Fig. 1.1
(a) Canaliculus superior stenosis. (b) Canaliculus communis stenosis. (c) Stenosis of superior portion of lacrimal sac. (d) Deep stenosis of lacrimal sac
Dacryocystography: the level and severity of stenosis, identification of fistulae or tumors,
ENT examination: exclusion of local obstructions e.g. by polyps, deviated septum.
Sonography: exclusion of foreign bodies e.g. calcified stones, lost punctum plugs.
Functional tear tests:
Dye test with 2 % fluorescein into the conjunctival sac: if fluorescein is in the nose after 2 min, then the test is said to be positive. If the dye appears after syringing with saline in the nose, this means a positive secondary dye test.
Taste test: The presence of saline in the nasopharynx can be tasted.
Results of Syringing (Fig. 1.1)
Stenosis of the inferior canaliculus: the saline regurgitates along the same canaliculus.
Stenosis of the common canaliculus or superior saccus: the saline regurgitates along the opposite canaliculus.
Stenosis of the sac or the nasolacrimal duct: mucus regurgitates along the opposite canaliculus.
Anesthesia for Lacrimal Surgery
Probing and syringing in children up to 1 year of age and adults can be done under topical anesthesia with eye drops e.g. tetracaine or proxymetacaine hydrochloride. We recommend general anesthesia for most lacrimal procedures for other patients, e.g. older children or handicapped patients.
In children, lacrimal surgery is usually done under general anesthesia. Children are rarely presented with complex congenital syndromes. The saline used for syringing after probing could be aspirated. The anesthesiologist must protect the airways from obstruction by saline solution and blood. Due to these complications endotracheal intubation is preferred. After surgery the fluids should be suctioned, the head should be placed head-down. Lacrimal surgery in adults may be carried out conveniently using general anaesthesia. If general anaesthesia is not possible some minimal invasive methods could be done using local anaesthesia. Usually general anesthesia is preferred. General anaesthesia has the advantage that both the airways and the blood pressure are under control. This is much more comfortable for the patient and the surgeon. If the patient needs local anaesthesia, a spray containing cocaine 4 % with a drop 1:1000 adrenaline is sprayed into the nose. The skin over the lacrimal sac is infiltrated with mepivacaine and adrenaline. The nasociliary nerve has to be blocked below the trochlea and the superior alveolar nerve proximal to the infraorbital foramen. Usually systemic sedation is helpful.
Adults undergoing lacrimal surgery are mostly older than 55 years of age. Others diseases, e.g. asthma, bleeding diathesis, hypertension, have to be identified before surgery and controlled during anesthesia. A detailed history and physical examination allow the anesthesiologist to assess the risk of complications. Aspirin therapy or other antiplatelet drugs should be stopped at least 8 days, or preferably, 14 days before surgery otherwise platelet infusions may be required. New antiplatelet drugs e.g. Dabigatran, Rivaroxaban or Apixaban should be stopped before surgery, if possible. Heparin should be discontinued 5 h before surgery and continued 5 h after surgery. Special patients (e.g. bleeder) should be crossed and typed for blood transfusion. Antiplatelet drugs should only be stopped after consultation with the general practitioner.
Antihypertensive medication should be taken on the day of surgery because arterial hypotension during the surgery is an advantage (limit to 70 % of the patient’s normal systolic and diastolic blood pressure). To reduce the swelling of the nasal mucosa Xylometazoline or Tetryzoline nasal spray is administered before surgery. DCR may be performed under local anesthesia, but general anesthesia is preferable. An oral right atrial enlargement tube and a throat pack can be used. For local nerve block Xylocaine and Epinephrine 1:100,000 is injected in combination with systemically administered sedative agents. It is important not to obtund protective airway reflexes. During surgery the patient should be positioned with head-up, feet-down position (reverse Trendelenburg position) to control the blood loss.
Patients should be prepared so that they will wake up with one eye patched and both nasal passages packed. With DCR involving the sinus the anesthesiologist should be aware of the oculocardiac reflex and the potential for blood loss. Drug interactions and side effects must be expected.
