Endoscopy-Guided Transcaruncular Jones Tube Intubation without Dacryocystorhinostomy

Purpose

To evaluate the functional surgical success, complications, and degree of satisfaction after endoscopy-guided transcaruncular Jones tube intubation without dacryocystorhinostomy (DCR).

Methods

A pair of Westcott scissors was passed into the nose from the side of the caruncle, and the lacrimal bone was penetrated between the lacrimal sac and the nasal mucosa. After the proper length of Jones tube was decided, the tube was inserted into the nasal cavity and fixed at the caruncle with nonabsorbable suture material. This procedure was done without DCR. We retrospectively reviewed the 60 patients (70 eyes) with canalicular obstruction who underwent Jones tube intubation in this manner.

Results

The overall success rate was 91.4%. The length of Jones tube used ranged from 16 to 30?mm. Retrograde air blowing into the eye via the Jones tube was the most common complaint (25 of 70 eyes). Complications of this technique included tube problems (25.7%), in particular, downward displacement (22.9%), which was corrected easily in the outpatient clinic, and extrusion. Other complications were frequent inflammation and conjunctival growth over the tube opening.

Conclusions

Endoscopy-guided Jones tube intubation without DCR is a simple and useful procedure for correcting canalicular obstruction.?Jpn J Ophthalmol 2006;50:141–146 © Japanese Ophthalmological Society 2006     

189例主诉流泪患者的病因分析

目的 分析以流泪为主诉患者的病因。设计 回顾性病例系列。研究对象 2013年1月～2014年12月以流泪为主诉就诊于大连大学附属中山医院的成年患者189例（321眼）。方法 所有患者完成问卷调查,外眼、裂隙灯显微镜、鼻腔检查及泪道冲洗。有眼干涩或异物感等症状或泪河高度偏低者行泪液分泌试验及泪膜破裂时间（BUT）检查。主要指标 病因构成比。结果 321眼中各种原因泪道狭窄或阻塞174眼（54.21%）,干眼症27眼（8.41%）,结膜松弛8眼（2.49%）,泪阜肥大2眼（0.62%）,眼睑松弛2眼（0.62%）,鼻腔疾病2眼（0.62%）,结膜炎8眼（2.49%）,鳄鱼泪2眼（0.62%）,视疲劳20眼（6.23%）。2种以上原因76眼（23.68%）,其中泪道狭窄或阻塞合并干眼症43眼（13.40%）,泪道狭窄或阻塞并干眼症与结膜松弛6眼（1.87%）,泪道狭窄并干眼症与结膜炎2眼（0.62%）,干眼症及结膜松弛6眼（1.87%）,泪道狭窄或阻塞合并结膜松弛9眼（2.80%）,结膜松弛及泪阜肥大5眼（1.56%）,泪道狭窄或阻塞合并结膜松弛及眼睑松弛3眼（0.94%）,泪道阻塞合并泪阜肥大1眼（0.31%）,泪道阻塞合并倒睫1眼（0.31%）。结论 泪道狭窄或阻塞是主诉流泪者的主要原因,多因素原因中干眼症合并泪道狭窄或阻塞比例较大。（眼科,2016, 25：343-346）     

高密度多孔聚乙烯包裹玻璃管植入泪道旁路术的临床分析

目的探讨高密度多孔聚乙烯（HDPP）包裹玻璃管植入泪道旁路术的有效性和安全性。方法溢泪症状明显且无法再通泪道患者26例（26只眼）,其中10例泪小点和泪管缺失、泪囊存在患者行结膜鼻腔泪囊吻合联合HDPP包裹玻璃管植入泪道旁路术,16例泪小点和泪管缺失且无泪囊患者行单纯HDPP包裹玻璃管植入泪道旁路术。术后随访4—28个月,记录手术适应证、手术方式及其成功率,观察手术并发症的发生情况,对数据结果进行分析。结果术后患者溢泪症状消失或明显改善,义管冲洗通畅者23例（88．5％）,对手术结果满意者21例（80．8％）,无义管排出或严重移位者。术后并发症包括义管阻塞9例（手术再通8例）、不适感4例、义管长度不当2例、义管位置不当1例、感染1例,复视1例,角膜上皮损伤1例、鼻腔分泌物反流1例。结论HDPP包裹玻璃管植入泪道旁路术可有效解决泪道无法再通患者的溢泪症状,手术成功率较高,手术安全、有效。     

