Intubation or stenting of the lacrimal drainage system should be considered as a first-line therapy whenever possible. Intubation of the nasolacrimal drainage system can usually be performed successfully when the patient has symptomatic canalicular constriction but not complete occlusion. For canalicular scarring, the use of a balloon catheter alone is usually not sufficient to correct the condition.
Reconstruction of an obstructed canaliculus is often successful when only a few millimeters are involved. If a limited area of total occlusion is discovered near the punctum, the occluded canaliculus can be resected and the cut ends of the canaliculus anastomosed over a stent. For distal obstructions, including the common canaliculus, trephination with lacrimal stenting can be useful. This is most successful for distal monocanalicular obstructions, followed by distal bicanalicular, common, and proximal obstructions.
Khoubian JF, Kikkawa DO, Gonnering RS. Trephination and silicone stent intubation for the treatment of canalicular obstruction: effect of the level of obstruction. Ophthalmic Plast Reconstr Surg. 2006;22(4):248–252.
If the common canaliculus is totally obstructed or the lacrimal sac is sclerotic, a canaliculodacryocystorhinostomy or canaliculorhinostomy may be performed. In these procedures, the area of total common canalicular obstruction is removed, and the remaining patent canalicular system is directly anastomosed to the lacrimal sac mucosa or the lateral nasal wall mucosa with placement of a lacrimal stent.
Lee JH, Young SM, Kim YD, Woo KI, Yum JH. Canaliculorhinostomy—indications and surgical results. Am J Ophthalmol. 2017;181:134–139.
When 1 or both canaliculi are severely obstructed, a CDCR may be required. This procedure creates a complete bypass of the lacrimal drainage system. The beginning of this surgical technique is similar to a DCR (described later in this chapter) and is followed by placement of a Jones tube through a tract created from the caruncle into the middle nasal meatus. The surgeon should have tubes of different lengths available at the time of surgery to ensure implantation of a tube that emerges clearly in the nose without abutting the nasal septum (Fig 15-18).
Postoperative care and complications can be troublesome. Patients with obstructive sleep apnea may be bothered by air reflux from their continuous positive airway pressure machine. This can sometimes be alleviated by switching to a full-face mask, but it may be so bothersome that the patient requests removal of the tube. Periodic removal, cleaning, and replacement of the Jones tube in the office is required to maintain its proper function and to avoid buildup of debris that can lead to chronic inflammation and even pyogenic granuloma formation. Between in-office cleanings, a daily routine including nasal lavage with saline solution and “snuffing” of artificial tears through the tube can help clear mucous debris and prevent obstruction.
Figure 15-18 Conjunctivodacryocystorhinostomy. A, The surgical tract is enlarged with a gold dilator. B, The Jones tube is introduced into the tract using a Bowman probe as a guide. C, External view of well-positioned Jones tube. D, Endoscopic view of well-positioned Jones tube.
(Parts A–C courtesy of Morris Hartstein; part D courtesy of Eric A. Steele, MD.)
Because the tube must be easily removable for cleaning and maintenance, extrusion and migration of the tube can occur, requiring prompt replacement to avoid contracture of the CDCR tract. Various tube modifications have been proposed to help with extrusion, but there is no clear advantage of these modifications over the original Jones tube, particularly because some of the modified tubes prevent easy removal for required periodic cleaning. Despite these drawbacks, conjunctivodacryocystorhinostomy helps many patients with otherwise intractable epiphora.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.