EDITORIAL
Management of Distal Common Canalicular Obstruction: Internal or External Approach? Chee Chew Yip, MBBS(S’pore), MMed (Ophth) (S’pore), FRCS (Edin), FAMS
O
bstruction of the lacrimal drainage system can cause disturbing epiphora that may impair vision. In comparison with nasolacrimal duct obstruction, a distal common canalicular obstruction (DCCO) is a less frequent cause of epiphora in the ophthalmic practice. Kumar et al1 reported their experience in the management of DCCO (in 14 patients) with external dacryocystorhinostomy (DCR), membranectomy, intraoperative mitomycin C (MMC) application, and bicanalicular silicone intubation in this issue of the journal. They included DCCO cases with soft stop, canalicular obstruction (Q12 mm from the punctum) on probing, and intraoperative visualization of distal canaliculus membranous obstruction. It is noteworthy that routine clinical preoperative evaluation is less sensitive in identifying a membranous obstruction of common canalicular opening than intraoperative direct inspection.2 The pathologic changes of DCCO seem to indicate nonspecific inflammation with associated fibrotic stenosis of the canalicular lumen3; however, cases demonstrating sebaceous gland adenoma, skeletal muscle, adipose tissue, and bone also have been identified.3 The roles of viral infections (such as herpes zoster, herpes simplex, chicken pox, and vaccina) and antivirals in the causation of canalicular stenosis are well known.4 Commonly used ophthalmic medications such as antiglaucoma agents, antibiotics, and vasoconstricting agents have also been implicated in punctal and canalicular stenosis including DCCO.4 Less frequently, iatrogenic etiologies such as trauma, surgery, chemotherapeutic agents (such as 5 fluorouracil and dacetaxel),5 and intracanalicular plug are found.6 Nonetheless, idiopathic cases of DCCO are sometimes encountered after excluding secondary causes. The optimal treatment of DCCO is unknown, and various modalities have been used to manage this difficult clinical problem. Bordoridis et al2 reported a larger series (59 patients) of DCCO treated with external DCR and intraoperative membranectomy with a similarly good success rate of 92%. Kumar et al proposed the management of canalicular pathology with an external DCR and membranectomy citing the advantages of open access with direct visualization, avoiding laser thermal damage at the surgical site and the opportunity for intraoperative MMC application. However, given the comparable high success rates of endoscopic (endonasal) DCR and external DCR,7 endoscopic DCR with membrane excision or lysis becomes a viable alternative. Endoscopically, DCCO may be approached from the nasal aspect in a retrograde fashion (endonasal endoscopic DCR) or in an antegrade direction via a fine transcanalicular endoscope (endocanalicular surgery). Approaching the DCCO endoscopically avoids: the potential complications (albeit rare) of external DCR surgery such as cutaneous scarring, medial canthal webbing (especially in Asians with epicanthal folds), and disruption of the lacrimal pump function. In endonasal endoscopic DCR, the use of a nasal endoscope enables a direct, magnified view of the membranous obstruction at the common canalicular opening within the nasal cavity to allow surgical intervention and minimize false passage creation. A microtrephine may be inserted transcanalicularly to incise and perforate the membranous obstruction8Y11 with a functional success (complete relief of epipbora) hovering approximately 80%. Khoubian et al9 reported a diminishing functional success rate with increasing proximity of the canalicular obstruction within the lacrimal passage. The membrane may also be excised endoscopically from the nasal aspect with fine otolaryngologic instruments (as in revision endonasal endoscopic DCR surgery) under the guidance and countertraction of a transcanalicular lacrimal probe. In some cases, concomitant endonasal surgery such as septoplasty and middle turbinectomy may be required to improve surgical assess and success.12 However, the cost, instrumentation, need for specialized training, learning curveYrelated problems, need for concomitant endonasal procedures, and facility requirements associated with endonasal endoscopic lacrimal surgery may pose a challenge for some centers.
