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 Table of Contents  
MAJOR REVIEW
Year : 2020  |  Volume : 32  |  Issue : 2  |  Page : 128-135

Surgeries of the lacrimal drainage system – A review


Department of Orbit and Oculoplasty Services, Sankara Eye Hospital, Coimbatore, Tamil Nadu, India

Date of Submission29-May-2020
Date of Acceptance30-May-2020
Date of Web Publication25-Aug-2020

Correspondence Address:
Dr. Shruthi Tara
Department of Orbit and Oculoplasty Services, Sankara Eye Hospital, Coimbatore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_70_20

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  Abstract 


Nasolacrimal system serves as a conduit for tear flow from eye to the nasal cavity. Periodic blinking initiates a pump mechanism, helping in the even distribution of tears over the ocular surface, which then flows into the lacrimal sac and finally to the nasal cavity via the nasolacrimal duct (NLD). Obstruction in this system leads to inadequate tear drainage, which clinically presents as epiphora. Lacrimal outflow system disorders are very annoying to the patients, and sometimes vision threatening. Surgery is a definitive solution for most outflow obstructions, and patients should be counseled accordingly. Chronic use of topical medications for NLD problems is neither cost-effective nor efficacious, but only prolongs agony. This article aims to provide a comprehensive insight into the commonly performed lacrimal drainage surgeries. Literature search using PubMed, Cochrane, and Google Scholar with a combination of various words appropriate to this article was done and relevant articles were reviewed.

Keywords: Balloon dacryoplasty, canalicular stenosis, dacryocystectomy, dacryocystorhinostomy, endoscopic dacryocystorhinostomy, endoscopic lacrimal duct recanalization


How to cite this article:
Tara S, Gupta S, Panickar N. Surgeries of the lacrimal drainage system – A review. Kerala J Ophthalmol 2020;32:128-35

How to cite this URL:
Tara S, Gupta S, Panickar N. Surgeries of the lacrimal drainage system – A review. Kerala J Ophthalmol [serial online] 2020 [cited 2020 Sep 29];32:128-35. Available from: http://www.kjophthal.com/text.asp?2020/32/2/128/293305




  Introduction Top


Epiphora, commonly known as excessive tearing, is a clinical sign with different etiologies, which can be classified into lacrimal hypersecretion, lacrimal pump failure, and lacrimal drainage obstruction. This clinical sign cannot be overlooked considering its influence on the quality of life. It needs to be appropriately diagnosed and treated.

Historically, the first mention of lacrimal surgery has been in 1750 BC in “The code of Hammurabi.” Celsus and Galen treated dacryocystitis using a red-hot cautery iron by passing it through the lacrimal bone into the nose to create a passage to drain abscess.[1],[2]

In 1904, Italian otolaryngologist, Addeo Toti, first published his technique of external dacryocystorhinostomy (DCR).[3] Caldwell described endonasal DCR as early as 1893,[4],[5],[6] to create a middle meatal osteotomy. During the 1970s, with the advent of rigid endoscopes and functional endoscopic sinus surgery, endoscopic lacrimal surgery became popular. Powered and mechanical endoscopic DCR was described by Peter John Wormald in 2002.[7]

In the recent times, state-of-the-art diagnostic, therapeutic endoscopic systems, and higher resolution imaging techniques have contributed toward our understanding of disorders, thereby helping in developing minimally invasive surgical techniques.


  Caution Top


The rapidly evolving coronavirus disease 2019 (COVID-19) pandemic has greatly affected the elective and emergency care in hospital's work culture. It is known to spread rapidly among the medical fraternity involved in surgeries around the “head and neck,” nose, and oral cavity, exposing dacryologists at a special risk. It is imperative to revisit the safety practices. The below-mentioned surgeries shall be executed only after following the governing body's standard operating procedure[8] and guidelines and be performed when needed with adequate precautions. This is applicable to investigations as well. The usage of mechanized drill and cautery generates aerosol and best avoided in the current situation.[8]


  Evaluation Top


Relevant ocular and nasal anatomy and detailed history are undoubtedly an absolute necessity prior to any surgery. Assessment of epiphora, mandatory endoscopic endonasal evaluation, although very important, is beyond the scope of this article.[9] Further reading on this subject is recommended.


