ABSTRACT

Purpose: To evaluate the success rate of dacryocysto-rhinostomy (DCR) for epiphora in patients with a clinicallypatent lacrimal drainage system.

Methods: A series of 51 patients, 12 men and 39 women,who underwent DCR surgery for epiphora with a clinicallypatent lacrimal drainage system in the background ofnormal eyelid examination, were evaluated. All patientsunderwent fluorescein dye disappearance testing and Jones1 and 2 testing with dacryocystograms in borderline cases.A standard DCR was performed with bicanalicular siliconetubing inserted in all cases. The average time for theremoval of the silicone tubes was 9.6 weeks.

Results: In 48 cases (94%) there was improvement in symp-toms with minimal or no significant epiphora postoperatively.

Conclusions: Epiphora with a patent lacrimal drainagesystem obstruction can be successfully treated by DCRbased on fluorescein dye disappearance tests and Jones 1and 2 tests, with dacryocystography in borderline cases.

Key words: dacryocystorhinostomy, epiphora, functionalnasolacrimal duct obstruction, partial lacrimal obstruction.

INTRODUCTION

There are no reports to date, of which the authors are aware,on the success rate of a standard external dacryocysto-rhinostomy (DCR) on patients with a clinically patentlacrimal drainage system diagnosed systematically with fluo-rescein dye disappearance testing, Jones 1 and 2 testing anddacryocystography.

We studied a consecutive series of patients withepiphora, clinical evidence of abnormal lacrimal drainagefunction, a patent lacrimal drainage system to syringing and normal eyelid examination. All patients underwent asystematic lacrimal function examination and DCR surgerywith intubation.

METHODS

The medical records of all patients who underwent externalDCR surgery for epiphora with a clinically patent lacrimaldrainage system were consecutively selected from the data-base of a specialist oculoplastic surgeon (B O’Donnell) whoexamined and operated on all patients.

The diagnosis was made after a thorough history andclinical examination, with a routine standardized series ofdiagnostic tests performed. Patients younger than 16 yearswere excluded. Patients who underwent endonasal surgerywere excluded. The conjunctiva, globe and tear film wereexamined to exclude secondary epiphora. Schirmer’s testwas performed in equivocal cases. Patients were examinedfor canthal ligament laxity, eyelid tone and position, andpunctal patency and position. Patients were only included inthe study if the above findings were within normal limits sothat the effect of lacrimal surgery alone could be assessed.Patients with punctal abnormality underwent punctal snipsurgery and were reassessed after 2 months. If their punctaremained open but epiphora persisted with abnormal Jones1 and 2 testing, they were included in the study.

Lacrimal function was routinely assessed as follows. Afluorescein dye disappearance test (FDDT) was performedfirst with instillation of 2% fluorescein into the conjunctivalsac.1 The patient’s results were recorded after 2 min (anormal lacrimal system will pump this solution into the nosein 1 min).2 A Jones 1 test was performed after 5 min and followed immediately by a Jones 2 test.3 The lower canalicu-lus was routinely syringed and probed. Patency to the noseand any reflux via the upper canaliculus, or canalicularobstruction, was recorded. Patients with canalicular abnor-mality or complete nasolacrimal duct obstruction wereexcluded.

When the results of Jones testing was borderline or therewas minimal reflux via the upper canaliculus, dacryocysto-graphy (DCG) was carried out to radiographically assess thenasolacrimal sac and duct. Abnormalities looked for onDCG included dilatation of the proximal system with distalnarrowing, narrowing throughout the length of the sac andduct, presence of a calculus and delay of passage of dye.

Clinical and Experimental Ophthalmology (2001) 29, 27–29

Original Article

Dacryocystorhinostomy for epiphora in the presence of apatent lacrimal systemBrett O’Donnell FRACO and Rajiv Shah MBBSDepartments of Ophthalmology, Royal North Shore Hospital and St Vincent’s Hospital, Sydney, New South Wales, Australia

■ Correspondence: Dr Brett O’Donnell, North Shore Medical Centre, Level 2, Suite 3, 66 Pacific Highway, St Leonards, New South Wales 2065, Australia.

Email: brett.odonnell@island.net.au

External DCR surgery was routinely performed underassisted local anaesthetic. All patients are routinely intu-bated to avoid the possibility of postoperative canalicularclosure. Patients were excluded if there was any intraoper-ative evidence of canalicular abnormality. Postoperativeroutine prophylactic topical chloramphenicol drops and oralcephalexin were prescribed.3,4 Following removal of thesilastic tube, patients with no (or minimal) epiphora wereclassified as a successful outcome.

Patients with significant postoperative epiphora wereoffered further investigation and treatment. This routinelyincluded the FDDT and Jones 1 and 2 test. Nasal endo-scopic examination in the office was then carried out tocheck the size and position of the ostium, presence of adhesions, granulation tissue or sump formation. If anyabnormality was found, revision DCR surgery (usually endo-scopic) was discussed.

