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Balloon-Assisted Dacryoplasty in Adults
John Pak and Mark T. Duffy
In recent years, there has been an emerging interest in the development and application of alternative therapeutic approaches for the treatment of complete and incomplete nasolacrimal duct (NLD) obstructions (NLDOs). For complete NLDOs, it is generally accepted that an inci- sional dacryocystorhinostomy (DCR), because of its high rate of success (more than 90%), is the treatment of choice.1 Despite such effi cacy, controversies around anesthetic choices and rare, cosmetically signifi - cant scarring have aroused interest in alternative treatment modalities.
Increasing attention has recently focused on balloon dacryocystoplasty, a technique based on dilation of a completely or incompletely stenotic aperture along the NLD using a balloon catheter device similar to those used in vascular dilation.
Balloon dacryocystoplasty initially emerged as a fl uoroscopic- assisted retrograde technique aimed at dilating the stenotic NLD.
This involved the use of a guide wire that cannulated the NLD and, subsequently, placed a balloon catheter through the area of stenosis.
Over the past decade, the technique has undergone signifi cant inno- vations. Most notable is the transition from a retrograde to antero- grade approach using specially designed lacrimal system balloon catheters. Balloon dacryoplasty has also been used in association with temporary silicone tube stenting of the NLD to increase the success rate.2 Lastly, a recent report also describes signifi cant effi cacy in combination with endoscopy.3 Despite these advances, varying degrees of success have been reported using this technique for com- plete or incomplete NLDO. In this chapter, the authors examine the effi cacy of balloon dacryocystoplasty for complete and incomplete NLDOs.
Procedure
Balloon dacryocystoplasty is performed by the authors using a tech- nique previously published by others.2 Oxymetazoline 0.05% nasal spray is insuffl ated or sprayed into the chosen nasal cavity and the
corresponding inferior turbinate region is packed with gauze soaked in 0.05% oxymetazoline or 4% cocaine. Topical tetracaine or propara- caine is instilled on the conjunctival surface. An injection of 2% lido- caine with 1 : 100,000 units of epinephrine is given in the infratrochlear region for a regional nerve block. This will anesthetize the lateral nasal wall, part of the nasal septum, and regionally around the medial canthus. Additional anesthetic can be injected locally in the medial upper and lower lids, and for supraorbital and infraorbital nerve blocks.
The nasal packing is removed. The puncta are dilated. The surgeon probes the upper and lower canaliculi and NLD using Bowman probes in the standard manner. After withdrawal of the probe, intubation of the canaliculus and passage through the NLD is undertaken using a defl ated 3-mm LacriCATHTM balloon catheter (Quest Medical, Inc., Allen, TX) from which the protective plastic sleeve has been removed (Figure 17.1). Either the superior or inferior punctum can be used. In general, the upper passage is recommended for several reasons3: it provides a more direct route into the NLD, and in the event a false passage is created, the more important inferior canaliculus will remain intact. The defl ated catheter is placed within the NLD until the 15-mm marking is adjacent to the punctum. The tip of the catheter can be identifi ed under the inferior turbinate by touching it with a probe or, if endoscopy is performed, the distal balloon can be directly visualized (Figure 17.2A–C).
FIGURE 17.1. Balloon catheter 15 × 3 mm. (Image courtesy of Michael Mercandetti, MD.)
15mm¥ 3mm
FIGURE 17.2. (A) Endoscopic view of lacrimal probe exiting inferior opening of lacrimal duct (valve of Hasner) lateral to infe- rior turbinate, which is displaced medially to the right. (B) Entry of balloon catheter into inferior meatus (same patient as A). (C) Infracture (medial displacement) of inferior turbinate in another patient with visualization of lac- rimal probe. (Image courtesy of Michael Mercandetti, MD.)
A
B
C
FIGURE 17.3. Infl ation device. (Image courtesy of Michael Mercandetti, MD.)
