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Endoscopic dacryocystorhinostomy in children
Endoscopic Dacryocystorhinostomy in Children Deborah K. VanderVeen, MD,a* Dwight T. Jones, MD,b* Henry Tan, MD,b and Robert A. Petersen, MDa Background: Persistent nasolacrimal duct obstruction (NLDO) often requires treatment by probing, intubation, or balloon dacryoplasty. Refractory cases have been managed by external dacryocystorhinostomy (DCR), which leaves a scar; however, this procedure is generally avoided in young children. Endoscopic DCR has been successfully performed in adults and described in children. We report the success of this procedure in a series of pediatric patients. Methods: A retrospective review of all endoscopic lacrimal procedures performed in a 3-year period was undertaken. Seventeen children (22 ducts) with persistent NLDO after at least one failed probing, with or without silicone tube placement, underwent endoscopic DCR. Follow-up ranged from 6 to 36 months, and success was defined as resolution of tearing and discharge by follow-up clinical evaluation and by parental history. Results: All but 2 patients (88%) with NLDO showed complete resolution of tearing and discharge. These 2 patients had recurrent symptoms after the Crawford tubes were removed and required revision endoscopic DCR. No complications from this procedure were noted. Conclusions: Endoscopic DCR is a safe and effective means of treating persistent NLDO in infants and young children when simple probing, intubation, or balloon procedures have failed. The team ophthalmology-otolaryngology endoscopic approach provides a highly successful alternative for patients with a persistent distal obstruction that might otherwise require an external procedure. (J AAPOS 2001;5:143-7)
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ersistent tearing in patients with congenital nasolacrimal duct obstruction (NLDO) for whom multiple procedures have failed, or in whom a complete bony obstruction is encountered, has traditionally led to an external dacryocystorhinostomy (DCR). This procedure is generally avoided in patients younger than 5 years; however, with an overall success rate of about 90% in adults1-6 and 80%7-11 in children, external DCR continues to be the gold standard for definitive treatment. With the advent of nasal endoscopes for endoscopic sinus surgery, an increasing number of patients with lacrimal duct obstruction are undergoing endoscopic DCR. The literature describes this technique and its success in adult patients with acquired lacrimal duct obstruction,4,5,12-18 with relatively little focus on the usage of endoscopic DCR in children.19,20 We have used endoscopic techniques for patients with persistent NLDO after traditional procedures have failed and review our technique of performing a DCR endoscopically, the success rates, and the apparent causes of failure. From the Department of Ophthalmologya and Department of Otolaryngology,b Children’s Hospital, Boston, Massachusetts. *Co-first author from respective departments. Submitted May 1, 2000. Revision accepted February 5, 2001. Reprint requests: Deborah K. VanderVeen, MD, Department of Ophthalmology, Fegan 4, 300 Longwood Avenue, Boston, MA 02115 (e-mail: [email protected]). Copyright © 2001 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/2001/$35.00 + 0 75/1/114910 doi:10.1067/mpa.2001.114910
Journal of AAPOS
SUBJECTS AND METHODS Private charts and hospital records of all patients undergoing endoscopic lacrimal procedures at Children’s Hospital, Boston, during a 3-year period were retrospectively reviewed. The Table describes the characteristics of patients with persistent congenital NLDO who underwent endoscopic DCR. These patients were brought to the hospital because of continued epiphora, and most experienced intermittent crusty discharge. All patients had been treated conservatively initially, and all underwent at least one probe without success. The probe could not be passed at all in 5 ducts of 3 patients due to complete bony obstruction of the nasolacrimal canal. Despite successful passage of a probe in other patients, further procedures were undertaken because of persistence of tearing and discharge. Success was defined as resolution of the symptoms of tearing and discharge, both as reported by the parents and as documented by clinical examination at the postoperative visits. All operations were performed with the patient under general anesthesia and in the supine position with the use of the following technique. Nasal packing soaked in 0.05% oxymetazoline solution is placed in the nasal cavity for 5 minutes, to aid in vasoconstriction. The upper punctum is dilated with a punctal dilator, and a Bowman probe is passed through the system initially to explore the passage and confirm the nature of the obstruction. A 20-gauge fiberoptic light pipe is then passed through the canalicular system, into the nasolacrimal sac, and as far into the naso-
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TABLE. Summary of patient characteristics Patient No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Age at eDCR (y, mo) 0 y, 11 mo 0, 11 1, 3 1, 8 1, 9 2, 0 2, 1 2, 3 2, 9 3, 10 3, 10 3, 11 5, 2 5, 5 5, 6 7, 1 18, 8
Other abnormalities None L aortic arch with aberrant R subclavian Cleft lip/palate; nasal deformity Thumb anomalies None None Down syndrome None None None None None None None None Loose anagen syndrome Cornelia de Lange syndrome
Laterality
Previous procedures
Follow-up (y, mo)
DCR location
OS OU
P P
2 y, 3 mo 0, 7
Middle Inferior
OU OS OD OD OD OS OD OD OU OS OS OD OU OU OS
P* P P, P, P P, P P* P, I P P, P, B, T, I P P, T P, P P, P, T P* P, P, P P
2, 2 2, 0 0, 9 2, 0 0, 4 0, 7 0, 8 2, 6 2, 5 2, 5 2, 8 2, 2 2, 11 1, 4 1, 3
Middle Inferior Middle Inferior Inferior Inferior Inferior Inferior Middle Inferior Middle Inferior Middle Middle Middle
*Cases with complete bony obstruction. eDCR, Endoscopic DCR; B, balloon dacryoplasty; I, infracture of turbinate; P, probing; T, intubation.
