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Treatment of Complete Obstruction of the Nasolacrimal System by Temporary Placement of Nasolacrimal Polyurethane Stents: Preliminary Results
Clinical Radiology (2003) 58: 876–882 doi:10.1016/S0009-9260(03)00269-1, available online at www.sciencedirect.com
Treatment of Complete Obstruction of the Nasolacrimal System by Temporary Placement of Nasolacrimal Polyurethane Stents: Preliminary Results ´ L, I. PINTO, J. M. VICENTE L. PAU Servicio de Radiologı´a, Seccio´n de Radiologı´a Vascular Intervencionista, Hospital Universitario de Getafe, Carretera de Toledo km 12.5, Getafe, Madrid, Spain Received: 18 March 2003
Revised: 25 May 2003
Accepted: 30 May 2003
AIM: To assess the efficacy of the temporary placement of polyurethane nasolacrimal stents as a treatment for complete post-saccal obstruction of the lacrimal apparatus. MATERIALS AND METHODS: Polyurethane nasolacrimal stents were inserted under radiological guidance in nine patients with grade IV epiphora due to complete obstruction of the lacrimal system, at the junction of the lacrimal sac and duct (eight patients) or in the lacrimal duct (one patient). On average, the stents were removed 4 months (range: 3 – 6 months) after insertion. Dacryocystography was performed immediately before and after each stent was removed. Subsequently, periodic clinical and radiological examinations were performed until recurrence of the epiphora, at which point follow-up concluded. RESULTS: All patients remained free of epiphora and clinical inflammation while the stents were in place, but re-obstruction of the lacrimal system occurred in all patients less than 2 months after the stents were removed. Adhesion of three stents to the lacrimal tract was observed upon removal. In seven cases the dacryocystography results at the end of follow-up revealed changes in the configuration of the lacrimal apparatus. CONCLUSION: Based on our preliminary experience, temporary placement of polyurethane stents would not appear to be an efficacious therapeutic option for treating epiphora caused by post-saccal obstruction. L. Pau´l et al. (2003). Clinical Radiology 58: 876–882. q 2003 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. Key words: lacrimal gland and duct, interventional procedures, nasolacrimal obstruction, stents and prostheses, temporary nasolacrimal intubation.
INTRODUCTION
Interventional techniques for treating epiphora, caused by obstruction of the lacrimal system, that are better tolerated by patients, do not require anaesthesia, and do not cause facial scarring, have been developed in recent years in an effort to find alternatives to classical or endoscopic dacryocystorhinostomy. These techniques consist of balloon dilatation of the lacrimal tract (dacryocystoplasty) and the deployment of nasolacrimal stents. Both are fast, safe, reversible, do not require general anaesthesia, and do not leave facial scars. Development of these techniques has been encouraged because of these advantages, but to date the medium and long-term Guarantor and correspondent: Laura Pau´l Dı´az, Servicio de Radiologı´a, Hospital Universitario de Getafe, Carretera de Toledo km 12.5, Getafe, 28905 Madrid, Spain. Tel: þ 34-916839718; Fax: þ 34-913886622; E-mail: [email protected] 0009-9260/03/$30.00/0
results achieved have not been better than the results achieved using dacryocystorhinostomy [1 –5]. Dacryocystoplasty achieves immediate success in 50–95% of cases [6 –10], but re-obstruction rates are high, with patency rates after 1 year ranging from 20 –70% [6,8 –13]. Results are substantially worse in cases of complete obstruction of the lacrimal system, whereby treatment is less than 25% effective after 1 year [8,9,13]. Placement of a stent within the lacrimal apparatus initially relieves the epiphora in 70 –100% of patients, with the results achieved in cases of obstruction being better than the results obtained using dacryocystoplasty [14–17]. Recurrence rates after 1 year are 30% or more [15,17 –19], except in the series reported by Lee et al. [20] and Lanciego et al. [21], in which the re-obstruction rate was 8% after 22 months and 15% after 15 months, respectively. We have used stents on a temporary basis in patients with epiphora caused by complete obstruction of the lacrimal
q 2003 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
TEMPORARY POLYURETHANE NASOLACRIMAL STENTS TO TREAT COMPLETE NASOLACRIMAL OBSTRUCTION
system, in an effort to take advantage of the interventional radiological approach, while avoiding the problems that arise in long-term nasolacrimal stent placement. In undertaking this novel application of the technique, we took into account previous experience with dacryocystoplasty followed by intubation [22–24] and temporary deployment of stents to resolve abscesses of the lacrimal sac [25].
MATERIALS AND METHODS
This study presents nine consecutive treatments of epiphora by temporary insertion of a polyurethane nasolacrimal stent (PNL), performed by the Interventional Radiology Unit at Getafe University Hospital between November 2001 and April 2002. The patients included in the study had complete obstruction of the lacrimal apparatus at the junction of the lacrimal sac and duct (eight patients) or within the lacrimal duct itself [one patient (case 9)]. Clinical evaluation showed all the patients to have grade IV epiphora according to Munk’s scale [26], and two patients (cases 3 and 9) also had symptoms of inflammation (redness, itching, suppuration). Exclusion criteria for the study were: patients older than 78 years of age or in poor physical condition; patients awaiting cataract surgery; second PNL placed in patients who had already had one PNL removed as a consequence of occlusion; patient refusal to accept the temporary stent protocol; difficulty in negotiating the lacrimal system resulting in a decreased likelihood of successful repetition of the procedure, if necessary; initial failure of the intervention or uncertainty as to the technical success of the procedure, i.e., formation of a false tract during the procedure, radiological demonstration of stent malpositioning, immediate clinical or radiological stent malfunction suggestive of improper stent placement. In short, the study included only those interventions that were straightforward, repeatable, and successfully performed in patients who would not be harmed by this temporary treatment, had freely given their consent, and had not previously undergone treatment for lacrimal obstruction. For these reasons, the patients in this treatment group were not actually consecutive, in that there were intervening patients with epiphora who did not received this treatment, but the temporary PNL treatments considered in this report did comprise a consecutive series in themselves. The existence of dacryocystitis was not deemed to be a contraindication to performing the intervention, though in cases where this condition was present an antibiotic treatment was administered for 1 week prior to the intervention. The stents were inserted and then removed by our team under radiological guidance in the angiography room under sedation and local anaesthesia, on an ambulatory basis. Based on previous experience with temporary intubation of the lacrimal tract [22–25], it was decided to leave the temporary stents in place for 4 months. The sedative used was intravenous midazolam (Rovi S.A., Madrid, Spain), and the local anaesthesia consisted of infiltration with 2% lidocaine (supratrochlear nerve, infraorbital nerve, and nostril) and nasal packing impregnated with a solution of 10% tetracaine hydrochloride and epinephrine. The Song nasolacrimal duct
877
stent set (Cook Ireland Limited, Limerick, Ireland) was used in all cases, the set being composed of a rigid 0.018-inch ball guide-wire with balls at both ends, a 6 F dilator, and a polyurethane stent and pusher. The stent placement and removal technique was as described by Song et al. [14,27]. No balloon dilatation was performed before stent insertion. Dacryocystography was carried out on conclusion of every procedure to verify proper stent placement and patency. Maxitrol (Alcon Iberhis S.A., Madrid, Spain) and Rhinocort Aqua (Astra Espan˜a, Barcelona, Spain) were administered for 10 days after the procedure. Clinical and/or radiological examinations were carried out at 10 days, 1 month, 3 months, and 6 months after the procedure until the stent was removed. Dacryocystography was performed immediately before and after stent removal. The same examinations were subsequently repeated (10 days, 1 month, 3 months) until the recurrence of epiphora. Reobstruction of the lacrimal system marked the end point of follow-up.
