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Canaliculus Reconstruction with Homologous Vein Graft
676
AMERICAN JOURNAL OF OPHTHALMOLOGY ACKNOWLEDGMENT
I wish to thank Drs. A. Lerner, M. Lerner, R. Snell and M. Sears for their help in the prepar ation of this paper. REFERENCES
1. Reese, A. B.: Pigmentation of the palpebral conjunctiva resulting from mascara. Am. J. Ophth. 30:1352, 1947. 2. Duke-Elder, W. S.: Textbook of Ophthalmol ogy. St. Louis, Mosby, 1938, v. 2, p. 1764-1771. 3. Hogan, M. J., and Zimmerman, L. E.: Oph-
OCTOBER, 1966
thalmic Pathology: An Atlas and Textbook. Phila delphia, Saunders, 1962 ed. 2, p. 257. 4. Sedan, J.: Contribution a l'etude de la circu lation conjonctivale: Migration sous-conjonctivale d'encre de chine, ayant duroe cinq ans. Ann. ocul. 163 :600, 1926. 5. Dolle, S.: Plastic and Cosmetic Surgery, New York, Appleton, 1911, pp. 209-338. 6. Davis, S.: Plastic Surgery: Its Principles and Practice. Philadelphia, Blakiston, 1919, p. 46. 7. McC'all's (McCall Corp. New York). Feb. 1964, p. 114. 8. Vogue (Conde Nast Pub. New York.) Mar. 1964, p. 140.
CANALICULUS RECONSTRUCTION W I T H HOMOLOGOUS V E I N GRAFT J. R.
OLSON, M.D.,
AND N. A.
YOUNGS,
M.D.
Grand Forks, North Dakota
In the congenital absence of a punctum and a canaliculus, the following surgical method is proposed to create a functional punctum and canaliculus. Initially, an intact three-inch segment of vein is obtained from the patient's hand or forearm. An incision is made parallel to the selected vein; after the vein segment is iso lated and freed from adjacent subcutaneous tissue, it is ligated at each end, thus leaving a three-inch avascular segment of vein. This segment is dissected free and threaded over the end of a No. 90 polyethylene tube and is then placed in a saline solution for later use. The skin wound is closed with routine closure techniques. The second major step is the exposure of the lacrimal sac. First, the area over the lacrimal fossa is identified. A curved skin in cision is made six to seven mm medial to the medial canthal ligament and extended two cm inferiorly. The skin edges are under mined and retracted along with orbicularis fibers. Blunt dissection permits identification of the medial canthal ligament which is not severed; however, the angular vessels are ligated. The sac is now exposed and the perios teum, anterior and posterior, is separated from it. A vertical incision is made through the anterior wall of the sac. The third step is creating the punctum
site and anatomic course of the canaliculus. A stab wound extending inferiorly beneath the orbicularis fibers to the lacrimal sac is made in the margin of the lower lid at the future punctum site. A curved mosquito hemostat is inserted into the lacrimal sac and clamped onto the end of the scalpel before the scalpel is withdrawn. At this time it is necessary to withdraw the scalpel while guiding the hemostat through the stab pas sage in one continuous motion so that the tip of the hemostat emerges on the lid mar gin at the punctum site. The vein graft and polyethylene tube are adjusted by the assistant so that the polyethy lene tube is 12 inches long. The three-inch vein segment is adjusted on the polyethylene tube so that the tip of the polyethylene tube and the vein tip can be grasped by the tip of the hemostat. By slowly pulling on the he mostat the tip of the polyethylene tube and vein graft are pulled into the lacrimal sac. It is essential that care be taken to prevent the distal end of the vein graft from entering into the stab wound. Lister forceps are used to hold the end of the vein graft at the punctum site as the polyethylene tube is pulled downward until three inches of it re main extending from the punctum site. The vein graft is sutured to the lid mar gin by four interrupted 7-0 black silk su tures and the split halves of the lid on each
VOL. 62, NO. 4
677
CANALICULUS RECONSTRUCTION
side of the vein graft are closed by inter rupted sutures. The vein graft is adjusted so that the new punctum appears in a nor mal anatomic position for functional drain age of the tear lake. Completion of the procedure necessitates insertion of the inferior end of the poly ethylene tube into the nasolacrimal duct and into the nose, where it is located via the nares. The inferior end of the polyethylene tube is now withdrawn through the nares. The inferior end of the vein graft is checked to see that it still extends into the lacrimal sac, but it is not sutured to the lacrimal sac. Closure of the lacrimal sac with routine closure of the overlying structures completes this step. The final step involves taping the loose ends of the polyethylene tube to the fore head and cheek. A compression type dress ing is applied and changed 24 hours later for a smaller dressing. Several days later the patient is discharged home on a topical antibiotic. In four weeks the polyethylene tube is re moved. The tube is grasped at the nares and removed slowly and easily. No stress on the vein graft tip at the punctum site has been noted. All sutures, including the vein graft sutures at the punctum site, are removed on the seventh postoperative day. Normal sa line irrigation of the vein graft is per formed at weekly intervals for several weeks after removal of the tube. The procedure as described was used on the first patient while the same procedure with slight modification was used on four additional patients.
