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1 Department of Radiology, Uludag University, School of Medicine, Gorukle,
16059, Bursa, Turkey.
2 Department of Ophthalmology, Division of Ophthalmic Plastic and Reconstructive
Surgery, Uludag University, School of Medicine, Gorukle, 16059, Bursa,
Turkey.
Received October 10, 2001;
accepted after revision February 14, 2002.
Address correspondence to Z. Yazici.
Abstract
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SUBJECTS AND METHODS. Polyurethane stents were placed under fluoroscopic guidance in 52 eyes of 49 patients (mean age, 43 years) with severe epiphora due to idiopathic nasolacrimal duct obstruction. The obstruction was complete in 44 eyes and partial in eight. Clinical success was defined as complete resolution of or great improvement in the symptoms of epiphora and the patency of the lacrimal system to irrigation. Mean follow-up was 23 months (range, 14-44 months).
RESULTS. Stent placement was technically successful in 50 eyes (96%). The mean fluoroscopy screening time was 2.2 min (range, 0.2-5.8 min). Two patients were lost to follow-up. Clinical success was obtained in 33 (69%) of 48 eyes. Lacrimal symptoms developed in 23 (70%) of these 33 eyes at least once during the follow-up, but these patients responded well to topical drug treatment and lacrimal irrigation. External dacryocystorhinostomy was performed in 13 eyes after failure of the stents. At surgery, lacrimal sacs were shrunken, hyperemic, and fragile in all eyes, making it difficult to anastomose with nasal mucosa. Histologic examination showed granulation tissue and chronic inflammation of the sac epithelium.
CONCLUSION. The success rate of the nasolacrimal stent decreases as follow-up lengthens. After stent treatment, lacrimal symptoms frequently develop, even if the stent remains patent, and require multiple office visits and therapy. The polyurethane stent may induce a chronic inflammatory response in the lacrimal sac, which can interfere with subsequent dacryocystorhinostomy.
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In 1995, as an alternative to dacryocystorhinostomy, Song et al. [4] designed a polyurethane stent and in 1998 described its retrograde placement under fluoroscopic guidance. The early results of stent treatment were promising. In four studies with a follow-up of less than 1 year, the success rate of the procedure ranged from 85% to 98% [4,5,6,7]. However, the long-term results of a new treatment method are necessary before recommending it for general use. We evaluated the results of placement of 50 polyurethane stents after a mean follow-up of 23 months in adults with nasolacrimal duct obstruction.
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All patients had severe epiphora. Nasolacrimal duct obstruction was confirmed using the prolonged dye retention test and lacrimal irrigation. Digital subtraction macrodacryocystography was performed in all patients before the procedure. Patients with small lacrimal sacs were not included in the study. We also excluded any patient with evidence of canalicular obstruction, a lacrimal sac tumor or dacryolith, or traumatic obstruction. The procedure was performed in patients with acute dacryocystitis after resolution of acute inflammation.
On dacryocystography, the obstruction was at the junction between the lacrimal sac and the nasolacrimal duct in 41 eyes and in the nasolacrimal duct in 11 eyes. Forty-four obstructions were complete and eight were partial. Two eyes had undergone balloon dacryocystoplasty, with only transient improvement in epiphora. The average interval between the onset of epiphora and stent placement was 6 years (range, 2 months-20 years). The institutional review board approved the study protocol; informed consent was obtained from each patient.
All patients underwent stent placement on an outpatient basis under local anesthetic. The procedure was performed as described previously [7]. Briefly, the Ritleng probe (S1-1460; FCI Ophthalmics, Issy-Les Moulineaux Cedex, France) was used to pass the nasolacrimal duct obstruction. The probe was inserted through the upper punctum. A 0.018-inch guidewire with a flexible tip (Ultra-select nitinol guidewire; Microvena, White Bear Lake, MN) was advanced through the probe into the nasal cavity. The tip of the guidewire was manipulated out of the nose or pulled out with a hook when necessary. After the Ritleng probe was withdrawn, the sheath with a dilator from the Song set was introduced in retrograde fashion over the guidewire until the proximal tip of the sheath was in the lacrimal sac. After removing the dilator, we inserted the stent over the guidewire through the sheath, with particular attention given to placing the neck of the stent at the junction between the lacrimal sac and the nasolacrimal duct.