lacrimal canal as possible. The light pipe transilluminates the lateral nasal wall, and the area of maximal brightness corresponds with the inferior end of the lacrimal sac where the overlying bone is the thinnest. The 2- or 4-mm, zerodegree nasal endoscope is used in the nose for direct visualization of the illuminated mucosa, with the endoscope light source initially turned off or placed at the lowest setting so that the light from the fiber optic light pipe can be located. Once identified, the area of maximal illumination is injected with 1% lidocaine with epinephrine 1:100,000. An endoscopic knife is used to make a small vertical mucosal incision. If the middle or inferior turbinate is obstructing the view, it is infractured with a periosteal elevator. If there is bone covering the light, a small opening approximately 5 mm in diameter in the bone can easily be made with a small rat-tail punch. When a punch is used, care must be taken not to allow the punch to go further than 4 mm deep, since this depth will allow entry into the nasolacrimal sac without causing damage to adjacent or deeper structures. The opening can be enlarged with upbiting forceps, but no attempt is made to create mucosal flaps. Excess mucosa around the new bony opening is removed with forceps. Sufficient mucosal and bony tissue are removed until the light pipe can be easily passed through the new opening into the nasal vault. The light pipe is removed, and the Crawford tubes are then placed through the superior and inferior canaliculi. The tubes are easily retrieved by direct visualization and by grasping the olive tips with Blakesley forceps or a Crawford hook. The ends of the tubing are then adjusted and tied within the nasal cavity, so as to form a continuous loop that is anchored
to the lateral nasal wall with an absorbable suture. The tubing is left in place for 2 to 4 months. The patient is discharged and receives topical antibiotic or combination steroid-antibiotic ointment. The average operative time after the learning curve has been passed is 20 to 30 minutes per involved side.
RESULTS Seventeen patients, 7 males and 10 females, underwent endoscopic DCR. The age of the patients ranged from 11 months to 18 years. Five cases had bilateral involvement. All patients had tearing and discharge that first appeared in infancy, thus none had acquired NLDO. No patients were excluded on the basis of systemic abnormalities. Nine patients (13 ducts) underwent only 1 procedure before the endoscopic DCR. However, 3 of these patients (5 ducts) had complete bony obstruction allowing no initial probe passage. Of the other 6 patients (8 ducts), the probe passage was believed to be significantly tight distally in 3 (4 ducts). At the time of endoscopic DCR, the location of the obstruction in all patients was believed to be distal, most with some degree of bony constriction. Complete bony obstruction of the 5 ducts in which probe passage could not be obtained initially was confirmed. One patient was noted to have a tight common canaliculus in addition to a distal obstruction. The location of the ostium that was enlarged or newly created was below the middle turbinate in 8 cases and below the inferior turbinate in 9 cases. After the endoscopic DCR, all patients showed complete resolution of their symptoms of tearing and discharge except for 2, giving an overall procedure success
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rate of 88%. This represented a cure for 19 of 22 ducts, or 86%. Patient 3 had cleft lip, palate, and nasal deformities, as well as complete bony obstruction of the nasolacrimal canals. After the endoscopic DCR, this patient pulled the tube from the left side, which required a second procedure to replace the tube. Though some improvement in symptoms was reported, significant daily tearing continued, and intubation was repeated. At the time of this procedure, the previously created ostium was widely patent; however, the middle turbinate appeared to obstruct the ostium, and the nasal passages remained very tight due to her congenital anomalies. With the use of the endoscope, the turbinate was infractured and excess mucosa removed around the already patent ostium. Patient 5 showed no improvement after the endoscopic DCR. The revision required creation of a new ostium, because the first ostium was not clearly identified at the time of reoperation. No additional complications from the procedure were noted, although 1 other patient pulled the tubing out of the nose on the first postoperative day, and a second procedure was required to replace the tube. Though planned removal of the tubing was scheduled 2 to 4 months after the procedure, the tubes were prematurely removed from 5 ducts of 4 other patients at 2 to 6 weeks, yet the patients remained symptom free.
