Evaluation of Dacryocystorhinostomy Failure With Computed Tomography and Computed Tomographic Dacryocystography Herbert J. Glatt, M.D., Alex C. Chan, M.D., and Lynn Barrett, M.D.
Five patients with dacryocystorhinostomy failures were examined with computed tomography or computed tomographic dacryacystography. In computed tomographic dacryocystography, radiopaque dye was instilled into the lacrimal sac before computed tomography to show its shape, location, and relation to surrounding structures. Problems with the bony ostium were detected in all five patients. Recurrent nasal polyposis, a retained metallic dip, and an unreseded ethmoid air cell were also identified. Computed tomography and computed tomographic dacryocystography provided important information that facilitated reoperation after dacryocystorhinostomy failure. of the cause of dacryocystorhinostomy failure is essential in determining appropriate treatment. In the preoperative evaluation of these cases, the usual physical examination is sometimes supplemented by additional studies such as dacryocystography.'? endoscopy.' and computed tomography.s'" The combination of dacryocystography and computed tomography has been called computed tomographic dacryocystography." In this study, dacryocystorhinostomy failure was evalIDENTIFICATION
Accepted for publication July 22, 1991. From the Section of Ophthalmology, Department of Surgery, University of Tennessee Medical Center, and the Ophthalmology Service, Department of Surgery, East Tennessee Baptist Hospital, Knoxville, Tennessee (Dr. Glatt); Department of Radiology, University of Tennessee Medical Center, Knoxville, Tennessee (Dr. Chan); and Department of Radiology, St. Mary's Medical Center, Knoxville, Tennessee (Dr. Barrett). Reprint requests to Herbert J. Glatt, M.D., University Eye Surgeons, Ste. 324, 1928 Alcoa Hwy., Knoxville, TN 37920.
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JOURNAL OF OPHTHALMOLOGY
112:431-436,
uated by computed tomography or computed tomographic dacryocystography.
Material and Methods Patient population-Five consecutive patients referred after unsuccessful dacryocystorhinostomies by other physicians underwent a comprehensive examination that included slit-lamp examination, basic tear-secretion measurement, assessment of eyelid position and tone, nasal examination, and canalicular probing and lacrimal irrigation when possible. Radiologic techniques-Two patients were examined with computed tomography. In the face-down position, direct coronal computed tomography was performed with 3-mm contiguous cuts in the region of the lacrimal outflow tract. In the face-up position, axial computed tomography was performed with 3-mm contiguous cuts. Three patients were examined with computed tomographic dacryocystography. This technique was first performed in Case 2 and subsequently performed in all cases with patent canaliculi (Cases 3 and 5). A 22-gauge intravenous catheter was inserted into the lower canaliculus and a radiopaque agent (Pantopaque, Alcon, Inc., Humacao, Puerto Rico) was then injected into the lacrimal sac. Computed tomography was performed after a delay of approximately 15 minutes in the same manner. Results Coronal scans were generally more helpful than axial scans. Bone windows were helpful in assessing the adequacy of the bony ostium. Computed tomography or computed tomographic dacryocystography detected problems OCTOBER,
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with the bony ostium in all five patients, including improper location, suboptimal size, and bone regrowth. Recurrent nasal polyposis adjacent to the previous ostium was imaged in Case 1. A retained metallic clip was imaged in Case 4. An anterior ethmoid air cell requiring resection was imaged in Case 5. Radiologic findings were confirmed during repeat lacrimal surgery in all five patients.
Case Reports Case 1 A 28-year-old man underwent bilateral nasal polypectomies for severe nasal polyposis. He subsequently developed left epiphora and chronic dacryocystitis. Fifteen months after the nasal polypectomies, another physician performed a left dacryocystorhinostomy that did not relieve his symptoms. We first examined the patient nine months after the previous dacryocystorhinostomy. Manual pressure on the left lacrimal sac produced copious pus. Irrigation through the left lower canaliculus disclosed a total lacrimal block, with reflux of pus from the upper canaliculus. Extensive nasal polyposis was observed on nasal examination. Computed tomography disclosed severe recurrent polyposis throughout the nasal cavity. The previous dacryocystorhinostomy bony opening was contiguous with the polyps and was too small (Fig. 1).
