Treatment of nasolacrimal duct obstruction in adults with polyurethane stent

Treatment of Nasolacrimal Duct Obstructionin Adults With Polyurethane Stent

BULENT YAZICI, MD, ZEYNEP YAZICI, MD, AND MUFIT PARLAK, MD

● PURPOSE: To evaluate the efficacy of polyurethanenasolacrimal duct stents in the treatment of epiphoraresulting from primary acquired nasolacrimal duct ob-struction in adults.● MATERIALS AND METHODS: In 25 patients (21 womenand four men with mean age of 44 years, range 20 to 74years) with nasolacrimal duct obstruction, 28 hollowpolyurethane stents designed by Song and associates wereplaced under fluoroscopic guidance. The obstruction wascomplete in 20 lacrimal drainage systems and partial ineight. The lacrimal sac size was normal or large ondacryocystogram in all lacrimal drainage systems. ARitleng probe was introduced through the upper punc-tum and advanced past the obstruction. A guide wirewith a flexible tip was then introduced through the probe,over which the stent was advanced in retrograde fashionand placed into the lacrimal sac and nasolacrimal duct.Clinical success was defined by the demonstration of acompletely patent lacrimal drainage pathway throughsaline irrigation and no or minimal complaint of epiphora.● RESULTS: Stent placement was technically successfulin 26 of 28 lacrimal drainage systems (93%). The meantime of fluoroscopy screening was 3.2 minutes (range,1.4 to 5.8 minutes). The overall success rate was 82%(23 of 28 lacrimal drainage systems). Two stents werecompletely occluded. In one lacrimal drainage systemwith minimal epiphora, the stented drainage pathway waspartially occluded. The patients were followed up from 4to 22 months (mean, 7.2 months).● CONCLUSIONS: Retrograde placement of a hollowpolyurethane nasolacrimal duct stent is a technique thatis simple and well tolerated by patients. This methodachieves a high success rate and may be suggested as anonsurgical procedure for adults with primary nasolacri-mal duct obstruction and proper lacrimal sac size. TheRitleng probe facilitates the procedure. (Am J Oph-

thalmol 2001;131:37–43. © 2001 by Elsevier ScienceInc. All rights reserved.)

O BSTRUCTIVE EPIPHORA IS GENERALLY SECONDARY

to idiopathic inflammation of the nasolacrimal ductin adults. External dacryocystorhinostomy, a proce-

dure that fistulizes the lacrimal sac to the nasal cavity andchanges the natural pathway of tear drainage, is the mostfrequent treatment method for these cases. A more than 90%success rate with external dacryocystorhinostomy in experi-enced hands makes this procedure the gold standard againstwhich all the other methods should be compared.1,2 How-ever, external dacryocystorhinostomy is an invasive surgicalprocedure requiring skin incision and osteotomy. By place-ment of a nasolacrimal duct stent, it may be possible to avoiddacryocystorhinostomy. Recently, Song and associates3 de-signed a polyurethane stent set and described the retrogradeplacement of the stent with fluoroscopic guidance. The stentis 35 mm long and quite flexible (Figure 1). The proximal endof the stent, lying within the lacrimal sac, has a mushroom tip(5 mm in diameter and 5 mm in length) that can becompressed during delivery and be expanded spontaneouslywhen deployed. The body portion of the stent, lying withinthe nasolacrimal duct, is a hollow tube having an outerdiameter of 2 mm and an inner diameter of 1.5 mm.

In this study, we used the Ritleng probe to cross the siteof obstruction and introduce the guide wire through it, andinserted 28 nasolacrimal duct stents in 25 patients.

METHODS

BETWEEN JANUARY 1997 AND MAY 1999, 28 POLYURETHANE

nasolacrimal duct stents (Song Naso-Lacrimal Duct StentSet; Cook, Queensland, Australia) were placed in 25patients with epiphora caused by primary acquired naso-lacrimal duct obstruction. There were 21 women and fourmen, ranging in age from 20 to 74 years (mean, 44 years).

