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Endoscopically assisted balloon dacryoplasty treatment of incomplete nasolacrimal duct obstruction
Endoscopically Assisted Balloon Dacryoplasty Treatment of Incomplete Nasolacrimal Duct Obstruction Steven M. Couch, William L. White, MD Purpose: To report the success rate of endoscopically assisted balloon dacryoplasty (EADCP) for treatment of acquired incomplete nasolacrimal duct obstructions (NLDOs). Design: Retrospective, noncomparative case series. Participants: Records of patients treated for incomplete NLDOs with EADCP by one of the authors (WLW) were reviewed. Diagnosis of incomplete NLDO was based upon subjective complaints of tearing, dye disappearance testing, clinical evidence of epiphora, and nasolacrimal duct irrigation. Endoscopically assisted balloon dacryoplasty was performed for incomplete obstructions identified. Methods: One hundred forty-two nasolacrimal systems in 103 patients with incomplete NLDOs underwent EADCP for treatment of incomplete obstructions. A 3⫻15-mm balloon was utilized in all procedures, with silicone lacrimal tubes placed in 131 systems. Patients received postoperative topical antibiotic–steroid drops for 2 weeks and a 1-week tapering dosage of systemic methylprednisolone. Main Outcome Measures: Patients were assessed at their last postoperative visit by nasolacrimal system irrigation, dye disappearance testing, and subjective complaints of epiphora. Results: Eighty systems (56%) experienced complete resolution of symptoms after surgery. Forty-eight additional systems (34%) showed improvement but still experienced periodic epiphora. Fourteen systems (10%) showed no improvement. The average time before follow-up was 7.5 months. Conclusion: Endoscopically assisted balloon dacryoplasty as a treatment for incomplete NLDOs provides complete relief or substantial improvement in a significant percentage of patients. Nasal videoendoscopy adds significantly to the understanding of this procedure and its potential for success. Endoscopically assisted balloon dacryoplasty should be considered an appropriate treatment option for selected patients with incomplete NLDOs. Ophthalmology 2004;111:585–589 © 2004 by the American Academy of Ophthalmology.
Acquired nasolacrimal duct obstruction (NLDO) may result from one of many insults to the lacrimal outflow tract, with primary infection or age-related changes being 2 of the more common etiologies.1 The traditional treatment of a complete NLDO is incisional dacryocystorhinostomy (DCR), which is reported to have a success rate of ⱖ90%.2– 6 Selection of an optimal treatment for incomplete NLDO is more troublesome, and a surgical standard has yet to be established in a large case series. A balloon catheter has been developed for antegrade passage through an incompletely obstructed nasolacrimal duct (NLD) to allow dilation of the natural lacrimal tract Originally received: January 6, 2003. Accepted: June 18, 2003. Manuscript no. 230060. From the Eye Foundation of Kansas City, Department of Ophthalmology, University of Missouri–Kansas City School of Medicine, Kansas City, Missouri. Presented in part at: American Academy of Ophthalmology Annual Meeting, October 20 –21, 2002; Orlando. The authors have no proprietary interest in any devices or products discussed in this study. Reprint requests to William L. White, MD, St. Joseph Health Center Medical Mall, 1004 Carondelet, Suite 405, Kansas City, MO 64114. E-mail: [email protected]. © 2004 by the American Academy of Ophthalmology Published by Elsevier Inc.
(dacryoplasty). Here we report the results of a study of a large series of patients undergoing dacryoplasty in an antegrade fashion with videoendoscopic assistance (endoscopically assisted balloon dacryoplasty [EADCP]).
