Obstruction of the lacrimal tubules: causes, symptoms, diagnosis, treatment

The obstruction of lacrimal canalis develops more often due to inflammation of the mucous membrane of the eyelids and tubules with conjunctivitis. Small obliquity (1-1.5 mm) can be eliminated by probing, followed by the introduction of Alexeyev's probe into the lumen of the canaliculus for several weeks of bougie threads and tubules.

If the function of the inferior tear duct is not eliminated, the operation is shown - the activation of the upper lacrimal canaliculus. The essence of the operation is that, starting from the upper lacrimal point, the strip of the inner wall of the tubule is excised to the inner corner of the eye gap. In this case, a tear from the lacrimal lake will immediately fall into the open upper tear duct, which will prevent tearfulness.

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Treatment of obstruction of lacrimal canals

Treatment of impassability of lacrimal canals depends on the location and degree of obstruction.

• partial obstruction of the general, individual tubules or along the course of the canal canal can be resolved by intubation. The two ends of a long silicone tube are inserted into the upper and lower lacrimal points through the lacrimal sac down to the nose where they are secured with a special sleeve of Watzke and left in place for 3-6 months;
• when the tubule is completely obstructed, an anastomosis between the passable part of the tubule and a lacrimal sac (canaliculodacriocystorhinostomy) is placed between the lacrimal point and the site of the blockade with a minimum extension of the passable site of 8 mm and intubated. If the block is located less than 8 mm from the lacrimal point, the treatment includes co-conjunctivocryocystorinostomy and the installation of special Lester Jones tubes;
• complete obstruction of the lateral section of common tubules is usually found in idiopathic pericaiialicular fibrosis, when the entire common canaliculus is impassable. Dacryocystography shows disturbances in the filling of the common lacrimal canaliculus. Treatment: resection of an impassable common tubule and the imposition of a canaliculocarycystorinoanastomosis. The duration of intubation of lacrimal canal is 3-6 months;
• complete obstruction of the medial section of common tubules is often caused by a thin membrane at the junction with the lacrimal sac as a consequence of chronic dacryocystitis. Dacryocystography shows the filling of a common tubule. Treatment: lacrmocystorhinostomy and excision of the membrane from the site related to the lacrimal sac. The lacrimal system is intubated for 3-6 months.

Obstruction of the nasolacrimal canal

Causes

• Idiopathic stenosis.
• Nasorbital trauma.
• Granulomatosis Wegener.
• Germination of nasopharyngeal tumors.

Treatment depends on the degree of obstruction:

• with complete obstruction, dacryocystorhinostomy is performed.
• partial obstruction is allowed by intubation of the tear system with a silicone tube or stent if the tube or stent is easy. If difficulties arise during intubation, dacryocystorhinostomy is performed. In some cases balloon dilatation is used.

Principles of lacrimal duct surgery

Traditional dacryocystorhinostomy

Carried out with obstruction, localized after the medial course of the common tear duct (that is, a system of tubules is available). This operation consists in creating an anastomosis between the lacrimal sac and the middle nasal passage. The procedure is performed under general anesthesia with a hypothesis.

The technique of performing traditional dacryocystorhinostomy

• the mucous membrane of the mid-nasal passage is swabbed with a gauze swab with a 2% ligdocaine solution from 1: 200,000 epinephrine to achieve narrowing of the mucosal vessels;
• a straight vertical incision is made 10 mm medial to the inner corner of the eye gap, avoiding damage to the angular vein;
• produce a dissection of the anterior tear ridge in a blunt manner and secrete the surface part of the middle palpebral ligament;
• the periosteum is removed from the ridge on the front lacrimal ridge to the bottom of the sac and is withdrawn. The bag is withdrawn lateral to the tear fossa;
• the front tear ridge and bone from the tear fossa are removed;
• Through the lower canaliculus inject the probe into the lacrimal sac. In which an H-shaped incision is made to create two flaps;
• in the mucous membrane of the nose also produce a vertical and incision for the forms of propane and the anterior and posterior valves;
• stitch the rear doors;
• stitch the front doors;
• the medial part of the tendon of the internal solder is sutured to the periosteum, nodal seams are applied to the skin.

The results are generally satisfactory in more than 90% of cases.

Causes of failure: inadequate size and position of the lachrymal, unrecognized obstruction of the common tubule, scarring and congestion, in which the surgical opening in the tear bone is too small and high. In this case, in the enlarged and medial and below the level of the lower edge of the bone, a secretion accumulates in the lacrimal sac, without access to the nasal cavity.

Possible complications: cutaneous scar, internal ligament injury, bleeding, cellulitis and rhinorrhea of cerebrospinal fluid, if a subarachnoid space is accidentally opened.

Endoscopic dacryocystorhinostomy

Can be used for obstruction below the medial aperture of the common canal especially after a failed traditional dacryocystorhinostomy. The procedure can be performed under local or general anesthesia (without hypotension). Advantages over conventional dacryocystorhinostomy are a small incision of the skin, a reduction in the time of surgical intervention and the risk of disruption of the physiological mechanism of lacrimation, minimal blood loss, and the absence of risk of cerebrospinal rhinorrhea.

Technique for performing endoscopic dacryocystorhinostomy

A direct light tube is carried through the lacrimal point and tubules into the lacrimal sac, examining the nasal cavity from the inside with an endoscope. The remaining manipulations are performed from the nasal cavity.

• produce a compartment of the mucous membrane along the frontal process of the upper jaw;
• remove part of the nasal process of the upper jaw;
• open the lacrimal bone;
• open a tear sack;
• then spend silicone tubes through the upper and lower lacrimal points, remove the turn hole in the bone and fix it in the nasal cavity.

The result is positive in about 85% of cases.

Endolaser dacryocystorhinostomy

Endolaser dacryocystorhinostomy is performed using a holmium YAG laser. This is a quick procedure that can be performed under local anesthesia, which is preferable, especially in elderly patients. A positive result is achieved in approximately 70% of cases. Maintaining a normal anatomy in case of failure allows further surgical intervention.

Lester Jones

The installation of the Lester Jones tube is indicated in the absence of tubular function due to obstruction at a distance of less than 8 mm from the lacrimal point or disturbance of the tear suction mechanism.

• perform dacryocystorhinostomy before suturing the posterior valves;
• partially excised lacrimal flesh;
• Perform a through-cut with a Graefe knife from a point approximately 2 mm behind the inner corner of the eye gap (in place of the removed flesh) in the medial direction so that the tip of the knife appears just behind the anterior lobe of the lacrimal sac;
• expand microtracking stroke for free introduction of a polyethylene tube;
• impose seams, as in dacryocystorhinostomy:
• After 2 weeks, the polyethylene tube is replaced with a glass tube.

Balloon dacryocystoplasty

It can be effective in adults as the first stage of treatment of partial obstruction of the nasolacrimal canal, which proceeds without signs of chronic infection.