Year : 1972 | Volume
: 20 | Issue : 3 | Page : 133--135
A few observations on dacryocystorhinostomy in lacrimal fistula
Department of Ophthalmology, King George's Medical College, Lucknow, India
R C Saxena
Department of Ophthalmology, King George«SQ»s Medical College, Lucknow
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Saxena R C. A few observations on dacryocystorhinostomy in lacrimal fistula.Indian J Ophthalmol 1972;20:133-135
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Saxena R C. A few observations on dacryocystorhinostomy in lacrimal fistula. Indian J Ophthalmol [serial online] 1972 [cited 2021 Jun 21 ];20:133-135
Available from: https://www.ijo.in/text.asp?1972/20/3/133/34654
After the third decade, though, cases of chronic dacryocystitis were treated by dacryyocystorhinostomy, cases of lacrimal fistula were advocated dacryocystectomy, due to which complete relief of symptoms was not r)btained. Since more than a decade it was felt, that cases of lacrimal fistula could also be treated by dacryocystorhinostomy with perfect results. SARDA et al and SAXENA et al have reported a few cases of lacrimal fistula treated by dacryocystorhinostomy with encouraging results. KAILASH NATH et al however treated this condition by dacryofistulorhinostomy.
The author of this paper, after realising the utility of dacyocystorhinostomy in them, has advocated this operation nearly in all suitable cases of lacrimal fistula and has attained satisfactory results. A review of these cases is being presented herewith to demonstrate the results with valuable observations. This series of study includes a total number of 65 patients who have been collected from the Ophthalmic Section of G. M. and Ass. Hospitals, Lucknow during the last 5 years.
Review of the Cases:
Out of 65 cases of the present series, 55 patients (84.6%) were females and 10 patients (15.4%) were males.
Majority of the patients came during the third and forth decade of life.
Out of 65 cases, 7 patients had bilateral involvement whereas 58 cases had unilateral involvement. Thus the number of, eyes operated was 72.
In all the cases the fistulae were below the medial palpebral ligament and were opening along the medial and the inferior orbital borders. The direction of the track was invariably downwards and laterally. The other end of the track was connected to the anterior wall of the sac. 26 eyes had old fistulae, from 2-4 years old, whereas the rest 46 eyes had fresh fistulae, varied between 1 month to 6 months. Out of these, 27 eyes had the history of spontaneous healing with recurrences more than twice in the past. In 46 eyes of recent duration, there was no discolouration of skin and there was no sign of epithelialisation. In 12 eyes however slight induration was felt in the sac area. In all the 26 eyes with tong duration the colour of the skin around the opening was dark greyish and showed signs of epithelialisation. In 9 eyes, having old fistulae with recurrances in the past, too much cicatrisation of skin of the lower lid was responsible for slight amount of ectropion of medial part of lower lids.
In all the cases, a thorough ENT check-up was done and the condition of the underlying bone was assessed radiographically. Dacryocystography was not done in every case. However, flushing through lower punctum was done invariably in every case to find the patency of the lower canaliculus. Cases having canalicular block were not included in the present study.
The cases were operated under, both, local and general anaesthesia. The technique of operation was the one described by Dupuy-Dutemps and Bourgeuts. The incision in cases of fresh fistula was usual and did not include the opening but in cases of old fistula it included the opening in order io dissect out the whole track. The opening thus left in the anterior wall was given catgut suture. Since the sac in these cases was invariably large, a small part of posterior wall of the sac was excised to avoid laxity of the flaps after stitching.
First post-operative syringing was done with 4 % sterile sodium citrate solution on the third day. Then it was repeated on alternate days till the 7th day. After this weekly syringing was done with penicillin lotion (10,000 units/cc.) for 1 month and then monthly syringing was done for another 5 months. In cases where the track of the fistula was left as such, small amount of fluid regurgitated through the fistula on the third day. By the fifth day, no such regurgitation was seen which indicated spontaneous healing within 5 days.
After surgery, a follow-up of the patients was carried out upto six months and the results were assessed by the amount of epiphora, regurgitation and patency on syringing [Table 1].
There was no case of failure in the present series. 63 eyes (87.5%) had complete success and 9 eyes (12.5 %) showed partial success where although the syringing showed absolute patency, epiphora persisted due to mild ectropion of medial part of lower lid and perhaps atonia of the sac. Out of them complete success was again achieved in another 4 cases after correction of the ectropion by plastic repair.
Dacryocystorhinostomy finds a most suitable place in cases of lacrimal fistula also, both old and fresh. Out of the various techniques of operations, Dupuy-Dutemps and Bourgeut's technique is the one preferred because it provides a larger outlet for lacrimal fluid.
In fresh cases, since there is no epithelialisation of fistula there is no need to excise the track. This track closes by itself during the post-operative period within 5 days, because fluid prefers to pass through a larger opening into the nose rather than through the narrow and valvular track of fistula. Fistulectomy is, of course, necessary in old cases showing epithelialisation.
Haemorrhage during the operation is variable. In general it is moderate but in cases with marked cicatrisation, bleeding even is less than usual. In none of the cases, the bleeding was enormous.
As compared to other cases of dacryocystitis, the sac here lies closer to the skin due to which one should be careful from the very beginning. The size of the sac invariably is larger and sometimes shows adhesions to the periosteum of the lacrimal fossa. Posterior wall of the sac goes quite deep due to which its mobilisation and partial excision is necessary to avoid pouch formation and laxity of flaps.
Cases, in which slight ectropion develops due to heavy cicatrisation of skin of lower lid, come back with epiphora although syringing indicates patency of passages. In them, ectropion correction by plastic repair is always beneficial which gives complete relief of symptoms in majority of cases.
The results of dacryocystorhinostomy in lacrimal fistula are as good as in chronic dacryocystitis and therefore all the cases of lacrimal fistula should be treated by dacryocystorhirostomy.
A review of 65 cases having lacrimal fistula treated by Dupuy-Dutemps & Bourgeut's method of dacryocystorhinostomy is given with valuable observations. It has been emphasised that all the cases of lacrimal fistula should be treated by the above method to get complete recovery.
|1||Kailash Nath, Suresh Kumar and Shukla, B. R.: Dacryocystorhinostomy. J. All-India Ophthal. Soc. 10, 64-67 (1962).|
|2||Sarda, R. P. Dacryocystorhinostomy. Brit. J. Ophth., 45, 138-143 (1961).|
|3||Saxena, R. C. and Garg, K. C.: Scope of Dacryocystorhinostomy, J. of All-India Ophthal. Soc., 17, 55-58. (1969).|