|Year : 1967 | Volume
| Issue : 3 | Page : 86-93
University of Oregon Medical School, Portland Oregon, USA
|Date of Web Publication||21-Jan-2008|
L T Jones
University of Oregon Medical School, Portland Oregon
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Jones L T. Conjunctivodacryocystorhinostomy. Indian J Ophthalmol 1967;15:86-93
Epiphora though harmless can be extremely annoying. In an obstructed lacrimal sac, with or without infection, dacryocystorhinostomy has come to be adopted as a routine procedure. There are conditions however where epiphora results from (1) anomalies of the canaliculi (congenital, traumatic or cicatricial) or (2) due to non-functioning of the canaliculi of the lacrimal "pump". Such cases have been neglected or they cease complaining after a few disappointing consultations where they are advised to suffer in silence with a piece of "Kleenex" in their hands. A conjunctivo-dacryocystorhinostomy offers new hope to these unfortunates.
It is necessary first to determine whether there is a mechanical obstruction in the canaliculi, and if so where is it located or whether there is a physiological failure in the propulsion of tears through the lacrimal passages. It is therefore necessary to know the different tests for assessing the situation.
The canaliculus test: This is the routine test of syringing the lacrimal sac. If in the course of the injection, saline comes through the upper canaliculus, the test is positive, indicating that the canaliculi are patent upto their union with each other or with the sac.
The dye tests are of indispensable value in the differential diagnosis of partial obstructions. They tell us whether the epiphora is due to malfunction of the canaliculi or the nasolacrimal duct or to hypersecretion.
a. Primary dye test: One drop of 1% fluorescein solution is instilled in the conjunctival sac. A small cotton-tipped applicator, moistened with a mixture of 1:1,000 epinephrine and 5% cocaine solution, is introduced into the inferior meatus of the nose at intervals from one to five minutes. If the cotton comes out stained with the dye it is a positive test which proves that there is no obstruction in the lacrimal passages and that the epiphora is due to hypersecretion. If after three to five minutes, there is no dye on the cotton, it is a negative test.
b. Secondary dye test: If the result of the primary dye test is negative, the dye is washed from the conjunctival sac. The patient's head is now tipped forward far enough for fluid to run out from the anterior nares into a white tray. One cc of normal saline is injected by a. lacrimal cannula that has been inserted as far as the internal common punctum. If the fluid comes out of the nose stained with the dye, it is a positive test.
A positive secondary dye test proves that there is no obstruction at the puncturn nor in the canaliculus and that the lacrimal pump is functioning as far as the tear sac which fills with the dye. The partial obstruction is in the nasolacrimal duct. If there is no dye in the fluid from the nose, it is a negative test.
A negative secondary dye test proves that no dye has reached the tear sac: the primary cause of the epiphora lies in the canaliculi.
A condition prevails where a swelling which occurs over the lacrimal region, when pressed, empties into the nose. It means that there is a tear sac foreign body, "polyps" or a ball-valve obstruction.
Inspection must also rule out inverted, everted or phimotic puncta, canalicular foreign bodies, fungi and neoplasma, allergic edema and inflammations of the ducts as being the cause of the epiphora. Epiphora due to lacrimal hypersecretion is never an indication for surgery on the lacrimal excretory mechanism.
| Surgical Procedures|| |
Epiphora due to destruction of the lateral halves of the canaliculi usually can be cured by an intermarginal slitting of the patent medial parts. A closure of 2.0 mm or less of the nasal ends of the canaliculi often can be reopened. Both of these procedures have been reported previously - Jones (1962).
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 either of glass or one lined with epithelium, that possesses capillary attraction combined with a negative pressure exerted at its nasal end. This latter factor is furnished by the negative pressure phase, in the nose, of inspired air.
In our experience, there are only three acceptable types of surgery for canaliculur failure: (1) conjunctivodacryocystostomy, (2) conjunctivodacryocystorhinostomy (CDCR) and (3) conjunctivorhinostomy (CR). Many doctors prefer the term "laco" instead of "conjunctivo". The term conjunctivorhinostomy (CR) is used only in cases in which the tear sac is absent, removed or not functioning.
