|Year : 1975 | Volume
| Issue : 3 | Page : 16-19
Anastomotic surgery after the operation of dacryocystectomy
King George's Medical College, Lucknow, India
R C Saxena
Department of Ophthalmology, King George's Medical College, Lucknow
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Saxena R C. Anastomotic surgery after the operation of dacryocystectomy. Indian J Ophthalmol 1975;23:16-9
In our country, the treatment by dacryocystectomy still exists at many ophthalmic centres. Majority of the cases treated there continue to have epiphora, and unfortuately, a fair number even return back with recurrance of dacryocystitis. Since more than a decade, it has been realised that anastomotic procedures could be the method of choice in few of them also ,, .
During last 5 years the author of this paper has come across as many as 152 such cases with symptoms of epiphora, where dacryocystectomy was performed in past in one or the other ophthalmic centre. Out of them, 46 cases showed regurgitation on pressure. All these cases were screened thoroughly and those who were found suitable, were subjected to one of the anastomotic procedures. In this paper an effort is being made to present their method of screening, the surgical technique and their results.
| Material and Method|| |
Out of the 152 cases, 146 cases were operated once, 5 cases twice and I case thrice. In all, 3 cases had bilateral involvement. Thus the 155 eyes were examined.
All the eyes were subjected to the following procedures to assess if anastomotic surgery was possible.
1. The medial canthus was pressed to study the regurgitation. The presence of regurgitation (Group B) indicated a residual or a pseudo-sac. If the regurgitation was through both the puncta (Group B 1 ), it was assumed that both the canaliculi were patent. The preserce of regurgitation through one punctum only (Group B 2 & B 3 ) indicated the patency of that particular canaliculus. The absence of regurgitation (Group A) indicated that perhaps there was no residual sac, or else it was rudimentary without any inflammation. This finding did not reflect any light on the patency of the canaliculi [Table - 1].
2. Syringing was then performed through the lower punctum in all the cases and in some through the tipper punctum. We carefully noticed the site of regurgitation of the fluid. Regurgitation of the fluid through the same purctum indicated blockage in either one or both the canaliculi. Whereas, the regurgitation of fluid through the opposite punctum indicated patency of both the canaliculi. The cases of fistulae showed regurgitation of fluid through the fistulae themselves but when the fistulur opening was blocked digitally, the fluid regurgitated through the puncta. The regurgitation of turbid fluid, however, indicated that there were some exudates in the residual sac [Table - 1].
i) Plane skiagram of lacrimal bone helped to exclude pathology of the underlying bone.
ii) Dacryocystograms, with 70% Diaginol, demonstrated well the canaliculi and the residual sac only in group 'B'.
4. Examination of nose and paranasal sinuses was done to exclude nasal pathology.
By above assessment, a total of 51 eyes had residual sac. 54 eyes had upper and 51 had lower canalicular patency [Table - 2]. A total of 56 eyes (36.1%) were declared suitable for surgery, out of which 46 eyes, who had residual sac and patency of lower canaliculus, for dacryocysto-rhinostomy through residual sac and 5 eyes who had patency of both canaliculi with no residual sac for canaliculo-rhinostomy through common canaliculus. Another 5 eyes, who had residual sac but lower canalicular block were operated for canaliculo-dacryocystorhinostomy.
[Table - 3] demonstrates age and sex incidence of the above cases operated.
| Surgical Technique|| |
The cases were operated preferably under local anaesthesia. Only 3 cases required general anaesthesia.
The technique of operation of dacryocystorhinostomy was more or less according to the description of Dupuy-Dutemp's and Bourgeut's. Following modifications were, however, observed.
i) The site of previous scar was slightly on temporal side in all the cases. Where the scar was firm and thick, we preferred a seperate incision slightly on nasal side. Where the scar was thin and soft the incision was given at the previous site. In order to save the skin, it was not preferred to include opening of fistulae into the incision.
ii) Dissection was slightly difficult because of distorted anatomy, cicatrisation and moderate bleeding. The residual sac was invariably small and sometimes irregular in width. It was narrow in the upper part and almost normal size in the lower part, indicating that in majority, part of funds was excised in previous sittings. It was difficult to cut open the medial wall of the sac. Therefore, a lacrimal probe through the lower canaliculus was passed into the residual sac indenting its medial wall. The medial wall was then cut on the indented part with knife from where the incision was extended with scissors to extreme tipper and lower limits. Now the horizontal incisions were given to make the flaps free.
iii) In none of the cases, the opening in bone was less than 1.5 cm. in diameter. A larger opening was preferred to get larger flaps to compensate the smaller size of the sac. Stitching of flaps was difficult because at times the sac flaps were just sufficient to pass the stitches.
iv) In cases of fistula, the track was excised and its opening in anterior wall of the sac was closed with catgut stitch.