The patient underwent a combined procedure in which an otorhinolaryngologist performed bilateral nasal polypectomies and one of us/ an oculoplastic surgeon (H.I.G.), performed an external dacryocystorhinostomy. Intraoperative inspection confirmed that the osteotomy was too small and therefore, it was enlarged. Three months after surgery, fluid irrigated freely from the canaliculi to the nose. Eight months after surgery, the patient reported that he was free of epiphora and symptoms of dacryocystitis. Case 2 A 70-year-old woman with right epiphora and chronic dacryocystitis had undergone an unsuccessful right dacryocystorhinostomy by another physician. We first examined the patient four years later. Manual pressure on the right lacrimal sac produced copious pus. Irrigation through the lower canaliculus disclosed a total block with reflux of pus from the upper canaliculus. Computed tomographic dacryo-
Fig. 1 (Glatt, Chan, and Barrett). Case 1. Coronal computed tomogram of lacrimal obstruction associated with nasal polyposis, previous nasal polypectomy, and not relieved by previous dacryocystorhinostomy. Recurrent nasal polyposis appears on the computed tomogram as soft-tissue densities within the nasal cavity. This contrasts with the air density normally found within the nasal cavity and present in Figures 2 through 4. The osteotomy from the previous dacryocystorhinostomy is too small (arrow). Simultaneous repeat nasal polypectomy and enlargement of the osteotomy was performed.
cystography disclosed that the previous dacryocystorhinostomy bony opening was inferior to the lacrimal sac. A repeat external dacryocystorhinostomy was performed. Intraoperative inspection confirmed that the previous bony opening was inferior to the sac and therefore, it was enlarged superiorly. Four months after surgery, the patient was free of epiphora and symptoms of dacryocystitis and fluid irrigated freely from the canaliculi to the nose. Case 3 A 32-year-old woman had undergone endoscopic sinus surgery that included bilateral maxillary sinus osteoplasties, nasal septopiasty/ bilateral middle turbinectomies, bilateral ethmoidectomies, bilateral infracturing of the inferior turbinates, and partial inferior turbinectomies. She subsequently developed left epiphora and chronic dacryocystitis, presumably because of damage to the left nasolacrimal duct from excessive anterior enlargement of the maxillary sinus ostium.'? Five months later, an otorhinolaryngologist performed a left dacryo-
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A repeat external dacryocystorhinostomy was performed. Intraoperative inspection confirmed that the previous osteotomy was anterior to the lacrimal sac and therefore it was enlarged posteriorly. Four months after surgery, the patient was free of epiphora and symptoms of dacryocystitis and fluid irrigated freely from the canaliculi to the nose. Case 4
Fig. 2 (Glatt, Chan, and Barrett). Case 3. Coronal computed tomographic dacryocystographic scan of lacrimal obstruction not relieved by previous dacryocystorhinostomy. Radiopaque dye has been instilled in the lacrimal sac. Top, The bony ostium from the previous dacryocystorhinostomy is apparent but no dye is seen because the ostium is anterior to the lacrimal sac. Bottom, A more posterior coronal section discloses dye in the lacrimal sac and bone between the lacrimal sac and the nasal cavity, again indicating that the bony ostium is not posterior enough. Posterior enlargement of the osteotomy was performed during repeat dacryocystorhinostomy.
cystorhinostomy, which did not relieve her symptoms. We first examined the patient 14 months after the previous dacryocystorhinostomy. Irrigation through the left lower canaliculus disclosed total reflux into the conjunctival cul-de-sac through a medial canthal fistula. Computed tomographic dacryocystography disclosed that the previous dacryocystorhinostomy bony opening was anterior to the lacrimal sac (Fig. 2).
A 13-year-old girl who had epiphora caused by bilateral congenital absence of the canaliculi since early in life had undergone bilateral canalicular reconstruction and dacryocystorhinostomies by another physician, which did not relieve her symptoms. The previous physician stated that the entire bony wall of each lacrimal sac fossa had been removed. We first examined the patient two years later. Obvious bilateral epiphora was present. All four puncta were absent. A firm and uninflamed left lacrimal sac mass was observed. Computed tomography disclosed a mucocele of the left lacrimal sac. Bilateral bone regrowth had apparently developed, which separated the lacrimal sacs from the nasal cavity. A small dense object was detected in the superomediallacrimal sac (Fig. 3). A left conjunctival dacryocystorhinostomy with placement of a Jones tube was performed. Intraoperative inspection confirmed that bony regrowth had developed and therefore, a repeat osteotomy was performed. The dense object in the sac proved to be a metallic clip that had been placed around silicone tubing during the previous surgery and had remained in the sac after removal of the tubing. The clip was removed. Six weeks after surgery, she was free of epiphora and the Jones tube was in good position. Surgery on the right is planned. Case 5
An SO-year-old woman with left chronic dacryocystitis had undergone two unsuccessful left dacryocystorhinostomies. We first examined the patient ten years later. Manual pressure on the left lacrimal sac produced pus. Irrigation through the lower canaliculus disclosed a total block with reflux of pus from the upper canaliculus. Computed tomographic dacryocystography disclosed that the previous dacryocystorhinostomy bony opening was inferior to the lacrimal sac and that an unresected ethmoid air cell was adjacent to the lacrimal sac (Fig. 4). A repeat dacryocystorhinostomy was performed. Intraoperative inspection confirmed that the previous osteotomy was inferior to the
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Fig. 3 (Glatt, Chan, and Barrett). Case 4. Coronal computed tomogram of a patient with bilateral congenital absence of the canaliculi who had undergone unsuccessful bilateral canalicular reconstruction and dacryocystorhinostomy. Bilateral bone regrowth has apparently occurred, separating the lacrimal sacs from the nasal cavity. On the left side of the photograph (patient's right), a small bony defect is still present. On the right side of the photograph (patient's left), the lacrimal sac is separated from the nasal cavity by a thin layer of bone. The small round density in the patient's left superomedial sac proved to be a metallic clip.
