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| ORIGINAL ARTICLE |
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| Year : 1991 | Volume
: 39
| Issue : 4 | Page : 159-161 |
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Modified canaliculo-dacryocystorhinostomy
Ashok Kumar Grover, Ashok Kumar Gupta, Anju Rastogi
Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi 110 002, India
Correspondence Address:
Ashok Kumar Grover
Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi 110 002
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 1810875 
The management of cases with common canalicular obstruction poses a difficult problem. Nineteen patients presenting with common canalicular obstruction of unknown cause or in association with trauma, encysted mucocoele and previous sac surgery, were operated on by the modified canaliculodacryocystorhinostomy technique. The surgery involves a microsurgical dissection at the site of the common canalicular obstruction followed by anastomosis to the sac or nasal mucosa with silicone tube intubation of the passage using an improvised metallic introducer. The procedure was successful in 13 of the cases in a follow-up period varying from 4 months to 15 months. The complications included extrusion of the tube and nasal bleeding. The indications of the procedure, the precise technique and precautions to avoid intra and post operative complications have been elaborated in the paper.
How to cite this article:
Grover AK, Gupta AK, Rastogi A. Modified canaliculo-dacryocystorhinostomy. Indian J Ophthalmol 1991;39:159-61 |
| Introduction | |  |
Canalicular block is a frequent cause of troublesome epiphora. The management of cases with common canalicular obstruction is often unsatisfactory as medical measures or multiple probings are of no avail and conjunctivodacryocystorhinostomy with Jones' tube intubation [1] is relatively unphysiological and cumbersome with numerous potential complications [2]. The advent of silicone tube intubation [3],[4],[5],[6],[7] has provided a considerable advancement in the management of lacrimal obstructions. They have been used in immediate and late repair of canalicular injuries, for relief of canalicular stenosis, in congenital dacryocystitis which does not respond to routine probing and as an alternative to dacryocystorhinostomy (DCR) in patients with partial or intermittent nasolacrimal duct obstruction [8]. It has dramatically altered the prognosis in the management of obstructions in the common canaliculus. Canaliculodacryocystorhinostomy (CDCR) involving microsurgical dissection and removal of obstruction in the common canaliculus with silicone intubation has gained acceptance as the procedure of choice in this condition [9],[10],[11].
The paper reports our experience with silicone tube intubation and canaliculodacryocystorhinostomy in 19 cases of common canalicular obstruction.
| Material and methods | | |
Nineteen patients presenting to the oculoplastics orbital and lacrimal surgery clinic at Guru Nanak Eye Centre with clinically troublesome epiphora due to common canalicular obstruction were operated on. The diagnosis was established by irrigation and probing of the passages, supplemented by dacryocystography in selected cases. Twelve of the patients were females and 7 were males (Mean age of the patient was 43.3 years, range 18 to 63 years). Four of the cases had common canalicular block following a previous lacrimal surgery, one patient had obstruction due to a previous lacerated facial injury and 2 cases presented with an encysted mucucoele. In the other 12 cases there was no known cause for the common canalicular obstruction.
| Surgical technique | | |
A standard DCR skin incision is made and the anterior crus of the medial canthal tendon is incised from the periosteum and retracted temporally. A rhinostomy of desired size is created. The sac is opened and incised to form anterior and posterior flaps. Probes are passed into each canaliculus till the obstruction is encountered.
An attempt is made to negotiate the probe through the obstruction with only moderate force. If the obstruction is small and easily overcome so that the probe emerges into the sac, dissection of the common canaliculus is not necessary. In cases where the obstruction is firm, the most medial patent part of the common canaliculus is identified under magnification (preferably using a surgical microscope) by dissecting the common canaliculus from the posterior limb of the medial canthal tendon. The patent part of the common canaliculus is opened by cutting over the probe. The intervening obstructed part of the common canaliculus and the sac, if involved, is then excised. The patent common canaliculus is anastomosed with the lateral part of the sac by creating anterior and posterior flaps. If the sac is scarred or largely involved in the obstruction, as is often the case in patients with failed DCR, the common canaliculus is anastomosed directly to the nasal mucosal flaps with 6-0 absorbable sutures. Intubation is carried out from both the puncta before the anterior flaps are sutured, using an improvised stainless steel introducer (made from size 0 or 1 lacrimal probe, with ends rounded) and silicone tube (0.20" inner diameter, 0.37" outer diameter, Dow Cornig).