From the Ophthalmology and Visual Sciences Department, Khoo Teck Puat Hospital. Received for publication March 4, 2013; accepted March 4, 2013. The author has no conflicts of interest to report. Reprints: Chee Chew Yip, MBBS(S’pore), MMed (Ophth) (S’pore), FRCS (Edin), FAMS, Ophthalmology & Visual Sciences Department, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828. E-mail: [email protected]. Copyright * 2013 by Asia Pacific Academy of Ophthalmology ISSN: 2162-0989 DOI: 10.1097/APO.0b013e3182902ffe
Asia-Pacific Journal of Ophthalmology
&
Volume 2, Number 2, March/April 2013
www.apjo.org
Copyright © 2013 Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
73
Asia-Pacific Journal of Ophthalmology
Editorial
There is a growing interest in endocanalicular surgery with advances in microendoscope designs, fiber optic technology, and endoscopic instrumentation. Endocanalicular laser has been used in endoscopic DCR to create an osteomy as an alternative to microdrills or ronguers. Endocanalicular laser DCR surgery may raise the concern of having an insufficiently sized, low-lying intranasal ostium due to soft tissue scarring from thermal damage and the inability of laser to ablate thick, hard orbital bone higher up adjacent to the lacrimal sac fundus. These factors may probably account for the lower success rate of this surgery in comparison with endonasal endoscopic DCR in some series.13Y15 To improve the surgical success, intraoperative11,15Y17 and postoperative MMC application17 have been advocated to modulate the healing process to reduce scarring and ostial closure. Leveraging on the experience with endocanalicular laser DCR and with further refinements in laser optics, endocanalicular laser has evolved to treat focal canalicular pathology including stenosis and membranous obstruction (laser canaliculoplasty). Dutton and Holck18 described the use of Holmium laser canaliculoplasty (to create a 1 mm channel from the punctum to lacrimal sac) in combination with DCR to treat complete and near complete canalicular obstruction cases with some success. Kuchar19 adopted a more refined endocanalicular ErYAG laser to recanalize distal canalicular membranous obstructions (up to 2 mm in length) followed by silicone intubation with a success rate of 84.2% at 17 months follow-up. However, a raw, de-epithelialized surface with delayed or abnormal healing after laser treatment to the canalicular system may predispose to synechial closure or stenosis after lacrimal stent removal. The safe and atraumatic nature of balloon dacryoplasty on the nasolacrimal duct20 in animal study also has paved the way for its application to the canalicular system. Ko el al21 described the transcanalicular placement of a balloon catheter under fluoroscopic guidance (balloon canaliculoplasty) at the site of stenosis to mechanically dilate and relieve the obstruction with an anatomic success (patency) rate of 40% at 2 years of follow-up. Zoulmalan et al22 reported a functional success of 76.2% at 6 months of follow-up with a 2-mm balloon canaliculoplasty and silicone intubation. However, the lower success rate of this modality21 as compared with microtrephination8Y11 and laser canaliculoplasty19 limits its application clinically especially for cases with severe or long segment of canalicular stenosis. It may, however, still have a role as an adjunct after microtrephination canaliculoplasty to augment the surgical success in maintaining canalicular patency.23 Although the role of bicanalicular intubation is controversial in DCR surgery for nasolacrimal duct obstruction, it is widely accepted practice to intubate the lacrimal passage in canalicular surgeries2,8Y11,17Y19 and removing the stent later than in conventional DCR. The lacrimal stent functions to maintain the canalicular patency while the mucosal surface heals with an epithelial lining. The optimal timing of stent removal is however unknown and been reported to range from 2 to 24 months.2,9Y11,17Y19 Canaliculo-DCR has been conventionally described as a treatment for common canalicular obstruction. The procedure involves fashioning an anastomosis of the common canaliculus to the lacrimal sac medially after excising the obstructive pathology24 with an external DCR approach. However, the technical difficulty and unpredictability of the surgical outcome has made this a less popular option. Conjunctivodacryocystorhinostomy (CDCR) may be indicated as a second-line treatment for DCCO when canaliculoplasty or membranectomy fails. First described by Von Hoffman in 1904,25 CDCR involves the creation of a fistula tract that