RESULTS
Table 1 lists the time the stent was in place, clinical and radiological findings until the time of removal, subsequent clinical course, and the re-occlusion period for each patient. All patients remained free of epiphora and clinical inflammation while the stents were in place. Because of patient scheduling problems, not all the stents could be removed after 4 months, two of the stents were removed after 2.5 months and another two after 6 months. In three of the nine patients (cases 2, 3, and 4) difficulties in removing the stents were encountered because of adherence of the stents to the lacrimal tract, and thus greater than ordinary force had to be employed when pulling the stents out. This resulted in stretching of the stents and caused pain to the patients, and in one case the presence of tissue adhering to the upper end of the stent was observed. In none of these cases did another specialist have to be called in to assist in removing the stents. In the remaining six patients stent removal was accomplished without difficulty. In six cases the stent was patent on dacryocystography before removal. In one case (case 5) the stent had become occluded by mucoid secretions, which were observed in the stent after removal. In another patient (case 8) the stent had slid downwards and was obstructed by abutment of the lower end of the stent against the nasal floor, but no debris or sludge was observed inside the stent. In the final case (case 9) occlusion was probably the result of intercurrent catarrh, because the patient had already experienced self-limiting stent obstruction during follow-up coinciding with a cold; no obstructing matter was found inside the stent in this case either. In these three patients, the lacrimal system was patent on removal of the stent. Lacrimal obstruction was observed in two of the nine cases on dacryocystography performed immediately after removal of the stent. In one (case 3) adhesion of the stent was observed at the time of removal and dacryocystography post-removal showed lacrimal obstruction at the level of the sac. In the other (case 7) bleeding occurred on removal of the stent, and lavage
878
2 months: no changes 1 month: smaller, more irregular lacrimal sac Immediate epiphora Post-removal: obstruction common canaliculus. No sac filling No second PNL Progressive epiphora after 1 month 1 month: smaller lacrimal sac. No second PNL Progressive epiphora after 2 months 6 months: (dacryocystography for new PNL) smaller, more irregular lacrimal sac Moderate epiphora (an improvement) 10 days: smaller, more irregular during the first 2 months lacrimal sac Epiphora immediately Post-removal: small sac, no changes. No PNL Progressive epiphora and pus formation 1 month: More irregular lacrimal sac after 1 month Progressive epiphora and immediate 10 days: smaller, more irregular formation of grit in eye lacrimal sac
failed to achieve patency of the lacrimal system. These two patients experienced epiphora immediately upon removal of the stents, and lacrimal obstruction was confirmed radiologically 10 days later. In the remaining seven patients the lacrimal apparatus was patent upon removal of the stents, but early reobstruction occurred (Fig. 1). Epiphora recurred in all nine patients less than 2 months after stent removal. Radiologically, changes were observed in seven of the nine patients when the final dacryocystography results were compared with the dacryocystography examinations carried out before stent placement. These changes were a reduction in the size of the lacrimal sac (Fig. 2), irregular sac shape and the presence of filling defects (Fig. 1) to a greater or lesser extent in each case. In two of the patients (cases 3 and 4) the changes observed contraindicated immediate placement of a second stent, because refilling of the lacrimal sac did not take place. However, in one of these patients (case 3), the changes were subsequently observed improve (Fig. 3).
PNL, polyurethane nasolacrimal stent. Compared to the dacryocystography examinations carried out before stent placement.
