Nasolacrimal stents for the treatment of epiphora: technical problems and long-term results

Comparison of the surgical outcomes of endoscopic dacryocystorhinostomy in chronic dacryocystitis with or without previous bicanalicular silicone tube intubation

AIMS

To compare the outcomes of endoscopic dacryocystorhinostomy (En-DCR) in chronic dacryocystitis (CD) with or without previous bicanalicular silicone tube intubation (BSTI), and investigate whether previous BSTI influenced postoperative outcomes.

METHODS

We conducted a retrospective review of medical records of CD patients (group A) who had previously undergone BSTI for nasolacrimal duct stenosis and an age- and sex-matched control group of CD patients (group B) without previous intubation receiving En-DCR from November 2017 to January 2022. Sixty-one patients (61 eyes) were included in group A and age- and sex-matched 122 patients (122 eyes) in group B. Dacryocystic parameters were measured by computed tomography-dacryocystography and surgical findings were recorded during surgeries. The surgical success rates of the two groups were compared at 12 months post-operation.

RESULTS

The mean horizontal, sagittal, and vertical lengths were 6.06 ± 1.24, 6.03 ± 1.44, and 8.05 ± 2.00 mm, respectively, in group A and 6.33 ± 1.25, 6.26 ± 1.19, and 10.40 ± 2.45 mm, respectively, in group B. There were no differences in the horizontal or sagittal parameters between the two groups. The vertical parameter in group A was significantly lower than that in group B. Scar formation in the sac was observed in 54 patients in group A but was absent in group B. At 12 months postoperatively, the anatomical and functional success rates were 88.52 % and 85.25 %, respectively, in group A and 92.62 % and 89.34 %, respectively, in group B, with no difference between the two groups.

CONCLUSION

Previous BSTI reduced dacryocyst vertical parameter and caused dacryocyst scar formation but did not affect postoperative En-DCR efficacy.

Improvement in Contrast Sensitivity Function after Lacrimal Passage Intubation in Eyes with Epiphora

This prospective case series aimed to investigate the contrast sensitivity function before and after lacrimal passage intubation (LPI) in eyes with epiphora due to lacrimal passage obstruction. We included 58 eyes of 51 patients who underwent LPI for lacrimal passage obstruction. The best-corrected visual acuity (BCVA), contrast sensitivity function, and lower tear meniscus were compared before LPI and one month after lacrimal duct stent removal. The area under the log contrast sensitivity function (AULCSF) was calculated for the analyses. Lower tear meniscus was assessed using anterior segment optical coherence tomography. The BCVA was comparable (p = 0.61) before and after LPI, while AULCSF increased significantly after treatment (before LPI: 1.29 ± 0.17, after LPI: 1.37 ± 0.14, p < 0.0001). Treatment resulted in a significant increase in contrast sensitivity at all spatial frequencies, 3–18 cycles/degree (p < 0.01 for 3, p < 0.01 for 6, p < 0.0005 for 12, p < 0.05 for 18 cycles/degree). The lower tear meniscus parameters improved significantly after treatment (p < 0.005); however, no correlation between the changes in the tear meniscus and those of the AULCSF was found. The contrast sensitivity significantly improved after LPI in eyes with epiphora due to lacrimal passage obstruction.

The role of interventional radiology in the treatment of epiphora

Epiphora is a relatively common ophthalmologic affection representing almost 5% of clinical consultations in ophthalmology and it consists in the complete or partial obstruction of nasolacrimal duct, leading to insufficient drainage of tears. The traditional treatment is represented by surgery namely, external dacryocystorhinostomy (DCR). Despite the high success rate DCR has many disadvantages and limitations since it requires general anesthesia, it may arise in a permanent facial scar and it is often affected by the reobstruction of the anastomotic tract by fibrotic scars and osteogenic activity. Fluoroscopically guided interventional procedures are a therapeutic alternative to surgery for lacrimal duct system obstructions that can consist either in balloon dacryocystoplasty or in nasolacrimal stent placement. In both cases, a pre-operative imaging characterization of the occlusion is needed for a correct treatment planning. In this review, we propose to highlight the role of interventional radiology in the treatment of epiphora and the role of computed tomography dacryocystography (CTD) in depiction and the pre-interventional planning.