Management of Lacrimal Obstruction
Congenital Stenosis (Figs. 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 1.10, 1.11, 1.12, 1.13, and 1.14)
The most common cause for congenital stenosis with epiphora is the imperforation of the valve of Hasner. Therefore the common location of the obstruction is the end of the nasolacrimal duct under the inferior turbinate. Within most full-term babies the Hasner valve opens spontaneously at the age of 6 weeks. In case of chronic epiphora other causes e.g. absent puncta or punctual occlusion, accessory canaliculi, dacryocystocele, mucocele, craniofacial disorder, congenital glaucoma etc. should be ruled out. Before any surgical intervention the parents are recommended to massage the area around the nasalacrimal sac with a little finger (short cut nail) to reduce the risk of dacryocystitis and, hopefully, to treat the obstruction. Most problems are resolved in the first year and a further 60 % in the second year without intervention. The parents are informed about the importance of lid hygiene. Sticky lids and lashes can be cleaned with water, in case of dry periocular skin paraffin ointment can be applied. Topical antibiotics are only required in case of conjunctivitis after obtaining a culture and definition of the antibiotic sensitivity. In case of dacryocystitis systemic antibiotics are recommended. For the parents the most reassuring thing is the detailed information about the natural history of this disease. Usually they want to avoid invasive procedures and they will be patient.
Fig. 1.2
Dilatation with Wilder Lacrimal probe
Fig. 1.3
Syringing with Bangerter lacrimal probe
Fig. 1.4
Probing with Bangerter Lacrimal Probe Cannula
Fig. 1.5
Introducing a polypropylene suture with Juenemann Probe
Fig. 1.6
Picking the suture with a squint hook
Fig. 1.7
Intubation Seldinger 1
Fig. 1.8
Intubation Seldinger 2
Fig. 1.9
Intubation Seldinger 3
Fig. 1.10
Intubation Seldinger 4
Fig. 1.11
Intubation Seldinger 5
Fig. 1.12
Knot
Fig. 1.13
Cut
Fig. 1.14
Intubation
In case no improvement is observed after conservative treatment, probing can be performed between 3 and 12 months of age depending on the occurrence of mucopurulent infections. Newborns with congenital dacryocele (other terms: amniocele, amniotocele, dacryocystocele, neonatal mucocele,…) usually need therapy within 10 days after diagnosis. If probing alone fails within younger children (up to 10 months) then the additional insertion of a silastic intubation is recommended during general anesthesia. The success rate of probing alone is reduced with age because only the more severe obstructions remain. Therefore in cases of difficult probing or older children (older than 12 months) the silicone intubation should be performed additionally under general anesthesia.
Instruments for Probing and Intubation
Wilder lacrimal probe
Bangerter Lacrimal Probe Cannula
Juenemann Lacrimal Probe
Strabismus Hook short
5 ml saline filled syringe
4.0 prolene suture
Silicon Tubing diameter 0.6 mm (e.g. Hurricane Medical USA via Fa. Geuder Germany)
Alternative: Ritleng intubation system with an external diameter 0.64 mm (Fa. FCI): central silicone and polypropylene ends, Ritleng introducer
Medication and Dye
Xylometazoline 0.025 % nasal spray
Ophtocaine eye drops
Topical antibiotic eye drops
Fluorescein
Individual Steps
- 1.
Oxymetazoline hydrochloride 0.025 % tamponade
- 2.
Ophtocaine eye drops
- 3.
Punctal dilatation
- 4.
Syringing
- 5.
Probing
- 6.
Second syringing
- 7.
Intubation
- 8.
Postoperative care
The Surgery Step-by-Step
1. Oxymetazoline hydrochloride 0.025 % tamponade
Oxymetazoline hydrochloride 0.025 % should be administered into the nose to reduce the swelling of the nasal mucosa and the risk of bleeding.
2. Ophtocaine eye drops
Ophtocaine eye drops are administered into the conjunctival fornix.
3. Punctal dilatation
The Wilder Lacrimal Probe Cannula is inserted vertically for 2 mm. Then with the eyelid stretched the dilatator is rotated to the nose. The superior and inferior punctum and the proximal canaliculi are dilated horizontally.
Pitfall
Peripendicular rotating movements should be avoided because of the risk of injuring the canaliculus.
4. Syringing
The Bangerter Lacrimal Probe Cannula is inserted into the canaliculus. To identify a canaliculus problem by way of the reflux, irrigation of about 1 ml in the mid-canaliculus should be performed. With deeper irrigation mucus of the sac may regurgitate.
Pitfall
There is a risk of proximal false passage during syringing and probing. To prevent kinking of the canaliculus the lateral eyelid may be stretched gently.
