|Year : 1988 | Volume
| Issue : 4 | Page : 162-164
Comparative evaluation of Jones pyrex tubes and polyethylene tubes in conjunctivo-dacryocystorhinostomy
SM Betharia, Ritu Arora, Sushil Kumar
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, A.I.I.M.S., Ansari Nagar, New Delhi 110 029, India
S M Betharia
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, A.I.I.M.S., Ansari Nagar, New Delhi 110 029
Source of Support: None, Conflict of Interest: None
A comparative study of the use of Pyrex glass tubes and the polyethylene tubes in conjunctivo-dacryocystorhinostomy is presented in 20 patients. The various factors contributing to the success of the surgery are discussed. The merits and demerits of the two types of tubes used are also highlighted.
Keywords: DCR - Dacryo Cysto Rhinostomy
|How to cite this article:|
Betharia S M, Arora R, Kumar S. Comparative evaluation of Jones pyrex tubes and polyethylene tubes in conjunctivo-dacryocystorhinostomy. Indian J Ophthalmol 1988;36:162-4
|How to cite this URL:|
Betharia S M, Arora R, Kumar S. Comparative evaluation of Jones pyrex tubes and polyethylene tubes in conjunctivo-dacryocystorhinostomy. Indian J Ophthalmol [serial online] 1988 [cited 2020 Apr 5];36:162-4. Available from: http://www.ijo.in/text.asp?1988/36/4/162/26120
Canalicular and common canalicular blocks are very common in ophthalmic practice giving rise to the annoying symptom of epiphora. Where the canaliculi are absent or cannot be restored to normal function a substitute for the lacrimal pump must be found. Such a substitute is a tube that possesses capillary attraction combined with a negative pressure phase of the inspired air in the nose. The present comparative study is conducted with the use of pyrex glass tubes and the polyethylene tubes made at the laboratory of Dr. Rajendra Prasad Centre for Ophthalmic Sciences [Figure - 1][Figure - 2].
| Material & Methods|| |
20 patients with the complaint of epiphora due to punctal or canalicular problem were operated. In 10 patients conjunctival DCR was done with the insertion of pyrex tubes (group 'A') and in 10 patients polyethylene tubes (group 'B') were inserted. The various indications for the surgery in these patients are given in [Table - 1]. Pre-operative examination included syringing of the lacrimal passages, Schirmer's test, nasal examination bleeding and clotting time. Site of the block from the punctum was measured with the help of a Bowman's probe and a measuring scale [Figure - 3].
The surgery was performed under general or local anaesthesia depending upon the age and the patients co-operation. The steps were essentially similar to that of Jones' Conjunctivo-dacryocystorhinostomy with a few relevant differences. ,,sub After making the flaps the Bowman's probe was inserted from the medial most point of the caruncle to the nasal septum. The length of the tube to be inserted was equal to this distance, less 2 mm. The Bowman's probe served as a guide for the insertion of the pyrex or polythene tube. The tube was anchored by Putterman's technique  by threading the tube with 6-0 black silk and tying the knot near the medial canthal area. Ideal position and direction of the tube was judged by dropping an antibiotic solution in the conjunctival sac near the lateral cantus and nothing the course of drainage . The conjunctival end was buried deep so that it was not visible on the first few post-operative days [Figure - 4].
Postoperative evaluation - This included subjective assessment of epiphora, Jone's primary dye test, syringing, cleaning of the tube and nasal check up to see the nasal end of the tube. Follow up was done every week for 8 weeks and then fortnightly for 1 year. The average follow-up period was 6 months.
| Observations & Results|| |
At every follow-up the parameters evaluated were:
(1) Subjective relief of epiphora.
(2) Objectively, the fluorescein dye passage from the conjuctival sac into the nose.
(3) Free passage of antibiotic solution from the conjunctival sac into the nose.
(4) Alignment of the tube.
(5) State of the anchoring suture.
(6) Any collection of mucoid or mucopurulent discharge at the mouth of the tube.
(8) Formation of suture granuloma.
(9) Tube extrusion.
(10) Granulation tissue over the mouth of the tube.
(11) Presence of conjunctivitis with rhinitis.
As for epiphora, 7 patients in group A and 9 patients in group B had relief of epiphora [Table - 2]. It was seen that the polyethylene tube got blocked more frequently than the pyrex glass tube at every postoperative follow-up hence needing syringing more often.
