Epiphora resulting from either obstruction or lacrimal pump failure is a common problem. The most common causes of lacrimal obstruction are nasolacrimal duct stenosis and common canalicular obstruction. External dacryocystorhinostomy (DCR) is a standard procedure for the nasolacrimal duct stenosis with high success rate.1 Conjuctivo-DCR or canaliculo-DCR is preferred for proximal and distal canalicular obstruction.2–4 Although the functional result achieved with canalicular bypass tubes is usually good, there may be dissatisfaction from complications or simply the burden of postoperative tube management.3,5,6
The distal common canalicular block is caused by the membranous obstruction at its junction with the sac and accounts for two thirds of common canalicular obstructions.7 Remaining cases of common canalicular obstructions are caused by pericanalicular fibrosis at lateral end. The distal common canalicular obstruction can be treated by alternative technique of DCR with internal membranectomy and silicone intubation in cases where it is encountered intraoperatively.8 Although membranectomy is commonly performed, the long-term success of the procedure has not been studied previously in a prospective manner. The purpose of our study was to prospectively investigate this technique for distal common canalicular obstruction diagnosed preoperatively and its success rate over 1 year for a series of patients who have undergone this procedure.
MATERIALS AND METHODS
This is a prospective interventional case series performed at a tertiary eye center. Fifteen patients with the diagnosis of distal common canalicular block who presented between July 2008 and December 2009 were enrolled in the study. Inclusion criteria were age older than 15 years, significant epiphora, absent regurgitation on pressure over lacrimal sac, and 12 mm or more canalicular obstruction on probing. Patients with obstructions at any other level or due to previous surgery, trauma, epiphora due to functional causes, any nasal pathology, and bleeding diathesis were excluded. Ethics committee approval was obtained, and the study conforms to the provisions of the Declarations of Helsinki. A written informed consent of all the patients was taken before enrolment in the study. All the patients were operated on by the same surgeon (Kumar S).
The middle meatal area in front of the middle turbinate adjacent to the lacrimal fossa was packed with gauge soaked in lignocaine 4% and epinephrine before surgery. In all cases, local anesthesia was used. Skin incision was given, and dissection was done to expose the lacrimal sac. The sac was directly inflated with saline (Fig. 1), and anterior flaps slightly larger and posterior flaps were excised. Syringing showed the blockage of lacrimal passage, and a 0-number Bowman probe was inserted through the superior and inferior puncta after dilation, and common canalicular distal end was tented (Supplemental Digital Content 1; http://links.lww.com/APJO/A34). Necessary dissection (membranectomy) was done at the tenting site over the lacrimal probe with the use of forceps and scissors (Supplemental Digital Content 2; http://links.lww.com/APJO/A35). After dissection, mitomycin C (MMC) was applied in a concentration of 0.2 mg/mL for 5 minutes using soaked sponges followed by thorough wash with saline (Supplemental Digital Content 3; http://links.lww.com/APJO/A36). After adequate size osteotomy, nasal mucosal flaps were fashioned. The silicone intubation was carried out and the anterior sac and nasal mucosa flaps were sutured with 6–0 polyglactin (Fig. 2 and Supplemental Digital Content 4; http://links.lww.com/APJO/A37). The distal end of silicone tube was placed in nasal cavity, and incision was closed with 6–0 silk suture.
A course of antibiotic and anti-inflammatory drugs along with local antibiotic drops and ointment application over the wound area was advised for 1 week. The patients were also advised to use the nasal decongestants drops. The skin suture removal was done on the seventh day postoperatively.
Patients were followed up on the fourth day, seventh day, 1 month, and then monthly for at least 1 year. Relief in symptoms (epiphora and discharge) and level of tear meniscus were measured on every follow-up visit. An occurrence of any complication was noted. The silicone tube was removed at the end of 2 months after the surgery, and syringing was done to determine patency of the lacrimal passage. The fluorescein dye disappearance test (FDDT) was also done. Success was defined in terms of relief in subjective symptoms and patient satisfaction rates and objectively in terms of decrease in the tear meniscus level, patency of lacrimal pathway on irrigation (anatomical success) and positive FDDT (functional success). The observations were compiled, and statistical evaluation was made using the McNemar test. Difference in proportions of successful surgeries and failures was observed.