Normal Non-patent
DISCUSSION
p
2.5 9(45)
Normal Non-patent, PNL slippage
Patent irregular and stenotic lacrimal sac and duct
2.5 8(29)
Patent
Patent
4 7(76)
Patent
Normal
Patent lacrimal sac and duct stenotic with filling defect Self-limiting bleeding Non-patent 4 6(58)
Non-patent
Normal
Patent stenotic irregular and lacrimal sac and duct 4 5(53)
Patent
Adhesion of PNL
Patent 4 4(76)
Adhesion of PNL Patent
Patent Patent
Non-patent 6 3(66)
Progressive epiphora after 2 months Progressive epiphora after 1 month Patent Patent 4 6 1(67) 2(49)
Normal Adhesion of PNL
Post-removal dacryocystography Clinical follow-up to re-obstruction Case no. PNL time in Pre-removal dacryocystography PNL on removal (age) place (months)
Table 1 – Results of polyurethane nasolacrimal stent placement in nine patients
Radiological follow-up (changesp)
CLINICAL RADIOLOGY
The disadvantages of using nasolacrimal stents as a treatment for epiphora, caused by obstruction of the lacrimal apparatus, are long-term occlusion by detritus and the growth of inflammatory tissue [17]; the medium-term occlusion rates range between 15 and 50% [19,21,28], reaching 81– 95% after 5 years [29,30]. In addition, the growth of granulomatous and fibrotic tissue within the lacrimal tract in which a stent has been deployed can also cause the lacrimal sac to become irregular in shape and smaller in size or result in adhesion of the stent to the tract, making removal of the stent more difficult [30,31]. All these factors raise questions about the reversibility, and in particular, the efficacy of this therapeutic option as a definitive treatment for epiphora due to obstruction of the lacrimal system. Dacryocystoplasty has exhibited greater short-term efficacy in stenosis than in obstruction [6,8 –11]. Some experiences with balloon dacryocystoplasty, followed by temporary intubation of the lacrimal tract in small series of patients, have yielded encouraging results with respect to the medium and long-term efficacy [23,24], occasionally even in cases of complete obstruction of the lacrimal apparatus [22,25]. The present study was conducted to assess the duration of patency of the obstructed lacrimal system after temporary intubation. However, the results achieved were worse than expected when compared with the previous reports referred to above. Although different procedures were employed, all shared the same underlying concept of treatment based on temporary dilatation. In our study, deployment of the stent resolved the epiphora completely during the time the stent remained in place, but after removal of the stents the lacrimal systems re-obstructed in all the patients in less than 2 months. According to literature reports, Steinkogler et al. [24] performed dilatation of six post-saccal stenoses and then followed that by intubation for 3 months, and all six lacrimal systems remained patent after 6 months. Perry et al. [23] carried out dilatation followed by intubation for 2 months in 15 cases of stenosis, and the lacrimal tracts
TEMPORARY POLYURETHANE NASOLACRIMAL STENTS TO TREAT COMPLETE NASOLACRIMAL OBSTRUCTION
879
Fig. 1 – Case 5. (a) Dacryocystography of the left eye (anteroposterior projection) before stent placement showing obstruction of the lacrimal apparatus at the junction of the lacrimal sac and duct (arrow). (b) Dacryocystography of the left eye performed immediately after removal of the stent (post-removal) showing a patent lacrimal apparatus but with filling defects (arrows) visible in the lacrimal sac. Mucoid matter was found inside the stent on removal. (c) Follow-up dacryocystography performed 6 months after stent removal showing obstruction of the lacrimal apparatus at the junction of the lacrimal sac and duct. Clinically the patient began to complain of epiphora 2 months after removal of the stent, and at this time, the patient had grade IV epiphora.
880
CLINICAL RADIOLOGY
Fig. 2 – Case 4. (a) Dacryocystography of the left eye (anteroposterior projection) before stent placement, showing obstruction of the lacrimal apparatus at the junction of the lacrimal sac and duct (arrow) and a large, regularly shaped lacrimal sac. (b) Dacryocystography performed immediately after removal of the stent (post-removal) showing the left lacrimal apparatus to be patent, but with an irregularly shaped sac smaller in size than at the time of temporary stent placement, with filling defects (arrow). Stenoses are visible along the length of the lacrimal duct (arrow heads). Clinically the patient remained free of epiphora for 1 month. (c) Dacryocystography performed 1 month after removal of the stent. Clinically the patient had grade II –III epiphora. Obstruction of the lacrimal apparatus at the junction of the lacrimal sac and duct (arrow), the lacrimal sac being irregularly shaped and smaller in size compared with the initial findings.
remained patent in 73% of the patients in that series after 6 months. The discrepancy between these series and our results may be attributable to the fact that these authors treated stenoses rather than complete obstruction of the lacrimal apparatus. Conversely, Janssen et al. [25] employed temporary intubation to treat 10 abscesses of the lacrimal sac caused by post-saccal obstruction, with good patency and normal morphological characteristics of the lacrimal duct system seen in five cases at the end of the follow-up period (2 –13 months). Kuchar and Steinkogler [22] performed dilatations followed by intubation for 3 months in 30 patients with complete nasolacrimal duct obstructions and at 6 months 70% of all the cases were positive on irrigation. The difference between our series and these two studies was that we did not perform balloon dacryocystoplasty before intubation. In addition, the intubation material employed in the other series (a silicone tube in one case and a 6 –8 F polyurethane tube in the other) differed from the stents we used, and the pre and post-intervention antibiotic treatment employed in the other studies may also have contributed to the discrepancies in the results achieved.
The appearance of adverse stent-related effects, which ordinarily arise in the course of more “protracted” treatments, is another noteworthy finding of our study [17,19,30,31]. These adverse effects were, first, adhesion of some of the stents to the lacrimal tract after placement for 4 months, and second, negative morphological changes in most of the lacrimal systems (shrinkage and irregularities in the shape of the lacrimal sac and filling defects) as a result of treatment. However, it is likely that these changes were caused by an inflammatory response of the lacrimal apparatus to the stent, which may be variable in time and reversible, as was observed in one of the cases in this series. This is an important aspect to consider regarding the potential of this therapeutic option. In conclusion, based on this preliminary experience, temporary placement of polyurethane stents does not appear to be an efficacious therapeutic alternative for treating epiphora caused by post-saccal obstruction of the lacrimal system. Perhaps, balloon dilatation of the obstruction plays an essential role in treatment, and most likely, containment of inflammation of the lacrimal apparatus holds the key to a solution to this predicament. However, there is a need for further study to explore the potential for using this treatment technique in temporary applications.
TEMPORARY POLYURETHANE NASOLACRIMAL STENTS TO TREAT COMPLETE NASOLACRIMAL OBSTRUCTION
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Fig. 3 – Case 3. (a) Dacryocystography of the left eye (anteroposterior projection) before stent placement showing obstruction of the lacrimal apparatus at the junction of the lacrimal sac and duct. (b) Dacryocystography performed immediately after removal of the stent 4 months after placement showing obstruction of the lacrimal apparatus at the junction of the common canaliculus and the lacrimal duct (arrow head). Adhesion of the stent had occurred, making removal difficult. The patient had epiphora immediately upon removal of the stent, although she had remained free from epiphora during the 4 months the stent was in place. (c) Dacryocystography performed 10 days after stent removal. Clinical symptoms of grade IV epiphora persisted, and continued obstruction of the lacrimal system was demonstrated radiologically. However, the radiological findings were not the same as before. Filling of the lacrimal sac was achieved, even though the sac can be seen to be more irregularly shaped and smaller in size than it was before stent placement, showing that the lacrimal sac changes are reversible.
