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   Table of Contents      
ORIGINAL ARTICLE
Year : 2018  |  Volume : 66  |  Issue : 2  |  Page : 269-271

Assessing the outcomes of mini-Monoka stent dilatation for primary punctal stenosis using the lacrimal symptom questionnaire


1 Govindram Seksaria Institute of Dacryology, L. V. Prasad Eye Institute, Hyderabad, Telangana, India
2 Center for Clinical Epidemiology and Biostatistics, L. V. Prasad Eye Institute, Hyderabad, Telangana, India

Date of Submission29-Aug-2017
Date of Acceptance16-Nov-2017
Date of Web Publication30-Jan-2018

Correspondence Address:
Dr. Mohammad Javed Ali
Govindram Seksaria Institute of Dacryology, L. V. Prasad Eye Institute, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_799_17

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  Abstract 


Purpose: The objective of this study was to assess the quality of outcomes of mini-Monoka stent dilatation for punctal stenosis using the lacrimal symptom (Lac-Q) questionnaire. Methods: Prospective interventional case series of 45 eyes of 25 consecutive patients who underwent mini-Monoka stent dilatation for primary punctal stenosis were included in the study. The stents were extubated at 4 weeks. The Lac-Q questionnaire was administered preoperatively and at 12 weeks and 24 weeks following the intervention. Outcomes assessed were anatomical success, functional success, and changes in the questionnaire scores including total, social impact, and lacrimal symptom scores. Statistical analysis was performed using the Wilcoxon signed-rank test, and the probability of obtaining a certain score was calculated using the multinomial log-linear model. P < 0.05 was considered as significant. Results: Monoka stents were performed for 45 eyes. A total of 75 questionnaire responses were analyzed. At the last follow-up of 24 weeks, the anatomical and functional success rates were 93.3% (42/45). The changes in the mean total score (7.68 preoperatively to 0.82 at 24-week follow-up) were statistically significant (P ≤ 0.001). The mean social impact scores showed significant improvement postoperatively from 4.06 to 0.53 (P ≤ 0.001). The mean lacrimal symptom score changed from a preoperative value of 3.62 to 0.28 (P ≤ 0.001) at the last follow-up. Postoperative scoring correlated well with the anatomical and functional success rates. The symptom scores corroborated with changes in the clinical outcomes. Conclusion: Mini-Monoka stent dilatation is a very effective intervention for the management of primary punctal stenosis, and Lac-Q questionnaire is a simple and useful tool to evaluate the quality of outcomes in such cases.

Keywords: Lac-Q, lacrimal, Monoka stents, punctal stenosis, quality of life, questionnaire


How to cite this article:
Gupta S, Ali MJ, Ali MH, Naik MN. Assessing the outcomes of mini-Monoka stent dilatation for primary punctal stenosis using the lacrimal symptom questionnaire. Indian J Ophthalmol 2018;66:269-71

How to cite this URL:
Gupta S, Ali MJ, Ali MH, Naik MN. Assessing the outcomes of mini-Monoka stent dilatation for primary punctal stenosis using the lacrimal symptom questionnaire. Indian J Ophthalmol [serial online] 2018 [cited 2019 Dec 6];66:269-71. Available from: http://www.ijo.in/text.asp?2018/66/2/269/224116



Punctal stenosis is a common lacrimal drainage disorder and accounted for 8% of patients presenting with epiphora in a tertiary care setting.[1] The etiopathogenesis is believed to be a sequence of inflammation, fibrosis, and stenosis.[2] Common modalities of management include various types of punctoplasty, Kelly's punctal punching, and nonincisional procedures such as punctal dilatation with bicanalicular or mini-Monoka stents.[3],[4],[5] Punctoplasty procedures have several disadvantages including inducing more fibrosis, restenosis and violating the anatomical boundaries of the punctum which may partly explain the higher incidence of postprocedure functional epiphora.[3] The use of Monoka stents is minimally invasive and is believed to mitigate the disadvantages of punctoplasty. While assessment of outcome measures has predominantly been based on anatomical and functional success, it is equally important to assess the associated social and psychological impact along with the change in lacrimal symptoms.[6] The lacrimal symptom (Lac-Q) questionnaire is a simple tool devised specifically for lacrimal drainage disorders and has been found useful in assessing the quality of outcomes following interventions.[6],[7],[8] The current study specifically assesses the outcomes by studying the changes in the lacrimal and social impact scores, pre- and post mini- Monoka stents, in cases of punctal stenosis using the Lac-Q questionnaire.


