Netherlands Ophthalmological Society, 167th Meeting, Vlissingen 1972 Ophthalmologica, Basel 171: 353 357 (1975)

Experiences with the Jones Tube in the Rotterdam Eye Clinic de

B lecourt

Ten years ago, at a meeting of the American Academy of Ophthalmology and Otolaryngology, L ester T. J ones broke a lance for the better under­ standing and adequate treatment of the epiphora resulting from occlusion of the punctum lacrimale and the canaliculus lacrimalis. He called the stenoses in this region of the lacrimal passages a neglected domain in ophthalmology, often treated with frequent probing and eye drops, without satisfactory results. J ones then propounded the double-acting pump drain­ age mechanism, in which the lacrimal fluid is sucked in by dilation of the umpulla below the punctum and in which the fluid, when the eyelids are closed, is pressed through the canaliculus due to the closing off of the punctum lacrimale; subsequently it is sucked in by the dilated lacrimal sack. It is precisely this fine pump mechanism that is damaged by frequent probings, which was a reason for J ones to propose the foundation of a ‘Society for Prevention of Cruelty to Canaliculi’. The frequency of these high occlusions in the lacrimal drainage system has been increased in the past 10 years, especially due to the increasing number of traumas with insufficient surgical repair. In addition to this, there may be a congenital atresia of a punctum lacrimale or of a canali­ culus. A role of increasing importance can also be attributed to the iatrogenic punctum occlusion, for example after prolonged use of miotics. Pilocarpine, Glaucostat as well as the irreversible anticholinesterase in­ hibitors may be held responsible for this. This obstruction can be explained from a protracted constriction of the very fine constrictor muscle which surrounds the punctum lacrimale, which might cause an hypertrophy of the punctum. The use of phenylephrine is also said to be able to cause an obstruction of the canaliculus, a kind of intracanalicular plug being

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J. H. P ameijer, H. E. H enkes and P. W ildervanck

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Pameijer/H enkes /W ildervanck de B lécourt

The operation itself is performed under general anesthesia. First and foremost, the vena angularis, if not directly clearly visible, is localized by means of a strong light source placed in the nose. Then the so important length of the tube is determined by means of a pair of compasses. The two legs of the compasses are placed on the

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formed. Strictures after inflammations are of frequent occurrence, while the improper and frequent probing may also lead to strictures of the damaged canaliculi. The ophthalmic surgeon had tried to treat these stenoses in many ways. If probing was possible, silk threads or plastic cannules were carried through with the help of the Worst pigtail probe. In the case of occluded puncta lacrimaba one or three snip operations were carried out; in the case of strictures of the lateral half of the canaliculi these strictures were divided. Sometimes treatment was successful, but especially in strictures and stenoses of the medial half of the canaliculi it directly led to closing off of the canaliculi after removal of the materials which had been carried through. After this, probing was often no longer possible either. This led J o n es to the idea of mobilizing the fundus of the lacrimal sac and stitching it in the conjunctiva under the caruncle, i.e. making a conjunctivodacryostomy. Later he did at the same time a rhinostomy according to DupuisDutemps, in order to use the intranasal negative pressure that arises during inspiration. However, these stomata also stenosed rapidly, which was the reason for keeping them free first with plastic, later with glass tubes. Glass has the advantage of its capillary activity; moreover, it has less tendency to clogging than plastic. Since 1967, 47 tubes have been placed in 45 patients of the Rotterdam Eye Clinic, in the beginning with the aid of colleague W o r st , the original operation method being gradually modified. After the first steps, the importance of the ENT surgeon was realized, and in all further operations the indispensable help of colleague D e B l é c o u r t , oto-rhino-laryngologist, was available. Before the decision to resort to operation, the patient should be informed of the likely consequences of the operation. After these 5 years it has indeed appeared to us that patients must have a strong motivation for operation apart from the great nuisance of epiphora and the possible fall of visual acuity due to the looking through an edge of lacrimal fluid, and they must be prepared for reoperation if need be. If the decision to operate is taken, the first things to be done are canaliculus photography and the ENT pre-examination. The length of the obstruction in the canali­ culus is determined with the help of contrast fluid.

Experiences with the Jones Tube in the Rotterdam Eye Clinic

355

The suture system is intended to prevent the patient from removing the tube himself before the first ambulant inspection. The supramid suture through the lumen of the tube is removed after 2 weeks. The importance of this suture is that one can identify the outlet site of the tube in the nasal mucosa, should the collar become overgrown by nasal mucosa. The black silk suture remains present for 4 weeks. This suture shows its usefulness in conjunctival overgrowth of the tube, which is only rarely found after 4 weeks. The inspections should be very frequent during the first 2 weeks. In­ cipient conjunctival overgrowth of the tube in this period can be prevented by traction on the black suture. The conjunctiva can be forced back over the collar by means of this traction. The luxations of the tube occurring in spite of these adjustments can be explained from a number of factors. The most frequent luxations on the side of the eye are:

