Surgical Outcomes of Endonasal Conjunctivodacryocystorhinostomy According to Jones Tube Location:

Restrictive Strabismus Developing after Conjunctivodacryocystorhinostomy

Purpose: To report a case of diplopia caused by restrictive strabismus developing after conjunctivodacryocystorhinostomy (CDCR).Case summary: A 61-year-old female presented with persistent epiphora after failure to repair ipsilateral canalicular lacerations of the left eye caused by trauma occurred 25 years ago. CDCR was performed and the epiphora improved. Four months later, the patient presented with diplopia on the left gaze. An abduction limitation of -4 and a supraduction limitation of -3 were observed in the left eye. Therefore, Jones tube removal was performed 5 months after CDCR surgery. Two weeks later, as the limitations persisted, adhesiolysis of the conjunctiva and an amniotic membrane transplantation (AMT) were performed. This exposed a subconjunctival adhesion at the inferonasal conjunctiva; histopathological examination revealed fibrotic tissues. Three months later, the adhesions recurred and the patient was transferred to another hospital. Conjunctival adhesiolysis, AMT, and a 6.5 mm recession of medial rectus (MR) muscle were performed. One week later, exotropia occurred in the primary position, and the MR muscle of the left eye was advanced by 2 mm. Nine months after the final surgery, the primary gaze was orthotropia. The diplopia within the central 20° of visual field had disappeared. However, a levoelevation limitation of -1.5 remained in the left eye.Conclusions: CDCR is the only treatment method for patients with occlusion of both the upper and lower proximal lacrimal canaliculi. However, rare complications such as restrictive strabismus with diplopia may occur. As preventing adhesion is difficult, sufficient patient notice is required prior to surgery.

Surgical Technique to Retrieve a Migrated Lester Jones Lacrimal Tube

PURPOSE

To describe a technique for retrieving an inferomedially migrated Jones lacrimal tube.

METHODS

The distal end of the migrated Jones tube is visualized directly via the nose. The tip of an endoilluminator (23 Gauge Constellation Vision Systems) is bent to form a 45° to 60° angle using a mosquito forceps and inserted into the distal opening of the tube. The endoilluminator is used to push the tube upward toward the original medial canthal opening and limit downward displacement as the caruncular area is surgically explored. The light transilluminating the tube facilitates its visualization and retrieval in the caruncular area. A new tube may be threaded through the same passage, or if the ostium is traumatized, through a new passage.

RESULTS

This technique is time-efficient and has proven to be safe and successful in subsequent patients.

CONCLUSIONS

The described technique aids in retrieving an inferomedially migrated Jones tube with minimal trauma to the surrounding structures.

Application of a symptoms score questionnaire after conjunctivodacryocystorhinostomy: outcomes

Objective

To evaluate medium/long term outcomes and patient satisfaction through relief of symptoms and improved quality of life (QoL) after Jones tube conjunctivodacryocystorhinostomy (JT-CDCR) using the Naso Lacrimal Duct Obstruction symptom-score (NLDO-SS).

Methods

We conducted a retrospective, non-comparative, multicentric study including patients with complete obstruction of the superior and inferior proximal lacrimal drainage system. All patients underwent JT-CDCR, and the patency of the tube was evaluated with saline irrigation and endoscopic examination. We assessed patient satisfaction and quality of life administering the NLDO-SS.

Results

We enrolled 16 patients, for a total of 21 eyes operated. The success rate for procedures was 81%. The success rate for single parameters was globally 95.9%; if considered separately, ocular symptoms and nasal symptoms were respectively 94.3% and 100%.

Conclusions

JT-CDCR was a reliable procedure, able to solve symptoms in a majority of patients and guaranteed a good quality of life over a long period of time.

Conjunctivodacryocystorhinostomy (CDCR) success rates and complications in endoscopic vs non-endoscopic approaches: a systematic review

BACKGROUND

Epiphora due to refractory bicanalicular obstructions is typically managed by conjunctivodacryocystorhinostomy (CDCR) with or without the assistance of nasal endoscopy. However, the evidence for its benefit is unclear.

METHODS

A systematic review of the literature on the treatment of epiphora by CDCR was performed (March 1, 2018). All studies reporting original data on patients suffering from epiphora treated with CDCR surgery were included. Primary outcomes were success and satisfaction rates. Secondary outcomes were CDCR complications. A comparison was made between the results obtained in patients undergoing CDCR with vs without assistance of nasal endoscopy.

RESULTS

Fifty-four studies representing information on 2555 CDCR procedures were included in the systematic review. All the studies are case series, most of them retrospective. Lester Jones tube (LJT) is the most commonly used in CDCR (66.7%). The overall success rate with all studies included (n = 2555) was 88.9%; 90.8% (n = 890) in CDCR with assistance of nasal endoscope and 87.7% (n = 1575) in the non-endoscopic approach. The overall "tube displacement" rate, the most common complication, was 24.5% (n = 2522), 20.8% (n = 1575) tube displacement in CDCR with assistance of nasal endoscope vs 26.7% (n = 1575) in the non-endoscopic approach. Only 3 studies (5.5%) used patient-reported outcome measures (PROMs) to evaluate epiphora improvement. Due to the low level of evidence and the high bias of the studies, a meta-analysis was not performed.

CONCLUSION

Based on the data available in the literature, CDCR is considered an effective procedure for treating epiphora due to proximal obstruction. Controlled and qualitative studies are needed to clarify the significance of the endoscope's contribution to CDCR.