882
CLINICAL RADIOLOGY
REFERENCES 1 Rosen N, Shamir M, Moverman DC, Rosner M. Dacryocystorhinostomy with silicone tubes: evaluation of 253 cases. Opthalmol Surg, 1989;20:115– 119. 2 Hartikainen J, Grenman R, Puukka P, Seppa H. Prospective randomized comparison of external dacryocystorhinostomy and endonasal laser dacryocystorhinostomy. Ophthalmology, 1998;105:1106–1113. 3 Cokkeseer Y, Evereklioglu C, Er H. Comparative external versus endoscopic dacryocystorhinostomy: results in 115 patients (130 eyes). Otolaryngol Head Neck Surg 123: 488 –491. 4 Liao SL, Kao SCS, Tseng JHS, et al. Results of intraoperative mitomycin C. Application in dacryocystorhinostomy. Br J Ophthalmol, 2000;84:903– 906. 5 Camara JG, Bengzon AU, Henson RD. The safety and efficacy of Mitomycin C in endonasal endoscopic laser-assisted dacryocystorhinostomy. Ophthal Plast Reconstr Surg, 2000;16:114 –118. 6 Berkefeld J, Kirchner J, Mu¨ller HM, et al. Balloon dacryocystoplasty: indications and contraindications. Radiology, 1997;205:785–790. 7 Liermann D, Berkefeld J, Fries U, et al. Balloon dacryocystoplasty: an alternative treatment for obstructed tear ducts. Ophthalmologica, 1996; 10:319–324. 8 Song HY, Ahn HS, Park ChK, et al. Complete obstruction of the nasolacrimal system. Treatment with balloon dilatation. Radiology, 1993;186:367 –371. 9 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;192:503–508. 10 Fenton S, Clearly PE, Horan E, et al. Balloon dacryocystoplasty study in the management of adult epiphora. Eye, 2001;15:67–69. 11 Janssen AG, Mansour K, Bos JJ. Obstructed nasolacrimal duct system in epiphora: long-term results of dacryocystoplasty by means of balloon dilatation. Radiology, 1997;205:791–796. 12 McCullough CM. Naso–lacrimal duct balloon dilatation: medium to long-term follow-up. Clin Radiol, 2001;56:13–16. 13 Yazici Z, Yazici B, Parlak M, et al. Treatment of obstructive epiphora in adults by balloon dacryocystoplasty. Br J Ophthalmol, 1999;83: 692–696. 14 Song HY, Jin YH, Kim JH, et al. Nasolacrimal duct obstruction treated nonsurgically with use of plastic stents. Radiology, 1994;190:535 –539. 15 Song HY, Jin YH, Kim JH, et al. Nonsurgical placement of a nasolacrimal polyurethane stent: long-term effectiveness. Radiology, 1996;200:759 –763. 16 Pulido-Duque JM, Reyes R, Carreira JM, et al. Treatment of complete
17
18
19 20
21
22 23
24
25
26
27 28
29 30
31
and partial obstruction of the nasolacrimal system with polyurethane stents: initial experience. Cardiovasc Interv Radiol, 1998;21:450–453. Song HY, Lee DH, Ahn H, et al. Lacrimal system obstruction treated with lacrimal polyurethane stents: outcome of removal of occluded stents. Radiology, 1998;208:689–694. Pinto I, Paul L, Grande C, de la Cal MA. Nasolacrimal polyurethane stent placement for epiphora: technical long-term results. J Vasc Interv Radiol, 2001;12:67–71. Pau´l I, Pinto I, Vicente JM, et al. Nasolacrimal stents in the treatment of epiphora: long-term results. J Vasc Interv Radiol, 2002;13:83–88. Lee JS, Jung G, Oum BS, et al. Clinical efficacy of the polyurethane stent without fluoroscopic guidance in the treatment of nasolacrimal duct obstruction. Ophthalmology, 2000;107:1666– 1670. Lanciego C, De Miguel S, Perea M, et al. Nasolacrimal stents in the management of epiphora: medium-term of a multicenter prospective study. J Vasc Interv Radiol, 2001;12:701– 710. Kuchar A, Steinkogler FJ. Antegrade balloon dilatation of nasolacrimal duct obstruction in adults. Br J Ophthalmol, 2001;85:200–204. Perry JD, Maus M, Nowinski TS, Penne RB. Balloon catheter dilatation for treatment of adults with partial nasolacrimal duct obstruction: a preliminary report. Am J Ophthalmol, 1998;126:811 –816. Steinkogler FJ, Kuchar A, Huber E, Karnel F. Retrograde dilatation of post-saccal lacrimal stenosis. Ann Otol Rhinol Laryngol, 1994;103: 110– 114. Janssen AG, Mansour K, Bos JJ, et al. Abscess of the lacrimal sac due to chronic or subacute dacryocystitis: treatment with temporary stent placement in the nasolacrimal duct. Radiology, 2000;215:300–304. Munk PL, Lin DTC, Morris DC. Epiphora: treatment by means of dacryocystoplasty with balloon dilatation of the nasolacrimal drainage apparatus. Radiology, 1990;177:687–690. Song HY, Jin YH, Kim JH, et al. Nonsurgical placement of a nasolacrimal polyurethane stent. Radiology, 1995;194:233–237. Schaudig U, Maas R. The polyurethane nasolacrimal duct stent for lower tear duct obstruction: long-term success rate and complications. Graefe’s Arch Clin Exp Ophtalmol, 2000;238:733–737. Song HY, Lee DH, Ahn H, et al. Intervention in the lacrimal drainage system. Cardiovasc Interv Radiol, 2002;25:165– 170. Kang SG, Song HY, Lee DH, et al. Nonsurgically placed nasolacrimal stents for epiphora: long-term results and factors favoring stent patency. J Vasc Interv Radiol, 2002;13:293– 300. Kim HS, Song HY, Kim TH, et al. Use of a lacrimal stent retrieval hook in the removal of occluded plastic and expandable metallic lacrimal stent. J Vasc Interv Radiol, 2000;11:762– 766.
