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Method for Anchoring
NOTES, CASES, INSTRUMENTS M E T H O D FOR ANCHORING P O L Y E T H Y L E N E TUBES A N D R E - E S T A B L I S H
ING TEAR DRAINAGE* GILBERT A.
REESE,
M.D.
Sacramento, California Since their introduction, polyethylene tubes have been experimentally used in re establishing tear drainage in the lacrimai system. One of the principal problems, once the tube has been introduced, is proper anchoring. Several methods have been suggested, such as flaring the end of the tube as it emerges at the punctum.1 Various ways of anchoring the tube with suture material have also been reported.2"4 It has been found very difficult to pass suture material through the wall of the polyethylene tubes without entering the lumen, particularly the small tubes which have been found the most pliable and easiest to handle after they are introduced into the lacrimai system. As it is necessary for a tube to have several angular turns when in place in the nasolacrimal system, the larger polyethylene tubes will often produce pres sure necrosis of tissue due to their lack of pliability. The size of polyethylene tube which has been found the most desirable for this pro cedure has an inner diameter of 0.58 mm. and an outer diameter of 0.965 mm. In this size tube it was impossible to pass even a Grieshaber C-7 corneal needle under a microscope into the wall without creating a fistula. On irrigation of the tube with a fistula a portion of the fluid is, of course, flushed into the tissue, providing a con tinual source of infection. All too often, in spite of flaring the end of the tube at the punctum, it will slip through, particularly in a canaliculus that has had a great deal of instrumentation and has been dilated; or when the canaliculus has been slit.5 * From the United States Public Health Service Hospital, Galveston, Texas.
1063
The method to be presented involves no variation in the introduction of the poly ethylene tube other than it must be approxi mately 50 centimenters long. A plastic tub ing, thin-walled needle with the stylet in place is introduced through the punctum, canaliculus, and through the anterior lacri mai crest following a dacryocystectomy. Once the distal end of the needle is in the middle meatus of the nose a 50-cm. length of polyethylene tube is passed through the needle. The needle is removed from the lacrimai system, leaving the tube in place so that it can be threaded through the nose with ease. The long lateral end of the polyethylene tube is left emerging from the punctum so that approximately 40 cm. are available for the manipulation to follow. A 10-cm. length of surgical stainless-steel wire (gauge 32) is then passed into the long lateral end of the polyethylene tube. The steel wire is cut flush with the end of the tube. The tube with the wire enclosed is then molded in the fornix of the lower lid by making a sharp rightangle turn at the punctum down and medi ally. Another sharp turn in the tube is then made so that the tube lies in the cul-de-sac of the lower fornix. When the tube has been fashioned to fit properly into the cul-de-sac without de forming the lid or pressing on the globe it is removed through the punctum laterally, keeping the same form with its several angular turns. When approximately 40 cm. are available for manipulation on the lateral end, it is dipped in recently boiled water for 10 to 14 seconds to fix it in its angulated form and then allowed to cool for 30 sec onds. Care must be taken not to lose the short medial end emerging from the nose. The pliable steel wire is then removed and the polyethylene tube remains molded in its angular position. The tube is rethreaded back through the nose so that the several sharp turns in the tube prevent it from slipping out of place. After a proper fitting, it is very difficult
1064
NOTES, CASES, INSTRUMENTS
to tell that the tube is in place; it can be found only after close examination. It is advisable not to cut the long medial end emerging from the nose for seven to 10 days for, if the first fitting is not satisfac tory, with adequate tubing available the pro cedure can be repeated in the office at a later visit. When the surgeon is sure that a satisfactory fitting has been made, the tub ing can be cut as it emerges from the nose. The tube should always be irrigated from the nasal end, using a smooth-tip forceps and a dull needle or a lacrimai needle. There is a tendency in the first few weeks for mucus to plug the tube in the lower fornix. This gradually decreases in amount the longer the tube remains in place. Even when the tube becomes plugged, the patient continues to have tear drainage. Un doubtedly adequate drainage of tears occurs around the tube as well as through it. Hen derson8 has had a similar experience, and even doubts the need for irrigating the tubes once they are in place. The formation of a permanent epithelized tract for tear drain age is more certain the longer the tube re mains in place. It would seem that a tube anchored by the method herein described could be left in place indefinitely if desired.
tearing from the right eye. In 1949, the patient was kicked in the right side of the face and approximately two months later he was hit with a beer bottle, suffering lacera tions of the right upper and lower canalic ulus. This was sutured together but, since that time, he has had tearing over the right side of his face. The past history revealed the patient had a broken zygoma in 1953 and a submucous resection in the nose in 1953. Physical examination was essentially neg ative except for the eye. There was an ob struction of the right upper and lower canaliculus, five mm. from the punctum. There was a fistula emerging through the skin from the upper and lower canaliculus so that, when the irrigating needle was placed in the punctum, the fluid emerged through the fistula. The fistula was present
CASE REPORT CASE P.
