanalicular lesions. That is to say, trauma to the lacrimal system that involved only one canaliculus. Interestingly, the conclusion of this paper is that non-repair of a monocanalicular lesion is a valid approach that results in little or no morbidity. That is to say, not repairing a canalicular laceration if it just involves one is a valid approach. Now, personally, I haven’t found this to be true. The problem is that if there is scarring, if there is closure, and you need to open that up, that is to say, if there is tearing, and you need to fix this lesion, once it’s scarred shut, it can be a very difficult thing to deal with. So the second question that you need to ask yourself, when you’re looking at lacrimal trauma, is: What are my repair options? Well, as we just said, one option is just to repair the soft tissue, and don’t worry about the canaliculus. The second option is to repair this over a monocanalicular stent. And the third option is to close over a bicanalicular stent. So for those of you that don’t do much in the way of lacrimal repair, these are the kinds of stents that we’re talking about. The top ones are the Crawford stents, and these are ones that we often use, for example, doing a dacryocystorhinostomy. A DCR. On the right you see a mini-stent called a Mini Monoka. And there’s another option here for monocanalicular stents, and this one is attached to a probe. So it’s sort of a combination of the top one and the middle one. So if we decide not to put in a stent, that’s essentially the same as no canalicular repair, as far as I’m concerned. And in many cases, the canaliculus will scar shut. And I find that to be a difficult thing to repair later on. So I’m always advocating for repairing it primarily. So the third question you’re gonna ask yourself, once you decide to put in a stent through the canaliculus, is: How do I find the distal end of the laceration? Well, I find that in most cases, it’s usually pretty easy, after you clean up the area. So once you get the patient in the operating room, and get them either sedated or under general anesthesia, you can clean the area very well with saline and find the distal end fairly easily. Another method that some people use is to irrigate fluid through the non-injured punctum. That is to say, if the laceration is on the lower canaliculus, you inject fluid through the upper punctum, such as Kenalog or fluorescein dye, et cetera, and see where it comes out. Another way is just to put water over the area of the injury and push air through the upper punctum and see where the bubbles come out, or you can use a pigtail probe, and that’s what I typically do. You can see here, this is an area that’s been cleaned up. And the arrow is pointing at the distal end. And again, here’s the use of that pigtail probe. And we’ll see this again in a little bit. So next question: Which canaliculus is the one that’s most commonly Injured? Is it the superior canaliculus, the inferior canaliculus, or the common canaliculus? The inferior canaliculus. That is correct. So the fourth question is: What type of stent are we going to use? We’ve discussed monocanalicular and bicanalicular. So let’s talk about monocanalicular first. Here’s that Mini Monoka stent that I was talking about. There are certain advantages to using a monocanalicular stent. Number one, it means that we don’t have to do anything to the normal canaliculus. For example, if the laceration is on the bottom, we don’t have to do anything at all to the top, and therefore we can’t possibly injure the top. Advantage number two is these are pretty easy to remove at the slit lamp. And three, there’s no danger of cheese wiring or erosion of the punctum. So sometimes when we do a DCR, if we put in the stent too tight, it will cause erosion of the punctum, and make the punctum much larger than it normally is. You can avoid that with a monocanalicular stent. And last of all, there’s no need for suturing this into place. It’s anchored at the punctum, very much like a punctal plug. So this is a cartoon just sort of illustrating how these are seated at the punctum. And as you can see, it’s much like a punctal plug. So here’s a video that I found on the internet. And this is a Dr. Nair. And he’s placing a Mini Monoka monocanalicular stent. So you can see he dilated the punctum, cleaned the area, and here’s the stent that he’s gonna be putting in. He’s gonna first of all cut it to kind of bevel the tip, to make it easier to insert. He’s gonna place it through the punctum that he just dilated. And you can see it coming out through the proximal end of the laceration. Now he has to put it through the distal end. He’s gonna pull it through and anchor the end of it there. And the next thing he’s gonna do is take that beveled end and put it through the distal end of the laceration. And he does that. Makes it look easy. So now all he has to do is just do his typical soft tissue repair, and he’s done. Now, there are certain disadvantages to using a monocanalicular stent. Number one, they’re more expensive. Two, they may not be available. I find that when I have asked for these in the past, they don’t typically seem to