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 Table of Contents    
ORIGINAL ARTICLE
Year : 2021  |  Volume : 14  |  Issue : 3  |  Page : 157-161  

Iatrogenic nasolacrimal duct obstruction after adnexal intervention: An avoidable consequence


1 Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Sankara Nethralaya, Medical Research Foundation, Chennai, Tamil Nadu, India
2 Ophthalmic Plastic Surgery and Ocular Oncology Services, Advanced Eye Hospital and Institute; Aditya Jyot Eye Hospital, Mumbai, Maharashtra, India
3 Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Aditya Birla Sankara Nethralaya, Kolkata, West Bengal; A Unit of Medical Research Foundation, Chennai, Tamil Nadu, India

Date of Submission12-Dec-2020
Date of Decision13-Jun-2021
Date of Acceptance01-Jul-2021
Date of Web Publication20-Oct-2021

Correspondence Address:
Dr. Md Shahid Alam
Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Aditya Birla Sankara Nethralaya, Mukundapur, Kolkata, West Bengal; A Unit of Medical Research Foundation, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ojo.ojo_462_20

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   Abstract 


PURPOSE: Isolated cases of nasolacrimal duct obstruction (NLDO) secondary to rhino-orbito-facial reconstructive surgeries have been reported previously. We report the clinical profiles and management outcomes of a series of patients with iatrogenic INDO.
MATERIALS AND METHODS: Case records of all patients who presented with secondary NLDO over 5 years were retrospectively analyzed. The case series included seven patients with NLDO secondary to orbito-facial surgeries.
RESULTS: The study included six males and one female patient with a mean age of 29 ± 12.58 years. All the patients had a history of road traffic accidents following which they underwent an open reduction and internal fixation by maxilla-facial surgeons. All of them presented to the Ophthalmology outpatient department with epiphora following the surgical intervention. Imaging revealed the implants were responsible for obstructing the nasolacrimal ducts in all seven cases. Five patients underwent external dacryocystorhinostomy while dacryocystectomy was performed in two. Implant removal was necessary for five patients without any compromise on the structural integrity of the orbital walls.
CONCLUSION: Precise knowledge of the orbital anatomy, especially that of the lacrimal drainage system is imperative for surgeons performing surgeries in the midface area. A multidisciplinary approach and inclusion of surgeons trained in lacrimal surgeries can prevent such avoidable complications.

Keywords: Computerized tomography dacryocystography, dacryocystorhinostomy, implants, nasolacrimal duct obstruction, orbito-facial fractures


How to cite this article:
Mukherjee B, Gudkar AI, Nair AG, Poonam NS, Alam MS. Iatrogenic nasolacrimal duct obstruction after adnexal intervention: An avoidable consequence. Oman J Ophthalmol 2021;14:157-61

How to cite this URL:
Mukherjee B, Gudkar AI, Nair AG, Poonam NS, Alam MS. Iatrogenic nasolacrimal duct obstruction after adnexal intervention: An avoidable consequence. Oman J Ophthalmol [serial online] 2021 [cited 2021 Nov 27];14:157-61. Available from: https://www.ojoonline.org/text.asp?2021/14/3/157/328609




   Introduction Top


The proximity of the lacrimal drainage system consisting of the canaliculi, lacrimal sac, and the nasolacrimal duct to the maxillary, lacrimal, and nasal bones make them vulnerable to injury during operative procedures of the midface area. Iatrogenic trauma has been observed following the repair of orbital fractures.[1] Such patients may present immediately or years after the initial surgery. Since many of these surgical interventions are taken up by maxillofacial or plastic surgeons, the position of the nasolacrimal duct while placing fracture implants may be overlooked. The literature pertaining to nasolacrimal duct obstruction (NLDO) occurring after repair of orbito-facial fractures with implants is few and mostly limited to isolated case reports.[2],[3] We herewith report a series of seven such patients who developed iatrogenic INDO after orbito-facial surgery.


   Materials and Methods Top


This retrospective interventional study was carried out after approval from our institutional review board, and adhered to the tenets of the Declaration of Helsinki. The medical records of all patients with NLDO over 5 years (January 2013–December 2018) were analyzed. Patients presenting with complaints of watering and discharge after primary repair and radiographic evidence of screws, plates, or mesh, in and around the nasolacrimal drainage system causing nasolacrimal obstruction were included in this study. Patients with secondary acquired NLDO due to mid-facial fractures and patients with preexisting epiphora were excluded from the study.

