Management of epiphora and lacrimal obstruction in adults

Transcription

1 Management of epiphora and lacrimal obstruction in adults Louis Savar, MD 1,2, Stuart R. Seiff, MD, FACS 1,2, Angela Maria Dolmetsch, MD 3 1. Department of Ophthalmology, University of California, San Francisco, San Francisco, California. 2. Department of Ophthalmology, California Pacific Medical Center, San Francisco, California. 3. Clinica de Oftalmología de Cali, Universidad del Valle, Cali, Colombia. Funding: None Proprietary/financial interest: None Corresponding author address: Stuart R. Seiff, MD, FACS 2100 Webster Street, suite 214 San Francisco, CA Phone: sseiff@sfgh.ucsf.edu Date of submission: 24/03/2014 Date of approval: 16/04/2014 ABSTRACT While tearing patients have similar complaints, the etiology of their symptoms may vary widely and thus require a meticulous evaluation. A thorough history followed by systematic examination of the lids, ocular surface, anterior segment, and lacrimal system will lead the clinician to the proper diagnosis. Treatment options for lacrimal obstruction are varied and as surgical techniques continue to evolve, new studies are indicated to determine the approaches that provide the most successful outcomes while ensuring patient safety. Key words: Tears; Epiphora; Lacrimal obstruction; Dacryocystorhinostomy INTRODUCTION The tearing patient commonly presents to the office of an oculofacial plastic surgeon. In order to make the proper treatment decision, a thorough understanding of the physiology of tear production and drainage is necessary. 1 A methodical approach to these patients is critical. EVALUATION Before the patient is examined, key points of the history should be collected which may lead to the correct diagnosis. It is important to determine if tearing is intermittent or constant, unilateral or bilateral, associated with irritation or allergy, and any history of trauma or surgery. Figure 1. Lower lid ectropion PAN-AMERICA 37

2 REVIEW / Vis. Pan-Am. 2014;13(2):37-43 In addition, medication history should be reviewed. 2,3 Constant tearing that runs down the patient s face is highly suspicious for an obstruction, whereas intermittent tearing with irritation is more likely due to ocular surface abnormalities. After a complete history is taken, a full ophthalmic evaluation is performed. Particular attention must be paid to facial and trigeminal nerve function, ocular motility, palpation of the lacrimal sac, lid position, and the anterior segment. Next, testing is used to demonstrate evidence of abnormal tear production. This includes examination of the tear film, ocular surface, and tear production studies such as the Schirmer and basal tear production tests. If no evidence exists for reflex tearing, further testing includes probing and irrigation of the lacrimal drainage system in order to demonstrate patency or obstruction of the outflow passages. Treatments are based on the findings of this algorithmic approach to the patient with epiphora. Physical examination begins with the face as a whole. Orbicularis weakness, for example, in the setting of facial nerve palsy, may lead to a poor blink reflex, lagophthalmos, and lower lid ectropion (Figure 1). Each of these entities leads to exposure of the ocular surface and increased reflex tearing. Poor lid position also disrupts the natural pathway for tears to enter the lacrimal drainage system as well as its pump function. 4 Ectropion may also be seen in patients with floppy eyelid syndrome, involutional lid laxity, anterior lamellar shortening from cicatricial processes, mechanical deformity, and less frequently, congenital malformations. Careful slit lamp examination to rule out trichiasis, blepharitis, conjunctivitis, keratopathy or any evidence of intraocular inflammation is crucial before considering a diagnosis of lacrimal obstruction as the cause of epiphora. Evaluation of the tear lake may demonstrate an abnormally high or low tear meniscus. Evaluation of the punctum may reveal ectropion, stenosis or even atresia. An inflamed punctum may indicate canaliculitis, which is typically associated with chronic discharge and recurrent swelling of the lids. Palpation of the lacrimal sac may demonstrate tenderness, reflux, or mass, which may be associated with nasolacrimal duct obstruction, dacryocystitis, mucocele, dacryolith, or neoplasm. Paradoxically, inadequate and abnormal tear production are the most common causes of tearing. This may be part of the Dysfunctional Tear Syndrome (DTS). 5 In this syndrome, there is an abnormality of several aspects of tear production including the lipid (Meibomian and Zeis glands), aqueous (Krauss, Wolfring, and main glands), and mucinous (goblet cells) components. A distinction may be made between abnormalities of the anterior and posterior lamellae. Chronic irritation of the anterior lid margin, with associated crusting and lash loss (cilliary madarosis) is often due to seborrheic dermatitis, staphylococcal overgrowth and even demodex infection. Involvement of the posterior lamella, referred to as Meibomian gland dysfunction, is typically seen as increased lipid production, glandular obstruction, and glandular infection (meibomitis). This is all accentuated by an inadequate production of aqueous tear lysozyme, which typically produces an antimicrobial effect for the ocular surface. Thus, a situation of cycling infection and irritation is produced. These conditions are worse in the setting of underlying seborrhea or acne rosacea. Much of this can be identified by careful slit lamp evaluation of the lid margins and ocular surface. Poor production of mucin and lipid can be identified by a rapid corneal tear break up time. Further, in the absence of adequate aqueous tears, there may be overproduction of mucus (mucus stranding) and lipid (oily tear film). There are several tests to help identify inadequate aqueous tear production. 6 The Schirmer I test may be performed by wiping away excess lower fornix fluid, and placing a Schirmer strip into the lower fornix and draping the filter paper over the lower lid margin (Figure 2). After 5 minutes, a measurement of <10 mm on the strip is considered indicative of decreased basal tear production. Measurements of <5 mm are commonly seen in the setting of keratoconjunctivitis sicca. In patients with hypersecretion, such as those with crocodile tear syndrome after facial 38 PAN-AMERICA

