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Summary Study objective To study the performance of a pre-loaded Monoka stent in the management of congenital nasolacrimal duct obstruction (CNLDO). Study design Non-randomized study of consecutive cases. Materials and methods A preloaded classic Monoka silicone stent contained entirely inside its introducer (Lacrijet) was used to treat a consecutive series of subjects with CNLDO over an 11-month period (May 2019–March 2020). Only subjects with chronic symptomatic CNLDO were included. Subjects with intermittent tearing, canalicular pathology, trisomy 21, facial cleft, or history of lacrimal surgery were excluded. Intraoperative findings were recorded, including the degree and location of the nasolacrimal obstruction, successful metal to metal contact with the probe, any difficulties encountered by the Lacrijet device itself, procedure duration, tolerability of the fixation punctal plug, and finally, inspection of the stent after withdrawal of the inserter. Functional success was defined as disappearance of all symptoms of epiphora. Results A total of 45 preloaded Monoka Lacrijet stents (Lcj) were placed consecutively in 38 children. The mean age was 27.9 months (12–78 months). The mean procedural duration was 2.8 minutes (range: 1–10 min). The overall success with disappearance of all symptoms of epiphora was 88.8% (40/45). Surgery in cases of simple mucosal stenosis was successful in 92.2% (35/38) of cases, with a mean follow-up time of 7.9 months (range: 1 to 12 months). The duration of stent intubation was for this group was 32 days (range: 1–103). The surgical outcomes for the other 7 cases with more complex intraoperative findings are summarized in the publication. All withdrawn probes were intact. Conclusions The Lacrijet stent system is a simple and reliable pushed intubation device for CNLDO in appropriately selected cases where bony stenosis of the canal is minimal.

Summary Background Tearing and conjunctivitis in children are commonly due to lacrimal drainage system obstruction. Congenital nasolacrimal obstruction is a common pathology treated by probing with or without silicone stent insertion, depending upon the age of the child. The silicone stent is self-retaining and placed for at least one month. Masterka ® is a recent version of Monoka® , which may lead to the same surgical complications , such as intralacrimal migration. Subjects and methods The medical records of two patients surgically treated with the Masterka® probe for nasolacrimal duct obstruction , who developed intralacrimal migration of the stent, were retrospectively reviewed and analyzed. A 41-month-old child and an 18-month-old child presented with disappearance of the silicone tube after 7 days and 2 years respectively. In the first case, the tube migrated completely within the lacrimal system and became externalized through the nose at 2 years, while in the second case, the Masterka ® was retrieved through a canalicular approach. In both cases, infants had no further tearing. Discussion The frequency self-retaining stent disappearance is estimated at 15%. Among these cases, intralacrimal migration is only reported in 0.5% of cases. To prevent intralacrimal migration, the surgical technique must follow a certain number of rules. Management, based on residual epiphora , is discussed. Conclusion Prevention of intralacrimal migration of self-retaining stents involves a rigorous analysis of the relationship between the meatus and the fixation head at the time of placement. After lacrimal intubation, scheduled monitoring is necessary to screen for stent disappearance. Management is based on clinical findings, anterior rhinoscopy and even exploratory canaliculotomy.