D.
The patient entered the hospital on Octo ber 20, 1954, with the chief complaint of
Fig. 2 (Reese). The polyethylene tubing in place in the nasolacrimal system. Wire in the lateral tube emerges from the punctum in preparation for the molding procedure in the lower fornix.
1065
NOTES, CASES, INSTRUMENTS
in approximately the area of laceration suf fered five years ago. On October 22, 1954, a window was cre ated in the anterior lacrimai crest and the polyethylene tube was passed into the nose by this route. The tube was anchored to the medial palpebrai ligament with 6-0 silk. Postoperatively the patient did well and the tube irrigated freely. However, only 18 days later it slipped from position and moved up and down. Three weeks postoperatively, the patient came in with an acute cellulitis on the medial side of the right orbit with the tube extruding through the center of an abscess. The tube was removed and the pa tient treated with antibiotics until the in fection cleared. He was readmitted on April 6, 1955. He was placed on antibiotics and a second op eration was performed. A long, 50 cm., polyethylene tube, inner diameter 0.58 mm. and outer diameter 0.965 mm., was left in place. The lacrimai sac was dissected out and removed. The two sinus openings on the skin from the canaliculus were cauter ized. The patient remained on antibiotics three weeks following the operation and there was no postoperative infection. Two weeks postoperatively, the lateral long end of the polyethylene tube, emerging from the punctum, was threaded with gauge32 surgical stainless steel wire. The tube with the steel wire in place was threaded through the nose until the tube, containing the surgical wire, was in place at the lower lid. Under pontocaine anesthesia it was in troduced into the fornix of the lower lid and molded to fit snugly between the globe and lid. The tube was then removed laterally through the punctum, maintaining its angu lar form so that there was plenty of avail able tubing to manipulate the lateral molded portion into recently boiled water. After the tube had cooled, the pliable steel wire was removed, leaving the tubing in its pre viously molded angular shape. The poly ethylene tube was then rethreaded through
Fig. 3 (Reese). Postoperative. After proper fit ting, the tube usually is not seen in the eye. The marker is directed toward the cut tube in the nose.
the nose so that the lateral end emerging from the punctum could be placed into the fornix of the right lower lid. There was a tendency in the first few weeks for the right eye to form a white tenacious mucous secretion. This gradually subsided, however, and plugging the tube was not a serious problem. Three weeks postoperatively, the tube could easily be irrigated from the nasal end, which was cut off just inside the nostril. SUMMARY
1. A new method of fashioning poly ethylene tubes to provide secure anchorage after introduction into the nasolacrimal sys tem has been presented. 2. Steel wire is introduced into a 50-cm. length of polyethylene tube that is in place in the nasolacrimal system. Several angular turns are made in the tube so that it fits
1066
NOTES, CASES, INSTRUMENTS
snugly in the lower fornix between the globe and lower lid. The lateral angulated portion of the tube is removed from the lower lid and dipped in hot water to fix it in position, then the pliable steel wire is removed. The plastic tubing maintains its angulated form so that it fits securely in the fornix of the
lower lid when rethreaded through the nose. 3. Tear drainage appears to occur around the tube as well as through it. 4. The polyethylene tube can be left in place for an indefinite period of time without any disfiguration. 2901 Capitol Avenue (16).
REFERENCES
1. Moulton, O. C. : New method of keeping polyethylene tubing in place when used in the lacrimai canaliculi. Arch. Ophth., 51:375 (Mar.) 19S4. 2. Callahan, A. : Surgery of the Eye-Injuries. Springfield, Charles C Thomas, 19S0, ed. 1, pp. 79-80. 3. Henderson, J. W. : Management of obstruction of the lacrimai canaliculi with polyethylene tubes. Arch. Ophth, 49:182-184 (Feb.) 1953. 4. : Management of strictures of lacrimai canaliculi with polyethylene tubes. Arch. Ophth, 44: 198-203 (Aug.) 1950. 5. Daily, L. : Personal communication. 6. Henderson, J. W. : Personal communication.
OPHTHALMIC MINIATURE
I merely intend to draw attention to the examination of the field of vision, an examination which has not, in my opinion, been used for diag nostic purposes with the enthusiasm and exactness it rightly deserves... . In determining central visual acuity, we are only partially informed con cerning the patient's faculty of vision. The second and equally important part is the determination of the dimension and modality of eccentric vision. . . . A number of pathologic conditions are manifest for a time only by the changes in eccentric vision and it is only the last stage which induces progressive dimness of central vision. ALBRECHT VON GRAEFE,
Untersuchung des Gesichtfeld bei amblyopischen Affectionen, Arch. f. Ophth., 2:258 (Pt. 2) 1856.
