Treatment of Obstruction

Traditional Surgical Treatments

Nasolacrimal Duct Obstruction (NLDO) and Surgical Treatment Techniques

Nasolacrimal duct obstruction (NLDO) poses a common challenge in ophthalmology, affecting both pediatric and adult patients. This condition results from the blockage of the nasolacrimal drainage system, leading to epiphora, mucopurulent discharge, and discomfort. Various surgical techniques address NLDO, each with distinct benefits. Let us explore these modalities in detail:

1. Probing and Irrigation

Indications: Probing and irrigation serve as initial interventions, especially in infants. When conservative management (massage and topical antibiotics) fails, probing becomes essential. Procedure:

  • The ophthalmologist gently inserts a probe through the punctum, navigating it through the lacrimal drainage pathway.
  • The goal is to break down adhesions or blockages.
  • Probing is often performed under local anesthesia. 
  • Benefits:
    • Effective in many cases.
    • Minimally invasive.
    • Provides immediate relief in appropriately selected patients.

!Probing and Irrigation

2. Balloon Dacryoplasty (DCP)

Overview: Dacryoplasty involves balloon catheter dilation and is performed under general anesthesia. Procedure:

  • A deflated balloon catheter is inserted into the nasolacrimal duct.
  • Inflation dilates the obstructed area, widening the drainage passage.
  • Ideal for congenital NLDO cases where probing and irrigation have failed. 
  • Benefits:
    • Minimal scarring.
    • Expedited healing.
    • Reduced bruising and swelling.

!Balloon Dacryoplasty

3. Endoscopic Dacryocystorhinostomy (Endoscopic DCR)

Indications: Persistent NLDO cases unresponsive to conservative measures. Procedure:

  • Performed under general anesthesia.
  • An endoscope provides direct visualization to create a new drainage pathway between the lacrimal sac and nasal cavity.
  • Bone and tissue removal establish a direct connection.
  • Effective in both adults and children. 
  • Benefits:
    • Better illumination and magnification.
    • Potentially shorter surgical time.
    • Minimal scarring.
    • Early treatment option for acute dacryocystitis.

!Endoscopic DCR

4. Silicone Stent Intubation

Indications: Used in refractory NLDO cases. Procedure:

  • A silicone stent maintains patency by remaining in the nasolacrimal duct for several months.
  • Suitable for both congenital and acquired NLDO. 
  • Benefits:
    • Continuous drainage support.
    • Can be combined with other techniques.

!Silicone Stent Intubation

5. External Dacryocystorhinostomy (External DCR)

Indications: Used when endoscopic approaches are not feasible or unsuccessful. Procedure:

  • Performed under local or general anesthesia.
  • An oculoplastic surgeon creates an external incision near the medial canthus.
  • Directly connects the lacrimal sac to the nasal cavity.
  • Potential complications include visible scars and prolonged healing. 
  • Benefits:
    • Effective for both congenital and acquired NLDO.
    • Allows direct visualization of the lacrimal sac.

 

!External DCR

In summary, individualized management of NLDO involves thorough evaluation and informed decision-making. Whether probing, balloon dacryoplasty, endoscopic DCR, or silicone stent placement, ophthalmologists strive to restore tear drainage and improve patients’ quality of life.

 

 

 

 

 

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Probe / Intubate

 

Probe / Intubate
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  • The photograph to the right is immediately after surgery.
  • Note that the typical skin incision is quite small, often follows the curve, and is closed with skin sutures.

3 weeks after left DCR, incision is barely noticeable

ENDOSCOPIC DCR

Challenges of External DCR:

  • External DCR has its share of potential issues, as Dr. Lee highlighted. These include visible hypertrophic or hyperpigmented scars, suboptimal healing (especially in patients with darker skin tones), and the need for sutures and wound care due to the cutaneous incision. Patients must also guard against infection at the surgical site. Additionally, there’s a risk of weakening the orbicularis muscle and potential lagophthalmos.

The Endoscopic Approach:

  • Why opt for endoscopic DCR? Firstly, the endoscope provides superior illumination and magnification, making it an excellent educational tool. Compared to external DCR, the endoscopic procedure may reduce surgical time, expedite healing, and minimize bruising and swelling. It also offers an early treatment option for acute dacryocystitis.
  • Dr. Lee emphasized that informed patients, having studied various approaches, may specifically request endoscopic DCR to avoid facial scarring.
  • Acknowledging their expertise lies primarily in eye-related matters, Dr. Lee acknowledged that ophthalmologists have limited experience with nasal procedures beyond this surgery. Managing bleeding during endoscopic DCR can pose an additional challenge. However, it remains their duty to educate patients about available options. Even if they don’t perform the procedure themselves, they can refer patients to ENT specialists or oculoplastic colleagues.

Success Rates:

  • While reports tout high success rates (90%-95%) for endoscopic DCR, Dr. Lee cautioned that some studies indicate lower outcomes. The reasons behind these variations warrant further exploration.

In summary, the debate between external and endoscopic DCR continues, and informed decision-making remains paramount.

 

BALOON DCP

 

 

 

 

STEP 1:

The LacriCATH ® balloon catheter (shown in the picture) is inserted through an opening in the corner of the eye and down into the tear duct .® balloon catheter (shown in the picture) is inserted through an opening in the corner of the eye and down into the tear duct .balloon catheter (shown in the picture) is inserted through an opening in the corner of the eye and down into the tear duct .

Step 1  - Pediatric LacriCath
 
STEP 2:

The balloon catheter is inflated with sterile water to dilate the tear duct for a period of 90 seconds. It is then deflated, and reinflated for 60 seconds.

Step 2  - Pediatric LacriCath
 
STEP 3:

The balloon catheter is then repositioned slightly higher in the duct and inflated twice as in step 2.

Step 3 - Pediatric LacriCath

The balloon catheter is then deflated and removed.

Here you can see the balloon as it is inflated within the nose Here you can see the balloon as it is inflated within the nose
Here you can see the balloon as it is inflated within the nose

Movies of Surgical Lacrimal Duct Procedures

 

Lacrimal Stents 

 

CDCR / JONES tube / PG tube

If the "tear duct" obstruction is beyond repair, It may possibly be necessary to surgically implant an artificial "tear duct" behind the inner corner of the eyelids to drain the tears into the nose. The artificial "tear duct" is made of Pyrex glass and is called a "Jones tube." or Putterman-Gladstone (PG) tube.

CDCR / JONES tube / PG tube

These may possibly be purchased at Gunther Weiss Glass Science, located in Portland Oregon. 503-644-3507

Dacryocystorhinostomy surgery provides relief to millions of people every year who suffer from tear duct problems ranging from collapsed tear ducts and excessive tearing caused by accident or injury, birth defects or environmental strain. Left untreated, patients may possibly experience swelling, infections, increased swelling, tearing ("wet eye") and severe pain.

In 1961, Lester T. Jones and Gunther Weiss paired up to develop a solution for tear duct problems. They developed highly specialized glass tubes (called "Lester T. Jones Tear Duct Tubes") designed for insertion into the nasolacrimal duct. The body develops scar tissue around the tube, which holds it in place, forming a new permanent tear duct.

Gunther Weiss Scientific Glass Blowing Company offers Lester T. Jones Tear Duct Tubes in a variety of lengths and diameters to address most patient needs. In adds to, tubes can be custom-fabricated to accommodate unique angles and sizes