Partial excision of the tear gland as a means of reducing epiphora is now obsolete.
| Conjunctivodacryocystostomy (CD)|| |
The fundus of the sac is first mobilized through the regular incision for exposing the sac.
[Figure - 1]. illustrates how the fundus of the sac can be pulled up through a stab incision in the lacus and can be stitched to the conjunctival incision.
The disadvantages are: (1) Difficulty of adequate mobilization of the fundus (2) Difficulty in keeping the ostium from closing. (3) a tube with a collar inserted into the ostium to keep it open will rise above the lacus with lid movements and prevent drainage. (4) the pumping effect of the preseptal muscles is lost.
| 2. Conjunctivodacryocystorhinostomy (CDCR)|| |
The following technique is offered as the most successful form of treatment in all cases of nonfunctioning canaliculi with or without a tear sac.
However, no ophthalmologist should attempt this procedure unless he is willing to observe the intranasal end of the tube and ostium, at nearly every postoperative visit, or, in lieu of this, to work closely with a rhinologist.
A preliminary nasal inspection must be made to rule out obstruction that might impinge on the end of the tube or impair the airway. If nasal surgery is necessary, it should be done as a preliminary procedure, although it can be done at the same time as the lacrimal surgery.
The operation is done preferably under a local anesthetic with 2% novocain with adrenalin. Besides the regional anesthesia, a small amount is injected lateral to the sac, posterior to the septum orbitale. The nasal mucous membrane is anesthetised with a pack of 10% cocaine with adrenalin, particularly in the region over the anterior end of the middle turbinate.
Tilting the table about 20˚ down towards the feet helps hemostasis.
Standing by the side of the patient while operating, the operator has better visibility of the bony mall. From this position the medial palpebral tendon need not be cut and looking up under the ligament one can tell when enough bone has been removed to clear the area for the new passage into the nose.
The steps of the operation are the same as those for doing a dacryocystorhinostomy. We mention below some salient points which we observe during this procedure.
(1) We make the incision 11 mm medial to the medial commisure beginning slightly above the level of the medial palpebral ligament, extending downwards and outwards for an inch and a quarter.
(2) We dissect the sac with the periosteum from the underlying bone from 5 mm. medial to and below the margin of the anterior lacrimal crest, (dotted line in [Figure - 3]) to the posterior lacrimal crest.
(3) We insert a small sponge dipped in 10% cocain with adrenalin solution between the raised periosteum and the hone to protect the sac from damage during the chiselling and removal of bone. It also acts as a hemostatic and supplements the anesthesia.
(4) We remove not only the medial wall of the fossa but also the medial part of the naso-lacrimal canal. The nasal muco periosteum is separated first from the canal down to the inferior turbinate. [Figure - 4]. A flat chisel is used to separate the anterior attachment of the canal from the maxilla. The posterior attachment is so thin that it usually breaks when the anterior attachment is severed. The bone is then mobilized and removed with a straight hemostat. A good rule in all tear sac surgery is never to have a bony margin nearer than 5 mm to the internal common punctum.
(5) The medial palpebral tendon should never be cut as it is a most important guide for placing the tube later.
After the posterior flaps of the tear sac and nasal mucous membrane are sutured with cat-gut (plain 4-0), when CDCR is planned, before the anterior flaps are sutured, the tube is inserted in the following way. The caruncle is first excised, being careful not to remove any of the adjacent conjunctival tissue with it, A 23-wage hypodermic needle, 30 mm long, is bent into a curve so that the point of the needle is on the inside of the curve. The needle should be held with the concavity of the curve facing anteriorly. The point is then inserted in the lacus exactly 2.0 mm posterior to the cutaneous margin of the canthal angle, It is then pushed in a direction that will cause its point to emerge just posterior to the anterior tear sac flap and slightly below the level of the palpebral fissure [Figure - 5]. It must be anterior to the body of the ethmoid and middle turbinate, whose anterior end should be resected if it interferes with the tip of the needle. see [Figure - 4].
A cataract knife of medium width is then inserted into the sac, following the guide needle. The needle is then removed and the knife [Figure - 6] enlarges the passage superiorly and inferiorly just enough to allow insertion of a No. 240 polyethylene tube. Do not remove the knife until the tube is in place, as will be described later.
