Stent placement, which will be described in Sect. 3.7, should be selected with caution as a Þrst-line therapeutic option in patients who refuse surgical procedures or cannot be given general anaesthesia. Although the initial results of stent placement in patients with complete obstructions of the lacrimal drainage system are excellent, long-term results have to be improved.

In 1978, Hanafee and Dayton Þrst described the use of radiologic technology for interventional application in the lacrimal system [26]. In a small number of patients they dilated native nasolacrimal ducts (NLD) using sialography cannulas under ßuoroscopic guidance with a low success rate.

In 1989 Becker and Berry [5], followed by Munk et al. in 1990 [62], reported on the use of radiological instrumentation. Becker and Berry introduced a 3Ð4mm coronary angioplasty catheter through the cannaliculus in an antegrade approach, whereas Munk et al. introduced a 3Ð4-mm tibial angioplasty catheter through the inferior opening of the nasolacrimal duct in a retrograde approach. Meanwhile special lowproÞle dacryocystoplasty catheters have been designed

allowing safe balloon dilation performed antegradely using the transcanalicular access [87, 89]). Therefore no further nasal manipulation is necessary, resulting in greater patient comfort and acceptance of the procedure.

3.6.1 Indications for Balloon Dilatation

Balloon DCR surgery is used in children and adults with partial or incomplete stenoses of the canaliculi and the nasolacrimal duct [32, 41, 44, 74, 88, 92] and in adults with complete stenoses of the nasolacrimal duct.

The Lacricath System (Quest Medical Inc., Allen, Texas, USA; NMP Neuwirth Medical Products GmbH, Obernburg, Germany) is speciÞcally designed for the treatment of the lacrimal system and has different balloons for different clinical situations and is described below:

Two millimetres (Fig. 3.9) Ð incomplete stenosis in children younger than 30 months (dacryoplasty (DCP) )

Three millimetres Ð incomplete stenosis in children older than 30 months or in adults (dacryoplasty) Five millimetres (Fig. 3.10 aÐc)Ð complete stenosis, revision DCR

Nine millimetres (Fig. 3.11) Ð complete stenosis, revision DCR Ð transnasally

3.6.2 Anaesthesia for Balloon Dilatation

In contrast to most surgical procedures, balloon dilation can be performed as an outpatient procedure under local anaesthesia, except in children who do not cooperate with the procedure.

3.6.3Surgical Technique with 2 mm or 3 mm Balloon for Incomplete Stenosis

Fig. 3.9 Balloon dilatation with Lacricath¨ system in complete stenosis of nasolacrimal duct in an adult (5 mm balloon) (schematic drawing). With permission from Quest Medical, Inc., An Atrion Company as well as Bruce Becker, MD

A Þne-tipped punctal dilator is selected to perform atraumatic, bloodless superior punctal dilation. After gentle and thorough punctal dilation has been

c

Fig. 3.10 Balloon dilatation with Lacricath¨ system in incomplete stenosis of nasolacrimal duct (2 mm balloon). (a) Deßated. (b) Inßated. (c) Schematic drawing. With permission from Quest Medical, Inc., An Atrion Company as well as Bruce Becker, MD

completed, lacrimal probes are used to dilate the superior canaliculus carefully and gradually. If the nasal mucosa is adequately decongested, the endoscope should allow a good view of the area beneath the inferior turbinate near the valve of Hasner, thereby conÞrming a successful probe passage. In some instances, the inferior turbinate must be infractured in order to allow adequate visualisation. When necessary, this should be done as atraumatically as possible to avoid

bleeding, which can obstruct the view. Suction may be necessary if signiÞcant bleeding occurs. If passage of a lacrimal probe is not possible, it is highly unlikely that the balloon catheter will pass successfully.

