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Abstract
Summary
The aim of this work was to evaluate the safety and efficacy of insertion of Jones tube without dacryocystorhinostomy (DCR) by a comparative study between it and insertion of Jones tube with dacryocystorhinostomy CDCR in the management of canalicular obstruction.
Surgery was performed on 78 patients (100 eyes) 60 were females and 18 males (mean 37.0+8.0). Age of the patients ranged between 16 and 60 years. Patients were divided into two groups: Group I included 50 eyes that undergone CDCR with Lester Jones tube insertion and Group II included 50 eyes that undergone transcaruncular Lester Jones tube insertion without DCR. Canalicular obstruction in the cases of this study was due to: Failed open DCR in (32 eyes), Failed closed DCR ( 9 eyes), chronic dacryocystitis with rough probing (11 eyes), trauma with canalicular damage in (4 eyes) and 44 eyes of idiopathic canalicular obstruction.
Preoperative assessment was done by comprehensive ocular examination, tests of lacrimal drainage as dye disappearance test, Jones’ tests, probing and syringing of the lacrimal passages, tests of lacrimal secretion as tear break up time, Schirmer’s tests, and nasal examination to assess the nasal mucosa, septum and turbinate.
The operative procedures performed were CDCR with insertion of Lester Jones tube in 50 cases, and transcarucular insertion of Lester Jones tube without DCR in 50 cases.
Postoperative follow-up included, assessment for symptomatic improvement and appearance of new symptoms, syringing and cleaning of the tubes.
Our results were disappearance of epiphora in 88 % of the cases. Complications occurred in 52% of the cases in group I, and 42% of cases in group II.
Epiphora disappeared in 88%, which is comparable to other results such as Rose et al 91% and charmaine et al 94% . . Incidence of complications was 52% in group I and 42% in group II, which is better than other studies such as Sekhar et al 57.9% and Hurwitz et al 50%, we attributed our lower incidence in group II to the small bony ostium which stabilized the tube in the early postoperative period. As Regarding individual complications: Lateral displacement was 22% in group II worse than Sekhar et al 13%. Medial displacements were 0% in group II better than Sekhar et al 9%. Tube loss happened in 22% in group II better than Rose et al 44%.we had closure of the CDCR tract within 24 hours of tube removal and recurrence of epiphora in all cases.
Conclusions
DCR is indicted there is no other solution for treating epiphora, however it is a procedure that needs long-term tedious follow up and rapid diagnosis and management of its complications, needing patient doctor continuous contact and feedback.
Patients with mild epiphora or high marginal tear film shouldn’t undergo the procedure. The results and patient expectations should be discussed making sure that patients totally understand the long follow-up and all the complications they might face.
Conclusions are:
•Transcaruncular Jones tube insertion is a safe and efficient operation in the management of canalicular obstruction.
• Transcaruncular Jones tube insertion is an operation of least manipulation and of short operative time.
• Transcaruncular Jones tube insertion can be done under local anaesthesia and sedation.
•Transcaruncular Jones tube insertion is of less intraoperative and postoperative complications compared to CDCR
Recommendations.
As regards to the operative procedure we came up with a few recommendations:
• Positioning of the tube is critical; it should be directed almost at a 45°angle downwards, as drainage is mainly dependant on gravity the lateral end should be immersed in the lacrimal lake and the medial end should lay two to three millimeters from the nasal septum.
•Avoiding excision of the caruncle is important, as it protects the globe from continuous friction with the edge of the tube flange.
•Silk sutures (6/0) are mandatory around the tube flange or through a hole in the flange to fix the tube in the early postoperative period and should be kept as long as possible minimum 6 weeks. Fixing the shaft of the tube in its ideal direction and angulation with nonabsorbable (6/0) suture such as prolene to lower lid or the medial canthus by forming a loop around the tube and through the tube help in tube fixation.
• During follow up, patients are taught to come as soon as their tubes are lost as the tract closes within 24 hours and reinsertion later will need a new surgical intervention.
•Patients should be advised to put the index finger over the conjunctival end of the tube while sneezing and coughing or close their eyes firmly during the first six months, to avoid tube extrusion.