Obstruction of the lacrimal drainage system was deter-mined by delayed fluorescein dye disappearance and salineirrigation showing conspicuous reflux through the oppos-ing punctum. Each patient underwent digital subtractionmacrodacryocystography to determine whether the ob-

Accepted for publication Jul 18, 2000.From the Departments of Ophthalmology (Dr Bulent Yazici) and

Radiology (Drs Zeynep Yazici and Mufit Parlak), Uludag UniversitySchool of Medicine, Bursa, Turkey.

Requests for reprints to Bulent Yazici, MD, Uludag University Schoolof Medicine, Department of Ophthalmology, Gorukle Bursa 16059Turkey; fax: (90) 224 442 8070; [email protected]

© 2001 BY ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED.0002-9394/01/$20.00 37PII S0002-9394(00)00702-9

struction was complete or partial. Any patient with evi-dence of a lacrimal sac neoplasm or dacryolith, ortraumatic obstruction was excluded from the study. Thelacrimal drainage systems with small lacrimal sacs ondacryocystograms, which might not allow the mushroomtip of the stent to expand completely, were not included inthe study. The stent placement was performed in patientswith acute dacryocystitis after resolution of the acuteinflammation. Informed consent was obtained from eachpatient.

According to the dacryocystographic findings, the ob-struction was at the junction between the lacrimal sac andnasolacrimal duct in 17 lacrimal drainage systems and inthe nasolacrimal duct in 11. Twenty obstructions werecomplete, and eight were partial.

All patients complained of severe epiphora. Eight pa-tients had a history of acute dacryocystitis. Two patientshad undergone balloon dacryocystoplasty with only tem-porary improvement. The average interval between theonset of epiphora and stent placement was 7.1 years, witha range of 4 months to 20 years.

Proparacaine hydrochloride 0.5% was instilled in theinferior conjunctival cul-de-sac. The nasal passage was

decongested with xylometazoline 0.05% nasal spray. In-fratrochlear and infraorbital nerve blocks were obtainedwith a mixture of lidocaine 2% and epinephrine (1:100,000). Then, a cotton pledget, soaked with the samemixture, was placed under the inferior turbinate. Oralsedation with 5 mg of diazepam was used in 19 patients.After the nasal pack was removed, the upper two-thirds ofthe face was cleansed with 5% povidone-iodine solutionand draped.

The upper punctum was dilated with a punctal dilator.In three patients, we enlarged the punctum with a one-snip procedure. The lacrimal sac was filled with a smallamount of contrast media to ensure proper positioning ofthe probe. The Ritleng probe (S1-1460; FCI Ophthalmics,Issy-Les Moulineaux Cedex, France), a hollow tube mea-suring 1 mm in diameter and 105 mm long with a slit, wasused to pass the obstruction. We gave an anterior curve tothe tip of the probe to adjust it to the angle between thesuperomedial orbital rim and the nasolacrimal duct. Theprobe was inserted through the upper punctum into thecanaliculus and advanced gently across the obstructioninto the inferior meatus of the nasal cavity with fluoro-scopic guidance (Figure 2, top left). We shaped the flexibletip of an 0.018-inch guide wire (Ultra-select nitinol guidewire; Microvena Corporation, White Bear Lake, Minne-sota) into a slight curve and introduced it through theprobe into the nasal cavity (Figure 2, top right). The tip ofthe guide wire was manipulated out of the nose or pulledout with a hook when necessary. After the Ritleng probewas withdrawn superiorly from the canaliculus, the rest ofthe procedure was performed in a manner identical to thatpreviously described by Song and associates.3 The 6.3-Fsheath with a dilator from the Song set was introducedover the guide wire and advanced in a retrograde wayacross the obstruction until the proximal tip of the dilatorwas in the lacrimal sac. After the dilator was withdrawnfrom the sheath, a stent was introduced over the guide wireinto the sheath with the aid of a stent loader and advancedby means of a pusher catheter until the radiopaque tip ofthe stent was located at the sheath tip (Figure 2, bottomleft). The pusher catheter was held in place while thesheath was withdrawn. This action freed the stent, allow-ing the mushroom tip to expand and to lie within thelacrimal sac. After the stent was released from the sheath,the sheath containing the pusher catheter was pulled outthrough the inferior nasal meatus and the guide wirethrough the upper punctum. For proper placement of themushroom tip of the stent in the sac, the expansion of themushroom tip was confirmed fluoroscopically (Figure 2,bottom right). After the stent was placed, the drainagepathway was irrigated with saline through the uppercanaliculus. Topical antibiotic and steroid eye drops wereadministered postoperatively for 1 week.