RESULTS

Dacryocystorhinostomy surgery was performed on 51 con-secutive patients (12 men and 39 women). The average agewas 58 (range 16–88) years. No patients had bilateralsurgery. Standard external DCR surgery with O’Donoghueintubation was performed in all cases. Anterior ethmoidec-tomy was performed in 43% (22/51). The average time toremoval of the silicone tubes was 9.6 (range 5–23) weeks andthe average follow-up interval was 14.7 (range 5–101) weeks.

Four patients (8%) underwent punctal surgery prior toDCR surgery. Their diagnosis of nasolacrimal drainage dys-function was made at re-examination 2 months after punctalsurgery, since their puncta remained open but the epiphorapersisted. These patients all underwent subsequent success-ful DCR surgery.

A successful outcome of no or minimal symptoms wasachieved in 48 of 51 patients (94%; 82% with no epiphoraand 12% with minimal symptoms). Surgery failed in threepatients with significant postoperative epiphora. Thesepatients were offered further investigation and surgery. Onlyone patient felt that the symptoms were bad enough toproceed with revision DCR surgery which was unsuccessful.This patient had mildly delayed FDDT but dye was easilydetectable in the nose within 5 min and no definite cause forthe persistent symptoms was evident.

DISCUSSION

There have been varying definitions of patients withepiphora secondary to partial, functional or incompleteanatomical nasolacrimal duct obstruction. Duke-Elder hadpreviously grouped cases with patent systems under theumbrella of lacrimal insufficiency and included pathologyfrom punctal eversion to lacrimal sac tumours.5 Demorestand Milder first introduced the term functional block in 1955and described a case with an abnormal dacryocystogram:‘moderately distended sac’ and ‘retention of dye’ on dacry-ocystography that was clinically patent to syringing.6

Hurwitz et al. described patients with ‘functional blocks’ asthose having ‘epiphora and normal dacryocystograms’.7Rosenstock and Hurwitz excluded patients with anatomicabnormalities but included patients with punctal stenosisand lid laxity and suggested a new term ‘physiological dys-function’ to include the above.8 The latter authors define‘functional’ as to ‘indicate normal anatomic relations withinthe lacrimal drainage passages’. The terminology of ‘func-tional’ obstruction has been avoided in the present study andinstead, we have confined our description of patients as clinically patent to syringing.

Patients with partial obstruction of the lacrimal drainagesystem are more difficult to diagnose and predict successfulDCR surgery than in those with complete obstruction.Conway surveyed the members (138 responses from 300members) of the American Society of Ophthalmic Plasticand Reconstructive Surgery and found that only 21% did aJones test and 19% did a FDDT initially in their approach toa patient with epiphora and a normal external examination.9He also found that 48% did not include the Jones test at allas one of their diagnostic procedures. Dacryocystographywas used by 10% when examination showed no obvioustotal blockage. Only 41% of respondents said they wouldperform a DCR if testing indicated a ‘pump failure’. Silasticintubation alone was used by 15% with the success ratebeing described as ‘fair, at best’. Silastic intubation has beenproven to be successful in adult partial nasolacrimal ductblockage; Angrist and Dortzbach achieved good results withsilicone intubation in 74% of patients with a partial obstruc-tion.10 Based on success rate of 94% found in the presentstudy, we recommend DCR with intubation in preference tosilicone intubation alone.

Guzek et al. have recently directly compared macrodacryo-cystography with Jones testing, FDDT, lacrimal scintigraphyand canalicular probing.11 They found that lacrimal scinti-graphy added little or no additional information. They recommend FDDT, Jones testing and canalicular probing todiagnose obstruction and exclude hypersecretion, anddacryocystography when the FDDT fails to prove obstruc-tion. This essentially is our recommendation also.

In the present series, high quality subtraction DCG wasused in 12% of cases. No total obstructions were seen but alldemonstrated at least one of the abnormalities as discussedearlier. Dacryocystography was not used routinely butrather to look for an anatomic abnormality when the clini-cal tests were equivocal in the background of epiphora.

Demorest and Milder suggested that a radiographicallydemonstrated functional block in a patient with chronicepiphora is an indication for DCR and reported that patientsrespond just as dramatically as those with an anatomicblockage.6 Our experience confirms these early observa-tions. The success rate of a standard DCR with temporarysilastic intubation for nasolacrimal duct obstruction is gen-erally regarded as being in the order of 95% or higher. The94% success rate we observed after surgery confirms ourapproach is efficient for the management of patients withepiphora and clinically patent lacrimal drainage system.

28 O’Donnell and Shah

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10. Angrist RC, Dortzbach RK. Silicone intubation for partial andtotal nasolacrimal duct obstructions in adults. Ophthalmic Plast.Reconstr. Surg. 1985; 1: 51–4.

11. Guzek JP, Ching AS, Hoang TA et al. Clinical and radiologicallacrimal testing in patients with epiphora. Ophthalmology 1997;104: 1875–81.

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