DISCUSSION Surgical access to the nasal cavity has been greatly enhanced by the development of endoscopic techniques. Small diameter endoscopes with angled fields of view provide excellent intranasal visualization. These scopes, coupled with specially designed pediatric endoscopic instruments, have enabled the surgeon to identify and open the lacrimal sac with relative ease from inside the nasal cavity, even in the infant population. Endoscopic instrumentation allows for the rapid identification and correction of intranasal causes of epiphora, including persistent membranous or bony obstruction, adhesions from previous procedures, redundant mucosa, or enlarged middle or inferior turbinates. The endoscope can be used to confirm that the probe has passed into the nasal cavity or emerged through its natural path in the inferior meatus and can enable the surgeon to identify redundant mucosa or a closely apposed turbinate that may require infracture. The use of video endoscopy also provides an excellent tool for teaching the surgical technique. Although nasal endoscopy is not necessary for most cases of congenital NLDO, it has become a useful aid in cases in which the initial procedures have failed to produce a cure. Congenital NLDO is usually caused by failure of the distal system to establish patency during development, which results in a persistent membranous or sometimes bony-membranous obstruction.21-23 Maldevelopment of the proximal portion of the system occurs less commonly. Attention to the nature of the obstruction and the anatomy at the time of the initial probing allows the surgeon to
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proceed with an appropriate secondary procedure when the initial probe fails. As noted previously, surgeons may prefer a second or third probing, silicone intubation, or balloon dacryoplasty; or, finally, they may opt for a DCR. If the distal portion of the system is initially believed to be restricted or anomalous, direct endoscopic guidance may be useful for the second procedure. Although the management of nasolacrimal duct obstruction is sometimes controversial, the advantages of endoscopy allow for more definitive management in difficult cases. The operative procedure in this study was performed as a team and used the skills of both the ophthalmologist and the otolaryngologist. The ophthalmologist passes the lacrimal probe, the fiber optic light pipe, and finally the Crawford tubes through the canaliculi into the lacrimal sac, and the otolaryngologist performs the nasal endoscopy and creates or enlarges the nasal ostium. Usually, the entire procedure can be performed with a video camera attached to the nasal endoscope so that both surgical teams can simultaneously observe the intranasal manipulations on a video monitor. Because infants and children have small nasal cavities and the working space is markedly reduced compared with adults, experience in pediatric intranasal procedures is useful. We were successful when we created or enlarged the ostium in the area most illuminated by the light pipe and did not find any difference in complications or failures based on whether the ostium was located near the middle or inferior turbinate. When an ostium is enlarged or created, other factors such as enlarged turbinates or redundant mucosa should be considered and dealt with when recognized. Medialization of the inferior turbinate, or at times the middle turbinate, was necessary in nearly all patients to visualize the light pipe and help determine where the ostium should be located. If a deviated septum or other abnormality is present and inhibiting access to the area or may be problematic in healing and the final outcome, then it should be addressed at the time the DCR takes place. Other secondary procedures that may be required include septoplasty, resection of a turbinate, or ethmoidectomy. These were usually not necessary in this group of patients. External DCR has been the mainstay of surgical therapy for patients with complicated lacrimal duct obstructions, with an overall success rate of 90%.1-11 In our group of patients undergoing endoscopic surgery, the success rate was 88%. Even by eliminating the patients who underwent only one probe and who were not documented to have significant distal obstruction before the endoscopic DCR, the procedure success rate was 85%. Several series of adult patients undergoing endoscopic lacrimal procedures have reported success rates of around 90%.12-17 However, the prospective randomized studies comparing endoscopic DCR with external DCR in adults showed significantly lower success rates with endoscopic procedures.4,5 Nonetheless, given a potentially good success rate, endoscopic DCR has several advantages over the external approach.
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Unlike external DCR, endoscopic DCR allows for the drainage of an obstructed lacrimal sac and system without a facial incision and subsequent scar. Endoscopic DCR also causes less surgical trauma to medial canthal and orbital tissue and causes less bleeding than is observed in conventional surgery.2 Endoscopic DCR takes much less time than conventional external DCR.4 None of our patients required hospitalization after the procedure, supporting that this may be safely done as an outpatient procedure with faster resumption of normal daily activities and increased cost-effectiveness. Laser endoscopic DCR is performed in adults5,16-18 and may be an option in children. Although the laser has the advantage of giving better hemostasis, we found bleeding with our technique to be very minimal, and the risks of the laser to the patient and the operating room personnel were avoided. Success rates with the laser rather than a conventional burr or punch vary widely, from 63%5 to 100%,17 for a primary DCR. In general, success of the laser in revision DCR has been comparable to standard revision surgery. Reported failures in DCR are usually attributed to fibrosis and subsequent closure of the newly created or enlarged ostium. In one review of adults, the mean diameter of the healed ostium was 1.88 mm.24 Even with a small ostium, once healing has taken place and patency is established, good lacrimal drainage will