On the following day, saline irrigation was performed todislodge any possible clot. Clinical examinations wereperformed at 1 week, 1 month, 3 months, and 6 months

FIGURE 1. Polyurethane nasolacrimal duct stent.

AMERICAN JOURNAL OF OPHTHALMOLOGY38 JANUARY 2001

FIGURE 2. Radiograms showing placement of the nasolacrimal duct stent. (Top left) Ritleng probe placed through the lacrimaldrainage pathway. (Top right) A guide wire with a flexible and curved tip, indicated by an arrow, is passed through the Ritleng probeand advanced out of the nose. (Bottom left) Nasolacrimal stent (arrow) is advanced over the guide wire in a retrograde manner.(Bottom right) Appearance of the stent after the placement.

NASOLACRIMAL DUCT OBSTRUCTION IN ADULTS WITH POLYURETHANE STENTVOL. 131, NO. 1 39

after stent placement and every 6 months thereafter. Thepatency of the lacrimal drainage system was evaluated byirrigation. To assess subjective improvement, we askedpatients to describe their level of epiphora and graded theircomplaints according to the following scale: grade 0 5 noepiphora, complete resolution of tearing; grade 1 5 mini-mal epiphora, great improvement after the stent place-ment, occasional tearing, but not troublesome to thepatient; grade 2 5 moderate epiphora, less frequent tearingafter the procedure, but still troublesome to the patient;grade 3 5 severe epiphora, no improvement. Procedurewas considered successful if the patient had grade 0 orgrade 1 epiphora and complete patency was confirmed byirrigation at the final visit.

RESULTS

STENT PLACEMENT WAS TECHNICALLY SUCCESSFUL IN 26

of 28 lacrimal drainage systems (93%). Total proceduretime ranged from 15 to 45 minutes (mean, 22 minutes).The average time of fluoroscopic monitoring was 3.2minutes (range, 1.4 to 5.8 minutes). All patients expressedmild pain during retrograde introduction of the dilator andsheath through the obstruction. In four patients, a hookwas needed to pull the guide wire out of the external naris.Most of the patients had slightly blood-stained nasaldischarge at the end of the procedure, which stoppedspontaneously.

In two complete obstructions at the junction betweenthe lacrimal sac and the nasolacrimal duct, the stent wasimproperly positioned partially outside the drainage path-way. The false passage was created medial to the usualtract; therefore, the mushroom tip of the stent was locatedin the lacrimal sac, but its body in the middle meatus of thenasal cavity. In one of them, we were able to remove thestent by sticking the dilator over the guide wire into thestent to pull it out of the nose. In the other patient, thestent was removed through the nose by using a hemostatunder nasal endoscopic guidance. Later on, externaldacryocystorhinostomy was performed in these two pa-tients uneventfully.

On the day after successful stent placement, the epi-phora stopped immediately in all patients and there was noresistance to lacrimal irrigation. At the time of the lastexamination, 19 of 26 lacrimal drainage systems had notearing, and five systems had grade 1 (minimal) epiphora.Saline irrigation demonstrated complete patency in 23 ofthese 24 lacrimal drainage systems (Figure 3). One lacrimaldrainage system with grade 1 epiphora had conspicuousreflux from the opposite punctum with some irrigation intothe nasopharynx at 7 months after the procedure. Thedacryocystogram revealed that the head of the stent wasplaced at the level of the internal puncta and a large fillingdefect was noticed in the mushroom of the stent (Figure4). In this patient, the height of the lacrimal sac was less

