Figure 5 After resection of the redundant mucosal edges, wide exposure must be confirmed. Note the location and exposure of the common internal punctum, a critical step in the procedure. (Reprinted with permission from Ramakrishnan VR, et al: Outcomes after endoscopic dacryocystorhinostomy without mucosal flap preservation. Am J Rhinol 2007(21):753-757, OceanSide Publications, Inc.)

with microscissors or a small angled microdebrider. Wide exposure of the common internal punctum, and opening several millimeters superior to this landmark must be achieved (Figure 5). Elevation and dissection of the medial lacrimal sac may be challenging in the revision case due to scarring and obliterated tissue planes. “Tenting” of the sac can help tremendously during this portion of the case, further defining the surgical target.

Throughout the procedure, care is taken to keep bone exposure to a minimum through meticulous dissection. When exposed bone is observed, portions of the mucosal flaps may be preserved and laid over the exposed areas in hopes of reducing postoperative stenosis. It is our opinion that redundant mucosal edges may lead to web formation and ostial stenosis, so we prefer to trim the edges of the flaps. When finished, ostium size should range from 10 to 20 mm in the vertical dimension and 10 to 15 mm in the horizontal dimension. In the revision case, middle turbinate instability may need to be addressed by either partial resection or stabilization to the septum with an anchoring suture. Silicone lacrimal intubation stents are routinely placed and tied intranasally. Additional packing is avoided.

Additional considerations

Stents are left in place as long as tolerated, which has been a topic of controversy. Contrary to previous studies, a recent prospective randomized study demonstrated improved success at 6 months when silicone stents were not used.19 At this time, their routine use is a part of our practice.

Results with the intraoperative use of topical mitomycin have been inconclusive, although its use has generally been considered safe at a number of concentrations.20-22 In a prospective controlled study, topical mitomycin C applied

intraoperatively for 2 minutes demonstrated a statistically significant correlation between concentration used and postoperative ostium size as measured endoscopically at 6 months.23 If we accept the hypothesis that success is a function of ostium size, then perhaps this may be of benefit. However, that link has not yet been established. We have elected to use topical mitomycin in patients with systemic inflammatory disorders such as sarcoidosis or Wegener’s granulomatosis, or in patients who have failed after at least one previous revision surgery.

The patient is placed on nasal saline spray four times daily, as well as saline irrigations beginning at 1 day after the procedure. Combination antibiotic-steroid eye drops are used for 5 days. Oral antibiotics and oral steroids are not routinely administered, but they may be given based on intraoperative findings. Endoscopic examination and debridement of the surgical site is performed at 1 week and 4 weeks after the procedure. Steroids, oral and/or intranasal, may be used if granulation or erythema is noted on endoscopic examination. Some authors have advocated the use of injected triamcinolone in the presence of prolonged granulation at the ostium.

Complications

Complications are infrequent with this technique. Intranasal complications include ostial scarring and stenosis, middle turbinate destabilization, and epistaxis. Intraoperative cerebrospinal fluid leak has been reported, but appears to be related to performance of adjunctive intranasal procedures. Rare orbital complications, such as fat herniation, orbital emphysema, medial rectus injury, and retrobulbar hemorrhage, may occur. Stent-related complications include stent prolapse and rare punctal erosion.

Discussion

A number of studies have established the efficacy of endoscopic DCR in the treatment of NLDO. Limited data exist regarding outcomes from revision endoscopic DCR, and these are inherently difficult to interpret given the etiology of recurrent or persistent disease. These studies and our personal experience suggest a success rate for revision endoscopic DCR in the 76-100% range. Common causes of failure include improper placement of the osteotomy, incomplete osteotomy, ostial stenosis, obstructive synechiae or granulation, lateralization of the middle turbinate, and concurrent sinonasal disease such as septal deviation and anterior ethmoid mucosal disease. Meticulous primary surgery and continued medical management of mucosal disease can prevent the occurrence of some of these factors. If encountered, most will be easily managed with revision endoscopic DCR. However, a subset of patients with functional NLDO may not improve with revision surgery. Additionally, patients who have undergone multiple revisions will also have a decreased chance of success. Nonetheless, endoscopic approaches to revision cases offer distinct advantages of improved visualization, hemostasis, and the ability to address concurrent intranasal factors. At its core,

the same principles of primary endoscopic DCR apply, namely (1) thorough anatomic understanding, (2) wide exposure of the sac, and (3) complete incision and marupialization of the lacrimal mucosa. These goals are facilitated by technologic improvements in videoscopy and instrument design. The intraoperative use of mitomycin and maintenance of postoperative stents are still controversial at this time, but may have a role in selected patient populations.