continue. Closure of adjacent flaps of the nasal and lacrimal mucosa is commonly performed in external DCR and should theoretically provide a patent epithelial-lined tract for tear drainage. Our described technique does not incorporate mucosal flaps. In practice, the necessity of mucosal flaps is questionable, because a 92.5% success rate was obtained in a series of 41 external DCRs performed by using stents without mucosal flaps.25 Placement of silicone tubing or other stenting material is generally accepted as useful and is probably necessary to maintain patency during the healing phase.18,26 The use of mitomycin C, which has been shown to decrease fibrosis and shrinkage of the ostium size during healing, may also be useful to increase success rates.27,28 The use of mitomycin C in pediatric DCR cases has not been reported, and we have not found its use to be warranted in any of our cases to date. In this series, 2 patients did not experience long-term resolution of symptoms. The cause for the unsuccessful procedure in 1 patient was found to be due to obstruction of a patent ostium by redundant mucosa and a large turbinate in a small nasal passage. In the other patient, recurrence of symptoms was noted when the silicone tubing was removed at 2 months. The original ostium could not be found at the time of reoperation, and a new opening was fashioned. The precise mechanism of failure in this patient is uncertain, though closure of the initially created ostium appears to have occurred. The main disadvantage of the endoscopic technique is its requirement for specialized training and instrumentation. Potential complications include bleeding, infection, orbital
Journal of AAPOS Volume 5 Number 3 June 2001
injury, intracranial injury, lacrimal sac fibrosis, and scarring. None of these complications were noted in our series. This study demonstrates that endoscopic lacrimal procedures, including endoscopic DCR, may be performed safely and effectively in infants and young children. The cure rate for patients with persistent tearing from congenital NLDO in this series was 88%. Endoscopic techniques may provide direct visualization of the cause of distal obstruction and be useful in guiding secondary procedures after failed probings. Endoscopic DCR provides an effective surgical approach for these patients and provides a reasonable alternative for patients who might otherwise require an external procedure. References 1. Beigi B, Westlake W, Chang B, Marsh C, Jacob J, Chatfield J. Dacryocystorhinostomy in south west England. Eye 1998;12:358-62. 2. Dresner SC, Klussman KG, Meyer DR, Linberg JV. Outpatient dacryocystorhinostomy. Ophthalmic Surg 1991;22:222-4. 3. Goh SH, Seah LL, Chiang C. Results of dacryocystorhinostomy in Singapore General Hospital. Ann Acad Med Singapore 1989;18:234-7. 4. Hartikainen J, Antila J, Varpula M, Puukka P, Seppa H, Grenman R. Prospective randomized comparison of endonasal endoscopic dacryocystorhinostomy and external dacryocystorhinostomy. Laryngoscope 1998;108:1861-6. 5. Hartikainen J, Grenman R, Puukka P, Seppa H. Prospective randomized comparison of external dacryocystorhinostomy and endonasal laser dacryocystorhinostomy. Ophthalmology 1998;105:1106-13. 6. Tarbet KJ, Custer PL. External dacryocystorhinostomy. Surgical success, patient satisfaction, and economic cost. Ophthalmology 1995;102:1065-70. 7. Elder MJ. Paediatric dacryocystorhinostomy. Aust N Z J Ophthalmol 1992;20:333-6. 8. Hakin KN, Sullivan TJ, Sharma A, Welham RA. Paediatric dacryocystorhinostomy. Aust N Z J Ophthalmol 1994;22:231-5. 9. Harrison MS, Mukherjee AK. Dacryocystorhinostomy in children and infants. J Laryngol Otol 1967;81:45-50. 10. Nowinski TS, Flanagan JC, Mauriello J. Pediatric dacryocystorhinostomy. Arch Ophthalmol 1985;103:1226-8. 11. Welham RA, Hughes SM. Lacrimal surgery in children. Am J Ophthalmol 1985;99:27-34. 12. Eloy P, Bertrand B, Martinez M, Hoebeke M, Watelet JB, Jamart J. Endonasal dacryocystorhinostomy: indications, technique and results. Rhinology 1995;33:229-33. 13. Sprekelsen MB, Barberan MT. Endoscopic dacryocystorhinostomy: surgical technique and results. Laryngoscope 1996;106:187-9. 14. Yung MW, Hardman-Lea S. Endoscopic inferior dacryocystorhinostomy. Clin Otolaryngol 1998;23:152-7. 15. Zhou W, Zhou M, Li Z, Wang T. Endoscopic intranasal dacryocystorhinostomy in forty-five patients. Chin Med J 1996;109:747-8. 16. Metson R, Woog JJ, Puliafito CA. Endoscopic laser dacryocystorhinostomy. Laryngoscope 1994;104:269-74. 17. Mickelson SA, Kim DK, Stein IM. Endoscopic laser-assisted dacryocystorhinostomy. Am J Otolaryngol 1997;18:107-11. 18. Sadiq SA, Ohrlich S, Jones NS, Downes RN. Endonasal laser dacryocystorhinostomy—medium term results. Br J Ophthalmol 1997; 81:1089-92. 19. Cunningham MJ, Woog JJ. Endonasal endoscopic dacryocystorhinostomy in children. Arch Otolaryngol Head Neck Surg 1998;124:328-33. 20. Wong JF, Woog JJ, Cunningham MJ, Rubin PA, Curtin HD, Carter BL. A multidisciplinary approach to atypical lacrimal obstruction in childhood. Ophthal Plast Reconstr Surg 1999;15:293-8. 21. Guerry D, Kendy EL. Congenital impatency of the nasolacrimal duct. Arch Ophthalmol 1948;39:193–204.
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22. Cassidy JV. Developmental anatomy of the nasolacrimal duct. Arch Ophthalmol 1952;47:141-58. 23. Busse H, Muller KM, Droll P. Radiological and histological findings of the lacrimal passages of newborns. Arch Ophthalmol 1980;98:528-32. 24. Linberg JV, McCormick SA. Primary acquired nasolacrimal duct obstruction: a clinicopathologic report and biopsy technique. Ophthalmology 1986;93:1055-63. 25. Becker BB. Dacryocystorhinostomy without flaps. Ophthalmic Surgery 1988;19:419-27.
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26. Bartley GB. Simultaneous silicone intubation through the osteotomy and the nasolacrimal duct during dacryocystorhinostomy. Am J Ophthalmol 1996;121:586-7. 27. Kao SC, Liao CL PK, Tseng JH, Chen MS, Hou PK. Dacryocystorhinostomy with intraoperative mitomycin C. Ophthalmology 1997; 104:86-91. 28. Ugurbas SH, Zilelioglu G, Sargon MF, Anadolu Y, Akiner M, Akturk T. Histopathologic effects of mitomycin-C on endoscopic transnasal dacryocystorhinostomy. Ophthalmic Surg Lasers 1997;28:300-4.
