THE EXTERNAL DACRYOCYSTORHINOSTOMY (DCR)

Transcription

1 Outcome of External Dacryocystorhinostomy Combined With Membranectomy of a Distal Canalicular Obstruction KOSTAS G. BOBORIDIS, MD, CATEY BUNCE, DSC, AND GEOFFREY E. ROSE, FRCS, FRCOPHTH PURPOSE: To investigate the accuracy of the preoperative evaluation in identifying a membranous obstruction of the distal canaliculus and the success rate of an external dacryocystorhinostomy (DCR) when membranectomy of the canalicular obstruction is also performed. DESIGN: Retrospective, interventional case series. METHODS: The surgical records of the lacrimal cases operated at Moorfields Eye Hospital between January 1997 and December 1999 were reviewed. All the patients with evidence of a membranous block of the canalicular opening into the sac identified and excised during the course of a standard DCR procedure with silastic intubation and a minimum follow-up period of 12 months were selected for this study. The records were analyzed for preoperative evaluation with syringing and probing, surgical details, outcome, and complications. RESULTS: In 59 (85%) cases a functional anastomosis was established after tube removal. Additionally, 5 cases (7%) had patent system but required later ectropion repair and considered successful. Only 4 (6%) patients needed further lacrimal surgery, and one was referred to the ENT department for nasal polyps. The silastic tube was removed at a mean period of 6 weeks (SD 4; range, 2-24 weeks), and the mean follow-up period was 13 months (SD 3; range, months). The preoperative evaluation failed to identify the membranous obstruction in 30 (43%) cases, which were correctly diagnosed intraoperatively. CONCLUSIONS: In our series the anatomic success rate of 92% after DCR with membranectomy is comparable to the outcome of the DCR procedure. The distal canalicular membranous obstruction is an anatomic factor that may lead to surgical failure if not identified and Accepted for publication Jan 5, From the Ophthalmology Department (K.G.B.), Aristotle University, Thessaloniki, Greece, and Moorfields Eye Hospital (K.G.B., C.B., G.E.R.), London, United Kingdom. Inquiries to Kostas Boboridis MD, Pavlou Mela 16, Thessaloniki, Greece; fax: ; kosbob@otenet.gr excised. (Am J Ophthalmol 2005;139: by Elsevier Inc. All rights reserved.) THE EXTERNAL DACRYOCYSTORHINOSTOMY (DCR) has been established as the most efficient cure for epiphora from nasolacrimal duct stenosis or obstruction, with a success rate higher than 92% for cases with no canalicular disease. 1 Although failure of surgery is rare, it is mainly attributed to common canalicular obstruction, sump syndrome, occlusion of the anastomosis medial to the canaliculi, and no entry into the nose. 2 These factors are related to the underlying pathology, nasal anatomy, and, mainly, surgical technique. 3,4 Although several modifications of the procedure have been introduced to address technical difficulties, 5 the distal area of the common canalicular opening into the sac cavity remains the least investigated factor for lacrimal drainage obstruction and subsequent failure of a DCR procedure. 6,7 A membranous condensation may functionally obstruct or anatomically block the common canalicular opening into the sac, and, if not correctly identified and excised, may affect the outcome of an external DCR. The purpose of our study was to investigate the accuracy of the preoperative evaluation in identifying such a membranous obstruction and the success rate of an external DCR with membranectomy of a distal canalicular obstruction. METHODS THIS STUDY WAS A RETROSPECTIVE, NONCOMPARATIVE interventional case series. From the operating theater records and the computer administration system of Moorfields Eye Hospital, we identified 812 consecutive cases of open lacrimal surgery performed over a 3-year period (January 1997-December 1999). Further selection revealed 71 (9%) cases of external DCR with membranectomy from the distal opening of the common or of one of the canaliculi which were included in our study. After ethics /05/$ BY ELSEVIER INC. ALL RIGHTS RESERVED doi: /j.ajo

