We report two cases of lacrimal obstruction after ocular infection with monkeypox virus (MPX) in the 2022 outbreak. One of them was a distal canalicular obstruction and the other was a proximal canalicular obstruction. In the first days of MPX they presented with conjunctivitis and periocular skin vesicles. Several months after the ophthalmic condition was cured, they showed persistence of epiphora, and the lacrimal problem was diagnosed. The photographs taken during the inflammation of the anterior pole were reviewed and vesicles located in the same area as the canalicular damage were observed. One patient underwent a canaliculodacryorhinostomy and the other an exploratory punctoplasty. Both surgical operations failed to restore normal tear flow. Lacrimal drainage disorders related to ocular MPX have not yet been described. And, in addition, these cases are the first relation of viral vesicular skin lesions and canalicular obstructions.

Several chemotherapeutic agents are known to induce lacrimal drainage stenosis and obstruction, resulting in epiphora. Pemetrexed is one such drug and is used in the management of mesotheliomas and non-small cell lung carcinomas. Pemetrexed inhibits folate metabolism at multiple levels. The present case is the second report of pemetrexed induced punctal and canalicular stenosis, but the first to document dacryoendoscopy findings and report balloon puncto-canaliculoplasty as a minimally-invasive treatment option.

OBJECTIVE: The Kaneka Lacriflow CL (Lacriflow) bicanalicular lacrimal intubation system was evaluated as a self-retaining alternative to traditional modalities for stenting and dilation of the lacrimal drainage system in proximal lacrimal drainage system stenosis.
METHODS: A retrospective chart review was conducted to assess the use of the Lacriflow system for treatment of patients with punctal and canalicular stenosis. Anesthesia type, operative time, and complications were assessed.
RESULTS: In the time period evaluated, a total of 72 Lacriflow stents were placed in 45 patients, most commonly under intravenous sedation. Stents were left in place for a mean of 145 days, with 9 stents left in place for more than 1 year, and a mean follow-up time of 263 days. Early complications within 90 days included prolapse in 1 stent, symptomatic colonization for 2 stents, and corneal abrasion in 1 stent in a patient with anterior basement membrane dystrophy. Five additional stents developed colonization in the late postoperative period (four of which were more than 1 year after stent placement). The overall complication rate (per stent) at 3 months after surgery was 5.6% and at all follow-up time points was 13.9%. Operative times were significantly shorter for a cohort of patients undergoing bicanalicular intubation with the Ritleng system (P = 0.015).
CONCLUSIONS: The Lacriflow bicanalicular stent can be easily placed without general anesthesia. Complication rates are comparable to other bicanalicular intubation systems, but increase with longer time that stents are left in place.

OBJECTIVE: To investigate long-term outcome and report reoperation rate of non-infected, complete acquired lacrimal drainage obstruction (ALDO) treated with canaliculodacryocystoplasty (CDCP) depending on site of stenosis.
METHODS: Consecutive adult patients with non-infected, complete ALDO treated with CDCP were followed for 76 months. Location of stenosis at preoperative visit and intraoperative probing was recorded, and during follow-up, recurrence of stenosis prompting additional surgery and complications were noted. Survival analysis was applied to compare reoperation rate depending on site of stenosis. A follow-up questionnaire was sent to patients not requiring reoperation asking to grade current epiphora problems.
RESULTS: Among 85 included cases (71 patients), 57 were classified as canalicular stenosis and 28 as nasolacrimal duct obstruction (NLDO) preoperatively. At the end of follow-up, 39% (33/85) of cases had required additional surgery due to persistent/recurrent symptoms. No statistical difference was found between these groups. During CDCP, 25 of the 57 preoperatively classified canalicular stenosis were found to have an additional obstruction below the sac. The group with only canalicular stenosis had a statistically significant higher survival compared with cases with NLDO or multiple obstructions (p = 0.03). Of patients responding to the follow-up questionnaire, 11/37 cases experienced epiphora often or constant.
CONCLUSIONS: Treating complete NLDO with CDCP results in a high reoperation rate and seems an insufficient alternative. Canaliculodacryocystoplasty (CDCP) may be discussed if preoperative examination indicates canalicular stenosis and dacryocystorhinostomy is not desirable. However, the patient needs to be aware of the higher risk for additional surgery, especially if a second stenosis is found during probing.

OBJECTIVE: To assess the usefulness of sequential probing for diagnosing lacrimal canalicular stenosis, and the effectiveness of bicanalicular silicone intubation after sequential dilatation in treatment.
METHODS: Canalicular stenosis was diagnosed by sequential probing in 22 patients (22 eyes) who were misdiagnosed as canalicular obstruction. The patients were treated by bicanalicular silicone intubation after sequential dilatation. Anatomical improvements and functional relief of epiphora were evaluated. In addition, complications were evaluated.
RESULTS: The average age of the 22 patients was 57 years, and the average follow-up period was 13 months. The silicone tube was left in place for an average of 14 weeks. The anatomical success rate was 100 %. Fifty-four percent of patients achieved complete relief of epiphora, 32 % partial relief, and 14 % no relief. There were no complications.
CONCLUSIONS: Sequential probing is an useful diagnostic method for canalicular stenosis. Bicanalicular silicone intubation after sequential dilatation is a simple and effective treatment, and could be performed as primary procedure for canalicular stenosis before invasive surgery.

Lacrimal outflow can be compromised by anatomical obstructions or stenoses (nonfunctional epiphora) or by defective lacrimal \"pump\" function (functional epiphora). Although classic imaging modalities, such as X-ray dacryocystography, computed tomography, or magnetic resonance imaging can effectively evaluate the former, their success is much less in the evaluation of the latter. This is largely due to the fact that forced diagnostic injection of fluid into the canalicular system can overcome partial obstruction sites. On the other hand, lacrimal scintigraphy mimicks \"physiological\" lacrimal outflow, being performed under pressure gradients present in everyday life. This is why it is considered more suitable for the study of functional epiphora. Furthermore, quantitative lacrimal scintigraphy (with time-activity curves) enables the accurate measurement of lacrimal clearance from the conjunctival fornices and may be used to study the physiology of the lacrimal \"pump.\" Data obtained from the scintigraphic study of lacrimal outflow may be used to design more effective procedures in the management of functional and nonfunctional epiphora. This is a review article, based on a literature search with emphasis on recent publications and on those supporting interdisciplinary cooperation between ophthalmology and nuclear medicine.

Epiphora is a common complaint of patients who present to an Ophthalmology Clinic. In many cases, epiphora is due to an obstruction in the lacrimal drainage system. However, a subgroup of symptomatic patients with epiphora has a patent lacrimal drainage system. Such cases are usually termed \'functional obstruction\' and / or \'stenosis of the lacrimal drainage system\'. Various etiologies and diagnostic and therapeutic approaches have been described in literature, which implies the lack of a standardized approach. This article will review the evolving diagnostic and therapeutic approaches in literature, and in the end, propose a paradigm in approaching this group of patients.