Materials and Methods Patients presented to one of the authors (WLW) with chronic epiphora and were diagnosed with incomplete NLDO based upon dye disappearance testing, nasolacrimal system irrigation, and absence of other abnormalities known to induce epiphora, such as entropion, ectropion, trichiasis, etc. Quantitation of fluid reflux during lacrimal irrigation was estimated subjectively by the examiner. Patients who had no flow of fluid into the nose were diagnosed with complete NLDO and were not considered candidates for dacryoplasty. Patient medical records were used as a reference for study, and institutional review board/ethics committee approval was obtained. General anesthesia was induced, typically utilizing a laryngeal mask airway. The medial canthal area and the lateral wall of the nose were anesthetized with a mixture of 2% lidocaine with epinephrine and 0.75% bupivicaine with hyaluronidase. (A few early cases were treated without the aid of supplemental local anesthesia, and some patients experienced significant postoperative discomfort. All subsequent patients received supplemental ISSN 0161-6420/04/$–see front matter doi:10.1016/j.ophtha.2003.06.013
585
Ophthalmology Volume 111, Number 3, March 2004 local anesthesia.) The nose was packed with 0.05% oxymetazoline-soaked cottonoids. The superior and inferior puncta were dilated atraumatically. A size 0 lacrimal probe was passed through the superior canalicular system and the NLD into the inferior meatus. The inferior turbinate was medialized with a Freer elevator to allow visualization of the inferior meatus to confirm proper passage of the probe through the valve of Hasner (Fig 1). After proper confirmation of passage of the size 0 probe, a size 1 and then a size 2 probe were passed, with endoscopic confirmation of correct placement. A 3⫻15-mm LacriCATH (Atrion Medical Products Inc., Allen, TX) balloon was lubricated with ophthalmic ointment and passed through the superior canaliculus and the NLD. The catheter was visualized endoscopically, confirming proper passage through the valve of Hasner (Fig 2). The balloon was then inflated to 9 atmospheres of pressure for 90 seconds and deflated. It was subsequently inflated again to 9 atmospheres for 60 seconds and deflated. The inflation pressures and times are those recommended by Atrion. The balloon was next pulled back to the proximal black ring, and the double inflation process was repeated. The balloon was pulled back to the distal black ring, and the inflation sequence repeated for the third time. The catheter was vigorously aspirated as it was withdrawn. The dilated tract was irrigated with balanced salt solution. Silicone lacrimal tubes were then placed in a standard fashion. The tubes were retrieved in the nose with a Crawford hook (JEDMED, St. Louis, MO) using the videoendoscope. The tubes were tied to themselves with 3 square throws and then to the lateral wall of the nose with a 5-0 polypropylene suture. Intraoperatively, patients received 4 to 12 mg of dexamethasone IV in compliance with the protocol recommended by the manufacturer. Postoperatively, patients received antibiotic–steroid drops 4 times daily for a minimum of 2 weeks. If silicone tubes were placed in the lacrimal tract, ophthalmic antibiotic ointment was applied at bedtime to the medial interpalpebral fissure as long as the tubes were in place. Silicone lacrimal tubes were removed 6 to 8 weeks postoperatively, and patients received an additional 2 weeks of antibiotic–steroid drops. Three measures were used to grade the success of the procedure. Patients were asked to quantitate any epiphora they had after the procedure. Clinical assessment of lacrimal patency was assessed by irrigation of the lacrimal system. Dye disappearance testing was used as an objective measure of functional lacrimal drainage. The results were categorized as follows: 1. Complete resolution. Patients did not experience any epiphora, had little or no reflux after irrigation, and exhibited a normal dye disappearance test. 2. Better. Patients experienced occasional epiphora with mildly prolonged dye disappearance testing and some reflux on lacrimal irrigation. This group was further divided into 2 subcategories: a. Improved with concomitant ocular surface disease and potential reflex hypersecretion. These patients experienced occasional epiphora and had comorbid conditions such as dry eye, allergic conjuctivitis, and blepharoconjunctivitis. b. Improved with no obvious sources of reflex hypersecretion. These were the patients who did not have complete resolution of epiphora but were improved and had no evidence of comorbid conditions known to induce hypersecretion. 3. No improvement. Patients did not have any significant improvement in epiphora postoperatively with prolonged dye disappearance testing, and had significant reflux during irrigation.
586
Results One hundred three patients, 28 men and 75 women, underwent EADCP for primary treatment of epiphora secondary to incomplete NLDO (Table 1). The length of follow-up ranged from 1 to 39 months, and averaged 7.5 months. Twenty-five patients (24%) had a right-sided surgery, 39 (38%) had a left-sided surgery, and 39 (38%) had bilateral procedures. Patients ranged in age from 1.5 to 91 years. The average age was 53 years. One hundred thirty-one of 142 systems were intubated with silicone tubes. The length of intubation ranged from 1 week to 1 year, and averaged 12.2 weeks. The standard protocol was to remove the tubes 6 to 8 weeks postoperatively. Some patients who experienced significant improvement in their epiphora refused tube removal at that time. Some patients inadvertently removed their tubes before 6 weeks. No tubes were removed purposefully before the 6-week postoperative visit. Patients who were under 4 years of age did not have silicone tubes placed, as recommended by the manufacturer. Overall, 128 (90%) of the systems in 92 patients who underwent EADCP experienced improvement in their epiphora postoperatively. Eighty (56%) systems in 63 patients experienced complete resolution of epiphora. Forty-eight eyes (34%) in 29 patients were improved after surgery but still experienced occasional epiphora. Many of these patients with improved but occasional tearing had secondary conditions that may have contributed to their tearing. Of these 48 lacrimal systems that were better after the procedure, 17 (35%) had concomitant problems such as dry eye, allergic conjuctivitis, and blepharoconjunctivitis that commonly lead to tear overflow. Fourteen systems (10%) in 11 patients had no improvement in epiphora noted after EADCP (Fig 3).
