Chapter 13

SURGERY OF THE TEAR SAC

Francois Codere, Russell Gonnering, John L. Wobig, and Roger A. Dailey

Dacryocystorhinostomy (DCR) is fundamental to the cure of most patients with epiphora due to lacrimal excretory obstruction. When conservative methods fail, it is indicated:

The following technique is essentially that which Ohm first described in 1920. He split the medial wall of the tear sac as well as the nasal mucosae parallel and adjacent to it and sutured both posterior flaps together. The anterior flaps were sutured next. Although not the fastest method, it has had as high or higher percentages of cures than any other method.

DACRYOCYSTORHINOSTOMY

The eye on the operative side is topically anesthetized with proparacaine hydrochloride. Infiltrate subcutaneously with lidocaine 2% with epinephrine (1:100,000) in the operative area below the medial canthus and in the region of the infratrochlear nerve above the medial canthal tendon (Fig. 13-1). Packing gauze, 0.5 in. wide and 6 to 8 in. long, saturated with equal parts of cocaine hydrochloride 10% and epinephrine hydrochloride (1:1,000) or NeoSynephrine hydrochloride 2% is packed into the nose in the region of the attachment of the anterior tip of the middle turbinate. When a general anesthetic is used, the same infiltration and nasal packing are employed.

The skin incision is made 11 mm medial to the medial commissure, starting just superior to the medial canthal tendon insertion and extending inferiorly and slightly laterally for ~ 20 mm (Fig. 13-2). The knife should not cut deeper than the subcutaneous fascia. After cutting through the remaining subcutaneous tissue with a sharp Stevens scissors, insert a self-retaining, spring-type retractor such as the Agricola (Fig. 13-3). Hemostasis is obtained using a handheld battery cautery unit. This facilitates initial orbicularis fiber separation as well.

With two Freer elevators, locate the angular vein as it crosses the medial canthal tendon (Fig. 13-4). Press the vein to the medial side (as in this case) or lateral side with one elevator while the other elevator begins the separation of muscle and periosteum exactly beneath the point where the medial canthal tendon attaches to the bone. With pressure against the bone, direct the tip of the elevator inferiorly and outward until the region below the spine of the anterior lacrimal crest is reached. The periosteal division will be ~ 3 to 5 mm medial to and will extend inferior to the margin of the anterior lacrimal crest. Now elevate the periosteum on both sides of this incision and over the anterior lacrimal crest, then posteriorly beneath the tendon to the posterior lacrimal crest. Next, free the nasolacrimal duct from the bone inferiorly as far as possible in the nasolacrimal canal.

FIGURE 13-1   Topical anesthesia with proparacaine hydrochloride is followed by infiltration of subcutaneous lidocaine 2% with epinephrine (1:100,000) in the area shown. (Adapted from Nerad, JA. Oculoplastic Surgery: The Requisites in Ophthalmology. St Louis: CV Mosby; 2001. Used with permission.)

FIGURE 13-2   Skin incision 11 mm nasal to the medial commissure, starting just superior to the medial canthal tendon insertion and extending inferiorly and slightly laterally ~ 20 mm. (Adapted from Nerad, JA. Oculoplastic Surgery: The Requisites in Ophthalmology. St Louis: CV Mosby; 2001. Used with permission.)

FIGURE 13-3   Incision held open with self-retaining, spring-type retractor. (Adapted from Nerad, JA. Oculoplastic Surgery: The Requisites in Ophthalmology. St Louis: CV Mosby; 2001. Used with permission.)

FIGURE 13-4   Angular vein shown pressed to the medial side where it crosses the medial canthal tendon. The elevator at right is used to separate muscle and periosteum beneath the point where the medial canthal tendon attaches to the bone.

The lacrimal sac is now infiltrated with local anesthetic and a 0.5 in. square cottonoid is then inserted between the soft-tissue lacrimal sac and bony lacrimal fossa (Fig. 13-5). The cottonoid should previously have been dipped into a mixture of epinephrine hydrochloride (1:1,000) followed by cocaine hydrochloride 10%. The cottonoid then serves three purposes: hemostasis, anesthesia, and protection of the sac during bone removal.