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bypasses the lacrimal passage from the conjunctiva sac to the nasal cavity. Lester Jones26,27 advocated CDCR with a Jones Pyrex glass tube to manage proximal canalicular obstructions. Despite its efficacy and a success rate approaching 90%, CDCR is associated with 2 significant complications: tube malpositions (22%Y28%) and tube extrusion (28%Y51%).28Y31 Other reported complications include tube obstruction, tube breakage, and granuloma formation.23Y29 Patient selection is important to optimize the success of CDCR. The patient must be motivated and educated on the need for lifetime maintenance of the tube patency.30,32 If the patient is medically unfit or refuses CDCR, botulinum toxin type A injection to the lacrimal gland to reduce tear production may be considered.33,34 Nonetheless, the cost, need for repeated injections, and complications such as ptosis and diplopia make this option unacceptable to some patients. The treatment of DCCO is evolving with technological and instrumentation advancement. There seems to be a trend toward an internal endoscopic approach (endonasal or endocanalicular) using less invasive procedures (microtrephination, laser canaliculoplasty, balloon canaliculoplasty) to obviate a skin incision. Despite this, external DCR with membranectomy may still be a feasible option to manage DCCO when there are constraints of cost, expertise, and manpower. The surgical success of canalicular surgery may be influenced by the location of the obstruction within the lacrimal passage, the thickness of the obstructing membrane or soft tissue and the length of obstruction. REFERENCES 1. Kumar S, Dulgach P, Kamal S, Goel R. Long-term success of modified external dacryocystorhinostomy for the treatment of distal common canalicular block. Asia-Pac J Ophthal. 2013;2:94Y98. 2. Boboridis KG, Bunce C, Rose GE. Outcome of external dacryocystorhinostomy combined with membranectomy of a distal canalicular obstruction. Am J Ophthalmol. 2005;139:1051Y1055. 3. Everman KR, Czyz CN, Kalwerisky K, et al. Canalicular obstruction: a histopathologic case series. Can J Ophthalmol. 2012;47:500Y503. 4. Harley RD, Stefanyszyn MA, Apt L, et al. Herpetic canalicular obstruction. Ophthalmic Surg. 1987;18:367Y370. 5. McNab AA. Lacrimal canalicular obstruction associated with topical ocular medication. Aust N Z J Ophthalmol. 1998;26:219Y223. 6. Dolan L, MacEwen CJ, White P. Common canalicular obstruction secondary to the use of Herrick lacrimal plugs, requiring endoscopic dacryocystorhinostomy. J Laryngol Otol. 2009;123:129Y130. 7. Ben Simon GJ, Joseph J, Lee S, et al. External versus endoscopic dacryocystorhinostomy for acquired nasolacrimal duct obstruction in a tertiary referral center. Ophthalmology. 2005;112:1463Y1468. 8. Ibrahim HA, Noble JL, Batterbury M, et al. Endoscopic-guided trephination dacryocystorhinostomy (Hesham DCR): technique and pilot trial. Ophthalmology. 2001;108:2337Y2345; discussion 2345Y6. 9. Paik JS, Cho WK, Yang SW. Bicanalicular double silicone stenting in endoscopic dacryocystorhinostomy with lacrimal trephination in distal or common canalicular obstruction. Eur Arch Otorhinolaryngol. 2012;269:1605Y1611. 10. Khoubian JF, Kikkawa DO, Gonnering RS. Trephination and silicone stent intubation for the treatment of canalicular obstruction: effect of the level of obstruction. Ophthal Plast Reconstr Surg. 2006;22:248Y252. 11. Nemet AY, Wilcsek G, Francis IC. Endoscopic dacryocystorhinostomy with adjunctive mitomycin C for canalicular obstruction. Orbit. 2007;26:97Y100. 12. Basmak H, Caklı H, Sahin A, et al. Comparison of endocanalicular laser dacryocystorhinostomy with and without endonasal procedures. Graefes Arch Clin Exp Ophthalmol. 2011;249:737Y743.
* 2013 Asia Pacific Academy of Ophthalmology
Copyright © 2013 Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
Asia-Pacific Journal of Ophthalmology
&
Volume 2, Number 2, March/April 2013
Editorial
13. Hong JE, Hatton MP, Leib ML, et al. Endocanalicular laser dacryocystorhinostomy analysis of 118 consecutive surgeries. Ophthalmology. 2005;112:1629Y1633.