  Nasolacrimal Duct Obstruction Surgeries Top


Dacryocystectomy (DCT)

DCT is a very well-established oculoplasty surgery, which involves complete removal of the lacrimal sac. Once considered a procedure of choice for chronic dacryocystitis associated with nasolacrimal duct (NLD) obstruction, DCT is now largely replaced by DCR, with the only absolute indication for DCT being tumors of the lacrimal sac.[10] Other relative indications are severe dry eye, bleeding disorders, elderly with comorbidities, cicatricial pemphigoid, systemic lupus erythematosus, severe atrophic rhinitis, and Crohn's disease, which have predilection for nasal scarring.[11]

Dacryocystorhinostomy

External DCR is a time-honored procedure used to correct Nasolacrimal duct obstruction (NLDO), combined with silicone intubation whenever canalicular stenosis is present. Documented success rate is around 99%.[12] Of many accepted techniques, the authors prefer the one described below.[12] Thorough knowledge of anatomy and diligent evaluation of the patient improves success rate in difficult scenarios, thus preventing intraoperative surprises.

DCR involves creating an anastomosis between lacrimal sac and nasal mucosa via a bony ostium. It may be performed through an external skin incision or intranasally with endoscopic visualization.

Indications

  1. Congenital NLD obstructions (CNLDO) after failed prior therapies
  2. Primary acquired NLD obstructions
  3. Secondary acquired NLD obstructions.


Preoperative requisites

  1. Detailed evaluation to confirm the diagnosis
  2. Hemoglobin level, bleeding time, and clotting time
  3. Well-controlled blood pressure to reduce the risk of intraoperative bleeding
  4. Withhold blood thinners and anticoagulants under physician's consultation
  5. Controlled blood sugar levels and other general anesthesia (GA) investigations as deemed necessary
  6. Other infective serology tests as per requirement and protocol.


Anesthesia and nasal packing

The procedure is commonly performed under local anesthesia (LA), although GA may be considered in certain conditions.[13] A combination of injection 2% lignocaine and 0.5% bupivacaine with or without adrenaline is used. Infratrochlear nerve supplying lacrimal apparatus is blocked at the supraorbital notch. A local infiltration subcutaneously along the anterior lacrimal crest is given, which is further injected into the deeper plane till the periosteum both superiorly and inferiorly. Infraorbital nerve block, dorsal nasal nerve block, and transcaruncular and anterior ethmoidal nerve blocks can be administered to enhance patient's comfort level.

Nasal mucosa is sprayed with 10% lignocaine 1–2 puffs, followed by packing with 4% lignocaine and 0.5% xylometazoline. The forceps should guide the medicated soft gauze superiorly and backward toward the middle meatus, at the site of the proposed ostium.

Procedure

A curvilinear incision is made along the anterior lacrimal crest measuring 10 mm long and 3 mm from the medial canthus over the skin. Transconjunctival approach has also been described for superior cosmetic outcomes.[14] Dissecting bluntly, orbicularis fibers are separated to reach the periosteum just anterior to the anterior lacrimal crest. A Freer elevator is used to reflect the lacrimal sac along with periosteum to expose the lacrimal fossa. It is preferable to preserve medial canthal tendon (MCT). Vertical suture line within the lacrimal fossa between the frontal process of maxilla and lacrimal bone is identified and the bone is penetrated. Kerrison punch is gently inserted between the bone and nasal mucosa and bony ostium is sequentially enlarged [Figure 1]a and b].
Figure 1: External dacryocystorhinostomy. (a) Creating bony ostium using Kerrison punch, (b) large bony ostium, (c) lacrimal sac flap

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  1. Superiorly, up to 2 mm above the MCT
  2. Inferiorly till the bony NLD
  3. Anteriorly till the smallest punch can be easily insinuated between the bone and nasal mucosa
  4. Posteriorly till the aerated ethmoid (the ethmoidal mucosa is thin and pale and can be easily differentiated from thick nasal mucosa).


