Conjunctivodacryocystorhinostomy
Christopher L. Weller, MD
DISEASE DESCRIPTION
Canalicular obstruction can result from a variety of mechanisms including trauma, infection, retained punctal plugs, systemic inflammatory diseases, and certain chemotherapeutic agents including 5-fluorouracil, docetaxel, and idoxuridine. Such obstruction may affect the superior, inferior, or common canaliculus and can result in a range of clinical manifestations from asymptomatic to constant epiphora. Patients with canalicular obstruction typically present with unilateral or bilateral tearing, and the diagnosis is established through a combination of patient history, clinical examination, and canalicular probing with or without irrigation.
MANAGEMENT OPTIONS
Depending on the location, size, and mechanism of canalicular obstruction, initial surgical reconstruction may be attempted through canalicular stenting or direct surgical reanastomoses with conjunctivodacryocystorhinostomy being reserved for recalcitrant cases.
INDICATIONS FOR SURGERY
Conjunctivodacryocystorhinostomy (CDCR) is a surgical procedure that creates an alternative path for tear drainage from the tear lake into the nasal cavity, completely bypassing the canalicular and nasolacrimal drainage system. A prefabricated glass tube, known as a Jones tube, is placed to maintain patency of the new lacrimal outflow tract. CDCR is indicated in patients with clinically significant epiphora resulting from canalicular pathology that has failed alternative means of canalicular reconstruction or conservative medical therapy.
SURGICAL DESCRIPTION
CDCR is performed under general anesthesia and typically requires 45 to 60 minutes of surgical time.
Use Westcott scissors to make a retrocaruncular incision, starting just inferior to the level of the medial commissure and extending inferiorly for approximately 3 mm (Figure 29.1).
Gently probe with tenotomy scissors to identify the anterior lacrimal crest, posterior lacrimal crest, and intervening nasolacrimal fossa (Figure 29.2A).
Advance the tenotomy scissors medially until the hard stop of the nasal bone or frontal process of the maxillary bone is encountered.
Advance the closed tips of the scissors posteriorly, sliding along the surface of the bone while maintaining gentle medial pressure. The elevation of the anterior lacrimal crest, followed by the concavity of the nasolacrimal fossa, and elevation of the posterior lacrimal crest are identified. These anatomic landmarks allow for accurate identification of the nasolacrimal fossa.
If previous dacryocystorhinostomy was performed, the existing rhinostomy is identified in a similar manner.
Once the posterior portion of the nasolacrimal fossa (or preexisting rhinostomy) is identified, bluntly dissect using small-amplitude, high-frequency spreading to create a tunnel through the medial canthal soft tissue to the preperiosteal plane.
Advance a curved hemostat through the soft tissue tunnel to the bone of the posterior portion of the nasolacrimal fossa. Apply pressure medially on the tips of the hemostat to infracture the bone to create the rhinostomy (Figure 29.2B).
The tunnel-rhinostomy complex should travel medially, inferiorly, and slightly posteriorly to ensure the required angulation of the passage for passive/gravitational tear drainage is achieved (Figure 29.2B).
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