Canaliculo-rhinostomy was performed in 5 cases of Group 'A' where both canaliculi were patent with no residual sac. Since there was no sac, difficulty of stitching mucosal flaps was expected. Therefore, during dissection a cut on periosteum along anterior lacrimal crest was made. The periosteum of lacrimal fossa was undermined and reflected laterally. Now, a lacrimal probe was passed through lower canaliculus and indentation produced on medial aspect of the periosteum. Over this indentation, a vertical cut was given. This was extended upwards and downwards. Thus, common canaliculus was cut open and small anterior and posterior flaps, were made out of the periosteum. The opening of common canaliculus was dilated with lacrimal probes and then a 1 mm. size polyethylene tube was passed rhrough lower punctum, canaliculus and newly made opening. This end of the tube was taken out of the nostril through the bony opening. Over the check the two ends of the tube were tied together, the muscosal flaps were stitched to the flaps of the periosteum and wound was closed. The tube was left for 2 months and then removed.
Canaliculo-dacryocysto-rhinostoty was performed in 5 cases of group B 3 where residual sac was present with lower canalicular block. The technique of operation was the one described by the author. 
In the past we used to bandage the eye throughout post-operative phase, but recently we have started giving Tincture Benzoin seal on 2nd or 3rd day of surgery.
| Results|| |
The results were assessed by the amount of epiphora, regurgitation, and patency on syringing [Table 5]. In present series, a total of 46 eyes (82.1%) showed complete success who neither had epiphora nor regurgitation and the passages were freely patent. 7 eyes (12.5%) had partial success who had occasional epiphora with no regurgitation. Out of them 5 eyes had partially patent passages. Lastly, 3 eyes (5.4%) had failure in whom neither the epiphora was relieved nor the patency was achieved. One eye even continued regurgitation.
| Discussion|| |
After dealing with a total of 56 eyes, I have a strong feeling that all the cases of dacrocystectomy with symptoms of epiphora with or without regurgitation should be properly screened for the possibility of anastomotic surgery. Those, who possess some residual or pseudo-sac with both canalicular patency are most suitable cases. Upper canalicular block also showed encouraging results.
Absence of sac with both canalicular patency always posed a problem in stitching the mucosal flaps. Use of periosteum for this purpose in present series had been ideal.
Tinc Benzoin seal advocated in postoperative phase cut short hospitalisation, avoided daily dressings, made the patient comfortable and in cases of dacryocystorhinostomy brought anastomotic channel to function early.
Partial success and failures in this series could be attributed to stricture formation in the newly formed passage in canaliculus or possibly to granulations developing near the opening.
Inspite of this, a large number of eyes (63.9%) who showed absence of sac with both canalicular block, unfortunately, were left. How far conjunctivo-rhinostomy or some other procedure could be tried in them, is yet to be ascertained?
| Summary|| |
During last 5 years as many as 152 cases (155, eyes), operated for dacryocystectomy, were screened for possibility of anastomotic surgery to relieve their symptoms. Those who were found suitable were subjected to dacryocystorhinostomy, canaliculo-rhinostomy and canaliculo-dacryocysto-rhinostomy. Their results were assessed by the amount of epiphora, regurgitation and patency on syringing. In all, 82.1% had complete success, 12.5% had partial success and 5.4% had failures.
A larger number of the eyes (63.9%) who showed absence of sac with both canalicular block, however, were left over in present study.
| References|| |
Chandra, D.B., 1961, All-India Ophthal. Soc.
Dupuy-Dutemps and Bourgeut, 1933, An., d'Oc.,
Sarda, R.P., Kulshrestha, O.P., Mathur, R.N., 1961, Brit. J. Ophthal. 45,
Saxena, R.C., 1970, J. All-India Ophthal. Soc.,
Saxena, R.C. and Garg, K.C., 1969, J. All-India Ophthal. Soc., 17,
[Table - 1], [Table - 2], [Table - 3]