lacrimal sac and therefore, it was enlarged superiorly. An ethmoid air cell adjacent to the lacrimal sac was resected. Three months after surgery, the patient was free of epiphora and dacryocystitis and fluid irrigated freely from the canaliculi to the nose.
Discussion Dacryocystorhinostomy failure may result from the following causes'r't (1) ostium; inappropriate size or location, or both, bone regrowth, or soft-tissue regrowth; (2) lacrimal sac; scarring from trauma, previous surgery, nonabsorbable sutures or clips, or inadequate surgical opening; (3) canalicular abnormalities; (4) anatomic variants of nasal cavity or sinuses; anterior ethmoids, anterior middle turbinate, or deviated septum; (5) tumors; lacrimal sac, nasal, or sinus; (6) inflammatory diseases; sarcoid or pseudotumor; and (7) epiphora unrelated to lacrimal outflow tract abnormalities. In Welham and WUIc'SI study of 208 dacryocystorhinostomy failures, problems with the
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Fig. 4 (Glatt, Chan, and Barrett). Case 5. Coronal computed tomographic dacryocystographic scan of lacrimal obstruction not relieved by two previous dacryocystorhinostomies. Radiopaque dye has been instilled in the lacrimal sac. On the right side of the photograph (patient's left), dye is seen in the lacrimal sac. The ostium from the previous dacryocystorhinostomy is inferior to the sac. The sac is separated from the nasal cavity by the bony wall of the lacrimal sac fossa and an anterior ethmoid air cell. Both had to be resected during repeat dacryocystorhinostomy.
bony ostium were found in over half the cases and represented the most common cause of dacryocystorhinostomy failure. For external dacryocystorhinostomy, most authors recommend a relatively large osteotomy that eliminates all bone between the lacrimal sac and nasal mucosa.':" that ensures that no bone is left within 5 mm of the common canaliculus,' and that measures at least 15 mm in diameter.2,12.14 Two recent studies of transnasal laser dacryocystorhinostomy have recommended a smaller bony ostium measuring 5 to 7 mm. 15•16 This recommendation may not be applicable to external dacryocystorhinostomy. In our study, the previous ostium was improperly located in three patients (Cases 2, 3, and 5), and did not meet the usually recommended size criteria in one patient (Case 1). Bone regrowth after dacryocystorhinostomy is unusual.P is more common in children, I and apparently developed in Case 4 of our study. Computed tomography or computed tomographic dacryocystography facilitated reoperation after dacryocystorhinostomy failure by determining what modifications were required in the bony ostium. A transnasal endoscopic approach to dacryocystorhinostomy failure has been described in
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two recent studies.v' This approach has the advantage of avoiding a skin incision. It also allows examination and correction of intranasal abnormalities. Orcutt, Hillel, and Weymuller? stated that a preoperative assessment of bony ostium by use of conventional dacryocystography or computed tomography was a prerequisite for this approach. In every case in our study, computed tomography or computed tomographic dacryocystography detected a problem with the bony ostium and an external dacryocystorhinostomy was performed through a skin incision. If preoperative imaging studies indicate that the bony ostium is of adequate size and location, a transnasal endoscopic approach can be considered. Anatomic variations and diseases of the nasal cavity and sinuses are other important causes of dacryocystorhinostomy failure,I,3,4,6,7 and factored in two of our cases. Examination with a nasal speculum or endoscope, or both, can often detect these problems.' Computed tomography or computed tomographic dacryocystography may also provide additional information in some cases. Other reports on the use of computed tomography in the evaluation of dacryocystorhinostomy failure have appeared in the literature. Computed tomography has documented dacryocystorhinostomy failure from tumors,3,5,6 orbital pseudotumor," and nasal septal deviation."> Computed tomography has demonstrated that persistent epiphora after dacryocystorhinostomy was a result of a basilar skull fracture causing a cerebrospinal fluid leak." Computed tomography has been used to evaluate the adequacy of the bony ostium before endoscopic repair of dacryocystorhinostomy failure." In our method of computed tomographic dacryocystography, a radiopaque agent was injected into the lacrimal sac through a catheter placed in the lower canaliculus. Zinreich and associates" devised a method of computed tomographic dacryocystography in which metrizamide eyedrops were placed into the conjunctival cul-de-sac. By obviating the need for canalicular intubation, their method increases patient comfort, can be performed in children, and eliminates the need for a physician or technician skilled in canalicular intubation. Although we suspect that our method might result in better filling of the lacrimal sac in some cases, we do not have any experience with their method. In the computed tomographic dacryocysto-
435
grams in our study, there was a delay of approximately 15 minutes between the instillation of radiopaque agent and the performance of the computed tomography. This delay was caused by our early inefficiency in coordinating the two steps. We have subsequently eliminated these inefficiencies and now perform the computed tomography immediately after the instillation of the dye. As conventional dacryocystography and computed tomography are already performed in many institutions, computed tomographic dacryocystography can easily be implemented with only minor adaptation of preexisting techniques. This technique can be performed on most repeat dacryocystorhinostomy candidates, but obviously cannot be performed on patients who have total canalicular obstructions. After previous dacryocystorhinostomy failure, identification of the lacrimal sac on computed tomography and during surgery may be challenging because of scarring and alteration of anatomic landmarks. By identifying the lacrimal sac's shape, location, and relation to surrounding structures, computed tomographic dacryocystography facilitates the treatment of these difficult cases.