ING TEAR DRAINAGE* GILBERT A.
REESE,
M.D.
Sacramento, California Since their introduction, polyethylene tubes have been experimentally used in re establishing tear drainage in the lacrimai system. One of the principal problems, once the tube has been introduced, is proper anchoring. Several methods have been suggested, such as flaring the end of the tube as it emerges at the punctum.1 Various ways of anchoring the tube with suture material have also been reported.2"4 It has been found very difficult to pass suture material through the wall of the polyethylene tubes without entering the lumen, particularly the small tubes which have been found the most pliable and easiest to handle after they are introduced into the lacrimai system. As it is necessary for a tube to have several angular turns when in place in the nasolacrimal system, the larger polyethylene tubes will often produce pres sure necrosis of tissue due to their lack of pliability. The size of polyethylene tube which has been found the most desirable for this pro cedure has an inner diameter of 0.58 mm. and an outer diameter of 0.965 mm. In this size tube it was impossible to pass even a Grieshaber C-7 corneal needle under a microscope into the wall without creating a fistula. On irrigation of the tube with a fistula a portion of the fluid is, of course, flushed into the tissue, providing a con tinual source of infection. All too often, in spite of flaring the end of the tube at the punctum, it will slip through, particularly in a canaliculus that has had a great deal of instrumentation and has been dilated; or when the canaliculus has been slit.5 * From the United States Public Health Service Hospital, Galveston, Texas.
1063
The method to be presented involves no variation in the introduction of the poly ethylene tube other than it must be approxi mately 50 centimenters long. A plastic tub ing, thin-walled needle with the stylet in place is introduced through the punctum, canaliculus, and through the anterior lacri mai crest following a dacryocystectomy. Once the distal end of the needle is in the middle meatus of the nose a 50-cm. length of polyethylene tube is passed through the needle. The needle is removed from the lacrimai system, leaving the tube in place so that it can be threaded through the nose with ease. The long lateral end of the polyethylene tube is left emerging from the punctum so that approximately 40 cm. are available for the manipulation to follow. A 10-cm. length of surgical stainless-steel wire (gauge 32) is then passed into the long lateral end of the polyethylene tube. The steel wire is cut flush with the end of the tube. The tube with the wire enclosed is then molded in the fornix of the lower lid by making a sharp rightangle turn at the punctum down and medi ally. Another sharp turn in the tube is then made so that the tube lies in the cul-de-sac of the lower fornix. When the tube has been fashioned to fit properly into the cul-de-sac without de forming the lid or pressing on the globe it is removed through the punctum laterally, keeping the same form with its several angular turns. When approximately 40 cm. are available for manipulation on the lateral end, it is dipped in recently boiled water for 10 to 14 seconds to fix it in its angulated form and then allowed to cool for 30 sec onds. Care must be taken not to lose the short medial end emerging from the nose. The pliable steel wire is then removed and the polyethylene tube remains molded in its angular position. The tube is rethreaded back through the nose so that the several sharp turns in the tube prevent it from slipping out of place. After a proper fitting, it is very difficult
1064
NOTES, CASES, INSTRUMENTS
to tell that the tube is in place; it can be found only after close examination. It is advisable not to cut the long medial end emerging from the nose for seven to 10 days for, if the first fitting is not satisfac tory, with adequate tubing available the pro cedure can be repeated in the office at a later visit. When the surgeon is sure that a satisfactory fitting has been made, the tub ing can be cut as it emerges from the nose. The tube should always be irrigated from the nasal end, using a smooth-tip forceps and a dull needle or a lacrimai needle. There is a tendency in the first few weeks for mucus to plug the tube in the lower fornix. This gradually decreases in amount the longer the tube remains in place. Even when the tube becomes plugged, the patient continues to have tear drainage. Un doubtedly adequate drainage of tears occurs around the tube as well as through it. Hen derson8 has had a similar experience, and even doubts the need for irrigating the tubes once they are in place. The formation of a permanent epithelized tract for tear drain age is more certain the longer the tube re mains in place. It would seem that a tube anchored by the method herein described could be left in place indefinitely if desired.
tearing from the right eye. In 1949, the patient was kicked in the right side of the face and approximately two months later he was hit with a beer bottle, suffering lacera tions of the right upper and lower canalic ulus. This was sutured together but, since that time, he has had tearing over the right side of his face. The past history revealed the patient had a broken zygoma in 1953 and a submucous resection in the nose in 1953. Physical examination was essentially neg ative except for the eye. There was an ob struction of the right upper and lower canaliculus, five mm. from the punctum. There was a fistula emerging through the skin from the upper and lower canaliculus so that, when the irrigating needle was placed in the punctum, the fluid emerged through the fistula. The fistula was present
CASE REPORT CASE P.