The balloon catheter is lubricated with ophthalmic antibiotic ointment and passed through the superior canaliculus until it reaches a Òhard stopÓ in the lacrimal sac. As the balloon catheter is slid along the bony medial wall, the tip is directed inferiorly and posteriorly through the NLD. The balloon catheter device is advanced down the NLD until it is visible beneath the inferior turbinate by endoscopy. The tip of the balloon catheter is advanced at least 2 mm beyond the valve of Hasner. Often, this position places the punctum between the two black rings on the anterior working end of the balloon catheter device. If the proximal ring is visible on the catheter, the device is advanced until that ring rests at the superior punctum prior to initial inßation. The inßation device, with dead space evacuated, is attached to the proximal end of the balloon catheter. The balloon is inßated and afterwards gently retracted up the NLD until the distal ring of the catheter rests at the superior punctum. Here, the balloon is again inßated. The dilation is complete at this point, and the balloon is completely deßated by vigorous aspiration with a 10-mL Luer-Loc syringe. The catheter is removed through the upper punctum and canaliculus while being aspirated. Irrigation of the lacrimal drainage system may be performed at this point

with a ßuorescein-tinted saline solution instilled via a syringe connected to a 23-gauge lacrimal cannula inserted into the canaliculus. Retrieval of ßuoresceintinted ßuid in the nose is accomplished with a soft suction catheter and conÞrms patency of the NLD. Treatment with topical antibiotics is initiated in the operating room or in the recovery room. Silicone tubes can be used, but there is no proof of efÞcacy.

3.6.3.1 Post-Operative Care

Topical antibiotic or combined antibiotic/steroid drops, such as gentamicin and prednisolone acetate 1% are administered 4 times daily for 10Ð14 days post-operatively. An age-appropriate nasal decongestant may be administered for 3Ð4 days after surgery.

3.6.3.2 Complications

Complications following pediatric balloon DCP include failed surgery, creation of false lacrimal passages, canalicular stenosis, and epistaxis.

3.6.3.3 Results

Reported success rates of balloon DCP vary greatly. It is difÞcult to compare cases that include studies done outside the United States with those done in the United States using the Atrion system, as the balloons and the method of balloon placement are considerably different. Many studies include patients with both incomplete and complete nasolacrimal obstructions. True long-term (more than 5 years) success rates are also unknown, as lacrimal duct balloon technology is new and evolving.

Perry et al. reported a 6-month post-operative success rate of 73% in 15 patients with incomplete NLDO using the LacriCatheter; in this study, success was deÞned by patency to irrigation [64]. Berkefeld and colleagues reported that in 79% of 47 patients they were able to accomplish the procedure technically using a transnasal approach over a guidewire [7]. Six months following the procedure, 28 of 37 patients (76%) in whom the procedure was technically accomplished were free of epiphora, resulting in an overall success rate of 60% (28 of 47 patients). These researchers

identiÞed several risk factors for reocclusion, including active inßammation, dacryoliths, traumatic stenosis, and long nasolacrimal strictures. Yazici et al. reported a 25% success rate with DCP in patients with complete NLDO and a 50% success rate with the procedure in patients with incomplete obstruction (mean follow-up period of 14 months) [98]. Perry et al. have speculated that post-operative lacrimal intubation may be correlated with their higher long-term success rate [64].

In pediatric patients several authors have reported generally favourable outcomes treated with balloon catheter NLD dilation. Reported success rates for pediatric DCP generally exceed 90% [6, 31, 40].

3.6.4Surgical Technique with 5 mm Balloon for Complete Stenosis or Revision Cases of DCR According to Ref. [98]

Using the LacriCath 5 × 8-mm balloon, a true DCR ostium between the lacrimal sac and the nasal antrum is created or enlarged.

After punctal dilation, a size 3 or size 4, specially hardended, stainless steel lacrimal probe is passed through the superior punctum and canaliculus until a Òhard stopÓ in the lacrimal sac is reached. The probe is directed inferiorly and posteriorly to a weak and thin point in the bony wall between the lacrimal sac and the nasal cavity. Before pushing the probe through the wall of the lacrimal sac fossa, the nasal packing is removed. The nasal endoscope is then passed and directed toward the anterior tip of the middle turbinate. While viewing the intranasal area around the anterior tip of the middle turbinate, the lacrimal probe, which is already in the lacrimal sac, is slowly advanced. A bulge in the nasal mucosa may be seen as the probe begins to advance. Alternatively, no change in the nasal mucosa may be seen if the probe is entering the nasal cavity beneath the anterior tip on the middle turbinate. In this situation, an attempt is made to change the position of the tip of the lacrimal probe in order to allow the creation of the ostium just anterior and superior to the anterior tip of the middle turbinate. Positioning the ostium here may allow the surgeon to avoid any manipulation of the turbinate. At times, the ostium cannot be placed anywhere but beneath the anterior tip of the middle turbinate. In

this circumstance, the middle turbinate must be medialised or reduced so far as necessary. This can be done with through-cutting nasal forcepses or punges or a microdebrider. In some cases resecetion of the uncinate process is also necessary.