Purpose To study the CT appearance of the nasolacrimal canal (NLC) in cases of congenital nasolacrimal duct obstruction (CNLDO) where there is a tactile sensation of a hard contact (HC) stop in the duct preventing stent intubation. Methods The authors retrospectively reviewed all consecutive cases of chronic CNLDO observed between 2003 and 2018 in which an apparent HC obstruction prevented nasolacrimal intubation. CT scans were reviewed to determine the cause of probing failure: distal stenosis, loss of parallelism of the NLC walls, abnormal angulations or an adjacent obstacle blocking tear outflow. Results Nine patients (12 sides) met the following criteria: CNLDO + HC + probing failure. The mean age at the time of the first HC was 3.9 years (range: 0.8-8.1 years) and at the time of a second confirmation of HC with subsequent dacryocystorhinostomy was 7.8 years (range: 4.1-9.2 years). Nasolacrimal duct opacification was noted in 33% of cases (4/12). Abnormalities of the NLC occurred in 8 of the 12 cases of CNLDO (8/12 = 66.6%) and on the asymptomatic side in 1 case (1/6 = 16.6%). A canine tooth bud situated in the same plane as the NLC was observed in 9 cases of CNLDO (9/12 = 75%) and on the asymptomatic side in 2 cases (2/6 = 33.3%). Conclusions HC noted during probing is a sensitive but relatively nonspecific sign which, nevertheless, does indicate either a complex obstruction or at least potential intubation difficulties. As confirmed by CT imaging, a significant anatomical variant is not necessarily predictive of epiphora, but nevertheless may complicate the intubation procedure.The authors describe hard contact palpation during probing for CLNDO and its relationship to anatomic location and etiologies of obstruction in the nasolacrimal canal by CT imaging.

Summary Study objective To study the intraoperative deployment of a pre-loaded probe for a “pushed” monocanalicular nasolacrimal intubation . Study design Non-randomized study of consecutive cases. Materials and methods Description: A classical Monoka™ silicone stent with the silicone tube attached at right angles to the punctal plug is contained entirely inside an introducer connected to a piston. Insertion: The procedure begins with intubation of the nasolacrimal duct with the metallic introducer. Traction on the piston retracts the metallic introducer inside the handpiece. This relative shortening progressively ejects the stent, starting with its free end at the bottom of the introducer. The operation was observed endoscopically under single-blind conditions. Results Twenty-eight preloaded Monoka™ stents were placed consecutively, in 28 congenital nasolacrimal duct intubations in 22 patients (28 sides). Endoscopic examination showed that the free part of the stent was progressively ejected from the introducer during retraction of the piston. Insertion of this pushed stent into the nasal cavity was effective in 23/28 cases (82.1%). A total of 28 preloaded stent insertions were attempted and 23 were correctly deployed. Difficulties encountered At the end of nasolacrimal duct intubation, contact between the punctal plug and the lacrimal punctum was problematic in four cases (4/28 = 14.2%). At the beginning of stent placement, premature ejection of the punctal plug within the end of the introducer occurred in five cases (5/28 = 17.8%). These five stents failed to insert properly into the nasal cavity. At the end of insertion, retention of the punctal plug in the introducer occurred in two cases (2/28 = 7.1%). Complications No cases of intraoperative or postoperative epistaxis were observed. Conclusions Intraoperative nasal endoscopy validated the concept of the preloaded Monoka stent and its deployment. Reproducibility and improved reliability may require a change in stenting technique and a design modification.

The authors report the case of a 7-year old child with failed probing with stent intubation, who was found to have an unusual curvature of the nasolacrimal duct on the symptomatic side. CT imaging revealed a permanent maxillary canine tooth adjacent to the duct. It appeared that the relationship of the tooth bud to the curved nasolacrimal duct was most likely responsible for the symptoms of epiphora on this anomalous side.

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Purpose To present our experience with a “pushed” monocanalicular nasolacrimal intubation device in the management of nasolacrimal duct obstruction in children. Methods The cases of consecutive patients with nasolacrimal duct obstruction who were treated with primary probing and intubation with the Masterka were reviewed retrospectively. The Masterka includes a metal guide placed inside a silicone tube for “pushed” intubation as opposed to material attached at the distal end of the silicone for intranasal retrieval (“pulled” intubations). All procedures were accomplished with the patients receiving masked airway anesthesia; neither laryngeal mask airway nor endotracheal intubation was necessary. Only patients noted to have a membranous (mucosal) obstruction were considered for treatment with the Masterka. The duration of operation, duration of stent intubation, and severity of symptoms on follow-up were noted. Success was defined as absence of symptoms after stent removal or loss. Results A total of 110 eyes of 88 patients were included (average age, 2.4 years; range, 1-8 years). The average operating time was 3 minutes (range, 2-9 minutes). Persistent tearing on follow-up with the stent in place was noted in 26 eyes (24%); tearing resolved after stent removal in 19 eyes (73%). Success was achieved in 94 eyes (85%). with an average follow-up of 33.7 weeks (range, 4-139). Keratitis was noted in 2 eyes (2%). Early stent loss occurred in 17 ducts (15%). Conclusions The Masterka was an effective primary treatment for nasolacrimal duct obstruction associated with mucosal obstructions in this small series of patients.