逆行植入泪道扩张引流管的并发症及处理经验

目的:总结逆行植入泪道扩张引流管治疗鼻泪管阻塞和慢性泪囊炎的并发症及解决方法。方法:对临床诊断为鼻泪管阻塞和慢性泪囊炎的110例113眼患者,逆行植入泪道扩张引流管治疗,观察术后至拔管4mo内出现的并发症。结果:拔管困难26眼（23.0%）,鼻腔残端隐藏5眼（4.4%）,引流管脱落3眼（2.7%）,泪道支撑管刺破泪阜1眼（占B型管5.9%）,泪小管狭窄7眼（6.2%）,鼻泪道冲洗返流5眼（4.4%）。结论:泪道扩张引流管植入是治疗鼻泪管阻塞或慢性泪囊炎的一种有效、安全的治疗方法,只要医生细心、认真、温和地操作,会避免很多并发症的发生,提高治愈率。     

Intranasal endoscopic diagnosis and treatment in congenital nasolacrimal duct obstruction

BACKGROUND AND OBJECTIVE: To identify the causes of congenital nasolacrimal duct obstruction using intranasal endoscopy. PATIENTS AND METHODS: Eleven children with symptoms of epiphora since birth were selected for treatment. A silicone tube was inserted after identifying the causes of prior probing failures by observing the probing tip directly with intranasal endoscopy. RESULTS: As confirmed through intranasal endoscopic examination, tearing was caused by mucosal obstruction, submucosal passing of the probe, pus collection, and inferior turbinate impaction. The probe passed into the submucosal space in 5 patients and, by performing probing medially instead in the usual posterolateral direction, probing succeeded in 4 patients. One case was accompanied by a bone abnormality; we bent the probe tip into the nasal cavity to form the lacrimal pathway. CONCLUSION: By using intranasal endoscopy, a silicone tube can be inserted under direct visualization and any causative abnormalities can be identified. This can also minimize the intranasal trauma sometimes caused by blind probing.     

Postherpetic lacrimal obstruction

OBJECTIVE: The purpose of the study was to review the surgical management of postherpetic lacrimal obstruction. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: One hundred sixty patients (111 female, 49 male) with a mean age at presentation of 31 years. All had a history typical of primary herpes simplex blepharoconjunctivitis. INTERVENTION: Open lacrimal surgery was performed on 158 patients (171 eyes), of whom 99 patients (108 eyes) had undergone no surgery before being seen at Moorfields. The most common primary procedure was dacryocystorhinostomy (DCR) with anterograde or retrograde intubation (94 eyes, 54%), and primary placement of a Lester Jones tube (conjunctivo-DCR) was performed in 56 eyes (32%). A secondary procedure was required in 43 eyes (26%), the most common being closed placement of a Lester Jones tube (40 eyes). MAIN OUTCOME MEASURES: Persistent symptoms of impaired lacrimal drainage and need for additional surgery. RESULTS: Reduction of epiphora was good or complete in 171/173 eyes (98%). CONCLUSIONS: This study shows that there is a justification for procedures that use any remaining unaffected portion of canaliculi, such as DCR, with anterograde or retrograde intubation, as well as the more commonly used Lester Jones tube.     

球囊管扩张术治疗儿童先天性泪道阻塞的临床观察

目的 观察球囊管扩张术治疗儿童先天性泪道阻塞的手术方法、疗效与并发症.方法 前瞻性研究.2008年5月至2009年10月,对就诊于首都医科大学附属北京儿童医院眼科的31例(50只眼)泪道探通、插管和激光术后失败的先天性鼻泪管阻塞患儿进行全身麻醉下鼻泪管球囊管扩张术,探针经泪小管探通直至鼻泪管,顺行插入尾端带有球囊的导管探针,进行鼻泪道球囊管扩张.手术前后进行症状评估、荧光染料消失试验以及泪道冲洗检查,同时对术中出血、水肿、假道形成等并发症进行观察与分析.随访时间为术后4～17个月.结果 50只眼中44只眼治愈,总成功率为88.0%(95%CI 85.5%～96.9%),荧光染料消失试验40只眼(80.0%)显示为1级或0级.主要术中并发症有10只眼(20.0%)鼻腔少量出血,有2只眼(4.0%)出现泪小点裂伤.结论 球囊管扩张术是一种便捷、安全、有效,不破坏局部解剖结构的新型儿童泪道手术方法,可用于泪道探通、插管或泪道激光手术失败后的儿童先天性泪道阻塞治疗.

