Original Investigation
Scanning Electron Microscopic Features of Nasolacrimal
Silastic Stents Retained for Prolong Durations Following
Dacryocystorhinostomy
Mohammad Javed Ali, F.R.C.S.*, Farhana Baig, M.D.†, Mekala Lakshman, Ph.D.‡,
and Milind N. Naik, M.D.*
*Dacryology Service, L.V. Prasad Eye Institute; †Department of Pathology, Global Hospital; and
‡Ruska Labs, College of Veterinary Sciences, Hyderabad, India
Purpose: The aims of this study were to examine the scanning
electron microscopic features of silastic nasolacrimal duct stents
retained for long durations following a dacryocystorhinostomy.
Methods: A prospective interventional study was performed
on stents retrieved from patients who were lost to follow up
after a dacryocystorhinostomy with Crawford stent insertion.
Long duration was defined as stents retrieved at a minimum of
1 year following a dacryocystorhinostomy. None of the patients
had any evidence of postoperative infection. After removal,
the stent segments were subjected to biofilm and physical
deposit analysis using standard protocols of scanning electron
microscopy. These stent segments were compared against sterile
stents which acted as controls.
Results: A total of 7 stents were studied. Five were consecutive
patient samples, and 2 were sterile stents. All the 5 stents were
retrieved from patients who were lost to follow up for a minimum
of 12 months following surgery. The mean duration of intubation
at retrieval was 21 months. All the stents demonstrated evidence
of biofilm formation and physical deposits. However, as the
duration of retention increased, the deposits and biofilms were
noted to be progressively denser, multilayered and extensive.
Certain areas demonstrated thick biofilm integration with the
deposits. Polymicrobial communities were noted within the
exopolysaccharide matrix.
Conclusions: This is the first study to exclusively report
on scanning electron microscopic features of lacrimal stents
retained for long durations. Further studies on physical elements
within the deposits and protein analysis would provide more
insights into stent–tissue interactions.
(Ophthal Plast Reconstr Surg 2016;32:20–23)
D acryocystorhinostomy (DCR) with silicone intubation is
commonly performed for the treatment of nasolacrimal
duct obstruction.1,2 Complex microbial communities encased in
a self-produced exopolysaccharide matrix constitute biofilms,
which render the organisms highly resistant to conventional
antibiotics.3,4 Biofilms are known to irreversibly attach them-
selves to the implant surfaces like venous and urinary catheters
Accepted for publication December 2, 2014.
The authors have no financial or conflicts of interest to disclose.
Address correspondence and reprint requests to Mohammad Javed
Ali, F.R.C.S., Dacryology Service, L. V. Prasad Eye Institute, Road No 2,
Banjara Hills, Hyderabad 500028, Telangana, India. E-mail: drjaved007@
gmail.com.
DOI: 10.1097/IOP.0000000000000395
20 Ophthal Plast Reconstr Surg, Vol. 32, No. 1, 2016
and hence contribute to persistence of infection and progressive
chronic inflammation.5–7 Parsa et al.8 were the first to document
biofilms on the surface of a single silicone stent and discussed
its significance in culture-negative patients. Four studies dem-
onstrated biofilms on lacrimal mucosa and stents in patients
with and without soft-tissue infections.9–12 The authors group
have earlier demonstrated the presence of biofilms as early as 4
weeks following intubation in all their cases and demonstrated
the quantification of the stent biomass.13 To further understand
the lacrimal stent–related biofilms, the authors sought to exam-
ine the scanning electron microscopic features of stents retained
beyond 1 year and to compare them with the controls.
METHODS
Study Design and Sample Collection. Institutional review board
approval was obtained prior to the commencement of this study
(LEC 01-14-006, January 24, 2014). Five Crawford stents obtained
from patients who were lost to follow up after uneventful standard
DCR surgeries2,14 were included in the study. Long duration was
defined as stents retrieved at a minimum of 1 year following a DCR.
Endoscopic examination of the stent and ostium was performed
before retrieval. All the patient stents were aseptically retrieved
by cutting the ocular loop and subsequently removed through the
nose under endoscopic guidance. These stents were compared to
2 sterile stents which served as controls. After removal, the stent
segments were subjected to biofilm and physical deposit analysis
using standard protocols of scanning electron microscopy (SEM).
SEM Protocol. SEM specimens were fixed in a solution
of 2.5% glutaraldehyde in 0.1 M phosphate buffer (pH 7.2)
for 24 hours at 4°C. The samples were then postfixed in 2%
aqueous osmium tetroxides for 4 hours and subjected to serial
dehydration in a series of graded alcohols. This was followed
by drying using silica vacuum desiccation for 45 minutes. The
processed samples were mounted over the stubs with double-
sided carbon conductivity tape, and a thin layer of gold coating
was performed for 3 minutes using the automated sputter coater
(JFC-1600, JEOL Ltd., Tokyo, Japan).
Image Acquisition and Analysis. Images were taken using
a JSM 5600 SEM (JEOL Ltd.) at an accelerated voltage of
10 kV, and at various magnifications between ×120 and ×35,000
focusing on the external surface of the stent.
Bacterial biofilms on SEM were defined as presence of
microcolony clusters and towers consisting of bacterial bod-
ies 0.05 μm to 5.0 μm surrounded within exopolysaccharide
matrix, complex water channels, and 3-dimensional structure.13
Ophthal Plast Reconstr Surg, Vol. 32, No. 1, 2016 Nasolacrimal Silastic Stents Retained for Prolong Durations

