Surgery of the lacrimal system

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CHAPTER 52 Surgery of the lacrimal system

See Video image

Background

Lacrimal surgery existed in the Middle Ages for the treatment of dacryocystitis from a blocked nasolacrimal duct, albeit restricted to crude external drainage of abscess and extirpation of the lacrimal sac. It is not until the late 18th century that more modern techniques for draining the tear sac into the nose were introduced and it took some years for such dacryocystorhinostomy (DCR) surgery to be widely available (Fig. 52.1).

image

Fig. 52.1 Diagram of endonasal DCR by West.

West JM, A window resection in the nasal duct in cases of stenosis. Trans Am Ophthalmol Soc 1910;12:654–8. Kept at Royal Society of Medicine in London.

The spectrum of lacrimal disease was significantly more severe in the pre-antibiotic area. The French Impressionist artist Camille Pissarro (1830–1903) apparently suffered from recurrent chronic dacryocystitis, an illness which prevented him from working for some periods of time and which is said to have influenced his paintings.

The most common cause of a watering eye (epiphora) is a blocked nasolacrimal duct. Simple watering eye from a narrowed nasolacrimal duct (stenosis or partial nasolacrimal duct obstruction) is also an indication for DCR. The spectrum of disease has changed from dacryocystitis to simpler partial nasolacrimal duct obstructions and hence the threshold for surgery changed to include operating on lesser degrees of obstruction. The sophistication of lacrimal surgery has also advanced using more precise and delicate surgical techniques with miniature powered intranasal tools. This shift is very similar to the shift in cataract surgery also seen over the last 20 years, from intracapsular to extracapsular cataract extraction for dense white cataracts or dark nucleosclerosis, then to phaco-extraction for nucleosclerosis and subtle lenticular opacity. Patient expectation of surgery has increased and quality of life studies show that a real benefit can be obtained for patients with watering eyes by dacryocystorhinostomy surgery, whether it is by the external or the endonasal approach.

In many centers lacrimal surgery is now done almost exclusively endonasally and predominantly endoscopically (a microscope can be used instead), using powered tools and functional endoscopic sinus surgery instruments for adult and pediatric DCR. Endonasal endoscopic monitoring of syringe and probing and endoscopic placement of Jones glass bypass tubes are also standard.

However, the external approach DCR through the skin remains a useful operation where endonasal equipment and skills are not available, and can be particularly important for learning the anatomy of the medial canthus and sac area.

Definitions

There are various abbreviations and different operations.

image

Fig. 52.2 Dacryocystorhinostomy (DCR).

Courtesy of Santiago Ortiz-Perez.

Table 52.1 Etymology of the term Dacryocystorhinostomy

4 parts: dacro – cysto – rhino – stomy
Ancient Greek Transliteration Translation
image dakruon tear
image kustis bladder, sac
image rhis nose
image stoma mouth

Normal anatomy

Etiology and assessment of watering eye

Blocked nasolacrimal duct in adults

The causes of a watering eye include hypersecretion and epiphora. Causes of hypersecretion (conjunctivitis, keratitis, corneal foreign body, etc.) should be excluded (Fig. 52.7A–D). Surgery of the lacrimal system is for epiphora, which is an outflow problem cause by a stenosis or obstruction of the lacrimal excretory system or very poor functional drainage, as for instance may occur in facial nerve paralysis.

The periorbital area should be examined and a mucocoele, dacyocystitis (Fig. 52.8), and fistula from the lacrimal sac should be excluded. Eyelid position, particularly punctual apposition to the globe, should also be recorded.

Canaliculitis is an often missed yet relatively common condition (Fig. 52.9). It is a simple diagnosis because the small swelling is medial to the punctum, which commonly has with some yellow discharge. It can be chronic and partially responsive to topical medication, with surgery the definitive treatment.