Fig. 30.1
Canaliculus repair with CJDCR. (a) Absence of lower canaliculus with the presence of a secondary canaliculus within cartilaginous appendage. Complete stenosis of the distal third of the upper canaliculus. (b, c) Four years following CJDCR with patent bypass tube in good position
Fig. 30.2
Craniofacial deformity and repair. (a) Example of craniofacial deformity demonstrating Tessier clefts 4 and 7 present on the right side with macrostomia. (b) Partial cryptophthalmos. (c) Following coloboma repair with Mustarde rotating cheek flap and cleft lip repair. (d) Open-approach CJDCR. (e) Ten days following surgery with spectacle camouflage. (f) Seven years following placement of bypass tube
Once an upper system block is identified, the most important step in determining whether a patient is a candidate for CJDCR surgery is to fully delineate the extent of the obstruction. Since bypass surgery requires long-term attention, alternative procedures should be thoroughly explored. Both the length and the location of the obstruction can influence the choice of surgical technique.
In general, the smaller the obstruction, the greater the chance the native lacrimal system can be reconstructed and opened. If a distal canalicular obstruction is limited to the entrance into the lacrimal sac, Silastic intubation in combination with a dacryocystorhinostomy (DCR) should first be attempted [11]. In addition, distal canalicular trephination with bicanalicular stenting with DCR can improve success [12]. Intuitively, the likelihood of achieving a successful result with these procedures is far greater if the probe can be easily passed through the obstruction without creating a false passage. For those situations where the blockage is more severe, some surgeons have advocated performing a DCR with Silastic intubation in combination with a CJDCR, so that in the event that the DCR and Silastic intubation fail, a bypass permanent tube is already in place [13, 14]. If the bypass tube can be temporarily occluded without recurrence of tearing , then the Pyrex tube can be subsequently removed. Unfortunately, with younger children, limited cooperation makes this far less practical, and we do not routinely follow this suggestion.
As an alternative to a DCR with Silastic intubation , some surgeons have advocated open excision of the segment of blocked canaliculus with reanastomosis directly to the lacrimal sac (Fig. 30.3). This technique is termed a canaliculodacryocystorhinostomy (CLDCR). Although CLDCRs are associated with a significant failure rate, this technique can be particularly useful for those obstructions limited to the common canaliculus [15, 16]. In the appropriate patient, a DCR can be performed in combination with excision of the blockage, suturing of the canalicular flaps to the lacrimal sac, and insertion of Silastic tubing as a stent.
Fig. 30.3
Common canaliculodacryocystorhinostomy (CLDCR). Anastomosis of patent area of common canaliculus to nasal mucosa
A CJDCR, therefore, can be contemplated in any patient with canalicular obstruction that has either failed a DCR with Silastic intubation or a canaliculodacryocystorhinostomy or has such extensive blockage that an alternative procedure cannot be performed. A patient falling into any of these categories must then be assessed for severity of symptoms. In general, when the epiphora is mild or occurring intermittently in a young child, we recommend delaying surgery and reevaluating the patient at a future date. This is partly due to the fact that the rapid growth of the face in the first 5 years of life may often require revisions of the static small tube as it is outgrown. A CJDCR also becomes a much more attractive solution for epiphora once a patient is old enough to tolerate in-office manipulations of the bypass tube as well. For those younger patients with constant epiphora or recurrent bouts of infection, the benefits from a CJDCR may prove substantial enough to warrant earlier intervention.
Children with craniofacial syndromes are managed in a slightly different manner in that the threshold for performing a bypass procedure may be somewhat lower. Such patients will undoubtedly require multiple procedures under general anesthesia, and thus the opportunity to revise or adjust a bypass tube more readily exists. Additionally, these patients and their families are usually more accepting of the reality that multiple surgical attempts may be required to manage difficult upper system obstructions.
By far the most important consideration in deciding to perform a CJDCR is whether a fully informed family is prepared to devote the time and effort necessary to assure a successful outcome. They must understand from the beginning that their child may have to undergo multiple procedures requiring general anesthesia. In addition to revisions or adjustments that will be performed in the hospital or office, the parents or guardians will have to devote time to the care of their child’s bypass tube on a regular basis. Daily maintenance of the tube is required throughout a lifetime. Frequent physician follow-up visits are necessary even in the most ideal situation, with a minimum of two visits a year. Once the family has been well informed and has fully accepted the challenge, a CJDCR can be the solution to a very persistent and aggravating problem.
Surgical Technique
Lester Jones first introduced his surgical technique in 1962, and since that time the placement of a Pyrex tube has become the standard and most popular method of performing a CJDCR [1]. Although surgeons have experimented with several different bypass materials, none have functioned as well as the Jones tube . Silicone, polyethylene, polypropylene, and polytetrafluorethylene have all been tried as substitute materials for bypass tubes, but the excellent capillarity of Pyrex cannot be reproduced with any of these alternative materials [17, 18]. Additionally, accumulation of protein deposits in the lumen with other synthetic materials has tended to be greater than with glass. Venous and mucous membrane grafts have also been used but once again demonstrate inferior capillarity function [19, 20]. Unfortunately, these grafts are not sturdy and undergo gradual stenosis, which further limits tear flow. A more recently described approach using a tubed pedicle of nasal mucosa in adults may show some promise but may be more challenging to accomplish in pediatric patients with smaller amounts of tissue available, especially at younger ages [21].
