Endoscopic revision of failed dacryocystorhinostomy

Table 56.1

Indications for surgery

Symptomatic epiphora secondary to failed dacryocystorhinostomy
History of acute dacryocystitis
Excessive mucoid discharge secondary to chronic dacryocystitis
Sump syndrome after DCR surgery

Table 56.2

Preoperative evaluation

Elicit prior surgical history; method of prior DCR – endonasal or external; stent placement; any surgical complications; any relief of symptoms prior to recurrence
Probing and irrigation of canaliculi – determine location of obstruction
Look for canalicular slitting from prior stent placement
External pressure to assess presence of mucoid reflux; mucoid discharge indicates a sac remnant and a relatively good prognosis if repeat DCR is performed
Nasal exam to assess prior ostium site, presence of scarring, adhesions; rule out intranasal pathology and septal deviation
If epiphora is present with patent irrigation, consider dacryocystogram to rule out sump syndrome
If any medial canthal or intranasal masses detected or bloody tears present, orbital and paranasal sinus imaging should be performed to rule out neoplasm

Introduction

Recurrent epiphora after prior dacryocystorhinostomy (DCR) is uncommon but presents the patient and lacrimal surgeon with a challenging dilemma. Patients should be observed for at least 6 months after surgery to allow for complete healing prior to considering any further intervention. If symptoms are improved compared to the preoperative state, observation may be the most prudent approach. If symptoms are similar or worse, then a consideration could be given to re-operation. If atypical symptoms are present with an abnormal exam, neoplasm should be considered and ruled out with imaging and biopsy of suspicious masses.

There are many possible causes of failure after prior DCR. Pre-lacrimal causes such as eyelid malposition and punctal stenosis should be ruled out and addressed ( Chapter 25 , Chapter 26 , Chapter 63 ). Common causes of DCR failure include the bony ostium being of inadequate size, common canalicular obstruction, and intranasal adhesions between the nasal septum and ostium site. Other less common causes include occult tumor, lacrimal sump syndrome and canalicular slitting from silicone stents tied excessively tight.

After the appropriate work-up has been performed, as outlined in Table 56.2 , a detailed discussion should be undertaken with the patient regarding expectations, goals, and potential complications. If significant canalicular obstruction exists, CDCR with Jones tube should be considered ( Chapter 59 ). The patient should be cautioned that any revisional surgery may also be unsuccessful. In our opinion, the endoscopic approach provides the best method to revise failed lacrimal procedures.