After the initial ostial opening is created by passage of a size 3 or size 4 lacrimal probe and the position of the ostium is optimised, the probe is repeatedly advanced out of a retracted back into the lacrimal sac in different locations to widen the ostium mechanically. The area of the intended ostium is, in effect, ÒhoneycombedÓ with small holes in preparation for the placement of the balloon catheter device. The perforations in the bone are made contiguously with size 3 or size 4 lacrimal probe. A lubricated, 5 × 8-mm balloon catheter is inserted through the superior punctum and canaliculus, through the common canaliculus and lacrimal sac, and then positioned in the ostium that was previously created with the probe. The endoscope is used to conÞrm correct positioning of the tip of the balloon catheter at least 2 mm past the nasal mucosa in the nasal cavity. Once the correct position is established, the balloon is attached to the inßation device and is inßated. At times, the balloon device may advance further into the nasal cavity during inßation. It is catheter tip is observed during inßation using the videoendoscope. The balloon is then deßated by releasing the pressure with the manometer. It is again positioned in the ostium using the endoscope. It is reinßated. During the second inßation, mucosal or bone fragments are carefully removed from around the perimeter of the ostium and balloon, using Þne ear forceps. It is important to remove any such fragments to minimise the risk of closure of the ostium during the healing process. Some surgeons may prefer to enlarge the ostium transnasally with a nerve hook or rongeurs. Following the second inßation, the balloon is completely deßated and removed. Endoscopic observation of the balloon tip in the nose conÞrms complete deßation of the balloon prior to withdrawal of the balloon catheter through the upper canaliculus and punctum. Mild resistance may be encountered during the withdrawal of the balloon device. For this reason, some surgeons elect to cut the shaft of the metal portion of the balloon catheter and remove the balloon end of the device through the nostril. This manoeuvre may reduce trauma to the canaliculus.

Secondary balloon DCRs can be performed in the same way as the primary, using the 5-mm diameter

balloon. Some surgeons may elect to additionally apply mitomycin C, 0.4 mg/cc, transnasally to the ostium via a 0.5 × 0.5-in. cottonoid for 5 min, after which the ostium is copiously irrigated transnasally [98]. After removal of the inßation device, a speciÞcally designed lacrimal stent (Stentube, Quest Medical, Allen, Texas, USA; NMP Neuwirth Medical Products GmbH, Obernburg, Germany) can be inserted. The tubing remains in position for 3 or 4 months. Some surgeons may elect to use a traditional lacrimal stent and leave it in place longer, rather than using the Sten tube.

The 9 mm balloon (Fig. 3.11) can be used for transnasal DCR, particularly in revision cases with scarring of the DCR opening. The author has no experiences and insights in the transnasal Lacricath@ procedure.

3.6.4.1 Post-Operative Care

Systemic and topical antibiotics are administered for 10Ð14 days post-operatively. Gentamycin is frequently selected for use as a topical ocular antibiotic and is administered every 2h while awake for the Þrst 2 days and continued four times daily for an additional 8 days.

Topical ocular and intranasal steroids are administered to reduce inßammation and scarring. Some authors [87] recommend additional systemic steroids for 10 days.

3.6.4.2 Results

Since the initial reports by Becker and Berry [6], several large series have attested to the efÞcacy of lacrimal balloon dilatation. Technical success rates of 89Ð95% have been reported. According to the experiences of Lee et al. with 430 eyes of 350 patients, the technical success rate and the overall initial improvement rate were 95 and 57%, respectively [44]. The 2-month, 1-year and 5-year improvement rates were 48, 39 and 37% respectively.

This technique can be successfully used in congenital dacryostenosis [30]. Wilhelm also found a cumulative clinical success rate in 98% after a mean follow-up of 18.4 months in 46 children (mean age 23.5 months) [88].

A 4-year, retrospective, sequential review of endoscopic, balloon-assisted DCR revealed an initial