have them available. It can be awkward to put these in, especially if the tissue is very swollen or very torn up. And they can be easily dislodged. So when you put these in children, children tend to want to pick at it with their fingers, and they can pull them out fairly easily. So next question. Name one advantage of monocanalicular stents. Number one, avoids the undamaged canaliculus. Number two, easy to remove. Number three, you don’t have to suture it in. Or number four, all of the above. Yes, all of the above. So there’s several versions of this stent. I showed you the Mini Monoka. There’s one that’s a little bit larger, called the Medium Monoka, and it’s on a wire, and there’s a third one, called the self-threading Monoka. And we won’t go into details about those, but they are available. So the next one we’re gonna talk about is closure over a bicanalicular stent. So there’s two ways of doing this. One way is to use sort of the standard Crawford lacrimal tube set, and place it very similar to the way we place stents after a DCR. And the second way is to use a pigtail probe, placing the stent over a suture. So these are the Crawford stents that I typically use. You can get these from lots of different places. But they’re all very similar. They have a guide wire with an olive tip. And then you have the stent portion, which is wedged onto the guide wire, and you can find these just about anywhere. Now, again, the important thing about placing these stents is you have to remember the anatomy. So as we said, after the punctum, there’s a 2 millimeter vertical section of the canaliculus. Then there’s a horizontal portion of the canaliculus, which goes into the common canaliculus, and then into the lacrimal sac. And at that point, you have to turn the guide wire vertically. And as you push it through the nasolacrimal duct, it’s going to come out under the inferior turbinate. Now, in children this can be tricky, because especially after an injury, the tissues are swollen. The inferior turbinate is pushed very firmly up against the lateral wall there. So it can be tricky to find that guide wire under that inferior turbinate. Now, when you place these, the first thing you want to do is go 2 millimeters vertical. And then you want to pull on the lid horizontally. So that you don’t get bunching up of the tissue. If you feel this soft stop, you know that you’re not pulling it correctly. Once it’s in, and you’ve pushed it down through the nasolacrimal duct, you’re gonna pull it out, as we said, from under the inferior turbinate. And there’s a couple of different types of instruments that you can use for this. One is called a Crawford Hook. And one is called a grooved director. Now, I tend to prefer the grooved director, because it’s very blunt, and you can’t cause mini-injuries. Whereas the Crawford Hook can actually tear up the tissue fairly vigorously, if you don’t use it properly. The grooved director tends to be safer. So once the stents are both retrieved, and they’re in place, you can then repair the canaliculus and tendon. Now, in some of the older books, you’ll see pictures like this. Where we’re actually trying to suture the canaliculus together with very small sutures like 9-0 or 10-0 nylon. And some of these pictures look really complex. But it was a paper published by Bob Kersten — many of you may know Dr. Kersten. And he showed that once the stent is through the canaliculus, you don’t actually have to put stitches through the canalicular tissue. You can put one suture around it and pull it together, and that is sufficient. So once the stents are in place, and the wound is closed, we typically leave the stents in place for somewhere around 4 to 6 months. You can leave it in even longer, if you need to. So here’s a video illustrating how that’s done. You can see this lid is lacerated in several different places. So they’re placing this olive tip Crawford stent. First through the puncta. There they are, dilating the upper punctum. Showing you where the laceration is. And placing the guide wire with the olive tip through the upper laceration. Now comes the tricky part. Getting it through the distal end of the laceration. Having that hook there to show you can help. Now they’ve turned it vertically, and they’re gonna push it through the nasolacrimal duct, and then pull it out under the inferior turbinate. And you can see they’ve got the piece of metal in the nose, and they’re pulling out the guide wire. Now, in that particular case, they were using not a grooved director, but a Crawford Hook. So that’s the bicanalicular technique, using the Crawford stents, sort of in a standard way. Now we’re gonna talk about using the pigtail probe. So many of you have seen this instrument. This is a typical pigtail probe. Now, it comes in a couple of different versions. This one is your friend. You’ll notice it’s got a very blunt tip, and it’s got an opening on the tip. Here’s another version of that. This is the one you’re looking for. This is the one you want. This one is not your friend. As you can see, it is not open on the end, and it’s got this hook. Now, this probe was developed by a Dr. Worst. That’s