References

1.Dolman PJ: Comparison of external dacryocystorhinostomy with nonlaser endonasal dacryocystorhinostomy. Ophthalmology 110:78-84, 2003

2.Woog J, Kennedy RH, Custer PL, et al: Endonasal dacryocystorhinostomy. A report by the American Academy of Ophthalmology. Ophthalmology 108:2369-2377, 2001

3.Tsirbas A, Davis G, Wormald PJ: Mechanical endonasal dacryocystorhinostomy versus external dacryocystorhinostomy. Ophthal Plast Reconstr Surg 20:50-56, 2004

4.Ben Simon GJ, Joseph J, Lee S, et al: External versus endoscopic dacryocystorhinostomy for acquired nasolacrimal duct obstruction in a tertiary referral center. Ophthalmology 112:1463-1468, 2005

5.Welham R, Wulc A: Management of unsuccessful lacrimal surgery. Br J Opthalmol 71:152-157, 1987

6.Linberg JV, Anderson RL, Busted RM, et al: Study of intranasal ostium external dacryocystorhinostomy. Arch Ophthalmol 100:17581762, 1982

7.Mann BS, Wormald PJ: Endoscopic assessment of dacryocystorhinostomy ostium after endoscopic surgery. Laryngoscope 116:1172-1174, 2006

8.Demarco R, Strose A, Araújo M, et al: Endoscopic revision of external dacryocystorhinostomy. Otolaryngol Head Neck Surg 137:497-499, 2007

9.Tsirbas A, Davis G, Wormald PJ: Revision dacryocystorhinostomy: A comparison of endoscopic and external techniques. Am J Rhinol 19: 322-325, 2005

10.Jones DT, Fajardo NF, Petersen RA, et al: Pediatric endoscopic dacryocystorhinostomy failures: who and why? Laryngoscope 117: 323-327, 2007

11.Wormald PJ, Tsirbas A: Investigation and endoscopic treatment for functional and anatomical obstruction of the nasolacrimal duct system. Clin Otolaryngol Allied Sci 29:352-356, 2004

12.Mansour K, Blanksma LJ, Vrakking H, et al: Scintigraphic evaluation for tear drainage, after dacryocystorhinostomy, in relation to patient satisfaction. Eye 22:414-419, 2008

13.Brewis C, Yung M, Merkonidis C, et al: Endoscopic dacryocystorhinostomy in functional lacrimal obstruction. J Laryngol Otol 27:1-3, 2007

14.Ramakrishnan VR, Hink EM, Durairaj VD, et al: Outcomes after endoscopic dacryocystorhinostomy without mucosal flap preservation. Am J Rhinol 21:753-757, 2007

15.Cokkeser Y, Evereklioglu ERH: Comparative external versus endoscopic dacryocystorhinostomy: results in 115 patients. Oto HNS 123: 488-491, 2000

16.Massegur H, Trias E, Adema JM: Endoscopic dacryocystorhinostomy: Modified technique. Oto HNS 130:39-46, 2004

17.Wormald PJ, Kew J, Van Hasselt A: Intranasal anatomy of the nasolacrimal sac in endoscopic dacryocystorhinostomy. Oto HNS 123:307310, 2000

18.Umapathy N, Kalra S, Skinner DW, et al: Long-term results of endonasal dacryocystorhinostomy. Oto HNS 135:81-84, 2006

19.Smirnov G, Tuomilehto H, Teräsvirta M, et al: Silicone tubing is not necessary after primary endoscopic dacryocystorhinostomy: A prospective randomized study. Am J Rhinol 22:214-7, 2008

20.Selig YK, Biesman BS, Rebeiz EE: Topical application of mitomy- cin-C in endoscopic dacryocystorhinostomy. Am J Rhinol 14:205-207, 2000

21.Roozitalab MH, Amirahmadi M, Namazi MR: Results of the application of intraoperative mitomycin C in dacryocystorhinostomy. Eur J Ophthalmol 14:461-463, 2004