The data regarding the demographic profile, detailed history including the type of primary surgery, clinical features, investigations, mechanism of obstruction, management, and outcomes were reviewed. Based on the clinical evaluation and lacrimal imaging, a definitive diagnosis of INDO was made in seven cases. All the patients underwent computerized tomography dacryocystography (CT-DCG) and the diagnosis was confirmed before any intervention. Irrigation of the lacrimal system was performed in all cases before surgery to confirm the diagnosis. All the patients were counseled regarding their clinical condition, need for surgical intervention, nature of the surgery, anesthesia, surgery-related complications, and failure rates.


   Results Top


A total of seven patients were included in the study. There were six males and one female. The age ranged from 15 to 48 years with a mean of 29 ± 12.58 years. The right eye was involved in three cases and the left eye was involved in the remaining four. All the patients had a history of road traffic accidents followed by open reduction and internal fixation by maxillofacial surgeons. The onset of watering and discharge from the affected eye ranged from the immediate postoperative period to 5 months after surgery. The relevant clinical details are in [Table 1]. All patients were noted to have improperly placed plates and screws impinging over the lacrimal sac or nasolacrimal duct [Figure 1] and [Figure 2]. CT-DCG further confirmed the nasolacrimal block and its level in all the patients [Figure 3], [Figure 4], [Figure 5]. Four patients needed removal of the offending screws while plate removal was done in one case. Five patients underwent external dacryocystorhinostomy (DCR) and two underwent dacryocystectomy (DCT). Silicone intubation was done in three patients which were removed after 6 weeks. Follow–up ranged from 1 week to 3 years. After DCR, all five patients had complete symptomatic relief with patent ostia at the last follow-up.
Table 1: Clinical presentations of the patients presenting with iatrogenic nasolacrimal duct obstruction

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Figure 1: Computed tomography showing screw (a) arrow head, (b) arrow head and arrow of the left naso-frontal plate in close vicinity of the bony nasolacrimal duct.

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Figure 2: Patient with a left sided orbital fracture with epiphora and enophthalmos. (a) Computerized tomography scan showing the screw impinging on the nasolacrimal duct, (b) The scan was performed during an episode of acute dacryocystitis– note the soft tissue edema visible in the scans

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Figure 3: Computerized tomography dacryocystography showing (a) No flow of contrast in left nasolacrimal duct (b) Screw anterior to the left nasolacrimal duct impinging on it

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Figure 4: Computerized tomography dacryocystography showing (a) Sagittal view showing flow of contrast in the right nasolacrimal duct. (b) Sagittal view showing no flow of contrast in the left nasolacrimal duct. (c) Axial view showing the right nasolacrimal duct to be partially filled with contrast while no flow of contrast seen in the left nasolacrimal duct. (d) Axial view showing a screw to be partly within the left lacrimal sac (white arrow)

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Figure 5: Computerized tomography dacryocystography showing (a) Coronal view with the titanium mesh causing avulsion of the sac-neck junction (white arrow) (b) Sagittal view showing the mesh at the level of the sac-neck junction (white arrow)

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   Discussion Top


Iatrogenic NLDO may be inadvertently caused by surgeries in the midface region during orbital fracture repair, orbital decompression, Caldwell-Luc operation, endoscopic sinus surgeries, and rhinoplasty.[1],[2],[3],[4],[5],[6] Inadequate knowledge of the anatomy of lacrimal drainage pathway; distorted anatomy due to previous surgical or accidental trauma, incorrect placement of large plates, and failure to anchor the plate properly leading to implant migration are the typical causes of INDO following orbito-facial fracture repair. In all our patients, improper screw/plate placement was found to be responsible for the NLDO.

