|Year : 1961 | Volume
| Issue : 4 | Page : 82-86
Dacryo-rhinostomy in absence of SAC
|Date of Web Publication||7-Apr-2008|
D B Chandra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Chandra D B. Dacryo-rhinostomy in absence of SAC. Indian J Ophthalmol 1961;9:82-6
This operation in its original form was first practised and reported by H. Arruga in 1935. It aims at the re-establishment of tear drainage from the eye to the nose in cases in which the sac is absent, mostly due to an excision done earlier, leading to an intractable epiphora. It is especially indicated in educated and sensitive individuals whose constant epiphora has compelled them to carry a kerchief continuously in their hands also leading to a sense of inferiority besides the perpetual discomfort.
Arruga emphasises as an essential pre-requisite, the permeability of the lacrimal canaliculi, especially the lower, to a point corresponding to the entrance of the extirpated sac for at least a distance of 5-6 mm. We feel that while it is desirable that the canaliculi be patent to that length, the operation can be successfully performed with necessary modifications in cases otherwise too. While Arruga's technique consists of the dissection of tissue in the canalicular area with creation of lips and their ultimate suturing with nasal mucosa flaps, our modification suggests a fashioning of flaps in the mode of Rycrofts technique of dacryocystorhinostomy, intubation with dilatation of the upper and lower canaliculi and the placement of a Rhinostomy tube to ensure better results.
The operation can be performed either under general or local anaesthesia with provisions of intratracheal tube in the general and pethedine premedication in the local.
Incision. While we employ the anterior and medial incision in cases of dacryocystorhinostomy with sac, it is our feeling that the lateral incision is more suitable in cases of absent sac. In these, in the case of medial incision, the traction on the medial terminal of the canaliculi is more, besides the added difficulty in the dissection of tissue contiguous to the canaliculi for fashioning the lip or flap on this end. After the skin incision, the tissue beneath is incised towards the bone at the level of the anterior lacrimal crest and the scar tissue is dissected and separated from the bone to the posterior lacrimal crest, which leaves a wound having two surfaces-a lateral and a medial. [Figure - 1].
Perforation of the bone. We use the hand operated Arruga-Rycroft trephines. Here, it is particularly important to have a large opening in the bone 2 cm. x 1.5 cm. especially in the thick part, as there must be sufficient amount of nasal mucosa to bring it up to the internal end of the lower canaliculus. The bony opening is enlarged to the requisite dimensions by suitable forceps and it is better to level the bony margin with cylindrical drills to facilitate the passage of the nasal mucosa.
Fashioning of Flaps .-(a) Tissue canaliculus-A probe now is passed through the lower canaliculus to protrude into the lateral surface of the opened wound in the soft tissue [Figure - 2]. A vertical incision is made in the tissue covering the end of the probe [Figure - 3]. This incision is enlarged 4.6 mm. up and down, fashioning an anterior and a posterior lip. In contra-distinction to the classical Arruga's technique we convert these lips into rectangular flaps on the lines suggested by Rycroft for his D. C. R. operations. This facilitates suturing of the flaps and does away with the traction on the external flaps.
(b) Nasal Mucosa.-The nasal mucosa is caught by a forceps in the centre of the bony opening and is pulled outside to assess its point of correspondence with the incision in the tissue-canaliculus incision after which it is incised and corresponding anterior and posterior flaps are fashioned.
Intubation of the canaliculi and the placement of rhinostomy tube - First the canaliculi are dilated by an ordinary canaliculus dilator or probe after which a 9" length of dermalon, nylon or thick silk are threaded through the canaliculi into the wound either by their own weight and stiffness or on a blunt, rounded needle. Both the upper and lower threads are secured and kept aside. After the posterior flaps are sutured and tied, a rhinostomy tube or No. 6 size rubber catheter is put in the bed created by the approximation of the posterior flaps. The upper end of the tube is anchored to the upper-most part of the bed and the lower end is passed through the rhinostomy and out through the nostril. Now, the two intubing threads are placed on either side of the rhinostomy tube and brought out through the nostril below in the same fashion. Both of them are looped separately and the upper thread is stuck to the forehead by a elastoplast while the lower one on the cheek. Care is taken to avoid any rubbing of the cornea by either of these threads [Figure - 5].