RESULTS increase in the density, thickness, and extent of both the bio-
A total of 7 stents were studied. Five were consecutive patient
films and deposits. Prolong duration was also associated with
samples, and 2 were sterile stents or controls (Fig. 1A). The mean dura-
increasing brittle nature of the deposits. These features could be
tion of stent retention was 21 months (range 12–36 months). Ostium
secondary to increasing layer over layer deposits of mucus, pre-
evaluation showed entrapment of stents in 2 cases with gross cicatriza-
cipitation of various proteins from ocular and nasal secretions,
tion, while the remaining showed well-healed patent ostia with no evi-
and variable physiochemical interactions.
dence of tube-related reaction. At the time of stent retrieval, none of the
Although there are studies that demonstrated biofilms on
patients had any evidence of postoperative infection.
nasolacrimal stents, none looked specifically at features follow-
The surface morphology of stents showed distinct differences
ing a long-duration retention postsurgery. Samimi et al.10 dem-
onstrated biofilms among 4 stents that were imaged in their study
with duration of stents (Fig. 1A–D). Figures 2 and 3 show detailed fea-
where the median time of intubation was 11 weeks. Although
tures of stents at 1 and 3 years, respectively. All the stents demonstrated
the range of stent retention prior to retrieval was between 2 and
evidence of biofilm formation and physical deposits. However, as the
128 weeks, the study did not analyze the differences with rela-
duration of retention increased, the deposits and biofilms were noted
tion to time. Ibanez et al.11 described biofilms on all the 7 Song’s
to be progressively denser, multilayered, and extensive (Figs. 1–3). The
polyurethane stents that were retrieved after the device failed to
deposits were multilaminar, rough with variable porosities, and irregu-
function (mean follow-up of 21.5 months, range 11–30 months).
lar in shapes and sizes with a usual granular surface (Figs. 2A–D and
They proposed that biofilm colonization could play a major role
3A–C). Certain areas demonstrated thick biofilm integration with the
in failure of these devices and that the failure is contributed by
deposits (Figs. 2C,D and 3D,E). Occasional areas showed features of
granulation tissue, mucus, and nature of the implanted material.
brittle deposits, and these were more frequently noted in stents beyond 2
Numerous factors may predispose an implant or a stent
years of retention (Fig. 3A,B). Higher power magnification SEM dem-
to microbial colonization and subsequent biofilm formation and
onstrated complex 3-dimensional exopolysaccharide structures, plank-
include native flora in areas of implantation, implant materi-
tonic bacteria, formation of water channels, and embedded bacterial
als, preexisting infections, and the ability of the organisms to
bodies (Figs. 2E,F and 3D–F). Polymicrobial communities were noted
produce biofilms.10 Studies from systemic literature have shown
within the exopolysaccharide matrix (Figs. 2F and 3F).
positive association of biofilms with persistence of infection,
symptoms, and poor quality of life.15,16
DISCUSSION The literature on lacrimal stents is not conclusive about
The current study examined the scanning electron microscopic the association of biofilms and poorer surgical outcomes. While
features of nasolacrimal silastic stents retrieved after prolong some studies demonstrated microbial colonization and biofilms
durations of intubation following DCR. As compared to con- on stents from infected cases,8,10,17 others correlated the loss of
trols and stents retrieved at 4 weeks, there was demonstrable function of stents to presence of biofilms.11 However, it is also

FIG. 1.  Scanning electron microscopy images showing the surface features of silicone stents from a control (A), a 4-week-old stent
(B), a 1-year-old stent (C), and a 3-year-old stent (D). Note the differences in the surface images and deposits.

© 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. 21
M. J. Ali et al. Ophthal Plast Reconstr Surg, Vol. 32, No. 1, 2016

FIG. 2.  Scanning electron microscopy images from a 1-year-old silicone stent. Low-magnification image showing numerous focal
physical deposits (SEM ×70, A) and focal areas of deposits and biofilms (SEM ×700, B). Higher magnification showing the multilayered,
coarse deposits (SEM ×3500, C; and SEM ×20000, D). Very high magnification showing numerous planktonic bacteria, embedded bac-
terial bodies (SEM ×8000, E) and 3-dimensional water channels with polymicrobial organisms (SEM ×20000, F)

important to realize that mere presence of biofilms on the stents
should not be alarming. Although the stents were retrieved at
very long durations, the current study patients did not show any
signs of postoperative infections. This finding was corroborated
with earlier microbiology and biofilm studies,13,18 and taken
together, the overall results suggest that unless there is an evi-
dence of associated soft-tissue infection, just the presence of
biofilms or microbial colonization cannot be correlated with
adverse outcomes.
CONCLUSION
In conclusion, although the sample size was understandably
small, extensive but variable degrees of deposits and biofilms
were demonstrated in all the silastic stents retrieved beyond 1
year following surgery. Current evidence is inconclusive regard-
ing the influence of biofilms on postoperative infections or out-
comes of a DCR surgery. Further studies on physical elements
within the deposits and protein analysis would provide more
insights into stent–tissue interactions.
CONTRIBUTORSHIP STATEMENT
Mohammad Javed Ali: Concepts, data collection, and manuscript
drafting.
Farhana Baig: Concepts and electron microscopy.
Mekala Lakshman: Electron microscopy.
Milind N. Naik: Critical review.

22 © 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Ophthal Plast Reconstr Surg, Vol. 32, No. 1, 2016 Nasolacrimal Silastic Stents Retained for Prolong Durations

FIG. 3.  Scanning electron microscopy images from a 3-year-old stent. Low-magnification images showing diffuse, thick, multilami-
nar, and brittle deposits. Compare with Figs. 1B and 2A (SEM ×70, A,B). Higher magnification of the cracked physical deposits (SEM
×1000, C). Very high power images demonstrating complex 3-dimensional exopolysaccharide structures and water channels (SEM
×8000, D), integration of biofilms and physical deposits (SEM ×7000, E), and polymicrobial planktonic bacteria (SEM ×20,000, F).

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© 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. 23