In this lecture, Dr. Khan discusses various treatment options for a tearing patient. He also explains about probing and non-endoscopic endonasal DCR using surgical videos.
Lecture location: on-board the Orbis Flying Eye Hospital in Yaoundé, Cameroon
Lecturer: Dr. Yasser A. Khan, McMaster University and University of Toronto
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DR KHAN: Okay. So let’s talk about tearing. About treatment. And again, how I finished in the last talk — I’m gonna start with this talk. Don’t treat them — even back home, you know, there’s a saying in English we have: If it isn’t broke, broken, don’t fix it. Right? So which statement is true? Most congenital nasolacrimal duct obstructions do not resolve and need to be probed. 90% of congenital obstructions resolve within one year of age. And probing is the main treatment of choice in a child over five years old. And DCR should never be done in a child. Probing is an effective method to treat nasolacrimal duct obstruction in adults. A Jones tube and conjunctival DCR is recommended for the following: Nasolacrimal duct obstruction, punctal stenosis, canalicular obstruction, or congenital nasolacrimal duct obstruction. I mean, I’ve already spoken about this part. Treat the eyelid and lashes first. Right? So you guys already know this. Treat the ectropion, entropion, the caruncle hypertrophy, the conjunctival chalasis, and the facial nerve palsy first. So this is an example of a patient who was tearing, with right-sided facial nerve palsy. And I put a gold weight in the upper eyelid, to help them close their eye better. So when it comes to… You must see a lot of… I mean, I know back home in Toronto, where we have a very multicultural society, people from all over the world, we see a lot of punctal stenosis. We get a lot of people from Africa and Asia who live in Toronto. And so I see a lot of this, because they all have had trachoma or different things, coming from their countries. So we see a lot of punctal stenosis and ectropion. And you can do a punctoplasty, medial punctal ectropion repair, or change their glaucoma medication, if they have this going on. Okay. So these are examples of… You probably can’t see it. The patient’s too white. You probably can’t see it here. They have punctal stenosis. And you can see you dilate the punctum, and using a Westcott, you do a three-snip punctoplasty to open up the punctum here. This is an example of a punctoplasty. This is a stenotic punctum. I put some local anesthetic here. So I put some local anesthetic either on the outside or subconjunctivally. So they’re frozen. You don’t need a lot of… I take a punctal dilator to try and open the punctum. This is the lower eyelid. Then I take a Westcott scissors, and I do a one-snip or a three-snip punctoplasty. What I mean by one had snip or three-snip is how many cuts you make to open up the hole. Right? Yeah. You can see this triangle right there. Okay? So what I do is I make one central cut, and you’re usually left with a little triangle, and I cut this triangle off. Okay? And that’s my three-snip, basically. And you can see now: It’s open. Right? Make sure, if they bleed, don’t cauterize. Because you will close the scar, the canaliculus. So don’t cauterize. Just put some pressure on. The bleeding will stop. But don’t cauterize. Not the first time. Okay? If it happens again, you know, or happens a third time, then I’ll put a stent in. I don’t do it for the first time, no. Now, if a patient comes in with a history of trachoma, or some kind of chemical injury, or whatever, then maybe I’ll consider putting a stent in the first time. But if it’s not that, if it’s something minor, not a lot of scarring, then I won’t put a stent in. There’s a procedure that we do for patients who have come to us with punctal… With severe punctal stenosis or canalicular stenosis, because of glaucoma medications, because of trachoma, because of cancer medications like chemotherapy, and all this. Okay? We do a canalicular reconstruction without stents. And that kind of… It increases the success of the procedure. And I think I have some videos of that. But I can show that to you after. So that’s a really nice technique, and you don’t need stents for that. I use sutures to open up the canaliculus and keep it open. And that really increases the success rate. So let’s talk about congenital nasolacrimal duct obstruction. So you guys are experts already now. You know that there’s a persistence of the membrane of the valve of Hasner. 