FP858 : Outcome of Paediatric External Dacryocystorhinostomy (DCR) in a Tertiary Care Centre.

Dr. Akshay Kothari, K17272, Dr. Somnath Mukhopadhyay, Dr. Anirban Chakrabarti

Authors: Dr.SomnathMukhopadhyay( S10232 )

Dr Kothari Akshay Anil ( K17272 )

DrAnirbanChakraborty (

Department of Ophthalmology, NRS Medical College, Kolkata-14.

Presenting author: Dr Kothari Akshay Anil

Mail :aks142@gmail.com

Abstract–

Purpose:

To compare the outcomes of external DCR in children between 6 – 12 years of age without intubation (A), with Jones tube intubation (B) or with Silicone tube intubation (C).

Materials and Methods:

50 cases underwent DCR after failed probing and syringing in between May, 2008 to May, 2016. 18 cases underwent DCR without intubation (A), 16 cases underwent DCR with Jones tube (B) and 16 cases underwent DCR with Silicone tube (C). Surgical success was defined by resolution of epiphora and successful syringing. Cases were followed up for 1 year post-operatively.

Results:

In A group: 13 cases were successful (72%); 5 required revision due to canalicular fibrosis. In B group: 11 cases were successful (69%); 2 cases tube blockage, 2 cases tube extrusion and 1 case wound infection occurred. In C group: 15 cases were successful (94%).

Conclusion:

Pediatric external DCR should be preferably done with Silicone tube intubation as its success rate is much higher with fewer complications.

Conflict of interest and financial disclosure: None

Full Text

Introduction:

The most common indication for dacryocystorhinostomy (DCR) in the pediatric age group is congenital nasolacrimal duct obstruction (NLDO). . Chronic dacryocystitis (CDC) is always secondary to the obstruction in the nasolacrimal duct (NLD) and in a majority of cases the cause is obscure. However it is seen more commonly in females (80%) and patients with nasal anomalies like deviated nasal septum, nasal polyps, etc. Some patients show a familial tendency so a genetic basis cannot be ruled out. Other indications for pediatric DCR are traumatic obstructions, punctal/canalicular agenesis; cases associated with other systemic (eg cleft) anomalies, and acquired cases of NLDO.^1, 4Most cases however remain of unknown etiology. Conservative medical therapy with hydrostatic pressure on the lacrimal sac, topical antibiotics, probing, and silicone intubation if necessary, are usually effective in clearing the obstruction.^{1, 2, 3, 4} .Due to the persistent epiphora and discharge from the sac the patients of CDC seek early treatment and a large number of patients seek surgical intervention. The following are the treatment modalities for C.D.C with NLD block : a) External DCR with or without Stenting. b) Endonasal DCR c) Laser DCR d) Balloon Dacryocystoplasty.⁵Of all these the External DCR remains the most preferred method of managing CDC.

The aim of the study was to compare the outcome of external DCR with and without stenting with silicon tube or Jones tube and analyse the results of intubation whether it improves the overall success rate of DCR

Material & Methods:

The 8 year study was a prospective study conducted in the Post Graduate Department of Ophthalmology, Nilratan Sircar Medical College, Kolkata. A total of 50 cases were taken up for the study and were divided into three groups, Group ‘A’ in which 18 patients underwent external DCR without intubation, Group ‘B’ in which 16 patients underwent external DCR with Jones tube intubation and Group ‘C’ in which 16 patients underwent external DCR with silicon tube intubation.

A detailed history of complaints and their duration was taken from the patients with regards to the epiphora and any other relevant history. All patients underwent a routine Ocular Examination to establish a diagnosis of CDC with NLD block. Specific ocular examination was done with inspection of the sac area to see any visible sac swelling, tear collection in lacus, height of lower tear meniscus, regurgitation of sac contents on applying pressure over the sac area. In most cases diagnosis of CDC with NLD block could be established by these methods only. Careful lacrimal syringing was done through the upper punctum to confirm the diagnosis of CDC with NLD block.

Criteria for Inclusion:

1. a) Persistent Epiphora
2. b) Positive ROPLAS (Regurgitation on pressure over lacrimal sac with non patent distal passage )
3. c) Lacrimal Mucocele communicating with the conjuctival cul de sac
4. d) Absence of gross nasal pathology
5. e) Age <12 or >6 years

Pre-operative evaluation apart from routine and specific ocular examination related to CDC include a routine rhinological examination

Surgical Procedure:

Operative Procedure for Group ‘A ‘ was External DCR without any stenting.

Operative procedure for Group ‘B’ was external DCR with Jones tube intubation(JTI).

