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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 107  |  Issue : 3  |  Page : 136-141

Double bicanalicular silicone intubation versus single intubation with mitomycin C in conjunction with canaliculo-dacryocystorhinostomy for the management of common and distal canalicular obstruction


Ophthalmology Department, Faculty of Medicine, Minia University Hospital, Minia University, Minia, Egypt

Date of Submission21-Jan-2014
Date of Acceptance30-Jun-2014
Date of Web Publication30-Dec-2014

Correspondence Address:
Mohamed F Khalil
Oculoplastic Unit, Ophthalmology Department, Minia University Hospital, 98 Korneesh El Nile Street, Minia, 61111
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2090-0686.148110

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  Abstract 

Introduction
Canalicular obstruction is one of the most difficult lacrimal conditions to treat and conjunctivo-dacryocystorhinostomy with a Jones tube is the standard treatment with a high rate of anatomic success, but with a relatively high rate of complications.
Canaliculo-dacryocystorhinostomy (canaliculo-DCR) was performed for the management of distal and common canalicular obstruction, and the results depend on the distance of obstruction from the lacrimal sac; restenosis of the canaliculus around the silicone tube is the most common reason for the failure of canaliculo-DCR.
Objective
The aim of this study was to examine the effect of two separate adjunctive methods used in conjunction with canaliculo-DCR: the use of double intubation of the canaliculi and the use of single intubation plus administration of intraoperative mitomycin C 0.2 mg/ml in cases with membranous and fibrous obstruction of the common and distal canaliculi.
Design
This prospective nonrandomized comparative interventional case-series study was carried out in the Ophthalmology Department, Minia University Hospital, in the period from March 2009 to December 2011.
Patients and methods
One hundred and twenty-eight eyes of 109 patients were studied. All cases had distal or common canalicular obstruction with at least 8 mm of patent proximal canaliculi. Canaliculo-DCR operations were carried out. After intraoperative identification of the type of obstruction, membranous or fibrous, we divided the patients into four groups: group 1 included 23 patients with membranous obstruction who received double silicone tubes, group 2 included 23 patients with membranous obstruction who received a single tube plus intraoperative mitomycin C, group 3 included 41 patients with fibrous obstruction who received double silicone tubes, and group 4 included 41 patients with fibrous obstruction who received a single tube plus intraoperative mitomycin C.
Silicone tubes were removed after 6 months and patients were followed up monthly for at least another 6 months with evaluation of the patency of the lacrimal passages subjectively and objectively.
Results
After a mean follow-up of 18.90 months, 79.7% of the patients showed successful results. Membranous groups (group 1 and 2) had an 86.9% success rate, which is higher than that of patients in fibrous groups (75.6%).
Patients in group 1 had a lower success rate (82.6%) than patients in group 2 (91.3), but patients in group 3 had a higher success rate (80.5%) than patients in group 4 (70.7%); however, these differences were not statistically significant (P = 0.6 and 0.4, respectively).
Patients who received double silicone tubes (group 1and 3) had a success rate of 81.2%, whereas only 78.1% of the patients who received a single tube plus mitomycin C (group 2 and 4) achieved successful results
Conclusion
Mitomycin C with single intubation is better than double intubation in case of membranous obstruction of the common canaliculus, whereas double intubation is superior to mitomycin C with single intubation in case of fibrous obstruction of the distal and common canaliculus.

Keywords: canalicular obstruction, canaliculo-dacryocystorhinostomy, double intubation, mitomycin C


How to cite this article:
Khalil MF, Abdelrazik ST. Double bicanalicular silicone intubation versus single intubation with mitomycin C in conjunction with canaliculo-dacryocystorhinostomy for the management of common and distal canalicular obstruction. J Egypt Ophthalmol Soc 2014;107:136-41

How to cite this URL:
Khalil MF, Abdelrazik ST. Double bicanalicular silicone intubation versus single intubation with mitomycin C in conjunction with canaliculo-dacryocystorhinostomy for the management of common and distal canalicular obstruction. J Egypt Ophthalmol Soc [serial online] 2014 [cited 2019 Aug 19];107:136-41. Available from: http://www.jeos.eg.net/text.asp?2014/107/3/136/148110


  Introduction Top


Canalicular obstruction is one of the most difficult lacrimal conditions to treat and conjunctivo-dacryocystorhinostomy (conjunctivo-DCR) with a Jones tube is the standard treatment with a high rate of anatomic success, but with a relatively high rate of complications such as tube displacement and obstruction in addition to a lifetime of maintenance. Because of this, there is a tendency to attempt treatment with alternative techniques whenever possible and to perform this procedure as a last resort [1,2].

Common canaliculus is either obstructed by a membrane over the common canalicular opening inside the sac or by a dense fibrous tissue involving the common or distal canaliculi [3].