References 1. Welham, R. A. N., and Wulc, A. E.: Management of unsuccessful lacrimal surgery. Br. J. Ophthai mol. 71:152, 1987. 2. McLachlan, D. L., Shannon, G. M., and Flanagan, J. c.: Results of dacryocystorhinostomy. Analysis of the reoperations. Ophthalmic Surg. 11:427, 1980. 3. Hurwitz, J. J., and Victor, W. H.: The role of sophisticated radiological testing in the assessment and management of epiphora. Ophthalmology 92:407, 1985. 4. Allen, K. M., Berlin, A. J., and Levine, H. L.: Intranasal endoscopic analysis of dacryocystorhinostomy failure. Ophthalmic Plast. Reconstr. Surg. 4:143, 1988. 5. Carnevali, L., Trimarchi, F., Rosso, R., and Stringa, M.: Haemangiopericytoma of the lacrimal sac. A case report. Br. J. Ophthalmol. 72:782, 1988. 6. Sternberg, I., and Levine, M. R.: Ethmoidal sinus osteoma. A primary cause of nasolacrimal duct obstruction and dacryocystorhinostomy failure. Ophthalmic Surg. 15:295, 1984. 7. Orcutt, J. c.. Hillel, A., and Weymuller, E. A.: Endoscopic repair of failed dacryocystorhinostomy. Ophthalmic Piast. Reconstr. Surg. 6:197, 1990. 8. Dryden, R. M., and Wuk, A. E.: Pseudo-
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epiphora from cerebrospinal fluid leak. Case report. Br. J. Ophthalmol. 70:570, 1986. 9. Zinreich, S. J., Miller, N. R., Freeman, L. N., Glorioso, L. W., and Rosenbaum, A. E.: Computed tomographic dacryocystography using topical contrast media for lacrimal system visualization. Orbit 9:79,1990. 10. Serdahl, C. L., Berris, C. E., and Chole, R. A.: Nasolacrimal duct obstruction after endoscopic sinus surgery. Arch. Ophthalmol. 108:391, 1990. 11. Putterman, A. M.: Oculoplastic surgery. In Peyman, G. A., Sanders, D. R., and Goldberg, M. F. (eds.): Principles and Practice of Ophthalmology. Philadelphia, W. B. Saunders Co., 1980, pp. 22812288. 12. McPherson, S. D., and Egleston, D.: Dacryo-
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cystorhinostomy. A review of 106 operations. Am. J. Ophthalmol. 47:328, 1959. 13. Hecht, S. D.: Dacryocystorhinostomy. In Hornblass, A., and Hanig, C. J. (eds.): Oculoplastic. Orbital, and Reconstructive Surgery. Baltimore, Williams & Wilkins, 1990, pp. 1433-1440. 14. Patrinely, J. R., and Anderson, R. L.: A review of lacrimal drainage surgery. Ophthalmic Plast. Reconstr. Surg. 2:97, 1986. 15. Massaro, B. M., Gonnering, R. S., and Harris, G. J.: Endonasallaser dacryocystorhinostomy. A new approach to nasolacrimal duct obstruction. Arch. OphthalmoL 108:1172, 1990. 16. Gonnering, R. S., Lyon, D. B., and Fisher, J. c.. Endoscopic laser-assisted lacrimal surgery. Am. J. Ophthalmol. 111:152, 1991.