There were a total of 15 patients with the mean (SD) age of 42.53 (9.88) years (Table 1). The right side was involved in 11 (73%) cases. Most of the patients were female (93%). The presenting symptom was epiphora in all cases, with the mean duration of approximately 18 months. The regurgitation on pressure over lacrimal sac area was negative in all cases. On syringing, 12 (80%) cases had regurgitation of clear fluid, and in the rest of the cases, there was regurgitation of fluid with mucus strands. There was “soft stop” on probing in each case. The follow-up period ranged from 13 to 18 months with a mean of 15.4 months.
Intraoperatively, the membranous obstruction was seen in all cases near the distal end of the canaliculus. Excessive bleeding was present in 2 (13%) cases, which was controlled by applying packs soaked in saline and adrenaline. In the rest of the patients, surgery was uneventful.
The postoperative complications noted were nasal bleeding, lateral displacement of silicone tube at medial canthus, complete extrusion of silicone tube (at 4 weeks), and noticeable incisional scar, each in 1 case. During the first 2 months, when the tube was in situ, 4 cases complained of watering. It was probably caused by irritation due to the tube end at the medial canthus.
After silicone tube removal at 2 months after surgery, all patients were relieved of watering. Syringing was freely patent in 12 (80%) cases, and in 3 cases, there was some resistance, but lacrimal pathway was patent. These 12 cases also showed positive FDDT test. In the remaining 3 cases, flushing was done with saline, and after it, the FDDT was positive. In 2 of these cases, pressure syringing was done with upper punctum occlusion. In the third case, where early extrusion of tube was noted, repeated weekly probing and syringing were done to ensure patency.
At the end of the 12 months of follow-up, 14 (93%) patients were freely patent with tear meniscus level less than 1 mm and positive FDDT. One patient developed proximal canalicular obstruction during the follow-up period. All the rest of the patients had relief of watering and were satisfied with surgery. The result was statistically significant (P = 0.0001).
Canalicular block is a frequent cause of troublesome epiphora and accounts for up to 25% of cases.9 Management of common canalicular obstruction poses unusual problems and has largely been unsatisfactory. The procedure of canaliculo-DCR as described for common canaliculus obstruction traditionally involves the excision of the obstructed portion and formation of flaps from common canaliculus, which are sutured to medial wall of lacrimal sac.10 The success rate of this procedure varies from 75% to 80%, and results may not be universal.4,11
The conjunctivo-DCR, consisting of Jones tube placement,5 is a bypass surgery that is standard for irreparable proximal lacrimal obstruction. It is advised to reconstruct the system rather than inserting a permanent artificial prosthesis. The indication includes individual canalicular obstruction, failed canaliculo-DCR, severe trauma to the lacrimal system, and punctual agenesis. The eventual success rate after repeated attempts may vary from 41% to 100%.10 However, the potential problems associated are lifelong care of the tube, patient dissatisfaction, and extrusion or plugging of tube, and granulation tissue formation.
In a retrospective study by Boboridis et al,8 preoperative evaluation may fail to detect obstruction at distal common canaliculus because of the presence of a partial membranous obstruction or anatomical variations in the distal canalicular opening to the sac. Although the success rate is reported to be 92% by Boboridis et al,8 in 52% of patients in their series, the diagnosis of membranous obstruction was missed preoperatively. In our case series, such an obstruction was diagnosed preoperatively in all cases, and therefore, we anticipated the presence of thick membranous obstruction. Hence, the patient characteristics in our series were different from the previous report by Boboridis et al.8
The valve of Rosenmuller is normally found in 45% to 60% of the lacrimal sacs at the opening of internal common canaliculus.11 Chronic inflammation can result in fibrosis and adherence of this valve to the mucosa resulting in obstruction at distal common canaliculus.8 In contrast, some believe that Rosenmuller valve is not a true valve, but in fact an angulated common canaliculus. Common canaliculus kinking is seen with sac distension in cases such as mucocele. In our cases with common canaliculus obstruction, there was no sac distension seen clinically or intraoperatively. Under direct visualization, we observe the presence of membrane at the orifice of common canaliculus with in the sac mucosa. After opening the sac from the lateral side, meticulous dissection of such a membrane was performed by tenting it with the use of a lacrimal probe until it could be visualized. Therefore, we avoided the excision of a portion of common canaliculus. This is in comparison with canaliculo-DCR, where obstructed portion of common canaliculus is excised and canalicular flaps are made from normal canaliculus. This can further damage the normal portion of common canaliculus, and also, the placement of sutures in such a small space can lead to even more scarring. Hence, avoiding these steps in cases of distal common canalicular obstruction can increase the success rate of procedure.