23. Yang SW, Park HY, Kikkawa DO. Ballooning canaliculoplasty after lacrimal trephination in monocanalicular and common canalicular obstruction. Jpn J Ophthalmol. 2008;52:444Y449.
14. Gras-Cabrerizo JR, Montserrat-Gili JR, Leo´n-Vintro´ X, Lopez-Vilas M, ´ guez-eˆlvarez F, Bonafonte-Royo S, AlegrU ´ a A, MassegurRodrU Solench H. Endonasal endoscopic scalpel-forceps dacryocystorhinostomy vs endocanalicular diode laser dacryocystorhinostomy. Eur J Ophthalmol. 2013:23:7Y12.
24. Hurwitz JJ. The lacrimal surgery. Philadelphia: Lippincott-Raven; 1996.
15. Henson RD, Henson RG Jr, Cruz HL Jr, et al. Use of the diode laser with intraoperative mitomycin C in endocanalicular laser dacryocystorhinostomy. Ophthal Plast Reconstr Surg. 2007; 23:134Y137. 16. Liao SL, Kao SC, Tseng JH, et al. Results of intraoperative mitomycin C application in DCR. Br J Ophthalmol. 2000;84:903Y906. 17. Henson RD, Cruz HL, Henson RG Jr, et al. Postoperative application of mitomycin-C in endocanalicular laser dacryocystorhinostomy. Ophthal Plast Reconstr Surg. 2012;28:192Y195. 18. Dutton JJ, Holck DE. Holmium laser canaliculoplasty. Ophthal Plast Reconstr Surg. 1996;12:211Y217. 19. Kuchar A, Novak P, Pieh S, et al. Endoscopic laser recanalisation of presaccal canalicular obstruction. Br J Ophthalmol. 1999;83:443Y447. 20. Goldstein SM, Katowitz JA, Syed NA. The histopathologic effects of balloon dacryoplasty on the rabbit nasolacrimal duct. J AAPOS. 2006;10:333Y335.
25. Athansiov PA, Madge S, Kakizaki H, et al. A review of bypass tubes for proximal lacrimal drainage obstruction. Surv Ophthalmol. 2011; 56:252Y266. 26. Jones LT. The cure of epiphora due to canalicular disorders, trauma and surgical failures on the lacrimal passages. Trans Am Acad Ophthalmol Otolaryngol. 1962;66:506Y524. 27. Jones LT. Conjunctivodacryocystorhinostomy. Am J Ophthalmol. 1965;59:773Y783. 28. Steinsapir KD, Glstt HJ, Putterman AM. A 16-year study of conjunctivodacryocystorhinostomy. Am J Ophthalmol. 1990; 109:387Y393. 29. Sekhar GC, Dortzbach RK, Gonnering RS, et al. Problems associated with conjunctivodacryocystorhinostomy. Am J Ophthalmol. 1991; 112:502Y506. 30. Rose GE, Welham RN. Jones lacrimal canalicular bypass tubes: twenty five years’ experience. Eye. 1991;5:13Y19. 31. Lim C, Martin P, Benger R, et al. Lacrimal canalicular bypass surgery with the Lester Jones tube. Am J Ophthalmol. 2004;137:101Y108. 32. Hurwitz JJ, Howcroft MJ. Use of Lester Jones tubes: a review of 40 cases. Can J Ophthalmol. 1981;16:176Y177.
21. Ko GY, Lee DH, Ahn HS, et al. Balloon catheter dilation in common canalicular obstruction of the lacrimal system: safety and long-term effectiveness. Radiology. 2000;214:781Y786.
33. Wojno TH. Results of lacrimal gland botulinum toxin injection for epiphora in lacrimal obstruction and gustatory tearing. Ophthal Plast Reconstr Surg. 2011;27:119Y121.
22. Zoumalan CI, Maher EA, Lelli GJ Jr, et al. Balloon canaliculoplasty for acquired canalicular stenosis. Ophthal Plast Reconstr Surg. 2010;26:459Y461.
