|Year : 1970 | Volume
| Issue : 2 | Page : 69-74
Dacryocystorhinostomy with preparation of a horizontally oval bony ostium
Gajra Raja Medical College, Gwalior, India
M L Agarwal
Gajra Raja Medical College, Gwalior
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Agarwal M L. Dacryocystorhinostomy with preparation of a horizontally oval bony ostium. Indian J Ophthalmol 1970;18:69-74
Fascinated by the apparently simple anastomotic operation with gratifying results, wide variations in technique with wide range of various instruments and materials used, with varied postoperative care, it was thought to undertake a study in Dacryocysto Rhinostomy. In the present paper 83 cases have been studied. The technique, followed, with a modification in the preparation of bony-ostium and flaps, viz. a horizontally oval bony-ostium, short posterior and large anterior flaps, have been described.
| Material and Methods|| |
The cases for this study were selected from the Ophthalmic Out-Patient's Department at Maharaja Yashwant Rao Hospital, Indore during the period 1962-1966. All the cases having a fairly enlarged sac were taken for this surgery. The cases which gave a history of trauma or acute infection were subjected to dacryocystography. Only those cases which demonstrated a fairly enlarged sac with little or no irregularity in the shape of the sac were taken in the series. In all the cases, syringing was done from the lower punctum to exclude obstruction of the lower canaliculus. Nasal examination was conducted in all the cases. The cases showing any gross affection of nasal muscosa were excluded.
| Method|| |
The usual preanaesthetic medications are given on the night before and on the day of the operation. After anaesthetising the nasal mucous membrane, and the conjunctiva with Amethocain (Anethain 1%), the skin over the sac and the lid margins are infiltrated with 20% Lidocain. No local infiltration was done in the cases which were to be operated under general anaesthesia.
| Operation|| |
The lids are sutured to protect cornea from drying and trauma. After usual incision and dissection the medial palpebral ligment is cut at its medial attachment. The periostium just above the anterior lacrimal crest is incised, concentric with the crest. The lacrimal sac alongwith the periostium is reflected laterally up to the posterior lacrimal crest. The periostium on the frontal process of maxilla is pushed up-ward. At this stage, a three pronged retractor is applied to expose the field of operation.
| Resection of Bone|| |
By chisel and hammer the bone from the anterior lacrimal crest is chiselled out gradually so as to make an ostium large enough to allow entry of the punch forceps by which the ostium is enlarged below upto the end of nasolacrimal duct, upwards upto the attachment of medial palpebral ligament, anteriorly upto the nasal bone and posteriorly upto just anterior to the posterior lacrimal crest. Thereby a horizontally oval ostium is prepared, The margins of the ostium are made even and smooth [Figure - 1].
| Preparation of Flaps|| |
Lacrimal Flap - A stab incision is made in the lacrimal sac with its periostium at its upper end, which is extended downwards upto the naso - lacrimal duct so as to leave a small posterior flap and a large anterior flap. The lower end of the sac was cut transversely. This afforded free mobility to the lacrimal sac. A transverse incision was made at the upper end giving an appearance of a "T" shaped incision [Figure - 2]. A lacrimal canula was passed through the lower punctum to identify the sac cavity.
Nasal Flaps:- After removal of the nasal pack, two horizontal incisions are made at the upper and lower extremity of the ostium. A vertical incision is made preparing a small posterior flap and a large anterior flap. The incision gives an appearance of a horizontally placed "H" shaped incision [Figure - 2],[Figure - 3].
| Suturing of the Flaps|| |
Stitching of the anterior and posterior flaps together is effected in the usual way. A couple of anchoring sutures are taken at those spots where the lacrimal flap appears likely to curl upon itself, by taking a suture through the anterior lacrimal flap at that spot and anchoring it to the nasal periosteum. The wound is closed by passing 4-6 interrupted skin sutures by 2-0 black silk. The dressing is done with a firm pressure.
Next day, the dressing is changed and syringing done. Thereafter dressing and syringing are done on alternate days. Skin sutures are removed on ,the 4th to 6th day and dressing is continued for three days more. All the cases are given streptopenicillin 1 gm. intramuscularly daily for 5 days. The patient is advised to come for syringing every week for three or four weeks and then every 15th day. He is advised to report immediately on the slightest epiphora.
| Observation|| |
In this series of 83 cases the age incidence and sex ratio was as follows[Table - 1]
| Probable Etiological Factors|| |
The etiological factors in this series were unknown 52, Trauma 2, Smallpox 7, Trachoma 4, Following delivery 1 and Acute Infection 17 cases.
Out of the 17 cases which had acute infection of the lacrimal sac, 8 cases were treated by surgery and 9 cases responded to medical line of treatment.