W-O-R-S-T. And this is the Worst probe. And this one I’m not a fan of. And the reason is because, if you’re not used to using this, as you manipulate it in the tissue, this hook can really tear up that soft tissue that we find in the lacrimal drainage system. So I don’t advocate using this. I think using the blunt probe is much safer. Especially if you’re something of a novice in repairing these types of injuries. So here’s an injury that we sometimes see. So this gentleman’s eyelids were torn up pretty badly. You can see I’ve labeled it, so you can kind of see where the tissues are, so you can orient yourself. But this is exactly the type of injury that you’re gonna need to repair the canaliculus on. So here’s the technique. And I’m gonna walk you through this. I’ve got photographs of me doing this over on the left hand side of the screen. And on the right hand side is a cartoon from a publication by Dr. Dave Jordan. Who is the one who taught me this technique. Now, you can see we’ve got the pigtail probe, and the cartoon shows the pigtail probe has been rotated through the upper punctum, and is coming out the distal laceration, there on the bottom. Now, on the left hand side of my photograph, I rotated it through this end and out the normal punctum. And here’s a close-up of that. You can see it’s a blunt pigtail probe, and there’s an opening in the end there. Now, the next thing that I’m gonna do is to take a prolene suture. You can use just about any type of suture. I like prolene. And in fact, this is a 5-0 prolene. And I’ve cut a piece of it, and I’m pushing it through the eye of the pigtail probe. And now I’m starting to rotate the probe and pull that suture through. So you can see it in the photograph, on the left hand side. The 5-0 prolene is going through the normal punctum in the upper eyelid. The uninjured canaliculus. And it’s gonna be coming out through the distal end of the wound. That’s what I’ve done there. So now I have a 5-0 prolene going through the normal upper punctum. Through the normal upper canaliculus. Through the lacrimal sac. And then out through the distal end of the wound. Now what I do here is I dilate the normal… I’m sorry, the lacerated punctum. And I put my pigtail probe through that lacerated punctum. And now I’m gonna pull my suture through that. So I put the pigtail probe in. I put the suture in. And then I rotate it through. So now you can see I’ve got this 5-0 prolene suture going through the entire lacrimal system. Now, the next thing I’m gonna do is take that Crawford stent set that we looked at earlier. And I’m gonna cut a portion, about 20 to 25 millimeters in length. Now, in adults, I usually use 25 millimeters. In children, I’m gonna use 20 millimeters. And this doesn’t have to be exact. But it has to be pretty close. If it’s too short, it’s gonna be too tight, and it won’t work. And if it’s too long, we’re gonna have a lot of extra floppy stent hanging out, and that’s gonna be bothersome. So think 20 millimeters in children. 25 millimeters in adults. So I’ve now threaded that over the prolene suture that I’ve got, that is going through the lacrimal system. You can see in the cartoon he shows 20 to 24 millimeters. And now I’ve started to rotate that through. Now, what you find is that as you pull the suture quite often the stent will hang up on the tissue, and you just start pulling the suture through the stent. So you can see what I’ve done is I’ve used my needle driver and I’ve clamped down on the suture to anchor it, so that as I pull on the inferior part of that suture, it’s gonna push the stent through the upper portion. And now I’ve rotated it through, and you can see that the stent is now starting to come out through that lower injured punctum. So now I have a 5-0 prolene that’s going through the entire system. And I also have a Crawford stent over that suture that’s going through the entire system. And that’s shown here on the cartoon. Now, once you have the Crawford stent over the suture, that’s through the entire system, you just tie a knot, and that’ll bring the two ends of the stent together. Now, when you’re tying these knots, it’s easy to tie a lot of knots. But then you’re gonna have a problem with the knot that’s too big. So I advocate putting in about 4 throws to tie this knot. So when you tie the knot, it brings the two ends together. And then you’re gonna rotate that knot by rotating the stent. So what I do is I grab the stent with two pairs of forceps, and then gently rotate it through either the upper punctum or the lower punctum, so that the knot is pointing toward the common canaliculus. Once that’s done, you can just suture the medial canthal tendon back together, and I’ve done that here, using a vicryl suture. And as you can see in the cartoon, there are sutures through the lid wound, and you can see that the stent is through the entire canalicular system, and the knot has been rotated toward the common canaliculus. So it looks like this. All right. Here’s our next question. What’s the name of the pigtail probe that Dr. Pelton advises against using? Is it the Best pigtail probe, or the Worst pigtail probe, or the Neely pigtail