Abstract：

Objective To introduce the procedure of balloon dacryocystoplasty and to evaluate its effectiveness and complications as the treatment of congenital nasolacrimal duct obstruction after a previous unsuccessful surgery. Methods Prospective case series. Balloon dacryocystoplasty was performed under general anesthesia in 50 eyes of 31 children with congenital nasolacrimal duct obstruction following previous unsuccessful surgery in Beijing Children's Hospital between May 2008 and October 2009. A probe was introduced through the punctum into the inferior meatus of the nasal cavity. A deflated balloon catheter was introduced anterogradely and the balloon was inflated several times to perform the dilation of the nasolacrimal duct. Treatment success was defined as absence of epiphora and mucous discharge,negative results of fluorescein dye disappearance test(FDDT) and the unobstructed irrigation of the lacrimal system during the follow-up period of 4 - 17 months after tube removal. Results Successful operation was reported in 44 of 50 eyes ( 88.0%;95% confidence interval 85.5% - 96. 9% ). Forty of 50 eyes were FDDT 0 - 1(80. 0% ). Major complications included epistaxis (10 eyes,20. 0% ) and lacrimal duct laceration (2 eyes,4. 0% ). Conclusion Balloon dacryocystoplasty is a safe,simple and effective procedure for congenital nasolacrimal duct obstruction following previous unsuccessful surgery without disturbing the anatomy of normal lacrimal drainage system.     

Selective non-intubation of a silicone tube in external dacryocystorhinostomy

PURPOSE: To evaluate whether silicone tube insertion is always necessary in external dacryocystorhinostomy (DCR). METHODS: During external DCR for primary nasolacrimal duct obstruction carried out between January 2001 and October 2004, silicone intubation was not performed selectively if the lacrimal sac was large and the nasal cavity was not severely narrowed. RESULTS: Of a total of 166 DCR cases in 153 patients, no silicone tube was placed in 74 eyes of 69 patients (44.6%). Anatomic patency of rhinostomy was achieved in all non-intubation group eyes. However, four (6.7%) of these 69 eyes showed persistent epiphora even with anatomic patency. CONCLUSIONS: Silicone tubing can be avoided in about 50% of cases of external DCR without detrimentally affecting the success rate. Cases in which intubation was avoided had a large lacrimal sac and a wide nasal cavity.     

Treatment of nasolacrimal duct obstruction in adults with polyurethane stent

PURPOSE: To evaluate the efficacy of polyurethane nasolacrimal duct stents in the treatment of epiphora resulting from primary acquired nasolacrimal duct obstruction in adults. MATERIALS AND METHODS: In 25 patients (21 women and four men with mean age of 44 years, range 20 to 74 years) with nasolacrimal duct obstruction, 28 hollow polyurethane stents designed by Song and associates were placed under fluoroscopic guidance. The obstruction was complete in 20 lacrimal drainage systems and partial in eight. The lacrimal sac size was normal or large on dacryocystogram in all lacrimal drainage systems. A Ritleng probe was introduced through the upper punctum and advanced past the obstruction. A guide wire with a flexible tip was then introduced through the probe, over which the stent was advanced in retrograde fashion and placed into the lacrimal sac and nasolacrimal duct. Clinical success was defined by the demonstration of a completely patent lacrimal drainage pathway through saline irrigation and no or minimal complaint of epiphora. RESULTS: Stent placement was technically successful in 26 of 28 lacrimal drainage systems (93%). The mean time of fluoroscopy screening was 3.2 minutes (range, 1.4 to 5.8 minutes). The overall success rate was 82% (23 of 28 lacrimal drainage systems). Two stents were completely occluded. In one lacrimal drainage system with minimal epiphora, the stented drainage pathway was partially occluded. The patients were followed up from 4 to 22 months (mean, 7.2 months). CONCLUSIONS: Retrograde placement of a hollow polyurethane nasolacrimal duct stent is a technique that is simple and well tolerated by patients. This method achieves a high success rate and may be suggested as a nonsurgical procedure for adults with primary nasolacrimal duct obstruction and proper lacrimal sac size. The Ritleng probe facilitates the procedure.     

