|Year : 1979 | Volume
| Issue : 4 | Page : 41-43
Lacrimal communicating operations with intubation
G.G.S. Medical College, Faridkot, Punjab, India
S S Sangha
Professor of Ophthalmology, G. G. S. Medical College, Faridkot, Punjab
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sangha S S. Lacrimal communicating operations with intubation. Indian J Ophthalmol 1979;27:41-3
Obstruction in the lacrimal passage, is, usually the forerunner of infections/inflammations in this region, Continuous epiphora with or without infection is not only a constant hazard for the eye, but a spiteful social malady also. The correct treatment, obviously lies in removing or by-passing the site of obstruction. Prior to Toti, who envisaged, communicating the lacrimal sac with nose, the best we could do for these patients, was to extirpate the infected sac; which no doubt removed the infection but left the patient condemned for the rest of the life with constant epiphora. The ushering in of canaliculorhinostomy (CCR) of Arruga proved to be a boon for those patients, whose sacs had been removed or rendered unsuitable for dacryocystorhinostomy (DCR), due to infection, fibrosis or fistula.
The prominent among the causes of failure of the operations, are the closure of the alternative channel by blood clots, fibrosis and granulation tissue. To obviate this, the lacrimal passages were intubated with fine silicone tubes after the operation. To evaluate the usefulness of this procedure, is the purpose of this communication.
| Methods and material|| |
20 patients were selected from those who attended the hospital, for the treatment of continuous epinhora and/or pus discharge from the lacrimal puncta on pressure on the side of the nose below the medial canthus. Syringing was done through the lower canaliculus to ensure its patency and localise the site of obstruction as precisely as possible. Nose was examined by an E.N.T. surgeon for any abnormality/contraindication in the nose for the communicating procedure. X-ray of the region was done wherever necessary. Other routine lab. investigations were attended to.
Technique of operation
Except where age did not permit, local anaesthesia was used. Nose was packed with gauze soaked in 4% xylocaine mixed with adrenaline. Temporary tarsorrhaphy was done in the middle of the lids to protect the eye ball from injury and it was released at the end of the operation.
To expose the sac, curved incision, 3-4 mm. lateral to the anterior lacrimal crest starting 2-3 mm. above the medial palpebral tendon was preferred. The sac along with periosteum was retracted laterally. The fragile bone in the lacrimal fossa was broken posteriorly, with a periosteum elevator and osteum enlarged to about 12mm x 10mm, with the help of varying sizes of bone punches. Nasal mucosa was always lifted off the bone before applying the punch. Correspondingly similar anterior and posterior flaps were fashioned from the medial wall of sac and the nasal mucosa, with the help of Werb's scissors. The posterior flaps were stitched together with 2-3 interruped sutures.
The upper and lower canaliculi were probed and dilated. A fine silicone tube about 15 cm. long was taken and its one end was slipped over the canaliculus introducer, which is a very simple probe, made of a flexible, metal with one tapering bulbus end. This was introduced in the lower canaliculus, carrying the silicone tube on its plain end. When it was seen in the sac cavity, it was pulled out and the silicone tube was taken off it. A similar procedure was practised for the upper canaliculus. When both ends of silicone tube were seen in the cavity they were pulled and taken through the rhinostomy opening and the homolateral pares. They were fixed over the cheek with sellotape. The anterior flaps of the sac and nasal mucosa were then stiched together. Medial palpebral tendon was restiched and wound closed in layers.
Skin stiches were removed after 6.7 days and silicone tubes kept in place for two to three weeks after which they were also pulled out from the conjunctival side.
Canaliculorhinostomy (CCR) was done according to the author's modification. Intubation was done in exactly the same manner already described for DCR
Sometimes, it was not possible to intubate the upper canaliculus, then the free end out at the lower punctum and the other end outside the nose were sellotaped over the cheek. [Figure - 1].
Occasionally, the canalicLtli were so narrow that they would not permit the passage of the tube. Such patients were excluded from the series.
Hallpike head lamp (Keeler London) focusses the light in the cavity and is an asset for lacrimal surgery and it was used in this study.
Patients were called every month for 3 months and syringing was done on every visit.
| Observations|| |
Age of the patients varied from 9 months to 60 years.