than normal, although the fundus of the lacrimal sacappeared large. In another patient with grade 1 epiphora,the distal tip of the stent touched the nasal floor, but noinflammatory reaction around the stent was noticed atnasal endoscopy performed 7 weeks after the procedure.The side holes of the stent gave access to the tears, andsaline irrigation was uneventful. Dacryocystography per-formed in another three lacrimal drainage systems withgrade 1 epiphora did not show any filling defect in thestented drainage pathway. Two stents became completelyoccluded 1 week and 5 months after the procedure. In thelatter one, stent occlusion followed an acute dacryocystitis.The overall success rate was 82% (23 of 28 lacrimaldrainage systems). The patients were followed up from 4 to22 months (mean, 7.2 months).

DISCUSSION

HOLLOW STENT PLACEMENT AT THE NASOLACRIMAL DUCT

in a retrograde fashion was suggested as an alternative todacryocystorhinostomy in the middle of this century.4,5 In1993, Song and associates6 described a technique of stentplacement in retrograde fashion with fluoroscopic guid-ance. Subsequently, Song and associates3 designed a naso-lacrimal polyurethane stent with an introducer set and ahook. They reported a success rate of 69% in 270 systemswith complete obstruction of the lacrimal sac or nasolac-rimal duct, with a follow-up period of more than 1 year.7The patency rate of stent placement in cases with obstruc-tion at the nasolacrimal duct was higher in this study(85%). Of two different studies using the same stent, oneincluded 40 cases with total or partial nasolacrimal ductobstruction and the other included 20 cases; the successrates were 98% and 85%, respectively.8,9 In the presentstudy, we accurately inserted polyurethane stents in 26 of28 lacrimal drainage systems (93%) with nasolacrimal ductobstruction by using a modified technique. The stentsremained patent in 23 of 26 lacrimal drainage systems(88%) with successful placement. Thus, the overall successrate was 82% (23 of 28 lacrimal drainage systems).

There are some differences in patient selection andtechniques between the study of Song and associates7 andours. Their study includes patients who had undergonedacryocystorhinostomy before the stent placement as wellas those with traumatic obstruction or with incompleteobstruction at the common canaliculus. In all of theirpatients, obstruction was complete. Although they do notspecifically provide information about the size of thelacrimal sac, the obstruction was at the level of thelacrimal sac on dacryocystogram in 52 of their 283 lacrimaldrainage systems. They usually used a ball-tipped guidewire to pass the obstruction. In none of our patients wasthere canalicular obstruction or traumatic cause. Theobstruction was partial in eight lacrimal drainage systems.In all systems, the lacrimal sacs appeared normal or dilated


on dacryocystogram. We used the Ritleng probe to pass theobstruction.

Initially, we tried to use the ball-tipped guide wiresupplied by the Song’s set, but we found that the Ritlengprobe is easier to manipulate while passing the obstruction.The guide wire was too flexible to overcome the obstruc-tion, particularly in cases with tight obstruction. In addi-tion, the Ritleng probe facilitated bringing the guide wireforward through the external nare. In most of our patients,we did not need to use a hook to pull the guide wire out ofthe nose. A disadvantage of the probe was that the guidewire could get wedged in the slit of the probe and so bedamaged. A further modification of the probe may lessenthis probability.

There may be several reasons for failure of the stentprocedure. Traumatic obstruction or a small fibrotic lacri-mal sac appears to be a significant factor in technicalfailure.7 In two lacrimal drainage systems, in which a falsepassage was created, the obstruction was very tight. Thesize of the sac should allow proper placement of the stentbelow the internal punctum and complete expansion of

the mushroom tip. When the head of the stent is locatedhigh in the sac, the stent may contact the internalpunctum, blocking tear drainage and causing commoncanalicular obstruction.10 In addition, the accumulation ofthe tear under the head of the stent may predispose thelacrimal sac to infection. The length of the stent is toolong in some patients, causing the distal tip of the stent tocontact the nasal floor, which can cause poor drainage oftears.