鼻泪管阻塞的球囊扩张治疗

目的 介绍鼻泪管阻塞的球囊成形术治疗方法。方法 对50例56眼鼻泪管阻塞进行鼻泪管球囊扩张，经上泪小管顺行引入导丝，逆行进行球囊扩张。术前与术后均地数字减影泪道造影。结果 所有56眼均一次扩张治疗成功。术后随访10－24个月（平均16．3个月），29眼溢泪消失，12眼溢泪明显减轻，有效率为73．2％，15眼（26．8％）溢泪症状无明显改善，无严重并发症发生。结论 球囊泪道成形术是一种安全，简单，有效及不改变局部解剖结构的方法。     

Clinical efficacy of the polyurethane stent without fluoroscopic guidance in the treatment of nasolacrimal duct obstruction

PURPOSE: To evaluate the clinical efficacy of the polyurethane (Song) stent in the treatment of nasolacrimal duct obstruction without fluoroscopic guidance, especially at the junction between the lacrimal sac and nasolacrimal duct or at the nasolacrimal duct. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: This study evaluated 59 cases of nasolacrimal duct obstruction in 53 patients, with mean epiphora of 36 months (range, 2 months-17 years). METHODS: Without the assistance of a radiologist, a polyurethane nasolacrimal stent was placed by introducing a guidewire through the superior or inferior punctum into the canaliculus and advancing it across the obstruction into the opening of the inferior meatus of the nasal cavity. The mean follow-up period was 22 months (range, 12 months-48 months). MAIN OUTCOME MEASURES: Patency of the lacrimal passage to irrigation and the duration of this procedure. RESULTS: Complete resolution of epiphora was accomplished in 55 (93.2%) of the 59 eyes. There was recurrence of epiphora in four cases because of obstruction of the stent in three cases and obstruction of the common canaliculus by recurrent dacryocystitis in one case. CONCLUSIONS: Polyurethane stenting without fluoroscopic guidance seems to be a valuable technique for primary management of nasolacrimal duct obstruction before dacryocystorhinostomy.     

Use of the Crawford tube for symptomatic epiphora without nasolacrimal obstruction

AIM: To evaluate the effectiveness of the Crawford tube in treating symptomatic epiphora without nasolacrimal obstruction. METHODS: A protocol was adopted for the management of symptomatic epiphora without nasolacrimal obstruction. Patients who suffered symptomatic epiphora without nasolacrimal obstruction in both eyes were included in the study. One eye was treated with Crawford tube intubation and the other eye was treated with medication therapy. Degree of watering, patient satisfaction, and symptomatic improvement were carefully evaluated by one of the authors at the end of the follow-up period, after Crawford tube removal, to ascertain functional results. RESULTS: Thirty-seven adult patients (37 eyes) underwent Crawford tube intubation for functional epiphora. The mean follow-up time after removal of the tube was 14.8±4.8mo. The procedure was an overall success in 28 eyes (75.7%), with symptoms improving significantly. Two eyes (5.4%) were relieved of indoor epiphora, two (5.4%) had minimal epiphora outdoors, but only with wind or cold, and five (13.5%) continued to experience tearing both indoors and outdoors. Thirty of the patients (81%) expressed satisfaction with the procedure. CONCLUSION: Crawford tube insertion is an effective, safe, simple, and relatively noninvasive treatment strategy for functional lacrimal system obstruction.     

Problems associated with conjunctivodacryocystorhinostomy

Fifty-eight patients (69 eyes) underwent conjunctivodacryocystorhinostomy for lacrimal canalicular obstruction. The cause of lacrimal obstruction and the results and complications of the operation were analyzed. Trauma and idiopathic disease were the most common causes of lacrimal canalicular obstruction in 24 of 69 (34.8%) eyes each. Relief of epiphora was achieved in 68 of the 69 eyes (98.5%). The complications included tube displacement in 40 of the 69 eyes (57.9%), tube obstruction in 19 of the 69 eyes (27.5%), and infection of the lacrimal sac in four of the 69 eyes (5.8%). Despite frequent complications, most Jones tubes can be made to function satisfactorily. Conjunctivodacryocystorhinostomy remains the best surgical treatment at this time for permanent loss of canalicular function.     

