Dacryocystorhinostomy is a procedure in which the lacrimal sac is opened into the nose and so it bypasses the blockage by creating a stoma between the lacrimal sac and the nasal cavity. DCR-surgery can be done externally from an incision or intranasally either endoscopically or with a help of a microscope. With both methods, the results of surgery are excellent and side effects are minimal.
DCR have become a popular procedure in the treatment of patients with NLDO. The success rates for both external and endonasal DCR are about 90% and a successful procedure has a significant impact on the quality of life.
Tears are important for the functioning of the eye because it keeps the eye moist and clean as well as carry oxygen and nutrients to the surface of the eye. Tear is excreted by palpebral lacrimal and main orbital gland as well as small additional tear glands and fat/ mucus secreting follicles.
Blinking activates a pumping muscle mechanism which helps tears to flow to the lacrimal duct and then through the nose down to the throat.
eye
Structure of the lacrimal tract
Tearing or “epiphora” may be due to tear hypersecretion or NLC blockage, but also dry eye can cause eye irritation.
The cause of the hypersecretion can be primary or secondary. Reasons for primary epiphora are inflammations (allergies, infections), tumors, as well as hypothyroidism and other hormonal causes (eg, contraceptive pills) without any precipitating cause.
Secondary causes include neurogenic irritation (trigeminus), local irritation (eyelid position errors and defects, foreign bodies), accommodative disorders, facial nerve or pterygopalatine ganglion irritation, as well as for example, yawning, crying, laughing and vomiting.
Reasons of nasolacrimal duct blockages in adults
Lacrimal canal obstructions can occur anywhere in lacrimal tract area, but the most common places are upper lacrimal tract pouches and tear duct in the lower lacrimal tract. The risk factors have been identified, including aging, female gender, and hormonal factors (Woog 2007). As mentioned earlier primary causes are mainly idiopathic.
The most common secondary causes include viruses, bacteria and fungi that cause infections, tear rocks, scarring after surgery, tumors of the surrounding areas (nose and sinuses, eyelid skin) and facial injuries. A number of general diseases, such as Wegener’s granulomatosis, sarcoidosis, scleroderma and Kawasaki’s disease, and radiation therapy can cause a secondary NLD obstruction (Woog 2007). NLD obstructions can be complete or partial.
Medical history and investigations
Typical symptoms of dacryostenosis are continuous watery eye as well as recurrent or persistent eye discharge. Other common symptoms include intermittent pain in the region of the eye, visual acuity fluctuation and burning.
If an adult patient has gone through a variety of NLDO treatments since childhood, the cause is usually congenital. It is important to ask when the symptoms exactly started. Ophthalmic infections, injuries, surgeries, radiation treatments in the surrounding areas, as well as various conditions that make the patient more susceptible for dacryostenosis should be investigated.
In a medical checkup, the doctor examines the eye area for scars and injuries, as well as the position of the eyelids and problems with closing the eye.
In case of chronic lacrimal sac inflammation, pressing the medial corner of the eye with a cotton swab or with finger would result in discharging; this discharge can be sent to the laboratory for cultivation. Nasal study will identify potential predisposing factors such as sinusitis and polyposis. Dry eye-induced conjunctiva irritation or watery eyes due to hypersecretion should be considered for differential diagnosis. Schirmer test (tear production measured by with a kind of filter paper) is a quick and easy survey to study tear secretion.
Patients with continuous or repeated dacryostenosis should be sent to an ophthalmologist or otolaryngologist specialist for advice. The specialist will do a basic lacrimal exploration through the pouches with the use if rinsing fluid to determine the openness of the tear roads and potential anatomical obstructions. After this investigation the doctor can already suggest some kind of treatment.
For pediatric patients a special dye (fluorescein) can be applied to the eye and the migration of this dye to the way of the nose can be monitored over time. Care planning depends on the outcome of these investigations. At the same time a plan is made of the further treatments and investigations, such as the correction of nasal septum. Lacrimal ducts can also be checked with thin fibrescopes, which are not yet in routine use.
duo10055c
Different levels of NL blocks that can be detected with the use of rinsing fluid (picture from terveysportti)
Lacrimal tract obstructions can be examined:
– With the use of contrast medium: dacryocystography – radiographic visualization of the lacrimal sacs and associated structures after injection of a contrast medium, it can be combined with computer tomography
– Without contrast medium (CT, MRI)
– Also, nuclear medicine is sometimes at stake (dacryoscintigraphy).
