30.1 Goals

The primary goal of conjunctivodacryocystorhinostomy (CDCR) is to reestablish communication between the ocular surface and the nose to allow the passage of tears, thus resolving symptoms of epiphora. Secondary goals include good cosmesis, long-lasting functionality, minimal irritation, and easy maintenance. These goals are best achieved by placing a tempered glass Jones tube of the appropriate size in the proper location and orientation. This chapter discusses some strategies to help ensure good surgical results and patient satisfaction.

30.2 Advantages

CDCR offers a complete bypass of the native nasolacrimal system. This is the preferred operative approach in cases of proximal lacrimal system pathology with total or severe canalicular obstruction, prior failed canalicular repair, tear pump failure, and prior dacryocystorhinostomy (DCR) with anatomic but not functional success. These scenarios can be due to a variety of causes: congenital agenesis, postinfection scarring and fibrosis, trauma, neoplasms, inflammation, chemotherapy, radiation, and facial nerve palsy. ¹ In such cases, salvaging the native proximal lacrimal system is not possible. Additionally, placement of a Jones tube serves to maintain the patency of the surgically created pathway. It should be noted that the option of canaliculorhinostomy (creating an anastomosis between the canaliculi and nasal mucosa) is available if there is at least 8 mm of normal canaliculus extending from the punctum. ²

30.3 Expectations

As with any surgery, a major key to a successful outcome is a thorough discussion of the procedure and expected postoperative course with the patient. As will be discussed later, the patient will need to ascribe to a maintenance regimen to preserve the function of the surgery. Most importantly, the patient should be prepared to have a glass tube in their medial canthus, and they should be aware that this tube is intended to remain there permanently. He or she should be aware of the potential for the tube to require adjustments, either in the office or potentially in the operating room. The patient should also expect some mild eye irritation following surgery, but this is usually transient as patients tend to adjust well to presence of the glass tube.

The patient should expect swelling, bruising, and some discomfort in the operative area. This is rarely severe, and can be well-managed with oral medication taken at home. If an external approach is employed, then the patient should be aware of the risk for a scar. Regardless of approach, the patient should be prepared for a nose bleed the day following surgery, but this is usually low volume and mild. However, in rare cases the patient may require nasal packing.

30.4 Key Principles

The key to a successful CDCR is providing adequate drainage for the tears to drain from the eye into the nose. In order to subvert abnormal and nonfunctional anatomy, the surgeon must have a complete understanding of that anatomy. Especially important is the three-dimensional relationship between orbital and nasal structures. An understanding of the location of the thin lacrimal bone is crucial for proper osteotomy placement. Otherwise, the surgeon may find himself or herself attempting to pass through the thick maxillary bone leading to great intraoperative difficulty and an improperly placed Jones tube. An appreciation of the middle turbinate and nasal septum is also important to prevent tube occlusion and patient discomfort. Once the surgeon has facility with the anatomical structures involved, the CDCR can be performed in an efficient, safe, and effective manner.

30.5 Indications

The CDCR with glass Jones tube placement is indicated in patients with proximal lacrimal system dysfunction. If the site of dysfunction is upstream of the nasolacrimal sac, it is the procedure of choice. There are many potential etiologies for proximal lacrimal obstruction. In pediatric patients, canalicular agenesis is a common cause. The canaliculi may also have acquired fibrosis from recurrent infection, autoimmune inflammation, or drug reaction such as Stevens-Johnson syndrome. Iatrogenic causes such as chemotherapy, especially noted with docetaxel, and radiation therapy are also known. Canalicular trauma can lead to scarring and stenosis if the laceration is not repaired promptly or properly. Additionally, trauma to eyelid and orbicularis muscle can lead to lacrimal pump failure despite proper canalicular repair. Facial paralysis can also produce an ineffective pump mechanism.

If the patient has had a prior DCR with anatomic but not functional success (a patent osteotomy into the nose with flow with forceful irrigation but persistent symptomatic epiphora), CDCR may be considered.

30.6 Contraindications

The first priority of any surgeon is to do no harm. If comorbidities place the patient at undue risk, surgery should be deferred until the patient is medically stable and better able to tolerate the procedure. As we tell all of our patients, “No one has ever died from tearing.”

The patient should discontinue any anticoagulant or antiplatelet therapy for an adequate duration for full reversal of the medication’s effects. Increased bleeding not only places the patient at risk for systemic complications from the surgery, but also makes performing a good and effective surgery more difficult due to poor visualization.

Even in patients with no increased bleeding risk, we advocate against bilateral surgery on the same day. Nasal packing may be required for postoperative bleeding, and bilateral nasal packing is uncomfortable and may place the patient in respiratory compromise. If only one side requires packing, postoperative edema and congestion in the contralateral nose may still make the patient uncomfortable and unable to breathe adequately.

Some physicians may prefer to defer surgery in pediatric patients, as maintenance of the Jones tube tends to be more difficult in children. Due to the active nature of pediatric patients, the tube may also be more likely to become displaced. Additionally, adjustments can rarely be performed in the office and would require general anesthesia.

Abnormal nasal anatomy may make placement of the Jones tube more difficult. Some patients with severe deviated septum or nasal fractures may require surgical repair of these issues. We recommend that any planned nasal procedures are performed prior to attempting CDCR.

30.7 Preoperative Preparation

As part of the preoperative exam, the surgeon should inspect the medial canthus and caruncle to assess for any potential problems in tube placement. Conjunctivochalasis or a large caruncle may need to be addressed at the time of surgery to prevent tube occlusion. It is also beneficial to perform a nasal exam in the clinic to evaluate for septum deviation and any other issues that may complicate tube placement.

Before the date of surgery, the surgeon should ensure that all equipment potentially needed for the case is available. Equipment needs depend on the surgical approach elected for the procedure. There are also several types and modifications of tubes available. Whichever tube type is preferred by the surgeon, multiple lengths and diameters should be available.

Adequate anesthesia is crucial to a successful surgery. Pain leads to increased blood pressure, which leads to increased bleeding, decreased visibility, increased manipulation, and increased pain. The most effective way to stop this cycle is to prevent it. CDCR can be performed under general anesthesia or monitored anesthesia care (MAC) with local blocks to the medial canthus, caruncle, medial peribulbar region, and lateral nasal wall. The surgeon, anesthesiologist, and patient should have a collaborative discussion to choose the best type of anesthesia for the case.

30.8 Operative Technique

A CDCR can be performed by an external or endonasal approach. We prefer to perform the surgery endonasally with an endoscope. We utilize a technique similar to those previously published. ^{1 ,​ 3 ,​ 4 ,​ 5 ,​ 6}

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