Discussion Success rates for incisional DCR in the treatment of complete NLDO are generally on the order of 90%.2– 6 Success rates for a seemingly less severe malady (incomplete NLDO) should equal if not exceed this if a comparable standard of care is to be recommended in the treatment of incomplete NLDO. Previous studies have reported success rates for balloon dilation of the NLD varying between 25% and 90% utilizing a variety of techniques.7,8 Procedures performed in the United States usually involve antegrade passage of a balloon catheter such as in our study. Procedures performed in countries outside of the United States typically utilize a retrograde placement of the balloon catheter.9 –11 A guide wire is passed through the NLD and retrieved in the nose. A balloon catheter is subsequently passed over the guide wire transnasally and inflated. Direct comparison of our results to those of patients reported in series from outside the United States is difficult, as patients with complete NLDO are frequently included.9 –12 It is generally accepted that complete NLDO is best treated with primary DCR and not dacryoplasty, employing methods and materials currently in use.12 Endoscopically assisted balloon dacryoplasty with silicone intubation seems to be more successful than silicone intubation alone in the treatment of acquired incomplete NLDO in adults. Silicone intubation alone without concomitant balloon dilation of the NLD has a success rate ranging from to 53% to 83%, which is below that observed in the present series.13–16 A study comparing these 2 treatment
Couch and White 䡠 Endoscopically Assisted Balloon Dacryoplasty
Figure 1. Normal probe passage. Videoendoscopy allows the visual confirmation of the nasolacrimal duct probe entrance into the inferior meatus through the valve of Hasner. Figure 2. Normal balloon passage. A, The balloon is visualized as it passes through the valve of Hasner into the inferior meatus. B, Once observed in the inferior meatus, the balloon is inflated for the initial dilation cycle. Figure 3. Patient graph reflecting the procedure results. Figure 4. Submucosal probe passage. The nasolacrimal probe is seen passing through the nasolacrimal duct submucosally, imparting a dull appearance. In this scenario no true entrance into the inferior meatus has been achieved. An incision was made to release the probe from its submucosal position. Figure 5. Fungal obstruction. A large aggregation of amorphous debris and fungi was seen obliterating the inferior meatus and concomitantly blocking the nasolacrimal duct. Endoscopically assisted balloon dacryoplasty was not indicated for this patient, who subsequently underwent functional endoscopic sinus surgery with full resolution of epiphora.
587
Ophthalmology Volume 111, Number 3, March 2004 Table 1. Patient Data
Table 1. Continued
Patient No.
Age
Gender
Surgery Side
Symptomatic
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 70 71 72 73 74 75 76 77
41 83 76 79 51 63 41 28 49 91 1.5 72 3 78 61 16 78 64 47 43 70 46 4 47 9 70 49 45 67 49 12 66 67 50 69 73 49 71 63 70 37 67 65 72 24 69 49 55 59 82 80 57 2 83 55 63 74 85 71 44 71 87 24 74 81 51 36 21
F M F M F F F F F M M M F F M M M F F M F F M F F F F F M F F F F M M F F M F F M F F F F F F F F F F M M F F F F F F F F F F F M F F M
OU OD OU OU OS OU OU OD OU OU OS OU OS OS OS OU OS OU OU OD OU OS OU OD OS OS OD OU OU OU OS OD OU OD OD OS OD OU OU OS OD OU OD OS OD OU OD OS OS OS OU OS OU OS OS OU OD OS OU OS OU OD OS OU OS OD OU OS
No Yes Better Yes No No No No OD, no; OS, yes Better No Yes No No No Better No Better No No No No Better Yes No Yes No Better Better Better No Better No No Better Yes No Better No Yes Better Better No No No Better No Better No No Better No No No No Better Better Better Better No Better Better No Better Yes No No No
588
Patient No.
Age
Gender
Surgery Side
Symptomatic
78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103
47 2 65 66 70 28 50 53 65 73 31 78 55 36 38 2 63 65 87 87 60 69 43 66 3 54
F F F M M F F F F M F F F F F F F F F F F M M M M F
OS OU OU OU OU OS OS OS OD OU OS OU OS OS OD OS OD OU OS OD OS OS OS OD OU OS
Yes Better No Better Better No No No No No No No No No No No No Better Better No No No No Better No No
F ⫽ female; M ⫽ male; OD ⫽ right eye; OS ⫽ left eye; OU ⫽ both eyes.
