Medical Care
For treatment of nasolacrimal duct obstruction, the type of antibiotic depends on the suspected infecting agent or the results of cultures and sensitivities.
Topical antibiotics with lacrimal massage may be adequate for early infections.
Systemic antibiotics may be necessary for more chronic or severe infections, such as those causing dacryocystitis, canaliculitis, or preseptal cellulitis (may progress to orbital abscesses).
Although sensitive to penicillin, Actinomyces organisms usually require complete removal of the canalicular stones for complete treatment.
Surgical Care
External dacryocystorhinostomy
See the list below:
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Criterion standard of lacrimal bypass surgeries
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Success rates up to 95%
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Facilitates identification and removal of dacryoliths and lacrimal sac tumors; also allows for biopsy of every lacrimal sac
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Requires skin incision
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Creates a communication between the lacrimal sac and nasal cavity, bypassing the obstructed nasolacrimal duct
Endoscopic mechanical/nonlaser dacryocystorhinostomy
See the list below:
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Involves the creation of a large ostium and construction of nasal and lacrimal sac mucosal flaps
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A viable option for the correction of acquired nasolacrimal duct obstruction and complex forms of congenital dacryostenosis in selected patients
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May be indicated on a primary basis or as revisional surgery
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Some studies comparing endonasal dacryocystorhinostomy with external dacryocystorhinostomy suggested lower success rates in the endonasal group. Other studies yielded success rates comparable with or exceeding those of external surgery.
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Complications of endonasal dacryocystorhinostomy do not generally appear to be greater in frequency or magnitude than those associated with external dacryocystorhinostomy.
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Disadvantages of endonasal dacryocystorhinostomy include the preferred use of general anesthesia by many surgeons, the high cost of expensive equipment and instrumentation, and the relatively steep learning curve for this procedure.
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Depending on the preference of the surgeon, more postoperative care may be required for patients undergoing endonasal dacryocystorhinostomy than external dacryocystorhinostomy. In one study, the success rate of 93.5% compares favorably with that of standard external dacryocystorhinostomy (95.8%).
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Anatomical success rate (91%) compares favorably with the success rate of other techniques for endonasal dacryocystorhinostomy and is also similar to the success of external dacryocystorhinostomy.
Endoscopic laser dacryocystorhinostomy
The KTP laser or the holmium:YAG laser is used.
In one study, the success rate in the endonasal group improved from 50% in the first 38 cases to 79% in the last 38 cases, thereby demonstrating a learning curve.
Endoscopic laser-assisted dacryocystorhinostomy
Advantages are as follows:
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No skin incision
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Less bleeding
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Faster recovery
Approaches are as follows:
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Endocanalicular
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Trans-conjunctival
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Endoscopic nasal
Endoscopic laser-assisted dacryocystorhinostomy is shown in the video below.
Conjunctivodacryocystorhinostomy
Conjunctivodacryocystorhinostomy (CDCR) is performed in cases of flaccid canaliculi, paralysis of lacrimal pump, absence or obliteration of canaliculi, when site of obstruction is proximal (punctum, canaliculi, lacrimal sac), congenital malformations, cicatricial conjunctival disease, chemical burns, irradiation, and tumors of the lacrimal sac.
The procedure uses a Pyrex Jones tube, which serves as a conduit between the medial conjunctival cul-de-sac and the nasal cavity.
Balloon catheter dilatation
The use of balloon catheter dilation for the treatment of adults with partial nasolacrimal duct obstruction and for children with congenital nasolacrimal duct obstruction has been described with good results in patients without active infection.
This treatment is effective for congenital nasolacrimal duct obstruction.
Highly successful in older children who failed previous probing
Success in children older than 24 months is 82.9%. Success in children younger than 24 months is 65.4%.
Balloon catheter dilatation is more effective than simple probing for older children with nasolacrimal duct obstruction because of stenosis that extends along the distal nasolacrimal duct.
No significant advantage exists over simple nasolacrimal duct probing in patients with typical membranous obstruction at the Hasner valve.
Endoscopically assisted balloon dacryoplasty has been shown as a treatment for incomplete NLDOs to provide substantial improvement or even complete relief.
Inferior meatus surgery
An endoscopic surgery for distal nasolacrimal duct obstruction at or near the Hasner valve
Confers 92.8% short-term success rate; 90% long-term success rate with a mean follow-up of 6.2 years [20]
Stents
Stents may be used as a first-line treatment for epiphora.
Polyurethane stents
See the list below:
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Low success rate for the treatment of PANDO
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May induce inflammation and fibrous tissue formation
Silicone
Double bicanalicular silicone intubation with the placement of 2 loops of silicone tubing through the nasolacrimal duct for the treatment of persistent nasolacrimal duct obstruction in children is an effective alternative to dacryocystorhinostomy in selected children who have failed conventional therapies.
For treatment of epiphora in adults with presumed functional nasolacrimal duct obstruction, silicone intubation has good long-term success, according to a study by Moscato et al. [21]
Hydrogel stents [22]
See the list below:
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Late success rate of 78.3%
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Well-tolerated for acquired nasolacrimal duct obstruction; decreases incidence of nasal adhesions
Polypropylene sutures 3/0 [23]
See the list below:
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Left in the lacrimal sac for 3 weeks
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Good results
See the list below:
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Cheap and easy self-retaining stent to ensure a patent rhinostomy
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Success rate of 73-82%
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Inserted without passing through the punctum but directly through the medial wall sac
Adjunctive use of mitomycin-C
Adjunctive use of mitomycin-C during dacryocystorhinostomy procedures significantly increases the success rate without adverse effects. [26, 27, 28, 29, 30] See the list below:
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Success rate of 87.5-95%
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Mitomycin-C, 0.2 mg/mL, may be used intraoperatively and postoperatively after external, endoscopic, and endolaser-assisted dacryocystorhinostomy and after balloon dacryoplasty.
Consultations
Nasolacrimal duct obstruction can be co-managed by the following specialists:
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Otolaryngologist
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Radiologist
Diet
Normal
Activity
As tolerated
Complications
See the list below:
Prevention
Early consultation when symptoms of tearing appear would be beneficial.
Appropriate antibiotics with lacrimal massage are the initial remedies for mild cases of obstruction.
Long-Term Monitoring
After the dacryocystorhinostomy, patients are given antibiotic eye drops and a nasal decongestant spray.
The silicone stent tube is removed after ≥3 months. In some situations (ie, Wegener granulomatosis), the stents may need to be retained indefinitely.
Further Inpatient Care
Dacryocystorhinostomy may be performed as an outpatient procedure, especially if performed with a laser; there is less bleeding and faster recovery.
Inpatient and Outpatient Medications
Antibiotic/steroid eye drops, such as tobramycin/dexamethasone combination eye drops, are prescribed postoperatively for use 2-3 times per day for 2-3 weeks as prophylaxis to infection and to decrease postoperative inflammation.
Nasal decongestant sprays are prescribed postoperatively for use 2-3 times per day for 2-3 weeks.
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Dacryocystitis of the left nasolacrimal system.
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Dacryocystogram. A patent nasolacrimal system on the right side of a patient and a blocked system on the contralateral side at the level of the nasolacrimal duct.
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Endoscopic laser-assisted dacryocystorhinostomy. Courtesy of Jorge G Camara, MD, University of Hawaii John A Burns School of Medicine.