The tube is passed through the rhinostomy into the nose, where the two tubes are secured to each other by suturing after moderate tightening to leave only a small loop protruding in the conjunctival sac [Figure - 1][Figure - 2][Figure - 3] . The tube is left in place for 6 months or more. Intraoperative difficulty of silicone tube at the punctum was overcome by a single snip at the punctum in some cases.
| Results | | |
The patients have been followed up for a period ranging from 4 to 15 months. In 2 of the patients the tube could not be retained for the required duration as the patients pulled out the tubes by mistake and the suture at the nasal end gave way. One patient had moderately severe bleeding in the early postoperative period and required nasal packing for 24 hours. The tubes were generally well tolerated with no incidence of corneal irritation or punctal slitting. The surgery was successful in 13 of the 19 patients as evidenced by absence of epiphora and patent passages on the last follow up , generally in the period of a few weeks after the removal of the tube.
| Discussion | | |
Management of common canalicular obstruction poses unusual problems and has largely been unsatisfactory. The use of silicon tubes for intubation and the use of microsurgical dissection to overcome the site of common canalicular obstruction [10,11] has significantly improved the prognosis in these cases. The surgical procedure of canaliculodacryocystorhinostomy (CDCR) maintains relatively physiological lacrimal passages, avoiding the difficulties associated with Jones' tube intubation.
It is important to choose the appropriate cases for surgery by establishing the site of obstruction unequivocally. Probing of the passages and dacryocystography prove valuable. Cases with an obstruction in the medial common canaliculus are relatively favourable. In cases where obstruction is less than 8 mm distal to the punctum (usually in an individual canaliculus), the surgery is technically more difficult and the chances of success are much poorer.
The cases where patency of the common canaliculus is established rather easily by a probe due to absence of any gross cicatriation, do reasonably well by silicone intubation alone. However, those with firmly established obstruction require dissection of the scar using microscopic visualisation and subsequent anastomosis either with the sac or nasal mucosa. It is helpful to have large nasal flaps to ease any tension on the anastomosis. Intubation of the passages by using a stainless steel Bowman's probe with rounded end as used by us is a simple procedure except in some cases where a single snip of the punctum is necessitated to facilitate intubation.
The advent of canaliculorhinostomy as a surgical procedure in cases with common canalicular obstruction offers a significant advancement providing a more successful and more physiological alternative.
| References | | |
| 1. | Jones L.T : The cure of epiphora due to canalicular disorders, trauma and surgical failures of the lacrimal passages. Trans. Am. Acad. Ophthalmoi Otolaryngol 66 : 506 - 24, 1962.  |
| 2. | Welham R.A.N. : Canalicular obstructions and the Lester Jones' tube: What to do when all else fails. Trans. Ophthal. Soc. U.K., 93: 623-32, 1973. |
| 3. | Quickert M.H. and Dryden R.M. : Probes for intubation in lacrimal drainage. Trans Am Acad Ophthalmol Otolaryngol. 74 : 431-433, 1970. |
| 4. | Crawford J.S. : Intubation of obstructions in the lacrimal system. Can. J. Ophthalmol, 12: 289-292, 1977. |
| 5. | Gibbs D.C. : New probe for intubation of lacrimal canaliculi with silicone rubber tubing. Br. J. Ophthalmol 51: 198. 1967. |
| 6. | Pashby R.C. and Rathbun J.E. : Silicone tube intubation on the lacrimal drainage system Arch Ophthalmol 97 : 1318-22. 1979. |
| 7. | Keith C.G. : Intubation of the lacrimal passages Am. J. Ophthalmol. 65 : 70-74, 1968. |
| 8. | Anderson R.L. and Edwards J.J. Indications, complications and results with silicone stents Ophthalmology 86 : 1474. 1979. |
| 9. | Doucet TW. and Hurwitz J.J. : Canaliculodacryocystorhinostomy in the management of unsuccessful lacrimal surgery. Arch. Ophthalmol. 100, 619-21, 1982. |
| 10. | Doucet T.W. and Hurwitz J.J. : Canaliculodacryocystorhinostomy in the treatment of canalicular obstruction. Arch. Ophthalmol 100: 306. 1982 |
| 11. | Doucet TW. and Hurwitz J.J. : Canal icuIodacryocystorhinostomy. in Wesley, R.E.. Ed.. Techniques in Ophthalmic Plastic Surgery New York, Chichester, Brisbane, Toronto, Singapore. John Wiley and Sons 229-30. 1986 |
[Figure - 1], [Figure - 2], [Figure - 3]
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