34. Tu AH, Chang EL. Botulinum toxin for palliative treatment of epiphora in a patient with canalicular obstruction. Ophthalmology. 2005; 112:1469Y1471.
I fear the day that technology will surpass our human interaction. The world will have a generation of idiots. - Albert Einstein
* 2013 Asia Pacific Academy of Ophthalmology
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75
Management of Distal Common Canalicular Obstruction: Internal or External Approach? Chee Chew Yip, MBBS(S’pore), MMed (Ophth) (S’pore), FRCS (Edin), FAMS
O
bstruction of the lacrimal drainage system can cause disturbing epiphora that may impair vision. In comparison with nasolacrimal duct obstruction, a distal common canalicular obstruction (DCCO) is a less frequent cause of epiphora in the ophthalmic practice. Kumar et al1 reported their experience in the management of DCCO (in 14 patients) with external dacryocystorhinostomy (DCR), membranectomy, intraoperative mitomycin C (MMC) application, and bicanalicular silicone intubation in this issue of the journal. They included DCCO cases with soft stop, canalicular obstruction (Q12 mm from the punctum) on probing, and intraoperative visualization of distal canaliculus membranous obstruction. It is noteworthy that routine clinical preoperative evaluation is less sensitive in identifying a membranous obstruction of common canalicular opening than intraoperative direct inspection.2 The pathologic changes of DCCO seem to indicate nonspecific inflammation with associated fibrotic stenosis of the canalicular lumen3; however, cases demonstrating sebaceous gland adenoma, skeletal muscle, adipose tissue, and bone also have been identified.3 The roles of viral infections (such as herpes zoster, herpes simplex, chicken pox, and vaccina) and antivirals in the causation of canalicular stenosis are well known.4 Commonly used ophthalmic medications such as antiglaucoma agents, antibiotics, and vasoconstricting agents have also been implicated in punctal and canalicular stenosis including DCCO.4 Less frequently, iatrogenic etiologies such as trauma, surgery, chemotherapeutic agents (such as 5 fluorouracil and dacetaxel),5 and intracanalicular plug are found.6 Nonetheless, idiopathic cases of DCCO are sometimes encountered after excluding secondary causes. The optimal treatment of DCCO is unknown, and various modalities have been used to manage this difficult clinical problem. Bordoridis et al2 reported a larger series (59 patients) of DCCO treated with external DCR and intraoperative membranectomy with a similarly good success rate of 92%. Kumar et al proposed the management of canalicular pathology with an external DCR and membranectomy citing the advantages of open access with direct visualization, avoiding laser thermal damage at the surgical site and the opportunity for intraoperative MMC application. However, given the comparable high success rates of endoscopic (endonasal) DCR and external DCR,7 endoscopic DCR with membrane excision or lysis becomes a viable alternative. Endoscopically, DCCO may be approached from the nasal aspect in a retrograde fashion (endonasal endoscopic DCR) or in an antegrade direction via a fine transcanalicular endoscope (endocanalicular surgery). Approaching the DCCO endoscopically avoids: the potential complications (albeit rare) of external DCR surgery such as cutaneous scarring, medial canthal webbing (especially in Asians with epicanthal folds), and disruption of the lacrimal pump function. In endonasal endoscopic DCR, the use of a nasal endoscope enables a direct, magnified view of the membranous obstruction at the common canalicular opening within the nasal cavity to allow surgical intervention and minimize false passage creation. A microtrephine may be inserted transcanalicularly to incise and perforate the membranous obstruction8Y11 with a functional success (complete relief of epipbora) hovering approximately 80%. Khoubian et al9 reported a diminishing functional success rate with increasing proximity of the canalicular obstruction within the lacrimal passage. The membrane may also be excised endoscopically from the nasal aspect with fine otolaryngologic instruments (as in revision endonasal endoscopic DCR surgery) under the guidance and countertraction of a transcanalicular lacrimal probe. In some cases, concomitant endonasal surgery such as septoplasty and middle turbinectomy may be required to improve surgical assess and success.12 However, the cost, instrumentation, need for specialized training, learning curveYrelated problems, need for concomitant endonasal procedures, and facility requirements associated with endonasal endoscopic lacrimal surgery may pose a challenge for some centers.