probe? That’s correct. It is the Worst pigtail probe. The reason we want to avoid that one is because it has a hook on the end. And you’ll find that when you start trying to put in the pigtail probe, especially in the beginning, when you’re new to it, it takes a bit of finesse. So you’ll put it in and take it out and put it in and take it out. Sometimes I’ll put it through the uninjured portion and try to rotate it, and it won’t go, so I’ll turn it around and rotate it first through the distal end. So quite often, you’ll have to play around with it for a few minutes to get it to go through. You don’t ever want to force it. The problem with using the Worst pigtail probe is that it’s sharp on the end, and as you put it in and take it out, you can tear up the lacrimal drainage system, to the point that you can’t repair it at all. So just keep that in mind. When you’re thinking about buying a pigtail probe, you want to buy one that’s blunt on the end, and that has an opening on the end so you can thread suture through it. So here’s a video that was put together by a friend of mine, Dr. Rich Allen. And he’s showing this technique. What he’s doing here is he’s dilating the lower punctum. He’s gonna place a probe through here. And you can see the probe come out. There, medially, where the laceration is. He’s gonna dilate the upper punctum. Now he’s gonna rotate this pigtail probe through. And sometimes it goes through very easily, and sometimes, as I said, you’ll have to play around with it. But there it is, coming out the distal end. Now he’s placing a suture through the eye of the pigtail probe. And he’s gonna rotate that through. So now the suture is through the distal end of the laceration. And out the upper punctum. He’s threading this 25 millimeter section of Crawford tubing over the suture. And he’s rotating that through the laceration. See how he’s holding it? Now he’s gonna pull this through the lower punctum, through the injured canaliculus. And he’s gonna tie those together. Now you’ll see he’s gonna rotate that, so that the knot is buried. If the knot isn’t buried, your patient will let you know fairly quickly, because the ends of the prolene suture will rub the eye and cause a lot of pain and irritation. So here’s a patient that came to me. Unfortunately, this patient had some degree of dementia, and she only came after her family found her and asked her to come in. But she’s about two weeks after her injury. Now, when I was in training, I was taught that you have to repair these injuries as soon as you see them. That is to say, if you see one of these in the middle of the night, in the emergency room, it has to be repaired right away. And what I’ve learned through cases like this is that that’s not actually true. So this patient is about two weeks out from her injury. And you can see that she’s got quite a bit of scarring that’s gone on. You can see where her normal punctum is. And all the scar tissue around there. So basically what I did with this patient was to take her to the operating room, and then I was able to free up this scarred tissue, and I freshened up the edges, and then I put everything back in its place. And if you look closely, you can see there in the medial canthus — you can see the Crawford stent. And that little piece of blue suture going down through the middle of it. And this one turned out quite well. So here she is, about six weeks after her injury. And you’ll notice the suture is in place. With the Crawford stent over it. Now, I’m gonna leave this in for about four months, six months, somewhere in that range. And then what I do is to take them into my procedure room, and I put in some tetracaine or proparacaine, or sometimes some 4% lidocaine gel, and let that sit for a minute, and then I take two pairs of forceps, and I rotate this stent until I can see the knot. So I want the knot to be visible there in the medial canthus. And then I take a small pair of Westcott scissors, and I cut right next to the knot, and I grab the knot and pull all of this out. And it’ll come out in one piece. Now, what happens if you don’t do that? If you were to take this patient back in and cut it as it is right now, what you’ll find is that, when you grab the stent and pull it, you’re gonna get half of the stent, and half of it’s gonna be left in the lacrimal system. And that can cause a problem. So make sure that when you go to take these out — this is something you can do in your office. You don’t have to go back to the operating room. You just numb up the eye as best as you can with proparacaine, tetracaine, lidocaine, you just rotate it and take it out. In small children I typically have to go back to the operating room, but in adults, it’s a pretty simple thing to do. Here’s the patient we saw in the beginning, with his repaired eyelid. Same thing. He’s about 6 to 8 weeks out now. And you can see that stent with the suture in it. Here’s a child that had a dog bite. And you can see on the left hand side I’m dilating the punctum, showing where the laceration is. And then on the right side, she’s about 8 weeks out. And again, you can see the little stent that’s in there. Now, with her, as