- Author: Grant D Gilliland, MD; Chief Editor: Edsel Ing, MD, FRCSC more...
Further Outpatient Care
Most patients are treated surgically on an outpatient basis.
Further Inpatient Care
Admission to the hospital is required for the following:
Patients to be treated with intravenous antibiotic therapy
Patients with orbital cellulitis
Pediatric patients with periorbital or orbital cellulitis
Definitive surgical therapy should be performed; in most cases, this involves dacryocystorhinostomy.
Inpatient & Outpatient Medications
Topical antibiotics include Polytrim, gentamicin, tobramycin, and TobraDex (antibiotic/steroid combination drop).
Occasionally, nasal decongestants (eg, Afrin) are used on a short-term basis.
Oral antibiotics are useful in patients with acute dacryocystitis who are not acutely ill.
Intranasal saline may be useful postoperatively to keep the surgical ostium clean and open.
Patients may require transfer for diagnostic evaluation of associated systemic illnesses, such as Wegener granulomatosis, sarcoidosis, leukemia, lymphoma, and melanoma.
Proper eyelid hygiene, including warm compresses and eyelid scrubs, may prevent some cases of dacryocystitis.
Nasal hygiene with saline spray may help prevent distal lacrimal outflow obstruction.
Dacryocystorhinostomy, when properly performed, is a very safe and effective procedure. However, as with all surgical procedures, severe complications can occur.
Hemorrhage is the most notable complication and has been reported to occur in approximately 3% of patients. Considerations are as follows:
Bleeding is encountered commonly from the angular vessels, the nasal mucosa, and, occasionally, the anterior ethmoidal artery.
Most cases of hemorrhage can be controlled with judicious use of cautery and cottonoids soaked in thrombin. Rarely, the nose must be packed.
Any surgeon performing a dacryocystorhinostomy should be adept at placing an anterior nasal pack.
A posterior nasal pack usually is not required. It has been noticed that insertion of an absorbable homeostatic agent, such as Instat or Gelfoam, soaked in thrombin is effective in decreasing the incidence of hemorrhage.
Infection is also a serious concern with dacryocystorhinostomy. Almost routinely, patients with diabetes and children who undergo dacryocystorhinostomy are on postoperative oral antibiotics. Some surgeons advocate spraying antibiotic drops into the nose postoperatively. More commonly, a suture abscess is noted, which can be treated with removal of the offending suture, hot compresses, and oral and topical antibiotics.
Cerebrospinal fluid (CSF) leakage is the most dreaded complication of dacryocystorhinostomy. Because the cribriform plate lies just above the medial canthal tendon, tears in the bony plate with resultant CSF leakage can occur during creation of the osteotomy. Variations in anatomy are frequently responsible for the above complication. The author has observed a CSF leakage from dacryocystorhinostomy in a patient who had an arachnoid cyst extending from the anterior cranial fossa into the nasal vestibule just under the surface of the skin.
Failure of the dacryocystorhinostomy is most commonly due to an inadequate osteotomy or a fibrous closure at the surgical ostium. Most cases of the latter can be treated with dilation of the ostium with successively larger Bowman probes. Balloon dacryocystoplasty has been shown to be effective in patients who fail dacryocystorhinostomy surgery.
Rarely, a papilloma, which is occluding the ostium, can be seen intranasally. This can be removed during intranasal revision of the osteotomy.
Fortunately, few patients fail dacryocystorhinostomy; those patients who do most often necessitate placement of a Jones tube.
The success rate of external dacryocystorhinostomy has traditionally been regarded as approximately 95%.
Premature stent loss (prior to 2 months in one study ) resulted in a success rate of 90%.
Intranasal dacryocystorhinostomy has a slightly lower success rate, presumably due to the inability to create as large an ostium.
Laser-assisted dacryocystorhinostomy is promising in that less morbidity is seen with the procedure; however, the success rate appears to be approximately 80-85%.
A 2014 meta-analysis suggests lower success rates with nasolacrimal surgery than the figures that are traditionally quoted above.
Balloon dacryoplasty is also a useful procedure in select patients and in patients who fail primary dacryocystorhinostomy. The author offers balloon dacryoplasty to patients with focal partial stenosis.
The conjunctival flora has been shown to normalize a few weeks after dacryocystorhinostomy.
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