Original Investigation
Traumatic Canalicular Laceration Repair with a New
Monocanalicular Silicone Tube
Mehdi Tavakoli, M.D., F.I.C.O., Sayeh Karimi, M.D., Bahareh Behdad, M.D., Setareh Dizani, M.D., and
Hossein Salour, M.D.
Ophthalmic Research Centre, Shahid Beheshti University of Medical Sciences, Tehran, Iran
Purpose: This study evaluated the efficacy of a new pushed
monocanalicular silicone tube in reconstructing traumatic
canalicular laceration.
Methods: This interventional case series enrolled 48
patients with a traumatic canalicular laceration. Patients with
bicanalicular involvement were excluded. Canalicular repair
was performed under an operating microscope and involved
proximal end exploration of the canaliculus, stenting of the
canaliculus with a 35-mm Masterka tube, and approximation of
the lacerated canaliculi margins. After 6 months, anatomical and
functional success rates were evaluated by diagnostic probing
and by asking the patients (or their guardians) about tearing.
Results: The mean age of patients was 32.2 ± 21.2 years
(1.5–75 years). Of the 48 patients included, 38 were males. Lower
canaliculus was involved in 35 patients. Other ocular injuries
were observed in 38 patients. The average interval between the
surgery and Masterka removal was 12.2 ± 1.4 weeks (10–16
weeks). Early tube extrusion was observed in 3 patients. No
significant complication was observed in this series. Anatomical
and functional success rates were 87% and 100%, respectively.
Conclusion: The results demonstrated that intubation of
lacerated canaliculi with Masterka tube for canalicular repair
was safe, effective, and simple with minimal complications.
(Ophthal Plast Reconstr Surg 2016;XX:00–00)
L acrimal canaliculi are known to be highly susceptible to
trauma. This vulnerability partly arises from the lack of tar-
sus as a supportive structure in the medial portion of the eyelids.1
Canalicular laceration may result from direct or indirect trauma.
In addition, both penetrating and nonpenetrating injuries at the
medial canthal region may result in canalicular laceration.2
Canalicular laceration may occur at any age2,3; however,
it is more common in children and young adults and com-
monly affects the inferior canaliculus.4 Canalicular laceration
frequently accompanies other ocular injuries, including eyelid
and globe lacerations.5 Unrepaired canalicular lacerations may
cause inflammation, scar, and canalicular stenosis or obstruc-
tion, leading to subsequent epiphora.4 Several methods are
available for reconstructing the lacerated canaliculus, including
repair of the lacerated eyelid without a lacrimal stent, intubation
Accepted for publication November 18, 2015.
This work has been presented in part, at the World Ophthalmic Congress
(WOC) meeting in Tokyo, 2014.
The authors have no financial or conflicts of interest to disclose.
Address correspondence and reprint requests to Mehdi Tavakoli, M.D.,
F.I.C.O., #23, Paydarifard Street, Pasdaran Avenue, Tehran, 16666, Iran.
E-mail: mehditavakolimd@yahoo.com
DOI: 10.1097/IOP.0000000000000620
Ophthal Plast Reconstr Surg, Vol. XX, No. XX, 2016 1
Copyright © 2016 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
of the lacerated duct with monocanalicular or bicanalicular
stents with or without mucosal anastomosis, or early canalicu-
lodacryocystorhinostomy.1,2,6–8 Although there is no consensus
among lacrimal surgeons on surgical techniques for repairing
canalicular laceration, most surgeons believe that reconstruc-
tion of a lacerated canaliculus with a stent is necessary.6
Bicanalicular intubation is a conventional method that
requires uninvolved canaliculus manipulation. In addition, this
method requires the tube to be retrieved from the nasal cavity,
which requires thorough experience to prevent nasal muco-
sal injury. On the other hand, monocanalicular tubes, such as
Monoka and Mini-Monoka (FCI Ophthalmics, Marshfield
Hills, MA), have been reported to be safe and efficacious.1,5,6,9,10
Masterka (FCI Ophthalmics, Marshfield Hills, MA) is a new
monocanalicular silicone tube designed in recent years. This
tube comprises 2 parts. The first part is a silicone tube (simi-
lar to Mini-Monoka) that is fixed to the lacrimal punctum by
a punctal plug at its proximal end. The second part is a metal
probe that lies within the stent lumen and works as a guid-
ing probe, which similar to an arterial catheter, facilitates the
insertion of the silicone stent. Once the lacrimal canaliculus is
intubated, the metal probe is withdrawn, and the silicone stent
remains in the canaliculus (Fig.1).11
The primary indication for the use of Masterka tube, as
indicated by the manufacturer, is the obstruction of the nasolac-
rimal duct in children. To the best of our knowledge, this is the
first study to report the outcomes of canalicular intubation with
Masterka tube for reconstructing traumatic canalicular laceration.