I said, I had to take her back to the operating room, because I find most children won’t participate in allowing me to remove this in the office. One of the things that I find frequently is that I will get a patient in that has an injury, but I can’t quite tell if it involves the canaliculus or the lacrimal system or not. Now, if that’s the case, what you need to do in your office is to do what I’m doing here. To dilate the punctum. Quite often, just dilating the punctum is going to show you whether or not there’s an injury. But if dilating the punctum doesn’t show you, then you need to probe the wound. What I use are Bowman probes. The same ones we use for DCR. It’s the same ones that the pediatric ophthalmologists use when they’re doing a nasolacrimal duct probing. You can also just use the type of probes that you typically use to irrigate the lacrimal system. And if you can’t tell, or if the patient is not cooperative enough to do that in the office, then you need to take them into the operating room, to accomplish this. But don’t allow the patient to leave until you know whether or not the lacrimal system is intact. So, to summarize, when it comes to lacrimal trauma, remember that you have multiple options. You need to know those options, and based upon what you have at hand, you can make a choice as to how to do this. As I said, you don’t have to do this immediately. That is to say, if the patient is unstable, you can take them to the operating room even two weeks after the injury. There have been multiple times that I have seen patients in the intensive care unit that have been in bad motor vehicle accidents, and they were too unstable to undergo any kind of procedure, and once they were stabilized, days or weeks later, we were able to take them in. So it doesn’t have to be done immediately. So hopefully this has been helpful for you. If you see this type of injury, it’s complex when you first look at it. But everything pulls together, and using some of the techniques that we’ve used today, you can repair this gentleman and get him back to good health. So that ends my presentation. I welcome questions. If you have any, please submit them. >> Thanks, Dr. Pelton. We have two questions so far, if you want to stop sharing your screen. And then you can open up the Q and A box.

DR PELTON: So the first question is — that is submitted — talks about 5-0 prolene sutures. It says: I’m afraid of losing the knot. It says: Just a single knot with a 4-0 throw is enough? I don’t think that a single throw is going to be enough. If you use suture that’s too big, it may not allow you to put a piece of Crawford tubing over it. I used to use 6-0 prolene. I found that 6-0 prolene was so soft that when I tried to thread it through the canaliculus, I would struggle. Whereas the 5-0 prolene is stiff enough that it goes through much easier, without bending. But 4-0 might be too big. If you have to use 4-0, I wouldn’t use more than about three throws of the knot. But I don’t think a single knot would work. What would you do with a patient that has trauma right in the vertical portion of the canaliculus, and you can’t find the anatomy? So I’m assuming what you’re talking about is if you have, for example, a laceration that goes through the vertical portion, which is the punctum, and the 2 millimeters of canaliculus after that. If you were to rotate a pigtail probe through the upper portion, of the lacrimal system — that is, say, for example, if the lower punctum and canaliculus was lacerated, if you rotate it through the upper punctum, it will come out through the lacerated area, and that will help you define your anatomy. So once you know where the lacerations are, then you can kind of figure out where the anatomy is. And then just repair it as we talked about here. That is to say, get the stent in place, and then use the appropriate sutures to close the soft tissue around it. The next question is: In what situation don’t you repair the canaliculus? So there aren’t very many situations in which I don’t do this. That is to say, any time I can repair the canaliculus, I do. Now, if a patient were to come to me, for example, a month after, I might not be able to repair the canaliculus. But I think that any time I can, I’m going to. Because, as I said, if you don’t, and the patient does have problems later on, that’s a patient that’s gonna be much harder to fix. So I’m a strong advocate for repairing the canaliculus any time you can. The next question is: When you see a patient in the ICU with lacrimal trauma, if we plan to operate later, how do we manage it in the interim? So, for example, one of the patients that I was discussing was a patient in the ICU that had head trauma, and was very unstable. So the trauma doctor asked me to come see the patient, because of the facial lacerations and the lacrimal lacerations. And what I did in that case was just keep ointment on the wounds, to keep them soft. And I really didn’t do anything else other than that. Until they were stable enough to go to the operating room. And once they were stable enough, we were able to go in, and there was no sign of infection, because we put