OPHTHALMIC MINIATURE
And as I faced him, with levelled gun shaking in my hands, I had time to note the worn and haggard appearance of his face. It was as if some strong anxiety had wasted it. The cheeks were sunken, and there was a wearied, puckered expression on the brow. And it seemed to me that his eyes were strange, not only the expression, but the physical seeming, as though the optic nerves and supporting muscles had suffered strain and slightly twisted the eyeballs. Jack London, The Sea Wolf New York, Bantam Books, 1986, p. 208
Five patients with dacryocystorhinostomy failures were examined with computed tomography or computed tomographic dacryacystography. In computed tomographic dacryocystography, radiopaque dye was instilled into the lacrimal sac before computed tomography to show its shape, location, and relation to surrounding structures. Problems with the bony ostium were detected in all five patients. Recurrent nasal polyposis, a retained metallic dip, and an unreseded ethmoid air cell were also identified. Computed tomography and computed tomographic dacryocystography provided important information that facilitated reoperation after dacryocystorhinostomy failure. of the cause of dacryocystorhinostomy failure is essential in determining appropriate treatment. In the preoperative evaluation of these cases, the usual physical examination is sometimes supplemented by additional studies such as dacryocystography.'? endoscopy.' and computed tomography.s'" The combination of dacryocystography and computed tomography has been called computed tomographic dacryocystography." In this study, dacryocystorhinostomy failure was evalIDENTIFICATION
Accepted for publication July 22, 1991. From the Section of Ophthalmology, Department of Surgery, University of Tennessee Medical Center, and the Ophthalmology Service, Department of Surgery, East Tennessee Baptist Hospital, Knoxville, Tennessee (Dr. Glatt); Department of Radiology, University of Tennessee Medical Center, Knoxville, Tennessee (Dr. Chan); and Department of Radiology, St. Mary's Medical Center, Knoxville, Tennessee (Dr. Barrett). Reprint requests to Herbert J. Glatt, M.D., University Eye Surgeons, Ste. 324, 1928 Alcoa Hwy., Knoxville, TN 37920.
©AMERICAN
JOURNAL OF OPHTHALMOLOGY
112:431-436,
uated by computed tomography or computed tomographic dacryocystography.
Material and Methods Patient population-Five consecutive patients referred after unsuccessful dacryocystorhinostomies by other physicians underwent a comprehensive examination that included slit-lamp examination, basic tear-secretion measurement, assessment of eyelid position and tone, nasal examination, and canalicular probing and lacrimal irrigation when possible. Radiologic techniques-Two patients were examined with computed tomography. In the face-down position, direct coronal computed tomography was performed with 3-mm contiguous cuts in the region of the lacrimal outflow tract. In the face-up position, axial computed tomography was performed with 3-mm contiguous cuts. Three patients were examined with computed tomographic dacryocystography. This technique was first performed in Case 2 and subsequently performed in all cases with patent canaliculi (Cases 3 and 5). A 22-gauge intravenous catheter was inserted into the lower canaliculus and a radiopaque agent (Pantopaque, Alcon, Inc., Humacao, Puerto Rico) was then injected into the lacrimal sac. Computed tomography was performed after a delay of approximately 15 minutes in the same manner. Results Coronal scans were generally more helpful than axial scans. Bone windows were helpful in assessing the adequacy of the bony ostium. Computed tomography or computed tomographic dacryocystography detected problems OCTOBER,
1991
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with the bony ostium in all five patients, including improper location, suboptimal size, and bone regrowth. Recurrent nasal polyposis adjacent to the previous ostium was imaged in Case 1. A retained metallic clip was imaged in Case 4. An anterior ethmoid air cell requiring resection was imaged in Case 5. Radiologic findings were confirmed during repeat lacrimal surgery in all five patients.
Case Reports Case 1 A 28-year-old man underwent bilateral nasal polypectomies for severe nasal polyposis. He subsequently developed left epiphora and chronic dacryocystitis. Fifteen months after the nasal polypectomies, another physician performed a left dacryocystorhinostomy that did not relieve his symptoms. We first examined the patient nine months after the previous dacryocystorhinostomy. Manual pressure on the left lacrimal sac produced copious pus. Irrigation through the left lower canaliculus disclosed a total lacrimal block, with reflux of pus from the upper canaliculus. Extensive nasal polyposis was observed on nasal examination. Computed tomography disclosed severe recurrent polyposis throughout the nasal cavity. The previous dacryocystorhinostomy bony opening was contiguous with the polyps and was too small (Fig. 1).
The patient underwent a combined procedure in which an otorhinolaryngologist performed bilateral nasal polypectomies and one of us/ an oculoplastic surgeon (H.I.G.), performed an external dacryocystorhinostomy. Intraoperative inspection confirmed that the osteotomy was too small and therefore, it was enlarged. Three months after surgery, fluid irrigated freely from the canaliculi to the nose. Eight months after surgery, the patient reported that he was free of epiphora and symptoms of dacryocystitis. Case 2 A 70-year-old woman with right epiphora and chronic dacryocystitis had undergone an unsuccessful right dacryocystorhinostomy by another physician. We first examined the patient four years later. Manual pressure on the right lacrimal sac produced copious pus. Irrigation through the lower canaliculus disclosed a total block with reflux of pus from the upper canaliculus. Computed tomographic dacryo-
Fig. 1 (Glatt, Chan, and Barrett). Case 1. Coronal computed tomogram of lacrimal obstruction associated with nasal polyposis, previous nasal polypectomy, and not relieved by previous dacryocystorhinostomy. Recurrent nasal polyposis appears on the computed tomogram as soft-tissue densities within the nasal cavity. This contrasts with the air density normally found within the nasal cavity and present in Figures 2 through 4. The osteotomy from the previous dacryocystorhinostomy is too small (arrow). Simultaneous repeat nasal polypectomy and enlargement of the osteotomy was performed.