90% will get better after the first year of life. What I do is, when they come in at 6, 7, 8, 9 months, if they’re having a lot of infections and very red eye, I will give them a topical antibiotic, and I’ll encourage mother or father to massage on a regular basis. And what I do is I actually go to the mother, and I do it on the mother or father, just so they know how to do it. The way I like to do it, the way I think is easy, is I say: Take your finger and your thumb, and just massage like that. Like that, downwards. Like this. And I will actually do it on the father or mother, just so they know what to do. And that’s very easy. You know, going like this is kind of difficult. But just go like that, and regular massage, plus or minus antibiotics, if they’re getting infections, is good enough, and about 90% of them do well. It’s very important to teach these parents the proper technique, okay? And they can massage as often as they want. Every two hours, or as needed. Okay? And usually they resolve in the first year. Yeah. So, I mean, these are just some of the antibiotics that I use. But whatever you have in Cameroon is fine for antibiotics, I think. Anything is fine. Because the bacteria is… Oh my God. What’s the word, Nick? Bacteria? Multimicrobial. If this does not work, and the child is over 12 months, then you start thinking about doing a procedure. But sometimes, to be honest, you can wait. My own son, I waited until 18 months, because he had it as well. And it resolved after 18 months. And we had to do nothing. Right? So it doesn’t always have to be 12 months. But that’s a guideline. Typically it should get better by 12 months. If it doesn’t, then you think about doing something. So with probing and irrigation, it has to be done under general anesthetic. But what we do typically is… What I do, because it’s a quick procedure… It takes two minutes to do… I will just bring the child in, and if the anesthesiologist is comfortable, I’ll just put some gas on them. Right? So the anesthesiologist will put some gas, put them to sleep for two minutes, go in, come out. Okay? This way the child doesn’t have to be intubated and all this complicated stuff. Right? Sometimes we’ll just give them gas and do it. With just probing and irrigation, 95% of children are successful. 5% who are not I do a repeat probing. Okay? Again. Or, if I find that they’re 3, they’re 4 years old, and it’s really bad, I will put stents in. You know, putting stents in is a good thing. But, to be honest, there’s two things. Even after 15 years, I still struggle sometimes putting stents in. Right? And also, here, I guess, stents are not available. So I think you may want to just probe them again. If the child is older, so they’re 5 years or older, I will do a DCR. Okay? I did this in fellowship, a balloon dacryoplasty. I do not do this, and I’ve never done this after my fellowship, 15 years ago. I basically… If they’re over 5, I’ll do a DCR. This is actually very expensive. It’s $500, $600, or something like that. Yeah, very expensive. So I don’t bother doing it. And I will do a DCR. But I find this is more successful anyways. It’s the gold standard procedure, anyways. So this is all you need for your lacrimal probing setup. This is fluorescein. I don’t even use fluorescein anymore. Okay? But you need a punctal dilator. You need a punctal probe. And you need lacrimal irrigation with a cannula to irrigate. So I dilate the punctum first. Once I dilate the punctum, I will put a probe in. Typically, in most children, if it’s an older child, I’ll use 1-0 probe. You know, there’s different sizes. There’s 0, 00, 000, 1, 2, 3, 4. So if it’s a small child, I will use 0 probe. If it’s an older child, I’ll use 1 or 2. Not bigger than that. So this is where you have to know your anatomy. So I go all the way straight ’til I get hard stop. What does the hard stop mean? The hard stop means that you’re in the lacrimal sac. Okay? Against the bone. So you’re in the sac. This is a hard stop. So you’re in the sac here. You’re against bone. Okay? Once I know I’m in hard stop, then I turn my probe, I aim for the lateral nare — okay? That’s where I aim for. You are there. Then you aim for the lateral nare. Okay? Of the nose. Right there. Depending on what side you’re on. Okay? And that’s when I go down. It’s very important. If you don’t do this right, you will go through the canaliculus and make a false opening. And that’s not good. So I will aim for this here. Okay? And then once I’m done, I confirm that my metal probe is in the nose. I go metal on metal touch. Okay? And I’ll show you a video of this. And I leave it there for one minute. And then I come out. And then I irrigate after, to make sure they’re open. So this is how I do my probing. Okay? So here I am. I’ve already dilated the punctum from before. And now I’m