METHODS
This interventional case series included 48 patients with trau-
matic canalicular laceration who were scheduled to undergo surgical
repair during a 6-month period. All the patients were informed regard-
ing the surgical procedure, potential benefits, disadvantages of the new
silicone tube, and purpose of the study. Each patient signed an informed
FIG.1.  Masterka tube; a new pushed silicone tube comprising
2 parts: a silicone tube with a punctal plug and a metal probe
that lies within the tube lumen.
 M. Tavakoli et al. Ophthal Plast Reconstr Surg, Vol. XX, No. XX, 2016
FIG.2. A patient with a lower canalicular laceration due to a
sharp injury before (left) and after (right) reconstruction. The
punctal plug is visible at the lower punctum.
consent form before the surgery. The study was approved by the Ethics
and Scientific Committee of the Ophthalmic Research Center, Shahid
Beheshti University of Medical Sciences. All the study protocols were
in strict accordance to the Helsinki Declaration. In the emergency
room, each patient underwent a thorough ocular examination, including
measurement of visual acuity with Snellen chart, RAPD examination,
eyelids and ocular adnexa examinations, slit-lamp examination, appla-
nation tonometry, and funduscopic examination.
Consultation was requested from ENT, maxillofacial, and neu-
rosurgeon colleagues when necessary. In patients with suspected cana-
licular laceration, presence of a laceration was confirmed by canalicular
probing. Demographic and other data on the type of injury and concom-
itant eye and noneye injuries were collected for each patient. Patients
with bicanalicular laceration were excluded from the study. In addition,
patients who were repaired more than 7 days after trauma or those who
did not complete the 6-month follow-up were excluded from the study.
Surgery was performed under general or local anesthesia. In the case
of concomitant globe laceration, it was addressed before eyelid and
canalicular repair. Canalicular laceration was repaired under a surgical
microscope. First, the proximal portion of the canaliculus was explored.
Subsequently, the punctum was dilated using a punctum dilator and a
35-mm Masterka tube was then inserted in the punctum. Following in-
tubation of the proximal and distal portions of the lacerated canaliculus
and nasolacrimal canal, the tube was fixed in the punctum through its
plug and the metal guide was withdrawn from the silicone stent. The
punctal plug was held with a tying forceps to prevent the silicone stent
be pulled out while the metal probe was withdrawn. Subsequently, the 2
ends of the lacerated canaliculus were approximated using a 7-0 Vicryl
suture. Eventually, the eyelid margin and other parts of the eyelids were
repaired using 6-0 silk sutures (Figs.2 and 3). After the surgery, chlor-
amphenicol and betamethasone eye drops (4 times a day for 5 days) and
tetracycline eye ointment (twice a day) were prescribed to all patients.
All subjects were asked to visit the hospital on the first and third
days following the surgery; at the end of the first week after the surgery,
and at the end of the first, third, and sixth month after the surgery. The
Masterka tube was removed at 3 months after the surgery. Success rate
FIG. 3. A patient with canalicular laceration as well as an extensive lower eyelid laceration after a motor vehicle accident before (left)
and after (middle) reconstruction. The punctal plug is visible at the lower punctum (right).
2 © 2016 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Copyright © 2016 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
was determined at 6 months after the surgery by diagnostic probing and
irrigation (anatomical success) and by asking patients or his/her guard-
ians about tearing (functional success). For all patients, the surgical pro-
cedures and diagnostic probing at follow-up visits were performed by
the same surgeon. Diagnostic probing was performed under intravenous
sedation for noncooperative children. Statistical analysis was performed
using SPSS version 17 (SPSS Inc., Chicago, IL).
RESULTS
In all, 48 patients were enrolled in the study and completed the
6-month follow-up. The mean age of the patients was 32.2 ± 21.3 years
(1.5–75 years). Of the 48 patients, 38 (79%) were males and 10 (21%)
were females. Other data related to canalicular trauma has been sum-
marized in Tables 1 and 2.