D.
The patient entered the hospital on Octo ber 20, 1954, with the chief complaint of
Fig. 2 (Reese). The polyethylene tubing in place in the nasolacrimal system. Wire in the lateral tube emerges from the punctum in preparation for the molding procedure in the lower fornix.
1065
NOTES, CASES, INSTRUMENTS
in approximately the area of laceration suf fered five years ago. On October 22, 1954, a window was cre ated in the anterior lacrimai crest and the polyethylene tube was passed into the nose by this route. The tube was anchored to the medial palpebrai ligament with 6-0 silk. Postoperatively the patient did well and the tube irrigated freely. However, only 18 days later it slipped from position and moved up and down. Three weeks postoperatively, the patient came in with an acute cellulitis on the medial side of the right orbit with the tube extruding through the center of an abscess. The tube was removed and the pa tient treated with antibiotics until the in fection cleared. He was readmitted on April 6, 1955. He was placed on antibiotics and a second op eration was performed. A long, 50 cm., polyethylene tube, inner diameter 0.58 mm. and outer diameter 0.965 mm., was left in place. The lacrimai sac was dissected out and removed. The two sinus openings on the skin from the canaliculus were cauter ized. The patient remained on antibiotics three weeks following the operation and there was no postoperative infection. Two weeks postoperatively, the lateral long end of the polyethylene tube, emerging from the punctum, was threaded with gauge32 surgical stainless steel wire. The tube with the steel wire in place was threaded through the nose until the tube, containing the surgical wire, was in place at the lower lid. Under pontocaine anesthesia it was in troduced into the fornix of the lower lid and molded to fit snugly between the globe and lid. The tube was then removed laterally through the punctum, maintaining its angu lar form so that there was plenty of avail able tubing to manipulate the lateral molded portion into recently boiled water. After the tube had cooled, the pliable steel wire was removed, leaving the tubing in its pre viously molded angular shape. The poly ethylene tube was then rethreaded through
Fig. 3 (Reese). Postoperative. After proper fit ting, the tube usually is not seen in the eye. The marker is directed toward the cut tube in the nose.
the nose so that the lateral end emerging from the punctum could be placed into the fornix of the right lower lid. There was a tendency in the first few weeks for the right eye to form a white tenacious mucous secretion. This gradually subsided, however, and plugging the tube was not a serious problem. Three weeks postoperatively, the tube could easily be irrigated from the nasal end, which was cut off just inside the nostril. SUMMARY
1. A new method of fashioning poly ethylene tubes to provide secure anchorage after introduction into the nasolacrimal sys tem has been presented. 2. Steel wire is introduced into a 50-cm. length of polyethylene tube that is in place in the nasolacrimal system. Several angular turns are made in the tube so that it fits
1066
NOTES, CASES, INSTRUMENTS
snugly in the lower fornix between the globe and lower lid. The lateral angulated portion of the tube is removed from the lower lid and dipped in hot water to fix it in position, then the pliable steel wire is removed. The plastic tubing maintains its angulated form so that it fits securely in the fornix of the
lower lid when rethreaded through the nose. 3. Tear drainage appears to occur around the tube as well as through it. 4. The polyethylene tube can be left in place for an indefinite period of time without any disfiguration. 2901 Capitol Avenue (16).
REFERENCES
1. Moulton, O. C. : New method of keeping polyethylene tubing in place when used in the lacrimai canaliculi. Arch. Ophth., 51:375 (Mar.) 19S4. 2. Callahan, A. : Surgery of the Eye-Injuries. Springfield, Charles C Thomas, 19S0, ed. 1, pp. 79-80. 3. Henderson, J. W. : Management of obstruction of the lacrimai canaliculi with polyethylene tubes. Arch. Ophth, 49:182-184 (Feb.) 1953. 4. : Management of strictures of lacrimai canaliculi with polyethylene tubes. Arch. Ophth, 44: 198-203 (Aug.) 1950. 5. Daily, L. : Personal communication. 6. Henderson, J. W. : Personal communication.
OPHTHALMIC MINIATURE
I merely intend to draw attention to the examination of the field of vision, an examination which has not, in my opinion, been used for diag nostic purposes with the enthusiasm and exactness it rightly deserves... . In determining central visual acuity, we are only partially informed con cerning the patient's faculty of vision. The second and equally important part is the determination of the dimension and modality of eccentric vision. . . . A number of pathologic conditions are manifest for a time only by the changes in eccentric vision and it is only the last stage which induces progressive dimness of central vision. ALBRECHT VON GRAEFE,
Untersuchung des Gesichtfeld bei amblyopischen Affectionen, Arch. f. Ophth., 2:258 (Pt. 2) 1856.