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Thalmon Campagnoli, Yandong Bian, Stacy Scofield-Kaplan, Larissa Ghadiali, Christine Zemsky, Bryan J Winn; Presumed preservative-related punctal congestion. Invest. Ophthalmol. Vis. Sci. 2017;58(8):3849.
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© ARVO (1962-2015); The Authors (2016-present)
Preserved topical ophthalmic medications have been associated with ocular surface changes, ocular discomfort, tear film instability, conjunctival inflammation, subconjunctival fibrosis, and corneal surface impairment. We report a syndrome of presumed preservative toxicity from steroid or steroid/antibiotic combination drops causing punctal congestion and chronic epiphora. We performed a retrospective, observational clinical study to learn about the prevalence, risk factors, management and outcomes of this entity.
A systematic chart review of patients diagnosed with epiphora and punctal stenosis by a single surgeon (BJW) between 1/1/2014 and 9/30/2016 was performed. Patient demographics, clinical history, duration of symptoms, laterally, examination findings, treatment regimen, and time to resolution of symptoms were recorded. Exclusion criteria included canalicular or nasolacrimal duct obstruction and lack of follow up.
90 patients with epiphora and punctal stenosis were identified. Of those, 13 (14%) were identified with the syndrome of presumed preservative-related punctal congestion. All had associated chronic conjunctivitis and a history of preserved drop use. The average age was 63 (STD = 15 years) and 69% were female. Findings were bilateral in 69%. Initial events that preceded the patient being treated with preserved drops included acute conjunctivitis, blepharitis, dry eye syndrome, glaucoma, uveitis and prior intraocular or periocular surgery. Patients experienced epiphora for an average of 3.8 months (range, 1-8 months) prior to presentation. All were taken off all preserved drops and ointments. 69% were also treated with a non-preserved loteprednol etabonate 0.5% ophthalmic ointment taper. All improved. Partial relief of symptoms was achieved on average by 1.6 months and near complete/complete resolution by 2.6 months. The resolution of chronic conjunctival inflammation lagged behind resolution of epiphora. Average length of follow up was 3.2 months, range, 1-7.5 months.
Presumed preservative-related punctal congestion is a common, and previously unreported, cause of reversible punctal stenosis with epiphora. Treatment consists of removal of all preservative exposure. Topical non-preserved steroid preparations may help alleviate symptoms by decreasing conjunctival inflammation and punctal congestion during this period of preservative toxicity wash-out.
This is an abstract that was submitted for the 2017 ARVO Annual Meeting, held in Baltimore, MD, May 7-11, 2017.
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