cystography disclosed that the previous dacryocystorhinostomy bony opening was inferior to the lacrimal sac. A repeat external dacryocystorhinostomy was performed. Intraoperative inspection confirmed that the previous bony opening was inferior to the sac and therefore, it was enlarged superiorly. Four months after surgery, the patient was free of epiphora and symptoms of dacryocystitis and fluid irrigated freely from the canaliculi to the nose. Case 3 A 32-year-old woman had undergone endoscopic sinus surgery that included bilateral maxillary sinus osteoplasties, nasal septopiasty/ bilateral middle turbinectomies, bilateral ethmoidectomies, bilateral infracturing of the inferior turbinates, and partial inferior turbinectomies. She subsequently developed left epiphora and chronic dacryocystitis, presumably because of damage to the left nasolacrimal duct from excessive anterior enlargement of the maxillary sinus ostium.'? Five months later, an otorhinolaryngologist performed a left dacryo-
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A repeat external dacryocystorhinostomy was performed. Intraoperative inspection confirmed that the previous osteotomy was anterior to the lacrimal sac and therefore it was enlarged posteriorly. Four months after surgery, the patient was free of epiphora and symptoms of dacryocystitis and fluid irrigated freely from the canaliculi to the nose. Case 4
Fig. 2 (Glatt, Chan, and Barrett). Case 3. Coronal computed tomographic dacryocystographic scan of lacrimal obstruction not relieved by previous dacryocystorhinostomy. Radiopaque dye has been instilled in the lacrimal sac. Top, The bony ostium from the previous dacryocystorhinostomy is apparent but no dye is seen because the ostium is anterior to the lacrimal sac. Bottom, A more posterior coronal section discloses dye in the lacrimal sac and bone between the lacrimal sac and the nasal cavity, again indicating that the bony ostium is not posterior enough. Posterior enlargement of the osteotomy was performed during repeat dacryocystorhinostomy.
cystorhinostomy, which did not relieve her symptoms. We first examined the patient 14 months after the previous dacryocystorhinostomy. Irrigation through the left lower canaliculus disclosed total reflux into the conjunctival cul-de-sac through a medial canthal fistula. Computed tomographic dacryocystography disclosed that the previous dacryocystorhinostomy bony opening was anterior to the lacrimal sac (Fig. 2).
A 13-year-old girl who had epiphora caused by bilateral congenital absence of the canaliculi since early in life had undergone bilateral canalicular reconstruction and dacryocystorhinostomies by another physician, which did not relieve her symptoms. The previous physician stated that the entire bony wall of each lacrimal sac fossa had been removed. We first examined the patient two years later. Obvious bilateral epiphora was present. All four puncta were absent. A firm and uninflamed left lacrimal sac mass was observed. Computed tomography disclosed a mucocele of the left lacrimal sac. Bilateral bone regrowth had apparently developed, which separated the lacrimal sacs from the nasal cavity. A small dense object was detected in the superomediallacrimal sac (Fig. 3). A left conjunctival dacryocystorhinostomy with placement of a Jones tube was performed. Intraoperative inspection confirmed that bony regrowth had developed and therefore, a repeat osteotomy was performed. The dense object in the sac proved to be a metallic clip that had been placed around silicone tubing during the previous surgery and had remained in the sac after removal of the tubing. The clip was removed. Six weeks after surgery, she was free of epiphora and the Jones tube was in good position. Surgery on the right is planned. Case 5
An SO-year-old woman with left chronic dacryocystitis had undergone two unsuccessful left dacryocystorhinostomies. We first examined the patient ten years later. Manual pressure on the left lacrimal sac produced pus. Irrigation through the lower canaliculus disclosed a total block with reflux of pus from the upper canaliculus. Computed tomographic dacryocystography disclosed that the previous dacryocystorhinostomy bony opening was inferior to the lacrimal sac and that an unresected ethmoid air cell was adjacent to the lacrimal sac (Fig. 4). A repeat dacryocystorhinostomy was performed. Intraoperative inspection confirmed that the previous osteotomy was inferior to the
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Fig. 3 (Glatt, Chan, and Barrett). Case 4. Coronal computed tomogram of a patient with bilateral congenital absence of the canaliculi who had undergone unsuccessful bilateral canalicular reconstruction and dacryocystorhinostomy. Bilateral bone regrowth has apparently occurred, separating the lacrimal sacs from the nasal cavity. On the left side of the photograph (patient's right), a small bony defect is still present. On the right side of the photograph (patient's left), the lacrimal sac is separated from the nasal cavity by a thin layer of bone. The small round density in the patient's left superomedial sac proved to be a metallic clip.
lacrimal sac and therefore, it was enlarged superiorly. An ethmoid air cell adjacent to the lacrimal sac was resected. Three months after surgery, the patient was free of epiphora and dacryocystitis and fluid irrigated freely from the canaliculi to the nose.