  Methods Top


Institutional review board approval was obtained before conduct of the study. Prospective interventional case series was performed on 45 eyes of 25 patients diagnosed as primary punctal stenosis and who underwent simple mini-Monoka stent dilatation without any snips or incisions on the punctal wall. Punctal stenosis of grades 1 and 2 and presumed grade 0 but not so following exploration were included in the study [9] and patients with associated canalicular or nasolacrimal duct obstructions were excluded from the study. The Monoka stents were trimmed to avoid intubation of the distal drainage pathways and were inserted following a dilatation with rapid taper punctal dilator. All the stents were uniformly removed at 4 weeks. The Lac-Q questionnaire [8] was administered preoperatively, at 12 weeks and 24 weeks following the intervention, for all the patients. The Lac-Q questionnaire has two themes; social impact theme with five questions and lacrimal symptoms theme with four categories, each related to the most common symptoms of watery eye, pain, sticky eye, and swelling.[8] Since pain, sticky eyes, and swelling were not seen in any of the patients in the current study nor are they commonly expected in cases with primary punctal stenosis, the maximum lacrimal symptom score possible was 4 for each eye. The total score is the sum of social (max score = 5) and lacrimal symptoms (max score = 4, for each eye). Outcomes assessed were changes in the social impact and lacrimal symptoms scores over a period of 6 months. Anatomical success was defined as patent punctum and functional success was defined as resolution of epiphora. The statistical analysis was performed using the R 3.1.2. software (R Foundation for Statistical Computing, Vienna, Austria). A multinomial log-linear model was used to get the probability of getting a score at different time points, and this probability value was used to plot a dot chart. A Wilcoxon signed-rank test was used to compare score at presentation and after 6 months. P < 0.05 was considered significant.


  Results Top


Twenty-five consecutive patients were included in the study of which twenty had bilateral and five had unilateral punctal stenosis. There were 13 males and 12 females, and the mean age of patients was 44.8 years (range: 23–76 years). Mini-Monoka stents were performed for all the 45 eyes. A number of eyes with grade 1, 2 and presumed grade 0 were 23, 21, and 1, respectively. A total of 75 questionnaire responses were analyzed. The mean total score preoperatively was 7.68 and improved to 1.77 at 12-week follow-up and 0.82 at 24-week follow-up (P ≤ 0.001). The mean lacrimal symptom score preoperatively was 3.62 and improved to 1.02 at 12-week follow-up and 0.28 at 24-week follow-up (P ≤ 0.001). The mean social impact score preoperatively was 4.06 and improved to 0.75 at 12 weeks and 0.53 at 24 weeks (P ≤ 0.001). These changes were significant and correlated with changes in the clinical outcomes. [Figure 1],[Figure 2],[Figure 3] show individual patient scores (total, lacrimal, and social impact) and changes over 12- and 24-week follow-ups. The tables also show probability plots, which reflect the probabilities of a patient's status over defined follow-up times, with a certain preoperative score. At the last follow-up of 24 weeks, the anatomical and functional success rates were 93.3% (42/45). Three eyes with unsuccessful outcomes had issues with one punctum each (1 punctum was effaced and 2 subsequently showed proximal canalicular obstruction). The proximal obstruction cases could potentially be either due to an intraoperative trauma or continuous aggressive cicatricial progress of the disease into the canaliculus.
Figure 1: Individual patient data demonstrating total scores at each visit. The plot on the left is the probability plot. The worst possible score is 9. Note that the probability of patients presenting with a score 9 is 0.6 or 60% and note its change over 3- and 6-month follow-up. Similarly, the probability of patients having a score of 1 or 0 increases with the two follow-ups

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Figure 2: Individual patient data demonstrating lacrimal symptom scores at each visit. The plot on the left is the probability plot

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Figure 3: Individual patient data demonstrating social impact scores at each visit. The plot on the left is the probability plot

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  Discussion Top


The current study performed detailed outcome evaluation based on the Lac-Q questionnaire and found it to be simple and useful tool for assessing the severity of lacrimal symptoms in punctal stenosis and their social impact and changes in these parameters following a minimally invasive intervention in the form of mini-Monoka stent dilatation. The Lac-Q score reflected changes in the clinical outcomes. These patient-reported outcomes have the potential to better assess the interventions from the patient's perspectives and pave ways for better management.