modalities in a rigorous scientific fashion has yet to be performed. Becker and Berry were the first to report on the antegrade passage of a balloon catheter passed through the canaliculi and into the NLD.17 The balloon was passed over a guide wire in these cases, however, and the dilations were performed with a device manufactured for use in coronary arteries. They achieved improvement in epiphora in 3 of their 4 patients who had complete NLDO after failed DCR. Perry et al reported a series of 13 patients who underwent treatment of 15 incomplete NLDOs utilizing the same balloon catheter used in the present series with subsequent placement of silicone tubes for 2 months.1 Eleven of the 15 (73%) incomplete obstructions they treated were patent to irrigation at 6 months. Our clinical results seem to parallel theirs in improving epiphora. In their series, the balloon was visualized with a nasal speculum or touched with a Bowman probe to confirm proper positioning. We observed several patients who were found to have submucosal passage of the balloon by endoscopy (Fig 4). They required manipulation of the balloon or even incision of the nasal mucosa to ensure that the balloon actually entered the inferior meatus rather than remained submucosal in location. Since Perry and colleagues (1998) placed silicone tubes after balloon dilation, patients were guaranteed that a nasolacrimal tract was patent, but not necessarily that the mucosal entrance into the nose had been dilated by the balloon if the balloon was not directly visualized. We feel that observation of the balloon passing through the valve of Hasner is necessary to confirm that the true NLD is cannulated. During passage of the
Couch and White 䡠 Endoscopically Assisted Balloon Dacryoplasty balloon through a particularly tight NLD, a primary exit out the medial aspect of the nasolacrimal sac is possible, thus making it a primary balloon DCR. Occasionally, videoendoscopy will yield a cause for epiphora that the balloon may not be able to improve, such as concretions completely obstructing the inferior meatus (Fig 5). A few patients were found to have dacryoliths, which the balloon advanced out into the inferior meatus after inflation. Early in the series it was appreciated endoscopically that passage of the catheter to the proximal black ring as recommended by the manufacturer did not guarantee entry of the device into the inferior meatus. Some surgeons may be tempted to perform dacryoplasty in an office setting. No patients in the present series required cautery to control bleeding, but with several patients additional intraoperative nasal packing was necessary to obtain hemostasis. This could be cumbersome in an office setting with an anxious patient, especially if no suction is available. Incisional DCR can be performed with local anesthesia and supplemental intravenous sedation in an ambulatory outpatient setting. Dacryoplasty can also be performed in the same manner. Occasionally, when lacrimal surgery is performed in such a manner, control of the airway becomes difficult, especially if there is blood running posteriorly into the pharynx. It is a personal preference of one of the authors (WLW) to perform lacrimal surgery under laryngeal mask airway anesthesia when possible, because it offers control of the airway and rapid patient recovery postoperatively. In patients who are not candidates for laryngeal mask airway anesthesia, the procedure can be performed under local anesthesia with supplemental intravenous sedation, or even under general endotracheal anesthesia, if necessary. Patient acceptance of dacryoplasty is high because the natural tear drainage tract is maintained and there is no visible scarring or incision. Dacryoplasty may not, however, have as high a success rate as incisional DCR. Further studies reporting longer patient follow-up (⬎5 years) may be difficult to achieve, as asymptomatic patients are difficult to get to return for examination when following a noncancerous, non–life threatening problem. We feel that dacryoplasty has been firmly established as an accepted treatment choice in patients with incomplete NLDOs in the absence of secondary causes of epiphora, and should be performed with nasal videoendoscopy whenever possible.
References 1. Perry JD, Maus M, Nowinski TS, Penne RB. Balloon catheter dilation for treatment of adults with partial nasolacrimal duct obstruction: a preliminary report. Am J Ophthalmol 1998;126: 811– 6. 2. Becker BB. Dacryocystorhinostomy without flaps. Ophthalmic Surg 1988;19:419 –27. 3. Rosen N, Sharir M, Moverman DC, Rosner M. Dacrocystorhinostomy with silicone tubes: evaluation of 253 cases. Ophthalmic Surg 1989;20:115–9. 4. Tarbet KJ, Custer PL. External dacryocystorhinostomy. Surgical success, patient satisfaction, and economic cost. Ophthalmology 1995;102:1065–70. 5. Walland MJ, Rose GE. Factors affecting the success rate of open lacrimal surgery. Br J Ophthalmol 1994;78:888 –91. 6. Zolli CL, Shannon GM. Dacryocystorhinostomy: a review of 119 cases. Ophthalmic Surg 1982;13:905–10. 7. Lee JM, Song HY, Han YM, et al. Balloon dacryocystoplasty: results in the treatment of complete and partial obstructions of the nasolacrimal system. Radiology 1994;192:503– 8. 8. Janssen AG, Mansour K, Krabbe GJ, et al. Dacryocystoplasty: treatment of epiphora by means of balloon dilation of the obstructed nasolacrimal duct system. Radiology 1994;193: 453– 6. 9. Berkefeld J, Kirchner J, Mu¨ ller HM, et al. Balloon dacryocystoplasty: indications and contraindications. Radiology 1997;205:785–90. 10. Kumar EN. Technical note: non-surgical treatment of epiphora by balloon dacryocystoplasty—the technique. Br J Radiol 1995;68:1116 – 8. 11. Robinson R, Turner N, Brettle P, et al. The treatment of epiphora with balloon dacryocystoplasty. Eye 1993;7:687–90. 12. Yazici Z, Yazici B, Parlak M, et al. Treatment of obstructive epiphora in adults by balloon dacryocystoplasty. Br J Ophthalmol 1999;83:692– 6. 13. Angrist RC, Dortzbach RK. Silicone intubation for partial and total nasolacrimal duct obstruction in adults. Ophthal Plast Reconstr Surg 1985;1:51– 4. ¨ ge I¨, O ¨ ge F, et al. Silicone intubation for obstruc14. Aritu¨ rk N, O tion of the nasolacrimal duct in adults. Acta Ophthalmol Scand 1999;77:481–2. 15. Fulcher T, O’Connor M, Moriarty P. Nasolacrimal intubation in adults. Br J Ophthalmol 1998;82:1039 – 41. 16. Pashby RC, Rathbun JE. Silicone tube intubation of the lacrimal drainage system. Arch Ophthalmol 1979;97:1318 –22. 17. Becker BB, Berry FD. Balloon catheter dilation in lacrimal surgery. Ophthalmic Surg 1989;20:193– 8.