Follow-up examinations were scheduled for 1 week, 1 month, 3 months, and 6 months after stent placement and at 6-month intervals thereafter. At each visit, lacrimal irrigation was performed. To assess subjective improvement, we asked the patients to grade their complaints according to the following scale: grade 0, no epiphora and complete resolution of tearing; grade 1, minimal epiphora and great improvement after stent placement with occasional tearing but not troublesome to the patient; grade 2, moderate epiphora and less frequent tearing after the procedure but still troublesome to the patient; and grade 3, severe epiphora and no improvement [7]. The procedure was considered successful if the patient had grade 0 or grade 1 epiphora and complete patency of the lacrimal drainage system confirmed by irrigation at the final visit. Patients were followed up for 14-44 months (mean, 23 months).
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Two patients were lost to follow-up. Of the remaining 48 eyes with successful stent placement, 28 had grade 0 and five had grade 1 epiphora with a patent lacrimal drainage system on irrigation at the last clinical follow-up visit (Fig. 1A,1B). The success rate was 62.5% (5/8) in cases with partial obstruction and 70% (28/40) in those with complete obstruction. The overall clinical success rate was 69% (33/48).
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Twenty-three (70%) of the 33 eyes experienced tearing, mucous or mucopurulent discharge, conjunctival itching, pain in the medial canthal region, or combinations of these at least once and at most four times (mean, 1.7) during the follow-up period. Each time, the symptoms resolved after 1 week of treatment with antibiotics and corticosteroid eye drops and forceful lacrimal irrigation. In two eyes with epiphora, dacryocystography revealed that the stent migrated into the nasolacrimal duct. However, the complaint resolved after medical treatment in both eyes, and the patients were doing well at the last examination.
Stent treatment failed in 15 eyes. Thirteen stents became completely or partially occluded 4-6 months after the procedure and grade 2 or 3 epiphora developed (Fig. 2A,2B,2C,2D). Two stents were patent on irrigation, but the patients had severe epiphora.
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Thirteen eyes with failed stents underwent external dacryocystorhinostomy 4-39 months after stent placement, one of which was the eye with the patent lacrimal system at irrigation. At surgery, the lacrimal sac was shrunken and firmly attached to the stent with fibrous bands in all eyes. Tissue growths were covering and intruding into the mushroom heads of the stents (Fig. 2A,2B,2C,2D). Mucoid debris was also noticed in the stents. Because of the adhesions, the stents were removed with difficulty. The sac wall was thin, hyperemic, and fragile. Particular effort was made not to damage the sac wall during removal of the stent. Besides, fashioning flaps from the lacrimal sac was difficult. Dacryocystorhinostomy was combined with silicone intubation in 11 eyes to prevent closure of the mucosal anastomosis because of a possible excessive inflammatory response and scarring. Histologic examination of tissue samples obtained from the removed stents and of the lacrimal sac biopsy specimens showed chronic inflammation and granulation tissue. Dacryocystorhinostomy failed in one eye owing to anastomotic obstruction 1 month after surgery. The other patients were free of symptoms after dacryocystorhinostomy. One of the last two patients with a failed stent did not return for surgery, and one is still waiting for surgery.
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In the present study, the success rate was 69%. Nevertheless, our series did not include patients with traumatic obstruction or obstruction of the canaliculi or sac. In such cases, stent treatment is more likely to fail [7, 8]. All eyes required normal or large lacrimal sacs to achieve complete expansion of the mushroom tip of the stent in the sac. Despite this meticulous patient selection, the long-term success rate was low.
The main reason for stent failure seemed to be chronic inflammation of the lacrimal sac mucosa. All the eyes that underwent dacryocystorhinostomy had chronic inflammation and granulation tissue based on the pathologic results for the lacrimal sac biopsy specimens. In a study, 65% of 142 removed stents were occluded by granulation tissue [11].
Two eyes in our study had severe epiphora, although the lacrimal drainage system was open to irrigation. Some studies mentioned similar cases in which the cause was not clearly identified [8, 12, 13]. At dacryocystorhinostomy of such a case, we observed diffuse attachment of the lacrimal sac to the stent by fibrous bands.