Treatment of Complete Obstruction of the Nasolacrimal System by Temporary Placement of Nasolacrimal Polyurethane Stents: Preliminary Results ´ L, I. PINTO, J. M. VICENTE L. PAU Servicio de Radiologı´a, Seccio´n de Radiologı´a Vascular Intervencionista, Hospital Universitario de Getafe, Carretera de Toledo km 12.5, Getafe, Madrid, Spain Received: 18 March 2003
Revised: 25 May 2003
Accepted: 30 May 2003
AIM: To assess the efficacy of the temporary placement of polyurethane nasolacrimal stents as a treatment for complete post-saccal obstruction of the lacrimal apparatus. MATERIALS AND METHODS: Polyurethane nasolacrimal stents were inserted under radiological guidance in nine patients with grade IV epiphora due to complete obstruction of the lacrimal system, at the junction of the lacrimal sac and duct (eight patients) or in the lacrimal duct (one patient). On average, the stents were removed 4 months (range: 3 – 6 months) after insertion. Dacryocystography was performed immediately before and after each stent was removed. Subsequently, periodic clinical and radiological examinations were performed until recurrence of the epiphora, at which point follow-up concluded. RESULTS: All patients remained free of epiphora and clinical inflammation while the stents were in place, but re-obstruction of the lacrimal system occurred in all patients less than 2 months after the stents were removed. Adhesion of three stents to the lacrimal tract was observed upon removal. In seven cases the dacryocystography results at the end of follow-up revealed changes in the configuration of the lacrimal apparatus. CONCLUSION: Based on our preliminary experience, temporary placement of polyurethane stents would not appear to be an efficacious therapeutic option for treating epiphora caused by post-saccal obstruction. L. Pau´l et al. (2003). Clinical Radiology 58: 876–882. q 2003 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. Key words: lacrimal gland and duct, interventional procedures, nasolacrimal obstruction, stents and prostheses, temporary nasolacrimal intubation.
INTRODUCTION
Interventional techniques for treating epiphora, caused by obstruction of the lacrimal system, that are better tolerated by patients, do not require anaesthesia, and do not cause facial scarring, have been developed in recent years in an effort to find alternatives to classical or endoscopic dacryocystorhinostomy. These techniques consist of balloon dilatation of the lacrimal tract (dacryocystoplasty) and the deployment of nasolacrimal stents. Both are fast, safe, reversible, do not require general anaesthesia, and do not leave facial scars. Development of these techniques has been encouraged because of these advantages, but to date the medium and long-term Guarantor and correspondent: Laura Pau´l Dı´az, Servicio de Radiologı´a, Hospital Universitario de Getafe, Carretera de Toledo km 12.5, Getafe, 28905 Madrid, Spain. Tel: þ 34-916839718; Fax: þ 34-913886622; E-mail: [email protected] 0009-9260/03/$30.00/0
results achieved have not been better than the results achieved using dacryocystorhinostomy [1 –5]. Dacryocystoplasty achieves immediate success in 50–95% of cases [6 –10], but re-obstruction rates are high, with patency rates after 1 year ranging from 20 –70% [6,8 –13]. Results are substantially worse in cases of complete obstruction of the lacrimal system, whereby treatment is less than 25% effective after 1 year [8,9,13]. Placement of a stent within the lacrimal apparatus initially relieves the epiphora in 70 –100% of patients, with the results achieved in cases of obstruction being better than the results obtained using dacryocystoplasty [14–17]. Recurrence rates after 1 year are 30% or more [15,17 –19], except in the series reported by Lee et al. [20] and Lanciego et al. [21], in which the re-obstruction rate was 8% after 22 months and 15% after 15 months, respectively. We have used stents on a temporary basis in patients with epiphora caused by complete obstruction of the lacrimal
q 2003 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
TEMPORARY POLYURETHANE NASOLACRIMAL STENTS TO TREAT COMPLETE NASOLACRIMAL OBSTRUCTION
system, in an effort to take advantage of the interventional radiological approach, while avoiding the problems that arise in long-term nasolacrimal stent placement. In undertaking this novel application of the technique, we took into account previous experience with dacryocystoplasty followed by intubation [22–24] and temporary deployment of stents to resolve abscesses of the lacrimal sac [25].
MATERIALS AND METHODS
This study presents nine consecutive treatments of epiphora by temporary insertion of a polyurethane nasolacrimal stent (PNL), performed by the Interventional Radiology Unit at Getafe University Hospital between November 2001 and April 2002. The patients included in the study had complete obstruction of the lacrimal apparatus at the junction of the lacrimal sac and duct (eight patients) or within the lacrimal duct itself [one patient (case 9)]. Clinical evaluation showed all the patients to have grade IV epiphora according to Munk’s scale [26], and two patients (cases 3 and 9) also had symptoms of inflammation (redness, itching, suppuration). Exclusion criteria for the study were: patients older than 78 years of age or in poor physical condition; patients awaiting cataract surgery; second PNL placed in patients who had already had one PNL removed as a consequence of occlusion; patient refusal to accept the temporary stent protocol; difficulty in negotiating the lacrimal system resulting in a decreased likelihood of successful repetition of the procedure, if necessary; initial failure of the intervention or uncertainty as to the technical success of the procedure, i.e., formation of a false tract during the procedure, radiological demonstration of stent malpositioning, immediate clinical or radiological stent malfunction suggestive of improper stent placement. In short, the study included only those interventions that were straightforward, repeatable, and successfully performed in patients who would not be harmed by this temporary treatment, had freely given their consent, and had not previously undergone treatment for lacrimal obstruction. For these reasons, the patients in this treatment group were not actually consecutive, in that there were intervening patients with epiphora who did not received this treatment, but the temporary PNL treatments considered in this report did comprise a consecutive series in themselves. The existence of dacryocystitis was not deemed to be a contraindication to performing the intervention, though in cases where this condition was present an antibiotic treatment was administered for 1 week prior to the intervention. The stents were inserted and then removed by our team under radiological guidance in the angiography room under sedation and local anaesthesia, on an ambulatory basis. Based on previous experience with temporary intubation of the lacrimal tract [22–25], it was decided to leave the temporary stents in place for 4 months. The sedative used was intravenous midazolam (Rovi S.A., Madrid, Spain), and the local anaesthesia consisted of infiltration with 2% lidocaine (supratrochlear nerve, infraorbital nerve, and nostril) and nasal packing impregnated with a solution of 10% tetracaine hydrochloride and epinephrine. The Song nasolacrimal duct
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stent set (Cook Ireland Limited, Limerick, Ireland) was used in all cases, the set being composed of a rigid 0.018-inch ball guide-wire with balls at both ends, a 6 F dilator, and a polyurethane stent and pusher. The stent placement and removal technique was as described by Song et al. [14,27]. No balloon dilatation was performed before stent insertion. Dacryocystography was carried out on conclusion of every procedure to verify proper stent placement and patency. Maxitrol (Alcon Iberhis S.A., Madrid, Spain) and Rhinocort Aqua (Astra Espan˜a, Barcelona, Spain) were administered for 10 days after the procedure. Clinical and/or radiological examinations were carried out at 10 days, 1 month, 3 months, and 6 months after the procedure until the stent was removed. Dacryocystography was performed immediately before and after stent removal. The same examinations were subsequently repeated (10 days, 1 month, 3 months) until the recurrence of epiphora. Reobstruction of the lacrimal system marked the end point of follow-up.
