Most traumatic injuries to the canaliculi occur in 1 of2 ways: by direct laceration,

such as a stab wound or dog bite; or by trac tion, which occurs when sudden lateral
displacement of the eyelid tears the medial canthal tendon and associated
canaliculus. Being without
tarsal support, the canaliculus lies within the weakest part of the eyelid and is often
the first structure to yield. Whenever blunt trauma, such as from a fi st or an air
bag, results in a full-thickness eyelid laceration, the cl inician should slispect and
evaluate for an associated
medial injury. The avulsion injury often appears tr ivial on superficial inspection .
with its full extent revealed only on detailed examination of the area. When
possible, diagnostic canalicular pro bing and irrigation may be helpful. Because
some patients who have only I functioning canaliculus may be asymptomatic. some
clinicians consider the repair of an isolated single canalicular laceration to be
optional. However, it is estimated that among patients with only 1 functioning
canaliculus, [0% suffer from constant or nearly constant epiphora and 40% have
symptomatic
epiphora with ocular irritation, leaving only 50% fairly asymptomatic. Moreover, the
success rate of a primary repair is much higher than that of a secondary
reconstruction . Therefore, given the common occurrence of epiphora and the
difficulties associated with delayed reconstruction, most surgeons recommend
repair of all canalicular lacerations. Repair of injured canaliculi should be performed
as soon as possible, preferably within 48 hours of injury. The first step of the repair
is locating the severed ends of the canalicular
system. This can often be frustrat ing, but the controlled conditions of an operating
room, including the use of gene ral anesthesia and magnifi cation with optimal
illumination, facilitate the search. A thorough understanding of the medial canthal
anatomy gu ides the surgeon to the appropriate area to begin exploration for the
medial end of the severed canaliculus. Laterally, the canaliculus is located near the
eyelid margin , but for lacerations close to the lacrimal sac, the canaliculus is deep
to the anterior limb of the medial canthal
tendon. Irrigation using air, fluo rescein , or yellow viscoelastic through an intact
adjacent canaliculus may be helpfu l. Methylene blue should be avoided, as it tends
to stain the entire operative fi eld. In difficult cases, the careful use of a smooth
-tipped pigtail probe
may be helpful for identi fica tion of the medial cut end. The probe is introduced
through the opposite, uninvolved punctum, passed through the common
canaliculus, and finally passed through the medial cut end. Stenting of the injured
canaliculus is usually performed to help prevent postoperative canalicular st
rictures. By putting th e stent on traction, the surgeon draws together the severed
canalicular ends and other soft-tissue structu res, replaci ng them in the ir normal

anatomical positio ns. Direct anas tomosis of th e cut canaliculus over the silicone
tube can be accomplished with closure of the pericanalicular ti ssues. Direct
suturing of the canalicular ends is probably not necessary. Lacrimal intubation also
facilitates the soft-tissue reconstruction of the medial canthal tendon and eyelid
margin. Traditionally, bicanalicular stents have been used, but monocanalicular
stents are gaining popular ity (see Fig 13-4). One type of monocanalicular stent is
attached distally to a metal guiding probe. This probe is retrieved intranasally. Thus,
the monocanalicular stent can be used in soft-tissue approximation similar to the
way a bicanalicular system is used. Another monocanalicular stent is inse rted into
the punctum and directly into the lacerated canaliculus to bridge the laceration.
Other advantages of monocanalicular stents are the greatly reduced risk of punctal
injury, or cheese-wiring, and their easier retrieval. Stents are usually left in place for
3 months or longer. However, cheese-wiring, ocular irritation, infection. local
inflammation, or pyogenic granuloma form ation may necessitate early removal. Bi
canalicular stents are usually cut at the medial canthus and retrieved from the nose.
Monocanalicu lar stents are simply pulled through the punctum.