antibiotic ointment in there, and the tissues were soft because of that as well. So you don’t need to do a lot. So the next question is: Can you elaborate more on the suturing technique at the two cut ends of the canaliculus and the repair of the medial canthal tendon? So what I was showing there was some rather complex suturing of the canalicular tissue. That is to say, the small thin tissue that forms the canaliculus. And years ago, we used to put a lot of effort into actually making the two ends of the canaliculus suture together, using very small sutures, like 9-0 or 10-0 nylon. We don’t do that at all anymore. So, in short, you don’t have to suture the two cut ends of the canaliculus. Because they’re over a stent, when you pull the soft tissue around it, together, that is to say, when you suture the orbicularis muscle together, the two cut ends of that canaliculus will come together, and they will heal themselves back together over the stent. And having the stent in place keeps them from healing shut or scarring shut. Now, with respect to repair of the medial canthal tendon, what I do is to take my forceps and grab the tissue in the area of the tendon. And when you just pull on it, you can tell whether you have tendon or not. Because if you pull, it resists your pull. That is to say, it’s not very spongy. It’s very much like tendon tissue. And I will take a vicryl suture, and there’s a type of needle that’s called a P2 needle. And those are the half circle needles. They’re like this. And you can get into a very small space with that needle, and I pass it first through the distal end of the torn medial canthal tendon. And then I come back through and pass it through the proximal end of the torn medial canthal tendon. Which is gonna be just inferior to your canaliculus. And when you pull those together, as you can see in that woman I showed you there at the end, how it pulls the tissues back into place. And sometimes you have to experiment with it a little bit. That is to say, you put your suture in place, and you pull it together to tie it, and you see that it doesn’t look right. In that case, you take the suture out. And you replace it and try it again. And you keep doing that until you get the lid back where it should be. And you can tell by looking at where the lid is, whether it’s touching the eyelid or not. I’m sorry, touching the globe or not, or whether it is away from the globe, causing ectropion. So sometimes you have to play around with it a little bit. But once you pull the soft tissue around the stent together, you put your vicryl or other suture in for the medial canthal tendon, it tends to pull together and look good. Our next question is: The patient lost the punctum or the tissue sometimes. What will you do? So there are cases where a portion of the eyelid is actually missing. I do a fair amount of tissue repair after cancer surgery. So after a Mohs cancer surgeon has removed the cancer, sometimes the punctum is missing. And in those cases, you just have to work with the tissue that you have left. So there are some cases where you don’t have a punctum. And I still will put a stent through the lacrimal system, as if a punctum was there. And what you’ll find is that quite often this will work just fine. So even if the tissue is lost, or some of the tissue is lost, I will put the stent through the system to keep open what’s left behind. The next question is: What do you do if the common canaliculus or even the lacrimal sac is injured? So if I can get a stent through, I just treat it like any other lacrimal injury. There are cases where the injury is so severe or, for example, after cancer, cancer surgery, where there’s almost nothing left behind, and in those cases what I do is repair what’s left. I put in a stent if I can. And then about four months or six months later, we take a look at it and see what we have left. Now, many of you are familiar with something called a Jones tube. So if there isn’t any lacrimal system left, because it’s all been so badly injured or is missing, we will bring these patients back at some point and put in a glass tube. It’s a glass Pyrex tube called a Jones tube. But by repairing the canaliculus, using these techniques, we can often avoid having to put in a Jones tube. If there is no canaliculus, so there is no lacrimal sac, then we have to put in a Jones tube. The next question is: Do we need to check the patency of the passage in follow-up visit, and when? So once I take out the stent, I’ve got the eye numbed up using tetracaine or proparacaine or lidocaine. That’s a good time to check the patency of the lacrimal system. And it’s pretty simple to do. And quite often as you inject you’ll find the patient starts choking on the fluid. Then you know it’s open. Ultimately what matters is what the patient’s symptoms are. Even if the passage is open, if they have tearing, you may have some more work to do. And that’s sort of beyond the scope of this talk. But a good time to check it is when you take the stent out. Next question is: What topical medications do you give after canalicular repair, and for how long? I use something very simple. I use antibiotic