589
Acquired nasolacrimal duct obstruction (NLDO) may result from one of many insults to the lacrimal outflow tract, with primary infection or age-related changes being 2 of the more common etiologies.1 The traditional treatment of a complete NLDO is incisional dacryocystorhinostomy (DCR), which is reported to have a success rate of ⱖ90%.2– 6 Selection of an optimal treatment for incomplete NLDO is more troublesome, and a surgical standard has yet to be established in a large case series. A balloon catheter has been developed for antegrade passage through an incompletely obstructed nasolacrimal duct (NLD) to allow dilation of the natural lacrimal tract Originally received: January 6, 2003. Accepted: June 18, 2003. Manuscript no. 230060. From the Eye Foundation of Kansas City, Department of Ophthalmology, University of Missouri–Kansas City School of Medicine, Kansas City, Missouri. Presented in part at: American Academy of Ophthalmology Annual Meeting, October 20 –21, 2002; Orlando. The authors have no proprietary interest in any devices or products discussed in this study. Reprint requests to William L. White, MD, St. Joseph Health Center Medical Mall, 1004 Carondelet, Suite 405, Kansas City, MO 64114. E-mail: [email protected]. © 2004 by the American Academy of Ophthalmology Published by Elsevier Inc.
(dacryoplasty). Here we report the results of a study of a large series of patients undergoing dacryoplasty in an antegrade fashion with videoendoscopic assistance (endoscopically assisted balloon dacryoplasty [EADCP]).
Materials and Methods Patients presented to one of the authors (WLW) with chronic epiphora and were diagnosed with incomplete NLDO based upon dye disappearance testing, nasolacrimal system irrigation, and absence of other abnormalities known to induce epiphora, such as entropion, ectropion, trichiasis, etc. Quantitation of fluid reflux during lacrimal irrigation was estimated subjectively by the examiner. Patients who had no flow of fluid into the nose were diagnosed with complete NLDO and were not considered candidates for dacryoplasty. Patient medical records were used as a reference for study, and institutional review board/ethics committee approval was obtained. General anesthesia was induced, typically utilizing a laryngeal mask airway. The medial canthal area and the lateral wall of the nose were anesthetized with a mixture of 2% lidocaine with epinephrine and 0.75% bupivicaine with hyaluronidase. (A few early cases were treated without the aid of supplemental local anesthesia, and some patients experienced significant postoperative discomfort. All subsequent patients received supplemental ISSN 0161-6420/04/$–see front matter doi:10.1016/j.ophtha.2003.06.013
585
Ophthalmology Volume 111, Number 3, March 2004 local anesthesia.) The nose was packed with 0.05% oxymetazoline-soaked cottonoids. The superior and inferior puncta were dilated atraumatically. A size 0 lacrimal probe was passed through the superior canalicular system and the NLD into the inferior meatus. The inferior turbinate was medialized with a Freer elevator to allow visualization of the inferior meatus to confirm proper passage of the probe through the valve of Hasner (Fig 1). After proper confirmation of passage of the size 0 probe, a size 1 and then a size 2 probe were passed, with endoscopic confirmation of correct placement. A 3⫻15-mm LacriCATH (Atrion Medical Products Inc., Allen, TX) balloon was lubricated with ophthalmic ointment and passed through the superior canaliculus and the NLD. The catheter was visualized endoscopically, confirming proper passage through the valve of Hasner (Fig 2). The balloon was then inflated to 9 atmospheres of pressure for 90 seconds and deflated. It was subsequently inflated again to 9 atmospheres for 60 seconds and deflated. The inflation pressures and times are those recommended by Atrion. The balloon was next pulled back to the proximal black ring, and the double inflation process was repeated. The balloon was pulled back to the distal black ring, and the inflation sequence repeated for the third time. The catheter was vigorously aspirated as it was withdrawn. The dilated tract was irrigated with balanced salt solution. Silicone lacrimal tubes were then placed in a standard fashion. The tubes were retrieved in the nose with a Crawford hook (JEDMED, St. Louis, MO) using the videoendoscope. The tubes were tied to themselves with 3 square throws and then to the lateral wall of the nose with a 5-0 polypropylene suture. Intraoperatively, patients received 4 to 12 mg of dexamethasone IV in compliance with the protocol recommended by the manufacturer. Postoperatively, patients received antibiotic–steroid drops 4 times daily for a minimum of 2 weeks. If silicone tubes were placed in the lacrimal tract, ophthalmic antibiotic ointment was applied at bedtime to the medial interpalpebral fissure as long as the tubes were in place. Silicone lacrimal tubes were removed 6 to 8 weeks postoperatively, and patients received an additional 2 weeks of antibiotic–steroid drops. Three measures were used to grade the success of the procedure. Patients were asked to quantitate any epiphora they had after the procedure. Clinical assessment of lacrimal patency was assessed by irrigation of the lacrimal system. Dye disappearance testing was used as an objective measure of functional lacrimal drainage. The results were categorized as follows: 1. Complete resolution. Patients did not experience any epiphora, had little or no reflux after irrigation, and exhibited a normal dye disappearance test. 2. Better. Patients experienced occasional epiphora with mildly prolonged dye disappearance testing and some reflux on lacrimal irrigation. This group was further divided into 2 subcategories: a. Improved with concomitant ocular surface disease and potential reflex hypersecretion. These patients experienced occasional epiphora and had comorbid conditions such as dry eye, allergic conjuctivitis, and blepharoconjunctivitis. b. Improved with no obvious sources of reflex hypersecretion. These were the patients who did not have complete resolution of epiphora but were improved and had no evidence of comorbid conditions known to induce hypersecretion. 