ORIGINAL PAPERS

ORIGINAL PAPERS
Adv Clin Exp Med 2009, 18, 5, 501–506
ISSN 1230−025X
© Copyright by Wroclaw Medical University
PIOTR WÓJCICKI 1, 2, IRENEUSZ SIEWIERA2
External Dacryocystorhinostomy in the Treatment
of Congenital and Acquired Lacrimal Duct Stenoses
Dakryocystorynostomia zewnętrzna w leczeniu wrodzonej
i nabytej niedrożności dróg łzowych
1
2
Plastic Surgery Clinic, Wroclaw Medical University, Poland
Department of Plastic Surgery, Specialistic Medical Centre, Polanica Zdrój, Poland
Abstract
Background. The surgical treatment of lacrimal duct stenosis consists of the formation of a fistula between the
lacrimal sac and the nasal passage, which facilitates the outflow of tears.
Objectives. The aim of the study was to evaluate the efficacy of dacryocystorhinostomy (DCR) with the external
approach depending on the etiology of the defect.
Material and Methods. Fifty−four patients 3–70 years of age with lacrimal duct obstruction were treated at the
Clinic of Plastic Surgery in Polanica Zdrój. In 19 patients the lactimal duct defect was congenital and in 35 it was
a consequence of injury or tumor. A total of 65 dacryocystorhinostomies with the external approach were per−
formed.
Results. The efficacy of dacryocystorhinostomy was 83.3%. In the patients with a congenital etiology it was 84.2%
and in the group with an acquired defect 82.9%.
Conclusions. External dacryocystorhinostomy appears a highly safe and effective method. In combination with
other reconstruction methods, it has advantageous over endoscopic methods especially in cases of an acquired
defect (Adv Clin Exp Med 2009, 18, 5, 501–506).
Key words: dacryocystorhinostomy, DCR, lacrimal duct stenoses.
Streszczenie
Wprowadzenie. Chirurgiczne leczenie niedrożności dróg łzowych polega na wytworzeniu przetoki między wo−
reczkiem łzowym a przewodem nosowym umożliwiającej odpływ łez.
Cel pracy. Ocena skuteczności zabiegów dakryocystorynostomii (DCR) z dostępu zewnętrznego w zależności od
etiologii schorzenia.
Materiał i metody. W Klinice Chirurgii Plastycznej w Polanicy Zdroju leczono 54 pacjentów z niedrożnością dróg
łzowych w wieku 3–70 lat. U 19 chorych przyczyną niedrożności dróg łzowych były wady wrodzone, a u 35 cho−
rych następstwa urazów i chorób nowotworowych. Wykonano 65 zabiegów DCR z dostępu zewnętrznego.
Wyniki. Skuteczność dakryocystorynostomii wyniosła ogółem 83,3%, w tym w grupie o etiologii wrodzonej
84,2%, a w grupie o etiologii nabytej 82,8%.
Wnioski. Dakryocystorynostomia z dostępu zewnętrznego jest zabiegiem skutecznym i bezpiecznym. W połącze−
niu z innymi metodami rekonstrukcyjnymi ma niewątpliwą przewagę nad metodami endoskopowymi, zwłaszcza
w przypadkach o etiologii nabytej (Adv Clin Exp Med 2009, 18, 5, 501–506).
Słowa kluczowe: dakryocystorynostomia zewnętrzna, DCR, niedrożność dróg łzowych.
Lacrimal duct stenosis is a pathology which
manifests mainly with excess overflow of tears,
called by the Greek word epiphora. It was
described in the Talmud and in ancient Egyptian
papyruses and was also mentioned in the works of
Celsius and Avicenna [1]. Surgical procedures
aimed at restoring lacrimal duct patency by form−
ing a fistula between the tear sac and nasolacrimal
duct were performed at the turn of the 19th and 20th
centuries by Caldwell. In 1904, an Italian ophthal−
mologist, Addeo Toti, was the first to present the
external approach [2]. In 1911, West proposed the
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P. WÓJCICKI, I. SIEWIERA
lacrimal gland (gruczoł łzowy)
punctum (punkt łzowy)
upper canaliculus
(kanalik łzowy górny)
lacrimal sac
(woreczek łzowy)
lower canaliculus
(kanalik łzowy dolny)
nasolacrimal duct
(przewód nosowo−łzowy)
Drawing: I. Siewiera
Fig. 1. Lacrimal tract anatomy
Ryc 1. Schemat budowy dróg łzowych
nasal approach; however, the method did not find
many followers due to lack of adequate instru−
ments. In 1920, Dupuy−Dutemps and Borguet [3]
described a modified method of the external
approach consisting of combining flaps of nasal
mucosa and the lacrimal sac. In 1974, Casper pro−
posed his own method of suturing the lacrimal sac
with the nasolacrimal duct without the necessity of
using mucosal flaps [4]. Subsequent studies by
Becker [5] and Burns [6] confirmed the high effec−
tiveness of this method. Progress in technology
and a tendency to limit invasiveness by the use of
endoscopic methods with fiberoptics and laser
tools found their application in the treatment of
lacrimal duct stenosis. The first dacryocystorhi−
nostomy (DCR) with the use of a Nd:YAG laser
with the nasal approach, without skin scarring,
was described in 1997 [7].