Summary Purpose To present our experience with pushed monocanalicular nasolacrimal intubation in the management of 90 consecutive cases of nasolacrimal outflow obstruction. Materials and method This paper reports a non-randomized study of 90 consecutive cases treated with a pushed Monoka intubation system (Masterka™). A metal guide is placed inside a silicone tube rather than being attached at the distal end of the tube, as done with traditional pulled intubations. Three probe lengths are available: 30, 35, and 40 mm. Surgical procedure The silicone stent was pushed into a punctum, canaliculus, and nasolacrimal duct by means of the guide. After passing through the valve of Hasner and reaching the nasal floor, the guide was then delicately withdrawn while remaining oriented along the axis of the lacrimal sac and duct. Throughout this phase, the anchoring plug was held in contact with the punctum. Three study groups were set up chronologically: group 1: endo-DCR procedures done with Masterka insertions under endoscopic observation. Group 2: Masterka insertions done with endoscopic guidance. Group 3: blind Masterka insertions without endoscopic guidance. The patients in groups 2 and 3 were selected on the information obtained by lacrimal probing. Only cases with mucosal nasolacrimal stenoses were included. All patients had surgery under general anesthesia with mechanically assisted ventilation (groups 1 and 2) or spontaneous ventilation (group 3). The anchoring plug was inserted into the punctum and vertical canaliculus, either by pulling on the probe (group 1) or using an inserting instrument. Results A total of 90 pushed Monoka intubations were done. Endoscopic examination (groups 1 and 2) demonstrated visually that the pushed intubation method was effective. In none of the 28 cases did the silicone bunch up when the guide was withdrawn. Degree of difficulty This was dependent upon proper selection for pushed Monoka intubation; the length of the probe and confirmation that there no false passage was created. The pushed intubation technique was only slightly more difficult than a simple lacrimal probing. The average operating time, excluding the anesthetic procedures, was respectively 5 min (group 2) and 4 min (group 3). Complications during surgery There were no anesthetic or general problems observed in the three groups. Epistaxis was also not noted. Postoperative complications Fifteen percent (13/90). The 13 complications noted were: two cases of canaliculitis, one intracanalicular migration, eight probes that disappeared, one keratitis, and one case of involuntary removal by the patient. Deleterious side effects Tearing with the probe was in place was noted in 21.1% of the cases (19/90). This tearing disappeared as soon as the probe was removed in 50% of these cases (10/19). Functional Results Overall, the success rate (absence of epiphora, absence of mucous discharge) was 90% (81/90) with an average follow-up period of 19 weeks (Range, 1 day to 60 weeks). Two cases were lost to follow-up at day 1 and day 7. Group 1: 90.9% (20/22 cases; average age: 65 years, with an average follow-up period of 24 weeks). Group 2: 100% (6/6 cases; average age: 3.1 years, with an average follow-up period of 14 weeks). Group 3: 88.3% (53/60 cases excluding the two cases that were lost to follow-up; mean age: 2.3 years, with an average follow-up period of 16 weeks). Conclusions From a technical perspective, pushed nasolacrimal intubation is much simpler than the traditional pulled types of nasolacrimal intubation. The anesthetic procedure required is the same as that for a late probing procedure, but the functional results are better. The Masterka is an alternative to simple late probing in the treatment of mucosal nasolacrimal stenoses in patients of over 12 months of age.