No intraoperative complication occurred. The average interval
between the surgery and Masterka tube removal was 12.2 ± 1.4 weeks
(10–16 weeks). Punctal stenosis, formation of granulation tissue, intra-
canalicular migration of the stent, and chronic irritation were not ob-
served in any patient. However, spontaneous early tube loss was noted
in 3 (6%) patients, 2 of these 3 patients were younger than 10 years old.
Anatomical success, determined by diagnostic probing and irri-
gation, was 87% (42 patients). Canalicular stenosis was detected during
the irrigation test in the remaining 6 patients. In 2 of these 6 patients, the
Masterka tube had been extruded spontaneously. The functional success
was 100%, indicating that none of the 48 patients complained of tearing
at the end of 6 months.
DISCUSSION
In this study, 48 patients with traumatic canalicular
laceration underwent surgical repair with the Masterka tube,
a new monocanalicular silicon tube. The outcomes of the sur-
gery showed high effectiveness, with functional and anatomi-
cal success rates of 100% and 87%, respectively. The mean age
of the patients was about 32 years, 28% of patients were aged
<10 years and 84% were aged <40 years. Furthermore, 79%
of patients were male. Higher prevalence of canalicular injury
among youth and men may be related to their occupational
and social activities. A study by Naik et al. involving the Mini-
Monoka tube for repairing canalicular laceration reported 66
patients underwent eyelid laceration repair, of which 24 (36%)
had involvement of the canalicular ducts. The mean age of these
patients was 16 years, and 83% of these patients were males.5
Similar findings were reported by other studies.1,2,4 In this study,
the lower eyelid was involved in a large percent of patients with
canalicular laceration. This finding was consistent with that of
most other studies.1–6 The incidence of canalicular laceration is
estimated to be 3- to 4.5-times higher in the lower eyelids than
in the upper eyelids.2 Simultaneous globe and other periocu-
lar injuries are common in patients with traumatic eyelid and
 Ophthal Plast Reconstr Surg, Vol. XX, No. XX, 2016 Traumatic Canalicular Repair with Masterka
TABLE 1.  Demographic and clinical features of the
patients with traumatic canalicular laceration
Mean age (years) 32.2 ± 21.3
Male 38 (79%)
Penetrating injury 25 (52%)
Right eye 28 (56%)
Lower canaliculus 35 (73%)
Interval between injury to repair (hours) 12.4 ± 7.6
Mean time of tube removal (weeks) 12.2 ± 1.4
TABLE 2.  Ocular injuries accompanied with canalicular
laceration
Eyelid laceration* 28 (58%)
Conjunctival laceration 4 (8.3%)
Scleral laceration 4 (8.3%)
Medial canthal avulsion 4 (8.3%)
Orbital fracture 3 (6.2%)
Hyphema 8 (16.6%)
Commotio retina 10 (20.8%)
Without accompanied injury 10 (20.8%)
*Includes eyelid lacerations extending more than 1 cm from the involved
canaliculus.
canalicular lacerations. In the study by Naik et al.,5 simultane-
ous globe injury was reported in 25% patients. In another study
by Leibovitch et al.,9 5 out of 19 patients had concurrent globe
rupture or orbital fractures. In the present study, 2 patients dem-
onstrated simultaneous globe laceration and upper canaliculi. In
addition, 1 of these patients had an intraocular foreign body that
was removed later through pars plana vitrectomy. The associa-
tion between upper canalicular injury and globe rupture has also
been mentioned in other studies.5–12 These findings illustrate the
importance of a thorough and careful eye examination in all
patients with traumatic eyelid and canalicular laceration.
