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The Official Scientific Journal of Delhi Ophthalmological Society
Evaluation of Functional Outcome of Silicone Intubation on Patency of Lacrimal System in Canalicular Obstruction and Revision Surgeries
Rashmi Joshi, Sarita Maharia, Anju Kochar 
Department of Ophthalmology, Sardar Patel Medical College, Bikaner, India

Corresponding Author:
Rashmi Joshi MS
Assistant Professor 
Department of Ophthalmology, 
Sardar Patel Medical College, Bikaner, India
Email id: drashishrashmi@yahoo.co.in
Received: 27-JUL-2017 Accepted: 26-NOV-2017 Published Online: 01-MAR-2018
DOI: http://dx.doi.org/10.7869/djo.329
Abstract
Purpose:- The purpose of the present study is to report authors’ experience of functional outcome of Silicone intubation on patency of lacrimal system in canalicular obstruction and revision surgeries. 

Materials and Methods:- This study was conducted at Sardar Patel Medical College from January 2015 to March 2017. A total of 32 cases were enrolled in this study. Twelve patients of canalicular block and 20 patients of various failed DCR techniques were recruited for the study. Two patients had failed DCR twice, and 18 patients had failed DCR once. Twelve of these previous failed DCR were endoscopic DCR, and 6 were external dacryocystorhinostomy (E-DCR). All cases were operated by a single surgeon using the same technique of intubation. 

Results:- In our study we found that Silicone intubation is an effective method for treating canalicular block and failed DCR. Silicone tube is soft, relatively inert, and flexible, causing minimal injury to the delicate canaliculi and nasal mucosa. It maintained duct patency by maintaining an opening. The main outcome measures were the resolution of epiphora and the anatomical and functional successes by patency on follow up. 

Conclusion:- The success rates reported for silicone intubation range from 69% to 100% in various studies. The 94.5% success rate noted in the present study is entirely comparable to these previously reported results, with minimal complication. 
Keywords : Silicone Intubation, endoscopic DCR, external dacryocystorhinostomy (DCR), epiphora

Introduction
Epiphora is the main presenting symptom of chronic dacryocystitis and is a common ophthalmic problem.1 External Dacryocystorhinostomy or DCR is among the common oculoplastics surgeries performed for managing epiphora due to nasolacrimal duct obstruction. Despite meticulous surgery, failures are often met with. Epiphora after Dacryocystorhinostomy (DCR) is a distressing situation for both patient and the surgeon. Failure rate for external DCR has been reported to be 5%–10%4-6 or less and 35%–40%7-9 for endonasal DCR. 

The most common causes of DCR failure are common canalicular obstruction and obstruction at the rhinostomy site due to reduction in osteotomy size2, granulation tissue formation3, fibrosis in anastomosis and defective identification and anastomosis. Silicone intubation has been shown to be successful in the management of failed DCR and canalicular block. Silicone intubation is a simple procedure; the effectiveness of this procedure was assessed. A basic surgical principle is to reach the most successful results with the least possible complication. In the modern surgical era, achieving successful results in a cost effective fashion is also important. The aim of this study to evaluate the success rate of silicone intubation in canalicular block as primary surgery and in failed DCR as revised surgery. 

Material and Methods
This study was conducted at Sardar Patel Medical College from January 2015 to March 2017. A total of 32 cases were enrolled in this study. These included 12 patients of canalicular block, that were operated for the first time and 20 patients of various failed DCR techniques. Two patients had failed DCR twice, and 18 patients had failed DCR once. 12 of these previous failed DCR were endoscopic DCR, and 6 were external dacryocystorhinostomy (DCR). 

The inclusion criteria for the procedures were patients having epiphora after previous surgery and common canalicular block. Exclusion criteria was patients having absent puncta, suspicion of malignancy, radiation therapy, posttraumatic lids and bony deformity, nasolacrimal duct block (not operated previously).

