Current Eye Research

ISSN: 0271-3683 (Print) 1460-2202 (Online) Journal homepage: https://www.tandfonline.com/loi/icey20

Human Lacrimal Drainage System Reconstruction,

Recanalization, and Regeneration

Mohammad Javed Ali & Friedrich Paulsen

To cite this article: Mohammad Javed Ali & Friedrich Paulsen (2019): Human Lacrimal Drainage
System Reconstruction, Recanalization, and Regeneration, Current Eye Research, DOI:
10.1080/02713683.2019.1580376

To link to this article: https://doi.org/10.1080/02713683.2019.1580376

Published online: 22 Feb 2019.

Submit your article to this journal

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=icey20
CURRENT EYE RESEARCH
https://doi.org/10.1080/02713683.2019.1580376

Human Lacrimal Drainage System Reconstruction, Recanalization, and Regeneration

Mohammad Javed Alia,b and Friedrich Paulsena
a
Institute of Functional and Clinical Anatomy, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany; bGovindram Seksaria
Institute of Dacryology, L.V. Prasad Eye Institute, Hyderabad, India

ABSTRACT ARTICLE HISTORY

Purpose: This review examines the broad contexts of the reconstructive and recanalization strategies of Received 13 November 2018
the human lacrimal drainage system. Revised 25 January 2019
Materials and methods: A PubMed search was performed using individually and combination of the Accepted 1 February 2019
terms “lacrimal,” “reconstruction”, “recanalization,” “canaliculus,” “canalicular,” “stenosis,” “obstruction,” KEYWORDS
“block,” “drainage,” “disorder,” “disease,” “nasolacrimal duct (NLD),” “endoscopy,” “dacryoendoscopy,” Lacrimal drainage; canaliculi;
“trauma,” “laceration,” “stents,” “repair,” “tubes,” “tear,” “eyelid,” “Sisler,” “trephine,” and “trephination”. nasolacrimal duct;
Selections from these lists were the basis of examination of reconstruction and recanalization strategies reconstruction;
of multiple lacrimal disorders and their outcomes. recanalization
Results: The major focus areas of this review are obstructions of the canaliculi and the NLD, traumatic
involvement of the lacrimal drainage and their reconstruction strategies, and dacryoendoscopy-guided
recanalization of the NLDs. The review found evidence for lack of uniformity in accurately defining the
concepts of lacrimal drainage stenosis, partial or complete obstructions. Canalicular obstructions are
difficult to manage and outcomes depend on the location of the obstruction. High success rates were
reported in cases of canalicular lacerations managed by repair and silicone intubation. Controversies
exists in the recanalization strategies involving the NLD. In the absence of any current regenerative
strategies, NLD recanalization appears to be promising, but skepticism is well justified until its long-term
effects are well known.
Conclusions: Reconstructive strategies in canalicular trauma are highly successful. Recanalization stra-
tegies for the lacrimal drainage system are promising and there is a need to explore stem cells and
regenerative modalities to take the lacrimal drainage science a step forward.

Introduction protrusions and invaginations into the lumen of the lacrimal

sac and the nasolacrimal duct (NLD) that could possibly have
The lacrimal drainage system is an organization of tear-
been termed valves (of Foltz, Bochdalek, Rosenmüller,
conduit channels that drain the used tears (tear film) from
Huschke, Aubaret, Krause, Taillefer and Hasner) in the past
the ocular surface to the inferior meatus of the nasal cavity.1–3
but are likely to be based on the different swelling states of the
It begins on the eyelid margin with an opening termed
cavernous body surrounding the lacrimal sac and the NLD
“punctum,” which lies on a fibrous mound called the lacrimal
and which is densely innervated.2,3 The lacrimal sac continues
papilla. The punctum is 0.2–0.3 mm in diameter with the
as the NLD, which has a comparable epithelial lining as that
inferior punctum lying 0.5 to 1 mm more temporally as
of the sac but with denser goblet cells and microvilli.1
compared to the superior. Each punctum continues into the
Absorption studies in animals have indicated that probably
lacrimal canaliculus which has approximately a 2-mm vertical
reabsorption of tear fluid components also takes place from
portion and a 10 mm horizontal portion.1,2 The canalicular
the human NLDs, supporting the idea of a feedback mechan-
epithelium is of the non-keratinized, stratified squamous type.
ism for tear fluid production.1–3 The NLD traverses its bony
The upper and the lower canaliculi normally (>95%) unite to
canal in the maxilla and opens in the inferior meatus of the
form a common canaliculus which empties itself into the
nasal cavity, close to the head of the inferior turbinate. The
sinus of Maier within the lacrimal sac.1–3 The lacrimal sac is
current review examines in detail the reconstructive and reca-
10–15 mm in length and in most cases has a fundus that
nalization strategies for the canalicular stenosis, canalicular
towers the entrance area of the common canaliculus or the
obstructions, canalicular trauma, NLD stenosis as well as
openings of the two canaliculi (if they open separately). The
obstructions.
body of the lacrimal sac is housed in the bony lacrimal sac
fossa. Its mucosal lining consists of the stratified columnar
epithelium composed of single goblet cells or a group of Methods
characteristic intra-epithelial mucous glands. The epithelial
A PubMed search was performed for all articles published using
cells are lined by the microvilli.3 The mucosa often forms
individually and combination of the terms “lacrimal,”

CONTACT Friedrich Paulsen friedrich.paulsen@fau.de 19 Universitat Strase, 91054, Erlangen, Germany

Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/icey.
© 2019 Taylor & Francis Group, LLC
2 M. J. ALI AND F. PAULSEN

“reconstruction,” “recanalization,” “canaliculus,” “canalicular,” passage through the canaliculus and gives a feeling of hard
“stenosis,” “obstruction,” “block,” “drainage,” “disorder,” “dis- stop. For each thicker probe used, it is kept in the canaliculus
ease,” “NLD,” “endoscopy,” “dacryoendoscopy,” “trauma,” for 1–2 minutes till the thickest probe (0.9 mm) is easily
“laceration,” “stents,” “repair,” “tubes,” “tear,” “eyelid,” “Sisler,” passed with a hard stop. A lacrimal irrigation is then per-
“trephine,” and “trephination”. Suitable cross-references from formed to rule out associated NLD stenosis or obstruction. If
the articles were further analyzed. Selections from these lists was the irrigation is patent, the lacrimal system is then intubated
the basis of examination of reconstruction and recanalization with a bicanalicular silicone stent. This is followed by
strategies of multiple lacrimal disorders and their outcomes. a bicanalicular intubation. Park et al.10 reported improvement
in epiphora in 86% (n = 22) of their patients at a mean follow-
up of 13 months following a probe dilatation and intubation.
Results In a large series of 123 eyes of 77 consecutive patients, 72%
had canalicular stenosis and 46% showed a combined punctal
Canalicular stenosis
and canalicular stenosis.9 Following a treatment with mini-
Stenosis is defined as an abnormal narrowing or contraction monoka stents, 88% of these patients showed improvement in
of a duct or a canal. However with regard to the lacrimal their symptoms.
drainage stenosis, the published literature is confusing in Balloon canaliculoplasty has also been reported as a successful
quite a few reports between the terms “stenosis” and modality of managing canalicular stenosis (Figure 1). Lachmund
“obstruction”.4–8 The causes of canalicular stenosis include et al.23 demonstrated its efficacy in 36 cases of dacryocystography
chronic inflammations of the ocular surface structures such proven canalicular stenosis. A successful dilatation and intubation
as the conjunctiva and meibomian glands, bacterial or viral could be performed in 34 patients but 4 of these 34 patients
conjunctivitis, eyelid malposition or trauma.9–11 Stenosis can showed restenosis at 9 months follow-up. Zoumalan et al.11
also occur secondary to the toxicity from drugs like topical reported the use of balloon canaliculoplasty with silicone intuba-
fortified antibiotics and systemic chemotherapeutic agents like tion in 21 eyes with canalicular stenosis and at a mean follow-up
5-fluorouracil, docetaxel, S-1 and radioactive iodine.9–14 of 6 months post stent removal, they reported improvement in the
Rarely stenosis may also be congenital in nature or acquired
following a probing in cases of congenital nasolacrimal duct
obstruction (CNLDO).15 Moreover, a high incidence of cana-
licular stenosis (58%, 40/69) has been reported to be asso-
ciated with congenital anophthalmia or microphthalmia.16
A canalicular stenosis is usually diagnosed during clinical
examination with the help of lacrimal irrigation and probing
of the canaliculi. It can also be demonstrated radiologically
using a digital subtraction dacryocystography (DS-DCG) or
a computed tomography (CT-DCG) or a magnetic resonance
dacryocystography (MR-DCG).9,17–20 Direct canalicular endo-
scopy can also help in diagnosing and localizing the lesion
within the canaliculus.21 In addition, canalicular stenosis can
be associated with nasolacrimal stenosis, hence the examina-
tion should also be directed to rule this out.9,10,13 Canalicular
stenosis has also been proposed to be diagnosed clinically
using Miyake thin lacrimal probes to avoid subjective errors
on part of the examiner and to enhance the objectivity.10
These techniques are more objective because lacrimal probe
sizes are not standard and manufacture-dependent, single-
probe examinations may misdiagnose a canalicular stenosis
as an obstruction and the lacrimal irrigation findings cannot
be entirely relied upon.10,20,22
Treatment strategies have been variable and include lacri-
mal probe dilatation, topical steroids, mono or bi-canalicular
silicone intubation, balloon canaliculoplasty and occasionally
a laser dacryoplasty or even an endonasal dacryocy
storhinostomy.9–14,23–29 Treatment should also be directed at
stopping of the inciting agent if possible. The simplest treat-
ment described is a progressive dilatation of the canaliculus
with lacrimal probes. Although Viers.5 described it already in
1969, Park et al.10 recently discussed the technique in detail
using standardized Miyake probes. The Miyake probes range
from 0.45 mm in diameter to 0.9 mm. The sequential dilata- Figure 1. Schematic diagram demonstrating the concepts of balloon dacryo-
tion starts with the thinnest probe that allows a complete plasty in canalicular stenosis.