From the Ophthalmology and Visual Sciences Department, Khoo Teck Puat Hospital. Received for publication March 4, 2013; accepted March 4, 2013. The author has no conflicts of interest to report. Reprints: Chee Chew Yip, MBBS(S’pore), MMed (Ophth) (S’pore), FRCS (Edin), FAMS, Ophthalmology & Visual Sciences Department, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828. E-mail: [email protected]. Copyright * 2013 by Asia Pacific Academy of Ophthalmology ISSN: 2162-0989 DOI: 10.1097/APO.0b013e3182902ffe
Asia-Pacific Journal of Ophthalmology
&
Volume 2, Number 2, March/April 2013
www.apjo.org
Copyright © 2013 Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
73
Asia-Pacific Journal of Ophthalmology
Editorial
There is a growing interest in endocanalicular surgery with advances in microendoscope designs, fiber optic technology, and endoscopic instrumentation. Endocanalicular laser has been used in endoscopic DCR to create an osteomy as an alternative to microdrills or ronguers. Endocanalicular laser DCR surgery may raise the concern of having an insufficiently sized, low-lying intranasal ostium due to soft tissue scarring from thermal damage and the inability of laser to ablate thick, hard orbital bone higher up adjacent to the lacrimal sac fundus. These factors may probably account for the lower success rate of this surgery in comparison with endonasal endoscopic DCR in some series.13Y15 To improve the surgical success, intraoperative11,15Y17 and postoperative MMC application17 have been advocated to modulate the healing process to reduce scarring and ostial closure. Leveraging on the experience with endocanalicular laser DCR and with further refinements in laser optics, endocanalicular laser has evolved to treat focal canalicular pathology including stenosis and membranous obstruction (laser canaliculoplasty). Dutton and Holck18 described the use of Holmium laser canaliculoplasty (to create a 1 mm channel from the punctum to lacrimal sac) in combination with DCR to treat complete and near complete canalicular obstruction cases with some success. Kuchar19 adopted a more refined endocanalicular ErYAG laser to recanalize distal canalicular membranous obstructions (up to 2 mm in length) followed by silicone intubation with a success rate of 84.2% at 17 months follow-up. However, a raw, de-epithelialized surface with delayed or abnormal healing after laser treatment to the canalicular system may predispose to synechial closure or stenosis after lacrimal stent removal. The safe and atraumatic nature of balloon dacryoplasty on the nasolacrimal duct20 in animal study also has paved the way for its application to the canalicular system. Ko el al21 described the transcanalicular placement of a balloon catheter under fluoroscopic guidance (balloon canaliculoplasty) at the site of stenosis to mechanically dilate and relieve the obstruction with an anatomic success (patency) rate of 40% at 2 years of follow-up. Zoulmalan et al22 reported a functional success of 76.2% at 6 months of follow-up with a 2-mm balloon canaliculoplasty and silicone intubation. However, the lower success rate of this modality21 as compared with microtrephination8Y11 and laser canaliculoplasty19 limits its application clinically especially for cases with severe or long segment of canalicular stenosis. It may, however, still have a role as an adjunct after microtrephination canaliculoplasty to augment the surgical success in maintaining canalicular patency.23 Although the role of bicanalicular intubation is controversial in DCR surgery for nasolacrimal duct obstruction, it is widely accepted practice to intubate the lacrimal passage in canalicular surgeries2,8Y11,17Y19 and removing the stent later than in conventional DCR. The lacrimal stent functions to maintain the canalicular patency while the mucosal surface heals with an epithelial lining. The optimal timing of stent removal is however unknown and been reported to range from 2 to 24 months.2,9Y11,17Y19 Canaliculo-DCR has been conventionally described as a treatment for common canalicular obstruction. The procedure involves fashioning an anastomosis of the common canaliculus to the lacrimal sac medially after excising the obstructive pathology24 with an external DCR approach. However, the technical difficulty and unpredictability of the surgical outcome has made this a less popular option. Conjunctivodacryocystorhinostomy (CDCR) may be indicated as a second-line treatment for DCCO when canaliculoplasty or membranectomy fails. First described by Von Hoffman in 1904,25 CDCR involves the creation of a fistula tract that