The lacrimal ducts consist of the lacrimal
puncta, lacrimal canals, lacrimal sac, and naso−
lacrimal canal (Fig. 1). Nasolacrimal drainage
stenosis may be congenital or acquired. The con−
genital form is rare. It may occur as an isolated
defect or may be associated with craniofacial
abnormalities. Obliteration of the lumen or a trans−
verse obstacle occurs most commonly at the junc−
tion of the nasolacrimal canal and nasal mucosa.
Dacryocystocele (or timo cyst) may be one of the
forms of congenital lacrimal canal obstruction.
The acquired form may originate as a consequence
of injury (car accident, a blow) (Fig. 2), inflamma−
tion, mechanical obstruction caused by dacry−
olithiasis, a foreign body, benign tumor (lacrimal
sac cyst), or malignant tumor originating from the
maxillary or ethmoid sinus.
Purulent inflammation of the lacrimal canal usu−
ally involves the upper canal. The symptoms include
swelling, pain, and redness over the lacrimal canal.
It is caused by streptococci, pneumococci, Pseudo−
monas aeruginosa, or fungi (Fig. 3). The diagnosis
is based on ophthalmological examination evaluat−
ing the dynamics of the production and outflow of
Fig. 2. Craniofacial injury – medial canthus recon−
struction and DCR
Ryc 2. Stan po urazie części twarzowej czaszki
– korekcja kąta przyśrodkowego i DCR
tears. The Jones test with fluorescein, dacryocystog−
raphy, scintigraphy, and taste tests are used. CT and
MR scanning are useful in cases of bone deformity
caused by injury. Intubation and probation of the
lacrimal ducts prior to surgery may confirm the diag−
nosis and determine the level of obstruction.
Surgical treatment of lacrimal duct obstruction is
contraindicated in cases of dry eye syndrome and
disturbances in bleeding and blood clotting.
Material and Methods
Sixty−five external dacryocystorhinostomies
were performed at the Hospital of Plastic Surgery
and then SCM Clinic and Department of Plastic
Surgery in Polanica Zdrój in the years 1985–2008.
Fifty−four patients aged 3–70 years (mean age:
27 years), were treated. Children up to 16 years of
age constituted 33.3% (n = 18) of the patients. The
investigated group included 32 males and 22 fe−
males. Twenty−three patients had nasolacrimal
obstruction on the right side, 27 on the left side,
and 4 had bilateral obstruction. In 19 patients the
nasolacrimal obstruction was due to congenital
abnormalities and in 35 patients it was a conse−
quence of an injury or tumor (Table 1).
The majority of the surgeries (83.3%) were
performed under general anesthesia. The surgeries
503
Dacryocystorhinostomy
were performed under local anesthesia in adult
patients (n = 9). All the surgeries were performed
with the external approach. Following infiltration
of the site with an anesthetic, a 15−mm incision
was made in the region of the medial canthus.
Then the tissues were prepared to expose the
lacrimal sac, which was separated from the
lacrimal bone and cut with a fraise or a gouge to
form an opening with a diameter of about 7 mm.
The nasal mucosa and lacrimal sac were incised
several times and sutured with resorbable sutures.
Thus a fistula was formed above the obstructed
site. In the majority of cases a bridge was formed
between the lacrimal ducts and the nasal canal
without connecting the mucosal flaps, in accor−
dance with the Casper technique. The lacrimal
ducts were intubated with drains inserted through
the lacrimal sac and the orifice formed in the lat−
eral bony wall of the nose. The drain ends were
tied and fixed in the nasal cavity (Fig. 4). The skin
wound was closed in layers. In two cases the inci−
sions were made along scars on the ciliary margin
resulting from previous surgery, and in one child
along a scar on the nose from surgery for hyper−
telorism. In most cases the dacryocystorhinostomy
was associated with medial canthus reconstruction
and shortening of the medial ligament. In two
cases the DCR procedure was associated with
medial canthus Z−plasty (Fig. 5).