22.Liao SL, Kao SC, Tseng JH, et al: Results of intraoperative mitomycin C application in dacryocystorhinostomy. Br J Ophthalmol 84:903-906, 2000

23.Deka A, Bhattacharjee K, Bhuyan SK, et al: G. Effect of mitomycin C on ostium in dacryocystorhinostomy. Clin Experiment Ophthalmol 34:557-561, 2006

KEYWORDS

Dacryocystorhinostomy; Endoscopic surgery; Balloon dilation; Nasolacrimal duct obstruction;

Epiphora

The goal of dacryocystorhinostomy is to create a fistula between the nasolacrimal sac and the nasal passageway to bypass nasolacrimal duct obstruction. Traditional external approaches have a very high success rate, but the disadvantages are numerous. Patients may have excess blood loss and facial ecchymosis as the result of injury to the angular artery, unsightly and uncomfortable scarring, as well as potential for diplopia as the result of injury of the inferior oblique muscle, which originates near the lacrimal crest. Endoscopic balloon-assisted dacryocystorhinostomy offers decreased postoperative sequelae, with less surgical time and decreased patient recovery time. The use of balloon-catheter dilation simplifies nasal manipulation and obviates the use of power instrumentation in most cases.

© 2008 Elsevier Inc. All rights reserved.

The traditional surgical treatment of nasolacrimal duct obstruction is external dacryocystorhinostomy (DCR), which was introduced by Toti in 1904.1 Several modifications have occurred, such as suturing of flaps, silicone tube intubation, and variations in the size and location of the incision, but the basic procedure is unchanged.2,3 The endonasal approach had changed significantly since its first introduction in 1893 by Caldwell, principally with the introduction of the rigid endonasal endoscope.4,5 The transnasal balloon catheter was introduced by Becker in 2002 as a simple and less traumatic alternative to incisional DCR.

The goal of DCR surgery is to bypass nasolacrimal duct obstruction (NLDO) by creating a fistula between the nasolacrimal sac and the nasal passageway. Traditional external approaches have a very high success rate of 91% to 100%, whereas endoscopic DCR has a lower success rate of 59% to 100%.6 The disadvantages of an external approach include the potential for excess blood loss and facial ecchymosis due to injury to the angular artery, unsightly and uncomfortable scarring, possible injury to the inferior oblique muscle which originates near the lacrimal crest, and disruption of the medial canthal anatomy and lacrimal pump function. Endoscopic balloon-assisted dacryocystorhinostomy offers decreased postoperative sequelae with less sur-

Supported in part by an unrestricted RPB Challenge Grant, Research to Prevent Blindness, New York, New York.

Address reprint requests and correspondence: Gabriela M. Espinoza, MD, Saint Louis University Eye Institute, 1755 South Grand Boulevard, Saint Louis, MO 63104.

E-mail address: gespinoz@slu.edu.

gical time and decreased patient recovery time. The use of balloon-catheter dilation simplifies nasal manipulation and obviates the use of power instrumentation in most cases.

Patient selection

General guidelines for surgical intervention of epiphora include significant symptoms of tearing, mattering of the eyelashes, recurrent or chronic dacryocystitis, and failure of measures directed at treating reversible causes of functional NLDO. Clinical examination and history will rule out hypersecretion of tears due to allergies, blepharitis, ocular foreign bodies, or dry eye. Eyelid malposition, abnormal blink, and congenital abnormalities should also be taken into consideration as failure to address these issues affect outcome.

The expression of clear or purulent fluid with gentle pressure over the lacrimal sac is confirmation of complete nasolacrimal duct obstruction. If there is no reflux, it is my preference to perform a simplified Jones irrigation test. A lacrimal irrigation cannula (23 or 27 gauge) on a waterfilled 3-mL syringe is inserted through the lower punctum and into the canaliculus. While the patient’s head is slightly reclined, water is gently irrigated into the sac. The patient is instructed to raise a hand if and when they feel fluid in their nose or pharynx. Immediate passage of fluid indicates a functional NLDO. If there is reflux of fluid with delayed passage, then there is likely a partial NLDO. Reflux of clear fluid with distension of the lacrimal sac is indicative of a complete NLDO.

Figure 1 A Bowman #3 probe is pushed through the thin wall of the nasolacrimal fossa into the middle meatus just anterior to the insertion of the middle turbinate.

