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| ARTICLES |
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| Year : 1955 | Volume
: 3
| Issue : 2 | Page : 37-44 |
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Dacryocystorhinostomy- A simplified technique with analysis of results
NS Jain, DV Sethi, OM Prakash
Department of Ophthalmology, Irwin Hospital, New Delhi, India
Correspondence Address:
N S Jain
Department of Ophthalmology, Irwin Hospital, New Delhi
India
 Source of Support: None, Conflict of Interest: None  | Check |
How to cite this article:
Jain N S, Sethi D V, Prakash O. Dacryocystorhinostomy- A simplified technique with analysis of results. Indian J Ophthalmol 1955;3:37-44 |
This paper is written with a view to describe a simplified technique of stitching both the anterior and the posterior flaps of the nasal membrane with those of the lacrimal sac, and to draw particular attention to practical points from our experience on ninety-five cases on whom dacryocystorhinostomy was performed. Many surgeons having experienced difficulties in suturing the two flaps have not felt encouraged to perform this otherwise simple and effective operation for the relief of epiphora due to a blocked nasolacrimal passage.
After Toti (1904) recommended drainage by removal of the bony wall, Kuhnt (1914) advocated anastamosis, but Ohm (1920) was the first to mention anastamosis by suturing both the anterior and the posterior flaps.
| Technique of Operation | |  |
A local or a general anaesthetic is employed, depending upon the age and mental attitude of the patient. In either case we pack the nasal cavity tightly with ribbon gauze soaked in 2 % Anethaine and adrenalin solution.
A vertically straight incision, 2 cm. long with its upper limit in level with the inner canthus and 1 cm. nasally to it is made boldly down to the bone in one sweep. With rugine the entire bony surface (area anterior and posterior to the anterior lacrimal crest) is exposed and the soft structures, including the lacrimal sac, retracted laterally away from the lacrimal fossa.
A sharp chisel is placed 7 mm. anterior to the anterior lacrimal crest and parallel to it and a cut is marked by gentle hammering. This line is enlarged to approximately 1.5 cm. so that its lower end is in level with the commencement of the nasolacrimal canal. Then two horizontal cuts are made from the upper and the lower ends of this vertical cut about 1.0 cm. long laterally towards the lacrimal fossa. The three cuts are deepened slowly and carefully to avoid injury to the underlying nasal mucous membrane. It is unnecessary to make a fourth cut posteriorly in the lacrimal fossa to make a complete rectangular bony window. With the rugine passed through the vertical cut between the nasal bone and the nasal mucous membrane the lateral bony piece marked out to be removed is levered away from the entire mucous membrane. This manouvre mobilises the bony piece which breaks posteriorly in the thin lacrimal fossa anterior to the anterior ethmoidal cells. A neatly cut bony window of the size of about 1.0 cm. transversely and 1.5 cm. vertically always results therefrom leaving the underlying nasal mucous membrane in tact. [Figure - 1].
The nasal pack is now removed and two mattress sutures with black silk and round bodied half circle needles of about 1.0 cm. size are passed a little anterior and posterior to the proposed longitudinal incision in the centre of the exposed nasal mucous membrane [Figure - 2]. The lower mattress suture intended to be in the posterior flap of the nasal mucous membrane is double armed. These sutures are pulled outwards and a vertical cut made in the mucous membrane between the two sutures. Two horizontal cuts at the upper and the lower ends of the vertical incision help to make the anterior and the posterior flaps in the nasal mucous membrane like a capital "I". With an iris hook passed under these flaps by turns the inner loop of the mattress suture is pulled out through the slit [Figure - 3]. The loops are divided in the centre to result in two interrupted sutures in each flap of the nasal mucous membrane.
A probe is now passed through the inferior punctum and the canaliculus into the sac and pushed medically to elevate the medial sac wall. A stab wound made in the medial sac wall with a pointed knife and enlarged upwards and downwards with the scissors results in two flaps in the medical sac wall. [Figure - 2],[Figure - 3].
The posterior flap of the nasal mucous membrane is now stitched with that of the lacrimal sac by needles already threaded to result in two interrupted sutures.
For suturing the anterior flaps the previously threaded needle is removed and needles threaded to the other ends brought out from inside by the iris hook. These are passed through the anterior flap of the sac wall [Figure - 4] and this and the anterior flap of the nasal mucous membrane are tied together to make the anterior wall of the new passage.
The skin edges are sutured in one layer only by interrupted or subcuticular stitches, a gauze roll placed on it, and the eye bandaged tightly. The patient is sent home or stays in the ward as the case may be.
POST OPERATIVE TREATMENT: Post operative treatment consists of sedatives given when necessary and antibiotics, as a rule, for 4 or 5 days.
First dressing is done after 48 ours, when, if there is no particular reactionary swelling, an adhesive tape is applied on the wound and the eye left open. At this time the nasal cavity is inspected and cleaned gently of any blood clot that may be present.
Fifth or the sixth day the skin stitches are removed and the passage syringed for the first time with penicillin solution. Syringing is repeated after a week and the nasal cavity re-examined.