2 committee approval, 69 of 71 (97%) surgical records were retrieved and retrospectively analyzed. All cases met our inclusion criteria of being operated by one consultant experienced in lacrimal surgery or supervised oculoplastic fellows and senior trainees with a uniform external DCR procedure combined with membranectomy from the distal canalicular opening, received silastic intubation, and had a minimum follow-up period of 12 months. The routine preoperative evaluation in our lacrimal clinic included assessment for ocular surface disease, eyelid and punctum position, and the presence of mucopurulent reflux. The possible site of lacrimal obstruction was investigated with probing and syringing through both upper and lower canaliculi and observation of the quality and quantity of the outflow through the opposite punctum. In some cases of upper system stenosis, functional block, or inconclusive findings, diagnosis was aided by dacryocystography or lacrimal scintigraphy. With our standard technique for external DCR, a vertical skin incision was placed 1 cm anterior to the medial canthus. The skin, orbicularis muscle, and nasal periosteum with the insertion of the medial canthal tendon were dissected and retracted. A large rhinostomy was fashioned (16-18 mm diameter) and an anterior ethmoidectomy performed where necessary to allow space for the posterior mucosal flaps and prevent sump syndrome. The lacrimal sac was opened widely with anterior and posterior flaps fashioned. The common canalicular opening was carefully examined with direct inspection and the insertion of a Bowman s probe through the upper and lower punctum. When present, a soft tissue obstruction, varying from a thin diaphanous membrane to a dense fibrous condensation, was identified over the probe at the distal canalicular opening. One or more incisions with a fine blade on the tissue over the metallic tip allowed for an adequate opening of the obstruction. The remaining of the membrane was excised from the sac mucosa around the canalicular opening until its orifice was clearly visible and unobstructed. Silastic tubes were placed in all cases with canalicular disease. Anterior and posterior mucosa flaps were sutured with interrupted 6/0 Vicryl suture (Ethicon, Somerville, New Jersey, USA). The medial canthal tendon was reattached by suturing the periosteal and orbicularis flaps, and the skin was closed with a continuous, horizontal mattress 6/0 nylon suture. All patients were prescribed oral antibiotics for 1 week and topical corticosteroid-antibiotic eyedrops for 4 weeks. Patients were routinely followed up the first week and first month and at 6 and 12 months after surgery. The final surgical outcome was assessed during the last postoperative visit when patients were discharged if no further intervention was required. Surgery was considered successful by the relief of symptoms and the anatomic patency of the system defined by at least one of the following tests: fluorescein disappearance time test of less than 2 minutes, patent anastomosis on syringing, and positive Jones I dye test. When the standard Jones test was equivocal, nasal endoscopy was used for direct inspection of the internal ostium and observation of the fluorescein flow through the distal canalicular opening. In a retrospective analysis, Pearson s chi-square and Fisher s exact tests were used to assess whether there was any association between surgical outcome and any of the following factors: preoperative pathology, methods of diagnosis, and grade of surgeons. A 95% confidence interval for the estimated success rate was computed using the exact binomial method. RESULTS THE TIME FOR REMOVAL OF SKIN SUTURES WAS 7 DAYS, THE silastic tube was removed at a mean period of 6 weeks (SD 4; range, 2-24 weeks), and the mean follow-up period was 13 months (SD 3; range months). There was no reported preoperative lid malposition, punctum stenosis, or canalicular obstruction in any of our cases. Fifty patients (72%) were women, and 19 (28%) were men with median age of 62 years. In 48 (70%) patients, the preoperative diagnosis was based on clinical examination with syringing and probing and successfully identified the membranous obstruction in 20 (41%) of them. When dacryocystography (DCG) was used in 20 (29%) additional patients, the site of obstruction was correctly located in 13 (65%) of them. Lacrimal scintigraphy failed to provide the correct diagnosis in 1 (1%) patient with functional block. In total, the pathology of common