Figure 2 The balloon catheter is brought up the nose and pushed halfway through the opening in the lateral nasal wall using the Bowman probe as a guide.

tored anesthesia care with sedation. Lidocaine 2% with epinephrine mixed 5:1 with bicarbonate is injected transconjunctivally directly into the nasolacrimal sac fossa after sedation. This same mixture is then injected submucosally using a 25-gauge spinal needle into the middle meatus just anterior and inferior to the insertion of the middle turbinate under direct visualization using a headlight and nasal speculum.

After the local injections are given, 1/2-inch cottonoids soaked in 4% cocaine in the awake patient and oxymetazoline hydrochloride 0.05% nasal spray in the asleep patient are packed into the middle meatus using bayonet forceps, a nasal speculum, and a headlight. The patient is prepped and draped with equipment set up as usual for routine endoscopic sinus surgery. The surgical approach is initiated with dilation of the upper and lower punctum using a punctal dilator. Care is taken to avoid trauma to the canaliculi which may cause late stenosis. The canaliculi are then serially dilated using a 1, 2, and then 3 Bowman probe. The nasolacrimal fossa can be felt as a hard stop with the tip of the Bowman probe. Gentle exploration of the fossa with constant firm pressure will often lead to the discovery of the suture line between the lacrimal and maxillary bones

Figure 3 The Bowman probe is withdrawn and the balloon catheter is gradually inflated to 8 atm with a dramatic enlargement of the ostium. Pressure is held for 90 seconds and then repeated for 60 seconds after readjusting the position of the catheter.

through which the probe can easily be popped through the thin bone (Figure 1).

At this point, the nasal packing is removed and a 0-de- gree endoscope is introduced. The location of the ostium should be just inferior to the anterior insertion of the middle turbinate. If the middle turbinate is crowding over the ostium, it should be infractured with a Freer elevator. Under endoscopic control, the probe is then pulled back and redirected inferiorly in three or four additional adjacent spots. Join these areas by moving the probe or tenting the tissue with the probe into the nasal cavity and filet the sac open using a crescent knife. Digital palpation of the external nasolacrimal sac fossa will aid in expressing any dacryoliths that may be present in the sac. Canalicular saline irrigation and nasal suction may be performed at this time to further assist complete emptying of the nasolacrimal sac, especially if there is purulent material. A cottonoid may be packed posterior to the ostium during irrigation to reduce patient discomfort or aspiration from pharyngeal fluid. Any bleeding that occurs may be improved by repacking the nose with the cocaine or oxymetazoline soaked cottonoids until the bleeding stops.

The surgeon then sets up the 9-mm transnasal catheter (LacriCATH, Quest Medical, Inc., Allen, TX). The protective sleeve is removed from the balloon tip of the catheter and this is connected to the saline-primed inflation device

(LacriCATH, Quest Medical, Inc.). The Bowman probe is again passed through the superior canalicular system and visualized endoscopically in the nose. The balloon catheter is then placed into the nose and pushed through the opening in the lateral nasal wall into the lacrimal sac, using the Bowman probe as a guide (Figure 2). The Bowman is gradually withdrawn as the device is pushed into position. The balloon is gradually inflated to 8 atm of pressure and left in place for 90 seconds. The balloon is then deflated and repositioned into the enlarged ostium, then gradually inflated to 8 atm for 60 seconds (Figure 3). The balloon is fully deflated, and then the catheter is withdrawn. Endoscopic visualization of the ostium confirms that a good opening has been achieved. Any bone fragments can be pushed into the nose using the Bowman probe and removed using bayonet forceps or Blakesley forceps.

Next, the canalicular system is intubated with a large diameter silicone tube (STENTTube, Quest Medical, Inc.). The silicone tube is designed with a thin segment, 0.86 mm diameter, that is meant to span the medial canthus between the upper and lower puncta. The larger 1.3-mm diameter portion of the stent maintains the canaliculi and the soft tissue opening of the ostium into the nose. The silicone tube is swedged onto olive-tipped probes that are retrieved in the nose with a Crawford hook under endoscopic control (Figure 4). The tubes are then tied to themselves using a 4-0 Prolene suture and cut so that the ends retract into the nose.

Figure 4 The olive-tipped probes are passed through the canaliculi and the ostium and should enter easily into the nose. The tubes are retrieved with a Crawford hook and tied to themselves, cut, and allowed to retract into the nose.