Dacryocystectomy with Lacrimal Silicone Intubation in Challenging Patients Affected by Recurrent Dacryocystitis and Epiphora: Expanding Minimally Invasive Approach Indications

Objective:

In this study, we evaluated the feasibility and safety of dacryocystectomy associated with lacrimal intubation, for the treatment of recurrent dacryocystitis and epiphora secondary to lacrimal obstruction with compromised lacrimal sac, was evaluated.

Subjects and Methods:

32 patients underwent dacryocystectomy with Crawford tubes canalicular insertion, performed by a single surgeon. Post-operative visits were scheduled at 1st and 10th day, 1, 3, and 6 months. At each follow-up visit, the prevalence of epiphora and dacryocystitis was evaluated and compared with baseline data. Also, we evaluated the prevalence of local and systemic post-operative adverse events during the follow-up period.

Results:

11 patients (34.38%) reported persistent epiphora, which lasted for 30 days after surgery. Among them, 9 subjects (28.13%) complained occasional epiphora even at the six months follow-up. In the event of dacryocystitis or subacute phlogosis before surgery, patients reported a definitive symptom resolution. Other reported adverse events were epithelial corneal erosion due to Crawford tube protrusion (4 cases, 12.5%), a Crawford tube extrusion case (3.13%), 3 cases of surgical wound dehiscence (9.36%), and a case of mild local bleeding persisting for 15 days

Conclusion:

A significative epiphora reduction was observed after surgery with an acceptable safety profile, expanding dacryocystectomy indications. This procedure provides a satisfactory resolution of recurrent dacryocystitis. However, this approach should be performed only in well-selected cases: elderly/frail patients with altered lacrimal sacs, epiphora associated with recurrent infections, and failure after dacryocystectomy.

Variation of the minimally invasive CDCR technique

Purpose: Traditional (tCDCR) and endoscopic conjunctivodacryocystorhinostomy (eCDCR) are challenging surgical techniques requiring general anesthesia, a facial incision, and a large osteotomy and mucosal flap. Minimally invasive CDCR (miCDCR) techniques eliminate the need for some of the steps in t/eCDCR. Introduced here is a variation of the miCDCR technique using a Naugle-Fleming knurled dilator (NKD) to create the osteotomy and instruments within a central line catheter kit to help easily place or replace a Jones' tube into position within a bony conduit.Methods: This IRB-approved retrospective chart review examined all patients who underwent this miCDCR technique performed by two oculoplastic surgeons at Hamilton Eye Institute at the University of Tennessee Health Sciences Center from 2014 to 2016. Inclusion criteria: need for CDCR (either primary or repeat). Exclusion criteria: loss to follow up prior to six months. Primary endpoints: operative time, incidence of tube migration and complications, and cessation of epiphora.Results: Sixteen patients (nine men, seven women) were reviewed, with three undergoing bilateral procedure, totaling 19 cases. Age range: 47.0 to 84.0 years, average of 66.6 years (SD = 11.1). Ten patients had surgery under local/MAC augmented with IV sedation, and six had general anesthesia (38%). Average operative time was 17.4 min (SD = 10.9). One patient (5%) required revision in the six-month immediate post-operative period because of tube migration. All patients had cessation of epiphora.Conclusions: This procedure can be done safely and quickly without general anesthesia, resulting in a satisfactorily lower rate of tube migration and cessation of epiphora rates.

Treatment of upper and lower lacrimal punctal occlusion using retrograde canaliculotomy and punctoplasty

This is a retrospective, noncomparative analysis of a case series to explore the safety and effectiveness of retrograde canaliculotomy and punctoplasty for treating epiphora due to upper and lower lacrimal punctal occlusion. During the procedure, the horizontal portion of the normal lower canaliculus was identified; the corresponding punctum was reconstructed via retrograde canaliculotomy and punctoplasty. Intubation was performed to prevent postoperative reocclusion. Patients were followed up for 12 to 24mo. A total of 16 patients with unilateral upper and lower lacrimal punctal occlusion were included. Satisfactory outcomes were achieved: all 16 patients exhibited improvement of epiphora; 31 rebuilt punctal openings and canaliculi achieved recanalization. Only one upper punctal opening could not be reconstructed because the corresponding canaliculus exhibited severe injury. No significant complications occurred as a result of the treatments. Retrograde canaliculotomy and punctoplasty appears to effective, safe, and minimally invasive for treatment of upper and lower punctal occlusion.

Jones lacrimal bypass tubes in children and adults

Background/aims

Although a Jones tube is considered the mainstay for epiphora in patients with total blockage of the canalicular system, it has been discouraged in children for reasons of inadequate self-care and maintenance. The purpose of this study is to compare the long-term outcome of Jones tube surgery in paediatric versus adult patients.

Methods

Retrospective, interventional case series of a single academic institution. The medical records of all children (≤16 years old) and adults (>16 years old) who underwent conjunctivorhinostomy with placement of a 130° angled extended Jones tube were reviewed. The outcome measures were patency and anatomical position of the tube, type and frequency of complications and subjective relief of epiphora.

Results

The study included 10 children (11 eyes) (range, 5.1–16.0 years old) and 102 adults (127 eyes) (range, 19.7–82.4 years old). The success and complication rate did not differ between the two age groups. Tube dislodgement and obstruction occurred in 4 (36.4%) of the paediatric tubes with an incidence rate of 6.1%/year and in 47 (37.0%) of the adult tubes with an incidence rate of 9.3%/year (p=0.3867). Two adults required routine self-irrigation of the tube. The median follow-up was 6.7 years for the children and 8.7 years for the adults (p=0.3430).

Conclusion

With a similar outcome profile and minimal self-care, young age is not a prognostic nor limiting factor for surgery with angled Jones tubes. Exchange with tubes of a longer length is not required during growth.