symptoms in 76.2% (16/21). There was an initial reservation with
the use of balloon dacryoplasty in view of its potential to cause
punctal and canalicular trauma, but this does not hold true any-
more with the advent of finer balloon catheters. However, larger
studies with longer follow-up are needed before balloon canalicu-
loplasty can be accepted as the procedure of choice for canalicular
stenosis.
The use of topical steroids or a combination of antibiotic
steroids have been reported with benefits in early cases of che-
motherapy induced canalicular stenosis.13 However, the use of
silicone intubation shows clear benefits in not only managing the
chemotherapy induced canalicular stenosis but also preventing
its progression.13,28,29 The duration of stent retention generally
in canalicular stenosis has varied from 1–6 months but in cases
of chemotherapy induced stenosis, it is important to continue it
for 1–3 months beyond cessation of the therapy.13 Spontaneous
resolution of epiphora can sometimes occur following comple-
tion of the chemotherapy but is rare.13,30
In summary, a timely identification and management of
canalicular stenosis prevents it from progressing to a stage of
canalicular obstruction and early interventions usually result
in satisfactory outcomes.
Canalicular obstructions and recanalization strategies
Canalicular obstructions are not very uncommon and have
been reported ranging from 0.92% to 4.5% of patients with
epiphora.7,31,32 The narrower diameters and multiple curves
are presumed to be the anatomical predispositions.10 The
etiological factors are similar to that of canalicular stenosis
and include congenital, trauma, viral infections, trachoma,
inflammatory conditions like Stevens-Johnson, ocular cicatri-
cial pemphigoid and lichen planus, eyelid malposition or pro-
long use of topical drugs like anti-glaucoma medications,
mitomycin-c and systemic use of drugs like docetaxel or
verteporfin.13,14,33–40 Recently a progressive inflammatory
condition named “idiopathic canalicular inflammatory disease
(ICID)” with five typical clinical stages evolving into
a complete canalicular obstruction has been reported.41
Other causes include post-radiotherapy and intrinsic canali-
cular tumors like squamous papillomas.34,42
Canalicular obstructions can be anatomically classified as
proximal (up to 3 mm from the punctum), mid-level (3 mm
to 6–8 mms) and distal (from membrane of the common
canaliculus to the lacrimal sac).7,33 However, there is confu-
sion regarding mid and distal segments. With the advent of
marked lacrimal probes,43 and for the sake of simplicity, the
authors of this review propose proximal (0–3 mms from the
punctum), mid-level (4–6 mms from the punctum) and distal
(>6 mm from the punctum) (Figure 2).
Canalicular obstructions can be identified with a relative
ease by clinical examination as compared to stenosis, using
the lacrimal probes and irrigation techniques. It is important
to use the thinnest probes (0000 Bowman”s or 0.45 mm
Miyake probes) to be sure and not to misdiagnose a stenosis
as an obstruction. They can also be demonstrated radiologi-
cally using the DS-DCG, CT-DCG, MR-DCG or dacryoscin-
tigraphy (DSG). A canalicular endoscopy can directly reveal
the degree of obstruction and its level.18,20,21,44
CURRENT EYE RESEARCH 3
Numerous management modalities have been described for
the canalicular obstructions and include canalicular trephination
with intubation, membranectomy, balloon canaliculoplasty, dou-
ble intubation, endocanalicular laser surgery, dacryocystorhinost-
omy (DCR) with intubation, canaliculodacryocystorhinostomy,
retrograde intubation dacryocystorhinostomy, canaliculocystot-
omy and conjunctivodacryocystorhinostomy.45–63
Canalicular trephination with intubation is the most preferred
modality in the management of canalicular obstructions.45–54
Canalicular trephination with intubation can be performed
alone or in combination with an endoscopic DCR or under
dacryoendoscopy guidance.45–54 The instrument commonly
used for canalicular trephination is the Sisler trephine, designed
considering the canalicular anatomy and has a standard operating
technique (Figure 3).54,55 Nathoo et al.45 reported vast majority
(73%) of their cases (45 eyes) had a common canalicular obstruc-
tion. Of these eyes, 64% did well following a single or repeat
trephination and intubation. Stents were retained for a mean
duration of 5.6 months. A DCR was required in 36% of the
cases. Khoubian et al.46 reported a complete relief from epiphora
in 49% and partial relief in 38% of their canalicular obstruction
patients (n = 32 patients and 41 eyes) who underwent a simple
trephination and silicone intubation. They observed that the out-
comes are dependent on the level of obstruction. High success
rates were noted in distal mono-canalicular obstruction followed
by distal bi-canalicular obstructions, common and proximal
obstructions. Zadeng et al.47 reported 83% success rate with the
use of trephination and mini-monoka stents in their series of 23
eyes with idiopathic distal canalicular obstructions.
The combination of a canalicular trephination with an endo-
scopic DCR was usually attempted for distal or common cana-
licular obstructions. Kong et al.48 reported a large series of 59
eyes where canalicular obstructions were encountered during an
endoscopic DCR. Although they reported a good anatomical
outcome at 1-month post-surgery (98%), this reduced signifi-
cantly at 6 months follow-up (84%). Interestingly, they showed
better outcomes at 6 months in the group operated by experi-
enced surgeons. This also reflects on the need for a good training
in canalicular trephination, which needs to be performed meti-
culously and with a lot of patience. Pari et al.49 reported
a successful outcome in 63% (5/8) of their patients who under-
went a canalicular trephination with an endoscopic DCR. Nemet
et al.51 used adjunctive mitomycin-C following their canalicular
trephination and endoscopic DCR and reported good outcomes
(80%, 4/5). However, a meaningful conclusion cannot be drawn
about the role of mitomycin-C because of low sample size and
lack of a control arm.
The use of double silicone intubation (intubation of two
tubes in a single canaliculus) with a DCR in cases of canali-
cular obstructions is not widely reported. In a large compara-
tive series, Paik et al.50 studied outcomes with the use of single
versus double silicone intubation in their series of 58 eyes of
54 patients with canalicular obstructions beyond 5 mms. They
reported a significant difference in the successful anatomical
outcomes between the double stent group versus the single
stent group (91.4% vs. 75%, P = 0.034). Hwang et al.56 simi-
larly showed a higher success rate with the double stent group
(96.5% vs. 85%), however they only studied common canali-
cular obstructions, which are known to have better outcomes.
4 M. J. ALI AND F. PAULSEN
Figure 2. Schematic diagram demonstrating the authors proposal for classification of canalicular obstructions. Images represent proximal (0–3 mm) (top panel), mid
(4–6 mm) (middle panel), and distal (>6 mm) (bottom panel) canalicular obstructions.
Figure 3. A Sisler canalicular trephine.
Histopathological analysis of the scarred canalicular tissue
following a trephination was investigated in 12 consecutive
cases.57 The common finding was that of non-specific inflam-
mation with fibrosis and this could also reflect the underlying
basic pathogenesis of canalicular obstructions. It was interesting
to note that histological sections also revealed the presence of
skeletal muscle and adipose tissue. This can be attributed to
a false passage or complete loss of canalicular anatomy second-
ary to dense scarring.
Anterograde balloon dacryoplasty is an evolving modality.
Wilhelm et al.58 first reported its benefits using a narrow catheter
as compared to earlier approaches where large diameter ones
were used with undesirable complications. Yang et al.59 reported
outcomes in a large series of 66 eyes with monocanalicular or
common canalicular obstructions, which underwent a 2-mm
balloon canaliculoplasty following trephination. They reported
good outcomes in 53.6% and 25% in common canalicular and
monocanalicular obstructions, respectively. Although the results
were not encouraging, the failures were attributed to causes like
combined NLD obstructions and canaliculitis. This emphasizes
the need for a careful patient selection. Larger series with longer
follow-up is needed to decide whether balloon canaliculoplasty
could become the preferred technique for the management of
canalicular obstructions.
Endocanalicular surgery using Holmium, Erbium or KTP
laser has been reported with variable success rates.27,33,61
Although the procedure is short with little morbidity, the