RESULTS
Table 1 lists the time the stent was in place, clinical and radiological findings until the time of removal, subsequent clinical course, and the re-occlusion period for each patient. All patients remained free of epiphora and clinical inflammation while the stents were in place. Because of patient scheduling problems, not all the stents could be removed after 4 months, two of the stents were removed after 2.5 months and another two after 6 months. In three of the nine patients (cases 2, 3, and 4) difficulties in removing the stents were encountered because of adherence of the stents to the lacrimal tract, and thus greater than ordinary force had to be employed when pulling the stents out. This resulted in stretching of the stents and caused pain to the patients, and in one case the presence of tissue adhering to the upper end of the stent was observed. In none of these cases did another specialist have to be called in to assist in removing the stents. In the remaining six patients stent removal was accomplished without difficulty. In six cases the stent was patent on dacryocystography before removal. In one case (case 5) the stent had become occluded by mucoid secretions, which were observed in the stent after removal. In another patient (case 8) the stent had slid downwards and was obstructed by abutment of the lower end of the stent against the nasal floor, but no debris or sludge was observed inside the stent. In the final case (case 9) occlusion was probably the result of intercurrent catarrh, because the patient had already experienced self-limiting stent obstruction during follow-up coinciding with a cold; no obstructing matter was found inside the stent in this case either. In these three patients, the lacrimal system was patent on removal of the stent. Lacrimal obstruction was observed in two of the nine cases on dacryocystography performed immediately after removal of the stent. In one (case 3) adhesion of the stent was observed at the time of removal and dacryocystography post-removal showed lacrimal obstruction at the level of the sac. In the other (case 7) bleeding occurred on removal of the stent, and lavage
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2 months: no changes 1 month: smaller, more irregular lacrimal sac Immediate epiphora Post-removal: obstruction common canaliculus. No sac filling No second PNL Progressive epiphora after 1 month 1 month: smaller lacrimal sac. No second PNL Progressive epiphora after 2 months 6 months: (dacryocystography for new PNL) smaller, more irregular lacrimal sac Moderate epiphora (an improvement) 10 days: smaller, more irregular during the first 2 months lacrimal sac Epiphora immediately Post-removal: small sac, no changes. No PNL Progressive epiphora and pus formation 1 month: More irregular lacrimal sac after 1 month Progressive epiphora and immediate 10 days: smaller, more irregular formation of grit in eye lacrimal sac
failed to achieve patency of the lacrimal system. These two patients experienced epiphora immediately upon removal of the stents, and lacrimal obstruction was confirmed radiologically 10 days later. In the remaining seven patients the lacrimal apparatus was patent upon removal of the stents, but early reobstruction occurred (Fig. 1). Epiphora recurred in all nine patients less than 2 months after stent removal. Radiologically, changes were observed in seven of the nine patients when the final dacryocystography results were compared with the dacryocystography examinations carried out before stent placement. These changes were a reduction in the size of the lacrimal sac (Fig. 2), irregular sac shape and the presence of filling defects (Fig. 1) to a greater or lesser extent in each case. In two of the patients (cases 3 and 4) the changes observed contraindicated immediate placement of a second stent, because refilling of the lacrimal sac did not take place. However, in one of these patients (case 3), the changes were subsequently observed improve (Fig. 3).
PNL, polyurethane nasolacrimal stent. Compared to the dacryocystography examinations carried out before stent placement.