An Eye on the Arts – The Arts on the Eye Something is up with Frankie, he’s upstairs blinking and blinking. She comes running up. What’s wrong with you? I’m making my eyes strong with the exercize [sic]. What exercize? The blinking. Blinking is not an exercize. Seamus in the hospital says you can’t beat a good blink for the strong eye. His uncle had powerful eyes from blinking. . . . I wash my eyes three times a day and blink til I get a pain in my eyebrows. I blink in school when the master isn’t looking and all the boys in my class are calling me Blinky and adding that to the list of names. —Frank McCourt (from Angela’s Ashes [memoirs of growing up poor in Limerick, Ireland] p 262)
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ersistent tearing in patients with congenital nasolacrimal duct obstruction (NLDO) for whom multiple procedures have failed, or in whom a complete bony obstruction is encountered, has traditionally led to an external dacryocystorhinostomy (DCR). This procedure is generally avoided in patients younger than 5 years; however, with an overall success rate of about 90% in adults1-6 and 80%7-11 in children, external DCR continues to be the gold standard for definitive treatment. With the advent of nasal endoscopes for endoscopic sinus surgery, an increasing number of patients with lacrimal duct obstruction are undergoing endoscopic DCR. The literature describes this technique and its success in adult patients with acquired lacrimal duct obstruction,4,5,12-18 with relatively little focus on the usage of endoscopic DCR in children.19,20 We have used endoscopic techniques for patients with persistent NLDO after traditional procedures have failed and review our technique of performing a DCR endoscopically, the success rates, and the apparent causes of failure. From the Department of Ophthalmologya and Department of Otolaryngology,b Children’s Hospital, Boston, Massachusetts. *Co-first author from respective departments. Submitted May 1, 2000. Revision accepted February 5, 2001. Reprint requests: Deborah K. VanderVeen, MD, Department of Ophthalmology, Fegan 4, 300 Longwood Avenue, Boston, MA 02115 (e-mail: [email protected]). Copyright © 2001 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/2001/$35.00 + 0 75/1/114910 doi:10.1067/mpa.2001.114910
Journal of AAPOS
SUBJECTS AND METHODS Private charts and hospital records of all patients undergoing endoscopic lacrimal procedures at Children’s Hospital, Boston, during a 3-year period were retrospectively reviewed. The Table describes the characteristics of patients with persistent congenital NLDO who underwent endoscopic DCR. These patients were brought to the hospital because of continued epiphora, and most experienced intermittent crusty discharge. All patients had been treated conservatively initially, and all underwent at least one probe without success. The probe could not be passed at all in 5 ducts of 3 patients due to complete bony obstruction of the nasolacrimal canal. Despite successful passage of a probe in other patients, further procedures were undertaken because of persistence of tearing and discharge. Success was defined as resolution of the symptoms of tearing and discharge, both as reported by the parents and as documented by clinical examination at the postoperative visits. All operations were performed with the patient under general anesthesia and in the supine position with the use of the following technique. Nasal packing soaked in 0.05% oxymetazoline solution is placed in the nasal cavity for 5 minutes, to aid in vasoconstriction. The upper punctum is dilated with a punctal dilator, and a Bowman probe is passed through the system initially to explore the passage and confirm the nature of the obstruction. A 20-gauge fiberoptic light pipe is then passed through the canalicular system, into the nasolacrimal sac, and as far into the naso-
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TABLE. Summary of patient characteristics Patient No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Age at eDCR (y, mo) 0 y, 11 mo 0, 11 1, 3 1, 8 1, 9 2, 0 2, 1 2, 3 2, 9 3, 10 3, 10 3, 11 5, 2 5, 5 5, 6 7, 1 18, 8
Other abnormalities None L aortic arch with aberrant R subclavian Cleft lip/palate; nasal deformity Thumb anomalies None None Down syndrome None None None None None None None None Loose anagen syndrome Cornelia de Lange syndrome
Laterality
Previous procedures
Follow-up (y, mo)
DCR location
OS OU
P P
2 y, 3 mo 0, 7
Middle Inferior
OU OS OD OD OD OS OD OD OU OS OS OD OU OU OS
P* P P, P, P P, P P* P, I P P, P, B, T, I P P, T P, P P, P, T P* P, P, P P
2, 2 2, 0 0, 9 2, 0 0, 4 0, 7 0, 8 2, 6 2, 5 2, 5 2, 8 2, 2 2, 11 1, 4 1, 3
Middle Inferior Middle Inferior Inferior Inferior Inferior Inferior Middle Inferior Middle Inferior Middle Middle Middle
*Cases with complete bony obstruction. eDCR, Endoscopic DCR; B, balloon dacryoplasty; I, infracture of turbinate; P, probing; T, intubation.