Summary Objective To study the behavior of a “pushed” monocanalicular stent by means of nasal endoscopy. Patients and Methods Four children (six affected sides) with congenital nasolacrimal duct obstruction were treated with monocanalicular intubation with an anchoring plug . The children's mean age at the time of the operation was 33 months (range, 30–37 months). The procedure began with probing in order to verify (a) dacryostenosis (simple or extensive nasolacrimal duct impatency) and (b) the metal-to-metal contact in the lower nasal meatus. The stent was similar to a Monoka TM , but the guide (a malleable stainless steel probe) is located inside the silicone stent rather than projecting from it. The silicone's total length is 40 mm and the external diameter 0.96 mm. Simultaneously, the guide acts to catheterize the nasolacrimal duct by pushing the silicone through the upper and lower parts of the outflow system. The guide is removed via a punctal approach. This mode of intubation dispenses with the nasal recovery step. Nasal endoscopy was used to monitor (a) the position of the stent in the lower nasal meatus (free or submucosal), (b) mucosal damage and bleeding, and (c) the behavior of the silicone tube during removal of the guide. Results Because of the complexity of nasolacrimal ducts, two of the six sides were treated with the classical Monoka intubation method of pulling the silicone tubing out from the nasal exit of the duct (the pull technique). The pushed intubation method was used for the four simple nasolacrimal stenoses, with no problems whatsoever. In all four cases, endoscopic examination showed (a) no submucosal tunneling (false passage), (b) no noteworthy mucosal damage, and (c) no retraction (bunch-up) of the silicone tube during the metal guide removal. No particular complications were reported during the procedure or the intubation period, which lasted an average of 3 weeks. The stents were removed in the consulting room. Tearing ceased during the 1 st week in two cases, during the intubation period. Tearing persisted throughout the intubation period in the other two cases, but ceased during the week following stent removal. The follow-up lasted 2 months. Conclusions The pushed procedure simplifies monocanalicular nasal intubation. Its indications remain to be determined.

An endonasal dacryocystorhinostomy (DCR) was followed by cerebrospinal fluid leakage and pneumoencephalocele in an 80-year-old female patient presenting four independent risk factors for an ethmoidal breach: severe septal deviation requiring forced reclining, a cranial insertion of the perpendicular plate of the ethmoid directly onto the cribriform plate, meningeal prolapse, and extensive osteoporosis of the skull base. The use of a Killian valve speculum to recline the nasal septum was probably the main cause of the anterior skull base fracture. The defect was repaired by a composite patch of septal cartilage, abdominal fat grafts, Surgicel, and inferior turbinate mucosa. Thirty-four months after surgery, there was no residual symptom. A narrow nasal fossa makes endoscopic DCR more difficult to perform. The use of a Killian valve speculum to enlarge the nasal fossa may carry a risk for structural damage to the skull base. A narrow nasal fossa may require an external DCR or a prior endoscopic septoplasty to facilitate an endonasal approach. Closing an ethmoidal defect causing cerebrospinal fluid leakage can be successfully achieved by an endonasal approach rather than by a more conventional neurosurgical method.