Surgery was performed under general anesthesia. A self-retaining eye lid speculum is used to provide adequate exposure of the medial conjunctiva. Anterior half of the caruncle is excised using 15 blade. The posterior portion of the caruncle is left intact to protect the medial conjunctiva from inflammation that is associated with contact with the Jones tube.
The anterior edge of the incision is retracted using a fine double hook retractor. The soft tissues overlying the lacrimal bone are spread using blunt dissection. This procedure reveals the underlying lacrimal bone. An opening is created in the lacrimal bone with the help of high speed drill. The window created should be approximately 8 mm in diameter. A 14 gauge iv catheter that contains an internal trocar is introduced at a 45 degree angle through the window created in the lacrimal bone, penetrating the nasal mucosa to enter the nasal cavity. This procedure is ideally completed under endoscopic guidance. After measuring the approximate length of the cannula inserted, a Jones tube with 4 mm diameter is inserted via the cannula which is then removed after successful insertion. This step again is endoscopically guided. Jones tube is anchored in position using Vicryl sutures. The functioning of this tube is checked by instilling fluorescein dye impregnated solution in to the conjunctiva. Its clearance is checked using an endoscope and seeing it drain into the nose through the Jones tube.

Operative procedure for Group ‘C’ was external DCR with silicon tube intubation (STI).

A standard DCR skin incision is made and the anterior crus of the medial canthal tendon is incised from the periosteum and retracted temporally. A rhinostomy of desired size is created. The sac is opened and incised to form anterior and posterior flaps. Probes are passed into each canaliculus till the obstruction is encountered.An attempt is made to negotiate the probe through the obstruction with only moderate force. If the obstruction is small and easily overcome so that the probe emerges into the sac, dissection of the common canaliculus is not necessary. In cases where the obstruction is firm, the most medial patent part of the common canaliculus is identified under magnification (preferably using a surgical microscope) by dissecting the common canaliculus from the posterior limb of the medial canthal tendon. The patent part of the common canaliculus is opened by cutting over the probe. The intervening obstructed part of the common canaliculus and the sac, if involved, is then excised. The patent common canaliculus is anastomosed with the lateral part of the sac by creating anterior and posterior flaps. If the sac is scarred or largely involved in the obstruction, as is often the case in patients with failed DCR, the common canaliculus is anastomosed directly to the nasal mucosal flaps with 6-0 absorbable sutures. Intubation is carried out from both the puncta before the anterior flaps are sutured, using an improvised stainless steel introducer (made from size 0 or 1 lacrimal probe, with ends rounded) and silicone tube.The tube is passed through the rhinostomy into the nose, where the two tubes are secured to each other by suturing after moderate tightening to leave only a small loop protruding in the conjunctival sac. The tube is left in place for 6 months or more.

Post Operatively all patients received: a) Systemic oral antibiotics for 5 days. b) Topical steroid antibiotic drops from 1st PO day for 4 weeks. c) Oral NSAID’s .Group C patients with STI underwent manipulation of the S.T twice a week wherein the tube was gently moved in between the puncta with help of a plain forceps to break any adhesions and keep the passage patent. This was done twice a week for 4 weeks. The ST was removed after 6 months.

Follow Up: Groups were followed up as under: Group A once a week for 4 weeks. Group B twice a week for 4 weeks. Group C twice a week for 4 weeks. Then all groups every 2 weeks for 8 weeks. Then at 12,16, 18 and 24 weeks. Then S.O.S

Result –

Total number of cases was 50. Females were 35 and male 15 (Fig 1). Age ranged from 12 to 16 years, mean (13.5). Duration of follow up was 1 year. Post-operative syringing was avoided in all cases as far as possible .Results were analyzed at the end of one year to decide whether the Surgery was successful or not. Successful DCR was defined as: a)No Epiphora clinically.b) Positive Jones Test 1 if required in equivocal cases. Failed DCR was defined as: a) Constant Epiphora, b) Negative Jones 1, c) Blocked passage on Lac. Syringing. In failed D.C.R cases all efforts were made to analyze the causes of failure (including an Endonasal Examination by the ENT specialist ).

In A group: 13 cases were successful (72%); 5 of them required revision due to canalicular fibrosis. Revision was done using the silicone stent but the outcome was not included in this study.

In B group: 11 cases were successful (69%); 4 cases with Jones tubes had early complications involving 2 cases of Jones tubes extrusion and 2 cases of tube blockage. Late complications (6 months or more, postoperatively) included one case of wound infection.

In C group: 15 cases were successful (94%).Only 1 case had a tube blockage (Early complication). No case required a revision.