outcomes beyond a successful recanalization are doubtful. The
use of laser energy could have the potential to damage the
healthy epithelium in the vicinity of the scar and possibly
promote more scarring in the long-term. Canaliculodacry
ocystorhinostomy is usually performed for common canalicu-
lar obstructions, where the fibrous end is excised and the
patent canaliculi are directly exposed into the nasal cavity
with a circumferential cover of the lacrimal sac mucosa.33,62
This is followed by a bicanalicular intubation. Most of the
series discussed above, where a combination of trephination
and endoscopic DCR was performed for the distal most
obstructions, can be technically considered as canaliculo
dacryocystorhinostomy.
Conjunctivodacryocystorhinstomy or CDCR is a time-tested
by-pass modality for bicanalicular obstructions.63 Numerous
techniques and detailed large series with long-term outcomes
are known. Since this is strictly not a recanalization or recon-
struction of an obstructed canaliculus, it falls outside the scope of
this review.
Reconstruction strategies for canalicular trauma
Canalicular lacerations are the most frequently encountered
lacrimal system trauma and are common in periocular and
facial injuries (Figure 4).64,65 They get involved in 16% of
eyelid traumas and 20% of globe injuries.66,67 Children and
young adult males are more frequently affected and the inju-
ries are secondary to assaults, road traffic accidents, broken
spectacles, animal bites and blouse hooks injuries.68–74 Rarely
iatrogenic trauma during trans canalicular surgeries or cae-
sarian section delivery can result in canalicular lacerations.75
The lower canaliculus is more commonly involved and bica-
nalicular lacerations are seen in 6–24% of all canalicular
lacerations.68–70,76–78 Upper canalicular lacerations are
known to be associated with co-existing globe injuries in
20–25% of the cases.65,67,69,70 The susceptibility of the canali-
culus to trauma is secondary to two factors.79,80 Firstly, the
lack of a good connective tissue support in the vicinity pre-
disposes it to avulsions in response to shearing forces.
Secondly, the lacrimal drainage forms a base of a bony funnel
Figure 4. A clinical image of the left eye showing a lower lid eyelid tear with
a canalicular involvement.
CURRENT EYE RESEARCH 5
that has the tendency to redirect trauma forces or projectiles
towards the canaliculus.
A diagnosis of canalicular laceration is confirmed on clin-
ical examination. It is important to first assess the systemic
condition in any trauma scenarios and then look for co-
existing injuries to the globe and peri-ocular area; which
may take precedence in further management. A thorough
lacrimal system examination is also useful in any injury invol-
ving the medial canthal region or the medial eyelids.64,65
The general consensus today is that all canalicular lacerations
need to be repaired and the earlier laxity on mono-canalicular
lacerations does not hold ground anymore.64,81,82 Systematic tear
flow investigations for the transport capacity of upper and lower
canaliculi is lacking.3 Tear flow is usually similar in both the
canaliculi and canalicular dominance can be different in each eye
and can also vary between individuals.83,84 Evidence also sug-
gests that physiological restoration of tear flow is best when both
the canaliculi function well. Hence all mono-canalicular lacera-
tions should be repaired on similar grounds as one would do for
a bicanalicular laceration.
The repair of a canalicular laceration is not an immediate
emergency and is usually repaired in a controlled environ-
ment within 24 h. Numerous factors that play a role in
deciding the time of surgery include pediatric patients, sys-
temic status, complexity of the trauma, anesthesia and staff
support, access to proper health care, and pre-existing co-
morbidities. Chiang et al.85 found no differences in complica-
tions between the groups where the eyelid lacerations were
repaired <24 h (66.4%, 95/143) and >24 h (33.6%, 48/143).
However, 77 of these patients had canalicular lacerations and
the mean time to repair was 33.1 h (median 16.5 h, range:
2–584 h). Bai et al.86 reported successful outcomes in a large
series of 136 patients with a delayed canalicular repair, major-
ity of whom underwent a repair between 1–12 months after
the injury. Encouraging short and long-term outcomes were
also noted in cases repaired up to 4–7 days post injury.74,82
The general consensus based on the published literature as
discussed earlier is that a delay is acceptable in cases of
systemic or anesthesia related issues, but every effort should
be taken to repair it at the earliest convenient time.
The principle of a canalicular tear repair is two-fold; one
is to achieve a good layered wound closure and second is to
insert a stent across the tear ends of the canaliculus to
facilitate end to end anastomosis and subsequent normal
tear drainage (Figure 5). The eyelid laceration follows the
standard principles of tarsus and grey line anastomosis. The
challenge is to find the medial cut end of the canaliculus.
The difficulty may be compounded in complex trauma,
sunken sockets, severe edema and active ooze.87,88
Clinically, the cut end can be identified under good magni-
fication and illumination as a whitish ring in the vicinity of
pinkish-red tissues, often called the “calamari sign”.64
Numerous other techniques are also used when visualization
gets difficult and include saline irrigation, probing with soft
probes, use of round-tipped pigtail probe, air injection,
colored dyes, viscoelastic and the fiber-optic light.87–92 The
superiority of one over the other is unclear but the prefer-
ence of these simple techniques are based on the surgeon”s
comfort and the familiarity with them.
6 M. J. ALI AND F. PAULSEN
Figure 5. Clinical image of the left eye of the patient in Figure 4. Note the
repaired and well apposed eyelid.
Once the cut end is identified, the next step is to dilate the
punctum and intubate the whole canaliculus (Figures 6 and 7).
Both mono-canalicular intubation like mini-monoka or mas-
terka and bicanalicular stents like annular, bika or Crawford
types with their modifications have been used.64,93–96 There
has been a debate on the preference of the stent and each variant
has their advantages and disadvantages.64 There are proponents
of the use of two monoka stents in a bicanalicular laceration and
vice-versa, the use of a bicanalicular stent in a mono-canalicular
laceration.71,97,98 However, the general consensus is to use
a mono and bi-canalicular stents for the respective lacerations.64
Following intubation, approximation of the cut ends is
achieved following repair of the lacerated eyelid. Few of the
authors report better approximation when a microsurgical
mucosal anastomosis involving the cut ends of the canaliculus
is performed.64,99–104 Numerous techniques of peri-canalicular
suturing have been reported and include a single stitch or
a horizontal mattress.64,100–102 Direct repairs of the canalicular
wall have recently shown better outcomes compared to the peri-
canalicular sutures.104
Duration of silicone intubation is another subject of debate
and no clear-cut guidelines are available in trauma scenarios.
Figure 6. Intraoperative image demonstrating the monoka stenting of the
proximal lacerated segment.
Figure 7. Intraoperative image demonstrating the monoka stenting of the
proximal and distal cut ends.
Studies have intubated for a duration ranging from 1 month
to 12 months.68–74,105 A significantly better outcomes were
noted with bicanalicular intubation retained beyond 90 days
as compared to lesser durations.78 A study in a sheep model
recommended a duration of 12 weeks for histopathological
establishment of contiguity.106 However, the results of this
cannot be entirely extrapolated to human beings. The usual
durations in the literature are from 3–6 months. However,
there needs to be a consideration for stent related complica-
tions and potential harmful effects of biofilms that develops
beyond a specific retention time.107
In addition to these techniques, the concept of canalicular
transplantation has been attempted with success in two cases
so far.108,109 A larger series with longer follow-up is needed to
establish its indications and definitive role in canalicular
lacerations.
The overall outcomes are very successful in the majority of
patients undergoing a canalicular laceration repair with sili-
cone intubation. The success rates vary from 58–100% in the
literature.68–74 Good outcomes are maintained even in the
long-term.72,74 Two studies specifically assessed the risk fac-
tors predictive of outcomes.68,73 Successful outcomes were
associated with an operating room setting (as compared to
minor procedure room, P < 0.0001) and the level of training
of the physician (P < 0.001).68 Fellowship trained oculoplastic
surgeons had better outcomes than all other physician cate-
gories. The type of stent used (mini-monoka vs. Crawford)
was not significantly related to the success rate (P = 0.118).68
Singh et al.73 in addition noted that the mode of injury (road
traffic accidents) and non-standard stents (20G silicone rod)
were predictors of poorer outcomes.
Recanalization strategies for a nasolacrimal duct
obstruction
Primary acquired nasolacrimal duct obstruction (PANDO) is
a common problem of lacrimal drainage system in adults. Its
pathophysiology is unclear but believed to be initiated by either
a descending inflammation from the eye or an ascending inflam-
mation from the nose, which leads to remodeling of the helical