Canaliculo-dacryocystorhinostomy (canaliculo-DCR) was performed for the management of distal and common canalicular obstruction, and the results depend on the type of obstruction, whether membranous or fibrous, and on the distance of obstruction from the lacrimal sac [4,5].

As the most common reason for failure is restenosis of the canaliculus around the silicone tube or adhesion after the removal of the silicone tubes, double silicone tubes and single silicone tubes plus intraoperative mitomycin C as adjunctive measures were attempted separately and found to be effective in increasing the success rate of external and endoscopic DCR [6-9].


  Objective Top


The aim of the study was to examine the effect of two separate adjunctive methods used to enhance the success of canaliculo DCR in cases with membranous and fibrous obstruction of the common and distal canaliculi. One is the use of double intubation of the canaliculi and the other is the use of single intubation plus application of intraoperative mitomycin c 0.2 mg/ml.


  Design Top


This prospective nonrandomized comparative study was carried out in the Ophthalmology Department, Minia University Hospital, in the period from March 2009 to December 2011.


  Patients and methods Top


Between 2009 and 2011, all patients who complained of watering of the eyes attending the Oculoplastic Clinic in the Ophthalmology Department, Minia University Hospital, were evaluated by a comprehensive assessment of ophthalmic history and examination to exclude causes of over lacrimation and lower lid causes of watering such as lid ectropion and Bells palsy.

Then, evaluations of the lacrimal passages were performed as follows:

(1) Dye disappearance test to confirm the presence of lacrimal passage obstruction.

(2) Probing/irrigation of the lacrimal passage to detect the site of obstruction.

The possible site of lacrimal obstruction was sought by probing and syringing of both the upper and the lower canaliculi with observation of the quality and quantity of the outflow through the same and opposite puncti.

The level of canalicular obstruction was measured in millimeters from the punctum to the end of the probe where the blockage was felt.

All patients with common canalicular obstruction and distal lower or bicanalicular obstruction with at least 8 mm of patent proximal canaliculi were chosen for our study.

All patients who had undergone previous lacrimal passage surgery were excluded.

One hundred and twenty-eight eyes of 109 patients fulfilled our criteria, and after written consent was obtained, canaliculo-DCR operations were carried out under general anesthesia for all patients.

Surgical technique

Surgery was performed under hypotensive anesthesia and nasal packing with gauze soaked in saline with adrenaline 1 : 100 000. Skin incision was made midway between the midline and the inner canthus 15 mm in length 5 mm above and 10 mm below the medial palpebral ligament. Blunt dissection of the subcutaneous tissue and orbicularis muscle was performed down to the periosteum. Disinsertion of the medial canthal ligament and incision of the periosteum with its dissection off the underlying bone laterally were performed. 15×15 mm osteotomy was performed in the lacrimal sac fossa including the anterior lacrimal crest using Kerrisons rongeurs.

The sac was opened vertically from the fundus down to the opening of the nasolacrimal duct and the anterior flap was fashioned to be smaller than the posterior flap, whereas the nasal mucosa was incised to create large anterior and small posterior flaps.

The common canalicular opening was examined carefully by direct inspection and the insertion of a Bowman's probe through the upper and lower punctum toward the lacrimal sac.

If the obstruction of the common canaliculus is membranous, it would be tented out by the Bowman's probe and it can be easily peeled off the metallic tip of the probe so that the probe can easily and freely be extracted out of the common internal opening [Figure 1].
Figure 1: Membranous obstruction of common canaliculus.

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If the obstruction is fibrous, the fibrous tissue would be pushed medially by the Bowman's probe and then it can be excised to free the distal canaliculus from obstruction [Figure 2].
Figure 2: Excision of the fibrous band.

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In case of membranous obstruction of the common canaliculus, we aimed to alternatively insert double bicanalicular silicone tubes in one case [Figure 3] and a single bicanalicular silicone tube with mitomycin C irrigation of the lacrimal passage in the next case, and so on until the end of the study. The same rule would be applied to the cases with fibrous obstruction.
Figure 3: Double intubation.

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Posterior flaps were sutured together using 6/0 vicryl sutures and the silicone tubes were held together by a silicon sleeve at the level of the lacrimal sac to prevent its migration toward the punctum; then, the tubes were passed through the osteotomy site to the nasal cavity and both ends were tied together.

Anterior flaps were sutured with three interrupted 6/0 vicryl sutures and then the subcutaneous tissues, and the orbicularis muscles were reapproximated by 6/0 vicryl sutures.

After closure of the skin incision with 6/0 nylon interrupted sutures, the lacrimal passage was irrigated by mitomycin C 0.2 mg/ml for 3 min and then the lacrimal passage was washed out with copious amounts of saline solution.

Postoperative medications included a broad-spectrum systemic antibiotic for 1 week and topical antibiotic/steroid eye drops and ointment for 4 weeks.