Normal Non-patent
DISCUSSION
p
2.5 9(45)
Normal Non-patent, PNL slippage
Patent irregular and stenotic lacrimal sac and duct
2.5 8(29)
Patent
Patent
4 7(76)
Patent
Normal
Patent lacrimal sac and duct stenotic with filling defect Self-limiting bleeding Non-patent 4 6(58)
Non-patent
Normal
Patent stenotic irregular and lacrimal sac and duct 4 5(53)
Patent
Adhesion of PNL
Patent 4 4(76)
Adhesion of PNL Patent
Patent Patent
Non-patent 6 3(66)
Progressive epiphora after 2 months Progressive epiphora after 1 month Patent Patent 4 6 1(67) 2(49)
Normal Adhesion of PNL
Post-removal dacryocystography Clinical follow-up to re-obstruction Case no. PNL time in Pre-removal dacryocystography PNL on removal (age) place (months)
Table 1 – Results of polyurethane nasolacrimal stent placement in nine patients
Radiological follow-up (changesp)
CLINICAL RADIOLOGY
The disadvantages of using nasolacrimal stents as a treatment for epiphora, caused by obstruction of the lacrimal apparatus, are long-term occlusion by detritus and the growth of inflammatory tissue [17]; the medium-term occlusion rates range between 15 and 50% [19,21,28], reaching 81– 95% after 5 years [29,30]. In addition, the growth of granulomatous and fibrotic tissue within the lacrimal tract in which a stent has been deployed can also cause the lacrimal sac to become irregular in shape and smaller in size or result in adhesion of the stent to the tract, making removal of the stent more difficult [30,31]. All these factors raise questions about the reversibility, and in particular, the efficacy of this therapeutic option as a definitive treatment for epiphora due to obstruction of the lacrimal system. Dacryocystoplasty has exhibited greater short-term efficacy in stenosis than in obstruction [6,8 –11]. Some experiences with balloon dacryocystoplasty, followed by temporary intubation of the lacrimal tract in small series of patients, have yielded encouraging results with respect to the medium and long-term efficacy [23,24], occasionally even in cases of complete obstruction of the lacrimal apparatus [22,25]. The present study was conducted to assess the duration of patency of the obstructed lacrimal system after temporary intubation. However, the results achieved were worse than expected when compared with the previous reports referred to above. Although different procedures were employed, all shared the same underlying concept of treatment based on temporary dilatation. In our study, deployment of the stent resolved the epiphora completely during the time the stent remained in place, but after removal of the stents the lacrimal systems re-obstructed in all the patients in less than 2 months. According to literature reports, Steinkogler et al. [24] performed dilatation of six post-saccal stenoses and then followed that by intubation for 3 months, and all six lacrimal systems remained patent after 6 months. Perry et al. [23] carried out dilatation followed by intubation for 2 months in 15 cases of stenosis, and the lacrimal tracts
TEMPORARY POLYURETHANE NASOLACRIMAL STENTS TO TREAT COMPLETE NASOLACRIMAL OBSTRUCTION
879
Fig. 1 – Case 5. (a) Dacryocystography of the left eye (anteroposterior projection) before stent placement showing obstruction of the lacrimal apparatus at the junction of the lacrimal sac and duct (arrow). (b) Dacryocystography of the left eye performed immediately after removal of the stent (post-removal) showing a patent lacrimal apparatus but with filling defects (arrows) visible in the lacrimal sac. Mucoid matter was found inside the stent on removal. (c) Follow-up dacryocystography performed 6 months after stent removal showing obstruction of the lacrimal apparatus at the junction of the lacrimal sac and duct. Clinically the patient began to complain of epiphora 2 months after removal of the stent, and at this time, the patient had grade IV epiphora.
880
CLINICAL RADIOLOGY
Fig. 2 – Case 4. (a) Dacryocystography of the left eye (anteroposterior projection) before stent placement, showing obstruction of the lacrimal apparatus at the junction of the lacrimal sac and duct (arrow) and a large, regularly shaped lacrimal sac. (b) Dacryocystography performed immediately after removal of the stent (post-removal) showing the left lacrimal apparatus to be patent, but with an irregularly shaped sac smaller in size than at the time of temporary stent placement, with filling defects (arrow). Stenoses are visible along the length of the lacrimal duct (arrow heads). Clinically the patient remained free of epiphora for 1 month. (c) Dacryocystography performed 1 month after removal of the stent. Clinically the patient had grade II –III epiphora. Obstruction of the lacrimal apparatus at the junction of the lacrimal sac and duct (arrow), the lacrimal sac being irregularly shaped and smaller in size compared with the initial findings.
remained patent in 73% of the patients in that series after 6 months. The discrepancy between these series and our results may be attributable to the fact that these authors treated stenoses rather than complete obstruction of the lacrimal apparatus. Conversely, Janssen et al. [25] employed temporary intubation to treat 10 abscesses of the lacrimal sac caused by post-saccal obstruction, with good patency and normal morphological characteristics of the lacrimal duct system seen in five cases at the end of the follow-up period (2 –13 months). Kuchar and Steinkogler [22] performed dilatations followed by intubation for 3 months in 30 patients with complete nasolacrimal duct obstructions and at 6 months 70% of all the cases were positive on irrigation. The difference between our series and these two studies was that we did not perform balloon dacryocystoplasty before intubation. In addition, the intubation material employed in the other series (a silicone tube in one case and a 6 –8 F polyurethane tube in the other) differed from the stents we used, and the pre and post-intervention antibiotic treatment employed in the other studies may also have contributed to the discrepancies in the results achieved.
The appearance of adverse stent-related effects, which ordinarily arise in the course of more “protracted” treatments, is another noteworthy finding of our study [17,19,30,31]. These adverse effects were, first, adhesion of some of the stents to the lacrimal tract after placement for 4 months, and second, negative morphological changes in most of the lacrimal systems (shrinkage and irregularities in the shape of the lacrimal sac and filling defects) as a result of treatment. However, it is likely that these changes were caused by an inflammatory response of the lacrimal apparatus to the stent, which may be variable in time and reversible, as was observed in one of the cases in this series. This is an important aspect to consider regarding the potential of this therapeutic option. In conclusion, based on this preliminary experience, temporary placement of polyurethane stents does not appear to be an efficacious therapeutic alternative for treating epiphora caused by post-saccal obstruction of the lacrimal system. Perhaps, balloon dilatation of the obstruction plays an essential role in treatment, and most likely, containment of inflammation of the lacrimal apparatus holds the key to a solution to this predicament. However, there is a need for further study to explore the potential for using this treatment technique in temporary applications.
TEMPORARY POLYURETHANE NASOLACRIMAL STENTS TO TREAT COMPLETE NASOLACRIMAL OBSTRUCTION
881
Fig. 3 – Case 3. (a) Dacryocystography of the left eye (anteroposterior projection) before stent placement showing obstruction of the lacrimal apparatus at the junction of the lacrimal sac and duct. (b) Dacryocystography performed immediately after removal of the stent 4 months after placement showing obstruction of the lacrimal apparatus at the junction of the common canaliculus and the lacrimal duct (arrow head). Adhesion of the stent had occurred, making removal difficult. The patient had epiphora immediately upon removal of the stent, although she had remained free from epiphora during the 4 months the stent was in place. (c) Dacryocystography performed 10 days after stent removal. Clinical symptoms of grade IV epiphora persisted, and continued obstruction of the lacrimal system was demonstrated radiologically. However, the radiological findings were not the same as before. Filling of the lacrimal sac was achieved, even though the sac can be seen to be more irregularly shaped and smaller in size than it was before stent placement, showing that the lacrimal sac changes are reversible.
