Definition and treatment of lacrimal drainage disease

Epiphora is one of the most common problems in ophthalmological practice, and is caused by dysfunction of the lacrimal pathway. The lacrimal drainage system is a continuous anatomical structure consisting of the lacrimal punctum, inferior and superior canaliculi, common canaliculus, lacrimal sac, and nasolacrimal duct. Lacrimal disease can be medically treated in case of acute inflammation or partial obstruction at the beginning of treatment, but surgical treatment is necessary in most cases. This paper discusses the etiology, clinical features, diagnosis, and surgical treatment of various lacrimal diseases through a selective review of the relevant literature. Advances in lacrimal duct surgery can now be performed in such a way that the structural integrity and normal physiological function of the entire efferent lacrimal pathway is preserved.

Five-year Study of 120 Endoscopic Conjunctivodacryocystorhinostomy Using Porous Polyethylene-Coated Tear Drain

PURPOSE: To evaluate the long-term surgical results of 120 endoscopic conjunctivodacryocystorhinostomy (CDCR) procedures using a porous polyethylene (MEDPOR(R)) coated tear drain (MCTD(R)). METHODS: From 2002 to 2007, 120 patients who had been treated with endoscopic CDCR using MCTD(R) were investigated for its success rates and complications. After an osteotomy was made under nasal endoscopy, a tunnel was created from the caruncle in the conjunctival sac to the nasal cavity through the newly created ostium, and then the tunnel was enlarged to allow the insertion of the MCTD(R) The length of the tube to be inserted was determined under endoscopic examination. An anchoring suture was placed at the medial canthus to both the conjunctiva and the skin using a 5-0 Vicryl suture in the fashion of a purse string suture. RESULTS: Causes of obstruction included failed dacryocystorhinostomy (DCR) (74 cases) and idiopathic obstruction (22 cases). Postoperative complications were encountered in four cases with tube loss, 21 cases with a buried tube, 8 cases of extrusion to the conjunctival side, and 11 cases with obstruction caused by conjunctival incarceration or granuloma. The postoperative success rate was 89.1%. CONCLUSIONS: The authors concluded that endoscopic CDCR using MCTD(R) is an alternative to the standard conventional method for preventing dislodgement of the tube postoperatively. However, surgeons should consider that it may be challenging to insert the MCTD(R) and that in cases requiring removal, the tube can be difficult to remove due to adhesions.

Management of Complications after Conjunctivodacryocystorhinostomy with Jones Tube

PURPOSE: To analyze the surgical outcomes of conjunctivodacryocystorhinostomy(CDCR) with Jones tube on the postoperative management of complications. METHODS: We retrospectively analyzed the medical records of 87 eyes (79 patients) with at least 3 months follow-up who had undergone CDCR with Jones tube between January 1993 and December 2002. The patients were divided into several cases according to the results of postoperative management. RESULTS: Thirty eyes (34%) experienced no complications of Jones tube, over a mean follow-up period of 26.77 +/- 34.41 months. Forty-five eyes (52%) were improved by postoperative management of complications, over a mean follow-up period of 45.00 +/- 42.70 months. In these 45 eyes, the medial migration of the tube was corrected in 7 eyes after repositioning without fixed suture, in 9 eyes after repositioning with fixed suture, in 10 eyes after endonasal endoscopy-assisted repositioning with fixed suture, and in 1 eye after endonasal endoscopy-assisted tube exchange. The lateral migration of the tube was corrected in 1 eye after repositioning with fixed suture, and in 7 eyes after endonasal endoscopy-assisted tube exchange with fixed suture. The extrusion of the tube was corrected in 3 eyes after endonasal endoscopy-assisted tube reinsertion with fixed suture. Consecutive dacryocystitis improved in 1 eye after tube exchange with dacryocystectomy. The conjunctival obstruction of the tube was corrected in 6 eyes after resection of conjunctival tissue. Twelve eyes (14%) were not improved by CDCR or postoperative managements of complications, over follow-up period of 38.50 +/- 35.39 months. CONCLUSIONS: The complications of Jones tube occurred anytime during the postoperative period. If extrusion of the tube occurred reinsertion had to be done as soon as possible. Migration or obstruction of the tube was mostly improved by postoperative managements.

The Clinical Outcome of Endoscopic Transnasal Conjunctivodacryocystorhinostomy Using MEDPOR(R) Coated Tear Drain

PURPOSE: Tube displacement, consisting of protrusion, spontaneous loss, and intrusion, is the most common cause of failure in conjunctivodacryocystorhinostomy with Jones tube. Recently, MEDPOR(R) Coated Tear Drain was designed to minimize these complications. We evaluate the surgical outcome of conjunctivodacryocystorhinostomy with MEDPOR(R) Coated Tear Drain. METHODS: Primary conjunctivodacryocystorhinostomy or revision surgery using MEDPOR(R) Coated Tear Drain was done on 23 eyes of 23 patients and the development of displacement was monitored. Thirteen patients suffered from habitual displacement of Jones tube and underwent revision surgery, while the remaining 10 underwent primary conjunctivodacryocystorhinostomy. RESULTS: During 12-month follow-up after surgery, tube intrusion was noted in one among the 23 patients. Protrusion or spontaneous loss of tube did not develop. CONCLUSIONS: The use of MEDPOR(R) Coated Tear Drain may be very effective not only for revision surgery in patients who have suffered from habitual displacement of Jones tube but also on primary conjunctivodacryocystorhinostomy.