Endoscopic endonasal dacryocystorhinostomy with ostial stent intubation following nasolacrimal duct stent incarceration

PURPOSE

To study the feasibility of endoscopic endonasal dacryocystorhinostomy (EE-DCR) with novel lacrimal ostial stent (LOS) intubation for patients with chronic dacryocystitis with incarceration of a previously implanted nasolacrimal duct stent (NDS).

METHODS

According to surgical procedure, 166 patients (167 eyes) were divided into two groups: EE-DCR with LOS intubation was performed on 126 patients (127 eyes) in the EE-DCR group; while external dacryocystorhinostomy (E-DCR) with silicone tube intubation was performed on 40 patients (40 eyes) in the E-DCR group. The LOS or silicone tube was retained for 3-6 months. All patients were followed up for 12-36 months. Success rate of tear drainage reconstruction (TDR) and complications were retrospectively compared.

RESULTS

Excluding patients with early detachment of the LOS or the silicone tube, or with incomplete follow-up period, 117 patients (117 eyes) in the EE-DCR group and 36 patients (36 eyes) in the E-DCR group were included. The mean surgical time was 45.8 ± 11.5 min in the EE-DCR group and 68.1 ± 23.8 min in the E-DCR group (p < 0.001). Intraoperatively, the lacrimal sac was observed to become very small and its walls were thin, hyperemic and fragile, firmly attaching to the NDS by fibrous bands in all eyes. Upon final review, success rate of TDR was 83.8% (98/117) in the EE-DCR group, while 58.3% (21/36) in the E-DCR group (p < 0.01). Failure of TDR due to ostial closure by excessive fibrosis occurred in 14 out of 19 patients in the EE-DCR group, significantly less than the 11 out of 15 patients with failed TDR in the E-DCR group (χ(2 )= 6.959, p < 0.01). No significant difference existed in failures due to granuloma occluding the ostium or common canaliculus obstruction.

CONCLUSION

EE-DCR with LOS intubation may be an effective procedure to manage the special subgroup of patients with chronic dacryocystitis with incarcerations of a previously implanted NDS.

Randomized comparison of nasolacrimal cryoplasty versus plastic lacrimal stenting in the management of epiphora in adults

PURPOSE

To evaluate the efficacy of plastic polyurethane stents compared with nasolacrimal cryoplasty in the management of epiphora in adults.

MATERIALS AND METHODS

Patients (N = 37; mean age, 64 years; range, 34-86 y; six men, 31 women) with severe epiphora with partial/complete obstruction of the nasolacrimal system were randomized to have a plastic stent inserted (n = 19) or to undergo balloon dilation cryoplasty (n = 18). Both procedures were conducted on an outpatient basis. Patency was assessed with Kaplan-Meier curves.

RESULTS

Initial technical success rate and immediate resolution of epiphora was complete in all cases. At 6 months of follow-up, outcomes were already significantly different between the treatment groups and hence the study was discontinued. Plastic stent placement achieved a primary patency rate of 59.6% at 6 months, compared with 12.4% in the cryoplasty group (P < .0004). Multivariate analysis indicated that other measured variables (sex, age, etiology, previous treatment, and the interventional radiologist's expertise) had no significant effect on the outcomes (P > .05).

CONCLUSIONS

Initial success was good in both treatment groups, with nasolacrimal plastic stent placement achieving a level of primary patency superior to the cryoplasty procedure for the relief of epiphora on short-term follow-up. However, long-term outcome evaluation is needed before stent placement can be recommended as an alternative to more established surgical procedures.

Inclination of the superomedial orbital rim in relation to that of the nasolacrimal drainage system

The influence of the height of the superomedial orbital rim on the ease of nasolacrimal intubation has not been investigated. The authors measured the inclination of the height of the superomedial orbital rim and the nasolacrimal drainage system in 46 sides of Japanese cadavers. The inclinations to the coronal plane of the lacrimal sac and the nasolacrimal duct were measured. A straight probe was inserted into the lacrimal sac and allowed to rest on the superomedial orbital rim. The angle made by this probe and the coronal plane, defined as the inclination of the height of the superomedial orbital rim, was measured. The lacrimal sac was inclined 27.2 degrees +/- 7.6 degrees, the nasolacrimal duct was inclined 22.5 degrees +/- 9.7 degrees, and the height of the superomedial orbital rim was inclined 26.1 degrees +/- 9.1 degrees. For the height of the superomedial orbital rim-nasolacrimal duct angle, there were 33 sides with the anterior type and 13 sides with the posterior type. These results indicate that the height of the superomedial orbital rim may affect the ease of nasolacrimal intubation.