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Bruno Eric Fayet1,
William R Katowitz2, Emmanuel Racy3,
Jean-Marc Ruban4, James A Katowitz1
1Hotel de Ophthalmology,
Place Du Parvis Nôtre Dâme, Paris 75004, France
2Department of Ophthalmology 34th and
Civic Center Boulevard, the Children's Hospital of
Philadelphia, Pennsylvania 19104, USA
3Clinique
Saint-Jean-de-Dieu-ENT, 19 Rue Oudinot, Paris 75007, France
4Edouard Herriot Hospital
Place D’arsonval, Lyon 69003, France
Correspondence
to: William R Katowitz.
Department of Ophthalmology 34th and Civic Center Boulevard, the Children's Hospital of
Philadelphia, Pennsylvania 19104, USA. billkat@gmail.com
Received: 2015-06-18
Accepted: 2016-01-07
DOI:10.18240/ijo.2016.05.29
Citation: Fayet B, Katowitz WR, Racy E,
Ruban JM, Katowitz JA. An update to monocanalicular stent surgery.
Int J Ophthalmol 2016;9(5):797-798
Dear Sir,
In their article, “A
comparison between monocanalicular and pushed monocanalicular silicone
intubation in the treatment of congenital nasolacrimal duct obstruction”,
Andalib et al[1] present the results of a
prospective study on congenital nasolacrimal duct obstruction treated either
with a Monoka stent (using a Crawford hook for nasal retrieval) or a Masterka
pushed technique for insertion of the Masterka stent. The success rates were
respectively 90% and 50%. In this publication the authors did not document the
severity of ductal stenosis and treated patients with either the Monoka or
Masterka. It should be stressed, however, that Masterka stent is not designed
to be effective in cases of moderate to severe ductal stenosis. Thus, the
poorer results for the 20 cases of Masterka may be attributed either to a
Masterka that remained nestled inside the lacrimal sac, because it could not be
pushed beyond the area of ductal stenosis, or due to an insufficient time of
stent retention as demonstrated by an early Masterka stent loss rate of 30%.
We would like to present
our perspective regarding the relationship between failure with a Masterka
stent retained for the usual planned postop period of time and the rate seen
with early loss of the Masterka stent.
Since our first case in
2008, the analysis of complications had led to our recommending the following
precautions: 1) we prefer to place the Masterka in the upper canaliculus as it
is more difficult for the child to scratch the superior punctum than the
inferior punctum. We try to avoid stenting the lower canaliculus, since the
lower eyelid punctum is usually more lateral and the collarette of the stent
can thus come into contact with the cornea more easily; 2) for cases of ductal
stricturotomy (congenital or iatrogenic), it would appear preferable to switch
canaliculus or choose another method of intubation. With dilation of the
punctum, it is important to protect the integrity of the meatic ring at the
punctal opening to reduce the potential for extrusion of either type of stent;
3) our
initial surgical technique[2-5]
has been changed: currently, our
recommendation is that, the length of the Masterka should always be greater
than the distance between the superior punctum and the floor of the nasal fossa
in order to eliminate the risk of the probe being too short. When the guide
reaches the floor, the plug portion should be a few milimeters above the
punctum. As the guide is removed, the plug must then be held flush to the
punctum causing the distal portion of the stent to bend on the floor much like
seen with a pulled Monoka stent. After intubating with the Masterka, the collarette
must be apposed to the punctum while removing the introducer rod. If not, the
stent will likely not remain bent along the nasal floor and if the surgeon
attempts to push the stent in further it will simply fold within the
nasolacrimal system. In this scenario there is an upward force that will make
stent loss more likely due to the tendency for the stent to straighten and thus
unseat the collarette. This is not the case if the stent is long enough and has
bent to sit along the nasal floor (as in the case with the Monoka stent). A
video of this technique can be found on YouTube[6].