At this time, exchange the spring retractor for one with longer teeth, such as a Goldstein, which will reach the periosteum and give better deep exposure. Remove the nasal packing in preparation for bone removal. Using the Hall drill or similar substitute with a dental burr, an oblong area of bone anterior to the lacrimal crest is removed taking care not to injure the nasal mucoperiosteum (Fig. 13-6). Use irrigation to prevent excessive heat buildup and facilitate visualization. Separate the nasal mucoperiosteum from the underside of the bone using a dental burnisher or Clevdent No. 1 (Fig. 13-7). Remove the cottonoid and inject the nasal mucoperiosteum with the local anesthetic.

FIGURE 13-5   The lacrimal sac is infiltrated with local anesthetic.

FIGURE 13-6   Half-inch cottonoid placed between the soft-tissue lacrimal sac and bony lacrimal fossa. The spring retractor has been exchanged for one with longer teeth (Goldstein) to give better deep exposure. An oblong area of bone anterior to the lacrimal crest is removed using a Hall drill or similar substitute with a dental burr.

A 45-degree Kerrison punch is then used to enlarge the vertical dimensions of the bony opening (Fig. 13-8). The most important area to remove is just in front of the posterior lacrimal crest and under the medial canthal tendon. Never cut the tendon because it is a most important guide to adequate removal of the bone beneath its insertion.

FIGURE 13-7   Nasal mucoperiosteum separated from the underside of the bone using a dental burnisher (Clevdent No. 1).

The bony bridge of the anterior lacrimal crest that remains is then removed using a rongeur (Fig. 13-9). This occasionally will lead the surgeon into the anterior ethmoid air cells. This typically poses no problem, and we suggest a conservative “deskeletonization” of these cells.

FIGURE 13-8   Bony opening enlarged vertically using a 45-degree Kerrison punch. Care should be taken not to cut the medial canthal tendon, an important guide to adequate removal of the bone beneath its insertion.

FIGURE 13-9   The remaining bony bridge of anterior lacrimal crest is removed using a rongeur.

Attention is now focused on the tear sac. The Goldstein retractor is loosened and a zero probe inserted through either canaliculus to “tent” the medial wall toward the nasal mucoperiosteum (Fig. 13-10). A No. 11 Bard-Parker blade is used to cut through both the periosteal and the mucosal layers of the medial wall of the sac slightly lateral to the tip of the probe. When the wall has been perforated, remove the scalpel and insert one blade of a sharp curved Stevens or iris scissors into the sac. Extend the incision to the top of the fundus and to the bottom of the nasolacrimal duct. Make a similar incision in the nasal mucoperiosteum adjacent to and parallel with the one in the tear sac. Remove the posterior flap of the tear sac and nasal mucoperiosteum with a forceps and scissors. There is no need to sew these flaps together.

FIGURE 13-10   A zero probe is inserted through the canaliculus after loosening of the Goldstein retractor. Note the “tenting” of the medial wall toward the nasal mucoperiosteum.

At this point, a Quickert probe with a piece of silicone tubing glued on the sharp end can be inserted in either canaliculus and directed into the open sac, where it can be grasped, under direct visualization through the wound, using a straight hemostat placed up the nose (Fig. 13-11). Another Quickert probe attached to the opposite end of the silicone tube can then be passed through the opposite canaliculus in the same fashion. The silicone is tied with a square knot. Ensure that there is no tension on the puncta (Fig. 13-12). If bleeding is a problem at this point, 0.5-inch petroleum jelly gauze packing can be placed up the nose or an adequate amount of Instat 0ohnson & Johnson) can be placed beneath the flaps anterior to the tip of the middle turbinate.

FIGURE 13-11   A Quickert probe with a piece of silicone tubing glued on the sharp end is inserted in the canaliculus. Directed into the open sac, it can be grasped under direct visualization through the wound with a straight hemostat placed up the nose. (Adapted from Nerad, JA. Oculoplastic Surgery: The Requisites in Ophthalmology. St Louis: CV Mosby; 2001. Used with permission.)