Dacryocystorhinostomy in patients lacking an ipsilateral nasal cavity

Dacryocystorhinostomy (DCR) remains the surgery of choice for the treatment of epiphora secondary to nasolacrimal duct (NLD) obstruction. It involves creating a direct soft-tissue anastomosis between the lacrimal sac and the ipsilateral nasal cavity, via an osteotomy created by removal of the floor of the lacrimal fossa and surrounding bone. Successful surgery clearly requires the presence of a nasal space and absence of this poses a surgical challenge. We describe three patients with absent nasal cavity on the side of lacrimal obstruction, where DCR was performed by the creation of an anastomosis between the lacrimal sac and the contralateral nasal space.     

改良硅胶管逆行置管术治疗鼻泪管阻塞的临床观察

目的:观察改良硅胶管逆行置管治疗鼻泪管阻塞的临床疗效。方法:在门诊治疗的鼻泪管阻塞或合并慢性泪囊炎患者共68例74眼,在局部麻醉下行改良硅胶管逆行置管术,术后观察泪道通畅情况、溢泪现象、硅胶管位置及其洁净情况。结果:置管术后1wk泪道冲洗均通畅,拔管后1a总有效率为94.6%。结论:改良硅胶管逆行置管治疗鼻泪管阻塞操作安全、创伤小、时间短、出血少、疗效好。     

泪道激光联合引流管和支架治疗复杂性泪道阻塞的疗效

目的：探讨泪道激光联合泪道引流管及泪囊支架植入术治疗复杂性泪道阻塞的临床效果。
　　方法：对65例82眼复合性泪道阻塞患者进行泪道激光后植入泪道引流管和泪囊支架植入术,1mo 后鼻腔拔出泪囊支架,3~6mo 后鼻腔拔出泪道引流管。术后随访6mo ~1a。结果：65例82眼患者中,治愈71眼,好转5眼,有效率93%;仍然溢泪6眼(7%)。
　　结论：泪道激光联合泪道引流管及泪囊支架植入术能有效地治疗复杂性泪道阻塞。     

Conjunctivodacryocystorhinostomy with Jones tube

One hundred and eight patients (111 eyes) underwent conjunctivodacryocystorhinostomy with a Jones tube for treatment of epiphora resulting from canalicular obstruction. Sixty-nine patients (63.9%) were females and thirty-nine (36.1%) were males. Their ages ranged from 9 to 64 years, the mean age being 30.1 years. The causes of lacrimal drainage abnormalities included idiopathy (76 cases, 68.5%), trauma (15 cases 13.5%), tumors (8 cases, 7.2%) congenital abnormalities (6 cases, 5.4%) and conjunctival inflammation (6 cases, 5.4%). Twenty-eight (36.8%) eyes in the idiopathic group had previous failed dacryocystorhinostomies. The operation was successful in 90.1% of the eyes with relief of epiphora. Fifty-one out of 111 (45.9%) eyes had complications. Extrusion of the tube was the most frequent complication occurring in 20 (18%) eyes. Malposition (12 eyes 10.8%), infection (12 eyes, 10.8%) and obstruction of the tube (7 eyes, 6.3%) were the other major complications. Of the 20 eyes with tube extrusion, 11 experienced recurrent tube losses. Five of 11 eyes were free of epiphora after tube loss. Four out of five had the tube in place for 2 to 5 years and one had the tube, in place for one year. The remaining 6 eyes which had the tubes for 6 months to 3 years were complicated by epiphora. Our experience confirms the general belief that the tube should stay in place forever. The large majority of our patients could wear their tubes successfully and have done so in our practice for as long as 10 years.     