Most cases were followed upto three months and told to report thereafter in the event of a recurrence of epiphora.
| Incidence | | |
334 cases of dacryocystitis were treated during the period 1950 to 1955. Out of these 36 were in acute abscess form which required incision. Of they remaining 298 cases excision of the lacrimal sac was done in 203 and dacryocystorhinostomy in 95 cases.
[Table - 4] shows the different age groups in both sexes on whom dacryocystorhinostomy was performed.
| Discussion | | |
Pre-operative treatment :- In the preoperative care tight packing of the nasal cavity needs emphasis. The advantages are that it prevents damage to the underlying nasal mucous membrane while making the bony window during the operation and also minimizes bleeding. We have resorted to this as a routine and advocate the same from our experience of forty-five cases operated by Toti's technique and in most of our initial cases we failed to stitch largely because of lack of support to the underlying mucous membrane which got lacerated, sometimes very badly, as to preclude the possibility of getting the flaps for purposes of suturing.
Incision:- In agreement with Hallum, (1943) we make the incision well forwards, straight and bold down to the bone in one sweep. By doing this the angular vein is never cut and there is almost no bleeding. This gives an undoubtedly larger field and better visibility. There has never been the necessity of cutting the internal palpebral ligament in our series as recommended by DupuyDutemps (1920). Such an incision also avoids damage to the lacrimal sac. The disadvantage of the curved incision placed too near the inner canthus is reported to result in a mongoloid fold (Lyle, Cross, Simpson and Fraser, 1946) and contraction of the scar tissue accentuating the scar itself (Mosher 1937 and Hogan 1948).
Bony Window:- The bony window should be large and so far forwards as to be anterior to the anterior end of the middle turbinate and so low down as to avoid the anterior ethmoidal cells. More than half of the antero-posterior diameter of the osteum should be anterior to the anterior lacrimal crest. This renders the making of the two flaps in the nasal mucous membrane easier and facilitates suturing.
Bony edges should be sharp without any spicules. This is quite easily possible even with a sharp chisel and hammer since in none of our ninety-five cases the burr or the punch was available to us.
Anastainosis :- Round bodied half circle needles of about one centimetre size are the best as the cutting needles cut through the mucous membrane thus making their edges ragged and torn so as to make interrupted suturing impossible. In our initial cases this was one of the added causes of our failure to stitch both the flaps.
While making the flaps in the medial wall of the lacrimal sac care should be taken to avoid injury in the region of the entry of the lower canaliculus into the sac, since this may subsequently lead to failure by fibrous stricture.
Once both the flaps are sutured the opening gets lined with epithelium, thus preventing granulation tissue formation and minimizing the chances of closure, the lacrimal sac draining into the nose like any chronic sinus lined with epithelium.
Chandler's (1936) modification of making three flaps by a "T" shaped incision does not appear td us as simple and practical particularly when many ophthalmologists have not found even simple suturing of the anterior and posterior flaps easy.
Sometimes when the nasal mucous membrane is fragile suturing becomes impossible and cannot be helped. In certain cases it is impossible to obtain satisfactory flaps from the medial sac wall on account of its, being fibrosed, or being of a small size and in a pseudo-sac that has formed after a previous excision. In such cases a good functional result may be obtained by suturing a single anterior flap of the nasal mucous membrane to the soft tissues just anterior to the entry of the lacrimal canaliculus into the sac (Lyle, Cross, Simpson and Fraser 1946).
In our opinion if the anterior flap cannot be made in the mucous membrane of the nose the anterior flap from the sac should not be stitched to the muscle and the subcutaneous tissues anterior to the anterior end of the bony osteum. This was adopted in two cases and both rusulted in closure by fibrous tissue contraction.
Skin suturing:- In our opinion one layer stitching of the skin edges is no disadvantage and we definitely do not favour two layer stitching particularly where it has not been possible to make the anterior wall of the new passage by suturing the two anterior flaps of the lacrimal sac and the nasal mucous membrane. In such an event contraction of the subcutaneous scar tissue causes kinking and closure of the lacrimal canaliculus. This happened in two of our cases.
Dressing:- After the operation we recommend keeping a gauze roll on the site of the operation and a pressure bandage. This prevents tissue oedema and reactionary swelling. In our cases where this procedure was adopted there was no necessity of bandaging the eye on the third day at the time of the first dressing. Merely an adhesive tape was applied over the field of operation and the eye was left open.
Post-operative treatment :- Nursing is never done by us in a face down position as recommended by Hallum (1943).
We agree with Lyle that probing or frequent syringing is unnecessary after the operation, and at the end of the first week absence of patency on gentle syringing indicates failure, unless a temporary removable nasal factor such as a blood clot is present. In one case of ours this was present and when removed patency was easily restored.
In one case, a female, when syringing on the sixth day showed blockage due to stricture, six repeated probings to dilate the canaliculus on alternate days established patency. Cortisone drops were prescribed and there is no epiphora now.