Age and sex of the patient, history of presenting complaints, history of any acute attack of dacryocystitis, history of previous surgical procedures like dacryocystectomy (DCT), DCR or lacrimal abscess drainage were noted. Patients with acute or chronic dacryocystitis (CDC) were treated with systemic antibiotics for one week. All the patients recruited for the study were thoroughly evaluated. Complete ophthalmic examination was performed including visual acuity; corneal opacities or ulceration and other ocular co-morbidities were looked for.  The diagnosis was made on history of epiphora, history of previous surgery, regurgitation test, lids examination, nasal examination, probing and syringing. Simple regurgitation, syringing and probing provided proof of level of blockade in the lacrimal system. All patients were also systemically evaluated for diabetes mellitus and hypertension. Patients were investigated to rule out any bleeding/clotting disorders. A written informed consent was taken from all the patients. All patients were operated by the same surgeon under local anaesthesia. In all patients, silicone tube intubation was performed. Patients were put on antibiotic eye drops, nasal decongestant drops and systemic anti-inflammatory drugs post operatively. Patients were followed up next day after surgery, at 2 weeks and at the end of 3 months. Syringing was done on the next day and also during follow up visits. Tightness and mobility of the silicone tube was checked. Suture removal was done at the end of 2 weeks and silicone tube removal was done at 3 months and the lacrimal passage was irrigated. The tube was removed by cutting it between the puncta and by either blowing the nose or by extracting the tube from the nose with forceps in anterior rhinoscopy. The procedure was considered as successful when there was resolution of tearing and discharge, and also by lacrimal patency to irrigation. Any tube related complications like slitting of the punctum or canaliculus or granuloma formation were also looked for during follow up visits. 

Results
We evaluated the efficacy of intubation technique and the success rate in 32 patients undergoing intubation DCR (Jan 2015 to March 2017). All the patients were successfully intubated. The mean age was 43.31 ± 8.43 years (range 21–60) (Table 1 and Graph-1). There were 18 females (56.25%) and 14 (43.75%) males. Our success rate of initial silicone intubation in relieving signs and symptoms of dacrocystitis in patients with canalicular block among patients undergoing primary surgery was 83% and for patients with failed DCR was 93%. The patency of silicone tube intubation for patients with canalicular block was 100% among patients undergoing primary surgery, for patients with failed DCR, was 100% among patients with failed primary external DCR, and was 91.6% for patients with failed primary endoscopic DCR. (Table 2 and Graph 2 - follow up patency) Among 12 failed endoscopic DCR patients undergoing intubation-DCR we detected excessive granulation tissue in one patient after the surgery. (Table 3 and Graph 3-post operative complication)








There were no intraoperative or postoperative complications. in this study. No ophthalmic injuries occurred from planned or unplanned tube removal in the outpatient office. Also, complications associated with the silicone stent such as punctal erosion or corneal erosion, were absent.

Discussion
Silicone intubation is an effective method in treating canalicular block and failed DCR. Silicone tube is soft, relatively inert, and flexible. It causes minimal injury to the delicate canaliculi and nasal mucosa. It maintained duct patency by maintaining an opening. The success rates reported for silicone intubation range from 69% to 100% in various studies.13-16 The 94.5% success rate noted in the present study is entirely comparable to these previously reported results. (Table 4-comparison of success rate)

Conclusion
Silicone intubation can be useful to improve the outcome in repeat surgeries. The present study shows significantly better results with silicone tube intubation. The mechanism of higher success rate may be related to a constant flow of fluid around the tube induced by capillary action. A solid tube marginally lesser in diameter than the tube within which it is put induces this action.

References
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Rashmi Joshi, Sarita Maharia, Anju KocharEvaluation of Functional Outcome of Silicone Intubation on Patency of Lacrimal System in Canalicular Obstruction and Revision Surgeries.DJO 2018;28:26-28
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Rashmi Joshi, Sarita Maharia, Anju KocharEvaluation of Functional Outcome of Silicone Intubation on Patency of Lacrimal System in Canalicular Obstruction and Revision Surgeries.DJO [serial online] 2018[cited 2018 Nov 17];28:26-28. Available from: http://www.djo.org.in/articles/28/3/EvaluationofFunctionalOutcomeofSiliconeIntubationonPatencyofLacrimalSysteminCanalicularObstructionandRevisionSurgeries.html
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