A Bowman's probe is then passed through the sac to tent it posteriorly which helps in making an H-shaped incision on the sac such that a large anterior flap and a small posterior flap are created [Figure 1]c. The sac flap should extend from the fundus of the sac superiorly to the NLD inferiorly. Small posterior sac flap is excised. Similarly, an incision is made on the nasal mucosa along the borders of bony ostium to create an anteriorly hinged nasal flap [Figure 2]a using no. 11 blade. The nasal flap is sutured to the anterior sac flap edge to edge [Figure 2]b and [Figure 2]c. Excess nasal mucosa can be trimmed. Alternatively, to prevent flaps from sagging, one can tent them up by suturing to the overlying orbicularis, which is followed by skin closure.
Figure 2: (a) Raising nasal mucosal flap, (b and c) apposition and suturing of the nasal and anterior lacrimal sac flaps, respectively

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Patency is checked by syringing intraoperatively. After surgery, deep nasal packing is not necessary as it may damage the flaps. Adjunctively mitomycin-C (MMC) 0.04% and silicone intubation may be used in repeat DCRs, sac fibrosis, and in common canaliculus (CC) block.[15]

Soft silicone tube has a swaged metal probe at each end; these are passed down each canaliculus, into the opened up lacrimal sac and down into the nose. Two free ends of the tube are tied with a single square knot and ends cut short. There are various types of tubes available, and their usage is a matter of surgeon's choice [Table 1] and [Figure 3] and [Figure 4].
Table 1: Lacrimal stents

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Figure 3: Lacrimal stents, (a) Crawford stent, (b) Masterka stent, (c) Crawford–Monoka stent, (d) Mini-Monoka stent, (e) Self-retaining stent. Picture courtesy: FCI

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Figure 4: Ritleng bicanalicular stent

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Postoperatively, the patient is started on oral antibiotics and analgesics, topical antibiotic–steroid combination eye drops, and nasal decongestants. One week later, sutures are removed and topical drops are tapered. If the patient is intubated, tubes can be removed after 12 weeks. The most common complications encountered in DCR are discussed in [Table 2].[13],[16],[17]
Table 2: Complications of external dcr

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Tube-related complications are tube prolapse, granuloma, cheese wiring, and tube loss [Figure 5].
Figure 5: Tube-related complications. (a) Tube prolapse, (b) cheese wiring of punctum, (c) granuloma

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Figure 6: Endoscopic view of the bony ostium created in external dacryocystorhinostomy

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External DCR has been regarded superior to other techniques as it has a high success rate of close to 99%.[12] Surgery is considered a success when there is anatomical and physiological patency.

The advantages and disadvantages of external DCR are included in [Table 3].[13],[18]
Table 3: Advantages & disadvantages of external dcr

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  Endoscopic Endonasal Dacryocystorhinostomy Top


It is a preferred procedure in cosmetically conscious patients as it avoids the need of a skin incision and in patients with associated nasal pathologies, some of which can be corrected simultaneously. In this procedure, sac is approached through the nasal cavity with the help of a nasal endoscope. Endoscopic DCR is preferably done under GA.

Nasal mucosa is decongested with a soft gauze soaked in lignocaine and adrenaline as in external DCR.

Lateral wall and head of the middle turbinate is injected with 2% lignocaine and adrenaline.

Using a 0° nasal endoscope, the procedure begins by raising a posteriorly hinged nasal mucosal flap. A “U-” shaped incision is made using No. 15 blade, which begins 8 mm above the axilla of the middle turbinate and is extended anteriorly for 8 mm and continues downward as a vertical incision till the insertion of the inferior turbinate (2/3rd the height of the middle turbinate), and a horizontal incision is directed posteriorly toward the uncinate process.[19] [Figure 7].
Figure 7: Endoscopic endonasal dacryocystorhinostomy – Red dotted lines marking the site of incision on the nasal mucosa and black arrow pointing at the axilla of the middle turbinate

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Using a Freer elevator, the mucosal flap is reflected back. This is followed by removal of bone overlying the sac and NLD with the Kerrison punch. The bone gets thicker superiorly and usually not amenable to remove further by punching, and a mechanical drill is then used to enlarge the ostium to expose the fundus of the sac. Bowman's probe is used to tent the medial sac wall which is incised vertically along its entire length to create anterior and posterior flaps. The flaps are then reflected backward, thus exposing thecommon canaliculus (CC) opening. The previously made nasal mucosal flap should align with the posterior lacrimal flap.[20] To achieve this edge-to-edge alignment, excess nasal mucosa can be trimmed. The lacrimal system is then intubated with bicanlicular silicone intubation stent.[21]

All patients receive postoperative oral antibiotics, nonsteroidal anti-inflammatory drugs, topical antibiotic–steroid combination eye drops which is tapered over 4 weeks, and nasal saline spray for 4 weeks to prevent drying and crusting of the nasal mucosa.