canalicular obstruction was accurately identified preoperatively in 33 (48%) patients and was missed in the remaining 30 (43%), who were initially diagnosed to only suffer from nasolacrimal duct obstruction. It was also missed in 4 (6%) cases with patent but irregular or stenosed system and another 2 (3%) with functional epiphora (Table 1). Epiphora from primary acquired nasolacrimal duct obstruction (PANDO) 8 was the presenting symptom in 59 (85%) cases, mucous discharge from mucocele in 4 (6%), and 6 (9%) had recurrence of symptoms from a previous unsuccessful DCR procedure that failed because of distal canalicular obstruction. General anesthesia was used in 62 (90%) cases, with the consultant performing 34 (49%) of the procedures and the right side suffering more frequently 40 (58%; Table 2). Of the 63 primary DCR patients and the 6 who presented with recurrence, 59 (85%) were asymptomatic with patent anastomosis at the first control performed 1 year after surgery. Another 5 (7%) cases with anatomically patent systems had persistent epiphora due to lacrimal pump failure that was not evident preoperatively, which was cured with a horizontal lower lid-tightening procedure. For statistical analysis, this group was considered to have a successful outcome. In total, 64 (92%) cases with DCR and membranectomy had patent functional anastomosis. A similar success rate (92%) was calculated for the group of 1052 AMERICAN JOURNAL OF OPHTHALMOLOGY JUNE 2005

3 TABLE 1. Patient Demographic Data and Study Characteristics of the Diagnostic Method, Previous Condition, and Preoperative Diagnosis in Relation to Surgical Outcome Successful Outcome Study Characteristic n(%ofn 69) n(%ofn 69) Sex Male 19 (28%) 18 (26%) Fisher s exact Female 50 (72%) 46 (66%) P Diagnostic method Clinically 48 (70%) 45 (65%) 2 Dacryocystography 20 (29%) 18 (26%) P.829 Scintigraphy 1 (1%) 1 (1%) Previous condition PANDO 59 (85%) 54 (78%) 2 Failed DCR 6 (9%) 6 (9%) P.633 Mucocele 4 (6%) 4 (6%) Diagnosis Common canalicular block 33 (48%) 32 (46%) Nasolacrimal duct obstruction 30 (43%) 27 (39%) 2 Patent stenosed 4 (6%) 3 (4%) P.356 Functional block 2 (3%) 2 (3%) Age (years) Median 62 Interquartile range (55, 71) DCR dacryocystorhinostomy; PANDO primary acquired nasolacrimal duct obstruction. TABLE 2. Surgical Details Regarding Type of Anesthesia, Operated Side, and Grade of Surgeon in Relation to Surgical Outcome grade of surgeon, and time for tube removal had no statistical correlation with the outcome of the surgical procedure. Surgical Characteristics Successful Outcome n(%ofn 69) n(%ofn 69) Fisher s exact DISCUSSION Anesthetic General 62 (90%) 57 (82%) P Local 7 (10%) 7 (10%) Side Left 29 (42%) 27 (39%) P Right 40 (58%) 33 (53%) Surgeon Fellow 35 (51%) 31 (45%) P.356 Consultant 34 (49%) 33 (47%) primary cases, whereas it was calculated higher (100%) for the group with repeat surgery. Only 4 (6%) patients required additional lacrimal surgery (1 was cured with a repeated DCR, 2 had Lester Jones tube placement due to extensive scarring of the internal ostium, and 1 had canalicular trephination with silicon intubation due to a residual membranous obstruction). Finally, 1 patient was referred to the ENT department for treatment of nasal polyps that obstructed the anastomosis (Table 3). No major intraoperative or postoperative complications were observed. A self-limited epistaxis was reported in 3 patients and a mild medial periocular hematoma in 2 patients. The method of diagnosis, type of obstruction, EXTERNAL DCR, PROPOSED MORE THAN 80 YEARS AGO, 9 IS A reliable procedure with a high success rate, although it is not an easy technique and requires considerable surgical skill. Its limitations are the size of the ostium, suturing of the mucosal flaps, and the possible postoperative closure of the newly created lacrimal tract, either by formation of granulation tissue at the level of the osteotomy or by adhesion between the mucosal flaps. 10 Fashioning of a small bony ostium, incomplete opening of the lacrimal sac, poor inspection of the canalicular orifice, and failure to suture the anterior and posterior mucosal flaps to allow for a primary intention healing of the anastomosis have been reported as the main factors contributing to surgical failure. 11,12 Wide longitudinal opening of the medial sac wall is essential for a meticulous examination of the sac mucosa and content in cases of chronic inflammation or dacryolithiasis and also for direct inspection of the canalicular opening into the lateral sac wall. 13 A membranous block of the distal canaliculus may compromise the outcome of a DCR procedure, which primarily cures obstruction of the nasolacrimal duct. 14 The valve of Rosenmuller normally found to cover the internal ostium of the common canaliculus is a one-way valve VOL. 139, NO. 6 DACRYOCYSTORHINOSTOMY WITH MEMBRANECTOMY OF CANALICULAR OBSTRUCTION 1053