Figure 8. A Dacryoendoscope.
arrangement of connective tissue fibers, malfunctions in the sub-
epithelial cavernous body with reactive hyperemia, and temporary
occlusion of the lacrimal passage.3,110 Repeated isolated occur-
rences of inflammation leads to structural epithelial and sube-
pithelial changes, which may further lead either to a total fibrous
closure and obstruction of the lumen. Numerous other possibi-
lities are being currently investigated including hormonal micro-
environments, intrinsic cholinergic system, lysosomal enzymes
and defense glycoproteins.111–114 PANDO is widely and success-
fully treated with bypass surgeries like dacryocystorhinostomy.
The advent of micro-endoscopes and advances in the fiber-optic
systems have now enabled a good direct view of the stenosis or
obstructions and opened up multiple avenues to diagnose and
treat disorders of the lacrimal drainage system.115–117 The main
advantages of recanalization procedures are their minimally inva-
sive nature, less morbidity and early rehabilitation.
The instrumentation includes a dacryoendoscope, light source
and the camera head (Figure 8).21 The endoscope can be flexible
or rigid. The modern micro endoscopes vary from 0.3 to 1 mm in
the external diameter with an image quality ranging from 1500 to
10,000 pixels.54,118–120 The usual ones used are 0.6 to 0.8 mm with
a 60 –70 field view. Three port probes with an external diameter
of 1.1 and internal diameter of 0.7 to 0.9 can permit the additional
simultaneous use of micro-drills, laser probes, micro-punches and
miniature balloons (Figure 9).27,118,119,121
Recanalization strategies used include endoscopy guided
trephination using the Huco trephines, dacryorhinotomy,
microdrill dacryoplasty, anterograde balloon dacryoplasty,
Figure 9. Multiple side ports of a dacryoendoscope for microdrills and laser inlets.
CURRENT EYE RESEARCH 7
laser dacryoplasty, electro-cautery and radio frequency-based
techniques.119–134
Partial PANDO or nasolacrimal duct stenosis are usually
treated with either a silicone intubation (SI) or an anterograde
balloon dacryoplasty (BDCP) with silicone intubation.132–134
Successful outcomes of 3 mm BDCP with SI have been
reported in 71% (n = 12 patients). Studies have compared
the efficacy of BDCP+SI with SI alone and found no differ-
ence in the outcomes with either group (61% vs. 54%, n = 62
eyes and 52% vs. 57%, n = 70 eyes). A simple intubation with
or without BDCP can be a minimally invasive alternative in
cases of partial or evolving PANDO.
Lacrimal trephines have been used to overcome the
obstructive tissue of the NLD under dacryoendoscopy
guidance.54,125 The trephines can be either used separately
or simultaneously under visualization. The trephine with the
endoscope is passed into the NLD till the site of obstruction
and under visualization and positive pressure irrigation, the
obstructed segment is trephined till it smoothly passes into
the inferior meatus. This is followed by silicone intubation
with or without mitomycin C. Javate et al.125 studied the
efficacy of lacrimal duct recanalization in 86 patients with
PANDO, 26 of which were partial PANDO and reported
anatomical patency in 93% of them. They did not find sig-
nificant difference in the outcomes when compared to an
external DCR.
Microdrill dacryoplasty utilizes battery powered miniatur-
ized motor drills of 0.3 mm diameter, which can be easily
incorporated along with the dacryoendoscope.119,122,124 It is
useful to mechanically remove the obstructed tissue just like
a trephine but in a finer way due to the high speed of the drill.
Emmerich et al.114 reported successful outcomes in 82% of their
75 cases operated by microdrill dacryoplasty and proposed it as
a potential alternative to the conventional dacryocystorhinost-
omy. Zhi et al.124 similarly reported successful outcomes in
84.9% (n = 35 eyes) of their patients treated with microdrill
dacryoplasty. They found it to be better than laser dacryoplasty
for a nasolacrimal recanalization but found a higher rate of
post-operative complications such lacrimal bleeding and/or pal-
pebral edema as compared to laser dacryoplasty.
Laser dacryoplasty for nasolacrimal recanalization has been
in use for more than 2 decades. The lasers employed include
Nd-YAG, THC: YAG, Erbium: YAG and the Diode
laser.25,119,122,124,126 The laser probes can be passed through
the working channel into the NLD and then can be directly
applied to the obstructed tissue with an end-on dacryoendo-
scopic visualization. Successful outcomes were reported in
77% in a large series of 211 patients at a minimum follow-
up of 3 months.119 However, others reported good outcomes
in only 66.7% (n = 18 eyes) but with lesser rates of lacrimal
bleeding and post-operative edema as compared to the
mechanical microdrill methods.124 It is important to remem-
ber in this context that the current contraindications for
recanalization procedures include infections, acute inflamma-
tion, mucocele and post-traumatic NLDO.122
Electrocautery-based techniques have also been proposed for
NLD recanalization in cases of PANDO. The instrument used
for this is a lacrimal canaliser whose console can discharge
a power current of 50-150W at a frequency of 500 KHz. The
8 M. J. ALI AND F. PAULSEN
probe used is a copper silver alloy of 140 mm length and 1.2 mm
diameter with a 2 mm round tip. The proposed mechanism is
cauterization of the blocked tissue and clearing of the blocked
NLD with subsequent anatomical patency. Following the proce-
dure all patients are intubated with a silicone tube. Chen et al.127
in a large series of 506 patients demonstrated the benefits of
using lacrimal canaliser and successful outcomes in 93% of their
cases. However, the cases included were a wide variety of etiol-
ogies other than a pure PANDO including mucoceles, past failed