putting… Now I’m putting the probe in. And this is a small child. I think I’m using a 1-0 probe. I’ll go straight parallel to the eyelid. I hit a hard stop. Right there. Hard stop. See? And then I’ll change directions, aiming for the nose. The nare. The lateral nare. Okay. What I want to show you is that you want to make sure, once you’re in the nose, you want to make sure that the probe is where it should be. And where should it be? That’s the question. The inferior turbinate. You know? The inferior turbinate? It should be right next to the inferior turbinate, which is the lowest turbinate. Right? By the way, before I do my probing and irrigation, I should tell you: I always pack the nose with nasal decongestant. If you do not have a nasal decongestant, then you can use adrenaline to pack the nose for about 3, 4, 5 minutes. And that should cause a good vasoconstriction, so you can see everything. So, again, adrenaline, gauze soaked for about 4 minutes, and you go in, okay? And you should be at the inferior turbinate. Now, you want to make sure it’s in the right position. And I do that by metal on metal touch. This gives you an idea of how far down I am. So I measure my probe, and so my probe that I’ve put in should be over here. This gives me an idea how deep I’ve gone. Because you can go all the way down into the oropharynx. Very far. So this gives you an idea how far down you are. So then I’ll take a big probe, and I’ll try and do metal on metal, and try and feel this. Right? And you always go down this way. You don’t go up this way. Because that’s the middle turbinate. You want to be in the inferior turbinate. So you’re almost parallel to the floor of the nose. Right? And then you feel metal on metal, and you feel this moving. So always have a nasal speculum as well. That’s the inferior turbinate. That’s the lateral wall of the nose. And this is the meatus, which is a space. But that’s… So the probe should be underneath the inferior turbinate. So it should be over here. So now I will go there and try and feel it. So, see, I’m going in there. And trying to feel metal. I don’t feel it, so I’ll adjust a little bit. Okay. I did feel it. Okay. Then I always irrigate after. So that’s probing and irrigation. That’s the irrigation part. This is the case with stents. Okay? So this is… You can see putting stents in. Okay? This is a Crawford stent. It’s bicanalicular, so it’s got two ends. So, again, same thing. Hard stop, and then down. Aim towards that. The lateral nose. Nostril. And this tells me how far down I am. So I know where I am. Make sure you have a nasal speculum in your toolkit. I take this hook and grab it. But you can also take a hemostat and grab it. You don’t have to have a hook. So I’ll grab it here in a second. I probably already grabbed it and brought it out. So you can use anything to get it out. Sometimes it’s difficult. But I found it with a hook and I brought it out. Okay? And then I tie it with a suture. A 6-0 prolene or a 5-0 prolene. Actually, I’m stripping it here. Okay. That’s fine. There’s certain kinds of stents you can strip and tie. But usually I tie a suture. I use stents usually up to age 5. After that, I think a DCR works. I’ll use stents for recurrent cases, if it blocks again. The second time, I’ll use stents. Or if the child is around 4 years old, I’ll use stents. The only point I will make with this — because it’s very important — when you see a newborn, a neonate, with a mucocele or a dacryocystocele, sometimes they can have that where they have congenital obstruction. That’s very dangerous, because babies are nasal breathers, when they’re first born. Right? So if their nose — and sometimes once in a while, you can get it so large, it blocks the nose, and they can’t breathe. And they start turning blue. So in that case, it’s very simple. You can do it right at the bedside. If it’s a newborn, you don’t have to give them anesthesia. Just wrap them in a blanket and do the probing right there on the bedside. And relieve that blockage. Very, very important. If it’s a baby, you don’t have to give them anesthetic. Just wrap them up and do it. It doesn’t take very long. So sometimes you can get canalicular — a chronic canaliculitis. Which is a blocking of the canaliculus. It has a very, very classic appearance. You get this swelling of the punctum. And look how large the punctum is. Look how swollen it is. And it’s very red. And usually there’s yellow pus-y discharge from the punctum. And that’s canaliculitis. And you can see it’s usually blocked by lacrimal stones. Bacterial infected stones. And you can see what the stones look like. That’s a stone that’s coming out of the