The tube should have a collar at least 4.0 mm wide. It should be about 18 mm long and have a bevelled end. It is threaded collar first, over a No. 1 lacrimal probe, which is then passed along the flat side of the knife and the probe and is then pushed through the new passage. A 6-0 black silk suture on a cutting needle is passed through the collar of the tube and out through the adjoining skin of the commisure and tied. If the nasal end of the tube touches the septum, it is cut shorter.
Two or more sutures are now placed in the anterior tear sac and nasal mucosal flaps. The periosteum is similarly closed and the skin united with a running mattress suture of 6-0 black silk.
The polyethylene tube may be left in until the postoperative swelling subsides. However, a pyrex glass tube may be substituted any time after a week. The glass tubes recommended are 2.0 mm in outside diameter with a rounded 4.0 mm collar and a 2.25 mm enlargement at the nasal end [Figure - 7]. If the mouth of the tube lies at a poor angle in the lacus and does not drain well, a slight angle to the tube may be of value. After a month or two, a tube with a 3.0 mm collar is substituted for the 4.0 mm one [Figure - 8].
The glass tube has the advantage of being less irritating to the tissues. It possesses capillary attraction and does not get obstructed with secretions as easly as the plastic tube [Figure - 8].
(Following parotid duct transplantation, a tube with a slightly larger diameter might be adequate.)
Due to the invasion of fibroblasts, the new passage will contract down about the tube within a few minutes in the early postoperative stage. But in the later stages, contraction becomes greatly diminished the tube becomes loose and is often blown out or lost. This usually occurs about 18 to 24 months after the surgery. The patient must be taught not to blow his nose, or to hold his finger over the tube if he does.
This procedure is undertaken in the absence of the lacrimal sac. Several methods are available.
a). Instead of suturing the nasal mucosal flaps to the flaps of the tear sac, as in the operation just described, the nasal flaps are sutured to flaps fashioned from the lacrimal facia anterior and posterior to the point where the guide needle emerges. The technique of insertion of the tube is as mentioned above. It is necessary for the tube to hear "soft-tissue" suspension, so that it has free movement without contact with rigid structures during blinking.
b) Mucous Membrane flaps: Conjunctiva and nasal mucous membrane flaps converted into epithelial lined tubes have been advocated in cases without a tear sac. [Figure - 9] illustrates how a flap can be raised from the nasal mucosa opposite the middle concha and converted into a tube by rolling the lower end up and stitching it to the upper end. With the tear sac removed there should be no bone or mucous membrane separating the newly formed tube from the conjunctiva. After making a tract through the lacus with a needle and knife (as before) the tube is rolled into the conjunctival opening and secured into position by slipping the epithelial lined tube over a polyethylene tube.
c) Epithelial transplants: It would be easier to prepare an epithelial-lined tube from a thin graft taken from the buccal mucous membrane and suture it around a 3.0 mm polyethylene tube. The tube with the graft is inserted from the conjunctiva into the nose as described below. The tube may be removed subsequently but it may be necessary to insert a glass tube as described later to salvage a threatened closure.
| Postoperative Care|| |
Most of these cases will require very little postoperative care, but some will challenge the ingenuity of the surgeon. In our experience, every case can be saved as long as the nasal airway is patent.
| Complications|| |
a. The tube may come out. The patient must be seen as soon as possible. During the first few weeks, simply dilate the passage with a curved Ziegler punctum dilator and a Ziegler No. 12 probe (made by Sklar). The pyrex tube, threaded, over a No. 1 Bowman probe, can then easily be reinserted.
If the tube has been out too long and the passage has closed, inject about 0.5 cc of 2% novocaine with adrenaline solution above and below the medial canthus and cocainize the nasal mucosa in front of the middle turbinate. Install the tube by repassing the guide needle under intranasal inspection etc., as previously described. This can be done as an office procedure.
b. Infection with or without granulation tissue. This is usually due to the formation of a rough, hard, scalelike coating on the outside of the tube. A mucopurulent discharge is usually seen whenever the outside of the tube gets this deposit. Pressure from the collar of the tube against the upper lid and conjunctiva may also cause it. In one or two cases it has developed at the nasal end of the tube.