external dacryocystorhinostomy and fistulae. They also demon-
strated histopathological effects of electro cautery in NLD of 12
rhesus monkeys and found that the traumatized epithelium heals
completely after 1 month without any granulation tissue forma-
tion. Hong et al.128 similarly studied 32 patients with earlier
failed intubation who subsequently underwent an NLD recana-
lization with electrocautery. They reported good outcomes in
84.4% with 18 months post-operative follow-up. The time to
recurrence in failed cases was noted to be 2.6 ± 1.1 months.
Agrawal et al.129 used a 20G bipolar probe connected to a 7W
diathermy console for the NLD recanalization in their 151
patients and reported successful outcomes in 92.7% of the
patients at a follow-up of 24 months.
Dacryorhinotomy is a technique where an incision is taken
on the distal most patent NLD in the inferior meatus with
a radiofrequency scalpel followed by a silicone tube intubation.
Sasaki et al.123 reported a success rate of 87.5% (n = 40 eyes) at
6 months follow-up with the dacryorhinotomy in cases of mem-
branous obstructions of the NLD. A similar technique was
reported by Tanaka et al,131 who anastomosed the patent part
of the NLD to the inferior meatal mucosa using the eversion
technique followed by intubation. They studied six eyes and
reported cure in all of them at a mean follow-up of 32 months.
The factors hindering the wide acceptance of NLD recanali-
zation techniques include advance instrumentation, steep learn-
ing curve, ill-understood etiopathogenesis, ill-understood post-
operative healing mechanisms, ablation of the NLD with certain
techniques, collateral tissue trauma, insufficient endoscopic data
on post-operative changes, and unclear long-term outcomes.
While the results of various techniques are encouraging, the
paucity of knowledge with regards to definitive etiopathogenesis
and management is profound. Currently, skepticism is well
justified with regards to NLD recanalization. The above stated
reasons need to be resolved for these techniques to replace
dacryocystorhinostomy in the management of PANDO, for
which there is a lot of hope.
Regeneration of lacrimal drainage system
Lacrimal drainage system regeneration approaches so far
have not been reported. This is in clear contrast to
approaches to regenerate, for example, the lacrimal gland
tissues.135–137 However, lacrimal gland and the efferent tear
duct system are completely different tissues and much less
is known about the efferent tear duct system including
paucity of knowledge about its development/embryology.
The development of techniques and instrumentation for
managing lacrimal drainage disorders has possibly reached
its zenith and the way forward would be to focus on regen-
eration strategies. Fortunately, there is a good body of work
in tissues elsewhere in the body with well-developed meth-
odologies and protocols and these could be used as
a starting point. The focus areas could be detailed embry-
ological studies, search for stem cells and their characteriza-
tion, and subsequent in-vitro development of 2D and 3D
models of regenerated tissues. The goal is audacious but the
hopes are greater for a bright future.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
Mohammad Javed Ali received support from the Alexander von
Humboldt Foundation for his research and he also receives royalties
from Springer for the 2nd edition of the textbook “Principles and
Practice of Lacrimal Surgery” and treatise “Atlas of Lacrimal Drainage
Disorders”. Friedrich Paulsen was supported by Deutsche
Forschungsgemeinschaft (DFG) grants PA738/1-1 to 1-5 as well as
PA738/2-1. He receives royalties from Elsevier for the anatomy atlas
“Sobotta” and the “Sobotta Textbook of Anatomy”.
Statement
This manuscript is not been published elsewhere and has not been
submitted simultaneously for publication elsewhere.
References
1. Kakizaki H, Ali MJ. Anatomy, physiology and immunology of the
lacrimal system. In: Mj A, editor. Principles and practice of
lacrimal surgery. 2nd ed. Singapore: Springer; 2018. p. 19–39.
2. Paulsen F, Garreis F, Schicht M, Bráuer L, Ali MJ, Sel S. Anatomy
and physiology of the nasolacrimal ducts. HNO. 2016;64:354–66.
doi:10.1007/s00106-016-0164-4.
3. Paulsen F. The human nasolacrimal ducts. Adv Anat Embryol
Cell Biol. 2003;170:III-XI,1–106.
4. Morgan OG. Stenosis of the lower canaliculus. Br J Ophthalmol.
1950;34:113–14.
5. Veirs ER. Stenosis of the common canaliculus: correction with
a canalicular rod. Arch Ophthalmol. 1969;81:569–70.
6. Alnawaiseh M, Bohm MR, Wieneke AC, Zumhagen L, Merté RL,
Eter N, Procosch V. Micro-surgical treatment of canalicular ste-
nosis: long-term follow-up. Klin Monbl Augenheilkd.
2015;232:1082–85. doi:10.1055/s-0035-1546114.
7. Kashkouli MN, Pakdel F, Kiavash V. Assessment and manage-
ment of proximal and incomplete symptomatic obstruction of the
lacrimal drainage system. Middle East Afr J Ophthalmol.
2012;19:60–69. doi:10.4103/0974-9233.92117.
8. Maalouf T, Tessier M, George JL. Long-term outcome of Reny
canaliculoplasty for extended canalicular stenosis. Orbit.
2005;24:185–90. doi:10.1080/01676830500201026.
9. Hussain RN, Kanani H, McMullan T. Use of mini-monoka stents
for punctal/canalicular stenosis. Br J Ophthalmol. 2012;96:671–73.
doi:10.1136/bjophthalmol-2011-300670.
10. Park J, Kim H. Sequential probing and dilatation in canalicular
stenosis. Graefes Arch Clin Exp Ophthalmol. 2015;253:2007–13.
doi:10.1007/s00417-015-3151-7.
11. Zoumalan CI, Maher EA, Lelli GJ Jr, Lisman RD. Balloon cana-
liculoplasty for acquired canalicular stenosis. Ophthal Plast
Reconstr Surg. 2010;26:459–61. doi:10.1097/IOP.0b013e3181eea
303.
12. Weston BC, Loveless JW. Canalicular stenosis due to topical use
of fortified antibiotics. Can J Ophthalmol. 2000;35:334–35.