3 palsy, measurements >30 mm are common. However, due to variability of response to the irritation from the paper strips in the fornix, results of the Schirmer I are extremely variable. This potential irritation can be minimized by placing a drop of topical anesthetic, such as 0.5% proparacaine. This reduces the sensation and theoretically gives a better indication of base line tear production. Thus, this modification of the Schirmer I is termed the Basal Secretion Test. When extremely poor tear production is suspected, such as in Sjögren s Syndrome, a Schirmer II test may be performed in an effort to see if any tears can be produced in a situation of maximal irritation. In this test, the paper strips are placed in the inferior fornix without anesthetic and the nasal mucosa is irritated with a swab. The goal here is typically to see if any tears can be produced in the setting of severe dry eyes. The lacrimal outflow system can be evaluated in a simple fashion with the dye disappearance test. Here, a drop of fluorescein is placed in the inferior fornix of both eyes. After 5 minutes, if residual yellow dye is present, there may be poor lacrimal outflow. Further information may be gathered by comparing the two sides in a case of asymmetric tearing. The side with more retained dye is more likely to have poor outflow. Figure 2. Schirmer testing PAN-AMERICA 39

4 REVIEW / Vis. Pan-Am. 2014;13(2):37-43 Figure 3. External dacryocystorhinostomy Probing and irrigation is the definitive test for obstruction within the lacrimal drainage apparatus. In order for the test to be useful it must be done in a systematic manner. 7 First, a drop of topical anesthetic is placed in the fornix. A punctal dilator is then inserted vertically into the punctum approximately 2 mm and turned 90 degrees along the plane of the lid and advanced toward the medial canthal tendon. It is important to avoid using excessive force as this could inadvertently create a false passage. A 23-gauge cannula on a glass syringe filled with saline solution is then introduced into the canalicular system in the same fashion as the dilator, while placing lateral horizontal traction on the lid. The cannula should pass with minimal resistance until a hard stop is felt, indicating the cannula has reached the bony wall of the lacrimal sac fossa. If a soft stop is felt, this may indicate the presence of stenosis or obstruction proximally within the canaliculus or in the lacrimal sac. The syringe is then pulled back approximately 1-2 mm and gently emptied. The patient should feel fluid enter the nasopharynx. This indicates that the outflow system is generally patent, but does not rule out a functional obstruction of the nasolacrimal duct. 7 If no fluid passes into the nasopharynx, there is a complete nasolacrimal drainage system obstruction. Canalicular reflux is generally not of diagnostic significance. During syringing, a canalicular blockage may also be identified that may account for the epiphora. If there is tearing in the presence of a system open to irrigation, Jones testing is indicated. In this case, 2% fluorescein dye is instilled in the conjunctival cul de sac. Five minutes is allowed to pass and the region under the inferior turbinate in the nose is inspected for evidence of the dye. If dye is found (Positive Jones 1 test), this means the drainage system is open and hypersecretion may be present due to ocular surface disease or aberrant regeneration, such as is seen with crocodile tears. If no dye is recovered, the test is negative and we proceed to the Jones 2 test. Here, the system is irrigated after the negative Jones I test, as above, with saline, and the nose again inspected for evidence of dye. If dye is identified (positive Jones 2), this indicates that dye entered the sac, but could not pass inferiorly. This identifies a functional nasolacrimal duct obstruction. If no dye is found (negative Jones 2), then the dye could not enter the open sac and duct due to a failure of the lacrimal pump (eg lid laxity), or a punctal abnormality, such as ectropion. TREATMENT Treatment of tearing is thus targeted at the specific cause determined by 40 PAN-AMERICA