Purpose To establish the accurate surgical anatomy of endonasal dacryocystorhinostomy (DCR) based on the radiological analysis of underlying bony structures. Design Prospective noncomparative observational case series study. Participants Fifty-nine patients with complete nasolacrimal stenosis underwent a computed tomodensitometry (CT) scan before endonasal DCR. Methods High-resolution CT scanning with contrast injection of the lacrimal sac was performed. Image reconstruction was performed to obtain continuous 1.0-mm axial and coronal sections for review. Main Outcome Measures Relationship of the lacrimal fossa (LF) to the operculum of the middle turbinate (OMT), the uncinate process (UP), and the frontal recess (FR); symmetry of the right and left anatomies; location of the OMT; position of the most anterior insertion of the UP with respect to 2 main references (the posterior lacrimal crest and the junction between the maxillary and lacrimal bones) on axial sections at 3 different levels (upper, intermediate, and lower of the LF); height of the LF; and distance of the OMT from the lower limit of the LF. Results The OMT, the UP, and the FR were adjacent to the LF in 41 (53.2%), 73 (94.8%), and 23 cases (29.9%), respectively. There was a right-left symmetry in 10 of 18 patients (55%). The OMT was always anterior to the junction between the maxillary bone and the lacrimal bone. The UP was more frequently posterior (32.5%) or adjacent (45.5%) to the LF at the lower level, adjacent to the maxillary bone (55.8%) at the intermediate level, and adjacent to the middle turbinate (61%) at the upper level. The height of the LF was 12.06±1.93 mm. The OMT was located 5.96±2.05 mm upward from the lower limit of the LF. Conclusion The almost constant overlapping of the UP onto the LF at the level of the common canaliculus indicates that the most effective approach for successful DCR osteotomy is via a submucosal cleavage and resection of the anterior part of the UP. The management of these landmark structures should be an integral part of the endonasal DCR method.

Purpose To report the nature and frequency of complications occurring with endonasal dacryocystorhinostomy (DCR) based on routine unciformectomy. Design Prospective, noncomparative interventional consecutive case series study. Participants Endonasal DCR was performed on 300 patients with complete nasolacrimal stenosis. Methods The uncinate process was resected (unciformian endonasal DCR), except when the lacrimal fossa was anterior to its insertion (23 cases [7.7%]). Preoperative clinical assessment and computed tomography scans, intraoperative endoscopic video recording, and postoperative clinical and endoscopic follow-ups were analyzed for reported endonasal DCR failure and complications. The mean follow-up was 13±12.6 months (range, 1–57). Main outcome measures Failure rate, nature, frequency, and time of intraoperative and postoperative complications. Results Of the 300 patients treated, 39 (13%) suffered from residual epiphora and no passage upon irrigation; there was secondary canalicular stenosis in 2 cases (0.6%), sump syndrome in 4 cases (1.2%), a distal stenosis from progressive healing closure of the ostium in 21 cases (7.0%), a recurrence of lacrimal mucocele in 5 cases (1.7%), and adhesions between the ostium and septum in 2 cases (0.6%). Access to the surgical site required an anterior middle turbinectomy in 103 cases (34.3%) and a septoplasty in 1 case (0.3%). Intraoperative bleeding was minor in 183 (60.6%), moderate in 82 (27.3%), and severe in 35 cases (11.6%). Postoperative bleeding occurred in 4 cases, and was controlled by packing. Transient frontal sinusitis (n = 1), nasal mucosa burn (n = 1), cacosmia (n = 8), phlebitis (n = 1), and maxillary pain (n = 8) also occurred. Orbital fat prolapse, cerebrospinal fluid leaking, cutaneous scarring, diplopia, and loss of vision did not occur. Conclusion Complications from unciformian endonasal DCR may be less frequent or severe than with maxillary endonasal DCR, and comparable to or less frequent than those for external DCR.

Une enfant de 3 ans presentait une tumeur unique de la paupiere superieure droite, depuis un mois, traversant l‘epiderme et d’allure necrotique. Une resection chirurgicale fut faite sous anesthesie generale, sans incidents immediats et permettant une etude anatomo-pathologique de la piece. Il fut conclu a une lesion inflammatoire avec une composante granulomateuse tout a fait compatible avec un chalazion. Ce cas illustre bien la grande variete des presentations cliniques du chalazion, affection inflammatoire courante et benigne de la paupiere.