Any patient who remained free of epiphora and the passage was patent, was taken to as successful. The follow up varied from 4 months to 2 years.
| Discussion|| |
Lacrimal surgery, described as the step child of ophthalmology, deserves to be more affectionately treated and its care should not be entrusted to outsiders like rhinologist or orthopaedician for fear of maltreatment or pampering.
Toti, was the first to devise the communicating operation and later Dupuy-Dutemps and Bourget, modified the technique. In spite of various modifications suggested from time to time, the basic idea remains the same. Arruga, conceived CCR by which those patients whose lacrimal sac has already been excised or rendered unsuitable for DCR, can be helped.
75% of the patients were females and 25% males. They varied from 9 months to 60 years.
The intubation of lacrimal passages, in DCR Werb and CCR, has greatly influenced the outcome of these procedures. In this series whenever, the intubation had been satisfactory, it never failed, whereas without intubation, success rate varies from 80-96%, (Dupuy-Dutemp, Traquaire, Stallard, Romans, 1vlathur Singha and others).
Romanes put Jacques catheter no. 3 in the nose through rhinostomy passage and removed it after one week and claimed 95% success. The inlying tubes keep the passages patent and prevent blockage by blood clots, granulation tissue and fibrosis. To begin with, the tubes were kept in place for 3 months but one patient (5%) developed a granuloma in the caruncle region and from then onwards, this period was reduced to 3-4 weeks. Although, about 30% patients complained of irritation in the nose and 40% excessive lacrimation, but these complaints were of a minor nature.
Lacrimal fistula, is no longer an indication for dacryocystectomy. Saxena, Nath et al, Sarda, Stallard and others, have done DCR in fistula. In the present series, there were 4 cases of fistula. In two of these, DCR could be done and in other two, the sac had to be removed and CCR resorted to. It is difficult to agree with Saxena that in all such cases DCR can be done.
The age seems to be no bar to these operations. The minimum age at which DCR has been done is, 3 years, Stallard, 3-1/2 years, Aggarwal, and 3 years, Mathur. One of the patients of lacrimal fistula in the present series was 9 months old and DCR with intubation of lower canaliculus was done and the result was very satisfying. This patient appears to be the youngest, in the available English literature to have DCR, successfully done. Probing of the passage does help occasionally in fistula in small kids, but in case it dose not, then there is no point in undue waiting; DCR or CCR should be done, to avoid further damage.
| Summary and conclusions|| |
20 patients with varied lacrimal problems of obstructed drainage passage, like Chronic dacryocystitis, mucocoele, fistula, excised sacs, were treated by DCR and CCR with intubation of the passages with silicone tube, which was kept in for 3-4 weeks. 100% success was obtained. DCR and CCR can be done in lacrimal fistula, an infant of 9 months with fistula, appears to be the youngest in the literature, who has been subjected to DCR. It is suggested that if probing does not help in small children with fistula, DCR or CCR should be done without losing any more time.
| References|| |
Aggarwal, M.L , 1970, Jour. All India Ophthal. Soc.,
Arruga, H.. 1973, Ocular Surgery, 3rd. edition McGraw Hill Book Inc. N.Y., Tronto, London. 279.
Dupuy-Dutemps, P. and Bourget, 1920, Jour. Ann. Oculiss (Paris), 157, 445. c.f. Arruga. Ocular Surgery.
Mathur, S.P., 1958, Jour. All India Ophthal. Soc.,
Nath, K., Kumar, S. and Shukla, B.R., 1962, Jour. All India OPhthal. Soc.,
Romanes, G.T., 1955, Brit. Jour. Ophthal., 39,
Sarda, R.P., 1961, Brit. Jour. Ophthal. 43,
Saxena, R.C„ 1972, Jour. All India Ophthal. Soc.,
20, 3, 133.
Singha, S.S., 1969, Orient. Arch. Ophthal., 7,
Stallard, H.B., 1973, Eye Surgery, 5th. Edition Wright Bristol P. 322.
Toti, A., 1908, c.f- Eye Surgery Stallard, H.B. (1973).
Traquair, 1940, c.f. Eye Surgery Stallard (1973).
Werb, A. Personal communications.
[Figure - 1]
[Table - 1], [Table - 2], [Table - 3]