3. No improvement. Patients did not have any significant improvement in epiphora postoperatively with prolonged dye disappearance testing, and had significant reflux during irrigation.
586
Results One hundred three patients, 28 men and 75 women, underwent EADCP for primary treatment of epiphora secondary to incomplete NLDO (Table 1). The length of follow-up ranged from 1 to 39 months, and averaged 7.5 months. Twenty-five patients (24%) had a right-sided surgery, 39 (38%) had a left-sided surgery, and 39 (38%) had bilateral procedures. Patients ranged in age from 1.5 to 91 years. The average age was 53 years. One hundred thirty-one of 142 systems were intubated with silicone tubes. The length of intubation ranged from 1 week to 1 year, and averaged 12.2 weeks. The standard protocol was to remove the tubes 6 to 8 weeks postoperatively. Some patients who experienced significant improvement in their epiphora refused tube removal at that time. Some patients inadvertently removed their tubes before 6 weeks. No tubes were removed purposefully before the 6-week postoperative visit. Patients who were under 4 years of age did not have silicone tubes placed, as recommended by the manufacturer. Overall, 128 (90%) of the systems in 92 patients who underwent EADCP experienced improvement in their epiphora postoperatively. Eighty (56%) systems in 63 patients experienced complete resolution of epiphora. Forty-eight eyes (34%) in 29 patients were improved after surgery but still experienced occasional epiphora. Many of these patients with improved but occasional tearing had secondary conditions that may have contributed to their tearing. Of these 48 lacrimal systems that were better after the procedure, 17 (35%) had concomitant problems such as dry eye, allergic conjuctivitis, and blepharoconjunctivitis that commonly lead to tear overflow. Fourteen systems (10%) in 11 patients had no improvement in epiphora noted after EADCP (Fig 3).
Discussion Success rates for incisional DCR in the treatment of complete NLDO are generally on the order of 90%.2– 6 Success rates for a seemingly less severe malady (incomplete NLDO) should equal if not exceed this if a comparable standard of care is to be recommended in the treatment of incomplete NLDO. Previous studies have reported success rates for balloon dilation of the NLD varying between 25% and 90% utilizing a variety of techniques.7,8 Procedures performed in the United States usually involve antegrade passage of a balloon catheter such as in our study. Procedures performed in countries outside of the United States typically utilize a retrograde placement of the balloon catheter.9 –11 A guide wire is passed through the NLD and retrieved in the nose. A balloon catheter is subsequently passed over the guide wire transnasally and inflated. Direct comparison of our results to those of patients reported in series from outside the United States is difficult, as patients with complete NLDO are frequently included.9 –12 It is generally accepted that complete NLDO is best treated with primary DCR and not dacryoplasty, employing methods and materials currently in use.12 Endoscopically assisted balloon dacryoplasty with silicone intubation seems to be more successful than silicone intubation alone in the treatment of acquired incomplete NLDO in adults. Silicone intubation alone without concomitant balloon dilation of the NLD has a success rate ranging from to 53% to 83%, which is below that observed in the present series.13–16 A study comparing these 2 treatment
Couch and White 䡠 Endoscopically Assisted Balloon Dacryoplasty
Figure 1. Normal probe passage. Videoendoscopy allows the visual confirmation of the nasolacrimal duct probe entrance into the inferior meatus through the valve of Hasner. Figure 2. Normal balloon passage. A, The balloon is visualized as it passes through the valve of Hasner into the inferior meatus. B, Once observed in the inferior meatus, the balloon is inflated for the initial dilation cycle. Figure 3. Patient graph reflecting the procedure results. Figure 4. Submucosal probe passage. The nasolacrimal probe is seen passing through the nasolacrimal duct submucosally, imparting a dull appearance. In this scenario no true entrance into the inferior meatus has been achieved. An incision was made to release the probe from its submucosal position. Figure 5. Fungal obstruction. A large aggregation of amorphous debris and fungi was seen obliterating the inferior meatus and concomitantly blocking the nasolacrimal duct. Endoscopically assisted balloon dacryoplasty was not indicated for this patient, who subsequently underwent functional endoscopic sinus surgery with full resolution of epiphora.