Suture granuloma was seen in 6 patients in each group during follow-up which necessitated removal of the suture many times [Figure - 5].
5 patients in each group developed granulation tissue at the medial canthus near the conjunctival end of the tube.
The tube had to be removed in only one patient because of exuberant granulation tissue [Figure - 6].
Conjunctivitis in association with rhinitis was seen in 1 patient in each of the two groups.
| Discussion|| |
This comparative study of conjunctivo-dacryocystorhinostomy was undertaken in 2 groups of 10 patients each using the pyrex glass and the polyethylene tubes. Our procedure of surgery was similar to Jone's technique of conjunctival DCR except for a few differences these being the insertion of the pyrex/polyethylene tube in one sitting and the anchoring being done by the use of Putterman's technique.
The retention of the tube in conjunctival DCR depends upon several factors like the material of the tube, anastomosis between the sac and the nasal mucosal flaps, length of the tube„ depth of the insertion of the conjunctival end of the tube and the presence of anchoring suture. This tube retention is an important factor in maintaining the patency of the desired fistula between the conjunctival sac and the nose.
As per our study we found certain advantages and disadvantages of each tube which could influence the final result. The advantages of the Pyrex tubes over polyethylene tubes were less irritation to the tissues, better drainage of tears due to their hydrophilic, nature, lesser chances of obstruction with secretions because of the smooth surface thereby requiring syringing less often and hence less frequent follow up.
The advantages of the polythylene tube over the pyrex glass tube were better tube retention without the anchoring suture and easy availability of the required length of the tube. Polythylene tubes could be easily shaped over the flame in the operation theatre and the length required could be easily adjusted while the pyrex glass tube for its manufacture required a glass blower with proper expertise and multiple tubes of different lengths were required prior to surgery as exact estimation of the tube length required could not be judged prior to surgery. An important disadvantage of pyrex tube was that it could break during insertion, or postoperatively, thus posing a danger to the medial canthal tissues or nasal mucosa unlike polyethylene tubes.
The retention of the tube was an important factor contributory towards the final outcome of the surgery as the longer the tube retention, the greater is the chance for functional fistula formation from the medial canthus to the middle meatus of the nose. Tube retention depended upon (a) surgical factor i.e. good anterior and posterior flaps, tube mouth to be deeply buried in the caruncle area at the end of the surgery (Fig 14) (b) presence or absence of anchoring suture. In this respect we found that the polyethylene tube was retained longer without any anchoring suture while the pyrex tubes had more extrusion rate without the supporting suture hence requiring reinsertion more often. (c) Patients compliance to various instructions postoperatively.
Suture granuloma as a reaction to the anchoring suture and granulation tissue in and around the tube mouth had no relation to the type of tube inserted in the present study.
We feel that apart from the usual indications for conjunctival DCR it is a feasible solution in the management of epiphora in failed DCR cases with anterior and posterior flap adhesions. In operated dacryocystectomy cases with epiphora, this technique was modified into conjunctivo rhinostomy.
We found two cases developing severe epistaxis after conjunctivo-dacryocystorhinostomy with pyrex tubes as the nasal end of the tubes were later found to be rough. In 2 cases we also saw conjunctivitis when the patients were having rhinitias were seen by Lamping and Levine. 
In the present series polyethylene tubes were found to give better results by virtue of their potential for better retention in place as compared to pyrex glass tubes. We do not recommend this procedure in children because they are not cooperative for examination and postoperative syringing. Regular postoperative follow up is mandatory so as detect complications early and intervene whenever misalignment of the tube occurs.
| References|| |
Jones, L.T. 1962 Trans. Am. Acad, Ophthalmol. Otolaryngol. 66:506, 1962.
Jones, L.T. 1965 Am. J. Ophthalmol, 59:773.
Jones, L.T. 1974 Symposium on surgery of orbit and adnexa. Trans. New Orleans Acad. Ophthalmol. The C.V. Mosby Co.St. Louis, 205.
Putterman, A.M. 1974 Am. J. Ophthalmol 78:1026.
Callahan, A., Callahan, M.A. 1982 Conjunctivo-dacryocystorhinostomy, symposium on diseases and surgery of the lids, lacrimal apparatus and orbit. Trans. New Orleans Acad. Ophthalmol. The C.V. Mosby Co. St. Louis, 123.
Lamping, K., Levine, M. 1983., Arch. Ophthalmol. 101:260.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]
[Table - 1], [Table - 2]