5 this stepwise approach. Ocular surface disease and anterior segment inflammation are treated as necessary. This may require the use of topical lubricants, antibiotics and/or steroids. Lid position abnormalities are corrected. Depending on the type of ectropion, repair may be carried out via lid tightening, skin grafting and/or midface lifting procedures. Punctal ectropion may be corrected via a medial conjunctivoplasty, also referred to as a medial spindle technique. Lagophthalmos may require lid loading such as a gold weight to treat ocular exposure. Lacrimal hypersecretion has been successfully treated with botulinum toxin. 8 Lacrimal obstruction is a surgical disease and the location of the obstruction within the lacrimal drainage system dictates the treatment modality. Complete nasolacrimal duct obstruction, commonly seen after dacryocystitis, is treated via dacryocystorhinostomy (DCR)- creation of a new connection between the lacrimal sac and the nasal cavity. Common techniques include an external or endonasal approach with or without endoscopy. Preparation for either of these techniques includes general anesthesia or conscious sedation, with local anesthetic injected into the medial lids around the canaliculi, medial canthal area, and nasal mucosa around the lateral wall and middle turbinate. Additionally, neurosurgical pledgets soaked in cocaine 4% (or a 50/50 mixture of 4% lidocaine and oxymetazoline 0.05%) are packed under the middle turbinate in the middle meatus. When approaching the DCR externally, a vertical skin incision is made between the medial canthus and nasal bridge after local anesthetic has been injected in the area. Some prefer to make the incision slightly more inferiorly along the tear trough to help conceal any future scar. The periosteum is opened and then carried to the anterior lacrimal crest. A Freer elevator is used to elevate the lacrimal sac from the fossa. The lacrimal bone is then fractured using the elevator or a curved hemostat. The osteotomy is then enlarged anteriorly using a bone punch and rongeurs to approximately 15mm in diameter, taking care not to traumatize the underlying nasal mucosa. A Bowman probe is then introduced into the canaliculus and used to tent the lacrimal sac, which is incised along its length (Figure 3). Posterior and anterior flaps are fashioned by making a perpendicular cut at each end. A portion of the posterior sac may be submitted for pathologic evaluation, as well as any fluid or stone within the sac. A U shaped incision is made in the nasal mucosa. A silicone stent may then be passed through the superior and inferior canaliculi and externalized at the incision site. The two ends of the silicone are tied with several knots taking care not to place excessive tension on the puncta. Many surgeons are not using stents in the absence of canalicular disease. The nasal packing is removed and a curved hemostat is used to pull the ends of the tube out of the nostril. The ends are trimmed and allowed to retract back into the nasal cavity. The anterior mucosal flaps are then sutured to each PAN-AMERICA 41

6 REVIEW / Vis. Pan-Am. 2014;13(2):37-43 Figure 4. Dacriocistorrinostomía con endoscopia Figure 4. Endoscopic dacryocystorhinostomy other, thereby completing the mucosal anastomosis, followed by a layered closure of muscle and skin. The endonasal approach may be considered for various reasons including failed external DCR, and patient or surgeon preference. It has several advantages over the external approach including avoidance of a scar, shorter postoperative period, preservation of the medial canthal structures and a shorter surgical time. The technique is contraindicated in cases of suspected lacrimal tumor or stone, patients with complex anatomy, or implants after trauma. A 20 gauge disposable vitrectomy light pipe is introduced through the canaliculus and used to transilluminate the lacrimal bone to ensure proper location of the incision. The nasal packing is then removed and a crescent blade is used to incise the nasal mucosa just anterior to the base of the middle turbinate, corresponding to the location of the lacrimal sac fossa. The mucosa is reflected back with an elevator and an osteotomy is created, the lacrimal sac is tented using a probe and then incised (Figure 4). A silicone stent is passed through the canaliculi and the ends secured, again making sure not to place excessive tension on the puncta. Mitomycin 42 PAN-AMERICA