587
Ophthalmology Volume 111, Number 3, March 2004 Table 1. Patient Data
Table 1. Continued
Patient No.
Age
Gender
Surgery Side
Symptomatic
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 70 71 72 73 74 75 76 77
41 83 76 79 51 63 41 28 49 91 1.5 72 3 78 61 16 78 64 47 43 70 46 4 47 9 70 49 45 67 49 12 66 67 50 69 73 49 71 63 70 37 67 65 72 24 69 49 55 59 82 80 57 2 83 55 63 74 85 71 44 71 87 24 74 81 51 36 21
F M F M F F F F F M M M F F M M M F F M F F M F F F F F M F F F F M M F F M F F M F F F F F F F F F F M M F F F F F F F F F F F M F F M
OU OD OU OU OS OU OU OD OU OU OS OU OS OS OS OU OS OU OU OD OU OS OU OD OS OS OD OU OU OU OS OD OU OD OD OS OD OU OU OS OD OU OD OS OD OU OD OS OS OS OU OS OU OS OS OU OD OS OU OS OU OD OS OU OS OD OU OS
No Yes Better Yes No No No No OD, no; OS, yes Better No Yes No No No Better No Better No No No No Better Yes No Yes No Better Better Better No Better No No Better Yes No Better No Yes Better Better No No No Better No Better No No Better No No No No Better Better Better Better No Better Better No Better Yes No No No
588
Patient No.
Age
Gender
Surgery Side
Symptomatic
78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103
47 2 65 66 70 28 50 53 65 73 31 78 55 36 38 2 63 65 87 87 60 69 43 66 3 54
F F F M M F F F F M F F F F F F F F F F F M M M M F
OS OU OU OU OU OS OS OS OD OU OS OU OS OS OD OS OD OU OS OD OS OS OS OD OU OS
Yes Better No Better Better No No No No No No No No No No No No Better Better No No No No Better No No
F ⫽ female; M ⫽ male; OD ⫽ right eye; OS ⫽ left eye; OU ⫽ both eyes.
modalities in a rigorous scientific fashion has yet to be performed. Becker and Berry were the first to report on the antegrade passage of a balloon catheter passed through the canaliculi and into the NLD.17 The balloon was passed over a guide wire in these cases, however, and the dilations were performed with a device manufactured for use in coronary arteries. They achieved improvement in epiphora in 3 of their 4 patients who had complete NLDO after failed DCR. Perry et al reported a series of 13 patients who underwent treatment of 15 incomplete NLDOs utilizing the same balloon catheter used in the present series with subsequent placement of silicone tubes for 2 months.1 Eleven of the 15 (73%) incomplete obstructions they treated were patent to irrigation at 6 months. Our clinical results seem to parallel theirs in improving epiphora. In their series, the balloon was visualized with a nasal speculum or touched with a Bowman probe to confirm proper positioning. We observed several patients who were found to have submucosal passage of the balloon by endoscopy (Fig 4). They required manipulation of the balloon or even incision of the nasal mucosa to ensure that the balloon actually entered the inferior meatus rather than remained submucosal in location. Since Perry and colleagues (1998) placed silicone tubes after balloon dilation, patients were guaranteed that a nasolacrimal tract was patent, but not necessarily that the mucosal entrance into the nose had been dilated by the balloon if the balloon was not directly visualized. We feel that observation of the balloon passing through the valve of Hasner is necessary to confirm that the true NLD is cannulated. During passage of the
Couch and White 䡠 Endoscopically Assisted Balloon Dacryoplasty balloon through a particularly tight NLD, a primary exit out the medial aspect of the nasolacrimal sac is possible, thus making it a primary balloon DCR. Occasionally, videoendoscopy will yield a cause for epiphora that the balloon may not be able to improve, such as concretions completely obstructing the inferior meatus (Fig 5). A few patients were found to have dacryoliths, which the balloon advanced out into the inferior meatus after inflation. Early in the series it was appreciated endoscopically that passage of the catheter to the proximal black ring as recommended by the manufacturer did not guarantee entry of the device into the inferior meatus. Some surgeons may be tempted to perform dacryoplasty in an office setting. No patients in the present series required cautery to