The Jones Pyrex tube has thus withstood the test of time. The Jones Pyrex tube (Gunther Weiss, Portland, OR) is available in a variety of lengths, shapes, and angles, allowing the surgeon to more successfully fit a tube in both younger and older children (Fig. 30.4). In addition to size and shape, other modifications like frosted tubes, tubes coated in porous polyethylene, and distal soft silicone flanges have been brought to market as means to minimize migration [22–24]. These are however better suited for adult patients and are more prone to complications. Jones tubes can also be manufactured with a suture eye in the collar, which is a useful modification for the pediatric age group since these tubes often need to be exchanged over time. Securing the tube in place with a nonabsorbable suture makes postoperative management easier, because loss of the tube is less likely to occur with sneezing or nose blowing as well. For those tubes without a hole in the collar, the tube can still be secured by tying a suture beneath the collar around the outside diameter. Another system of Pyrex bypass tubes is also available. The Cox tube set (Eye Foundation Hospital, Birmingham, AL) is similar to that of the Jones tubes but includes a trocar, a stylet for insertion, and a measuring instrument to determine the appropriate length of tube needed (Fig. 30.5). Cox tubes come in a variety of lengths and angles; they vary slightly from the Jones tube in that they have a wider lumen and usually a larger collar or flange (Fig. 30.6).
Fig. 30.4
Jones tube set
Fig. 30.5
Cox tube set
Fig. 30.6
Apparatus. From top to bottom, left to right: gold dilator, polyethylene tube, Jones tube , Cox tube , Beaver blade, and trocar
Procedure
A DCR is essential for the best placement and function of the bypass tube. If the tube is placed without creating mucosal flaps, there may be a small potential for future dacryocystitis unless the canalicular system is completely scarred over and no tears can find their way into the lacrimal sac. If a DCR has been done in a prior surgical effort, the glass tube can be inserted by a closed approach. When there has been no previous DCR, an open approach for bypass tube placement is typically performed. Nasal endoscopy is an invaluable adjunct to CJDCR surgery and should be utilized at various points in the procedure, when available. It is of particular value in estimating tube position and length in the nose. If a nasal endoscope is not available, direct inspection of the nasal cavity with a speculum and headlamp can be substituted.
Closed Approach
This technique is used when a DCR has been done previously. The steps involved are as follows:
- 1.
A small portion of the caruncle may be excised if necessary to accommodate the flange of the tube (Fig. 30.7a).
- 2.
A sharp trocar, an 18 g needle, or a 14–18 g IV angiocatheter is passed at a 45° angle in an inferior and somewhat anterior direction (Fig. 30.7b). If the path is blocked by the middle turbinate, fiber-optic endoscopic assistance can be helpful in performing a partial anterior middle turbinectomy [25]. If a deviated septum inhibits proper placement of the tube, a septoplasty may be required.
- 3.
A #69 Beaver blade can be passed from the caruncle into the nose adjacent to the trocar (Fig. 30.7c). This is satisfactory for placement of the wider Cox tubes , but it is preferable for the thinner Jones tubes to pass the thin guide probe from the Cox set through the trocar opening. If an angiocatheter is used in place of the trocar, the catheter is left in place, and the guidewire can be passed down its lumen. In either instance, this permits placement of a 1.5 mm Henderson trephine passed down the probe to widen the pathway sufficiently for a snug fit around the Jones Pyrex tube [26].
- 4.
The measuring instrument belonging to the Cox set may be used to determine the appropriate length of tube needed, but we often prefer an alternative technique. After the trocar is advanced to the nasal septum, it is then clamped at the level of the caruncle (Fig. 30.7d). The length distal to the clamp is measured. This length minus 3 mm is the length of the tube that will sit in a position 3 mm from the septum (Fig. 30.7e). With this length as a guide, an endoscope is then used to estimate the width of the meatus. The ideal tube length is such that the tube projects 2–3 mm into the meatus from the lateral wall of the nose. As an aside, the angiocatheter can also be clamped in a similar fashion to estimate length prior to its removal.
- 5.
After the thin steel probe is passed through the channel made with the trocar and the trephine is used to widen the opening, the appropriate length Pyrex tube is inserted over the probe after a single 6–0 clear nylon suture has been passed through the hole in the tube collar (or slipped around the neck of the tube) and tied tightly. The tube is then pushed into the proper position using the silicone insertion cuff (Fig. 30.7f). If the thin Cox probe is unavailable, a Bowman probe can be substituted.
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