In most cases currently CT is used, which can take picture of the lacrimal roads and nearby areas, can detect possible tumors and rule out for example sinusitis and lacrimal mucous cysts.
Treatment
Conservative treatment:
Acute infections caused by microbes should be managed by local antibiotic/antimicrobial agent, targeting the existing or suspected pathogen. Acute inflammation of the lacrimal sac (dacryocystitis) causes swelling and redness of the eye and requires eye drops in addition to systemic antimicrobial treatment (first-generation cephalosporin, doxycycline, a macrolide).
Surgery for lower dacryostenosis:
The majority of blockages that requires surgical treatment are located in the lower NL area. Piping of the tear duct can treat adults with partial blockages in particular, but the treatment results vary widely (Demirci and Elner 2008).
According to P. P. Avasthy and T. P. Agrawal (1962): “Toti (1904) first described the drainage of the lacrimal sac by removal of the bony wall. Kuhnt (1914) stitched the nasal mucosa to the periosteum. Ohn (1920) first sutured the nasal mucosa to the sac. The operation was modified by Dupuy-Dutemps and Bourguet (1921). Morgan (1938), Lyle (1946), Hallum (1948), and Hogan (1948) also described various methods.”duo10055d
External DCR
External
DacryocystorhinostomyAccording to patient info from Southampton General Hospital: a small cut is made on the side of the nose to access the tear sac. A piece of bone between the tear sac and nose is removed in order to reach the inside of the nose. The tear sac is opened and sutured to the lining of the nose so a direct passage is made between the sac and the nose. A soft silicone tube is then inserted into the tear passage to keep it open during healing. This tube is not visible when in the correct place and is removed about 6 -12 weeks after the operation.
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The operation is performed only after examination and possibly X-rays have been done and the patient had a chance to discuss the risks and benefits with the doctor in advance. The operation takes about 1-1½ hours. Sometimes the surgeon will want to take a small piece of tissue from the lining of the tear sac or the nose and send it to the pathology laboratory for microscopic checks. It is not generally possible to know whether this will be necessary until during the operation. The results of such tests will be ready after a few weeks.
Endonasal dacryocystorhinostomy (EN-DCR)
The development of endoscopes has revolutionized NL duct surgery techniques. In endonasal surgery a stoma is made internally without an external cut to the skin. Surgery results are similar to the external surgical technique, but fewer side effects (no incision wound, less disruption to normal lacrimal function, shorter surgery times, generally less sickness, reduced bleeding and an excellent view of the surgical field) have led in recent years to the re-uptake of intranasal dacryocystorhinostomy (Cokkeser et al 2000, Wormald 2002, Tsirbas and Wormald 2003, Leong et al, 2010).
Endonasal endoscopic dacryocystorinostomy
1. diamond drill
2. endoscope
3. light probe
4. lachrymal sac
5. lacrimal ductduo10055e
According to Medscape the operation is performed with the patient under local or general anesthesia. The nose is stuffed with a solution containing 2 mL of 1:1000 adrenaline and 2 mL of 4% Xylocaine. The packing is left in the nose for 10 minutes. An endoscope, 4 mm in diameter, is used. The site of operation can be anesthesized with Xylocaine and adrenaline solution.
According to NHS Derby Hospitals an Endo-nasal DCR is carried out using a thin, flexible, fibre optic telescope called an endoscope. This is passed up the nose and guides instruments or a laser, which is used to make a small hole into the bone of the nose. A soft plastic tube is then threaded from the opening in the tear duct in the corner of the upper and lower eyelid, through the new channel and into the nose. The tube stops the new passage from sealing over.
These tubes stay in for a number of months following surgery.
The most common post-operative complications are infections, as well as the formation of scar-area (Allen and Berlin 1989, Boush et al, 1994, Ã-nerci 2002, Watkins et al 2003).
Patient case
I have chosen a patient, Eeva with preoperative diagnosis of impaired function/ stenosis of the nasolacrimal duct of the right eye (stenosis ductus nasolacrimalis-kyynelteiden ahtauma tai vajaatoiminta). She is 66 years old, 160 cm and 67 kg.
She wears glasses, has bridge and crown on her teeth but no dentures. She had mastectomy (mamma ca.) due to cancer in 2008; it was done in general anaesthesia and she experienced postoperative nausea and vomiting after it. She said she is cancer-free since then. She has bipolar disorder to which she takes medicines.