Discussion Dacryocystorhinostomy failure may result from the following causes'r't (1) ostium; inappropriate size or location, or both, bone regrowth, or soft-tissue regrowth; (2) lacrimal sac; scarring from trauma, previous surgery, nonabsorbable sutures or clips, or inadequate surgical opening; (3) canalicular abnormalities; (4) anatomic variants of nasal cavity or sinuses; anterior ethmoids, anterior middle turbinate, or deviated septum; (5) tumors; lacrimal sac, nasal, or sinus; (6) inflammatory diseases; sarcoid or pseudotumor; and (7) epiphora unrelated to lacrimal outflow tract abnormalities. In Welham and WUIc'SI study of 208 dacryocystorhinostomy failures, problems with the
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Fig. 4 (Glatt, Chan, and Barrett). Case 5. Coronal computed tomographic dacryocystographic scan of lacrimal obstruction not relieved by two previous dacryocystorhinostomies. Radiopaque dye has been instilled in the lacrimal sac. On the right side of the photograph (patient's left), dye is seen in the lacrimal sac. The ostium from the previous dacryocystorhinostomy is inferior to the sac. The sac is separated from the nasal cavity by the bony wall of the lacrimal sac fossa and an anterior ethmoid air cell. Both had to be resected during repeat dacryocystorhinostomy.
bony ostium were found in over half the cases and represented the most common cause of dacryocystorhinostomy failure. For external dacryocystorhinostomy, most authors recommend a relatively large osteotomy that eliminates all bone between the lacrimal sac and nasal mucosa.':" that ensures that no bone is left within 5 mm of the common canaliculus,' and that measures at least 15 mm in diameter.2,12.14 Two recent studies of transnasal laser dacryocystorhinostomy have recommended a smaller bony ostium measuring 5 to 7 mm. 15•16 This recommendation may not be applicable to external dacryocystorhinostomy. In our study, the previous ostium was improperly located in three patients (Cases 2, 3, and 5), and did not meet the usually recommended size criteria in one patient (Case 1). Bone regrowth after dacryocystorhinostomy is unusual.P is more common in children, I and apparently developed in Case 4 of our study. Computed tomography or computed tomographic dacryocystography facilitated reoperation after dacryocystorhinostomy failure by determining what modifications were required in the bony ostium. A transnasal endoscopic approach to dacryocystorhinostomy failure has been described in
Vol. 112, No.4
Evaluation of Dacryocystorhinostomy Failure
two recent studies.v' This approach has the advantage of avoiding a skin incision. It also allows examination and correction of intranasal abnormalities. Orcutt, Hillel, and Weymuller? stated that a preoperative assessment of bony ostium by use of conventional dacryocystography or computed tomography was a prerequisite for this approach. In every case in our study, computed tomography or computed tomographic dacryocystography detected a problem with the bony ostium and an external dacryocystorhinostomy was performed through a skin incision. If preoperative imaging studies indicate that the bony ostium is of adequate size and location, a transnasal endoscopic approach can be considered. Anatomic variations and diseases of the nasal cavity and sinuses are other important causes of dacryocystorhinostomy failure,I,3,4,6,7 and factored in two of our cases. Examination with a nasal speculum or endoscope, or both, can often detect these problems.' Computed tomography or computed tomographic dacryocystography may also provide additional information in some cases. Other reports on the use of computed tomography in the evaluation of dacryocystorhinostomy failure have appeared in the literature. Computed tomography has documented dacryocystorhinostomy failure from tumors,3,5,6 orbital pseudotumor," and nasal septal deviation."> Computed tomography has demonstrated that persistent epiphora after dacryocystorhinostomy was a result of a basilar skull fracture causing a cerebrospinal fluid leak." Computed tomography has been used to evaluate the adequacy of the bony ostium before endoscopic repair of dacryocystorhinostomy failure." In our method of computed tomographic dacryocystography, a radiopaque agent was injected into the lacrimal sac through a catheter placed in the lower canaliculus. Zinreich and associates" devised a method of computed tomographic dacryocystography in which metrizamide eyedrops were placed into the conjunctival cul-de-sac. By obviating the need for canalicular intubation, their method increases patient comfort, can be performed in children, and eliminates the need for a physician or technician skilled in canalicular intubation. Although we suspect that our method might result in better filling of the lacrimal sac in some cases, we do not have any experience with their method. In the computed tomographic dacryocysto-
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grams in our study, there was a delay of approximately 15 minutes between the instillation of radiopaque agent and the performance of the computed tomography. This delay was caused by our early inefficiency in coordinating the two steps. We have subsequently eliminated these inefficiencies and now perform the computed tomography immediately after the instillation of the dye. As conventional dacryocystography and computed tomography are already performed in many institutions, computed tomographic dacryocystography can easily be implemented with only minor adaptation of preexisting techniques. This technique can be performed on most repeat dacryocystorhinostomy candidates, but obviously cannot be performed on patients who have total canalicular obstructions. After previous dacryocystorhinostomy failure, identification of the lacrimal sac on computed tomography and during surgery may be challenging because of scarring and alteration of anatomic landmarks. By identifying the lacrimal sac's shape, location, and relation to surrounding structures, computed tomographic dacryocystography facilitates the treatment of these difficult cases.
