Jones lacrimal bypass tubes in children and adults

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.

Proximal lacrimal obstructions: a review

PURPOSE

The aims of the review are to summarize the aethiopathogenesis, management and outcomes of different treatments of proximal lacrimal obstructions.

METHODS

An electronic database (PubMed, MEDLINE and Google Scholar) search of all articles written in English and non-English language with abstract translated to English on proximal lacrimal obstructions was performed. The articles were reviewed along with their relevant cross references. Data reviewed included demographics, presentations, investigations, management, complications and outcomes.

RESULTS

Punctoplasty is as effective as punctal dilatation with monocanalicular or bicanalicular stent in case of punctal stenosis. Dacryocystorhinostomy with retrograde intubation is more effective in case of proximal canalicular obstructions than in case of mid-canalicular obstructions. Trephination and intubation is effective in both mid and distal canalicular obstructions in patients with no associated nasolacrimal duct obstruction. Canaliculodacryocystorhinostomy has a specific indication in case of proximal common canalicular obstruction. Bypass surgery is the preferred treatment if there is no residual patency, however surgical success may not match patient satisfaction.

CONCLUSION

Optimal choice of surgical method depends on identification of the site of obstruction. Mini-invasive techniques should be avoided in cases that would only benefit from standard surgical treatment.

Management of proximal lacrimal obstructions: a rationale

PURPOSE

To identify a rationale for correct surgical treatment of proximal lacrimal obstructions.

METHODS

Retrospective review of 775 consecutive patients (974 eyes) with proximal lacrimal obstructions, operated on with customized surgery by a senior surgeon (FMQL) from January 2003 to December 2018.

RESULTS

In case of punctal stenosis, punctoplasty was as effective as punctal dilatation with monocanalicular or bicanalicular stent (p > 0.05). In proximal canalicular obstructions, failure rate of dacrocystorhinostomy with retrograde intubation (R-DCR) was significantly higher in case of false inferior passage creation than in case of no false passage creation (p = 0.02). In mid-canalicular obstructions failure rate of R-DCR was 41.3%, and bypass surgery with Jones tube at second stage was likely. Trephination and monocanalicular intubation, performed in selected cases, had a failure rate respectively of 16.6% and 21.7% in mid and distal canalicular obstructions. Canaliculodacryocystorhinostomy (CDCR) was successful in 77% of cases of proximal common canalicular obstruction. Bypass surgery is the treatment of choice in case of no residual patency, and rates of tube extrusion were significantly reduced with the use of StopLoss Jones tubes (SLJT) (1.7%) with respect to standard tubes (12%), (p = 0.04, Fisher's exact test).

CONCLUSION

Patient history and accurate diagnosis of the site of obstruction are essential for a correct surgical choice. Less invasive techniques as trephination and intubation may be effective, but should be reserved to patients with no associated lower lacrimal obstruction. Further studies require specific randomized clinical trials, and a standardized protocol adopted by different clinical centres.