There is no use crying over spilt tears: the surgical management of primary acquired nasolacrimal duct obstruction

The lacrimal bypass tube for lacrimal pump failure attributable to facial palsy

PURPOSE

To describe the use of a lacrimal bypass tube in the management of epiphora in patients with epiphora attributable to lacrimal pump failure in facial palsy.

DESIGN

Multicenter retrospective interventional study.

METHODS

Information regarding patient demographics, diagnoses, symptoms, oculoplastic interventions, dacryocystorhinostomy, and Jones tube insertion were collected from patient charts.

RESULTS

Eighteen patients were identified, in all of whom epiphora was clinically and/or radiologically assessed as being attributable to pump failure, lid laxity having been corrected. All had constant epiphora prior to Jones tube insertion. Dacryocystorhinostomy was performed in all; insertion of a Jones tube was performed simultaneously in 12, with delayed insertion in 6. Patients' subjective epiphora improved postoperatively in 15 of 18 (83.3%) and at final median follow-up of 27.5 months (range, 6 months to 31 years); symptoms were improved in 13 of 18 (72.2%). Complications occurred in 13 of 18 (72.2%), including tube extrusion and the need for repositioning.

CONCLUSIONS

In this highly selected group of patients, Jones tube insertion led to symptom improvement in 83.3% postoperatively and in 72.2% at median follow-up of 27.5 months. Tube extrusion and migration were common, although such complications were not unexpected and were treatable.

Scarring in external dacryocystorhinostomy: fact or fiction?

PURPOSE

To determine patients' long-term satisfaction with external dacryocystorhinostomy (DCR) with respect to the visibility of the scar and the resolution of symptoms.

METHOD

A single postal questionnaire with stamped addressed envelope for reply was sent to 204 sequential external primary DCR patients operated on by AAM from January 1999 to April 2002.

RESULTS

Of the 79% who replied, 67% rated the scar as invisible with 97% happy with the scar. In 92% the epiphora was either improved or cured and 85% would recommend the operation. Younger patients were significantly more likely to rate the scar as visible but equally likely to rate the scar as good or better. Women were no more likely than men to rate the scar as visible, but if visible, were more likely to consider the scar poor.

CONCLUSIONS

There was an excellent response rate for a single questionnaire. Patient satisfaction with the DCR scar is very high, with the majority considering the scar invisible. Only 3% remained unhappy with the scar. Overall patient satisfaction with external DCR is very high, for the majority of patients the procedure is effective, and 85% would recommend the operation.

External dacryocystorhinostomy and local anesthesia: technique to measure minimized blood loss

PURPOSE

To describe the techniques required to minimize blood loss in external dacryocystorhinostomy (DCR) under local anesthesia and to accurately measure the intraoperative blood loss through application of these techniques.

METHODS

Prospective single-surgeon series to include the first 20 sequential external DCRs from June 2002. Hemostasis was maximized at each stage of the procedure. Blood loss was measured by attaching a collection pot to the first link in the vacuum tubing. Patient demographics and operative duration were recorded.

RESULTS

The mean blood loss was 4.5 mL (range, 1 to 14 mL). The mean operative duration was 36 minutes (range, 25 to 65 minutes). Seventy-five percent of patients were female and 25% were male. The mean age was 57 years (range, 48 to 76 years).

CONCLUSIONS

Intraoperative blood loss in external DCR can be reduced to a negligible level through careful patient preparation and operative technique. Minimal blood loss allows for patient comfort with DCR under local anesthesia.

Naso-lacrimal duct balloon dilatation: medium to long term follow-up

AIM

Subjective patient response to nasolacrimal duct balloon dilatation (dacryocystoplasty) for epiphora due to primary acquired nasolacrimal duct obstruction (PANDO), was sought over the medium to long term. The relevant dacryocystograms were reviewed to assess the relationship between treatment outcome and dacryocystographic appearances.

MATERIALS AND METHODS

Sixty-three patients who had, in the preceding 12-month to 8-year period, undergone 102 dacryocystoplasties were sent a postal questionnaire in which subjective response to treatment was requested. Fifty-seven original dacryocystograms were reviewed by the author and the appearances of the lacrimal sacs subjectively assessed.

RESULTS

The results showed that in 31% of respondents (total response 48/63, 76%) dacryocystoplasty was ineffective for treatment of PANDO. Treatment failures did not respond to repeat treatment. Sixty-nine per cent of patients considered themselves either cured or improved by the treatment, with a minimal relapse rate during the period studied. The original dacryocystoplasty appearances were unhelpful in predicting treatment response.

CONCLUSION

Dacryocystoplasty can be expected to relieve or improve epiphora in 69% patients with PANDO, (incomplete obstruction) and favourable response to treatment is durable in the medium to long term. Repeat treatment is not recommended for those who fail to respond, though may be appropriate for cases of temporary response. The technique is safe and well tolerated. McCullough, K. M. (2001). Clinical Radiology56, 13-16.

Advances in lacrimal surgery

For nearly a century the gold standard treatment for epiphora and nasolacrimal duct obstruction has been dacryocystorhinostomy (DCR). The definitive treatment of severe canalicular stricture remains conjunctivodacryocystorhinostomy. Although the high success rate of open external approaches continues to be confirmed in the literature, there have been promising advances for endocanalicular surgery and endonasal DCR. Despite a significant narrowing of the gap in outcomes, external DCR may hold the advantage in its ease of performance and lower economic impact. A minor controversy exists over the role of routine postoperative antibiotics. Intraoperative intravenous antibiotic dosing may be as effective as postoperative systemic antibiotics for patients at high risk of infection.