CASE 2
The second patient, a 45-year-old white woman, had bilateral dacryocystorhinostomy per formed twice with failure on the right side after the second procedure. Vein graft material from the patient's hand was used. One modification was made in placement of the vein graft. Because of the patients' history of dacryocystitis and nasola crimal duct obstruction, the vein graft was made somewhat longer to extend into the nasal cavity through the old dacryocystorhinostomy site in the lacrimal fossa. No attempt was made to suture the inferior end of the vein graft to the nasal mucosa. The same postoperative procedure was followed as in the original case. Two years later the patient is free of symptoms. SUMMARY
An intact three-inch segment of vein is obtained from the patient's hand or forearm for creation of a functional punctum and. canaliculus. After exposure of the lacrimal sac, the punctum site and anatomic course of the canaliculus are created by making a stab wound in the margin of the lower lid at the future punctum site. When the new punctum appears to be ready to provide functional drainage of the tear lake, the la crimal sac is closed. Finally, the polyethy lene tube is taped to the forehead and cheek. Several days later the patient is discharged on a topical antibiotic to return in approxi mately four weeks for removal of the poly ethylene tube. COMMENT
The method described is suggested as an alternate procedure when restoration of nor mal anatomic relationships is impossible be cause of pre-existing disease, trauma or congenital anomaly of all or part of the naso lacrimal apparatus. 221 South Fourth Street
CASE REPORTS CASE 1
The first patient, a 14-year-old boy, had con genital absence of the right lower punctum and canaliculus. He had a history of unilateral epi phora. Upon physical examination, no punctum could be located in the lower lid; however, a punctum was located in the upper lid through which normal saline could not be irrigated. Sur gical repair as already described gave excellent functional results two and one-half years later.
ADDENDUM
This procedure has been successfully performed on two other patients, (one patient bilateral). The postoperative follow-up has been less than one year, however. REFERENCE
Berens, C, and King, J. H., Jr.: An Atlas of Ophthalmic Surgery. Philadelphia, Lippincott, 1961, pp. 540-544.
AMERICAN JOURNAL OF OPHTHALMOLOGY ACKNOWLEDGMENT
I wish to thank Drs. A. Lerner, M. Lerner, R. Snell and M. Sears for their help in the prepar ation of this paper. REFERENCES
1. Reese, A. B.: Pigmentation of the palpebral conjunctiva resulting from mascara. Am. J. Ophth. 30:1352, 1947. 2. Duke-Elder, W. S.: Textbook of Ophthalmol ogy. St. Louis, Mosby, 1938, v. 2, p. 1764-1771. 3. Hogan, M. J., and Zimmerman, L. E.: Oph-
OCTOBER, 1966
thalmic Pathology: An Atlas and Textbook. Phila delphia, Saunders, 1962 ed. 2, p. 257. 4. Sedan, J.: Contribution a l'etude de la circu lation conjonctivale: Migration sous-conjonctivale d'encre de chine, ayant duroe cinq ans. Ann. ocul. 163 :600, 1926. 5. Dolle, S.: Plastic and Cosmetic Surgery, New York, Appleton, 1911, pp. 209-338. 6. Davis, S.: Plastic Surgery: Its Principles and Practice. Philadelphia, Blakiston, 1919, p. 46. 7. McC'all's (McCall Corp. New York). Feb. 1964, p. 114. 8. Vogue (Conde Nast Pub. New York.) Mar. 1964, p. 140.
CANALICULUS RECONSTRUCTION W I T H HOMOLOGOUS V E I N GRAFT J. R.
OLSON, M.D.,
AND N. A.
YOUNGS,
M.D.