She has had problems with blockage of NL duct since 2009. According to her medical history in 2011 she visited an ophthalmologist because she had discharge from her right eye, then she got eye drops to ease the symptoms. In January of 2012 she had the symptoms of chronic dacryostitis and nasolacrimal duct obstruction for 3 years already; her eyes were watery, her lacrimal ducts didn’t drain the tears. They rinsed the duct and suggested her to hospital waiting list for DCR surgery + exploration.
Pre-operative phase
She arrived on 22. 11. 2012. at 10:30 to HUS Eye clinics’ Polyclinic.
She was interviewed, she said she ate last time at 20:00 the previous day, in the morning she took 1,5 dl water and her own medicines:
-Seronil® (Fluoxetine) which is an antidepressant of the selective serotonin reuptake inhibitor (SSRI) class, took at 08:00
-Lito® (Lithium) to treat bipolar disorder, took at the evening
At the ward after she confirmed her identity by telling her ID code she got hospital pajamas and wristband to both of her wrists and a cabinet where she could put her own clothes. Her blood pressure was measured (147/93, pulse 73) and she said she doesn’t have any allergies. She had an ECG taken the previous day in Leppävaara HUSLab which was available from the hospital’s computer. She went to the toilet and then, because she was very nervous so she got 5 mg of Diapam® (Diazepam, which in this case was used to reduce tension and anxiety). She was asked does she have anyone at home who could check on her during the night, she said her daughter will come and do that which means she doesn’t have to stay in the hospital for the night. After these she could go to bed to relax. She got information about the postoperative self-care, she was explained that a silicone tube will be placed inside her nose and after the surgery she might have swelling and hematoma. The silicone tube will be kept in place for about 2-6 months. After the interview the nurses wrote all this data to the computer. A bit later the surgical department called and said they are ready to receive the patient. Nurses from the polyclinic are responsible to take the patient in a bed to the surgery and give report.
Surgery
Anesthesia
At the operating room the patient lies down to the operating table, gets a pillow under her knee. Her identity and site of the surgery is confirmed. 2 syringe-pumps are prepared ready. Nurses place ECG, blood pressure meter, pulse oximetry, entropy and peripheral nerve stimulator on the patient. Capnography and spirometry sensors are attached to the intubation tube. After a cannula is inserted by the anesthetic nurse, we cover her with a blanket and Bair hugger to keep her warm. 500ml Ringer is prepared, also:
– 15ml/150mg of Propofol (10mg/ml): which is a drug that causes relaxation, in higher doses sleep or loss of consciousness
– 5ml/50mg of Rocuron (10mg/ml) it is used to relax the muscles. It works by blocking the signals between the nerves and muscles. Rocuron is given before general anesthesia and it helps to keep the body still during surgery. It also relaxes the patient’s throat so an intubation tube can be more easily inserted before the surgery.
– Lidocain 20mg/2ml (10mg/ml): It is a local anesthetic which causes numbing by blocking nerve signals in the body. It helps to reduce pain or discomfort caused by invasive medical procedures such as surgery, needle punctures, or insertion of a catheter or breathing tube and in this case the pain in veins caused by Propofol.
– Fentanyl 100mcg/2ml (50µg/ml): which is an opiod to treat breakthrough pain, it also causes sedation
We also make “emergency drugs” ready in a syringe:
– Atropine: has many effects but in general anaesthesia it is used to maintain proper heart function and to elevate pulse fast
– Efedrine/Effortil: used to elevate blood pressure
And drugs for continuous infusion:
-Propofol
-Ultiva (Remifentanyl) which is an ultra-short acting opioid, we prepare it by mixing 1ml (2mg) Ultiva with 49 ml of NaCl 0,9% by this we get a solution containing 50µg Ultiva in 1ml
All the other emergency drugs and antagonists are in the drug counter, right next to the patient so they can be made ready fast.
She had GA earlier which caused her postoperative nausea and vomiting (PONV), so the anaesthesiologist decided not to give her inhaled anesthetic agents (Sevoflurane, Nitrous oxide) because they are more likely to cause PONV.
Before the surgery the nurse cleans the patient’s face with 80% ethanol, take special care to the eyes. She gets Obucain drops before the cleaning, so the ethanol wouldn’t cause so much discomfort for her eyes.