A significant difference regarding the need for revision was found between those groups (Linked variables, p<0.01, χ²=12.99). Both the Jones tube group and the non-intubated cases showed a statistically significant revision rate as compared to the silicone stented group. (p<0.001, χ²=15.34, and p<0.01, χ²=7.1, respectively)

Discussion –

Pediatric DCR differs from adult DCR for various reasons. At birth, up to one-third of infants have an underdeveloped tear-duct drainage system, which as a result of blockage, can lead to excess tearing and infection. Some believe that lacrimal surgery is not as successful in children owing to poorly-defined and changing anatomy, rapidly growing facial bone centers and a tendency toward vigorous repair processes producing hyperplastic scar tissue.⁶The optimal postoperative course following DCR is the achievement of an asymptomatic eye without epiphora or discharge, and no recurrence in the long-term

Common causes of failed DCR are: a) Stenosis of the common canalicular opening in the sac ( 80% cases of failure) b) Closure of sac mucosa anastomosis by fibrous tissue c) Incorrect position of the anastomosis ( high anastomosis ). d) Poor surgical procedure.⁷The success rate of D.C.R. without stenting varies between 75% to 90% according to various studies. In DCR without stenting and to obviate the most important cause of failure of DCR i.e. closure of the common canalicular opening into the sac by using a silicon tube stent or Jones tube stent. Blockade of the common canalicular opening into the sac in the early post-operative period remains the single most important cause of failure to establish a patent and permanent communication between the sac and nasal mucosa.⁸The cause for this usually is the collection of fibrin and other inflammatory debris around the opening causing early fibrosis and subsequent closure of this tiny opening. Other causes for fibrosis of common canalicular opening can be trauma to it during surgery, unnecessary intraoperative probing during surgery and other unknown causes. The remedy to prevent closure of the common canicular opening is to use a stent in the lacrimal passages which may be :a) Silicon tube, b) Jones tube, c) Fine poythene tubes, d) Fine rubber Catheters,e) Polymide suture material.^9-12 Of these the most commonly used are the Silicon tubes as silicon is inert flexible easy to insert and manipulate.^13,14

Success rate for external DCR without STI was 72% in our study. Success rate for external DCR with JTI was 69% in our study. Success rate for DCR with STI rose to 94%. Therefore DCR with STI is a highly successful procedure with a success rate of over 90%. Using the ST is a fairly simple procedure and takes just a few minutes to intubate the anastomosis. By using the ST the commonest cause of failure i.e. the closure of common canalicular opening is prevented thereby enhancing the success rate of DCR. The disadvantage is the potential for canalicular trauma and subsequent stenosis.¹⁵ which we believe is rare, and the need to perform an additional procedure for the removal of the silicone stent, usually requiring general anesthesia.

Pediatric canalicular NLD silicone stenting without DCR is advocated by many as the procedure of choice following failed probing, and has a success rate of 82–94%.^15-18 The success rate has been reported as being higher for children who undergo surgery between 1 and 4 years of age,³⁰ for patients with no acute dacryocystitis, and for cases of mild obstruction.¹⁷

Silicone stenting in pediatric DCR cases is controversial. Hakin et al have reported a very high cure rate of 96% for external DCR without canalicular pathology without silicone intubation, and a low complication rate.¹⁵ Other authors have advocated the use of silicone stenting for pediatric DCR if both upper and lower canaliculi are present.¹

In our series, despite the overall low revision rate, significantly less revisions were needed for cases in which silicone stenting was used. We believe that silicone stenting should be considered for all pediatric DCRs, and is essential in the presence of canalicular disease. Prospective and more cases are needed to conclude that stent usage was responsible for the higher success rate.

Jones tubes have a lower retention rate, are associated with a higher complication rate and have a lower overall success rate in children (79%)

Previous reports of Jones tubes in adults have shown a 45–50% complication rate.^18,19 These included malposition (18.0%), infection (10.8%), and obstruction (6.3%).¹⁸ In a recent study performed at Sydney Eye Hospital, complications occurred eventually in most cases following Jones tube placement in adults such that the tube required replacement, repositioning, or cleaning, with thirty-five percent of the patients reporting tube maintenance to be troublesome.¹⁹ . Children have a tendency for a vigorous repair process producing scar tissue,which may be associated with a more mobile tube and associated migration.

In the present series the majority of complications related to the presence of a Jones tube were 2 cases of tube blockage, 2 cases of tube extrusion and 1 case of wound infection.

 Conclusion

Out of all the options available, External DCR with silicone intubation is the safest and most effective surgery in pediatric patients. We believe that silicone stenting should be considered for all pediatric DCRs, and is essential in the presence of canalicular disease. The complications associated with silicone intubation are negligible. We recommend a longer follow up with more number of patients to evaluate its long time results. Prospective and more cases are needed to conclude that stent usage was responsible for the higher success rate.

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