lacrimal canal as possible. The light pipe transilluminates the lateral nasal wall, and the area of maximal brightness corresponds with the inferior end of the lacrimal sac where the overlying bone is the thinnest. The 2- or 4-mm, zerodegree nasal endoscope is used in the nose for direct visualization of the illuminated mucosa, with the endoscope light source initially turned off or placed at the lowest setting so that the light from the fiber optic light pipe can be located. Once identified, the area of maximal illumination is injected with 1% lidocaine with epinephrine 1:100,000. An endoscopic knife is used to make a small vertical mucosal incision. If the middle or inferior turbinate is obstructing the view, it is infractured with a periosteal elevator. If there is bone covering the light, a small opening approximately 5 mm in diameter in the bone can easily be made with a small rat-tail punch. When a punch is used, care must be taken not to allow the punch to go further than 4 mm deep, since this depth will allow entry into the nasolacrimal sac without causing damage to adjacent or deeper structures. The opening can be enlarged with upbiting forceps, but no attempt is made to create mucosal flaps. Excess mucosa around the new bony opening is removed with forceps. Sufficient mucosal and bony tissue are removed until the light pipe can be easily passed through the new opening into the nasal vault. The light pipe is removed, and the Crawford tubes are then placed through the superior and inferior canaliculi. The tubes are easily retrieved by direct visualization and by grasping the olive tips with Blakesley forceps or a Crawford hook. The ends of the tubing are then adjusted and tied within the nasal cavity, so as to form a continuous loop that is anchored
to the lateral nasal wall with an absorbable suture. The tubing is left in place for 2 to 4 months. The patient is discharged and receives topical antibiotic or combination steroid-antibiotic ointment. The average operative time after the learning curve has been passed is 20 to 30 minutes per involved side.
RESULTS Seventeen patients, 7 males and 10 females, underwent endoscopic DCR. The age of the patients ranged from 11 months to 18 years. Five cases had bilateral involvement. All patients had tearing and discharge that first appeared in infancy, thus none had acquired NLDO. No patients were excluded on the basis of systemic abnormalities. Nine patients (13 ducts) underwent only 1 procedure before the endoscopic DCR. However, 3 of these patients (5 ducts) had complete bony obstruction allowing no initial probe passage. Of the other 6 patients (8 ducts), the probe passage was believed to be significantly tight distally in 3 (4 ducts). At the time of endoscopic DCR, the location of the obstruction in all patients was believed to be distal, most with some degree of bony constriction. Complete bony obstruction of the 5 ducts in which probe passage could not be obtained initially was confirmed. One patient was noted to have a tight common canaliculus in addition to a distal obstruction. The location of the ostium that was enlarged or newly created was below the middle turbinate in 8 cases and below the inferior turbinate in 9 cases. After the endoscopic DCR, all patients showed complete resolution of their symptoms of tearing and discharge except for 2, giving an overall procedure success
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rate of 88%. This represented a cure for 19 of 22 ducts, or 86%. Patient 3 had cleft lip, palate, and nasal deformities, as well as complete bony obstruction of the nasolacrimal canals. After the endoscopic DCR, this patient pulled the tube from the left side, which required a second procedure to replace the tube. Though some improvement in symptoms was reported, significant daily tearing continued, and intubation was repeated. At the time of this procedure, the previously created ostium was widely patent; however, the middle turbinate appeared to obstruct the ostium, and the nasal passages remained very tight due to her congenital anomalies. With the use of the endoscope, the turbinate was infractured and excess mucosa removed around the already patent ostium. Patient 5 showed no improvement after the endoscopic DCR. The revision required creation of a new ostium, because the first ostium was not clearly identified at the time of reoperation. No additional complications from the procedure were noted, although 1 other patient pulled the tubing out of the nose on the first postoperative day, and a second procedure was required to replace the tube. Though planned removal of the tubing was scheduled 2 to 4 months after the procedure, the tubes were prematurely removed from 5 ducts of 4 other patients at 2 to 6 weeks, yet the patients remained symptom free.
DISCUSSION Surgical access to the nasal cavity has been greatly enhanced by the development of endoscopic techniques. Small diameter endoscopes with angled fields of view provide excellent intranasal visualization. These scopes, coupled with specially designed pediatric endoscopic instruments, have enabled the surgeon to identify and open the lacrimal sac with relative ease from inside the nasal cavity, even in the infant population. Endoscopic instrumentation allows for the rapid identification and correction of intranasal causes of epiphora, including persistent membranous or bony obstruction, adhesions from previous procedures, redundant mucosa, or enlarged middle or inferior turbinates. The endoscope can be used to confirm that the probe has passed into the nasal cavity or emerged through its natural path in the inferior meatus and can enable the surgeon to identify redundant mucosa or a closely apposed turbinate that may require infracture. The use of video endoscopy also provides an excellent tool for teaching the surgical technique. Although nasal endoscopy is not necessary for most cases of congenital NLDO, it has become a useful aid in cases in which the initial procedures have failed to produce a cure. Congenital NLDO is usually caused by failure of the distal system to establish patency during development, which results in a persistent membranous or sometimes bony-membranous obstruction.21-23 Maldevelopment of the proximal portion of the system occurs less commonly. Attention to the nature of the obstruction and the anatomy at the time of the initial probing allows the surgeon to