control bleeding, but with several patients additional intraoperative nasal packing was necessary to obtain hemostasis. This could be cumbersome in an office setting with an anxious patient, especially if no suction is available. Incisional DCR can be performed with local anesthesia and supplemental intravenous sedation in an ambulatory outpatient setting. Dacryoplasty can also be performed in the same manner. Occasionally, when lacrimal surgery is performed in such a manner, control of the airway becomes difficult, especially if there is blood running posteriorly into the pharynx. It is a personal preference of one of the authors (WLW) to perform lacrimal surgery under laryngeal mask airway anesthesia when possible, because it offers control of the airway and rapid patient recovery postoperatively. In patients who are not candidates for laryngeal mask airway anesthesia, the procedure can be performed under local anesthesia with supplemental intravenous sedation, or even under general endotracheal anesthesia, if necessary. Patient acceptance of dacryoplasty is high because the natural tear drainage tract is maintained and there is no visible scarring or incision. Dacryoplasty may not, however, have as high a success rate as incisional DCR. Further studies reporting longer patient follow-up (⬎5 years) may be difficult to achieve, as asymptomatic patients are difficult to get to return for examination when following a noncancerous, non–life threatening problem. We feel that dacryoplasty has been firmly established as an accepted treatment choice in patients with incomplete NLDOs in the absence of secondary causes of epiphora, and should be performed with nasal videoendoscopy whenever possible.
References 1. Perry JD, Maus M, Nowinski TS, Penne RB. Balloon catheter dilation for treatment of adults with partial nasolacrimal duct obstruction: a preliminary report. Am J Ophthalmol 1998;126: 811– 6. 2. Becker BB. Dacryocystorhinostomy without flaps. Ophthalmic Surg 1988;19:419 –27. 3. Rosen N, Sharir M, Moverman DC, Rosner M. Dacrocystorhinostomy with silicone tubes: evaluation of 253 cases. Ophthalmic Surg 1989;20:115–9. 4. Tarbet KJ, Custer PL. External dacryocystorhinostomy. Surgical success, patient satisfaction, and economic cost. Ophthalmology 1995;102:1065–70. 5. Walland MJ, Rose GE. Factors affecting the success rate of open lacrimal surgery. Br J Ophthalmol 1994;78:888 –91. 6. Zolli CL, Shannon GM. Dacryocystorhinostomy: a review of 119 cases. Ophthalmic Surg 1982;13:905–10. 7. Lee JM, Song HY, Han YM, et al. Balloon dacryocystoplasty: results in the treatment of complete and partial obstructions of the nasolacrimal system. Radiology 1994;192:503– 8. 8. Janssen AG, Mansour K, Krabbe GJ, et al. Dacryocystoplasty: treatment of epiphora by means of balloon dilation of the obstructed nasolacrimal duct system. Radiology 1994;193: 453– 6. 9. Berkefeld J, Kirchner J, Mu¨ ller HM, et al. Balloon dacryocystoplasty: indications and contraindications. Radiology 1997;205:785–90. 10. Kumar EN. Technical note: non-surgical treatment of epiphora by balloon dacryocystoplasty—the technique. Br J Radiol 1995;68:1116 – 8. 11. Robinson R, Turner N, Brettle P, et al. The treatment of epiphora with balloon dacryocystoplasty. Eye 1993;7:687–90. 12. Yazici Z, Yazici B, Parlak M, et al. Treatment of obstructive epiphora in adults by balloon dacryocystoplasty. Br J Ophthalmol 1999;83:692– 6. 13. Angrist RC, Dortzbach RK. Silicone intubation for partial and total nasolacrimal duct obstruction in adults. Ophthal Plast Reconstr Surg 1985;1:51– 4. ¨ ge I¨, O ¨ ge F, et al. Silicone intubation for obstruc14. Aritu¨ rk N, O tion of the nasolacrimal duct in adults. Acta Ophthalmol Scand 1999;77:481–2. 15. Fulcher T, O’Connor M, Moriarty P. Nasolacrimal intubation in adults. Br J Ophthalmol 1998;82:1039 – 41. 16. Pashby RC, Rathbun JE. Silicone tube intubation of the lacrimal drainage system. Arch Ophthalmol 1979;97:1318 –22. 17. Becker BB, Berry FD. Balloon catheter dilation in lacrimal surgery. Ophthalmic Surg 1989;20:193– 8.
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