鼻泪管支架植入术125例临床观察

目的观察鼻泪管支架植入术治疗慢性泪囊炎和鼻泪管阻塞的效果。方法鼻泪管支架植入术125例（135眼）。术前诊断为慢性泪囊炎或鼻泪管阻塞等。采用中南大学湘雅二院研制的鼻泪管支架。以空心泪道探针经上泪小管、泪总管、泪囊、鼻泪管探通入下鼻道,将引导钢丝插入空心探针,从前鼻孔钩出,将鼻泪管扩张器、鼻泪管支架、支架推注器先后穿入钢丝,经鼻泪管开口逆行扩张鼻泪管及泪囊,将支架逆行推入鼻泪管及泪囊。术后定期冲洗泪道。结果随访6-19个月,治愈率91．85％。结论鼻泪管支架植入术疗效与鼻腔泪囊吻合术相当,且微创安全。术后定期泪道冲洗有助于减少支架阻塞的发生率。     

Silicone intubation with the Ritleng method in children with congenital nasolacrimal duct obstruction.

PURPOSE: To evaluate the technical properties and clinical efficacy of bicanalicular silicone intubation with the Ritleng method in children with congenital nasolacrimal duct obstruction. METHODS: The Ritleng method was used for lacrimal intubation in 50 eyes of 42 consecutive patients (mean age, 37.3 months). All procedures were done by or under the supervision of one surgeon. The hollow Ritleng probe was inserted via the canaliculus into the inferior meatus. The polypropylene (Prolene) thread-guide, attached to the silicone tube, was advanced through the probe. Either the Prolene emerged from the nose spontaneously or it was retrieved using a hook without visualization. The tube ends were sutured to the nasal wall. Tube removal was planned for 3 months postoperatively. Resolution of signs and symptoms of lacrimal obstruction was assessed. The mean follow-up time was 18.1 months (range, 3 to 48 months). RESULTS: The silicone tube was placed successfully in all eyes except 1 (98%). The mean procedure time was 26 minutes for each eye (range, 15 to 45 minutes). Both Prolene guides spontaneously emerged from the nose in only 8 eyes (16%). In the others, one or both Prolene guides were retrieved with a hook. Inadvertent tube dislodgement occurred in 21% of the eyes and required early tube removal. Success, ie, relief of signs and symptoms, was achieved in 86% of eyes. CONCLUSIONS: The Ritleng method of intubation for congenital nasolacrimal duct obstruction yields a high rate of success. Contrary to previous reports, our experience suggests that the surgeon must be prepared to retrieve the Prolene guide from the nose.     

Inaccuracy of diagnosis in a cohort of patients on the waiting list for dacryocystorhinostomy when the diagnosis was made by only syringing the lacrimal system

PURPOSE: Accurate identification of the factors contributing to epiphora is essential in directing appropriate management and treatment strategies. The authors applied a methodical strategy of assessment for epiphora to patients who were already on the waiting list for dacryocystorhinostomy (DCR). The findings were compared to the original findings. METHODS: Forty-four eyes of 35 patients listed for DCR were re-examined. All canaliculi were examined using four tests: dye disappearance, Jones 1 (dye retrieval), probing using Bowman probes, and syringing of the nasolacrimal duct (NLD) under local anesthesia. Some patients were examined using an endocanalicular mini-endoscope. Patients with NLD obstruction underwent DCR and those with canalicular and NLD stenosis underwent intubation of the lacrimal system-canaliculus, lacrimal sac, and nasolacrimal duct-using silicone stents. The authors refer to this as canaliculodacryocystoplasty (CDCP). The patients were assessed for symptoms of epiphora at 12 months. Forty-four eyes had been listed for DCR. They had been originally diagnosed, by means of lacrimal syringing, as NLD obstruction (24 eyes) or stenosis (12 eyes), and functional blocks (8 eyes). RESULTS: Four out of the original 44 planned DCR surgeries were performed after re-evaluation. After re-examination, 28 lacrimal systems were found to have canalicular stenosis, 4 NLD stenosis, 4 NLD obstruction, 4 punctal phimosis, 3 ocular surface disease, and 1 patient was asymptomatic. Twenty-eight lacrimal systems underwent CDCP, 4 underwent DCR, 4 had punctoplasty, and 4 had probing alone. Three had treatment for ocular surface disease and one patient required no treatment. After a follow-up of 12 months, 41 (93%) systems had improvement or were free of their CONCLUSIONS: Syringing of the lacrimal apparatus may result in a high false positive diagnosis of NLD obstruction. Canalicular pathology is not uncommon in this cohort of patients and may be underdiagnosed.