Complications

Early and late failure is mainly due to faulty location of sac, inadequate bone removal, and improper sac marsupialization.[22] Synechiae formation due to aggressive handling of nasal mucosa and granuloma formation has also been reported.

Studies comparing external and endoscopic approaches showed comparable success in both the procedures.[23],[24] The advantages and disadvantages of endoscopic DCR are further listed in [Table 4].[4]
Table 4: Advantages and disadvantages of endoscopic dcr

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  Congenital Nasolacrimal Duct Obstructions Top


CNLDO is one of the most common causes of tearing in children, the reason being failure of opening of NLD into the inferior meatus by birth, at the level of valve of Hasner. Spontaneous resolution is rapid during the 1st month of life. 96% resolve by 1 year.[25],[26] Criggler's massage increases intrasac hydrostatic pressure and accelerates opening at the lower end of NLD.

Pediatric DCR needs a special mention. CNLDO which is unresponsive to routine syringing and probing responds fairly well to DCR surgery, either external or endoscopic. It is better to wait until the child is 2–4 years of age, although DCR being performed in younger children aged 12–18 months has been reported and has not been associated with disrupted bone growth as one believes.[4] Pediatric DCR is almost similar to adults except that ethmoids are not usually prominent in a child, and there is a need for routine bicanalicular silicone intubation primarily.

Syringing and probing done at the age of 12–14 months is more effective. In an event of dacryocele or acute dacryocystitis, early probing is an accepted treatment of choice after appropriate medical therapy. Effectiveness of probing reduces with age.[13] Under GA, serial probing is done gently with graded Bowman's probe, by guiding it into the canaliculus till a hard stop is felt. The probe is then withdrawn slightly into the sac lumen, and it is swung vertically down slightly posterior and laterally into the NLD. A “pop” must be felt as the probe is passed through the obstruction. Patency is confirmed by endoscopy. Alternatively, in the absence of endoscope, syringing can be done with dilute fluorescein dye which is recovered from the inferior meatus.

During the procedure, there should be minimal or no bleeding. Grating sensation, if felt while passing the probe, determines a false passage.


  Balloon Dacryoplasty Top


Balloon dacryoplasty, reported by Munk et al. in 1990,[27] has emerged as a popular option addressing failed probing and as a primary procedure in an older child.

NLD is probed in a standard manner.[28] After assembling balloon catheter with the inflation device, 3-mm lubricated balloon [Figure 8]a is passed through the superior punctum into the distal portion of NLD. This is determined by markings on the catheter [Figure 8]b which lies against the punctum. The balloon is inflated to 8 atm for 90 s, deflated and re-inflated to 8 atm for 60 s.[29],[30] It is then withdrawn to the second marking on the catheter, corresponding to the position of catheter at the proximal portion of NLD, and the cycle is repeated. Finally after deflating, the catheter is removed. The procedure is completed after intubating the canalicular system. Not being cost-effective is the main disadvantage of this procedure. Alternatively, cardiac balloon devices have been promising in this regard.[31]
Figure 8: Balloon dacryoplasty, (a) inflating device, (b) balloon catheter with markings A and B corresponding to the position of catheter at the proximal and distal portions of the nasolacrimal duct, respectively

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Balloon dacryoplasty has also been tried with some success in partially patent canalicular system as a primary procedure in adults.[32],[33],[34]