The mechanism of tear drainage is not completely understood; presumably with blinking, the contraction of the musculus orbicularis oculi makes the lacrimal sac dilate and creates negative pressure, sucking the tear fluid into the sac [14, 15]. Because fibrous adhesions between the lacrimal sac mucosa and the head of the stent may block this pump system, tear drainage would be insufficient even when the lacrimal drainage system is patent on irrigation.
It is usually believed that failure of stent treatment does not interfere with subsequent dacryocystorhinostomy [7, 8, 10, 12]. Our experience does not agree with this assumption. The lacrimal sacs of all eyes in our series were normal or large before stent placement. However, the sac was shrunken in all 13 eyes that underwent external dacryocystorhinostomy because of stent failure. The sac wall was so thin, fragile, and adhesive to the head of the stent that the sac wall was injured during removal of the stent. Except in the first two eyes, external dacryocystorhinostomy was combined with silicone intubation to avoid anastomosal scarring and failure. In one of 13 eyes in which silicone intubation was not performed, the surgery failed. Song et al. (presented at the Radiological Society of North America meeting, Chicago, November 2000) reported that the configuration of the lacrimal sac worsened in 38% of the systems after stent removal. Failed stent treatment may adversely affect subsequent dacryocystorhinostomy. The unsuccessful stents can be removed through the nose shortly after placement [11]. However, trying to remove the stent in this way at a later date may result in serious damage to the lacrimal sac and the canaliculi.
One of the important disadvantages of the nasolacrimal stent is that it frequently causes lacrimal symptoms. Therefore, patients with stents require office visits and treatment more frequently, whereas after a successful dacryocystorhinostomy, the lacrimal symptoms resolve permanently [3]. The most frequent complication of external dacryocystorhinostomy is the anastomosal obstruction and failure, which occurs in fewer than 10% of patients, and other complications such as postoperative nasal hemorrhage and skin incision scarring, which occur in fewer than 4% of patients [2, 3]. Dacryocystorhinostomy requires limited follow-up [3].
In our series, 70% of the 33 eyes with successful stent treatment presented with lacrimal symptoms at least once during the follow-up. The symptoms resolved after treatment with antibiotics, corticosteroid eye drops, and lacrimal irrigation. We surmised that the symptoms were due to mucoid impaction or low-grade inflammation of the lacrimal sac [8, 12]. Song et al. [11] noticed mucoid impaction in 35% of occluded stents that they removed. Goblet cells in the epithelium of the lacrimal sac and nasolacrimal duct synthesize mucins. The stent probably incites secretion of the mucins. The mucoid impaction that blocks tear drainage may predispose the lacrimal sac to infection. Lee et al. [10] periodically irrigated the stented lacrimal systems with a saline solution containing antibiotics and a mucolytic solution through the lacrimal puncta to prevent obstruction of the stent with mucus or inflammatory discharge. They reported a high success rate (93%) after a mean follow-up of 22 months.
Techniques such as probing, silicone intubation, and balloon dacryocystoplasty have been used to recanalize the occluded nasolacrimal duct. The success rate of these methods at long-term follow-up was approximately 50% or less [16,17,18,19]. In both probing and balloon dacryocystoplasty, the technique is simply to recanalize the occluded mucosal lumen. In silicone intubation to prevent reocclusion of the lumen, the solid silicone tube is left in the system for a few months. The main problem with these three methods is reobstruction of the nasolacrimal duct with time. In our patients, the use of the Song stent seemed to solve this problem, but it may prompt an inflammatory reaction in the surrounding tissue that results in obstruction.
Although the nasolacrimal polyurethane stent has the advantage of being an interventional radiologic procedure versus invasive surgery, we think that it should not be used as a primary treatment method for nasolacrimal duct obstruction. The success rate of the polyurethane stent is low compared with that of external dacryocystorhinostomy. Furthermore, lacrimal symptoms frequently develop even in the presence of a patent lacrimal system. The polyurethane stent may also lead to changes in the tissue of the lacrimal sac that may interfere with subsequent dacryocystorhinostomy. We believe that modification of the stent material and design may result in an improvement in the success rate of the retrograde stent placement method.
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