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.




Surgical Technique





Figure 56.1


Injection of local anesthetic

Tolerance for systemically absorbed vasoconstrictors should be discussed with the anesthesiologist prior to surgery, particularly if the patient has a cardiac history. Excellent nasal decongestion is generally obtained with the use of nasal packing soaked in 0.05% oxymetazoline and direct submucosal infiltration of 1% lidocaine with epinephrine 1 : 100,000 overlying the site of the ostium with a 22-gauge spinal needle being used to inject the anesthetic ( Figure 56.1 ). While intranasal cocaine can be used if necessary, there is a general tendency to avoid its use due to the potential for cardiac effects. If desired, additional nasal decongestion can be obtained with the use of nasal packing soaked in epinephrine at a concentration of 1 : 10,000.

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May 16, 2019 | Posted by in Reconstructive surgery | Comments Off on Endoscopic revision of failed dacryocystorhinostomy
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