References 1. Welham, R. A. N., and Wulc, A. E.: Management of unsuccessful lacrimal surgery. Br. J. Ophthai mol. 71:152, 1987. 2. McLachlan, D. L., Shannon, G. M., and Flanagan, J. c.: Results of dacryocystorhinostomy. Analysis of the reoperations. Ophthalmic Surg. 11:427, 1980. 3. Hurwitz, J. J., and Victor, W. H.: The role of sophisticated radiological testing in the assessment and management of epiphora. Ophthalmology 92:407, 1985. 4. Allen, K. M., Berlin, A. J., and Levine, H. L.: Intranasal endoscopic analysis of dacryocystorhinostomy failure. Ophthalmic Plast. Reconstr. Surg. 4:143, 1988. 5. Carnevali, L., Trimarchi, F., Rosso, R., and Stringa, M.: Haemangiopericytoma of the lacrimal sac. A case report. Br. J. Ophthalmol. 72:782, 1988. 6. Sternberg, I., and Levine, M. R.: Ethmoidal sinus osteoma. A primary cause of nasolacrimal duct obstruction and dacryocystorhinostomy failure. Ophthalmic Surg. 15:295, 1984. 7. Orcutt, J. c.. Hillel, A., and Weymuller, E. A.: Endoscopic repair of failed dacryocystorhinostomy. Ophthalmic Piast. Reconstr. Surg. 6:197, 1990. 8. Dryden, R. M., and Wuk, A. E.: Pseudo-
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epiphora from cerebrospinal fluid leak. Case report. Br. J. Ophthalmol. 70:570, 1986. 9. Zinreich, S. J., Miller, N. R., Freeman, L. N., Glorioso, L. W., and Rosenbaum, A. E.: Computed tomographic dacryocystography using topical contrast media for lacrimal system visualization. Orbit 9:79,1990. 10. Serdahl, C. L., Berris, C. E., and Chole, R. A.: Nasolacrimal duct obstruction after endoscopic sinus surgery. Arch. Ophthalmol. 108:391, 1990. 11. Putterman, A. M.: Oculoplastic surgery. In Peyman, G. A., Sanders, D. R., and Goldberg, M. F. (eds.): Principles and Practice of Ophthalmology. Philadelphia, W. B. Saunders Co., 1980, pp. 22812288. 12. McPherson, S. D., and Egleston, D.: Dacryo-
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cystorhinostomy. A review of 106 operations. Am. J. Ophthalmol. 47:328, 1959. 13. Hecht, S. D.: Dacryocystorhinostomy. In Hornblass, A., and Hanig, C. J. (eds.): Oculoplastic. Orbital, and Reconstructive Surgery. Baltimore, Williams & Wilkins, 1990, pp. 1433-1440. 14. Patrinely, J. R., and Anderson, R. L.: A review of lacrimal drainage surgery. Ophthalmic Plast. Reconstr. Surg. 2:97, 1986. 15. Massaro, B. M., Gonnering, R. S., and Harris, G. J.: Endonasallaser dacryocystorhinostomy. A new approach to nasolacrimal duct obstruction. Arch. OphthalmoL 108:1172, 1990. 16. Gonnering, R. S., Lyon, D. B., and Fisher, J. c.. Endoscopic laser-assisted lacrimal surgery. Am. J. Ophthalmol. 111:152, 1991.
OPHTHALMIC MINIATURE
And as I faced him, with levelled gun shaking in my hands, I had time to note the worn and haggard appearance of his face. It was as if some strong anxiety had wasted it. The cheeks were sunken, and there was a wearied, puckered expression on the brow. And it seemed to me that his eyes were strange, not only the expression, but the physical seeming, as though the optic nerves and supporting muscles had suffered strain and slightly twisted the eyeballs. Jack London, The Sea Wolf New York, Bantam Books, 1986, p. 208