After the catheter is properly positioned, a standard balloon infl ation device (Figure 17.3) is attached to the catheter. The balloon is infl ated to 8 atmospheres of pressure for 90 seconds (Figure 17.4A and B) and defl ated. The catheter is reinfl ated in the same manner for 90 seconds (Figure 17.5) and defl ated. The catheter is reinfl ated a third time to 8 atmospheres for 60 seconds and defl ated. Afterward, the balloon is pulled from the punctal side in order to align the 10-mm marking with the punctum (Figure 17.6). The sequence of infl ation and defl ation as described above is undertaken. This sequence of positions assures that the valve of Hasner, distal NLD, and proximal NLD are actually dilated by the balloon.
The catheter is removed and irrigation is performed with balanced salt solution. Subsequently, a Monoka silicone lacrimal tube is placed in the standard manner and removed 6–8 weeks postoperatively.
Crawford or Guibor tubes can also be placed. However, these are bicanalicular and need to be secured by suture to the lateral nasal wall.
This necessitates signifi cant manipulation for removal and usually means repeat general anesthesia in children.
Balloon canaliculoplasty can be performed with a 2-mm balloon after lysis of strictures or scar tissue with a needle or lacrimal probe.
Infl ation parameters are the same as for NLDO. Bicanalicular intuba- tion is preferred (e.g., Crawford, Guibor) because it allows passage of steroid drops and tears containing growth factors into the canaliculus and NLD, which may maintain patency of the system.
Postoperatively, topical prednisolone acetate 1%, one drop four times a day for 2 weeks, is placed on the conjunctival surface. This can be repeated again at the time of lacrimal stent extubation.
Finally, failed or insuffi ciently patent ostia after DCR can be dilated with either a 5-mm anterograde balloon or endonasally with a right- angle 9-mm LacriCATHTM balloon. This is also followed with bicana- licular intubation and steroid drops.
FIGURE 17.4. (A) Infl ation of balloon catheter. (B) Further infl ation of balloon catheter. (Image courtesy of Michael Mercandetti, MD.)
A
B
Discussion
Balloon Dacryocystoplasty and Complete Nasolacrimal Duct Obstruction
The standard treatment of complete NLDO has been incisional DCR, a procedure that has demonstrated a high success rate (more than 90%).
FIGURE 17.5. Balloon catheter defl ated. (Image courtesy of Michael Mercan- detti, MD.)
FIGURE 17.6. Balloon catheter further defl ated, twisted, and withdrawn.
(Image courtesy of Michael Mercandetti, MD.)
Despite the high rate of success, alternative therapies have been sought to obviate the need for general anesthesia and the creation of an exter- nal facial scar. Several reports have examined the effi cacy of balloon catheter dacryoplasty for cases of complete NLDO.4,5 Song et al.5 reported on the effi cacy of a retrograde, fl uoroscopically guided balloon dacryocystoplasty without subsequent placement of silicone tubing in patients with complete NLDO. In the study, complete NLDO was defi ned by the absence of contrast medium into the inferior meatus by dacryocystography and by negative Jones I and II tests. The results of the study were disappointing with an initial failure rate of 44%. Addi- tionally, of those NLDs that were initially patent, 45% became obstructed at the 2-month postoperative date.
These fi ndings were supported by other studies that demonstrated similar failure rates. Janssen et al.,4 also using a retrograde approach without silicone intubation, found a failure rate of 41% (11 of 27 patients).
The relatively poor rate of NLD patency in these two studies may be attributed to several key features such as the lack of silicone intubation, a retrograde approach, or use of balloon catheters not specifi cally designed for NLD catheterization.
In contrast to these disappointing results, some reports have dem- onstrated moderate success using anterograde balloon dacryocysto- plasty with silicone intubation for the treatment of complete NLDO.