Follow−up examinations associated with the
removal of drains were performed about six
Fig. 3. Lacrimal sac abscess – state after DCR
Ryc 3. Ropień woreczka łzowego – stan po DCR
Table 1. Etiology of the lacrimal duct stenoses of the patients treated by DCR
Tabela 1. Etiologia niedrożności dróg łzowych pacjentów poddanych DCR
Congenital form
(Postać wrodzona)
Acquired form
(Postać nabyta)
Congenital isolated form
(Wrodzona izolowana niedrożność
dróg łzowych)
5
craniofacial trauma
27
(uraz ze złamaniem kości części twarzowej czaszki)
(Multiple craniofacial abnormalities
(Mnogie wady części twarzowej czaszki)
3
soft tissue trauma
(uraz tkanek miękkich)
4
Unilateral cleft lip and palate
(Wada rozszczepowa jednostronna)
3
animal bite
(rana kąsana)
2
Bilateral cleft lip and palate
(Wada rozszczepowa obustronna)
3
burns
(oparzenie)
1
Hypertelorism, nasal cleft
(Hyperteloryzm, środkowy
rozszczep nosa)
2
excision of carcinoma
(stan po resekcji zmiany nowotworowej)
1
Dacryocystocele
(Skośny rozszczep twarzy)
1
Ectodermal dysplasia
(Dysplazaja ektodermalna)
1
Total
(Razem)
19
total
(razem)
35
504
P. WÓJCICKI, I. SIEWIERA
months after the surgery. Cessation of tearing and
maintenance of normal nasolacrimal drainage
were considered a good therapy outcome.
site of DCR ostium
(otwór w kości łzowej)
silicone tubing
(dren silikonowy)
Results
Drawing: I. Siewiera
Fig. 4. Scheme of DCR
Ryc 4. Schemat DCR
Fig. 5. Craniofacial injury – medial canthus Z−plasty
and DCR
Patients with post−traumatic injury to the naso−
lacrimal duct prevailed in this material. In such
cases the DCR procedure was one of the stages of
reconstructive therapy. The effectiveness of dacry−
ocystorhnostomy was 83.3% in the total group of
patients; in patients with congenital abnormality it
was 84.2% and in those with an acquired defect it
was 82.8%. This is a good outcome, comparable to
those achieved in other centers worldwide (Table 2).
Dacryocystorhinostomy may be associated with
early complications, such as bleeding and local
inflammation. The silicone drain fell out too early
in one patient and two patients developed lacrimal
sac abscess in the postoperative course. Permanent
obstruction is considered a poor outcome of treat−
ment. Failure to restore nasolacrimal duct patency
was observed in 9 patients, three with a congenital
abnormality and 6 with an acquired defect; these
patients were qualified for another surgery. Despite
reoperation, 2 patients did not achieve satisfactory
outcome. The relapse of tearing was usually due to
scarring and inflammatory condition. Dilatation of
the bone orifice in the lateral nasal wall was per−
formed during reoperation in one case.
Discussion
Ryc. 5. Stan po urazie części twarzowej czaszki
– wykonano Z−plastykę kąta przyśrodkowego oka
i DCR
Restoration of the patency of the lacrimal
ducts is performed by specialists in otolaryngolo−
Table 2. Outcomes achieved in other centers
Tabela 2. Wyniki uzyskane w innych ośrodkach
Author
(Autor)
Approach
(Dostęp operacyjny)
Number of patients
(Liczba pacjentów)
Efficacy
(Skuteczność)
%
Failures
(Powikłania)
%
Seider N 2007
Sieśkiewicz 2008
Emmerlich KH
Kominek P 2005
Tarbet KJ 1995
external
endoscopic
external
endoscopic
external
162
16
1014
34
169
81
87.5
85
82.3
95
Warren JF 2005
Beigi B 1998
Erdol H 2005
Delaney YM 2002
Struck HG 2001
Barnes EA 2002
Kashkouli MB 2003
Horix D 2004
external
external
external
external
external
external
external
external
9
12.5
–
–
3.9 bleeding
2.6 scarring
–
–
–
–
–
3
–
–
128/150
242
437
50
72
121
274
146
93
83.5
91.5
90
90.4
96
89.1
80.1
Dacryocystorhinostomy
Fig. 6. Palpebral reconstruction and DCR after burn
injury of the face
Ryc. 6. Stan po rekonstrukcji powiek po oparzeniu
twarzy i DCR
gy, ophthalmology, and reconstructive surgery. In
view of the various evaluation criteria and selec−
tion of patients, it is not easy to compare the out−
comes of lacrimal reconstructive surgery on the
basis of data from the literature. According to the
criteria of the Royal College of Ophthalmologists
of 1999, relief from symptoms of excessive tearing
for 3 months is considered a satisfactory outcome
(Fig. 6). The treatment of lacrimal duct obstruction
due to trauma, often accompanied by bone injury
and altered anatomical relations, is more difficult
and brings less advantageous outcomes. This has
been confirmed by other authors [8], who addi−
tionally point to a significant prognostic factor, i.e.