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proceed with an appropriate secondary procedure when the initial probe fails. As noted previously, surgeons may prefer a second or third probing, silicone intubation, or balloon dacryoplasty; or, finally, they may opt for a DCR. If the distal portion of the system is initially believed to be restricted or anomalous, direct endoscopic guidance may be useful for the second procedure. Although the management of nasolacrimal duct obstruction is sometimes controversial, the advantages of endoscopy allow for more definitive management in difficult cases. The operative procedure in this study was performed as a team and used the skills of both the ophthalmologist and the otolaryngologist. The ophthalmologist passes the lacrimal probe, the fiber optic light pipe, and finally the Crawford tubes through the canaliculi into the lacrimal sac, and the otolaryngologist performs the nasal endoscopy and creates or enlarges the nasal ostium. Usually, the entire procedure can be performed with a video camera attached to the nasal endoscope so that both surgical teams can simultaneously observe the intranasal manipulations on a video monitor. Because infants and children have small nasal cavities and the working space is markedly reduced compared with adults, experience in pediatric intranasal procedures is useful. We were successful when we created or enlarged the ostium in the area most illuminated by the light pipe and did not find any difference in complications or failures based on whether the ostium was located near the middle or inferior turbinate. When an ostium is enlarged or created, other factors such as enlarged turbinates or redundant mucosa should be considered and dealt with when recognized. Medialization of the inferior turbinate, or at times the middle turbinate, was necessary in nearly all patients to visualize the light pipe and help determine where the ostium should be located. If a deviated septum or other abnormality is present and inhibiting access to the area or may be problematic in healing and the final outcome, then it should be addressed at the time the DCR takes place. Other secondary procedures that may be required include septoplasty, resection of a turbinate, or ethmoidectomy. These were usually not necessary in this group of patients. External DCR has been the mainstay of surgical therapy for patients with complicated lacrimal duct obstructions, with an overall success rate of 90%.1-11 In our group of patients undergoing endoscopic surgery, the success rate was 88%. Even by eliminating the patients who underwent only one probe and who were not documented to have significant distal obstruction before the endoscopic DCR, the procedure success rate was 85%. Several series of adult patients undergoing endoscopic lacrimal procedures have reported success rates of around 90%.12-17 However, the prospective randomized studies comparing endoscopic DCR with external DCR in adults showed significantly lower success rates with endoscopic procedures.4,5 Nonetheless, given a potentially good success rate, endoscopic DCR has several advantages over the external approach.
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Unlike external DCR, endoscopic DCR allows for the drainage of an obstructed lacrimal sac and system without a facial incision and subsequent scar. Endoscopic DCR also causes less surgical trauma to medial canthal and orbital tissue and causes less bleeding than is observed in conventional surgery.2 Endoscopic DCR takes much less time than conventional external DCR.4 None of our patients required hospitalization after the procedure, supporting that this may be safely done as an outpatient procedure with faster resumption of normal daily activities and increased cost-effectiveness. Laser endoscopic DCR is performed in adults5,16-18 and may be an option in children. Although the laser has the advantage of giving better hemostasis, we found bleeding with our technique to be very minimal, and the risks of the laser to the patient and the operating room personnel were avoided. Success rates with the laser rather than a conventional burr or punch vary widely, from 63%5 to 100%,17 for a primary DCR. In general, success of the laser in revision DCR has been comparable to standard revision surgery. Reported failures in DCR are usually attributed to fibrosis and subsequent closure of the newly created or enlarged ostium. In one review of adults, the mean diameter of the healed ostium was 1.88 mm.24 Even with a small ostium, once healing has taken place and patency is established, good lacrimal drainage will continue. Closure of adjacent flaps of the nasal and lacrimal mucosa is commonly performed in external DCR and should theoretically provide a patent epithelial-lined tract for tear drainage. Our described technique does not incorporate mucosal flaps. In practice, the necessity of mucosal flaps is questionable, because a 92.5% success rate was obtained in a series of 41 external DCRs performed by using stents without mucosal flaps.25 Placement of silicone tubing or other stenting material is generally accepted as useful and is probably necessary to maintain patency during the healing phase.18,26 The use of mitomycin C, which has been shown to decrease fibrosis and shrinkage of the ostium size during healing, may also be useful to increase success rates.27,28 The use of mitomycin C in pediatric DCR cases has not been reported, and we have not found its use to be warranted in any of our cases to date. In this series, 2 patients did not experience long-term resolution of symptoms. The cause for the unsuccessful procedure in 1 patient was found to be due to obstruction of a patent ostium by redundant mucosa and a large turbinate in a small nasal passage. In the other patient, recurrence of symptoms was noted when the silicone tubing was removed at 2 months. The original ostium could not be found at the time of reoperation, and a new opening was fashioned. The precise mechanism of failure in this patient is uncertain, though closure of the initially created ostium appears to have occurred. The main disadvantage of the endoscopic technique is its requirement for specialized training and instrumentation. Potential complications include bleeding, infection, orbital