Song and associates11 removed 142 of 571 stents byusing nasal endoscope and hemostat because of recurrentepiphora and found that mucoid material in 35% andgranulation tissue in 65% caused obstruction of the stents.Granulomatous inflammation may be the result of a foreignbody reaction.12 Although polyurethane is thought of aschemically inert, the epithelium of the drainage pathwaymay be intolerant of this material.

The other recanalizing methods to avoid dacryocysto-rhinostomy in the treatment of obstructive epiphora inadults are probing, silicone intubation, and balloon dacryo-cystoplasty. Probing and silicone intubation are widely

FIGURE 3. (Left) Right dacryocystogram shows complete obstruction in the junction between the lacrimal sac and the nasolacrimalduct. (Right) Subtraction dacryocystogram obtained 6 months after the stent placement demonstrates good passage of contrastmedia.


used for the treatment of congenital dacryostenosis with ahigh success rate.13,14 The success rates of 52% and 50%reported in the literature for probing and silicone intuba-tion in adults, respectively, are low compared with thosefor placement of polyurethane nasolacrimal ductstents.15,16 In balloon dacryocystoplasty, the occludeddrainage system is recanalized by dilating a balloon at theobstruction site. There are several reports on balloondacryocystoplasty with significant differences in the successrates, ranging from 28% to 89% for retrograde techniqueand 60% for antegrade.17–20 Our results with retrogradeballoon dacryocystoplasty were not encouraging because ofthe high recurrence rates. Even in the partial obstructiongroup, in which balloon dacryocystoplasty appears morepromising, the success rate was only 50% with a meanfollow-up period of 14 months.21

External dacryocystorhinostomy yields consistent suc-cess rates of approximately 90%. However, dacryocystorhi-nostomy is a surgical procedure that requires skin incision,osteotomy, and occasionally general anesthesia. Althoughit is possible to avoid skin incision with endonasal dacryo-cystorhinostomy methods, the success rates achieved by

this approach are significantly less than the establishedexternal dacryocystorhinostomy rates.22,23 Furthermore,the endonasal approach requires using a nasal endoscopethat most ophthalmologists are not familiar with. Nonsur-gical placement of a nasolacrimal polyurethane stentrestores the natural tear drainage pathway. This procedureis simple and well tolerated by patients. Forceful irrigationwith saline can reopen the stent, if it is occluded duringfollow-up. In addition, the occluded stents can be retrievedwithout surgery, and some drainage systems may becomepatent after stent removal.11 Removal of the stent does notinterfere with subsequent dacryocystorhinostomy.

Although the current technique of stent placement issimple and shortens operation time, it requires expensivehigh-technology radiological equipment. The instrumentsused in external dacryocystorhinostomy are inexpensiveand readily available. In addition to the conventionalequipment, endonasal dacryocystorhinostomy requires anasal endoscope and sometimes laser equipment, depend-ing on the preferred surgical technique. In this study, thelacrimal passage remained open in 23 of 26 lacrimaldrainage systems (88%) with successful stent placement

FIGURE 4. (Left) On the preoperative dacryocystogram, the height of the lacrimal sac appears less than normal, although thefundus of the sac is large. (Right) Dacryocystogram obtained 7 months after the stent placement shows that contrast media passesto the nasal cavity, but there is a large filling defect (arrow) in the mushroom tip of the stent.


through a mean follow-up period of 7 months. Thedifference between early and late results of Song andassociates’ studies suggests that longer follow-up may dem-onstrate a higher failure rate.3,7

The radiation dose to the eye during the stent place-ment may be another concern. In the present study, themean fluoroscopy screening time was 3.2 minutes, whichwas significantly lower than those for cerebral angiographyor cerebral embolization, reported in the literature as 12.1and 34.1 minutes, respectively.24 The radiation dose to theeye even during the major interventional neuroradiologi-cal procedures is smaller than the minimum cataractogenicdose.25

In conclusion, our results are encouraging. We believethat hollow polyurethane stents can be suggested as a lessinvasive alternative to dacryocystorhinostomy in adultswith nasolacrimal duct obstruction. The size of the lacri-mal sac should be large enough for proper placement of thestent.

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Treatment of nasolacrimal duct obstruction in adults with polyurethane stent

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