There is no consensus among surgeons regarding the
need for repairing canalicular laceration. While some surgeons
believe that meticulous reconstruction with canalicular intuba-
tion is not mandatory in all cases, particularly in cases showing
upper canalicular involvement,13 other surgeons have reported
persistent epiphora in patients who have been operated without
a canalicular stent.4
In this study, the efficacy of the Masterka tube in repair-
ing traumatic canalicular lacerations was evaluated for the first
time. A few published studies on the Masterka tube have mainly
focused on the efficacy of this tube in children with congeni-
tal nasolacrimal duct obstruction.11–14 Use of the Masterka tube
for repairing canalicular laceration is associated with several
advantages. Potential complications associated with older pig-
tail and bicanalicular probes, including unnecessary manipu-
lation and injury of the normal canaliculus, can be avoided
using a monocanalicular stent. In addition, bicanalicular silicon
tubes and some types of monocanalicular tubes such as Mono-
Crawford require to be retrieved from the nasal cavity by using a
“pulled mechanism,” which may damage the nasal mucosa and
result in bleeding. In contrast, the Masterka tube is placed in
the canaliculus with a “pushed mechanism.”14 The only com-
plication observed in this series was the early extrusion of the
Masterka tube (in <1 month) in 3 patients. A study by Fayet
et al.11 evaluated the effectiveness of the Masterka tube in 90
patients with nasolacrimal outflow obstruction, reported several
complications, including canaliculitis, intracanalicular migra-
tion, and keratitis. None of these complications occurred in this
© 2016 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. 3
Copyright © 2016 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
series. Similar to this observation, the most common complica-
tion in Fayet’s11 series was early tube loss, which was reported
in 8 patients. Another study on the use of the Masterka tube
in 88 eyes of 110 patients with congenital nasolacrimal duct
obstruction reported early extrusion in 17 cases and keratitis
in 2 cases.14 Fayet believed that early tube extrusion may be
related to several factors. Unnecessary long tube may lead to
bending of the tube and an upward force to unseat the plug. The
second possible cause may be a false passage creation during
intubation which may produce an upward force and unseat the
stent. Another mechanism is the manipulation of the plug by the
patient.14 The authors observed 2 out of 3 cases of early tube
loss in young children and believe that self-manipulation is the
most probable mechanism in these cases.
Two potential complications of Masterka tube might be
inadvertent lacrimal system injury and false passage creation
during the insertion by the metal rod. To prevent these compli-
cations, the distal segment of the lacerated canaliculus must be
identified carefully and the stent should be pushed very gently.
Once the tube is inserted in the “true” passage, it will advance
with minimal resistance.
Most recent studies on the use of silicone tubes in repair-
ing canalicular laceration have focused on Mini-Monoka as a
monocanalicular tube.5,6,9,10 Both Mini-Monoka and Masterka
are monocanalicular stents that are fixed in the punctum by
a punctal plug and are inserted in the canaliculus by a push-
ing mechanism that prevents the manipulation of the nasal
mucosa.9–14 However, in contrast to Mini-Monoka, the Masterka
tube contains a metal rod introducer within the silicone part that
allows easy insertion of the stent and may reduce the operation
time. Absence of this metal rod sometimes results in the bend-
ing of the Mini-Monoka tube on itself during insertion, which
may increase the time required for the surgery and may require
surgeons with sufficient experience for insertion. However, this
could not be confirmed in the present case series and a com-
parison study is needed to validate the above findings.
One study that evaluated the efficacy of the Mini-Monoka
tube for repairing canalicular laceration reported high functional
and anatomical success rates of 94% and 100%, respectively.9
Another similar study reported an anatomical success rate of
90% and a functional success rate of 100%.5 These outcomes
are comparable with the results obtained for the Masterka tube
in the present study. Absence of tearing in patients with ana-
tomical stenosis may be related to the function of the healthy
canaliculus that compensates the tear drainage.
There are some disagreements between authors regarding
the time of removing the silicon tube. In the present study, the
authors removed the Masterka tubes after a mean of 12 weeks. In
the study by Fayet et al.11 on patients with congenital nasolacrimal
duct obstruction, the silicon tubes were removed within a maxi-
mum of 90 days. Mini-Monoka stents were removed in an aver-
age of 8.8 weeks by Chowdhury et al.10 while the mean time for
removing the Mini-Monoka tubes in studies by Naik et al.5 and
Leibovitch et al.9 was 15 weeks and 5 months, respectively. Conlon
et al.15 designed an animal model to evaluate various methods for
canalicular reconstruction after laceration and indicated that 12
weeks was an optimum time for leaving the silicon tubes in place.
The drawbacks of the present study are relatively low
sample size, lack of comparison with other similar studies, and
exclusion of patients with bicanalicular involvement, which
should be considered in future studies.
CONCLUSION
In summary, the Masterka tube is an effective and safe
stent for repairing canalicular laceration. The metal guide
 M. Tavakoli et al. Ophthal Plast Reconstr Surg, Vol. XX, No. XX, 2016

inside the silicon tube facilitates the insertion of the tube.
High functional success rate of this method can reduce the
requirement for reoperation. However, further investigations
are required to compare the advantages of the Masterka tube
with other stents.
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Copyright © 2016 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.