13. Mansur C, Pfieffer ML, Esmaeli B. Evaluation and management of
chemotherapy-induced epiphora, punctal and canalicular stenosis
and nasolacrimal duct obstruction. Ophthal Plast Reconstr Surg.
2017;33:9–12. doi:10.1097/IOP.0000000000000745.
14. Ahmadi MA, Esmaeli B. Surgical treatment of canalicular stenosis
in patients receiving docetaxel weekly. Arch Ophthalmol.
2001;119:1802–04.
15. Lyon DB, Dortzback RK, Lemke BN, Gonnering RS. Canalicular
stenosis following probing for congenital nasolacrimal duct
obstruction. Ophthalmic Surg. 1991;22:228–32.
16. Schittkowski MP, Guthoff RF. Results of lacrimal assessment in
patients with congenital clinical anophthalmos or blind
microphthalmos. Br J Ophthalmol. 2007;91:1624–26.
doi:10.1136/bjo.2007.120121.
17. Lúchtenberg M, Berkefeld J, Bink A. Presaccal stenosis as a cause
of epiphora. Radiologe. 2008;48:1164–68. doi:10.1007/s00117-008-
1692-z.
18. Hoffmann KT, Anders N, Hosten N, Holschbach A, Walkow T,
Sórensen R, Hartmann C, Felix R. High resolution functional mag-
netic resonance tomography with Gd-DTPA eyedrops in diagnosis
of lacrimal apparatus disease. Ophthalmologe. 1998;95:542–48.
19. Higashi H, Tamada T, Mizukawa K, Ito K. MR dacryocystogra-
phy: comparison with dacryoendoscopy in positional diagnosis of
nasolacrimal duct obstruction. Radiol Med. 2016;121:580–87.
doi:10.1007/s11547-016-0632-7.
20. Kim JS, Ahn M. Clinical evaluation and classification of nasola-
crimal duct obstruction site by dacryocystography. J Korean
Ophthalmol Soc. 2005;46:191–95.
21. Ali MJ. Dacryoendoscopic examination of the lacrimal system. In:
Mj A, editor. Principles and Practice of Lacrimal Surgery. 2nd ed.
Singapore: Springer; 2018. p. 103–10.
22. Clark RA. Dilatation probing as primary treatment for congenital
nasolacrimal duct obstruction. J AAPOS. 2002;6:364–67.
doi:10.1067/mpa.2002.128210.
23. Lachmund U, Ammann-Rauch D, Forrer A, Petralli C,
Remonda L, Roeren T, Vonmoos F, Wilhelm K. Balloon catheter
dilatation of common canalicular stenoses. Orbit. 2005;24:177–83.
doi:10.1080/01676830590930643.
24. Lee M, Song HY, Han YM. Balloon dacryoplasty. Results in the
treatment of complete and partial obstructions of the nasolacri-
mal system. Radiology. 1994;192:503–308. doi:10.1148/
radiology.192.2.8029423.
25. Stock L, Ungerechts R, Emmerich KH Recanalization of lacrimal
duct stenosis by laser dacryoplasty using a Diode laser – compar-
ison of success rates using an Erbium: yAGlaser. Klin Monbl
Augenheilkd 2017 (Epub).
26. Caversaccio M, Hausler R. Insertion of double bicanalicular silicone
tubes after endonasal dacryocystorhinostomy in lacrimal canalicular
stenosis: a 10 year experience. ORL J Otorhinolaryngol Relat Spec.
2006;68:266–69. doi:10.1159/000093096.
27. Kuchar A, Novak P, Pieh S, Fink M, Steinkogler FJ. Endoscopic
laser recanalization of presaccal canalicular obstruction. Br
J Ophthalmol. 1999;83:443–47.
28. Esmaeli B, Amin S, Valero V, Adinin R, Arbuckle R, Banay R,
Do KA, Rivera E. Prospective study of incidence and severity of
epiphora and canalicular stenosis in patients with metastatic
breast cancer receiving docetaxel. J Clin Oncol. 2006;24:3619–22.
doi:10.1200/JCO.2005.04.4453.
29. Esmaeli B, Hortobagyi GN, Esteva FJ, Booser D, Ahmadi MA,
Rivera E, Arbuckle R, Delpassand E, Guerra L, Valero V.
Canalicular stenosis secondary to weekly versus every-3-weeks
docetaxel in patients with metastatic breast cancer.
Ophthalmology. 2002;109:1188–91.
30. Stevens A, Spooner D. Lacrimal duct stenosis and other ocular
toxicity associated with adjuvant cyclophosphamide, methotrexate
and 5-fluoruracil combination chemotherapy for early stage breast
cancer. Clin Oncol (R Coll Radiol). 2001;13:438–40.
31. Das AV, Rath S, Naik MN, Ali MJ. The incidence of lacrimal
drainage disorders across a tertiary eye care network: customiza-
tion of an indigenously developed electronic medical record
CURRENT EYE RESEARCH 9
system – eyeSmart. Ophthal Plast Reconstr Surg. 2018;(Epub).
doi:10.1097/IOP.0000000000001257.
32. Bukhari A. Etiology of tearing in patients seen in an oculoplastic
clinic in Saudi Arabia. Middle East Afr J Ophthalmol.
2013;20:198–200. doi:10.4103/0974-9233.114790.
33. Liarakos VS, Boboridis KG, Mavrikakis E, Mavrikakis I.
Management of canalicular obstructions. Curr Opin Ophthalmol.
2009;20:395–400. doi:10.1097/ICU.0b013e32832ec3e0.
34. Bartely GB. Acquired lacrimal drainage obstruction: an etiological
classification system, case reports and a review of the literature.
Part 3. Ophthal Plast Reconstr Surg. 1993;9:11–26.
35. Satchi K, McNab AA. Idiopathic acquired lacrimal canalicular
obstruction. Ophthal Plast Reconstr Surg. 2018;(Epub).
doi:10.1097/IOP.0000000000001225.
36. Mohebbi M, Mirghorbani M, Afshan AB, Towfighi M. Lichen planus
in ocular surface: major presentations and treatments. Ocul Immunol
Inflamm. 2018;(Epub). doi:10.1080/09273948.2018.1485955.
37. Durrani OM, Verity DH, Meligonis G, Rose GE. Bicanalicular
obstruction in Lichen planus: a characteristic pattern of disease.
Ophthalmology. 2008;115:386–89. doi:10.1016/j.
ophtha.2007.03.081.
38. Kashkouli MB, Pakdel F, Hashemi M, Ghaempanah MJ, Rezaee R,
Kaghaz-Kanani R, Ahadian A. Comparing anatomical pattern of topi-
cal anti-glaucoma medications associated lacrimal obstruction with
a control group. Orbit. 2010;29:65–69. doi:10.3109/
01676830903324284.
39. Billing K, Karagiannis A, Selva D. Punctal-canalicular stenosis
associated with mitomycin-C for corneal epithelial dysplasia.
Am J Ophthalmol. 2003;136:746–47.
40. Yim JF, Crofts KP. Bilateral punctal-canalicular stenosis following
photodynamic therapy for choroidal neovascularization. Cutan
Ocul Toxicol. 2011;30:78–79. doi:10.3109/15569527.2010.521221.
41. Ali MJ. Idiopathic canalicular inflammatory disease: new disease
description of clinical patterns, investigations, management and
outcomes. Ophthal Plast Reconstr Surg. 2018;34(6):528–32.
doi:10.1097/IOP.0000000000001064.
42. Ali MJ, Singh S, Ganguly A, Naik MN. Dacryoendoscopy-guided
transcanalicular intralesional interferon alpha-2b for canalicular
squamous papillomas. Int Ophthalmol. 2018;38:1343–46.
doi:10.1007/s10792-017-0572-9.
43. Kothari M. Use of smart lacrimal probes. Indian J Ophthalmol.
2011;59:70–71.
44. Sasaki T, Miyashita H, Miyanaga T, Yamamoto K, Sugiyama K.
Dacryoendoscopic observation and incidence of canalicular
obstruction/stenosis associated with S-1, an oral anticancer
drug. Jpn J Ophthalmol. 2012;56:214–18. doi:10.1007/s10384-
012-0127-6.
45. Nathoo NA, Rath S, Wan D, Buffam F. Trephination for canali-
cular obstruction: experience in 45 eyes. Orbit. 2013;32:281–84.
doi:10.3109/01676830.2013.814685.
46. Khoubian JF, Kikawwa DO, Gonnering RS. Trephination and
silicone stent intubation for the treatment of canalicular obstruc-
tion: effect of the level of obstruction. Ophthal Plast Reconstr
Surg. 2006;22:248–52. doi:10.1097/01.iop.0000226863.21961.35.
47. Zadeng Z, Singh M, Singh U. Role of lacrimal canalicular trephina-
tion and mini-monoka stent in the management of idiopathic distal
canalicular obstructions: our experience of 23 cases. Asia-Pac
J Ophthalmol. 2014;3:27–31. doi:10.1097/APO.0000000000000002.
48. Kong YJ, Choi HS, Jang JW, Kim SJ, Jang SY. Surgical outcome of
canalicular trephination combined with endoscopic dacryocystor-
hinostomy in patients with distal or common canalicular
obstruction. Korean J Ophthalmol. 2015;29:368–74. doi:10.3341/
kjo.2015.29.6.368.
49. Shams PN, Pirbhai S, Selva D. A prospective outcomes study of
membranous and solid distal common canalicular obstructions.
Eye. 2016;30:621–26. doi:10.1038/eye.2016.11.
50. Paik JS, Cho W, Yang S. Bicanalicular double silicone stenting in
endoscopic dacryocystorhinostomy with lacrimal trephination in dis-
tal or common canalicular obstruction. Eur Arch Otorhinolaryngol.
2012;269:1605–11. doi:10.1007/s00405-011-1845-y.
10 M. J. ALI AND F. PAULSEN
