June 2009

 

OPHTHALMOLOGY NEWS

 

Lacrimal sac drainage


by Rich Daly EyeWorld Contributing Editor

 

 

Research on lacrimal sac abscess drainage found it is well tolerated with little risk of fistula formation or ectropion development

Lacrimal sac drainage can be confidently approached without fear of complications of patient pain, according to recent research on a specific surgical technique.

Although dacryocystitis, or inflammation of the lacrimal sac, is almost always secondary to nasolacrimal duct obstruction and up to 10% of adults aged 40 years or older have obstruction of the lacrimal drainage system, surgeons sometimes hesitate to directly address it. Concerns over inducing a fistula, orbital cellulites, or cicatricial ectropion, as well as patient pain stemming from ineffective local anesthesia, have led some surgeons to try indirect approaches—such as systemic antibiotics—over simply draining a pointing abscess.

A studied technique of anesthesia and lacrimal sac incision and drainage offers surgeons a safe and comfortable direct option, which promotes a rapid resolution of infection without complications.

A retrospective record review published in the September 2008 issue of the Archives of Ophthalmology of all patients with acute dacryocystitis, as well as lacrimal sac abscesses, treated surgically between 1994 and 2005 at the Massachusetts Eye and Ear Infirmary, Boston, identified some key steps to surgical success.

Two steps key

Successful drainage patients had both effective anesthesia and surgery. Drainage patients first received a topical instillation of proparacaine hydrochloride 0.5% in each eye, as well as an infraorbital nerve block by palpating the nerve’s foramen 1 cm below the junction of the medial 1/3 and lateral 2/3 of the inferior orbital rim. Approximately 1.5 mL of lidocaine 2% with epinephrine was injected with a 30-gauge, 0.5-inch needle just over the foramen without penetrating it.

In addition, a transconjunctival anterior ethmoidal nerve block was performed with a 25-gauge, 1.5-inch needle inserted at the lateral aspect of the caruncle. The needle was angled 10 degrees toward the medial orbital wall and redirected posteriorly every time bone was met until it was 24 mm from the anterior lacrimal crest. Surgeons injected 1.5 mL at this site.

Aspiration of the syringe was performed at every site to confirm that the needle was not positioned intravascularly.

The surgical approach began with a transcutaneous stab incision made over the apex of the pointing abscess, typically just inferior to the medial canthal ligament and directed toward the nasal ala.

“Great care was taken to drain the abscess’s two components, present in most patients: its submuscular pocket and the distended lacrimal sac,” wrote Patrick Roland Boulos, M.D., and Peter A.D. Rubin, M.D.

The surgeons used a fine-tipped hemostat or a chalazion curette to lyse loculations in the submuscular pocket of the abscess and completely drained them. This was followed by use of the curette to penetrate through the anterior face of the lacrimal sac to the second collection. Lacrimal sac suction followed.

Surgeons visualized the mucosa to confirm penetration of the lacrimal sac. Surgeons cultured extruding pus and smeared microscope slides for Gram staining.

The contiguous cavities were “copiously irrigated” with saline and packed with iodoform gauze before surgeons allowed the site to heal by secondary intention. Wounds usually received at least 10 cm of gauze with one centimeter of its distal end left out as a wick and covered with a steristrip to prevent accidental extrusion. The surgeons did not find a need to perform antibiotic irrigation.

Good comfort and clinical outcomes

The researchers examined 52 cases of lacrimal sac abscesses secondary to acute dacryocystitis that were treated with this technique and found that only eight needed to be done under general anesthesia and four required a repeated drainage. Edema completely resolved by a median of seven days. Fistulas and ectropion were not found.

“The bottom line with this study is drainage of a lacrimal sac abscess is well tolerated and can be performed with minimal risk of fistula formation or ectropion development,” said Bobby S. Korn, M.D., Ph.D., assistant professor of ophthalmology, Division of Oculofacial Plastic and Reconstructive Surgery, Department of Ophthalmology, Shiley Eye Center, University of California, San Diego.

The lack of any cases of cutaneolacrimal iatrogenic fistulas in the series surprised Dr. Korn because the technique included packing the puncture site with iodoform gauze. That outcome was likely related to timing of DCR surgery after abscess drainage, but the authors did not provide such timing details.

Dr. Korn was also somewhat surprised that the anterior ethmoidal block was easily tolerated in the setting of an acutely inflamed lacrimal sac and surrounding tissues. However, Dr. Korn agreed that both blocks “make good anatomic sense.”

“I have no doubt that there is rapid resolution of discomfort from the pressure caused by a distended and inflamed lacrimal sac,” Dr. Korn said.

The research authors’ findings also showed that after an acute lacrimal sac abscess is drained, patients usually require a definitive treatment such as a dacryocystorhinostomy or a dacryocystectomy.

Dr. Korn agreed that the only way to prevent recurrences is to perform definitive dacryocystorhinostomy.

“Otherwise, with continued nasolacrimal duct obstruction and impaired lacrimal outflow, a recurrence is highly likely,” he said.

Editors’ note: Dr. Korn has no financial interests related to his comments.

Contact information

Korn: 858-534-7402, bkorn@ucsd.edu

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