获得性泪点阻塞病因分析及手术治疗

Etiology and surgical management of acquired punctal stenosis

目的分析获得性泪点狭窄或阻塞的病因并评价手术治疗效果。设计前瞻性病例系列。研究对象2016年1月至2017年3月确诊为获得性泪点狭窄或阻塞并有溢泪症状接受手术治疗的患者40例(61眼),女性占83%,平均年龄(54±13.3)岁。方法术前根据Kashkouli方法进行裂隙灯下泪点开放程度分级,0级为无泪点及泪乳头,1级为泪乳头膜闭或纤维化,2级为泪点可辨认但小于正常,3级为正常大小。0级和1级泪点用25G针头穿刺造口再用直径由细到粗的泪点扩张器逐渐扩张泪点,泪点重建后行Ritleng人工泪管置人术。人工泪管取出后6个月分别从解剖和功能学评价手术效果,解剖成功为泪点3级及以上,功能成功为Munk溢泪症状评分0或1分且荧光染料消失试验阴性。主要指标泪点分级,Munk评分和荧光染料消失试验。结果双眼发病者21例(53%),上下泪点同时受累40眼(66%),病因不明的特发性病例31例(78%)。泪点平均分级术前为1.3±0.7,术后明显提高,为3.0±0.4(P<0.001)。术后泪点≥3级者95个,解剖成功率94%。Munk评分≤1分且FDDT阴性者56眼,功能成功率92%。仅2眼发生轻度泪点撕裂,其余无明显手术并发症。结论获得性泪点阻塞的病因以特发退行性改变为主,渐进式泪点扩张成形联合Ritleng人工泪管置入术安全有效,是治疗获得性泪点阻塞的理想术式。

Objective To assess the etiology and surgery effectiveness of the acquired punctal steno- sis. Design Prospective ease series. Participants Sixty-one eyes of 40 patients presenting with epiphora who were diagnosed as acquired punctal stenosis and underwent surgical management from January 2016 to March 2017 were assessed. Female accounted for 83% and the mean age was 54±13.3 years. Methods The severity of the stenosis was graded based on slit-lamp examination according to Kashkouli＇ s method. Grade 0 is no papilla and punctum, Grade 1 is papilla covered by a membrane or fibrosis and difficuh to recognize, Grade 2 is less than normal size but recognizable, and Grade 3 is normal. Sequential punctal dilation combined with Ritleng silicone intubation was performed in grading 0 - 2 of punetal opening size. A 25-G needle was used to open the papilla and then progressively larger dilators were used to dilate the ampulla to introduce a Rifleng probe. Anatomical success was defined as a well-patent puncta （ Grade 3- 5 ） and functional success as Munk epiphora scoring ≤ 1 and negative fluorescein dye disappearance test （FDDT） at 6 months after removal of silicone stents. Main Outcome Measures Punctal grading, Munk scoring, and FDDT. Results Twenty-one cases （53%） were bilateral and both upper and lower puncta were involved in 40 eyes （66%）. Thirty-one cases （78%） were idiopathic without any known causes. The mean pre-operative and post-operative punctal grading was 1.3±0. 7 and 3.0 ± 0. 4 respectively with statisti- cally significance （p 〈0. 001 ）. Anatomical success rate was 94% （95/101） and functional success rate was 92% （ 56/61 ）. No serious complication was noted except for mild punctal laceration in 2 eyes. Conclusion The most common underlying cause for acquired punctual stenosis was idiopathic involutional change in this series. Sequential punctal dilation with Rifleng intubation is a safe and efficient technique in the management of acquired punctal stenosis.