51. Nemet AY, Wilcsek G, Francis IC. Endoscopic dacryocystorhi-
nostomy with adjunctive mitomycin C for canalicular obstruction.
Orbit. 2007;26:97–100. doi:10.1080/01676830601174627.
52. Baek BJ, Hwang GR, Jung DH, Kim IS, Sin JM, Lee HM. Surgical
results of endoscopic dacryocystorhinostomy and lacrimal trephi-
nation in distal or common canalicular obstruction. Clin
Experiment Otorhinolaryngol. 2012;5:101–06. doi:10.3342/
ceo.2012.5.2.101.
53. Haefliger IO, Piffaretti JM. Lacrimal drainage system endoscopic
examination and surgery through the lacrimal punctum. Klin
Monatsbl Augenheilkd. 2001;218:384–87. doi:10.1055/s-2001-15907.
54. Ali MJ. Canalicular and nasolacrimal duct recanalization. In:
Ali MJ, editor. Principles and Practice of Lacrimal Surgery. 2nd
ed. Singapore: Springer; 2018. p. 349–53.
55. Sisler HA, Allarakhia L. New minitrephine makes lacrimal cana-
licular rehabilitation an office procedure. Ophthal Plast Reconstr
Surg. 1990;6:203–06.
56. Hwang SW, Khwarg SI, Kim JH, Choung HK, Kim NJ.
Bicanalicular double silicone intubation in external dacryocystor-
hinostomy and canaliculoplasty for distal canalicular obstruction.
Acta Ophthalmol. 2009;87:438–42. doi:10.1111/j.1755-
3768.2008.01292.x.
57. Everman KR, Czyz CN, Kalwerisky K, Hill RH, Foster JA, Cahill KV.
Canalicular obstruction: a histopathological case series. Can
J Ophthalmol. 2012;47:500–03. doi:10.1016/j.jcjo.2012.08.006.
58. Wilhelm KE, Hofer U, Textor HJ, Bóker T, Strunk H, Schild HH.
Non-surgical fluoroscopically guided dacryoplasty of common cana-
licular obstructions. Cardiovasc Intervent Radiol. 2000;23:1–8.
59. Yang SW, Park HY, Kikkawa DO. Ballooning canaliculoplasty
after lacrimal trephination in monocanalicular and common cana-
licular obstruction. Jpn J Ophthalmol. 2008;52:444–49.
doi:10.1007/s10384-008-0598-7.
60. Wearne MJ, Beigi B, Davis G, Rose GE. Retrograde intubation
dacryocystorhinostomy for proximal and mid-canalicular
obstruction. Ophthalmology. 1999;106:2325–28. doi:10.1016/
S0161-6420(99)90535-3.
61. Steinhauer J, Norda A, Emmerich KH, Meyer-Rúsenberg HW.
Laser canaliculoplasty. Ophthalmologe. 2000;97:692–95.
62. Doucet TW, Hurwitz JJ. Canaliculodacryocystorhinostomy in the
management of unsuccessful lacrimal surgery. Arch Ophthalmol.
1982;100:619–21.
63. Athanasiov PA, Madge S, Kakizaki H, Selva D. A review of bypass
tubes for proximal lacrimal drainage obstruction. Surv Ophthalmol.
2011;56:252–66. doi:10.1016/j.survophthal.2011.02.009.
64. Sundar G. Lacrimal trauma and its management. In: Ali MJ,
editor. Principles and Practice of Lacrimal Surgery. 2nd ed.
Singapore: Springer; 2018. p. 379–94.
65. Ko AC, Satterfield KR, Korn BS, Kikkawa DO. Eyelid and peri-
orbital soft-tissue trauma. Facial Plast Surg Clin North Am.
2017;25:605–16. doi:10.1016/j.fsc.2017.06.011.
66. Herzum H, Holle P, Hintschich C. Eyelid injuries: epidemiological
aspects. Ophthalmologe. 2001;98:1079–82.
67. Fayet B, Bernard JA, Ammar J, Karpouzas Y, Hamici S,
Hamache F, Pouliquen Y. Recent wounds of the lacrimal duct.
Apropos of 262 cases treated as emergencies. J Fr Ophtalmol.
1988;11:627–37.
68. Murchinson AP, Bilyk JR. Canalicular laceration repair: an ana-
lysis of variables affecting success. Ophthal Plast Reconstr Surg.
2014;30:410–14. doi:10.1097/IOP.0000000000000133.
69. Naik MN, Kelapure A, Rath S, Honavar SG. Management of
canalicular lacerations: epidemiological aspects and experience
with mini-monoka monocanalicular stents. Am J Ophthamol.
2008;145:375–80. doi:10.1016/j.ajo.2007.09.018.
70. Kennedy RH, May J, Dailey J, Flanagan JC. Canalicular laceration.
A 11-year epidemiologic and clinical study. Ophthal Plast
Reconstr Surg. 1990;6:46–53.
71. Jordan DR, Gilberg S, Mawn LA. The round-tipped, eyed pigtail
probe for canalicular intubation: A review of 228 patients.
Ophthal Plast Reconstr Surg. 2008;24:176–80. doi:10.1097/
IOP.0b013e31816b99df.
72. Kim T, Yeo CH, Chung KJ, Lee JH, Kim YH. Repair of lower
canalicular laceration using the mini-monoka stent. Primary and
revisional repairs. J Crainofac Surg. 2018;29:949–52. doi:10.1097/
SCS.0000000000004423.
73. Singh S, Ganguly A, Hardas A, Tripathy D, Rath S. Canalicular
lacerations: factors predicting outcome at a tertiary eye care
center. Orbit. 2017;36:13–18. doi:10.1080/01676830.2017.1279646.
74. Chowdhury HR, Rose GE, Ezra DG. Long-term outcomes of
mono-canalicular repair of canalicular lacerations. Ophthalmology.
2014;121:1665–66. doi:10.1016/j.ophtha.2014.02.027.
75. Timoney PJ, Stansfield B, Whitehead R, Lee HB, Nunery WR. Eyelid
lacerations secondary to caesarian section delivery. Ophthal Plast
Reconstr Surg. 2012;28:e90–92. doi:10.1097/IOP.0b013e3182364715.
76. Ejstrup R, Wiencke AK, Toft PB. Outcome after repair of con-
current upper and lower canalicular lacerations. Orbit.
2014;33:169–72. doi:10.3109/01676830.2014.881399.
77. Reifler DM. Management of canalicular laceration. Surv
Ophthalmol. 1991;36:113–32.
78. Wu SY, Ma L, Chen RJ, Tsai YJ, Chu YC. Analysis of bicanalicular
nasal intubation in the repair of canalicular lacerations. Jpn
J Ophthalmol. 2010;54:24–31. doi:10.1007/s10384-009-0755-7.
79. Wulc AE, Arterberry JF. The pathogenesis of canalicular
laceration. Ophthalmology. 1991;98:1243–49.
80. Jordan DR, Ziai S, Gilberg SM, Mawn LA. Pathogenesis of cana-
licular lacerations. Ophthal Plast Reconstr Surg. 2008;24:394–98.
doi:10.1097/IOP.0b013e318183267a.
81. Kalin-Hajdu E, Cadet N, Boulos PR. Controversies of the lacrimal
system. Surv Ophthalmol. 2016;61:309–13. doi:10.1016/j.
survophthal.2015.12.003.
82. Jordan DR. Monocanalicular lacerations: to reconstruct or not?
Can J Ophthalmol. 2002;37:245–46.
83. Murgatroyd H, Craig JP, Sloan B. Determination of relative contri-
bution of the superior and inferior canaliculi to the lacrimal drainage
system in health using the drop test. Clin Exp Ophthalmol.
2004;32:404–10. doi:10.1111/j.1442-9071.2004.00846.x.
84. White WL, Glover AT, Buckner AB, Hartshorne MF. Relative
canalicular tear flow as assessed by dacryoscintigraphy.
Ophthalmology. 1989;96:167–69.
85. Chiang E, Bee C, Harris GJ, Wells TS. Does delayed repair of
eyelid lacerations compromise the outcomes? Am J Emerg Med.
2017;35:1766–77. doi:10.1016/j.ajem.2017.04.062.
86. Bai F, Tao H, Zhang Y, Wang P, Han C, Huang YF, Tao Y. Old
canalicular laceration repair: a retrospective study of curative
effects and prognostic factors. Int J Ophthalmol. 2017;10:902–07.
doi:10.18240/ijo.2017.06.11.
87. Liu B, Li Y, Long C, Wang Z, Liang X, Ge J, Wang Z. Novel
air-injection to locate the medial cut end of lacerated canaliculus.
Br J Ophthalmol. 2013;97:1508–09. doi:10.1136/bjophthalmol-
2013-303822.
88. Orge FH, Dar SA. Canalicular laceration repair using
a viscoelastic injection to locate and dilate the proximal torn
edge. J AAPOS. 2015;19:217–19. doi:10.1016/j.jaapos.2015.02.013.
89. Zhuagn A, Jin X, Li Y, Fan X, Shi W. A new method for locating the
proximal lacerated bicanalicular ends in Chinese preschoolers and
long-term outcomes after surgical repair. Medicine (Baltimore).
2017;96(33):e7814. doi:10.1097/MD.0000000000007814.
90. Liang X, Liu Z, Li F, Liu J, Lin L, Li N, Zhong L, Huang D,
Wang Z, Wang Z. A novel modified soft probe for identifying the
distal cut end in single canalicular laceration. Br J Ophthamol.
2013;97:665–66. doi:10.1136/bjophthalmol-2012-302605.
91. Cho SH, Hyun DW, Kang JH, Ha MS. A simple method for
identifying the proximal cut end in lower canalicular laceration.
Kor J Ophthalmol. 2008;22:73–76. doi:10.3341/kjo.2008.22.2.73.
92. Peng W, Wang Y, Tan B, Wang H, Liu X, Liang X. A new method
for identifying the cut ends in canalicular laceration. Sci Rep.
2017;7:43325. doi:10.1038/srep43325.
93. Tavakoli M, Karimi S, Behdad B, Dizani S, Salour H. Traumatic
canalicular laceration repair with a new monocanalicular silicone
tube. Ophthal Plast Reconstr Surg. 2017;33:27–30. doi:10.1097/
IOP.0000000000000620.

