Dacryocystorhinostomy

Congenital or within the first few months of life?

• In newborns and infants, the most common site of obstruction is distally at the valve of Hasner, where canalization is often incomplete at the time of birth. In most patients, congenital nasolacrimal duct obstruction will resolve by the age of 6 to 12 months, so probing of the lacrimal system should be delayed until the end of the first year of life. Probing of the lacrimal system is most often curative at this age.

Complete medical history

• Bleeding/clotting disorders

• Hypertension-related pathology

• If the patient will be under general anesthesia, evaluation by the primary physician is frequently necessary.

In 8% to 14% of DCR surgeries, dacryoliths composed of precipitated organic material will be found.

• Affected patients may complain of intermittent tearing and pain and demonstrate a distended, tender lacrimal sacs but minimal or no inflammation.

• Alternatively, the dacryolith may mimic complete obstruction and occasionally cause acute dacryocystitis.

Patients may complain of tearing for one of three reasons:

• Hypersecretion of tears

  • Primary hypersecretion of tears is uncommon.

  • Secondary hypersecretion is a frequent cause of tearing.

    • May be due to a variety of ocular surface disorders, some as benign in nature as seasonal allergy. Associated symptoms and signs will help in making these diagnoses, and their proper treatment should proceed before surgical repair.

• Reflex hypersecretion in patients with ocular surface dryness (as in those with Graves disease) must be addressed by referral to an Ophthalmologist.

  • Abnormal eyelid position can cause reflex tearing by rubbing of lashes against the cornea or by desiccation of the cornea as a result of inadequate blinking or closure.

    • Patients’ complaints will assist in making the diagnosis inasmuch as those with surface disorders causing reflex hypersecretion will complain of burning and a foreign body sensation.

    • Fluorescein drops instilled into the conjunctival cul-de-sac will highlight defects in the corneal epithelium when viewed with a cobalt blue filter on a penlight in patients with dry eye.

• Impaired drainage of tears

  • In adults, tearing secondary to insufficient lacrimal drainage is common.

    • Functional obstruction includes poor function of the medial canthal lacrimal pump, usually secondary to eyelid malposition or aberrant anatomy.

    • Physical obstruction may occur at the level of the punctum, canaliculus, common canaliculus, lacrimal sac, or nasolacrimal duct. The latter two account for about 74% of lacrimal outflow obstructions and are treated with greater than 90% success by external DCR surgery.

• Combination of both hypersecretion and underdrainage

  • Most patients referred to an Otolaryngologist with complaints of tearing will already have been evaluated by an Ophthalmologist and treated for ocular surface disorders causing hypersecretion. If not, ophthalmologic evaluation should proceed before any consideration of lacrimal surgery for correction of tearing.

Complete endonasal examination, with particular attention paid to the distal end of the nasolacrimal duct beneath the inferior turbinate, should be performed in the office.

• Occasionally, physical obstruction of the ostium is visible and readily treated.

• Significant rhinitis should also be treated before surgical correction because it also rarely causes functional obstruction.

• Note of any septal defects or deviation is important, particularly if an endonasal approach is selected.

Dilation and irrigation of the lacrimal system in the office can be used to localize the outflow blockage.

• Probing of the lacrimal system, however, has no place in adult patients. This procedure is rarely if ever curative and will cause significant patient discomfort. In addition, there is a risk of trauma to the delicate mucosa-lined canalicular system, which is a considerably more difficult problem to treat than nasolacrimal duct obstruction.

• Quick, easy passage of saline into the nasopharynx after topical anesthesia and gentle injection into the canaliculus may call into question the diagnosis of lacrimal obstruction.

  • However, this will often occur in the setting of a dacryolith because the liquid will drain around the object.

  • It is also sometimes possible to open the nasolacrimal duct with forceful injection, but resistance will be palpable and indicates that the system is probably functionally obstructed (i.e., not functioning under the normal very low physiologic generation of negative pressure).

• The physician should note the speed and volume of flow, in addition to the presence of resistance or frank reflux of fluid.

  • Reflux in the presence of resistance to flow indicates obstruction.

  • If reflux occurs from the canaliculus being injected or if resistance to easy passage of a 22-gauge or smaller cannula is felt, canalicular obstruction is present, and DCR may not be appropriate.

  • Reflux of fluid from the opposite lid suggests obstruction distal to the common canaliculus, and DCR is likely to be curative.

May not be necessary in straightforward cases of lacrimal outflow obstruction

Mandatory in children who develop tearing at some point after birth (i.e., acquired not congenital nasolacrimal duct obstruction) in the presence of normal eyelids; this suggests development of a mass

• Magnetic resonance imaging (MRI) of the face with gadolinium

Computed tomography (CT) of the orbits and sinuses may be ordered in some situations to evaluate sinus and nasal anatomy and whenever a mass is suspected. It is particularly helpful where there is a history of previous facial trauma.

• CT of the face with or without intravenous (IV) contrast

Dacryoscintigraphy may be useful to pinpoint the area of obstruction, but irrigation in the office can usually localize the point of obstruction.

Acquired obstruction of the nasolacrimal duct

Acute dacryocystitis with an abscess unresponsive to antibiotic therapy

• Patients complain of tearing, discharge, swelling, and pain over the lacrimal sac.

• Some cases proceed to periorbital cellulitis before diagnosis, so a high index of suspicion in this setting must be maintained.

• Pressure over the sac produces purulent reflux from the punctum, which is often quite painful for the patient.

• Probing or irrigation at this time is useless and may complicate the situation.

• About two-thirds of acute infections grow gram-positive organisms in culture, and about 7% are anaerobic. Treatment of acute infection consists of at least 3 weeks of oral antibiotic, antibiotic-steroid drops, and warm compresses.

• An abscess in the area requires prompt percutaneous drainage, often possible in the office under local anesthesia. The sac may then be irrigated with antibiotic solution. Occasionally, poor response to oral therapy will require intravenous antibiotic treatment and prompt surgery.

  • This may, however, lead to a lacrimal fistula draining to the skin.

Endonasal DCR has enjoyed renewed interest since the 1980s but is less preferred because of lagging success rates and expense. Recent reports suggest that the technique is becoming more successful.

In the presence of any suspicion of a mass in the lacrimal system, external DCR with biopsy is mandatory.

• The symptom of bloody tears is particularly worrisome for the presence of a tumor.

• Palpation of a mass superior to the medial canthal tendon also suggests a lacrimal sac abnormality.

If a mass is suspected or found at surgery, it may be possible to complete the DCR if the sections are benign, if intraoperative frozen sections are available. If malignancy is found, however, dacryocystectomy with appropriate margins should be performed and creation of an ostium into the nose avoided.

Successful DCR requires a functional upper outflow system.

• Treatment of upper system (punctum, canaliculus, and common canaliculus) obstruction must be undertaken either separately or in the setting of surgical DCR.

  • Punctal stenosis may be treated by various punctoplasty techniques.

  • Canalicular stenosis may be treated with silicon intubation, generally only in the setting of incomplete obstruction.

  • Common canalicular stenosis may sometimes be treated in the setting of DCR by silicon intubation.

  • If intractable upper system obstruction is present, primary conjunctivodacryocystorhinostomy with placement of a Jones tube is necessary.