The following procedure is the simplest and most successful treatment in all cases in which both canaliculi on the same side are absent or obliterated, or when the medial 3 mm or more of the canaliculi are closed. It is also used in patients in which patent, flaccid canaliculi do not function and in those with paralysis of the lacrimal pump.

FIGURE 13-12   The silicone tube is passed back through the opposite canaliculus using another Quickert probe. The silicone is tied with a square knot, making sure there is no tension left on the puncta to prevent later “cheese-wiring.” (Adapted from Nerad, JA. Oculoplastic Surgery: The Requisites in Ophthalmology. St Louis: CV Mosby; 2001. Used with permission.)

A DCR is performed as described, stopping before closure of the anterior flaps. No silicone or nasal packing should be in at this point. Dissect away the medial half or all of the caruncle, taking care to remove as little conjunctiva as possible with it. If the caruncle is flat, it is not resected. Insert a sharp Stevens scissors into the lacus lacrimalis 2.5 mm posterior to the cutaneous margin of the commissure (Fig. 13-13). Using blunt and sharp dissection, gently manipulate the scissors into the opened tear sac, being sure they are anterior to the body of the middle turbinate. If the anterior tip of the turbinate interferes, it should be resected.

With the blades of the scissors in place and held slightly open, pass a zero probe with the appropriate Pyrex tube in place, just above or anterior to the scissors, between the opened blades, and into the opened sac (Fig. 13-14). Now remove the scissors and simultaneously push the Jones Pyrex tube down the course of the probe into position. The interior of the nose must be observed with a headlight, to be certain that the inner end does not touch the septum. This can sometimes be visualized through the wound with standard lighting. If the tube does touch the septum, a shorter one must be used. A 5 0 polyglactin 910 suture is then wrapped around the collar of the tube and tied and then sutured in place in the medial canthus. A 4 mm collar is usually used to start and can be exchanged for a smaller one later. Close the anterior flaps and remainder of the wound as described for a DCR.

Many of our patients have had previous DCRs that have failed. In those that cannot be repaired by a second DCR, such as phimotic canalicular or patent ducts in which the postoperative dye test is constantly negative, the Pyrex tube can be inserted by combined external and intranasal approach.

The nose is packed with gauze or cotton saturated with equal parts of cocaine hydrochloride (10%) with adrenaline chloride (1:2,000). Externally, the medial canthal area is injected with Xylocaine (2%) with epinephrine (1:100,000). After 15 minutes the nasal packing is removed and the technique just described is repeated, with the operators inspecting the nose. The guide needle or Stevens scissor must emerge anterior to the middle turbinate and slant downward a few degrees. It usually is not necessary to tie the tube in with sutures (silk 6-0), if the patient does not “blow his nose.”

FIGURE 13-13   Stevens scissors inserted into the lacus lacrimalis 2.5 mm posterior to the cutaneous margin of the commissure. The scissors are gently manipulated into the opened tear sac and on into the nose.

FIGURE 13-14   Zero probe with Pyrex tube in place being passed just anterior to the scissors. The tubing should be passed between the opened blades and into the opened sac. (Adapted from Nerad, JA. Oculoplastic Surgery: The Requisites in Ophthalmology. St Louis: CV Mosby; 2001. Used with permission.)

FIGURE 13-15   Gold dilator in place after Pyrex tube removed for cleaning.

The patient is told that, if the tube comes out, he should seek advice as soon as possible. If seen within the first 24 hours, initial insertion of the small end of the lacrimal dilator can be followed by insertion of the larger end, and next by insertion of the small end of the larger dilator (Fig. 13-15). Then the tube, which is threaded collar first over a No. 1 or No. 2 Bowman probe, is reinserted. If the insertion encounters any difficulty, the larger end of the larger dilator is inserted. Now the Pyrex tube will pass in easily. Ophthaine solution is dropped externally, and cocaine hydrochloride (10%) with adrenaline chloride (1:1,000) applied on a cotton-tipped applicator to the nasal mucosae internally usually provides sufficient anesthesia.

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