She gets gauze soaked in Hirsch solution (cocaine+ lidocain) as local anesthetic inside her nose
Induction
After all the medicines are made ready and the intubation set is prepared and tested, the anesthesiologist starts the process. First the patient gets oxygen from a mask hold over her face by the anesthesiologist nurse. We explain her that the sleeping agent is not coming from the mask; it is there only to provide her oxygen. She is asked to take deep breaths, and while doing so, the doctor starts to give the induction medicines intravenously. These are (everything i.v.):
– First 100 µg Fentanyl as a painkiller and sedative
– After it 20 mg Lidocain, to reduce the “burning” feeling in the vein of the Propofol
– Then 150 mg propofol to induce sleeping
– Also Propofol 1ml/h and Ultiva (Remifentanyl) 0,1ml/h (both are very slow rate) infusions are started from a syringe pump. In about 15 minutes their doses will be increased.
After some amount of Propofol is given (the amount varies among people), the patient falls asleep, which can be checked by gently touching her eyelashes. If this doesn’t cause any reaction (blinking or constricting eyelids) we can assume she is asleep. At this time the anesthesia nurse lifts the patient’s chin and places the ventilation mask tightly over her nose and mouth and starts to ventilate her manually with a bag. It is essential to monitor the effectiveness of the ventilating by checking saturation and chest movements.
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Meanwhile the doctor gives 40 mg of Rocuron (Esmeron) to relax the muscles for intubation. The relaxation can be monitored with a peripheral nerve stimulator that was earlier placed to the patients hand and wrist, in the screen it shows as TOF, the number can be 0-100, the lower the number – the more relaxed the patient is. GA causes loss of airway reflexes (such as coughing) and sometimes loss of a spontaneous breathing because of the effect of anesthetics, opioids, or muscle relaxants. The anesthesiologist takes over the ventilation and starts the intubation with the use of laryngoscope and an endotracheal tube (sized 7,0 with a cuff). Both tools have been checked earlier so they work. The cuff is filled with air and the ventilation tube is connected, and set to automatic ventilation. The doctor listens to breathing sounds in both lungs and finds out that the tube is in the right place and then tapes the tube to the patient’s face so it doesn’t slip out.
Then Propofol infusion is increased to 50ml/hour and Ultiva to 5ml/h to keep up the sleep and analgesia. Just before the surgery starts the patient receives Dexamethasone (Oradexon®) 4mg which is a glucocorticoid steroid drug, often used as antiemetic and prevention of PONV caused by opioids.
From the start of anaesthesia she receives:
-Oxygen 7l-7,5 l
– Air 1,3 l
The time between the start of anaesthesia and start of surgery is 20 minutes in this case.
When the surgery starts the surgeon orders 1g of Tranexamic acid (Caprilon®) to prevent excessive blood loss during surgery. Also her blood pressure drops (BP upon arrival is 132/75 mmHg and right after the surgery starts it is 75/40 mmHg) to which she gets 7,5 mg Efedrin which is an antihypotensive agent and an additional 5mg after 10 minutes.
10 minutes after the surgery started she receives 1,5 g Zinacef (Cefuroxime) as infusion to prevent further infection. The surgery takes about 30 minutes. All the time she is monitored, blood pressure is checked every 5 minutes, SpO2, FiO2 (percentage of inspired oxygen), EtCO2 (percentage of exhaled carbon dioxide), tidal volume, breathing frequency, PEEP/Peak (airway pressure), entropy and TOF are observed constantly. Besides hypotension, every other value is fine. When the surgery ends, Propofol and Ultiva infusions are stopped. Her muscle tone hasn’t returned yet completely (TOF=75), so the doctor orders 1ml of Glycostigmin (1ml contains 2,5 mg neostigmine methylsulfate and 0,5 mg glycopyrronium bromide) to reverse the effect of muscle relaxant Esmeron.
Soon the spirometry curve changes, spontaneous breathing attempts can be detected and the patient starts to move. Anesthesiologist stops the automatic ventilation and starts to ventilate by hand. The patient starts retching, she is asked to lift her head and she is able to do it so she is ready to be extubated. Her mouth and intubation tube is suctioned (in case of DCR surgery there might be blood in the throat and in the stomach which is good to be removed) and then extubated. She is placed in a hospital bed and fast transported to the recovery room.
During the surgery she received:
– Propofol 516 mg
– Rocuron 50mg
– Lidocain 20mg
– Fentanyl 100 µg
– Ultiva (Remifentanyl) 190µg
– Caprilon 1 g
– Oradexon 7,5 mg
– Ondansetron 4mg
– Ketorin 100mg
– Efedrin 12,5 mg
– Zinacef 1,5 g
– Glycostigmin 1ml
Instruments and surgery process:
Both the assistant nurse and the surgeon use hand disinfectant and puts on sterile gown, gloves, clean mask and cap. The circulating nurse prepares the instrument box and opens all the sterile packages and gives them to the assistant. The patient is covered with a sterile sheet. When preparation is ready the surgeon enters the room. Once again they confirm it is the right patient and the right surgery.