Grand Forks, North Dakota
In the congenital absence of a punctum and a canaliculus, the following surgical method is proposed to create a functional punctum and canaliculus. Initially, an intact three-inch segment of vein is obtained from the patient's hand or forearm. An incision is made parallel to the selected vein; after the vein segment is iso lated and freed from adjacent subcutaneous tissue, it is ligated at each end, thus leaving a three-inch avascular segment of vein. This segment is dissected free and threaded over the end of a No. 90 polyethylene tube and is then placed in a saline solution for later use. The skin wound is closed with routine closure techniques. The second major step is the exposure of the lacrimal sac. First, the area over the lacrimal fossa is identified. A curved skin in cision is made six to seven mm medial to the medial canthal ligament and extended two cm inferiorly. The skin edges are under mined and retracted along with orbicularis fibers. Blunt dissection permits identification of the medial canthal ligament which is not severed; however, the angular vessels are ligated. The sac is now exposed and the perios teum, anterior and posterior, is separated from it. A vertical incision is made through the anterior wall of the sac. The third step is creating the punctum
site and anatomic course of the canaliculus. A stab wound extending inferiorly beneath the orbicularis fibers to the lacrimal sac is made in the margin of the lower lid at the future punctum site. A curved mosquito hemostat is inserted into the lacrimal sac and clamped onto the end of the scalpel before the scalpel is withdrawn. At this time it is necessary to withdraw the scalpel while guiding the hemostat through the stab pas sage in one continuous motion so that the tip of the hemostat emerges on the lid mar gin at the punctum site. The vein graft and polyethylene tube are adjusted by the assistant so that the polyethy lene tube is 12 inches long. The three-inch vein segment is adjusted on the polyethylene tube so that the tip of the polyethylene tube and the vein tip can be grasped by the tip of the hemostat. By slowly pulling on the he mostat the tip of the polyethylene tube and vein graft are pulled into the lacrimal sac. It is essential that care be taken to prevent the distal end of the vein graft from entering into the stab wound. Lister forceps are used to hold the end of the vein graft at the punctum site as the polyethylene tube is pulled downward until three inches of it re main extending from the punctum site. The vein graft is sutured to the lid mar gin by four interrupted 7-0 black silk su tures and the split halves of the lid on each
VOL. 62, NO. 4
677
CANALICULUS RECONSTRUCTION
side of the vein graft are closed by inter rupted sutures. The vein graft is adjusted so that the new punctum appears in a nor mal anatomic position for functional drain age of the tear lake. Completion of the procedure necessitates insertion of the inferior end of the poly ethylene tube into the nasolacrimal duct and into the nose, where it is located via the nares. The inferior end of the polyethylene tube is now withdrawn through the nares. The inferior end of the vein graft is checked to see that it still extends into the lacrimal sac, but it is not sutured to the lacrimal sac. Closure of the lacrimal sac with routine closure of the overlying structures completes this step. The final step involves taping the loose ends of the polyethylene tube to the fore head and cheek. A compression type dress ing is applied and changed 24 hours later for a smaller dressing. Several days later the patient is discharged home on a topical antibiotic. In four weeks the polyethylene tube is re moved. The tube is grasped at the nares and removed slowly and easily. No stress on the vein graft tip at the punctum site has been noted. All sutures, including the vein graft sutures at the punctum site, are removed on the seventh postoperative day. Normal sa line irrigation of the vein graft is per formed at weekly intervals for several weeks after removal of the tube. The procedure as described was used on the first patient while the same procedure with slight modification was used on four additional patients.
CASE 2
The second patient, a 45-year-old white woman, had bilateral dacryocystorhinostomy per formed twice with failure on the right side after the second procedure. Vein graft material from the patient's hand was used. One modification was made in placement of the vein graft. Because of the patients' history of dacryocystitis and nasola crimal duct obstruction, the vein graft was made somewhat longer to extend into the nasal cavity through the old dacryocystorhinostomy site in the lacrimal fossa. No attempt was made to suture the inferior end of the vein graft to the nasal mucosa. The same postoperative procedure was followed as in the original case. Two years later the patient is free of symptoms. SUMMARY
An intact three-inch segment of vein is obtained from the patient's hand or forearm for creation of a functional punctum and. canaliculus. After exposure of the lacrimal sac, the punctum site and anatomic course of the canaliculus are created by making a stab wound in the margin of the lower lid at the future punctum site. When the new punctum appears to be ready to provide functional drainage of the tear lake, the la crimal sac is closed. Finally, the polyethy lene tube is taped to the forehead and cheek. Several days later the patient is discharged on a topical antibiotic to return in approxi mately four weeks for removal of the poly ethylene tube. COMMENT
The method described is suggested as an alternate procedure when restoration of nor mal anatomic relationships is impossible be cause of pre-existing disease, trauma or congenital anomaly of all or part of the naso lacrimal apparatus. 221 South Fourth Street
CASE REPORTS CASE 1
The first patient, a 14-year-old boy, had con genital absence of the right lower punctum and canaliculus. He had a history of unilateral epi phora. Upon physical examination, no punctum could be located in the lower lid; however, a punctum was located in the upper lid through which normal saline could not be irrigated. Sur gical repair as already described gave excellent functional results two and one-half years later.
ADDENDUM
This procedure has been successfully performed on two other patients, (one patient bilateral). The postoperative follow-up has been less than one year, however. REFERENCE
Berens, C, and King, J. H., Jr.: An Atlas of Ophthalmic Surgery. Philadelphia, Lippincott, 1961, pp. 540-544.