5. Probing
The Bangerter Lacrimal Probe Cannula is inserted through the upper canaliculus by placing the upper eyelid on gentle lateral traction. To avoid canaliculus injury the probe is advanced initially for 2 mm vertically and then 8 mm horizontally until the bone at the medial sac wall can be palpated. After minimal withdrawal the Bangerter Lacrimal Probe Cannula is swung gently vertically down the nasolacrimal duct. During this procedure the external part of the probe keeps contact with the child’s eyebrow. The probe can be advanced in an inferomedial direction (angle 10–15°). Every surgeon should keep in mind that the length of the nasolacrimal excretory system is 22–24 mm in a 1-year-old child. In case of uncertainty the distance down the duct can be calculated by measuring the external part of the Bangerter Lacrimal Probe Cannula. Passing the obstructed valve a little resistance is felt. Visualization of the probe means an additional risk of additional nasal bleeding so it should be avoided in this situation.
Pitfall
The lateral traction of the eyelid is important to avoid false passageway. If it is impossible to pass the probe down the nasolacrimal duct, every repetition means a higher risk of mucosal damage and via falsa. After the surgery a preseptal orbital cellulitis or dacryocystitis may occur in cases with a false passageway.
6. Second syringing
After probing another irrigation follows to confirm that the fluorescein stained saline reaches the nose e.g. by aspirating with a suction tube from the nose or the throat. If no intubation is planned proceed to point 8.
The presence of saline in the nose following a further syringing confirms that patency has been achieved.
7. Intubation
A Juenemann Lacrimal Probe is inserted into the lacrimal system via the upper canaliculus. A 6.0 polypropylene suture is introduced via the probe into the nose. The suture is removed from the nose with a small Strabismus Hook. The Strabismus Hook is inserted into the nose and then gently pulled out along the lateral wall. Over this suture a silastic intubation is brought into the system. The lower canaliculus is inserted the same way. Make a knot in the nose. Gently pull the silastic suture out of the nose and make 2–3 knots. When the suture is relaxed, the knot should be free in the nose.
Pitfall
Two to three attempts may be needed to catch the suture with the strabimushook. When this manoeuvre is performed for the first time more attempts may be necessary. Remain calm. The suture will be found. If it cannot be found, intubate the polypropylene suture anew, do not use any power in fishing for the suture. Severe bleeding or a fracture of the turbinate can occur. If you cannot find the suture, try to use a speculum. If one punctum and canaliculi are missing a monocanalicular intubation with a Monoka is indicated. If a dacryocystorhinostomy is required to ensure the child’s condition, it is better to wait until the child is aged 2–4 years.
8. Postoperative care
Topical antibiotic eye drops are recommended for up to 3 weeks. Usually a systemic antibiotic is only necessary in case of a complication. In case of extreme nasal bleeding the nose should be packed. Bloody tears or discharge from the nose could appear up to 2 weeks after surgery. Patients should avoidblowing their nose or rubbing their eyes.
The silastic tube is left in place for 3 months. To remove the tube mask anesthesia in the surgery room is rarely necessary. Usually topical anesthesia with ophtocaine eye drops is sufficient. Then hold the tube near the superior punctum, cut it near the inferior punctum and retrieve it through the superior canaliculus. After removal the same eye drops as after surgery are recommended three times a day for 1–3 weeks.
Pitfall
If the intubation is fixed too tightly an incision of the punctum may appear. Tube prolapse may cause an erosion of the cornea or conjunctiva. To avoid this especially with children, it is recommended to put an eye shield on the eye at bedtime. A repositioning during the first month may be achieved by nasal visualization and by pulling on the node. Otherwise the intubation has to be removed.
If the tube rips off during removal tell the patient to blow its nose.
If the procedure has not brought about a resolution of the symptoms, then it can be repeated after about 3 months. After two technically satisfactory procedures the parents are informed that a DCR may be necessary to solve the problem.
Microsurgery of the Lacrimal System by Microendoscopic Techniques
Since the 1990s it was possible to view the lacrimal system directly by microendoscopic transcanalicular techniques [2, 3]. These methods facilitate selection of the appropriate operative procedure for a mechanical obstruction of the lacrimal system, visualization and removal of foreign bodies or dacryoliths and identification and taking a biopsy of tumors. During the endoscopy the pictures are visible on a TV monitor and can be documented. Illumination is delivered by a cold light source connected to the camera by a TV adapter. The working channel allows the introduction of miniaturized tools e.g. a laser fiber, a sling or a drill. The microsurgery makes it possible to perform surgery on the lacrimal system and eliminate obstructions without external scars. The latest endoscopes have a diameter of 0.65–1.15 mm and allow transmission of 3000–10,000 pixels resulting in pictures of an acceptable quality (Figs. 1.15, 1.16 and 1.17).