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injury, intracranial injury, lacrimal sac fibrosis, and scarring. None of these complications were noted in our series. This study demonstrates that endoscopic lacrimal procedures, including endoscopic DCR, may be performed safely and effectively in infants and young children. The cure rate for patients with persistent tearing from congenital NLDO in this series was 88%. Endoscopic techniques may provide direct visualization of the cause of distal obstruction and be useful in guiding secondary procedures after failed probings. Endoscopic DCR provides an effective surgical approach for these patients and provides a reasonable alternative for patients who might otherwise require an external procedure. References 1. Beigi B, Westlake W, Chang B, Marsh C, Jacob J, Chatfield J. Dacryocystorhinostomy in south west England. Eye 1998;12:358-62. 2. Dresner SC, Klussman KG, Meyer DR, Linberg JV. Outpatient dacryocystorhinostomy. Ophthalmic Surg 1991;22:222-4. 3. Goh SH, Seah LL, Chiang C. Results of dacryocystorhinostomy in Singapore General Hospital. Ann Acad Med Singapore 1989;18:234-7. 4. Hartikainen J, Antila J, Varpula M, Puukka P, Seppa H, Grenman R. Prospective randomized comparison of endonasal endoscopic dacryocystorhinostomy and external dacryocystorhinostomy. Laryngoscope 1998;108:1861-6. 5. Hartikainen J, Grenman R, Puukka P, Seppa H. Prospective randomized comparison of external dacryocystorhinostomy and endonasal laser dacryocystorhinostomy. Ophthalmology 1998;105:1106-13. 6. Tarbet KJ, Custer PL. External dacryocystorhinostomy. Surgical success, patient satisfaction, and economic cost. Ophthalmology 1995;102:1065-70. 7. Elder MJ. Paediatric dacryocystorhinostomy. Aust N Z J Ophthalmol 1992;20:333-6. 8. Hakin KN, Sullivan TJ, Sharma A, Welham RA. Paediatric dacryocystorhinostomy. Aust N Z J Ophthalmol 1994;22:231-5. 9. Harrison MS, Mukherjee AK. Dacryocystorhinostomy in children and infants. J Laryngol Otol 1967;81:45-50. 10. Nowinski TS, Flanagan JC, Mauriello J. Pediatric dacryocystorhinostomy. Arch Ophthalmol 1985;103:1226-8. 11. Welham RA, Hughes SM. Lacrimal surgery in children. Am J Ophthalmol 1985;99:27-34. 12. Eloy P, Bertrand B, Martinez M, Hoebeke M, Watelet JB, Jamart J. Endonasal dacryocystorhinostomy: indications, technique and results. Rhinology 1995;33:229-33. 13. Sprekelsen MB, Barberan MT. Endoscopic dacryocystorhinostomy: surgical technique and results. Laryngoscope 1996;106:187-9. 14. Yung MW, Hardman-Lea S. Endoscopic inferior dacryocystorhinostomy. Clin Otolaryngol 1998;23:152-7. 15. Zhou W, Zhou M, Li Z, Wang T. Endoscopic intranasal dacryocystorhinostomy in forty-five patients. Chin Med J 1996;109:747-8. 16. Metson R, Woog JJ, Puliafito CA. Endoscopic laser dacryocystorhinostomy. Laryngoscope 1994;104:269-74. 17. Mickelson SA, Kim DK, Stein IM. Endoscopic laser-assisted dacryocystorhinostomy. Am J Otolaryngol 1997;18:107-11. 18. Sadiq SA, Ohrlich S, Jones NS, Downes RN. Endonasal laser dacryocystorhinostomy—medium term results. Br J Ophthalmol 1997; 81:1089-92. 19. Cunningham MJ, Woog JJ. Endonasal endoscopic dacryocystorhinostomy in children. Arch Otolaryngol Head Neck Surg 1998;124:328-33. 20. Wong JF, Woog JJ, Cunningham MJ, Rubin PA, Curtin HD, Carter BL. A multidisciplinary approach to atypical lacrimal obstruction in childhood. Ophthal Plast Reconstr Surg 1999;15:293-8. 21. Guerry D, Kendy EL. Congenital impatency of the nasolacrimal duct. Arch Ophthalmol 1948;39:193–204.
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22. Cassidy JV. Developmental anatomy of the nasolacrimal duct. Arch Ophthalmol 1952;47:141-58. 23. Busse H, Muller KM, Droll P. Radiological and histological findings of the lacrimal passages of newborns. Arch Ophthalmol 1980;98:528-32. 24. Linberg JV, McCormick SA. Primary acquired nasolacrimal duct obstruction: a clinicopathologic report and biopsy technique. Ophthalmology 1986;93:1055-63. 25. Becker BB. Dacryocystorhinostomy without flaps. Ophthalmic Surgery 1988;19:419-27.
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26. Bartley GB. Simultaneous silicone intubation through the osteotomy and the nasolacrimal duct during dacryocystorhinostomy. Am J Ophthalmol 1996;121:586-7. 27. Kao SC, Liao CL PK, Tseng JH, Chen MS, Hou PK. Dacryocystorhinostomy with intraoperative mitomycin C. Ophthalmology 1997; 104:86-91. 28. Ugurbas SH, Zilelioglu G, Sargon MF, Anadolu Y, Akiner M, Akturk T. Histopathologic effects of mitomycin-C on endoscopic transnasal dacryocystorhinostomy. Ophthalmic Surg Lasers 1997;28:300-4.
An Eye on the Arts – The Arts on the Eye Something is up with Frankie, he’s upstairs blinking and blinking. She comes running up. What’s wrong with you? I’m making my eyes strong with the exercize [sic]. What exercize? The blinking. Blinking is not an exercize. Seamus in the hospital says you can’t beat a good blink for the strong eye. His uncle had powerful eyes from blinking. . . . I wash my eyes three times a day and blink til I get a pain in my eyebrows. I blink in school when the master isn’t looking and all the boys in my class are calling me Blinky and adding that to the list of names. —Frank McCourt (from Angela’s Ashes [memoirs of growing up poor in Limerick, Ireland] p 262)