4 TABLE 3. Outcome of the Dacryocystorhinostomy With Membranectomy and Details of Recurrent Cases in Relation to Preoperative Pathology Outcome of Surgery Preoperative Diagnosis Successful Failed, Lower System Obstruction Failed, Canalicular Obstruction Common canalicular obstruction 32 (46%) 0 1 (1%) Nasolacrimal duct obstruction 27 (39%) 1 (1.5%) 2 (3%) Functional block stenosis 5 (7%) 1 (1.5%) 0 Total 64 (92%) 2 (3%) 3 (4%) Pearson 2 P.214 of the lacrimal pump mechanism allowing tear flow from the canaliculus into the sac cavity and preventing the reverse flow of the sac content. 15 Fibrous condensation or firm adherence of this membrane to the sac mucosa due to chronic inflammation may be a possible pathophysiologic mechanism for this distal canalicular obstruction. Failure to open the sac cavity widely because of an incomplete incision through the tissue layers of the medial sac wall or the fibrous septa and cavities filed with mucopurulent discharge in cases of chronic dacryocystitis may be misinterpreted as a membranous block of the canalicular opening. The routine preoperative assessment with syringing and probing of both canaliculi may fail to identify this site of lacrimal obstruction; this was evident in 43% of our cases in which the fibrous condensation was identified only during the intraoperative inspection and then excised. The inaccurate preoperative diagnosis in this group and also in the 9% of cases that were diagnosed with patent but stenosed systems may be explained with the presence of a partial membranous obstruction or the anatomic variations in the distal canalicular opening to the sac. Also, the findings during lacrimal syringing may have been influenced by a congested sac in cases of nasolacrimal duct obstruction, where the saline flow may have been blocked similarly to the cases of distal canalicular obstruction. The case of nasal polyps emphasizes the need for routine preoperative endoscopic nasal examination of lacrimal cases. The effect of silicon intubation and postoperative antibiotic cover on the outcome of lacrimal cases remains controversial. 16,17 We routinely prescribe oral antibiotics following all our DCR procedures and place silicon tubes in all cases with canalicular surgery such as distal canalicular membranectomy. In our series, the time of tube removal ranged from 2 to 24 months, depending on the intraoperative assessment of the internal canalicular orifice after membranectomy and did not influence the final outcome of the procedure. The functional block in two cases, which was cured with the combined external DCR with membranectomy procedure, may be explained by a partial aperture of the canalicular obstruction. The routine preoperative evaluation of eyelid position and function may underestimate the significance of horizontal lower lid laxity as a possible cause of functional epiphora due to lacrimal pump failure, as was evident in five of our patients with anatomically patent lacrimal anastomosis that required additional eyelid surgery to cure the symptoms of epiphora. The fact that one of the patients who required further lacrimal surgery was successfully treated with a repeat DCR procedure indicates that even with the most meticulous surgery the anastomosis may fail. The remaining two required a Lester Jones tube placement because of extensive postoperative scarring of the internal ostium, and one had canalicular trephination with silicon intubation for a residual distal canalicular membranous obstruction. The required ENT intervention for nasal polyps in one patient highlights the need for a routine nasal endoscopy in the preoperative evaluation, perioperative monitoring, and postoperative follow-up of lacrimal cases to diagnose nasal anatomic factors that may lead to poor outcome. 