Bleeding or oozing of blood is one of the main problems in sac surgery. The bleeding was mainly noticed from the bone in 24 cases, four cases had bleeding from the nasal mucosa and four cases had a tear of the angular vein.
In most of the cases bleeding was checked by using Adrenaline pack. In 5 cases of bleeding from bone, bone wax was used. The angular vein where cut, was sutured.
| Results|| |
Out of the total series of 83 cases, 3 cases had a failure. The percentage of successful result is 96.4 per cent.
The failure was observed in cases No. 22, 71 and 80 within a week of operation. In all these cases, on re-operation, thick granulation tissue was found and therefore dacryocystectomy was done.
| Comments|| |
The usual practice is to prepare a vertically oval bony ostium of 15 mm. x 10-20 mm or so (as reported by Stallard  , Samuel Mepherson and Egleston  , Sarda, Kulshreshtha and Mathur  , Shrivastava  , Mathur  , Romanes  , Jain Sethi and Prakash  , Chandra  . Keith-Lyle and Cross  , prefer to remove entire lacrimal bone, portion of frontal process of maxilla, neighbouring portion of lamina - papyracea of ethomoid. Rycroft  trephines a hole of ¾ x ½ inch. Pathak  removes lacrimal bone and portion of ascending process of maxilla.
Considering anatomically a vertically oval opening is in entire confirmity with vertically elongated lacrimal sac and lacrimal fossa. In the present series, however, a horizontally oval bony ostium has been prepared.
It is advisable to have the largest possible bony ostium, which will allow better access to the nasal mucosa, with easier preparation of the mucous membrane flaps for suturing.
It is not possible to extend the ostium posteriorly upwards or downwards, because of the limits imposed by the posterior lacrimal crest, anterior ethmoidal cells and the bony lacrimal duct respectively. The only way to make it big is to extend it anteriorly, where but for a small vein that passes through the bone, one can safely remove the frontal process of the maxilla and punch out a part of the nasal bone.
A horizontally oval bony ostium [Figure - 2] thus formed is better, safer and easier to prepare with less chances of wrong positioning of ostium„ less chances of encountering ethmoid air cells and better access to nasal mucosa with easy preparation of flaps and suturing.
Flaps and Suturing
Most common procedure for the preparation of flaps is to give an assymetrical "I" shaped incision in the lacrimal sac and nasal mucosa to avoid over-lapping of sutures as stated by Stallard, Y. Dayal, Samuel et al The importance of preparation of big anterior flaps and its suturing have been stressed by Hughes  , Keith-Lyle  et al, Rycroft  , Awasthi and Agarwall, and Prasad and Bajpeyi  .
In this series small posterior and large anterior flaps [Figure - 2],[Figure - 3] have been fashioned and stitched using anchoring stitches in the anterior lacrimal flaps wherever needed. The sac flaps particularly unstitched corners have a tendency to curl upon itself, producing epitheliazation and block. A small posterior sac flap with trimmed corners sutured with a small posterior nasal flap over the posterior margin of the bony ostium, namely posterior lacrimal crest leaves no chance for traction and block. A big anterior sac flap also trimmed and sutured to the big anterior nasal flap affords better approximation with no traction on sutures and forms a continous cover. In a few cases in which the anterior sac flap corners seem to be dropping, one or more anchoring stitches may be applied.
| Conclusion|| |
The success lies in the selection of a proper case. Etiological factors, if the nasal pathology is excluded age and sex have no direct or indirect effect, if the sac to be operated on is enlarged and regular. The bleeding from the bone may be occasionally troublesome and should be controlled effectively on the table. The presence of ethmoid air cells do create a problem during surgery. Its identification and exposure of the nasal mucosa is helped by passing a probe through the affected nostril. A horizontally oval bony ostium is easy to prepare and affords better access to the mucosa. Large anterior flaps and anchoring stitches gives a close and firm cover or the opening and prevent the sac flap to curl upon itself. The skin incision, fixing a tube, insufflation of wound, closure of the wound, post - operative care and syringing have no bearing on the ultimate prognosis of a case.
I am very thankful to Prof. B. K. Dhir & Dr. R. P. Dhanda, at present Professor, Institute of Ophthalmology, B. J. Medical College, Ahmedabad for his help, and guidance, without which the work would have remained incomplete.
| References|| |
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Dayal, Y.; External DCR. - Clinical records of 56 cases; Amer. J. Ophthal. 51, 514, (1961).
Dupuy-Dutems, P. and Bourguet, J.; Ann. Oculist (Paris); 157, 445 (1920).
Hughes, et al.; Dacryocystorhinostomy; Surg. Gynaec. Obst. 73, 375, (1941).
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[Figure - 1], [Figure - 2], [Figure - 3]
[Table - 1], [Table - 2]