Purpose To describe a standardized osteotomy method for endonasal dacryocystorhinostomy (en-DCR) and the results obtained. Design Prospective nonrandomized, noncomparative, interventional case series study. Participants One hundred consecutive adult patients (81 females, 19 males) underwent en-DCR performed by the same team of oculoplastic and rhinologic surgeons. Methods A standardized procedure was used in all cases. This included endoscopic assessment of the surgical site from the nasal aspect, diaphanoscopy of the common canaliculus, and endonasal osteotomy. Anterior unciformectomy was followed by resection of the lacrimal bone and protected drilling of the maxillary bone of the lacrimal fossa to expose the entire medial aspect of the lacrimal sac. The middle turbinate was preserved whenever atraumatic dissection of the nasal mucosa was possible or when it was resected partially before osteotomy. Main outcome measures Rate of direct localization of the lacrimal fossa, rate of turbinectomy/septoplasty, rate of residual postoperative tearing, rate and nature of complications Results Transillumination of the common canaliculus was obtained directly in 94% of cases; transillumination, required the opening of an ethmoidal cell in 2%, partial resection of the middle turbinate in 3%, and unciformectomy in 1%. Access to the surgical site required partial resection of the middle turbinate in 21% of cases, but no septoplasty. Osteotomy was initiated in 90% of cases by cleavage of the anterior insertion of the uncinate process, and in 5% by cleavage of the first, overdeveloped ethmoidal cell. The cleavage opened directly to the medial aspect of the lacrimal fossa in these 95 cases. Osteotomy was achieved by drilling alone in only five cases. Perioperative complications were limited to significant bleeding in six cases. Postoperative complications included one case of resolved frontal sinusitis on day 3, and one case of inferior lid hematoma with emphysema. Conclusions The authors suggest that anterior resection of the uncinate process is the most important surgical step to expose the medial aspect of the lacrimal fossa during endonasal DCR, whereas partial resection of the middle turbinate can be considered optional.

PURPOSE To describe a surgical technique for endoscopic endonasal dacryocystorhinostomy. METHODS A consecutive case series of adult endoscopic dacryocystorhinostomy surgery was reviewed. The specific surgical approach of uncinectomy with or without septoplasty and anterior middle turbinectomy was noted. Postoperative follow up including endoscopic examination and results were documented. RESULTS A total of 300 cases were included (271 patients) with average age of 66 (range 24-94). An uncinectomy was performed in 285 of 300 (95%) cases, a septoplasty in 82 of 300 (27%) cases and an anterior middle turbinectomy performed in 225 of 300 (75%) cases. Postoperative bleeding that required nasal packing occurred in 2 of 300 (0.6%) cases. Persistent nasolacrimal symptoms after surgery occurred in 18 of 300 (6.0%) cases with an average follow up of 28 months (range 1-70). Postoperative nasolacrimal symptoms were attributed to a persistent lacrimal sac (sump syndrome) in 1 of 300 (0.3%) cases, a mucocele recurrence in 2 of 300 (0.6%) cases, and scarring at the rhinostomy in 15 of 300 (5.0%) cases. CONCLUSIONS Endoscopic endonasal dacryocystorhinostomy is an effective treatment for nasolacrimal duct obstruction. An uncinectomy, septoplasty, and anterior middle turbinectomy contribute to the optimal clearance of the common canaliculus and ultimate surgical success.

PURPOSE We present the first report on a histopathological evaluation of the tolerance of human lacrimal canalicular mucosa to the implantation of a silicone punctal plug.METHODS A silicone punctum plug was implanted 10 to 15 days prior to planned surgical resection of the lacrimal canaliculus and adjacent inferior eyelid in 5 patients. The indication for canalicular resection was related to a basal cell carcinoma in 4 cases and to a squamous cell carcinoma in I case. Average duration of implantation was 15 days, with a 15-day punctum-free period in one case.RESULTS Histopathological analysis of specimens revealed a tight conformation of the mucosa to the plug wall. Mild atrophic and hypertrophic changes in mucosal epithelium as well as a moderate inflammatory reaction, consisting of macrophages and polymorphonuclear cells, was observed at the level of the epithelium but not in the adjacent connective tissue.CONCLUSION These results confirm the overall good tolerance of silicone plugs after mid-term impla...

