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| ORIGINAL ARTICLE |
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| Year : 1991 | Volume
: 39
| Issue : 4 | Page : 162-165 |
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Rail roading technique for intubation of the canaliculi with sutupak in cases of common canalicular duct obstruction
Saroj Sahdev, Shanta Motwane
Department of Ophthalmology, L.T.M.M. College & General Hospital, Sion, Mumbai-400 022, India
Correspondence Address:
Saroj Sahdev
Department of Ophthalmology, L.T.M.M. College & General Hospital, Sion, Mumbai-400 022
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 1810876 
A variety of methods and materials have been used for the treatment of the problems relating to the canalicular system. An insight into the rail roading technique for intubation of the canaliculi with sutupak in cases of common canalicular duct obstruction is presented here. About 30 patients with block at the common canalicular duct, which was detected by dacryocystography were operated for dacryocystorhinostomy with intubation of both the canaliculi with sutupak No. 0 by rail roading technique with good results.
How to cite this article:
Sahdev S, Motwane S. Rail roading technique for intubation of the canaliculi with sutupak in cases of common canalicular duct obstruction. Indian J Ophthalmol 1991;39:162-5 |
| Introduction | |  |
Silicon tubes [1],[2],[3 ] have been used for the intubation of the canaliculi in cases of common canalicular duct block, along with dacryocystorhinostomy surgery. The rail roading technique for intubation of the canaliculi with sutupak is presented here.
About 30 patients with block of the common canalicular duct, which was detected by dacryocystography were operated for dacryocystorhinostomy with intubation of both the canaliculi with sutupak No. 0 by rail roading technique. The sutupak was retained in situ for one year in all the patients. It was found that the sutupak is as effective as the silicon tubes for treating the blockage of the common canalicular duct or the canaliculi.
Jones test at the end of one year was positive in these cases.
It was also noticed that the epiphora was absent with the sutupak in situ. This could be due to the flow of the tears along the sides of the sutupak.
Also, cosmetically this technique has a distinct advantage due to the fact that the sutupak is entirely housed in the nasal cavity and is not visible externally. As such it can be kept in situ for a longer period i.e. a year, by which time reepithelisation of the canaliculi has occurred and chances of re-obstruction are less.
| Procedure | | |
Patient is sedated with intramuscular injection of fortwin and phenargan. Local anaesthesia with 2% lignocaine adrenalin (1 in 1 lac) for dacryocystorhinostomy is given. The conjunctival sac is anaesthetised with 4% lignocaine. The nose is packed with roller gauze soaked in 4% lignocaine and adrenalin half an hour before surgery.
The operative area is prepared and draped. The incision for dacryocystorhinostomy is made. The sac is identified and the anterior and posterior sac flaps are fashioned [Figure - 1]. The periosteum is elevated. A 10-12 mm ostium is made in and around the lacrimal fossa. A single posterior nasal flap is fashioned. This posterior nasal flap is sutured to the posterior sac flap with chromic catgut No. 6-0 with 3 sutures.
The nasal pack is then removed. The lower canaliculus being more important is intubated first to prevent operative trauma. Bowman's probes are passed one after the other in gradually increasing sizes, into the lower canaliculus and made to emerge into the, sac cavity, i.e. between the two sac flaps, thus, overcoming the obstruction. A thin straight round bodied needle is advanced with its eye end (blunt end) (to prevent formation of false passage) into the dilated lower punctum and canaliculus to emerge into the sac cavity, i.e. along the pathway made by Bowman's probes [Figure - 2]. The eye of the needle is then threaded with No. 0 sutupak. The needle is then gently withdrawn from the lower canaliculus and punctum, thereby intubating the lower canaliculus with sutupak [Figure - 3][Figure - 4]. Similarly, the Bowman's probes are gradually passed into the upper canaliculus and made to emerge into the sac cavity between the two sac flaps, overcoming the obstruction. The straight round bodied needle is similarly advanced with its eye and into the upper canaliculus to emerge into the sac cavity, i.e. along the pathway made with the Bowman's probes.
The eye of the needle is then threaded with thin prolene 6-0. [Figure - 5] The two ends of this prolene are held together in one hand and the needle is withdrawn gently from the upper canaliculus and punctum, thereby intubating the upper canaliculus with the prolene loop, and its two tying ends in the sac cavity. [Figure - 6].