Skin sutures were removed after 1 week and the silicone tubes after 6 months. Patients were then followed up every month for at least another 6 months after the removal of the silicone tubes and at each visit, the patency of the lacrimal passages was evaluated and the procedure was considered successful if:

(1) Epiphora disappeared;

(2) The dye disappearance test was not longer than 5 min; and

(3) Lacrimal passage was free on probing and fluid passed smoothly without resistance to the nasal cavity on irrigation.

At the end of the study, we encountered 46 cases with membranous obstruction and 82 cases with fibrous obstruction, and the patients were divided into four groups.

Group 1: 23 patients with membranous obstruction and double tubes.

Group 2: 23 patients with membranous obstruction and single tubes plus mitomycin C.

Group 3: 41 patients with fibrous obstruction and double tubes.

Group 4: 41 patients with fibrous obstruction and single tubes plus mitomycin C.

Data were collected and subjected to a statistical analysis using the SPSS software program for Windows (version 19; SPSS Inc., Chicago, Illinois, USA).

(1) Quantitative variables were described as mean, SD, and range.

(2) Qualitative variables were described as number and percentage.

(3) The χ2 -test was used to compare qualitative variables between groups.

(4) An unpaired t-test was used to compare two groups in terms of quantitative variables.

A statistically significant level was considered when the P value was less than 0.05.


  Results Top


The results are shown [Table 1] and [Table 2].
Table 1 Demographic data of the patients


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Table 2 Success rates in different groups


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Postoperative complications

We encountered one case of punctual slitting in group 3 and one case of infection at the surgical site and delayed wound healing in group 4.


  Discussion Top


Successful treatment of canalicular obstructions continues to represent a therapeutic challenge [10].

Canaliculo-DCR was performed in case of distal or common canalicular obstruction when at least 8 mm of the lateral upper or lower canaliculi, or both were patent. Although canaliculo DCR yielded a lower success rate than conjunctivo DCR with a Lester Jones tube the former is preferable as it is a less invasive alternative technique that still utilizes a healthy and functional part of the canaliculi [5].

In addition, although a high rate of anatomic success can be achieved with conjunctivo-DCR, many studies over the last 20 years have reported a relatively high rate of complications and poor patient satisfaction; thus, it should be the last resort after the failure of canalicular-DCR in distal or common canalicular obstruction [1,2].

The success rate of canaliculo-DCR is ~80% when the procedure is performed for common canalicular obstruction and 60% when it is performed for more lateral obstructions [5]. The most common reason for the 20-30% failure rate is restenosis of the canaliculus around the silicone tube or adhesion after the removal of the silicone tube [6].

To overcome the causes of failure, some surgeons used double bicanalicular silicone tubes in conjunction with canaliculo-DCR on the basis that a wider stent would keep the canalicular channel walls more separated, thereby increasing the chance of patency after the tube is removed, and they reported higher anatomical (96.5%) and functional success (88.3%) [7]; however, none of the above studies evaluated the impact of type of obstruction, either membranous or fibrous, on the results of canaliculo-DCR in case of distal or common canalicular obstruction.

Because of this and as the use of intraoperative mitomycin C with a silicone tube in external and endoscopic DCR has been found to increase the success rate of these operations [8,9], we aimed to evaluate the use of double silicone tubes versus a single tube plus intraoperative mitomycin C in case of membranous and fibrous distal or common canalicular obstruction.

The 128 eyes of the 109 patients who fulfilled our inclusion criteria with distal or common canalicular obstructions were operated upon with canaliculo-DCR, and according to the intraoperative identification of the type of obstruction at the distal and common canaliculus, 46 patients had membranous obstructions and 82 patients had fibrous obstructions.

In each group, half of the patients received only double silicone tubes and the other half received a single silicone tube plus intraoperative mitomycin C 0.2 mg/ml to irrigate the canalicular system for 3 min; thus, we had four groups, two for each type of obstruction.

In our study, the mean age of all the patients was 42.66 years. Although 16.4% of the patients were men and 83.6% were women, they showed equal distribution on right and left sides ([Table 1]).

After a mean follow-up period of 18.90 months, a success rate of 79.7% was obtained.

Patients who had a membranous obstruction of the common canaliculus (group 1 and group 2) had an 86.9% success rate, which is higher than that of patients with fibrous obstruction of the distal and common canaliculus (75.6%) ([Table 2]).

In the membranous obstruction groups, patients in group 1 who underwent canaliculo-DCR with double bicanalicular silicone tubes had a lower success rate (82.6%) than patients in group 2 who underwent canaliculo-DCR with a single bicanalicular silicone tube plus intraoperative mitomycin C (91.3%); however, that difference was not statistically significant (P = 0.6).