Suturing of the Flaps-Arruga advises the approximation of the nasal mucosa to the same margin of the opening where the lacrimal canaliculi terminate and considers this as the secret of the operative success because in his original technique-"the epithelium of the nasal mucosa must eventually become continuous with the epithelium lining the canaliculus, which is the best guarantee of cure." While we agree in principle it is our contention, however, that with the modified procedure of canalicular intubation plus the use of rhinostomy tube, the hazards of the classical technique are very much obviated. Three sutures each are used for suturing the anterior and posterior flaps in the usual way [Figure - 4], special care being taken about the central sutures to avoid injury to the canaliculi.
Post Operative:-Daily irrigation and wash for 10-15 days with penicillin 1 in 5,000 lotion. Cutaneous sutures are off on the 7th day. The patient is discharged on the 15th day after removing the canalicular thread and the rhinostomy tube. Weekly syringing is done thereafter till 8 weeks and thereby monthly check up is advised.
| Case Reports|| |
1. A male, aged 41, a postal clerk was operated upon for extirpation of left sac 2:; years before. Epiphora after the operation was excessive and patient had a miserable time especially during cold and windy weather and while working in the office. A classical Arruga's Dacryrhinostomy was done without canalicular intubation or rhinostomy tube. The immediate post-operative result was very good and the patient was very comfortable till about 3 months after which he came back with his old complaint of excessive epiphora. Probing was tried twice without relief. A conjunctivo-rhinostomy was advised but the patient did not agree for another operation. It is possible that in this case, the eventual continuity of the epithelium of the nasal mucosci with the epithelium lining the canaliculus did not occur, causing a stenosis and obstruction of the newly formed passage.
2. A female, aged 23, housewife was originally a case of chronic dacryocystitis, right side, for which excision of the sac was done in some district hospital in 1957. Later in early 1959, she developed chronic dacryocystitis of the left side also and came to us for treatment also complaining about the constant epiphora on the right side. A dacryocystorhinostomy was done on the left side and astringent drops were prescribed for the right eye. After two months, the patient came back complaining about the epiphora on the right side. Now that she could compare the difference between the two sides, viz. one side sac absent and the other a functioning rhinostomy, she was all the more insistant that the same operation be done on the previously operated side. The modified dacryorhinostomy was done in October 1959. The patient is related to a wardboy of the hospital and has been reporting complete relief from excessive epiphora.
3. A male, aged 28 years, a college teacher, was operated upon for dacryocystectomy right side five years before. He had been using various astringent drops with no relief and was extremely bothered by the kerchief habit. While lecturing in the class room, he had to hold his kerchief in the left hand to wipe his right eye in order to keep the right hand free to write on the black board. This act was particularly disturbing to him. The modified technique was adopted and he was operated upon in Feb. '60. He has satisfactory relief from epiphora up to date.
4. A female, aged 10 years, a student, was operated for dacryocystectomy right side 10 years back. Constant epiphora had been persisting and now that she was growing up, she was more conscious of this handicap esthetically in addition to the physical discomfort. A sense of inferiority was also creeping in due to the redicules from class-mates. The operation of modified dacryorhinostomy was first attempted under local anaesthesia but the patient became hysterical immediately after incision. The operation was again undertaken under general anaesthesia after a week and the result is extremely gratifying. This patient has left the hospital only about a month ago and the follow-up continues.
5. This case cited here is not strictly a case of dacryorhinostomy but it is somewhat a cross between dacryocysto-rhinostomy and dacryorhinostomy. While performing a dacryocysto-rhinostomy on a female, aged 26 years, house-wife, under local anaesthesia, we met with two very bad complications, viz. severe bleeding and extremely fragile nasal mucous membrane. The anterior flap of the nasal mucous membrane tore out during manipulation while opposing it with the anterior flap of the sac. We were, therefore, obliged to suture the anterior flap of the sac with the tissue contiguous to the area of the anterior nasal flap. A very careful follow up has been taken in this case and repeated syringings have been continued. The case continues to show very good results up to date in a follow up of six weeks.
Considering the number of dacryocystectomies performed in our country, it is rather strange that we have not been able to get more cases for the new operation. We feel that it is due partly to the adaptation of the lacrimal apparatus after sac excision and partly due to the reticence of the patients to undergo another operation. Obviously, a record of five cases only is extremely insufficient to form conclusive opinion regarding the efficacy of the new operation. Nevertheless, it has possibilities and I have put this preliminary report before you mainly to stimulate interest and provide data for attempting it.
| Summary|| |
Arruga's technique for this operation is modified by placement tubes in the upper and lower canaliculi and the rhinostomy opening. Five cases are described.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9]
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