Endoscopic conjunctivodacryocystorhinostomy







Table 59.1

Indications for surgery









Symptomatic epiphora secondary to canalicular obstruction or canalicular atresia
Intractable epiphora in the setting of failed prior lacrimal bypass procedures
Intractable epiphora in the setting of facial paralysis and poor lacrimal pump function


Table 59.2

Preoperative evaluation















Probing and irrigation of canaliculi to determine location of obstruction
Ocular surface examination including caruncle and plica semilunaris to determine optimal location for Jones tube
Nasal exam to rule out intranasal pathology and septal deviation that may interfere with Jones tube placement
Assess orbicularis strength and cranial nerve (CN) VII function
Assess eyelid laxity
Inspection of puncta to identify stenosis or atresia


Introduction


Conjunctivodacryocystorhinostomy (CDCR) with Jones tube is an operation performed for symptomatic epiphora secondary to canalicular obstruction untreatable by other means. It should not be undertaken lightly and must be viewed as a procedure that requires long-term follow-up and maintenance. CDCR can also be useful in some situations of multiple prior failed lacrimal bypass procedures and intractable epiphora secondary to facial nerve (CN VII) palsy. In cases of symptomatic isolated canalicular obstruction, a thorough discussion should be undertaken with the patient of other options available, such as canalicular trephination and silicone stent placement prior to proceeding with CDCR.


CDCR with placement of the Jones tube can be performed either through an external or endoscopic approach. Our preference is for the endoscopic approach, which provides direct intranasal visualization during the operation. Preoperative evaluation should include probing of the canaliculi to determine the location of the obstruction, examination of the ocular surface, and intranasal exam. For preoperative considerations for endoscopic surgery, please see Chapter 53 .


For optimum function, placement of the Jones tube should be as vertically oriented as possible. The location on the ocular surface should be at the junction of the plica semilunaris and caruncle. Although varying versions of the original glass tube have been fabricated, we prefer the straight Jones tube with 4.0 mm diameter flange and fixation hole. Fixation of the tube is performed with an 8-0 Vicryl suture to the surrounding conjunctiva. Intranasal location of the Jones tube should be just anterior and inferior to the origin of the middle turbinate. The tube should not abut the nasal septum or middle turbinate. Occasionally partial middle turbinectomy of the anterior tip is required to provide a clear unobstructed pathway for the tube.


Patients should be advised that extrusions and clogging of the tube can occur and regular maintenance is required. Daily “sniffing” through the tube with closed nostrils helps to clear the tube and ensure patency. Periodic removal with cleaning and replacement of the tube may be required. A porous polyethylene-coated tube can be used in cases of repeated extrusion. Despite complications and continued symptoms that may occur in up to 25% of patients in some published series, many patients experience complete relief of epiphora.




Surgical Technique





Figures 59.1A–D


Endonasal anatomy and surgical planning

Endoscopic visualization offers many advantages over “blind” Jones tube placement. With direct visualization, any intranasal process that may obstruct tear flow can be addressed. In this endoscopic view, the middle turbinate can be clearly visualized ( Figures 59.1A and 59.1B ). Concha bullosa or middle turbinate pneumatization may obstruct the outflow of the Jones tube and can be vertically incised and removed. If severe nasal septal deviation is present and prevents middle turbinate visualization, septoplasty may be required first or may be performed together with CDCR. Directly anterior to the middle turbinate is the course of the lacrimal sac within the lacrimal sac fossa, as shown in yellow ( Figure 59.1C ). The initial osteotomy site will be in this area similar to routine endoscopic DCR surgery as described in Chapter 53 ( Figure 59.1D ).

May 16, 2019 | Posted by in Reconstructive surgery | Comments Off on Endoscopic conjunctivodacryocystorhinostomy
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