Procedure of removing tear duct and nasal lacrimal obstructions

Tear ducts begin with  lacrimals points lying on the lacrimal papillae.  Lacrimal points lead to upper and lower tubular tear which  in its  final run flows into the lacrimal sac, separately or through a common duct. Then the nasal-lacrimal duct connects   the lacrimal sac with the nasal cavity, closely below the lower nasal concha.

Structures that can be easily clogged

Structures that may easily get clogged:

In children as a result of:

• Congenial obstruction of the nasal passages (most frequently)
• Clogging of the lacrimal ducts due to various injuries
• Deviation of the nasal septum
• Chemical or thermal burns
• Chronic sinusitis
• Viral and fungal inflammations
• Cancer

In neonates, tears start to be produced within a few days after birth, up to several weeks thereafter. Likewise , the symptoms of the lacrimal ducts obstruction   appear  later.

In adults as a result of :

• Mostly, due to different types of injuries
• Deviations of the nasal septum
• Chemical and thermal burns
• Chronic sinusitis
• Viral and fungal inflammations
• Cancer
• Auto-immuno diseases such as sarcoidosis, Wegner’s granulomatosis
• Tuberculosis
• Polyps
• Mucocellae.

Symptoms of lacrimal duct obstruction:

• Tearing (epiphora).
• Pain
• Redness
• Muco-purulent secretions in the eye (conjunctival sac), often – yellow-white
• Irritation of the eye area
• Swelling around tear ducts
• Infections are often accompanied by fever

The first symptom is  mostly lacrimation.

Symptoms may intensify  in the course of inflammation of the upper respiratory tracts (colds, sinusitis). In addition, during exposure to wind, cold and sunlight, symptoms may become noticeable or may intensify.

What increases the risk of blocking the tear ducts?

• Premature birth
• Structural and functional problems with lacrimal ducts caused by infections
• Family history of lacrimal duct obstructions

Treatment:

• Surgical – a unique method of laser micro endoscopy
• Anesthesia: in adults- under local anesthesia; in children- in general anasthesia
• It takes about 20 min.
• Discharge from hospital –about 1 to 2 hours after surgery

Lacrimal duct  surgery has been performed by our team   since 1992. Up till now,  we  have conducted several thousand treatments of  lacrimal duct patency restoration by all methods.

Micro-endoscopic laser method consists in entering a  micro-endoscope of  0.4 mm  in diameter  with  fiber optic laser emitting light of  980 nm long into the lacrimal duct .Ophthalmologist surgeon throughout the whole surgery on  the entire length of lacrimal duct is able to assess the anatomical status. Upon the  detection of the pathology,  the laser is activated and lacrimal ducts are reconstructed .At present, this is the only surgical method ,which allows to make a complete reconstruction of the lacrimal duct  obstruction at any level, under the control of the endoscope. In the event of extensive damage, the surgeon can make  a classical  fistula of lacrimal sac into the nasal cavity. The treatment ends  up with entering silicone intubation tubes, which are removed after 6-9 months.

One of the endoscopes used  in laser micro-endoscopy surgery

In children, it is mainly performed in reconstruction of  lacrimal ducts (recanalization).

In adults – in lacrimal sac fistula of the nasal cavity (dacryorhinostomia).

In rare cases of  total agenesis (congenital absence) of  tear ducts  or total destruction as a result of  chemical, thermal or mechanical injuries it is possible to carry out artificial connection of conjunctival sac to  the nasal cavity (coniuctivodacryocystorhinostomy = CDCR) with implantation of  so-called  Johns tube. This procedure is performed also by micro-endoscopic laser. and there are no scars left on the face.

Reconstruction of the lacrimal ducts. 
It is possible to carry out the reconstruction by a micro-endoscopic-laser, as well as by retrograde intubation (placing  a modified Whosrt  probe through  healthy duct  backward to the duct  that is damaged, removing  the adhesions or scars by laser or classically-surgically.
In case of both ducts damaged , they  can be reconstructed by our  own method,  from the side of  lacrimal sac or common duct)

Treatment of fungal dermatitis, and Actinomycetes. 
Treatment of fungal inflammations and Actinomycetes inflammation consists in surgical removal of the  fungus mass   or Actinomycetes deposits , and subsequent pharmacological treatment. Treatment is most often conducted  through natural duct  openings without affecting the continuity of tubular wall and leaving no scars either  on skin or on the wall of the duct . when there are  huge deposits it  is sometimes necessary to perform canaliculotomy (duct  wall incision and extraction of deposits).

Treatment of childrenAt   our center, we recommend  lacrimal duct probing in children  before ectasis  reach lacrimal sac (up to 3-6 months of age). In the case of existing  ectasis  and lacrimal sac recesses  and the innate dacryomycopyocele (muco-purulent cyst), we  offer  recanalization of the lacrimal ducts  in children, even below 1 year of age.

Recommandations after surgery:

• Return to normal life takes place usually up to 12 hours after surgery
• Check up is in one month after surgery

Complications (very rare):

• Swelling of eyelids
• Subcutaneous hematoma
• Slight sub-bleeding from nose
• Damage of ducts caused by non-compliance with recommendation

Occluded tubules in children

Quite a common problem in children is closed nasolacrimal duct, usually  causing tearing and  eye  suppuration . In  very young children, it is recommended to massage the area. If there is no spontaneous patency or the child’s condition suggests such a  need,  probing of the lacrimal duct should be carried out  (this treatment in our center is performed under local anesthesia). If it does  not give a positive effect,  micro –endoscopy of  lacrimal ducts  is to be considered, and possibly simultaneous laser treatment.

Post-traumatic occlusion of tubules

A common result of road accidents is damage of  lacrimal ducts . This problem can be solved only by  reconstruction of ducts  and, in extreme cases, by CDCR surgery  (at  our center also performed by using laser techniques that do not leave  scars), involving the implantation of a silicone tube that  permanently leads out tears.

Excessive tearing

Excessive tearing may also have another origin, besides  obstruction like: excessive laxity of the eyelids, incorrect lacrimal points` setting, abnormal shape and size of the lacrimal duct warts, lacrimal pump dysfunction, vision defects, allergies, etc.
To improve the running  of tears,  plastic surgeries  on the eyelids are  necessary, which are   also performed at  our center.

Persistent purulence

It can also be caused by obstructive lacrimal ducts . It is not possible to achieve any  improvement and permanent cure if the lacrimal ducts do not get patent  Frequent administration of antibiotics can lead to conjunctival sac and lacrimal  duct fungal inflammation
Such a  condition requires prompt surgical intervention as well as   general and local treatment.

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