The authors report a case of dacryocystocele (DCC) diagnosed in utero by ultrasound imaging. Postnatal examination, performed immediately after delivery by cesarean section, revealed a blueish subcutaneous cyst in the medial canthus. This DCC persisted until the 14th day of life, when a superinfection of the cyst, noted at day II, required the surgical resection of the wall of the intranasopharyngeal cystic expansion. The procedure achieved a complete drainage of the pus and a permanent resolution of the DCC. Histopathological analysis of the resected cyst wall revealed a nonspecific nasal mucosa with mild inflammatory infiltrate. These findings confirm the identity between a prenatal dilation of the lacrimal duct and a true postnatal DCC with a documented intranasopharyngeal cystic expansion. This observation further supports the prevailing theory of a prenatal functional “trapdoor” blockage of Rosenmuller' s valve in the pathogenesis of DCC.

The authors conducted a retrospective study on 120 consecutive cases of nasolacrimal duct obstructions (NLDO) in 85 children, operated on by a single surgeon (BF) from January 1988 to July 1992. Mean age at the time of surgery was 5.4 years (1 to 11 years). Seventy-seven bicanaliculo-nasal intubations (BCNI) and 43 monocanaliculo-nasal intubations (MCNI) were performed. MCNI were performed using the Fayet-Bernard ‘MonoKa’ tubing material (FCI, Paris, France). This device permits monocanalicular intubation with meatic fixation by a punctum-plug-like extremity. Among MCNI, 39 were placed into the superior canaliculus. Nine MCNI were indicated because of a true monocanalicular agenesis (inferior canaliculus agenesis in five cases and superior canaliculus agenesis in four cases).Mean follow-up was ten months. Average duration of intubation was seven months for BCNI and 5.1 months for MCNI. BCNI and MCNI resulted in complete resolution of the epiphora in 62.2 and 67.6% of cases respectively.Intermittent tearin...

Summary Purpose We studied the possibility of placing a new type of monocanalicular nasal intubation under general anesthesia with spontaneous mask ventilation in congenital nasolacrimal duct obstruction. Patients and method This was a non-randomized study of consecutive cases using a monocanalicular stent called the “pushed Monoka”. The benefits of anchoring with meatus fixation are similar to the original Monoka device, but the probe guide or introducer is inside the silicone tube. The external diameter of the “pushed Monoka” is 0.96 mm (versus 0.64 mm in the traditional Monoka). There are three lengths: 30, 35, and 40 mm. General anesthesia was administered by inhalation of a halogen gas using a facial mask. The technique was selected by lacrimal exploration to evaluate the extent of the stenosis (simple or complex). The location and freedom of movement of the stent into the inferior nasal meatus was tested using a second lacrimal probe. Only simple stenosis cases with positive metal-to-metal contact were included in the study. Insertion technique The introducer pushes the stent into the lacrimal duct. The introducer should be removed from the silicone sleeve very carefully by gently pulling it out, millimeter by millimeter. This action is carried out while paying careful attention to keeping the stent aligned with the major axis of the lacrimal sac. Throughout this phase, the anchoring plug should remain in contact with the lacrimal punctum. Once the introducer is completely removed, the anchoring plug is secured into the vertical canaliculus. A single-use plug inserter was used. Results Fourteen children (18 sides) with congenital nasolacrimal duct obstruction were consecutively included in the study. The pushed intubations were all performed under general anesthesia with spontaneous ventilation. The average age of the children was 26.2 months (range: 14 to 46 months). The average duration of the procedure, measured between the moment that the facial mask was put into place and the child's awakening (crying, restlessness) was 14 minutes (range: 9 to 27 minutes). The most variable parameter was the use of the venous portal. The introduction of the pushed probe itself required an average 7 minutes (range: 3 to 11 minutes). None of the children showed epistaxis. In general terms, no intraoperative or postoperative complications were noted. The “pushed Monoka” tubes were withdrawn during postoperative appointments with a mean intubation duration of 34 days (range: 1 to 59 days). Postoperative success (absence of epiphora, absence of mucous discharge) was achieved in 88% of cases (16/18 sides). The average follow-up was 8.7 weeks (range: 3 to 26 weeks). Complications and side effects were minimal. One stent was withdrawn on day 1 due to a keratitis with respect to the anchoring plug. Three stents were spontaneously lost (16%) between day 2 and day 30. Anterior rhinoscopy found none of the stents in the inferior nasal meatus. These four cases were all considered successful as there was no postoperative epiphora noted. Conclusions Pushed nasolacrimal intubation can be safely utilized under general anesthesia with spontaneous mask ventilation. This technique appears to be a simple and safe alternative to late and very late probing in the treatment of membranous congenital nasolacrimal duct obstruction in children older than 12 months.