The surgeon uses 2% Lidocaine solution as local anesthesia. (Its effect doesn’t wear off so fast- still effective after the surgery so the patient will need fewer painkillers).
Then blades are used to open up the skin over the lacrimal sac and scissors to cut the tissue. With the help of surgical tweezers or sutures the wound can be kept open. Suctioning of the blood is sometimes required.
Then the surgeon uses forceps to make a hole in bone (big/ small sized) between the tear sac and nose. By this an anastomosis is created. After this he places a silicone tube to the created to the anastomosis what can drain the tears down the nose. Probes are used to explore the lacrimal canaliculus. When the tube is in the right place, it can be sutured with absorbing thread. The surgeon makes the sutures with the help of a small needle holder.
Sutures of the skin need different threads, its thicker and not absorbing. After the skin is closed the doctor examines the nasal cavity with a speculum.
Post-operative phase
In the recovery room, nurses monitor the patient and document her condition. My patient arrived to the recovery room awake but tired, she didn’t have pain and her wound is intact. According to the surgeon’s order, she got a cold pack to the wound to reduce the risk of bleeding, swelling and pain. The cold pack needed to be kept in place for an hour.
During or after the surgery, the anesthesiologist gives orders about the patient’s pain/ nausea medications. In this case they were:
– Oxynorm 3mg iv/ 10mg p.o.
– Panadol 1g x 3 p.o./i.v or Panacod
– Ondansetron 4mg iv
She also got prescription for:
– Kefexin 500 mg 1 tablet 3 times a day
– Oftan dexa- chlora eye drops (dexamethasone1 mg/g- glucocorticoid class of steroid drug, it acts as an anti-inflammatory and chloramphenicol 2 mg/g which is a prototypical broad-spectrum antibiotic) 1 drop 3 times a day for 2 weeks period
Her blood pressure, pulse and saturation was continuously assessed. After about 1 hour in the recovery room she felt well enough to leave for the ward.
Nurses from the Polyclinic came to take her. We gave a report, explained how the surgery went, what medicines were used and gave basic post-operative instructions (the patient need to sleep with her upper body elevated, can’t have hot foods and drinks for 2 days, she need appointment for control in 2 months, she can go to her own health center to have the sutures removed in a week). All the meters were removed.
I left with the nurses and the patient for the ward. There she got a drink and later was allowed to eat too. It is important that the patient is able to void before she could go home (sometimes it’s hard to urinate after anesthesia, but she had no problems with it). Her nose started to bleed so she got a towel and an ice pack to her nose to reduce bleeding.
After she was relaxing little, the nurse printed out home care instructions to give it to the patient and also explained them. These were:
– She can use something cold, for example a pack of frozen vegetables, cover it with a towel and place it on the wound to reduce swelling and pain. She shouldn’t place the icepack directly to her skin because it can cause frostbite.
– If her nose starts to bleed she should take a half sitting position, press around the inner corner of her eye, around the nasal bone and she can put a cold pack to the back of her neck. If the bleeding doesn’t stop she have to call to the eye clinic no matter what time is it
– She can’t eat or drink anything hot, as explained earlier
– She can walk, but can’t do any heavier physical exercise
– She shouldn’t lain forward very much because the wound in her nose can start to bleed
– She should sleep with her head slightly elevated
– She is not allowed to blow her nose because it can cause bleeding
– No sauna for 2 weeks
– She can go to shower the following day
– If she experiences strange symptoms for example loss of vision or movement of the silicone tube she should call the clinic
– She didn’t have any medicine that she needed to stop because of the surgery, she can just continue them normally
After these instructions the nurses document everything in the computer.
The patient can change back to her own clothes. Her daughter will come to take her home and stay with her for the night, but if she didn’t have anyone at home she should have stayed at the hospital for the night (the medicines received during general anesthesia might cause her problems) and if she didn’t have anyone to take her home, nurses would order a taxi.
Evaluate
For me it was interesting to see the whole admission procedure, pre- and postoperative care, understanding the treatment process helped me to be more confident. I was afraid, but in the end it turned out to be a nice experience. At the time of the assignment I was only at the anaesthesia site, so my knowledge about the instruments is not yet complete.
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