The cure is simple-the tube is removed and cleaned and replaced after the granulation tissue has been excised.
c. The tube becomes obstructed. This usually denotes a conjunctival or nasal allergy or infection. The patient or one of his family is given a wire (such as the stylet which comes with 30 mm long hypodermic needles) and taught how to pass it through the tube to open it. Mucous accumulations around the nasal end may be removed with forceps. The patient is taught to use a daily nasal douche of normal saline, or "squirt" normal saline through with a medicine dropper.
d. The collar of the tube becomes partially or completely submerged. This is usually found in patients who habitually press on the tube or have a narrow canthal angle and do an abnormal amount of squeezing. The tissue over the collar should be cocainized and a Bowman No. 1 probe passed through the tube (this can usually be done even though the collar is completely submerged). The nasal mucosa is then cocainized and the tube is pushed back out along the probe with a small ring curette or spatula. If this fails, novocaine is injected around the collar and the constricting ring of tissue is cut with a pointed Bard-Parker blade or small pointed scissors. The intranasal procedure is then repeated.
e. The tube may drain poorly after several months. As the scar tissue at the medial canthus begins to relax, the tube sinks deeper into the nose and often rides against the nasal septum.
Whenever the surgeon can see that the tube is protruding more than 2.0 mm into the nose, it should be taken out and exchanged for a shorter one.
| Comment|| |
The question that is most frequently asked is "How long will the patient have to wear the tube?" This seems to depend on how long it takes the new passage to epithelize and when the fibroblasts in its walls will cease to contract. Cases in which canalicular epithelium helps line the passage do the best. In almost all cases the tube will begin to get looser after about one year. This is a sign that the fibroblastic contraction is diminishing.
The patient can buy the dilator shown in [Figure - 7] and be taught how to use it. He or one of his family, begins by learning to take the pyrex tube out and immediately reinserting it. He then learns to take the tube out, a few minutes and then put the dilator in for a while, always replacing the tube after withdrawing the dilator. Each day the interval of time between taking the tube out and putting the dilator in, is increased until he can take the tube out in the morning and insert the dilator in the evening. From that time on the patient can discontinue the use of the tube and use the dilator just often enough to keep the passage from contracting. One patient has solved the problem by working up to the point where she can take the tube out in the morning and reinsert it at night.
The question has been raised as to whether this operation is justified for the relief of epiphora alone, for only in an occasional traumatic case is there an infection medial to the canaliculi. Certainly, no patient with a minor handicap from epiphora should be encouraged to have the surgery. Elderly patients with the pseudo-epiphora of beginning decrease in function of the basic lacrimal glands (mucin-secreting conjunctival goblet cells, accessory lacrimal glands of Kraus and Wolfring, and oil producing glands) should not have the surgery. The condition can be diagnosed by instilling one or two drops of a local anesthetic into the conjunctival sac of both eyes and, after waiting a minute or two and drying the eye, taking a Schirmer test, the result of which is lower than normal.
Patients who are truly handicapped by epiphora are, however, most grateful for their relief. Children who feel socially rejected because of their tearing eye make remarkable adjustments.
| Summary|| |
In every case of disturbing epiphora due to a permanent failure of the canaliculi, a new passage should be created through which the tears can be propelled. A glass tube or an epitheliallined passage, possessing capillary attraction combined with the negative pressure phase of tidal respiration in the nose, is a satisfactory substitute for the lacrimal pump.
Various methods of creating such a passage are discussed and our experience with a conjunctivodacryostorhinostomy is given. In this procedure a pyrex glass tube is used until the new passage is completely epithelized and ceases to constrict.
| References|| |
Waldapfel, R.: (1953) Tr. Pacific Coast Oto-Ophth. Soc., 34: 289.
Jones, L. T.: (1962) Tr. Am. Acad Ophth., 66: 511; 66: 514, 523.
- : (1956) Tr. Pacific Coast Oto-Ophth. Soc.. 37: 59.
--: (1961) Arch. Ophth.. 66: 111-124
Ohm, J.: (1926) Klin. Monatsbl. 77: 825-832.
Dupuy-Dutemps, and Bourguet: (1921) Bull. Acad. Nat. Med., p. 293.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9]