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      A new surgical approach for punctal occlusion using fibrous tissue from under the lacrimal caruncle

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          Abstract

          Purpose

          Surgical punctal occlusion is indispensable for the treatment of severe dry eye in cases where punctal-plug insertion is not applicable due to an enlarged or deformed punctum. However, permanent punctal occlusion is difficult in some cases. In our aim to establish a more reliable punctal occlusion, we have devised a new surgical approach for punctal occlusion.

          Patients and methods

          This study involved 20 puncta of 12 eyes of 12 patients (1 male and 11 females; mean age: 65.2 years) with severe aqueous-tear-deficient dry eye. A new surgical procedure for punctal occlusion using fibrous tissue from under the lacrimal caruncle into the diathermy-induced deepithelialized canaliculus as supporting tissue for punctal closure was performed. In all patients, the assessment of eye symptoms, as well as the condition of punctal occlusion by slit-lamp biomicroscopy, tear volume (tear-meniscus radius [TMR] measurement by meniscometry), the condition of precorneal tear film (graded by interferometry [IG]), measurement of fluorescein breakup time (FBUT), and scoring of ocular surface staining (fluorescein score of area [FSA] and density [FSD], and lissamine green score [LGS]) were performed, and the preoperative and 6-month-postoperative values were compared.

          Results

          In regard to the postoperative improvement of symptoms, 11 patients showed remarkable improvement, 1 patient showed improvement, and no reopening of the closed punctum was found in any patient. Test values were all significantly improved post surgery (all: P<0.05) as compared to those prior to surgery (respective values [mean ± SD], and the pre- and postoperative P-values were: TMR (mm) [0.18±0.08; 0.56±0.28, P=0.002], IG [4.3±0.9; 2.7±0.8, P=0.009], FBUT [0.4±0.6; 4.1±2.9, P=0.004], FSA [1.6±0.7; 0.7±0.9, P=0.03], FSD [2.7±0.7; 0.6±0.7, P=0.003], and LGS [5.1±2.7; 1.1±2.1, P=0.005]). Moreover, no postoperative complications were observed.

          Conclusion

          The findings of this study showed that our novel surgical procedure for punctal occlusion is highly successful and that it results in improved and more complete punctal occlusion.

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          Most cited references29

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          Methodologies to diagnose and monitor dry eye disease: report of the Diagnostic Methodology Subcommittee of the International Dry Eye WorkShop (2007).

          (2007)
          The role of the Diagnostic Methodology Subcommittee of the Dry Eye Workshop was 1) to identify tests used to screen, diagnose and monitor dry eye disease, 2) to establish criteria for test performance, and 3) to consider the utility of tests in a variety of clinical settings. The committee created a database of tests used to diagnose and monitor dry eye, each compiled by an expert in the field (rapporteur) and presented within a standard template. Development of the templates involved an iterative process between the Chairman of the subcommittee, the rapporteurs, and, at times, an additional group of expert reviewers. This process is ongoing. Each rapporteur was instructed on how to the complete a template, using a proforma template and an example of a completed template. Rapporteurs used the literature and other available sources as the basis for constructing their assigned template. The chairman of the subcommittee modifed the template to produce a standardized version and reviewed it with the rapporteur. The completed database will be searchable by an alphabetical list of test names, as well as by functional groupings, for instance, tests of aqueous dynamics, lipid functions, etc. The templates can be accessed on the website of the Tear Film and Ocular Surface Society (www.tearfilm.org). This report provides a general overview of the criteria applied in the development of tests for screening and diagnosis.
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            Correlation of tear lipid layer interference patterns with the diagnosis and severity of dry eye.

            To observe and classify tear film lipid layer interference patterns in normal volunteers and dry eye patients and to investigate the relation between the lipid layer interference patterns in the dry eyes and the results of other dry eye examinations. Precorneal tear lipid layer interference patterns were observed at the central cornea in 25 eyes of 13 normal controls and 85 eyes of 48 dry eye patients. Observed patterns were classified in masked fashion by five physicians into five grades: grade 1, somewhat gray color, uniform distribution; grade 2, somewhat gray color, nonuniform distribution; grade 3, a few colors, nonuniform distribution; grade 4, many colors, nonuniform distribution; and grade 5, corneal surface partially exposed. Other methods of dry eye examination were also performed, including the cotton thread test, the Schirmer I test and modified Schirmer I test, measurement of tear film breakup time, scoring of corneal fluorescein staining density (grades 0 to 3) and area (grades 0 to 3), and rose bengal staining (grades 0 to 9). In 92 (84%) of 110 eyes, four or more of the five physicians agreed in their grade classifications. Among the 92 eyes, normal control eyes were classified into grades 1 and 2 (10 and 12 eyes, respectively) and dry eyes were classified into grades 2, 3, 4, and 5 (22, 26, 10, and 12 eyes, respectively). There was a significant correlation between the grading and the results of other dry eye examination modalities, including fluorescein staining, rose bengal staining, and tear film breakup time. Tear lipid layer interference patterns are highly correlated with dry eye severity.
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              A novel grading method for superficial punctate keratopathy magnitude and its correlation with corneal epithelial permeability.

              To propose a novel grading method for superficial punctate keratopathy (SPK) magnitude and to examine the quantitativeness of the method. In 351 eyes diagnosed as having dry eye syndrome, SPK was graded as follows. After fluorescein staining, the total sum of the area of SPK was graded from A0 through A3, and the density was graded from D0 through D3. The grading was represented as the combination of the area and density grades. The correlation between the SPK grade and the corneal epithelial permeability to fluorescence, measured using an anterior fluorophotometer, was analyzed in the 351 eyes. The correlation between the fluorescein concentration in the cornea and the sum of the area and density grades. The higher the density and area grades, the higher the fluorescein concentration, except for A3D2. There was a clear exponential correlation between the sum of the area and density grades and the fluorescein concentration in the cornea, measured using an anterior fluorophotometer. The regression curve was y = 61.2e(0.59x), where y is the fluorescein concentration (nanograms per milliliter), and x is the sum of the area and density grades (P<.001). The SPK grade is positively correlated with the corneal epithelial permeability to fluorescence, measured using an anterior fluorophotometer. Our results indicate that this grading method can be clinically useful.
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                Author and article information

                Journal
                Clin Ophthalmol
                Clin Ophthalmol
                Clinical Ophthalmology
                Clinical Ophthalmology (Auckland, N.Z.)
                Dove Medical Press
                1177-5467
                1177-5483
                2018
                06 March 2018
                : 12
                : 463-472
                Affiliations
                [1 ]Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
                [2 ]Department of Frontier Medical Science and Technology for Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
                Author notes
                Correspondence: Norihiko Yokoi, Department of Ophthalmology, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Hirokoji-agaru, Kawaramachi-dori, Kamigyo-ku, Kyoto 6020841, Japan, Tel +81 75 251 5578, Fax +81 75 251 5663, Email nyokoi@ 123456koto.kpu-m.ac.jp
                Article
                opth-12-463
                10.2147/OPTH.S155209
                5846759
                ab0b1742-eeaf-4ebf-946f-d5378086c49c
                © 2018 Yokoi et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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