canaliculus. Canaliculitis is a surgical disease. It’s not gonna get better by antibiotics. You have to go in there and open the punctum and get the stones out. Otherwise — it’s like an abscess. You have to drain it. You have to open it. This is an example of canaliculitis. See this pus-y discharge? This line is supposed to be over here. That’s where you make the cut when you want to open it up, okay? Not up here. This is an example of a canaliculotomy. But basically you make the cut over here and you open it and get all the stones out. Again here. Take all the stones out, and you’re left with a big opening. This is acute dacryocystitis. Of course you need to treat them with antibiotics. My first choice is second generation cephalosporin. Treat them for ten days. They will usually eventually need a DCR. But you don’t do DCR when they’re hot. You do it when they quiet down in about four weeks. Sometimes if you get this, you have to drain it with a little needle or a 15 blade. Poke a little hole and massage and let the pus out. Yeah. So Keflex is my first choice. Clindamycin you can give. Okay? Good. So this is just… If they’re blocked, then you proceed to a DCR. Okay? Now, a DCR is a 2,000-year-old procedure. It’s very simple. All you’re doing in a DCR is you’re making a hole. You’re making a hole between — because the blocking is here. The blocking is right there. Right? So you can’t fix this. Because this is in the bone. But what you can do is you can make a new hole. This is all blocked. You can make a hole here. So all you’re doing is you’re making a hole between the lacrimal sac and the bone. And the nose. So the tears will flow from the sac into the nose. That’s all you’re doing. It’s a very simple procedure. I mean, this is just what I do before a DCR. I always spray their nose with a nasal decongestant. If you don’t have this, you can use adrenaline. Okay? And I also inject around the nose and in the nose as well. For an external DCR, there’s five steps. Skin incision, you free the lacrimal sac, you create the ostomy between the lacrimal sac and nasal mucosa. You form the flaps, intubate, and close the incision. So here you are. Mark about a 4-millimeter incision. Halfway between the head of the brow and the middle of the nasal bridge. Inject anesthesia. And then you make your surgery. I’ll show you in a second. So here I’ve made the incision. Now I’m just… This patient is awake. So I’m doing a different nerve block. I’m injecting. I also did a supratrochlear nerve block. I’m making my skin incision. I’m spreading all the way down to periosteum. Cutting the periosteum. With a Freer elevator. Using a Kerrison rongeur to cut the bone out. To make an ostomy. Then once I’ve done my ostomy, I cut my lacrimal sac. And my nasal mucosa. Okay. We can go through this later. Let me skip this. Do you guys ever do Jones tubes? Has anybody ever seen Jones tubes? No? Okay. Jones tubes are used to treat anterior system blockage. When the canaliculus is completely scarred, a DCR, a normal DCR will not work. Okay? You need to make a new tear duct for them. And the way you do that is, because this will not work, you make a connection between the medial canthus and the nose by putting a glass tube, called a Jones tube, named after a man named Jones, and that works as your new tear duct. So you can see here: Most people will do a DCR. But remember, with a DCR, your anterior tear ducts don’t work. And then the Jones tube stays in the corner of your eye, draining the tears for the rest of your life. So this is a procedure that I do. I call it the NEED Procedure. It’s non-endoscopic endonasal DCR. So I do it without the endoscope. So remember what I told you? This is a perfect example of what I told you. Just because a patient is tearing doesn’t mean you have to do surgery. If they’re happy like her, you don’t have to do surgery on her, just because she’s tearing. Right? Only if they’re really bothered by their tearing, then you do surgery. So NEED Procedure. Non-endoscopic endonasal DCR. Okay? Don’t forget the goal of the DCR. What’s the goal of the DCR? You make a hole. That’s it. It’s very simple. I work in rules of 10. You need ten things. You need nasal speculum. You need some kind of surgical loupes. Okay? And a very simple surgical instrument setup. You need a retinal light pipe. You need a knife, a pituitary forceps, a Kerrison rongeur, forceps, needle holder, scissors, which we all have, and suction. That’s all you need. Okay? This is a retinal pipe. Most retinal ORs will have this. You can just cold sterilize it and use it again. Right? You don’t have to dispose of it and use it with one-time use, to be honest. Just put it in