the time from the onset of symptoms and the dura−
tion of inflammation [9]. In post−traumatic cases,
dacryocystorhinostomy is often a successive oper−
ation performed in the stage following the primary
management of fractures and soft tissue injury.
The surgery should be combined with shortening
of the medial ligament, as correction of the posi−
tion of the medial canthus and restoration of the
anatomical position of the lacrimal puncti are
indispensable for normal drainage of tears.
Increasing attention has been paid recently to
new endoscopic methods with or without the use
of a laser. Both modalities have their advantages
and disadvantages. Dolman compared the external
and the endoscopic method without the use of
laser on a large body of material of 349 cases. He
demonstrated almost identical effectiveness of the
two therapeutic modalities. Shorter time of surgery
505
in the case of the endoscopic method and the opin−
ions of patients with a bilateral defect in whom
both techniques were used indicate that the endo−
scopic method is more advantageous [10].
Hartikainen demonstrated a statistically significant
advantage of the procedure with the external
approach, the success rate being 91% for the con−
ventional surgery and 63% for the intranasal
approach with the use of a laser [11]. The duration
of the surgery with the nasal approach using
a Holmium: YAG laser is shorter. However, taking
into account the low effectiveness of this method
(70%) and the necessity to repeat the procedure,
Malhorta et al. [12] advocate the use of both meth−
ods depending on the indications in particular
cases of lacrimal duct obstruction. Considering the
economic aspect of the therapy, the endoscopic
procedure is cheaper. However, considering the
real costs of equipment and training, only large
centers can afford it.
In the present authors’ opinion, the external
approach is favorable for another reason: it gives
a detailed insight into the pathology underlying the
lacrimal duct obstruction. This method is effective
in practically every case of lacrimal duct obstruc−
tion and does not require any expensive or com−
plicated equipment. Only 2 patients (3.1%) failed
to achieve a complete cure. The scar remaining
after the external approach is not a problem for the
majority of patients [13]. According to Tarbet et
al., the appearance of a scar was satisfactory for
about 97% of patients [14]. In post−traumatic cases
the incision is usually made to follow a preexisting
scar.
Otolaryngologists often prefer the intranasal
approach as the method of choice, reserving the
procedure with the external approach for recurrent
cases [15]. The use of an endoscope with a diame−
ter of 4 mm enables operations on children even
before 1 year of age [16]. However, in such cases
the therapy should resort to conservative and least
traumatic methods (washing the canals, massage,
intubation, and ballooning). When this manage−
ment proves ineffective, the surgical reconstruc−
tion should be postponed until the child is one year
old. On the other hand, lower risk of damaging the
medial canthus is an advantage of the endoscopic
method [17]. The majority of the procedures were
performed under general anesthesia, although
according to some authors local anesthesia may
suffice, especially in uncomplicated cases [18].
The postsurgical management also arouses
a lot of discussion. Most authors recommend
removing the silicone drains 3–6 months after the
surgery. Maintaining the drains for too long a time
may result in a poorer functional effect. Removal
of the drain is a simple procedure performed on an
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P. WÓJCICKI, I. SIEWIERA
out−patient basis during a follow−up visit.
Smirnow G et al. compared two groups of patients
who had had endoscopic dacryocystorhinostomy
with and without silicone drains. The efficiency
rate was 89% in the group with drains and 75% in
the patients in whom drains were not inserted [19].
Some authors advocate additional washing of the
lacrimal ducts with steroids and others the local
intraoperative administration of mitomycin C [20].
The authors concluded that external dacry−
ocystorhinostomy is a highly effective and safe
procedure. In association with other reconstructive
methods it has an advantage over endoscopic
methods especially in cases with an acquired
defect, post−traumatic or neoplastic. Dacryocy−
storhinostomy may be successfully performed
even in small hospitals in view of the modest
instrumental requirements.
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Address for correspondence:
Piotr Wójcicki
Wojska Polskiego 23b
57−320 Polanica Zdrój
Poland
E−mail: [email protected]
Conflict of interest: None declared
Received: 22.06.2009
Revised: 3.07.2009
Accepted: 7.09.2009