Using anterograde balloon dacryoplasty with placement of silicone tubes on patients with complete NLDO, defi ned by canalicular irriga- tion and transcanalicular endoscopy, Kuchar and Steinkogler6 found 53.5% (15 of 28 patients) had open NLD, 35.7% (10 of 28 patients) had partially open NLD, and 10.7% (3 of 28 patients) had closed NLD, based on saline irrigation, after 1 year. The difference in patency rates may refl ect the changes in technique. Although these fi ndings were favor- able, the long-term effects of balloon dacryocystoplasty for the treat- ment of complete NLDO are unknown.
Balloon Dacryocystoplasty and Incomplete Nasolacrimal Duct Obstruction
The treatment modality most appropriate for the treatment of incom- plete NLDO has been a matter of considerable debate. Several studies have examined the effi cacy of balloon dacryocystoplasty under these clinical circumstances. In an initial study, 11 of 15 patients (73%) dem- onstrated patent NLDs (based on unimpeded NLD irrigation) after treatment with balloon dacryocystoplasty and silicone intubation.2 Similar fi ndings were observed when examining the medium to long- term outcomes (mean follow-up, 36 months) of balloon dacryocysto- plasty in incomplete NLDO.
Technical innovations to the procedure have been used in an attempt to augment the success rate of the procedure. One such change has been the use of video-assisted endoscopy. The use of video-assisted endoscopy may be an attractive ancillary component to balloon dac- ryocystoplasty because it can determine whether the balloon catheter cannulated the valve of Hasner. This is important because one source
of failure may be attributed to the inadvertent placement of the balloon catheter in the submucosal space of the nasal cavity. Furthermore, visualizing the nasal cavity and inferior meatus region could help identify abnormal structures or objects that may occlude the outlet of the inferior meatus. Identifying any structural abnormality would aid in the treatment by allowing the use of an appropriate surgical approach. In a recent study, after a follow-up period of approximately 7.5 months, 56% of patients demonstrated complete resolution of their symptoms and 34% of patients demonstrated partial improvement of symptoms.6 Based on these fi ndings, video-assisted endoscopy seems to be an important ancillary procedure for balloon dacryocystoplasty in adults as well as children with failed probing or previous failed balloon dilation.
Indications
Balloon dacryocystoplasty provides another approach in the treatment of complete and incomplete NLDO. Because of its less rigorous techni- cal requirements compared with DCR, its ability to be done without general anesthesia, and the avoidance of external facial incisions, this technique may be an appropriate fi rst-line treatment modality in certain selected cases.
Currently, there are no long-term studies evaluating the success rate of balloon dacryocystoplasty for cases of complete and incomplete NLDO. However, we support the use of this technique for those individuals demonstrating incomplete NLDO based on epiphora symptoms and imaging studies (e.g., computed tomography-dacryocys- tography). We continue to advocate surgical DCR as the treatment of choice for complete NLDO, but balloon dacryocystoplasty can be per- formed on patients who are unable to tolerate general anesthesia or used as a temporizing measure before performing a DCR.
References
1. Yeats RP. Acquired nasolacrimal duct obstruction. Ophthalmol Clin North Am 2000;13(4):719–729.
2. Perry JD, Maus M, Nowinski TS, Penne RB. Balloon catheter dilation for treatment of adults with partial nasolacrimal duct obstruction: a preliminary report. Am J Ophthalmol 1998;126:811–816.
3. Couch SM, White WL. Endoscopically assisted balloon dacryoplasty treat- ment of incomplete nasolacrimal duct obstruction. Ophthalmology 2004;
111(3):585–589.
4. Janssen AG, Mansour K, Bos JJ. Obstructed nasolacrimal duct system in epiphora: long-term results of dacryoplasty by means of balloon dilation.
Radiology 1997;205:791–796.
5. Song HY, Ahn HS, Park CK, Kwon SH, Kim CS, Choi KC. Complete obstruc- tion of the nasolacrimal system. Part I. Treatment with balloon dilation.
Radiology 1993;186:367–371.
6. Kuchar A, Steinkogler FJ. Antegrade balloon dilatation of nasolacrimal duct obstruction in adults. Br J Ophthalmol 2001;85:200–204.