some alcohol. It’ll kill everything. And then use it. I mean, the nose is not a sterile place in general, right? I do these under general anesthetic. But you can also do them under IV sedation. But remember: Same thing. You have to pack the nose and inject the lateral part of the nose. This is the setup, again. Maybe keep some probes. And Kerrison rongeur. Suction. Pituitary forceps. Nasal speculum. Freer elevator. Punctal dilator. Forceps. And crescent knife. The first thing you do is you put the retinal light into the punctum. Okay? And you can see: It illuminates… Nasal transillumination… It illuminates all the inside of the nose. You can see the bright light right here on the lateral wall. And then you know that that’s where the lacrimal sac is. So you can see here. So you can see the lacrimal… So the light is in, and you’re in the lacrimal sac. It visualizes this whole area. So then you know where to do surgery. Then I go in there, and I inject where the light is. So where the light is, that’s where I inject. This is an old slide. I don’t use cocaine anymore. It’s adrenaline. But anyways… So then I pack the nose with adrenaline. Okay? Then I take a crescent knife or a beaver blade, and I make an incision in the nasal mucosa. Right where the light is. Okay? And then I take my nasal mucosa off, with a pituitary forceps. Then I go with the Freer elevator, and I break the soft lacrimal bone. Infracture lacrimal bone. And then I take a Kerrison rongeur, and I do an ostomy. Remove the nasal bone. So once I remove the nasal bone, it becomes much brighter. Here you can see… This is before nasal bone is gone. And this is after nasal bone. So bone is gone. Only the lacrimal sac is left. And then I go in there and I cut this off. Once… And that’s it. Once I’m done, I make sure everything is open. If everything is open, then I go and put my stents in. My lacrimal stents. I stent everybody with a DCR. Okay? And I suture the stents with a 7-0 prolene. And the patient is done. So here’s an example. So this is an endonasal DCR, but I’m taping it. So I’m not doing it endoscopically. I’m recording it. So you can see… See how bright the light is? This is what I’m looking at. This is what your view is. Very bright. And that’s where I do my surgery. Wherever the light is. I take a pituitary… Sorry. The nasal mucosa off. Then I go in there and I break the lacrimal bone with a Freer elevator. I take a Kerrison rongeur, and I do my ostomy. See? I’m taking bone off here. Only bone. You can see the light getting brighter, as the bone comes off. Okay? And very, very bright now. Because all the bone is gone. Okay? Well, not all the bone. But the bone that I need to be gone. I take some extra bone off here. And now I’m happy. You can see here… That’s a lacrimal sac. See? See that? Lacrimal sac. I’m not through yet. And this is my view. I’m looking in with a nasal speculum. Now I cut my lacrimal sac. You can see everything. And I take my lacrimal sac off with the pituitary forceps. And now you can see my light pipe is free in the nose. See that? So I test, make sure I’m open, with irrigation. You can see the water coming through. See? The water coming through here. So we’re open. We’re open. And then I’ll go in there and put my lacrimal stents in. You can grab it with a hemostat, or you can use a grooved director, which is what I use. If everything goes well, it takes me 7, 8 minutes to do. But that’s me. I mean, that’s after doing thousands. Usually it’s about a 15, 20-minute procedure. Thank you. So the question was: With a canaliculotomy, how would you do it, or where would you make your incision? Initially, the canaliculi would be very swollen. Right? But it remains open and eventually heals. Eventually heals. You don’t have to do anything to it. If you’re afraid, you can put a stent in to help keep it open. But there’s no stents available here. So that’s not an option for you. What I would do is I would just open it. I usually irrigate with some iodine and saline. And I give them some antibiotics. And that’s it. And I watch them. There is a high risk of obstruction, because of all the inflammation. But, I mean, it doesn’t always happen. Usually it doesn’t. Usually it heals by itself. So you can, but the nasal anatomy is very hard to visualize with ultrasound. Very good thought. But it’s very hard. But I mean, to be honest, you don’t need an ultrasound. As long as you have a hard stop, you know you’re in the lacrimal sac. And then just aim for the lateral nostril. You’re fine. You know, it’ll be hard to differentiate things when you’re doing ultrasound, with all the bone and the artifact that the bone will create.
November 13, 2017