Monocanalicular intubation has been made effective by the manufacture of a device combining a punctal plug device and a connecting silicone tube or rod (the Mono-Ka® device) The results for congenital dacryostenosis are similar to those seen with bicanalicular intubation The Mono-Ka® device is particularly useful for cases of punctal atresia of a single channel with associated nasolacrimal duct obstruction The Mini-Mono-Ka® is a modified device with a punctal plug and a Silastic rod useful for the repair of canalicular lacerations Complications with these devices are infrequent but include early extrusion, damage to the punctum or burying of the device

Purpose To report on an uncommon, previously unidentified, progressive silicone punctal plug extrusion. Design Small, retrospective case series. Participants Five cases of punctal plug extrusion were identified among a series of 424 consecutive implantations. Histopathologic analysis was obtained in one case. One additional referred case was included in this report. Results The plugs were completely extruded from the punctal lumen 6 to 14 months after insertion after an otherwise uncomplicated postoperative course. All plugs were retained at the punctal margin by an encircling band of vascularized mucosal tissue originating from the canalicular lumen. The band consisted of connective tissue of canalicular mucosal origin, attached just below the junction of the punctal and canalicular epithelium. Mild mononuclear infiltration was present in the connective tissue component of the punctal region. There was no cytologic or architectural evidence of abnormal epithelium or connective tissue or of pyogenic granuloma. Conclusions These observations suggest that progressive lacrimal punctal plug extrusion may relate to mucosal dissection by the plug edges. We speculate that mechanical stress induced by eyelid closure on an improperly sized or placed implant may result in plug tilt. Subsequent epithelial hyperplasia further enhances the tilt, and the sharper edge of the conical bulb promotes separation of the canalicular mucosa from its distal luminal aspect. At the completion of the extrusion, the mucosal surface is separated from its connective tissue base, at a proximal subpunctal level, causing formation of an encircling tissue band.

Introduction La pathologie sinusienne frontale (sinusites, mucoceles) est une complication rare des dacryocystorhinostomies. Son mecanisme est mal connu. On peut imaginer soit l’aggravation d’une sinusite chronique meconnue, soit une lesion per-operatoire du systeme de drainage du sinus frontal. Materiels et Methodes Nous rapportons une observation d’une mucocele du sinus frontal, survenue dans les suites d’une DCR externe bilaterale, et illustrant la deuxieme hypothese. En preoperatoire, l’etat des fosses nasales et des sinus avait ete documente : Il n’existait aucun signe de sinusite chronique. Du cote ou est survenue la complication, une cellule ethmoidale etait en contact avec la gouttiere lacrymale et pas de l’autre. Discussion Le drainage du sinus frontal, par le recessus frontal, peut se faire dans l’ethmoide anterieur au contact de la gouttiere lacrymale dans 30 % des cas environ. Il est vraisemblable qu’un autre facteur associe soit necessaire compte tenu de la discordance entre ce rapport anatomique et la frequence de cette complication (1/500 environ). Conclusion La possibilite d’un drainage du sinus frontal contre la gouttiere lacrymale doit etre connue. L’effraction per-operatoire du recessus frontal est quasi invisible par voie externe. Le patient doit etre prevenu de cette complication rare. En cas de symptome evocateur, un bilan tomodensitometrique des cavites sinusiennes et un examen endoscopique s’imposent.