  Laser Dacryocystorhinostomy Top


A fiberoptic connected to an 810-nm wavelength diode laser is used.[35] Laser DCR is based on the principle of using a laser beam to make an ostium through the lacrimal bone.[36] Laser energy makes an opening through the lacrimal sac, lacrimal bone, and nasal mucosa to create an ostium. A nasal endoscope is used to confirm the opening into the nasal cavity. Patency of the passage is checked using lacrimal syringing. Success rate, however, is very inconsistent with a predilection for closure and is now seldom used as a primary procedure.[37],[38],[39],[40]


  Canalicular Surgery Top


The main drawback following DCT surgery is persisting epiphora; this can be secondarily corrected by canaliculo DCR, wherein an internal membranectomy is done at the occluded CC area after creating a bony ostium as in routine DCR. Large broad-based nasal mucosal flap is fashioned and is sutured to the soft tissue over the opened CC. This procedure needs adjunctive bicanalicular intubation and MMC.[41]

Canalicular bypass surgery

Conjunctivo-dacryocystorhinostomy with insertion of a Lester Jones Pyrex glass tube is a procedure which creates a lacrimal drainage route from the conjunctiva into the nasal cavity, bypassing the canaliculi. The proximal end of Jones tube lies in the medial canthus and distal end in the middle meatus. This procedure is indicated in very proximal obstruction, whether acquired or congenital.[42],[43],[44] The main drawbacks of this procedure are tube extrusion, blockage, granuloma, and infection.

Lester Jones glass bypass tube has been tried with some success in patients with idiopathic canalicular stenosis, frequently seen in older women.[45]

Canalicular trauma

Primary repair of canalicular laceration if done within 48 h of injury gives a success rate of almost 94.7%.[46] Difficulty in canalicular tear repair is identification of medial cut end. Several techniques have been described. The cut end is usually pouting and pale compared to the pink surrounding tissue. Air or fluorescein solution can be injected from the opposite punctum and flow is identified from the cut end. Mini-Monoka stent [Figure 3]d is inserted, with its distal end passing into the lacrimal sac and proximal end fitted over the punctum with its collarette. Two to three peri-canalicular sutures are used to secure the stent. Bicanalicular stents can also be used [Figure 3]a, which give a better anatomically oriented medial canthus angulation. Tube retrieval, however, requires endoscopic assistance.

Canalicular trephination

Use of topical steroids or a combination of antibiotic steroids drops has been reported with some success in early cases of chemotherapy-induced canalicular stenosis. However, the use of silicone intubation shows benefits in managing this and preventing its progression.

Canalicular trephination has been by large the preferred option to manage canalicular stenosis. This can be combined with DCR and intubation with a large diameter tube and also with dacryoendoscopy. Sisler trephine is commonly used [Figure 9]. Various success rates have been described in literature, and outcome depends on the site of block.[47]
Figure 9: Sisler trephine

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  Recent Advances Top


Endoscopic lacrimal duct recanalization

Lacrimal surgery has seen progress with the introduction of micro-endoscope [Figure 10]. This enables direct visualization of stenotic or obstructed part of the lacrimal drainage system. Instrumentation includes dacryoendoscope that can be either flexible or rigid with an external diameter of 0.3–1 mm and wide enough to permit micro-drills, laser probes, micro-punches, trephines, and miniature balloons. It also gives a field view of 60°–70°. Trephine with endoscope is passed into NLD till the site of obstruction. Under visualization, the obstructed segment is trephined till it smoothly passes. Very fine micro-debriders are also used to drill out the obstruction.[48]
Figure 10: Endoscopic lacrimal duct recanalization showing micro-endoscope and created opening intranasally (picture courtesy – Dr. Gangadhara Sundar, NUH, Singapore)

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  Conclusion Top


Better understanding of the nasal anatomy and that of lacrimal drainage system, coupled with advanced instrumentation along with refinement in surgical techniques, has led to higher success rate of lacrimal surgeries. The advent of newer canalicular reconstruction procedures has greatly helped in improving the patient's quality of life.

Patients with teary eyes may not lose their vision always but definitely suffer from blurring and sticky eyes, and it becomes our moral responsibility to take care of this segment of population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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  In this article
Abstract
Introduction
Caution
Evaluation
Nasolacrimal Duc...
Endoscopic Endon...
Congenital Nasol...
Balloon Dacryoplasty
Laser Dacryocyst...
Canalicular Surgery
Recent Advances
Conclusion
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