ointment. So bacitracin, erythromycin, neomycin. Just any type of antibiotic ointment. And I have them use it for about two weeks. What I typically tell the patients is just to use it at bedtime, because the ointment will make their vision so blurry that they don’t like using it during the day. But using it at nighttime shouldn’t be a problem. So really simple. Obviously if it’s a very dirty wound, if it happened on farm machinery or there’s dirt in there, I might put them on some oral antibiotics, but that’s very rare. I rarely do that. Typically the only medicine I give them is antibiotic ointment. The next question is: Regarding the Crawford tubes, are they available in one size fit all? The answer to that is yes. If you were to go on the internet and do a search for Crawford tubes, you’ll find that there are different versions of these. I always call them Crawford tubes, because that’s what I have always used. But there are various types of these tubes that are available. The next question is: Are all Crawford tubes hollow, where you thread the sutures through? With Crawford tubes, yes. Now, there are other types of tubes that aren’t hollow. And the nice thing about the hollow tubes is that they’re really soft. And so the patients don’t complain about feeling them very much. However, there are tubes out there that aren’t hollow. And to use the pigtail technique, you have to have a hollow tube. The next question is: For how long will you keep the tube? I usually leave it in for 4 to 6 months. The idea that I tell my patients is: It’s like when you get a piercing. For example, when a woman pierces her ears, I explain to the patients, if I put a needle through your ear and pull it right out, in just a matter of days that hole will close shut. But if I put a needle through the ear and leave it in for 4 months, you’ll have a pierced ear. It’s the same concept here. So we want to leave the tube in as long as there’s a healing process going on. And I find that 4 to 6 months is a pretty good length of time to do that. I’ve actually left them in children for a couple of years. And there’s no downside to doing that, in most cases. The next question is: Because the Monoka is not available all the time, can you use only 5-0 prolene or 5-0 nylon without the Monoka? So I’ve asked myself that question. I’ve never done that. I think the idea is that the suture is just so small that as the canaliculus comes around, more than likely it’s going to scar and close to the point that you won’t be able to get any fluid through the canaliculus. So I don’t think that would work. I think you need some type of tubing that’s roughly the same size as the canaliculus. And that’s what the Crawford tubing or the Monoka tubing is. So if you just put a prolene or nylon suture through, without putting a stent over it, I don’t think that would work. The next question is: When both puncta are lost, what can I do? I’ve had this happen before with a patient that’s had a large cancer removed from the medial canthus. And in those cases, you can… If you can find the distal ends of the wound, and you usually can, you can still put a stent through. And that may be of use to them. It may not. You may end up having to use a Jones tube at some point. If they’ve only lost the puncta and the horizontal limbs — the common canaliculus is there and the lacrimal sac is there, so if everything is there except the puncta, you can still do the pigtail probe or the other techniques, and it should work. The next question is: If the stent is lost inside the lacrimal system when trying to remove it, what to do? This is a good question. And that’s why I was taking care to explain how to remove this stent. Because if it’s in the system, it can be difficult. In fact, one of the things you might do is try to put a probe in, to see if you can push it through or pull it back out. But luckily, I’ve never been in this situation. So I’m afraid if it got stuck in there it might cause scarring and you may not be able to get it out. But if I lost a piece in there, I would irrigate to make sure fluid was going through, and I might try to put a probe in, a Bowman probe, to push through whatever remnant was left. The next question is: Can you use IV cannula cut if Crawford tubes aren’t available? That’s a good question. I think the problem is that IV cannula is probably gonna be too stiff. It might work. The other problem is I think it’s gonna be too big. Crawford stents are very small. They’re roughly the same size as the canaliculus. And I think IV tubing would be too big and too stiff. The next question is: Does the pigtail probe have size in numbers? Not that I’m aware of. But they do come in different sizes, in different amounts of spiraling. I should say. So I have, in each of my sets, two or three different pigtail probes that are of different size, because for a large adult, you’re gonna use a different type of probe than you would in a small child. So having more than one probe available is a good thing. And I think that’s all of the questions.

>> Yep, perfect timing. So thank you, Dr. Pelton.

DR PELTON: You’re very welcome. And hope to see you again soon.