Patients with fibrous obstruction in group 3 with double tubes had a higher success rate (80.5%) than patients in group 4 with a single tube and mitomycin C (70.7%), and again, this difference was not statistically significant (P = 0.4).

Patients who received double silicone tubes (group 1 and 3) had a success rate of 81.2%, which, compared with that obtained by Hwang et al. [7], seemed lower as they reported 96.5% anatomical success but 88.3% functional success, but 63% of their patients had membranous obstruction, whereas 65% of our patients had fibrous obstruction.

Only 78.1% of the patients who received a single tube plus mitomycin C in both group 2 and group 4 achieved successful results, which is very close to that obtained by Hwang et al. [7] in their study (85.5% anatomical and 81.2% functional success); although they used only single silicone tubes without intraoperative mitomycin C, the possible explanation for this might be that 72% (50/69) of their patients had membranous obstruction of the common canaliculus compared with only 35% (23/64) of our patients.

Also, these results were much lower than those obtained by Boboridis et al. [4], who reported a success rate of 92% after DCR with membranectomy and single silicone bicanalicular tubes without intraoperative mitomycin C; the explanation for this wide disparity might be that only 9% of the cases with nasolacrimal obstruction in their study had a membrane obstructing the canaliculus and the other 91% had only nasolacrimal obstruction.

Within each group of the study, the success rate was not significantly related to age or sex of the patient or the side of operation (P > 0.05).

In terms of the complications in our study, we encountered no postoperative complications related to the use of mitomycin C in group 1 and group 3 such as abnormal nasal bleeding or mucosal necrosis.

We only encountered postoperative complications in patients with fibrous obstruction, where one case in group 3 had punctal slitting that was because of intranasal fibrosis with traction of the silicone tubes medially, as evidenced by the lack of mobility of the tubes on attempting lateral traction of the tubes at the puncti; this was confirmed by direct visualization using nasal endoscopy and the postoperative results of that particular patient were unsuccessful.

Also, in group 4, one female patient developed infection at the surgical site and delayed wound healing; this patient had uncontrolled diabetes, which was properly controlled, and the inflammation subsided, with no effect on the postoperative results.


  Conclusion Top


Mitomycin C with single intubation is better than double intubation in case of membranous obstruction of the common canaliculus, whereas double intubation is superior to mitomycin C with single intubation in case of fibrous obstruction of the distal and common canaliculus.


  Acknowledgements Top


 
  References Top

1.
Lim C, Martin P, Benger R, Kourt G, Ghabrial R Lacrimal canalicular bypass surgery with the Lester Jones tube. Am J Ophthalmol 2004; 137 :101-108.  Back to cited text no. 1
    
2.
Rosen N, Ashkenazi I, Rosner M. Patient dissatisfaction after functionally successful conjunctivodacryocystorhinostomy with Jones tube. Am J Ophthalmol 1994; 117 :636-642.  Back to cited text no. 2
    
3.
Collin JRO. A manual of systematic eyelid surgery. 3rd ed. Philadelphia: Elsevier; 2006. 172-173.  Back to cited text no. 3
    
4.
Boboridis KG, Bunce C, Rose GE. Outcome of external dacryocystorhinostomy combined with membranectomy of a distal canalicular obstruction. Am J Ophthalmol 2005; 139 :1051-1055.  Back to cited text no. 4
    
5.
Hurwitz JJ, Archer KF. Canaliculodacryocystorhinostomy. In: Linberg JV, editor. Lacrimal surgery. New York: Churchill Livingstone 1988;263-280.  Back to cited text no. 5
    
6.
Gonnering RS. Dacryocystorhinostomy and conjunctivodacryocystorhinostomy. In: Dortzbach RK, editor. Ophthalmic plastic surgery: prevention and management of complications. New York: Lippincott-Raven Publishers; 1994;237-250.  Back to cited text no. 6
    
7.
Hwang SW, Khwarg SI, Kim JH, Choung HK, Kim NJ, Bicanalicular double silicone intubation in external dacryocystorhinostomy and canaliculoplasty for distal canalicular obstruction. Acta Ophthalmol 2009; 87 :438-442.  Back to cited text no. 7
    
8.
Liao SL, Kao SC, Tseng JH, Chen MS, Hou PK. Results of intraoperative mitomycin C application in dacryocystorhinostomy. Br J Ophthalmol 2000; 84 :903-906.  Back to cited text no. 8
    
9.
Nemet AY, Wilcsek G, Francis IC. Endoscopic dacryocystorhinostomy with adjunctive mitomycin C for canalicular obstruction. Orbit 2007; 26 :97-100.  Back to cited text no. 9
    
10.
Liarakos VS, Boboridis KG, Mavrikakis E, Mavrikakis I. Management of canalicular obstructions. Curr Opin Ophthalmol 2009; 20 :395-400.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

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