74
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&
Volume 2, Number 2, March/April 2013
bypasses the lacrimal passage from the conjunctiva sac to the nasal cavity. Lester Jones26,27 advocated CDCR with a Jones Pyrex glass tube to manage proximal canalicular obstructions. Despite its efficacy and a success rate approaching 90%, CDCR is associated with 2 significant complications: tube malpositions (22%Y28%) and tube extrusion (28%Y51%).28Y31 Other reported complications include tube obstruction, tube breakage, and granuloma formation.23Y29 Patient selection is important to optimize the success of CDCR. The patient must be motivated and educated on the need for lifetime maintenance of the tube patency.30,32 If the patient is medically unfit or refuses CDCR, botulinum toxin type A injection to the lacrimal gland to reduce tear production may be considered.33,34 Nonetheless, the cost, need for repeated injections, and complications such as ptosis and diplopia make this option unacceptable to some patients. The treatment of DCCO is evolving with technological and instrumentation advancement. There seems to be a trend toward an internal endoscopic approach (endonasal or endocanalicular) using less invasive procedures (microtrephination, laser canaliculoplasty, balloon canaliculoplasty) to obviate a skin incision. Despite this, external DCR with membranectomy may still be a feasible option to manage DCCO when there are constraints of cost, expertise, and manpower. The surgical success of canalicular surgery may be influenced by the location of the obstruction within the lacrimal passage, the thickness of the obstructing membrane or soft tissue and the length of obstruction. REFERENCES 1. Kumar S, Dulgach P, Kamal S, Goel R. Long-term success of modified external dacryocystorhinostomy for the treatment of distal common canalicular block. Asia-Pac J Ophthal. 2013;2:94Y98. 2. Boboridis KG, Bunce C, Rose GE. Outcome of external dacryocystorhinostomy combined with membranectomy of a distal canalicular obstruction. Am J Ophthalmol. 2005;139:1051Y1055. 3. Everman KR, Czyz CN, Kalwerisky K, et al. Canalicular obstruction: a histopathologic case series. Can J Ophthalmol. 2012;47:500Y503. 4. Harley RD, Stefanyszyn MA, Apt L, et al. Herpetic canalicular obstruction. Ophthalmic Surg. 1987;18:367Y370. 5. McNab AA. Lacrimal canalicular obstruction associated with topical ocular medication. Aust N Z J Ophthalmol. 1998;26:219Y223. 6. Dolan L, MacEwen CJ, White P. Common canalicular obstruction secondary to the use of Herrick lacrimal plugs, requiring endoscopic dacryocystorhinostomy. J Laryngol Otol. 2009;123:129Y130. 7. Ben Simon GJ, Joseph J, Lee S, et al. External versus endoscopic dacryocystorhinostomy for acquired nasolacrimal duct obstruction in a tertiary referral center. Ophthalmology. 2005;112:1463Y1468. 8. Ibrahim HA, Noble JL, Batterbury M, et al. Endoscopic-guided trephination dacryocystorhinostomy (Hesham DCR): technique and pilot trial. Ophthalmology. 2001;108:2337Y2345; discussion 2345Y6. 9. Paik JS, Cho WK, Yang SW. Bicanalicular double silicone stenting in endoscopic dacryocystorhinostomy with lacrimal trephination in distal or common canalicular obstruction. Eur Arch Otorhinolaryngol. 2012;269:1605Y1611. 10. Khoubian JF, Kikkawa DO, Gonnering RS. Trephination and silicone stent intubation for the treatment of canalicular obstruction: effect of the level of obstruction. Ophthal Plast Reconstr Surg. 2006;22:248Y252. 11. Nemet AY, Wilcsek G, Francis IC. Endoscopic dacryocystorhinostomy with adjunctive mitomycin C for canalicular obstruction. Orbit. 2007;26:97Y100. 12. Basmak H, Caklı H, Sahin A, et al. Comparison of endocanalicular laser dacryocystorhinostomy with and without endonasal procedures. Graefes Arch Clin Exp Ophthalmol. 2011;249:737Y743.