Bicanalicular silicone intubation has been recommended for the canalicular diseases. Although there have been dispute over its use,12–14 it is indicated in cases at high risk for surgical failure. The timing of silicone tube removal varies, to be as early as 4 weeks or even up to 1 year. Onerci15 has recommended that the silicone intubation may be used routinely for 2 months to have better results but no longer than 3 months to avoid complications. According to 1 retrospective review, the timing of tube removal does not affect the success rate of DCR.16 The tube removal in our study was done at 2 months after surgery, and high success rates in our study show that an epithelial-lined tract can be formed in a few weeks subsequent to which tube removal does not alter the surgical results. The extrusion of the silicone tube was observed at 4 weeks in 1 patient with favorable surgical outcome. In another patient, there was lateral displacement of tube at canthus, which was easily managed by pulling the tube through the nasal cavity with the aid of an endoscope. In 4 patients, mild watering and irritation were seen in early postoperative period. Silicone intubation can cause certain complications such as punctal erosion, punctal slitting, granuloma, corneal erosion, and chronic conjunctival or nasal irritation.15 No such complications were noted in our series.
Liao et al17 evaluated the long-term results of intraoperative MMC application in DCR in primary acquired nasolacrimal duct obstructions and concluded that intraoperative MMC application could improve the success rate. It appears that MMC inhibits fibroproliferative activity and scar formation to maintain a patent pathway. In our study, MMC was applied at the common canaliculus after internal membranectomy. We avoided the application of MMC to nasal mucosa because of the risk of abnormal nasal bleeding, mucosal necrosis, or infection.
Because anatomical success does not always lead to functional success,18 both were included as final outcome measures in our study. Canalicular obstruction has also been managed by the use of less invasive procedures. The reported success rate for complete relief of epiphora (functional success) has been 33.3% to 37%19,20 for balloon dacryocystoplasty, 59% to 84.4%21,22 for lacrimal trephination, and 86%23 for endoscopic transcanalicular dacryoplasty. In our study, we found the external DCR with internal membranectomy to be effective in 93% of cases. Therefore, we believe that the preferred technique in canalicular pathology should be external DCR because of the following advantages. First, open external method allows the removal of obstruction mechanically and healing by primary intention, thus reducing the chances of scarring and contraction, which could occur because of lasers.24,25 Second, because the procedure is performed under direct visualization, necessary dissection of membrane can be done without causing damage to surrounding normal tissue. Third, it allows direct application of the MMC to the reopened canaliculus. Fourth, creation of the opening directly into the middle meatus will reduce the resistance to tear drainage and allow complete relief of epiphora.26
There were few minor complications seen in our series. One patient complained of bleeding 48 hours after the surgery, probably related to clot retraction. After anterior nasal packing for 48 hours, the patient does not complain of bleeding on follow-ups. There was noticeable incision scar in 1 (7%) of 15 patients. The tube-related complications of lateral displacement and complete extrusion did not affect the final outcome.
There are few limitations of our study. This study is noncomparative, the sample size is small, and further studies with greater number of patients are required. Another disadvantage is the possibility of cutaneous scar. Although 1 patient in our study developed visible scar, she was satisfied with the appearance. Patients’ long-term satisfaction with DCR scar can be very high, and most will consider the scar invisible.27
In our study, 1 patient developed proximal canalicular obstruction at 1 year of follow-up period. Although the patient had epiphora, she refused for the second surgery. Thus, in our series, 14 (93%) patients were relieved of epiphora and had patent lacrimal passage at a mean follow-up of 15.4 months. These findings suggest that a higher success rate may reflect the combined effect of external DCR in allowing meticulous and complete dissection of membrane, in applying the MMC to prevent fibrosis, and in allowing the silicone tube to form an epithelial lined tract. Thus, all these procedures combined together have given such high rates of success for the management of distal common canalicular block in our study. However, the individual role of each needs to be established especially of MMC because it is a newer approach in the management of nasolacrimal obstructions.
To conclude, DCR with internal membranectomy with silicone intubation combined with MMC application is a safe and effective procedure for distal common canalicular blocks. This salvages the canaliculi and avoids the more difficult and cumbersome canaliculo-DCR and Jone intubation. Silicone tubes and MMC are generally well tolerated with very little complications.
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The mind of a bigot is like the pupil of the eye. The more light you shine on it, the more it will contract.
- Oliver Wendell Holmes Jr.