94. Goldberg RA. A pre-swedged silicone tube to simply pigtail
canaliculoplasty. Ophthalmic Surg Lasers. 1998;29:770–71.
95. Bi Y, Sui G, Zhou Q, Heindl LM, Bock F, Sun X, Tang S, Wang Z,
Cursiefen C. Two-step retrograde close stenting: a novel method
for treating canalicular lacerations in Chinese patients. Eye.
2013;27:1275–80. doi:10.1038/eye.2013.169.
96. Liang X, Lin Y, Wang Z, Lin L, Zeng S, Liu Z, Li N, Wang Z,
Liu Y. A modified bicanalicular intubation procedure to repair
canalicular lacerations using silicone tubes. Eye. 2012;26:1542–47.
doi:10.1038/eye.2012.212.
97. Naik MN, Gupta R, Honavar SG. Bicanalicular laceration mana-
ged by two mini-monoka monocanalicular stents. Orbit.
2008;27:135–37. doi:10.1080/01676830801924342.
98. Murchinson AP, Bilyk JR. Pediatric canalicular lacerations: epide-
miology and variables affecting repair success. J Pediatr Ophthalmol
Strabismus. 2014;51:242–48. doi:10.3928/01913913-20140604-05.
99. Nam SM. Microscope assisted reconstruction of canalicular
laceration using a mini-monoka. J Craniofac Surg.
2013;24:2056–58. doi:10.1097/SCS.0b013e3182a14b38.
100. Kersten RC, Kulwin DR. “One-stitch” canalicular repair:
A simplified approach for repair of canalicular laceration.
Ophthalmology. 1996;103:785–89.
101. Tao H, Wang P, Han C, Zhang J, Bai F, He ZY. One-stitch
anastomosis through the skin with bicanalicular intubation:
a modified approach for repair of bicanalicular laceration.
Int J Ophthalmol. 2013;6:656–58. doi:10.3980/j.issn.2222-
3959.2013.05.19.
102. Zolli CL. Microsurgical repair of lacrimal canaliculus in medial
canthal trauma. In: Hornblass A, editor. Oculoplastic Orbital and
Reconstructive surgery: eyelids. Baltimore, MD: Williams and
Wilkins; 1988. p. 426–32.
103. Della Rocca DA, Ahmad SM, Della Rocca RC. Direct repair of
canalicular lacerations. Facial Plast Surg. 2007;23:149–55.
doi:10.1055/s-2007-984553.
104. Chu Y, Ma L, Wu S, Tsai Y. Comparing pericanalicular sutures
with direct canalicular wall sutures for canalicular laceration.
Ophthal Plast Reconstr Surg. 2011;27:422–25. doi:10.1097/
IOP.0b013e31822113df.
105. Ho T, Lee V. National survey on the management of lacrimal
canalicular injury in United Kingdom. Clin Exp Ophthalmol.
2006;34:39–43. doi:10.1111/j.1442-9071.2006.01137.x.
106. Conlon MR, Smith KD, Cadera W, Shum D, Allen LH. An animal
model studying reconstruction techniques and histopathological
changes in repair of canalicular lacerations. Can J Ophthalmol.
1994;29:3–8.
107. Ali MJ, Baig F, Lakshman M, Naik MN. Scanning electron micro-
scopic feature of extubated monoka stents. Ophthal Plast Reconstr
Surg. 2017;33:90–92. doi:10.1097/IOP.0000000000000610.
108. Meltzer MA, Zatezalo CC, Zoltan S. Lacrimal canalicular trans-
plantation with composite eyelid graft. Ophthal Plast Reconstr
Surg. 2010;26:23–25. doi:10.1097/IOP.0b013e3181b8ee93.
109. Perry JD, Lewis CD. Lacrimal canalicular transposition with com-
posite eyelid graft. Ophthal Plast Reconstr Surg. 2011;27:306–07.
doi:10.1097/IOP.0b013e3181f9e05d.
110. Paulsen FP, Thale AB, Maune S, Tillmann BN. New insights into
the etiopathogenesis of primary acquired dacryostenosis.
Ophthalmology. 2001;108:2329–36.
111. Ali MJ, Schicht M, Paulsen F. Qualitative hormonal profiling of
the lacrimal drainage system: potential insights into the etiopatho-
genesis of primary acquired nasolacrimal duct obstruction.
Ophthal Plast Reconstr Surg. 2017;33:381–88. doi:10.1097/
IOP.0000000000000962.
112. Ali MJ, Glóckner M, Schicht M, Bráuer L, Paulsen F. Detection of
intrinsic cholinergic system in the human lacrimal drainage sys-
tem: evidence and potential implications. Graefes Arch Clin Exp
Ophthalmol. 2018;256:2097–102. doi:10.1007/s00417-018-4124-4.
113. Ali MJ, Venugopal A, Ranganath KS, Jagannadham MV,
Nadimpalli SK. Soluble glycoproteins of the lacrimal sac: role in
defense with special reference to prolactin-inducible protein
(PIP). Orbit. 2018;(Epub). doi:10.1080/01676830.2018.1514640.
CURRENT EYE RESEARCH 11
114. Ali MJ, Venugopal A, Ranganath KS, Kumar NS. Lysosomal
enzymes and mannose-6-phosphate receptors in the lacrimal drai-
nage system: evidence and its potential implications. Indian
J Ophthalmol. 2018;66:1595–99. doi:10.4103/ijo.IJO_286_18.
115. Emmerich KH, Meyer-Rϋsenberg HW, Simko P. Endoscopy of
the lacrimal drainage system. Ophthalmologe. 1997;94:732–35.
116. Mϋllner K, Bodner E, Mannor GE. Endoscopy of the lacrimal
system. Br J Ophthalmol. 1999;83:949–52.
117. Sasaki T, Nagata Y, Sugiyama K. Nasolacrimal duct obstruction
classified by dacryoendoscopy and treated with inferior meatal
dacryorhinotomy. Part I: positional diagnosis of primary nasola-
crimal duct obstruction by dacryoendoscopy. Am J Ophthalmol.
2005;140:1065–69. doi:10.1016/j.ajo.2005.07.038.
118. Athanasiov PA, Prabhakaran VC, Mannor G, Woog JJ, Selva D.
Transcanalicular approach to adult lacrimal duct obstruction:
A review of instruments and methods. Ophthalmic Surg Laser
Imaging. 2009;40:149–59. doi:10.3928/15428877-20090301-04.
119. Emmerich KH, Ungerechts R, Meyer-Rϋsenberg HW. Possibilities
and limits of minimal invasive lacrimal surgery. Orbit. 2000;19:67–71.
120. Emmerich KH, Steinhauer J, Meyer-Rϋsenberg HW,
Luchtenberg M. Dacryoendoscopy- current status. Ophthalmologe.
1998;95:820–22.
121. Meyer-Rϋsenberg HW, Emmerich KH, Luchtenberg M,
Steinhauer J. Endoscopic laser dacryoplasty. Methodology and
outcome after 3 months. Ophthalmologe. 1999;96:332–34.
122. Emmerich KH, Meyer-Rϋsenberg HW. Modern lacrimal duct
surgery from the ophthalmological perspective. Dtsch Arztebl
Int. 2010;107:254–58. doi:10.3238/arztebl.2010.0254.
123. Sasaki T, Nagata Y, Sugiyama K. Nasolacrimal duct obstruction
classified by dacryoendoscopy and treated with inferior meatal
dacryorhinotomy. Part II: inferior meatal dacryorhinotomy. Am
J Ophthalmol. 2005;140:1070–74. doi:10.1016/j.ajo.2005.07.039.
124. Wang Z, Huang Y, Chen W, Chen W, Zhang M, Chen F.
Diagnosis and treatment of lacrimal passage obstruction by lacri-
mal endoscope. J Huazhong Univ Sci Technolog Med Sci.
2007;27:593–97. doi:10.1007/s11596-007-0530-2.
125. Javate RM, Pamintuan FG, Cruz RT. Efficacy of endoscopic lacrimal
duct recanalization using microendoscope. Ophthal Plast Reconstr
Surg. 2010;26:330–33. doi:10.1097/IOP.0b013e3181c7577a.
126. Silkiss RZ. THC:YAG nasolacrimal duct recanalization.
Ophthalmic Surg. 1993;24:772–74.
127. Chen D, Ge J, Wang L, Gao Q, Ma P, Li N, Li DQ, Wang Z.
A simple and evolutional approach proven to recanalize the
nasolacrimal duct obstruction. Br J Ophthalmol.
2009;93:1438–43. doi:10.1136/bjo.2008.149393.
128. Hong J, Qian T, Wei A, Sun Z, Wu D, Chen Y, Marmalidou A,
Lu Y, Sun X, Liu Z, et al. Nasolacrimal recanalization as an
alternative to external dacryocystorhinostomy for treating failed
nasolacrimal duct intubation. Medicine (Baltimore). 2016;95(30):
e4350. doi:10.1097/MD.0000000000004864.
129. Agrawal S, Gupta SK, Singh V, Agrawal S. A novel technique to
recanalize the nasolacrimal duct with endodiathermy bipolar probe.
Indian J Ophthalmol. 2013;61:718–21. doi:10.4103/0301-4738.121180.
130. Garcia EA, Machado MA, Silva JA, Nose W. Recanalization of
nasolacrimal duct with radio frequency: preliminary study. Arq
Bras Oftalmol. 2012;75:412–14.
131. Tanaka Y, Hamamoto Y, Kogure T, Tamai M, Inoue S.
Microsurgical reconstruction of nasolacrimal duct obstruction
using an eversion technique. Plast Reconstr Surg. 2012;130:905e–
906e. doi:10.1097/PRS.0b013e31826da0ae.
132. Ali MJ, Naik MN. Efficacy of endoscopic guided anterograde 3mm
balloon dacryoplasty with silicone intubation in the treatment of
acquired partial nasolacrimal duct obstruction in adults. Saudi
J Ophthalmol. 2014;28:40–43. doi:10.1016/j.sjopt.2013.12.004.
133. Kashkouli MB, Beigi B, Tarassoly K, Kempster RC. Endoscopically
assisted balloon dacryoplasty and silicone intubation versus silicone
intubation alone in adults. Eur J Ophthalmol. 2006;16:514–19.
134. Bleyen I, van Den Bosch WA, Bockholts D, Mulder P,
Paridaens D. Silicone intubation with or without balloon
12 M. J. ALI AND F. PAULSEN

dacryoplasty in acquired partial nasolacrimal duct obstruction.
Am J Ophthalmol. 2007;144:776–80. doi:10.1016/j.
ajo.2007.07.030.
135. Schrader S, Liu L, Kasper K, Geerling G. Generation of two- and
three-dimensional lacrimal gland constructs. Dev Ophthalmol.
2010;45:49–56. doi:10.1159/000315019.
136. Dietrich J, Massie I, Roth M, Geerling G, Mertsch S, Schrader S.
Development of causative treatment strategies for lacrimal gland
insufficiency by tissue engineering and cell therapy. Part 1: regen-
eration of lacrimal gland tissue: can we stimulate lacrimal gland
renewal in vivo? Curr Eye Res. 2016;41:1131–42. doi:10.3109/
02713683.2016.1148741.
137. Massie I, Spaniol K, Barbian A, Geerling G, Metzger M,
Schrader S. Development of lacrimal gland spheroids for lacrimal
gland tissue regeneration. J Tissue Eng Regen Med. 2018;12:
e2001–e2009. doi:10.1002/term.2631.