* 2013 Asia Pacific Academy of Ophthalmology
Copyright © 2013 Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
Asia-Pacific Journal of Ophthalmology
&
Volume 2, Number 2, March/April 2013
Editorial
13. Hong JE, Hatton MP, Leib ML, et al. Endocanalicular laser dacryocystorhinostomy analysis of 118 consecutive surgeries. Ophthalmology. 2005;112:1629Y1633.
23. Yang SW, Park HY, Kikkawa DO. Ballooning canaliculoplasty after lacrimal trephination in monocanalicular and common canalicular obstruction. Jpn J Ophthalmol. 2008;52:444Y449.
14. Gras-Cabrerizo JR, Montserrat-Gili JR, Leo´n-Vintro´ X, Lopez-Vilas M, ´ guez-eˆlvarez F, Bonafonte-Royo S, AlegrU ´ a A, MassegurRodrU Solench H. Endonasal endoscopic scalpel-forceps dacryocystorhinostomy vs endocanalicular diode laser dacryocystorhinostomy. Eur J Ophthalmol. 2013:23:7Y12.
24. Hurwitz JJ. The lacrimal surgery. Philadelphia: Lippincott-Raven; 1996.
15. Henson RD, Henson RG Jr, Cruz HL Jr, et al. Use of the diode laser with intraoperative mitomycin C in endocanalicular laser dacryocystorhinostomy. Ophthal Plast Reconstr Surg. 2007; 23:134Y137. 16. Liao SL, Kao SC, Tseng JH, et al. Results of intraoperative mitomycin C application in DCR. Br J Ophthalmol. 2000;84:903Y906. 17. Henson RD, Cruz HL, Henson RG Jr, et al. Postoperative application of mitomycin-C in endocanalicular laser dacryocystorhinostomy. Ophthal Plast Reconstr Surg. 2012;28:192Y195. 18. Dutton JJ, Holck DE. Holmium laser canaliculoplasty. Ophthal Plast Reconstr Surg. 1996;12:211Y217. 19. Kuchar A, Novak P, Pieh S, et al. Endoscopic laser recanalisation of presaccal canalicular obstruction. Br J Ophthalmol. 1999;83:443Y447. 20. Goldstein SM, Katowitz JA, Syed NA. The histopathologic effects of balloon dacryoplasty on the rabbit nasolacrimal duct. J AAPOS. 2006;10:333Y335.
25. Athansiov PA, Madge S, Kakizaki H, et al. A review of bypass tubes for proximal lacrimal drainage obstruction. Surv Ophthalmol. 2011; 56:252Y266. 26. Jones LT. The cure of epiphora due to canalicular disorders, trauma and surgical failures on the lacrimal passages. Trans Am Acad Ophthalmol Otolaryngol. 1962;66:506Y524. 27. Jones LT. Conjunctivodacryocystorhinostomy. Am J Ophthalmol. 1965;59:773Y783. 28. Steinsapir KD, Glstt HJ, Putterman AM. A 16-year study of conjunctivodacryocystorhinostomy. Am J Ophthalmol. 1990; 109:387Y393. 29. Sekhar GC, Dortzbach RK, Gonnering RS, et al. Problems associated with conjunctivodacryocystorhinostomy. Am J Ophthalmol. 1991; 112:502Y506. 30. Rose GE, Welham RN. Jones lacrimal canalicular bypass tubes: twenty five years’ experience. Eye. 1991;5:13Y19. 31. Lim C, Martin P, Benger R, et al. Lacrimal canalicular bypass surgery with the Lester Jones tube. Am J Ophthalmol. 2004;137:101Y108. 32. Hurwitz JJ, Howcroft MJ. Use of Lester Jones tubes: a review of 40 cases. Can J Ophthalmol. 1981;16:176Y177.
21. Ko GY, Lee DH, Ahn HS, et al. Balloon catheter dilation in common canalicular obstruction of the lacrimal system: safety and long-term effectiveness. Radiology. 2000;214:781Y786.
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