|Year : 1998 | Volume
| Issue : 4 | Page : 253-254
Cyanoacrylate lacrimal system occlusion after failed Sac surgery
Nikhil S Gokhale
Gokhale Eye Hospital, Anant, Gokhale Road (S), Dadar, Mumbai - 400 028, India
Nikhil S Gokhale
Gokhale Eye Hospital, Anant, Gokhale Road (S), Dadar, Mumbai - 400 028
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gokhale NS. Cyanoacrylate lacrimal system occlusion after failed Sac surgery. Indian J Ophthalmol 1998;46:253-4
Failure is often encountered after lacrimal sac surgery for chronic dacryocystitis. A dacryocystogram followed by resurgery is the usual management practice in such cases. N-butyl cyanoacrylate adhesive has been previously employed for cannalicular occlusion for dry eyes., It was used for total lacrimal system occlusion as an emergency procedure in a patient with a perforated corneal ulcer prior to a therapeutic keratoplasty.
| Case Report|| |
A 50-year-old male patient was referred for a therapeutic keratoplasty for a perforated corneal ulcer in the left eye. On examination the right eye was normal. The involved eye on examination revealed meibomitis and lid edema, ciliary congestion and a central corneal ulcer (5x6 mm) with a central perforation (3 mm size). There was superficial and deep vascularisation in all four quadrants. The anterior chamber was flat and tension was low. Posterior segment examination was not possible. Regurgitation on pressure over the sac region was positive. There was a regurgitation of clear fluid and mucous from the upper punctum on syringing from the lower punctum.
The patient gave a history of dacryocystorhinostomy surgery 20 years back followed by dacryocystectomy 2 years later on the left side. However, both surgical procedures had failed. He also gave a history of central corneal opacity and poor vision in the left eye for 20 years.
The patient was on tobramycin sulfate 0.3% and ciprofloxacin hydrochloride 0.3% eye drops 6 times daily, and atropine sulfate 1% eye drops 3 times daily in the left eye for a month prior to his referral.
The patient underwent total lacrimal system occlusion with N-butyl cyanoacrylate adhesive. Under topical 4% xylocaine hydrochloride anesthesia the punctum was dilated and syringing was done with distilled water for injection, gentamicin sulfate injection (40 mg/ml) 2cc, and Betadine 5% w/v solution, in succession. Pressure was then applied over the sac to empty all fluid contents. 0.5cc cyanoacrylate adhesive was taken in a 2cc syringe with a lacrimal cannula and syringing was done through the lower punctum till the adhesive appeared at the upper punctum. A cotton tip applicator was placed over the upper punctum to absorb the excess adhesive. Pressure was then applied over the sac region and maintained for a minute. Particles of adhesive that had spilled onto the conjunctiva during the procedure were carefully removed with a jeweller's forceps under high magnification of an operating microscope. The conjunctival sac was irrigated and washed with saline solution.
Postoperatively the patient was given oral ciprofloxacin hydrochloride 500 mg twice daily for 5 days and topical antibiotics and atropine were continued as before. The patient was comfortable postoperatively and no regurgitation or discharge was noticed. No inflammatory reaction was observed. The patient underwent a successful therapeutic keratoplasty 3 days later. 6 months postoperatively there is occlusion of the nasolacrimal system with no discharge or regurgitation. The graft is hazy and vascularised.
| Discussion|| |
Cyanoacrylate adhesives have been used since the mid-1960s for a variety of indications, most commonly to seal small corneal perforations. They have been used for punctal occlusion and cannalicular occlusion in patients with dry eyes. [2, 3] Chronic dacryocystitis following a dacryocystectomy procedure could be due to incomplete excision, formation of a pseudosac or a sac diverticulum. A dacryocystogram is helpful in such situations prior to resurgery. In this particular case due to the perforated ulcer and the emergency nature of the situation it was not done. Instead cyanoacrylate lacrimal system occlusion was considered and done. There was no swelling and inflammatory reaction after the procedure that allowed an early therapeutic graft. This procedure may also have application among elderly patients with sac problems who may be unfit or unwilling to go through surgery. It may also be useful prior to emergency cataract operations in patients with sac problems. The risk of acute dacryocystitis following the procedure was considered. Preoperative antibiotics and cultures of sac contents will help reduce this risk. Cyanoacrylate injection into the sac occludes the potential space and its antibacterial effect may together reduce this risk. The validity of this procedure can be confirmed by future studies.
| References|| |
Refojo MF, Dohlman CH, Koliopoulos J. Adhesives in ophthalmology: a review. Surv Ophthalmol
Pattern JT. Punctal occlusion with N-butyl-cyanoacrylate tissue adhesive. Ophthalmic Surg
Diamond JP, Morgan JE, Virjee J, Easty DL. Cannalicular occlusion with cyanoacrylate adhesive: a new treatment for dry eye. Eye