Table 1 lists our unpublished data of
71 cases using this modified technique for the Masterka in comparison to other
published data comparing the pushed and pulled monocanalicular stent. The loss
of stent rate is only 4% (down from 11.8%).
Table 1 A comparison of our
unpublished data with previous studies of the monocanalicular stent
Authors |
Stent |
Year |
Intubations |
Complications |
Lacrimal duct findings |
Success |
||
Stent lost in canaliculus |
Stent unseated from punctum |
Stent loss |
||||||
Fayet et al[5] |
Monoka |
2010 |
1028 |
0.005 |
0.007 |
12.5% |
N/A |
90.6% |
Fayet et al[2] |
Masterka |
2012 |
110 |
0 |
0.036 |
12% |
Hasner membrane only |
85% |
Current study |
Masterka |
2015 |
71 |
0.014 |
0.028 |
4% |
Hasner membran only |
90% |
Andalib
et al[1] are correct that there is
a paucity of publications with the Masterka. Alañón et al[7] reported a 97.5% in 40 patients
treated for congenital nasolacrmial duct obstruction (CNLDO) with the Masterka.
In addition, there have been posters and presentations at international
meetings comparing the Masterka and Monoka. Katowitz et al[8] compared the success rates of the Monoka 86.8%
(125/144) to the Masterka 88.3% (53/60). Nazemzadeh reported a success rate of 81.6% (62/76
eyes) for the Masterka when used in all cases of CNLDO except severe ductal stenosis[5,9]. That the overall
success rate for Andailb et al[1] was significantly lower
compared to these other reports brings to light the challenge for proper
patient selection and choice of surgical technique when using the Masterka.
We think our modified
technique for inserting the Masterka offers improved surgical outcomes and
should be employed when using this pushed monocanalicular device.
ACKNOWLEDGEMENTS
Conflicts of Interest:
Fayet B, FCI Ophthalmics; Katowitz WR, None; Racy E, None;
Ruban, JM, None; Katowitz J, None.
REFERENCES
1
Andalib D, Gharabaghi D, Nabai R, Abbaszadeh M. Monocanalicular versus
bicanalicular silicone intubation for congenital nasolacrimal duct obstruction.
J AAPOS 2010;14(5):421-424. [CrossRef] [PubMed]
2
Fayet B, Katowitz WR, Racy E, Ruban JM, Katowitz JA. Pushed monocanalicular
intubation: an alternative stenting system for the management of congenital
nasolacrimal duct obstructions. J AAPOS 2012;16(5):468-472. [CrossRef] [PubMed]
3
Fayet B, Racy E, Ruban JM, Katowitz J. Pushed monocanalicular intubation.
Pitfalls, deleterious side effects, and complications. J Fr Ophtalmol
2011;34(9):597-607. [CrossRef] [PubMed]
4
Fayet B, Racy E, Ruban JM, Katowitz J. “Pushed” monocanalicular intubation in
children under general anesthesia with spontaneous ventilation. A preliminary
report. J Fr Ophtalmol 2010;33(7):455-464. [CrossRef] [PubMed]
5
Fayet B, Racy E, Renard G. Pushed monocanalicular intubation: a preliminary
report. J Fr Ophtalmol 2010;33(3):145-151. [CrossRef] [PubMed]
6 Youtube Video, Masterka 2014 jan, Jan
2014. Available at https://www.youtube.com/watch?v=Ecsz-HkyQrw&feature=youtu.be
7 Alañón FJ, Alañón MA, Marín-González
B, López-Marín I, Olmo N, Martínez A, Cárdenas M, Alarcón S. Self-adjusting
monocanalicular intubation for congenital lacrimal obstruction. Arch Soc Esp Oftalmol 2015;90(5):206-211.
8 Katowitz WR, Fayet B, Racy E, Ruban
JM, Katowitz J. Comparison of a
"pulled" versus a "pushed" Monocanalicular stent in the
treatment of congenital nasolacrimal duct obstruction. Fall ASOPRS 2011.
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