882
CLINICAL RADIOLOGY
REFERENCES 1 Rosen N, Shamir M, Moverman DC, Rosner M. Dacryocystorhinostomy with silicone tubes: evaluation of 253 cases. Opthalmol Surg, 1989;20:115– 119. 2 Hartikainen J, Grenman R, Puukka P, Seppa H. Prospective randomized comparison of external dacryocystorhinostomy and endonasal laser dacryocystorhinostomy. Ophthalmology, 1998;105:1106–1113. 3 Cokkeseer Y, Evereklioglu C, Er H. Comparative external versus endoscopic dacryocystorhinostomy: results in 115 patients (130 eyes). Otolaryngol Head Neck Surg 123: 488 –491. 4 Liao SL, Kao SCS, Tseng JHS, et al. Results of intraoperative mitomycin C. Application in dacryocystorhinostomy. Br J Ophthalmol, 2000;84:903– 906. 5 Camara JG, Bengzon AU, Henson RD. The safety and efficacy of Mitomycin C in endonasal endoscopic laser-assisted dacryocystorhinostomy. Ophthal Plast Reconstr Surg, 2000;16:114 –118. 6 Berkefeld J, Kirchner J, Mu¨ller HM, et al. Balloon dacryocystoplasty: indications and contraindications. Radiology, 1997;205:785–790. 7 Liermann D, Berkefeld J, Fries U, et al. Balloon dacryocystoplasty: an alternative treatment for obstructed tear ducts. Ophthalmologica, 1996; 10:319–324. 8 Song HY, Ahn HS, Park ChK, et al. Complete obstruction of the nasolacrimal system. Treatment with balloon dilatation. Radiology, 1993;186:367 –371. 9 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;192:503–508. 10 Fenton S, Clearly PE, Horan E, et al. Balloon dacryocystoplasty study in the management of adult epiphora. Eye, 2001;15:67–69. 11 Janssen AG, Mansour K, Bos JJ. Obstructed nasolacrimal duct system in epiphora: long-term results of dacryocystoplasty by means of balloon dilatation. Radiology, 1997;205:791–796. 12 McCullough CM. Naso–lacrimal duct balloon dilatation: medium to long-term follow-up. Clin Radiol, 2001;56:13–16. 13 Yazici Z, Yazici B, Parlak M, et al. Treatment of obstructive epiphora in adults by balloon dacryocystoplasty. Br J Ophthalmol, 1999;83: 692–696. 14 Song HY, Jin YH, Kim JH, et al. Nasolacrimal duct obstruction treated nonsurgically with use of plastic stents. Radiology, 1994;190:535 –539. 15 Song HY, Jin YH, Kim JH, et al. Nonsurgical placement of a nasolacrimal polyurethane stent: long-term effectiveness. Radiology, 1996;200:759 –763. 16 Pulido-Duque JM, Reyes R, Carreira JM, et al. Treatment of complete
17
18
19 20
21
22 23
24
25
26
27 28
29 30
31
and partial obstruction of the nasolacrimal system with polyurethane stents: initial experience. Cardiovasc Interv Radiol, 1998;21:450–453. Song HY, Lee DH, Ahn H, et al. Lacrimal system obstruction treated with lacrimal polyurethane stents: outcome of removal of occluded stents. Radiology, 1998;208:689–694. Pinto I, Paul L, Grande C, de la Cal MA. Nasolacrimal polyurethane stent placement for epiphora: technical long-term results. J Vasc Interv Radiol, 2001;12:67–71. Pau´l I, Pinto I, Vicente JM, et al. Nasolacrimal stents in the treatment of epiphora: long-term results. J Vasc Interv Radiol, 2002;13:83–88. Lee JS, Jung G, Oum BS, et al. Clinical efficacy of the polyurethane stent without fluoroscopic guidance in the treatment of nasolacrimal duct obstruction. Ophthalmology, 2000;107:1666– 1670. Lanciego C, De Miguel S, Perea M, et al. Nasolacrimal stents in the management of epiphora: medium-term of a multicenter prospective study. J Vasc Interv Radiol, 2001;12:701– 710. Kuchar A, Steinkogler FJ. Antegrade balloon dilatation of nasolacrimal duct obstruction in adults. Br J Ophthalmol, 2001;85:200–204. Perry JD, Maus M, Nowinski TS, Penne RB. Balloon catheter dilatation for treatment of adults with partial nasolacrimal duct obstruction: a preliminary report. Am J Ophthalmol, 1998;126:811 –816. Steinkogler FJ, Kuchar A, Huber E, Karnel F. Retrograde dilatation of post-saccal lacrimal stenosis. Ann Otol Rhinol Laryngol, 1994;103: 110– 114. Janssen AG, Mansour K, Bos JJ, et al. Abscess of the lacrimal sac due to chronic or subacute dacryocystitis: treatment with temporary stent placement in the nasolacrimal duct. Radiology, 2000;215:300–304. Munk PL, Lin DTC, Morris DC. Epiphora: treatment by means of dacryocystoplasty with balloon dilatation of the nasolacrimal drainage apparatus. Radiology, 1990;177:687–690. Song HY, Jin YH, Kim JH, et al. Nonsurgical placement of a nasolacrimal polyurethane stent. Radiology, 1995;194:233–237. Schaudig U, Maas R. The polyurethane nasolacrimal duct stent for lower tear duct obstruction: long-term success rate and complications. Graefe’s Arch Clin Exp Ophtalmol, 2000;238:733–737. Song HY, Lee DH, Ahn H, et al. Intervention in the lacrimal drainage system. Cardiovasc Interv Radiol, 2002;25:165– 170. Kang SG, Song HY, Lee DH, et al. Nonsurgically placed nasolacrimal stents for epiphora: long-term results and factors favoring stent patency. J Vasc Interv Radiol, 2002;13:293– 300. Kim HS, Song HY, Kim TH, et al. Use of a lacrimal stent retrieval hook in the removal of occluded plastic and expandable metallic lacrimal stent. J Vasc Interv Radiol, 2000;11:762– 766.