The needle is then separated from the prolene loop by breaking the eye of the needle with the needle holder [Figure - 7]. The end of the sutupak which is emerging from the lower punctum is looped into the loop of prolene which emerges from the upper punctum. [Figure - 8]. The two ends of the sutupak loop are held firmly together in one hand and the two ends of the prolene loop held together in the other hand. The prolene loop is then drawn into the sac cavity, which in turn carries with it the sutupak loop by rail roading into the upper canaliculus [Figure - 9]
The prolene loop is then separated from the sutupak loop and the loose end of the sutupak is gently drawn into the sac cavity. This intubates the upper canaliculus [Figure - 10]. The two ends of the sutupak emerging from the upper and the lower canaliculi in between the two sac flaps are then drawn through the ostium made for dacryocystorhinostomy into and then out of the nasal cavity with straight artery forceps passed into the ostium from the nose [Figure - 11].
The ends of the sutupak are then tied with 3 knots and the long ends are then cut short at the level of the inferior meatus and left inside the nasal cavity. The anterior sac flap is sutured to the periosteum with three sutures of 6-0 chromic catgut.
The subcutaneous tissue is sutured with 6-0 chromic catgut. The skin incision is closed with continuous subcuticular sutures 'of prolene 6-0. Soframycin ointment is applied and the wound is dressed.
Post-operative treatment includes systemic antibiotics and antiinflammatory tablets. Local antibiotic eye drops like chloramphenicol are instilled thrice a day into the conjunctival sac for about 2-3 months. Qtrivin nasal drops are instilled into the nose twice a day for 2-3 months.
| Discussion | | |
Epiphora due to blockage of the canaliculi or the common canalicular duct has been treated by intubating the canaliculi with different materials over the past years. The materials used for intubating the canaliculi are Polythene tube by Bonaccolto G [2]. , 4 metric blue monofilament nylon by Barrie Jones for canaliculo dacryocystorhinostomy , Jones Guibor silastic tube with a probe cemented to each end made by Concept company, Silicon tubes [3], Quickert Dryden [1] and Crawford probes [5].
Veirs rod which is a 10 mm long stainless steel rod of No. 1 Bowman's probe diameter with one end swaged with 4-0 silk suture which is kept in situ for 6. weeks [6].
Werb intubated canaliculi with nylon, with the help of polythene tube of 1 mm lumen diameter through which nylon is passed and the polythene tubing is then removed by breaking [4].
The advantages of using the sutupak for intubation of the canaliculi are:
1. Sutupak is easily available. 2. Both the upper and lower canaliculi are intubated. 3. As both the ends of the sutupak remain in the nasal cavity cosmetically it is of an advantage to the patient. 4. It can be kept in the canaliculi for a long time, i.e. upto a year. During this time the canaliculi are re-epithelialised and chances of re-obstruction are less. 5. It is useful in common canalicular duct block, upper and lower canalicular obstruction, in failed dacryocystorhinostomy and along with dacryocystorhinostomy surgery to prevent post-operative blockage of the canaliculi with blood clot or inflammation due to operative trauma. In such a case, it can be kept for a short period of about -3 months. 6. Epiphora is absent with sutupak in situ due to flow of tears along the sides of the sutupak. 7. It can be easily removed in the out patient by simply cutting the loop of the sutupak in the medial canthus and then pulling the two ends of the sutupak out from the nasal cavity. 8. As the sutupak is stiff and remains straight in the canaliculi when in situ, the canaliculi are not distorted during the healing period- an advantage, as with the use of Veirs rod. Due to these above advantages, it can prove useful as an alternative to other methods of treating canalicular obstruction.
| References | | |
| 1. | Quickert M.H.. Dryden R.M. : Probes for intubation in lacrimal drainage. Trans. Am. Acad. Ophthalmol Otolaryngol, 1970, 74:431.  |
| 2. | Bonaccolto G. : Dacryocystorhinostomy with polyethylene tubing: A simplified technique. J. International Coll. Surgeons 1957 28:789. |
| 3. | Dortzbach R.K., France To., Kushner B.J. et al. Silicone intubation for obstruction of the nasolacrimal duct in children : American Journal of Ophthalmology, 1982, 94:585-590. |
| 4. | M.J. Roper-Hall. Stallard's Eye Surgery; John Wright and Sons Ltd. ; 42-42 Triangle West Bristol BS8 IEX. Sixth Edition: 1980 page 295 and 299. |
| 5. | Allen M. Putterman, Principles and practice of Ophthalmology (ads) Peyman, Sanders, Goldberg: Volume 3, W.B. Saunders Co Philadelphia, London. Toronto Edition - 1 1980. pp.2279 to 2288. |
| 6. | Jack J. Kanski, Clinical Opthalmology. Butterworth & Co. (Publishers) Ltd. London, Boston, Singapore: 2nd Edition. 1989, Page 57. |
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10], [Figure - 11]
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