7 C placed on a pledget at the osteotomy site may be used to help prevent reobstruction and scarring. 9 In either approach, patients are typically treated with a course of topical combination antibiotic and steroid eye drops and intranasal steroid spray. The silicone tube is usually removed between 6 weeks to 6 months postoperatively. A recent meta-analysis including five randomized controlled trials and four cohort studies found no benefit with silicone intubation in primary DCR cases even though most surgeons still intubate at the time of DCR. 10 A recent survey of members of the American Society of Ophthalmic Plastic and Reconstructive Surgery found that the majority of respondents perform more external than endonasal DCRs, although success rates in the literature vary, ranging from % and 68-98% for external and endonasal, respectively. 11,12 In cases of lacrimal obstruction within the canaliculus, a DCR will not be sufficient. If a canalicular obstruction is focal, reconstruction may be an option whereby the obstruction is excised and the canaliculus is reanastamosed over a stent, or a trephine is passed through the obstruction, followed by nasolacrimal duct intubation to prevent recurrence of scar formation. Canalicular reconstruction is not always possible, in which case a lacrimal bypass must be created. 13 The conjunctivodacryocystorhinostomy procedure creates a direct connection between the medial fornix and the nasal cavity. A DCR ostium is created as described above, if not already present from prior surgery. Then a passage is created from the medial conjunctival cul de sac into the DCR passage, posterior to the caruncle. This is typically done with a trephine. Then a Jones tube, made of Pyrex glass, is passed over a guide angling inferiorly through the ostium into the nasal cavity. Correct tube position and length are critical for proper function. In some cases the anterior portion of the middle turbinate may be excised or a septoplasty performed to allow enough room for the tube to enter the nasal cavity without obstruction. The tube is then secured in place with an absorbable suture in the conjunctiva. In cases where the above evaluation suggests that a functional outflow obstruction may be the cause for epiphora, silicone intubation of the lacrimal system has been shown to be effective. 7 Canaliculitis that does not resolve with a course of topical antibiotic and steroid may require canalicular curettage, removal of debris or stones, and intubation. "La versión completa de este artículo en Español está disponible gratuitamente en o en " REFERENCES 1. Jones LT. The lacrimal apparatus: practical fundamentals of anatomy and physiology. Trans Am Acad Ophthalmol Otolaryngol 1958;62: Seiff SR, Shorr N, Adams T. Surgical treatment of punctalcanalicular fibrosis from 5-fluorouracil therapy. Cancer 1985;56: Esmaeli B, Valero V, Ahmadi MA et al. Canalicular Stenosis Secondary to Docetaxel (Taxotere). Ophthalmology 2001;108: Becker BB. Tricompartment model of the lacrimal pump mechanism. Ophthalmology 1992;99: Behrens A, Doyle JJ, Stern L et al. Dysfuntional tear syndrome: a Delphi approach to treatment recommendations. Cornea 2006;25: Espinoza GM, Israel H, Holds JB. Survey of oculoplastic surgeons regarding clinical use of tear production tests. Ophthal Plast Reconstr Surg 2009;25: Moscato EE, Dolmetsch AM, Silkiss RZ, Seiff SR. Silicone intubation for the treatment of epiphora in adults with presumed functional nasolacrimal duct obstruction. Ophtal Plast Reconstr Surg 2012;28: Montoya FJ, Riddell CE, Caesar R, Hague S. Treatment of gustatory hyperlacrimation (crocodile tears) with injection of botulinum toxin into the lacrimal gland. Eye 2002;16: Dolmetsch AM: NonLaser endoscopic endonasal dacryocystohinostomy with adjunctive mitomycin C in nasolacrimal duct obstruction in adults. Ophthalmology 2010;117(5): Feng YF, Cai JQ, Zhang JY, Han XH. A meta-analysis of primary dacryocystorhinostomy with and without silicone intubation. Can J Ophthalmol 2011;46: Barmettler A, Erlich J, Lelli G. Current preferences and reported success rates in dacryocystorhinostomy amongst ASOPRS members. Orbit 2013;32: Karim R, Ghabrial R, Lynch TF, Tang B. A comparison of external and endoscopic endonasal dacryocystorhinostomy for acquired nasolacrimal duct obstruction. 13. Steinsapir KD, Glatt HJ, Putterman AM. A 16 year study of conjunctival dacryocystorhinostomy. Am J Ophthalmol 1990;109: PAN-AMERICA 43