We have used cortisone suspension for syringing and as drops in half a dozen cases, especially in the ones that had been operated a second time for closure by granulation tissue. The results have been encouraging. Although it is too early to give a conclusive opinion of its actual role, yet we feel that it does help to keep the passage patent by inhibiting the formation of granulation tissue.
Complications:- During the operation the complications met with in our series are shown in [Table - 6].
Most of these complications were noted in our early cases. Delayed complications are shown in [Table - 2].
Sometimes epiphora is presistant inspite of a patent passage and is possibly due to kinking or tortuosity of the channel as suggested by Chandler (1936).
INDICATIONS AND CONTRAINDICATIONS:- Obstruction of the lower canaliculus and a malignant neoplasm of the lacrimal sac are absolute contraindications to dacryocystorhinostomy (Lyle, Cross, Simpson and Fraser, 1946). Tuberculosis of the lacrimal sac has also been mentioned as a contraindication.
Cases with acute dacryocystitis are operated upon later when the acute stage has first been treated conservatively.
Amongst the nasal causes subjects with atrophic rhinitis and gross nasal pathology, not amenable to previous treatment, are not suitable for dacryocystorhinostomy. Lyle, Cross, Simpson and Fraser (1946) advocate removal of a nasal polypus or an enlarged middle turbinate prior to the operation, but we agree with Hallum (1948) that a small polypus or a turbinate can be excised from outside at the time of the operation.
We have never encountered a case with a polypus, but in two cases with a moderate enlargement of the turbinate turbinectomy from outside through the bony window gave a satisfactory result.
We feel, therefore, that apart from the aforesaid points, all cases with epiphora or regurgitation through the canaliculus on pressure upon the sac, with or without a definite permanent obstruction of the nasolacrimal duct (including atonic sacs), with or without a lacrimal fistula, or even cases where a previous dacryocystectomy has been done, irrespective of the age, are suitable cases for dacryocystorhinostomy.
| Comments | | |
The various factors discussed in this paper show that the maximum number of failures and complications occurred in cases in which we had failed to suture both the flaps. We do not agree with Shuttleworth (1949) when he says that the exact technique of the operation does not matter in the ulimate result. We agree with Traquair (1941) that the external dacryocystorhinostomy gives excellent results even in the hands of relatively inexperienced operators, but maintain this provided proper suturing of both the flaps is achieved, which too, in our opinion, with the technique of suturing described by us should be easy for a relatively less experienced surgeon.
Whereas Chandler and Rychener (1936) quote 100% success with Chandler's technique and Traquair (1941) 90 to 95% success, our results by suturing both the flaps with our technique compare favourably with them, the percentage of success being 93 . 1. Hogan (1948), Martin and Cordes (1929) quote 85 to 95%; Lyle, Cross, Simpson and Fraser (1946) 78 and Dupuy-Dutemps (1920) 94% success. With Toti's technique we obtained only 64 . 4% success as compared to 72% obtained by Chandler and 50% by Tyrrell (1944-'45).
| Summary | | |
A simplified technique of anastamosis between the lacrimal sac and the nasal mucous membrane is described in the operation of dacryocystorhinostomy. Report on 95 cases is given to emphasize that stitching of both the flaps as advocated by Ohm, gives the best results-93 . 1% success against 64 . 4% by Toti's technique in our series. Complications and causes of failure are discussed and measures to minimise them recommended. The role of postoperative syringing with cortisone solution is suggested to prevent closure by granulation tissue, particularly where anastamosis has not been successfully performed.[12]
| References | | |
| 1. | Chandler, P. A. & Rychener (1936) - Trans. Am. Ophth. Soc., 34, 240-263.  |
| 2. | Dupuy-Dutemps (1920) - Ann. d'ocul., 157, 445. |
| 3. | Garfin, S. W. (1942) - Arch. Ophth., 27, 167-188. |
| 4. | Hallum, A. V. (1943) - J. M. A. Georgia, 32, 186-189. (1948) - Trans. Am. Oph. Soc., 46, 243-261. |
| 5. | Hogan, M. J. (1948) - Trans. Am. Ac. of Oph. & Otol., 52, 600-612. |
| 6. | Kuhnt, H. (1914) - Zeutralbl. f. d. ges. ophth. 1, 30. |
| 7. | Lyle, T. K., Cross, A. G., Simpson, J. F., Fraser, G. A. (1946) - Brit. J. Ophth., 30, 102-119. |
| 8. | Martin, R. C. (1933) - Trans. Pacific Coast Oto-ophth. Soc., 21, 50-58. |
| 9. | Martin, R. C. & Cordes, F. C. (1929) - Califor. & West Med., 31, 1-7. |
| 10. | Mosher, H. P. (1921) - Laryngoscope, 31, 492-521. |
| 11. | Traquair, H. M. (1941) - Arch. Ophth., 26, 165-180. |
| 12. | Tyrrell, T. M. (1944-45) - Proc. Royal Soc. Med., 38, 472. |
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6]
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