Conjunctivodacryocystorhinostomy with Rubber-Tipped Jones Tube

One of the problems of conjunctivodacryocystorhinostomy which employs the conventional Jones tube is that the end of Jones tube has to be manipulated by the surgeon so that the tube resides within the nasal cavity while not touching the middle turbinate and the nasal septum. As a result, for most of the patients who have high nasal septal deviation, paradoxical curvature, or middle turbinate hypertrophy, there wasn't enough room within the nasal cavity where one end of Jones tube could rest. Such patients required either septoplasty or turbinectomy before they underwent conjunctivodacryocystorhinostomy. In order to overcome such a problem, the authors connected a 4 Fr. rubber tube to the conventional Jones tube, and helped the end of the tube to reside within the nasal cavity regardless of the anatomical variation of either the nasal septum or the middle turbinate. When such modified procedure is used, the conven tional Jones tube will make contact with the conjunctiva, lacrimal sac, and the nasal mucosa while the rubber tube remained afloat within the nasal conjunctiva. Such modification helps the tube to reside within the nasal cavity without foreign body reactions and granulation tissue complications, and there is no need to change tubes in order to make up for the loss of tube length due to post operative tissue contracture. Between April 2000 and August 2001, the authors performed conjunctivodacryo cystorhinostomy with rubber-tipped Jones tube on 8 patients with nasolacrimal duct obstruction, and obtained satisfactory results without complications.

Treatment of Common Canalicular Obstruction Using Lacrimal Trephine

Conjunctivodacryocystorhinostom.y using Jones tube has been the treatment of choice for patients with epiphora due to common canalicular obstruction. But this procedure carries a lot of disadvantages including external scar formation and many complications result from general anesthesia, and necessity of permanent prosthesis and long-term follow-up. So authors have used a new instrument, the lacrimal trephine designed for creating an opening through 8 distally occluded lacrimal canaliculus to treat the common canalicular obstruction. From June 1996 to December 1996, we performed 8 lacrirnal trephination with silicone tube insertion in five patients diagnosed as common canalicu-lar obstruction. All of them have achieved the anatomical success and four of thein have shown clinical success.

Long-term follow-up of Conjunctivodacryocystorhinostomy

Conjunctivodacryocystorhinostomy(CDCR) with a Pyrex tube is an accepted procedure for the treatment of epiphora resulting from obstructed canaliculi. We analyzed the success rate, complications and it's treatment of 181 eyes who underwent CDCR with a Pyrex tube at Wallace Memorial Baptist Hospital between september 1986 and march 1996. Straight tubes, 18mm long(70 of 181 eyes; 38.7%) was most commonly used. Of 181 eyes, 172 eyes(95%) were successful. Complications of CDCR included submergence of Pyrex tube (13 of 181 eyes; 7.2%), tube extrusion(9 of 181 eyes; 4.9%), tube extraction(5 of 181 eyes; 8.9%). Of the 9 eyes of tube extraction, 7 eyes were 20mm in length, and the exchange of 20mm for 18mm was performed under topical anesthesia and two eyes, 18mm in length were replaced by 16mm in length. It was successful in 3 eyes but 6 eyes were dissatisfied because of residual tearing. In 13 eyes of tube submergence, tubes were sutured with 5-0 nylon to the skin of medial canthus and was successful in 10 eyes but was failed in 3 eyes. Of 181 eyes, 5 eyes(2.8%) lost their tube. 4 patients came for treatment 24 hours after tube loss and 1 patients came for treatment 72 hours after tube loss. A simple tube reinsertion was successful in all cases. Other complications were granuloma formation(16 of 181 eyes; 8.8%), conjunctival growth over the tube opening(8 of 181 eyes; 4.4%) and infection (5 of 181 eyes; 2.8%). Granuloma recurred two times in 4 eyes, three times in 2 eyes, four times in 1 eyes and was resected effectively each time under topical anesthesia. Conjunctival overgrowth was treated with conjunctival resection and tube manipulation. The infection resolved completely on consecutive treatment with topical and oral antibiotics.

Congenital Punctal Agenesis associated with Syndaotyly in a Family

Authers have experienced congenital punctal agenesis with syndactyly in sister and brother who complained purulent discharge and epiphora. Bilateral upper punctal agenesis, fistulas, and common canalicular obstruction in dacryocystogram were found in a 17 year-old brother. Bilateral upper and lower punctal agenesis was found in a 14 year-old sister. Syndactyly was found in both patients. In familial history, father of patients had syndactyly in upper and lower extremities and complained epiphora. Another sister of patients had experience of lacrimal system surgery. Conjunctivodacryocystorhinostomy using Jones tube was performed in both patients.