7,18 The routine clinical preoperative evaluation of lacrimal cases appears to have a relatively low success rate (41%) in identifying membranous obstructions involving the inner canalicular aperture, whereas intraoperative identification and excision of distal canalicular block was shown to be more accurate. Our noncomparative study has revealed a surgical success rate of 92% for cases with patent anastomosis after DCR with membranectomy, which is comparable but lower to the published outcome of the procedure without membranectomy. 1,19 Although the incidence of DCR cases that required membranectomy was relatively low (9%) in our series, we conclude that because distal canalicular membranous obstruction can be an anatomic factor leading to surgical failure, its presence should be carefully investigated preoperatively. Considering that clinical and radiologic investigations often fail to identify the presence of this condition, the internal canalicular aperture should be systematically controlled during open lacrimal surgery. In fact, this appears in fact highly effective in identifying such a condition. REFERENCES 1. Tarbet KJ, Custer PL. External dacryocystorhinostomy. Surgical success, patient satisfaction, and economic cost. 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5 2. Welham RA, Henderson PH. Results of dacryocystorhinostomy analysis of causes for failure. Trans Ophthalmol Soc U K 1973;93: Kashkouli MB, Parvaresh M, Modarreszadeh M, Hashemi M, Beigi B. Factors affecting the success of external dacryocystorhinostomy. Orbit 2003;22: Walland M, Rose G. Factors affecting the success rate of open lacrimal surgery. Br J Ophthalmol 1994;78: Baldeschi L, Nardi M, Hintschich CR, Koornneef L. Anterior suspended flaps: a modified approach for external dacryocystorhinostomy. Br J Ophthalmol 1998;82: Baldeschi L, Nolst Trenite GJ, Hintschich C, Koornneef L. The intranasal ostium after external dacryocystorhinostomy and the internal opening of the lacrimal canaliculi. Orbit 2000;19: Linberg JV, Anderson RL, Bumsted RM, Barreras R. Study of intranasal ostium external dacryocystorhinostomy. Arch Ophthalmol 1982;100: Linberg JV, McCormick SA. Primary acquired nasolacrimal duct obstruction. A clinicopathologic report and biopsy technique. Ophthalmology 1986;93: Dupuy-Dutemps L, Bourguet M. Procede plastique de dacryocysto-rhinostomie et ses resultats. Ann Ocul 1921;158: Ezra E, Restori M, Mannor GE, Rose GE. Ultrasonic assessment of rhinostomy size following external dacryocystorhinostomy. Br J Ophthalmol 1998;82: Welham RA, Wulc AE. Management of unsuccessful lacrimal surgery. Br J Ophthalmol 1987;71: Bumsted RM, Linberg JV, Anderson RL, Barreras R. External dacryocystorhinostomy. A prospective study comparing the size of the operative and healed ostium. Arch Otolaryngol 1982;108: Dryden RM, Wilkes TD. Lacrimal sac identification in dacryocystorhinostomy surgery. Ophthalmic Surg 1983;14: Boboridis K, Ziakas N, Georgiadis N. Nasolacrimal intubation with mitomycin C. Ophthalmology 2004;111: ; author reply Jones L. An anatomical approach to problems of the eyelids and lacrimal apparatus. Arch Ophthalmol 1961;66: Walland MJ, Rose GE. The effect of silicone intubation on failure and infection rates after dacryocystorhinostomy. Ophthalmic Surg 1994;25: Bartley GB. Lacrimal intubation during dacryocystorhinostomy. Am J Ophthalmol 1988;106: Boboridis K, Olver JM. Endoscopic endonasal assistance with Jones lacrimal bypass tubes. Ophthalmic Surg Lasers 2000; 31: Tsirbas A, Davis G, Wormald PJ. Mechanical endonasal dacryocystorhinostomy versus external dacryocystorhinostomy. Ophthal Plast Reconstr Surg 2004;20: VOL. 139, NO. 6 DACRYOCYSTORHINOSTOMY WITH MEMBRANECTOMY OF CANALICULAR OBSTRUCTION 1055

6 Biosketch Kostas G. Boboridis, MD, studied medicine in Thessaloniki, Greece. He was trained in ophthalmology in the United Kingdom, becoming a specialist in Since 1996, his main field of interest is orbital and oculoplastic surgery. He was a fellow to Jane Olver in London, Richard Downes in Nottingham, and Richard Collin in London. Currently, he is working in the Aristotle University of Thessaloniki and is running the Orbital and Oculoplastic Service in the University Department of Ophthalmology e1 AMERICAN JOURNAL OF OPHTHALMOLOGY JUNE 2005