Ali et al.[3] studied 145 puncta which underwent a less invasive rectangular punctoplasty and showed complete resolution of symptoms in only 74.7% of the patients. The high incidence of functional epiphora (10.4%) led them to re-emphasize the need for minimally invasive alternatives for punctal stenosis as elucidated in earlier studies.[4],[5] It is likely that incising the punctal walls or interfering with its anatomy may influence the pump mechanisms and generation of appropriate pressures to facilitate optimal tear drainage.[9] The current study shows a high success with the mini-Monoka stent dilatation, and the outcomes were better with this minimally invasive technique when compared to the earlier work [3] on punctoplasty by the authors themselves.

Mistry et al.[7] developed the Lac-Q questionnaire based on social impact and lacrimal symptoms and demonstrated its validity and simplicity in assessing patient-reported outcomes following a lacrimal surgical intervention. The questionnaire was found to be responsive to changes in the clinical outcomes. Ali et al.[8] assessed the outcomes of powered endoscopic dacryocystorhinostomy using the Lac-Q scoring system. They found it to be simple and easy to use tool in the clinics and their study supported many advantages of Lac-Q reported earlier by Mistry et al.[7]


  Conclusion Top


Lac-Q questionnaire is specifically based on lacrimal symptoms and is a useful quality tool in assessing the outcomes of mini-Monoka stent dilatation in cases of primary punctal stenosis. Further studies are required that are focused on designing of individual disease-specific questionnaire to enhance the value of outcome assessments.

Financial support and sponsorship

Dr. Ali's research is funded by the Alexander Von Humboldt Foundation of the Federal Republic of Germany.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mainville N, Jordan DR. Etiology of tearing: A retrospective analysis of referrals to a tertiary care oculoplastics practice. Ophthal Plast Reconstr Surg 2011;27:155-7.  Back to cited text no. 1
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2.
Ali MJ, Mishra DK, Baig F, Lakshman M, Naik MN. Punctal stenosis: Histopathology, immunology, and electron microscopic features-a step toward unraveling the mysterious etiopathogenesis. Ophthal Plast Reconstr Surg 2015;31:98-102.  Back to cited text no. 2
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3.
Ali MJ, Ayyar A, Naik MN. Outcomes of rectangular 3-snip punctoplasty in acquired punctal stenosis: Is there a need to be minimally invasive? Eye (Lond) 2015;29:515-8.  Back to cited text no. 3
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4.
Mathew RG, Olver JM. Mini-monoka made easy: A simple technique for mini-monoka insertion in acquired punctal stenosis. Ophthal Plast Reconstr Surg 2011;27:293-4.  Back to cited text no. 4
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Hussain RN, Kanani H, McMullan T. Use of mini-monoka stents for punctal/canalicular stenosis. Br J Ophthalmol 2012;96:671-3.  Back to cited text no. 5
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6.
Ali MJ, editor. Quality of life in lacrimal disorders and patient satisfaction following management. In: Principles and Practice of Lacrimal Surgery. New Delhi: Springer; 2015. p. 359-62.  Back to cited text no. 6
    
7.
Mistry N, Rockley TJ, Reynolds T, Hopkins C. Development and validation of a symptom questionnaire for recording outcomes in adult lacrimal surgery. Rhinol 2011;49:538-45.  Back to cited text no. 7
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8.
Ali MJ, Iram S, Ali MH, Naik MN. Assessing the outcomes of powered endoscopic dacryocystorhinostomy in adults using the lacrimal symptom (Lac-Q) questionnaire. Ophthal Plast Reconstr Surg 2017;33:65-8.  Back to cited text no. 8
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Kashkouli MB, Beigi B, Murthy R, Astbury N. Acquired external punctal stenosis: Etiology and associated findings. Am J Ophthalmol 2003;136:1079-84.  Back to cited text no. 9
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