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future outlet sites of the tube, namely under the caruncle and under the head of the medial concha. Subsequently only the skin is incised cautiously, often median to the angular vein. The subcutaneous tissues are separated by blunt dissection down to the periosteum, by which there is less risk of damaging the angular vein. The periosteum is incised and pushed from the bone towards the anterior lacrimal crest. In contrast to Jones, we leave the lacrimal sac itself entirely intact. A bone flap, about 3 x 4 mm, is prepared and luxated forward with the anterior lacrimal crest as rotation axis, and excised. The flap should be sufficiently large that the tube, with an external diameter of 3 mm, retains sufficient freedom of movement. The otologist now inspects the nose and indicates with an antrum hook the best site in the ex­ posed but still intact nasal mucosa, where the tube should perforate the mucosa and drain into the nose. The best outlet site is just anterior to the head of the middle concha; here the tube finds most space in the nose. Now we are ready for the bony passage of the tube. The soft trajectory of the tube, namely the conjunctiva, the musculus orbicularis and the periosteum, is constructed with the help of a trephine on a dental burr. The trephine is placed 2 mm behind the skin-conjunctiva junction below the caruncle and a channel is trephined in the direction of the bone flap. A supramid guide suture is led through the soft and the bony passage and picked up by the otologist in the nose. The length of the tube is again determined, by passing a rule with centimeter calibration down the passage, while the otologist indicates when the rod becomes visible in the nose. This second measurement often gives a 1-2 mm greater result, due to swelling of the tissues. The average value is taken as the desired length of the tube. The double-collared tube is led through the passage with the help of a silicone head and a conduction instrument, assisted by the supramid suture. The conjunctival end of the tube is fixed to the bridge of the nose with a black silk suture, together with the supramid suture. The wound is closed in layers. The patient is given chloramphenicol and naphazoline postoperatively, and general antibiotics if the operation has been carried out in an inflamed area.

Pameijer/H enkes /W ildervanck

de

B l £ court

(1) Conjunctival overgrowth. The collar of the tube cannot be found even with the slitlamp. The most important cause of this is a too short tube; overgrowth of the flaccid conjunctival mucosa occurs three times more frequently than overgrowth by the firmer nasal mucosa. Redressing is a difficult affair without a suture around the collar; pushing upwards of the tube from the nose with the assistance of the otologist, enables us to incise the conjunctiva over the collar. With a silk suture, traction on it and incision of the conjunctiva is sufficient. Closure of the conjunctiva behind the tube is to be recommended. (2) The tube begins to point into a wrong direction; the collar dis­ appears from the lacrimal fossa and may migrate deep into the fornix as well as pointing into the air through the lid border. Apart from an in­ correctly placed bone flap, this luxation can be caused by retraction by cicatricial strands in the wound region. These strands, often well palpable, are slit with an old Duvergier knife that is passed along the tube. (3) Directly after the operation, the collar does not lie well in the lacrimal fossa. This is caused by an incorrectly placed trephine; incision of the conjunctiva into the direction into which the collar has to be moved, with closure of the conjunctiva behind it, is often sufficient. The most frequent luxations at the nasal and are: (1) Overgrowth of the collar by nasal mucosa, due to a too short tube. The nasal mucosa area to be subjected to paracentesis is easily recognizable by the supramid suture and by a light source placed on the collar on the eye end. (2) The collar is lying against the septum, exerting a suction action on the mucosa and often forming there a small polyp after some time. The cause is a too long tube. For this a supramid suture is passed through the tube under local anesthesia. After scratching with a glass cutter the tube is broken; the two pieces are picked up; the channel is dilated up to dilator sound 3 and a shorter tube is introduced. Infrequent causes of a badly functioning tube are: (1) Breaking of the tube, which occurred once in our material after a mild trauma. (2) Ob­ struction of the tube, recorded several times in one patient. (3) Recurrent attacks of conjunctivitis and inflammatory manifestations in the tube pas­ sage. These always respond well to therapy. In many cases the tube passage becomes wider after a year. Then the tube can be moved easily; the channel is entirely epithelialized. Sometimes J o n es therefore removed his single-collar tubes. This is impossible for our double-collar tubes without damaging the epithelium of the passage; this is the reason why so far we have not dared to do this.

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356

Experiences with the Jones Tube in the Rotterdam Eye Clinic

357

In spite of the cured lacrimal symptoms, new complaints may sometimes arise, such as: during sneezing a mucosal plug flies from the tube against the spectacle glass; an air current before the eye during inspiration and expiration: the eye sits in a draught: when exhaling cigarette smoke through the nose, the smoke irritates the eye through the tube; the result is not always beautiful from the cosmetic point of view, for which reason we reduced the diameter of the collar to 3.2 mm. Fortunately, the patients cured from their complaints are still very happy, in spite of these some­ times somewhat annoying phenomena. It was this happiness that afforded me a real understanding of the so often underestimated troubles caused by epiphora. This happiness and the ultimate satisfaction on the part of the patient has kept us always on our toes in the somewhat difficult fight against the relatively frequent luxations. Prof. Dr. H. E. Henkes, Oogziekenhuis, Schiedamsevest 180, Rotterdam (The Nether­ lands)

D iscussion

C rone: At what age should correction take place in congenital canalicular atresia? Henkes: Correction can take place early, if need be soon after the 1st year of life.

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Von Winning: The high percentage of patients free of complaints after the oper­ ation gives reason for satisfaction, but it is a matter of some surprise if one realizes that lacrimating eyes not infrequently occur in association with patent lacrimal passages. Do you have an explanation for this? Henkes: The patency of the lacrimal passages is usually judged on the result of the test of Anel, in which the lacrimal passage is exposed to unphysiological pressure relationships. In spite of a so-called positive Anel. the lacrimal passage may be con­ stricted, in which an otherwise normal production of tears cannot be coped with, with lacrimating eyes as a result. The Jones tube has a much wider lumen and the passage between the conjunctival sac and the nasal cavity is short and straight, with the result that obstruction is a rare occurrence.

Experiences with the Jones tube in the Rotterdam Eye Clinic.

Netherlands Ophthalmological Society, 167th Meeting, Vlissingen 1972 Ophthalmologica, Basel 171: 353 357 (1975) Experiences with the Jones Tube in th...
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