Kohn et al. reported a case of orbital implant migration in a 7-year-old girl 32 months after repair of orbital floor fracture as the cause of epiphora and dacryocystitis.[1] Mauriello et al. reported a case of a 66-year-old woman who developed dacryocystitis 15 years after successful orbital floor fracture repair with a silicone implant wherein the implant was found in the area of the nasolacrimal duct.[2] Similarly, Chon et al. reported a case of hemolacria with orbital hemorrhage several years after orbital floor fracture repair due to erosion of the nasolacrimal duct caused by a displaced silicone implant combined with anticoagulation therapy.[3] Serdahl et al. reported a series of eight cases who developed epiphora following endoscopic sinus surgery and were successfully managed by DCR.[5] Osguthorpe and Calcaterra reported a series of 11 cases of the iatrogenic nasolacrimal system damage following nasoantral window procedures, rhinoplasty, and partial maxillectomy.[6]

CT scan of the lacrimal system can be extremely useful in the evaluation of posttraumatic epiphora. CT-DCG has the advantage of providing both the bony anatomic details and the level of obstruction in the lacrimal drainage system and is extremely helpful in managing such cases.[7] In addition, three-dimensional reconstructed images provide more information about the location of the previously placed mini plates and screws, titanium mesh, or silastic sheets. This, in turn, helps in preoperative planning and intraoperative decision-making. None of the patients in this series were advised a postoperative CT scan by the primary surgeon, though it is always advisable in symptomatic patients.[7]

The management of INDO is challenging because of the distorted anatomy; postoperative fibrosis; bony sclerosis; and the presence of plates and screws over the area of the proposed DCR ostium. A detailed preoperative patient counseling regarding the failure rates and complexity of the situation is indispensable. The implants may need removal in cases where they are malpositioned and are the direct cause for the NLDO. Five of our patients needed the removal of the screws (n = 4) and plate (n = 1) to proceed with the surgery. The external approach to DCR provides better access in all such cases and should be the procedure of choice. Care should be taken to create a large ostium. Adjuncts such as mitomycin C and intubation of the lacrimal pathway can be used to enhance the success rate.[8] Endoscopic DCR is difficult due to the distorted anatomy but the advent of navigation guidance has made this approach possible in selected cases.[9] General anesthesia is preferred as there may be sclerosis and gross thickening of the bones after trauma, requiring the use of drills or chisel-hammer to initiate the osteotomy.[8] In rare instances, the surrounding anatomy is so much distorted that it precludes the option of performing a DCR. The only option left in such cases is a DCT. We too had to perform DCT in two of our cases. The postoperative fibrosis also makes the lacrimal surgery difficult and quite challenging in these cases.

Facial fractures themselves can cause traumatic disruption of the nasolacrimal duct or the lacrimal sac and can result in epiphora. Hence, a complete evaluation of the lacrimal excretory pathway before taking up the patient for surgery cannot be over emphasized. The patient also needs to be counseled regarding the rare possibility of INDO.

Uraloğlu et al. have previously described the incidence of NLDO to be 68.4% following NOE fractures.[10] In their series, the majority of patients were not treated for fractures. It has been suggested that early repair of such fractures is likely to reduce the incidence of posttraumatic NLDO in these cases and that a delayed DCR is likely to be beneficial. It is important to distinguish between a posttraumatic NLDO and iatrogenic NLDO: In each of our cases, a mechanical disruption or obstruction of the nasolacrimal duct was noted intraoperatively– either a plate or a screw, which was directly responsible for the obstruction. At the time of primary repair, it is necessary to avoid disturbing the anatomy and avoid improper selection and placement of plates, mesh, or screws. We recommend postoperative scans in all patients undergoing fracture repair.[7] CT-DCG is an important diagnostic tool and should be requested whenever patients present with complaints of epiphora and discharge in the postoperative period. It can help localize the level of the obstruction and also point out the exact cause of the obstruction in cases of INDO. The drawback of the article is its small sample size and the retrospective design. Nonetheless, it provides insight into an avoidable complication following orbito-facial fracture repair.


   Conclusion Top


It is imperative for any surgeon operating in the midface area to have a sound knowledge of the lacrimal system anatomy. A multidisciplinary approach involving an oculoplasty surgeon in the team should be the preferred mode of management in midfacial fractures. The preferred mode of management of iatrogenic NLDO remains an external DCR with a large ostium ± intubation ± implant removal. However, in difficult circumstances, a DCT may be the only option to prevent infections, even if it leads to postoperative epiphora. Hence, the patients should be properly counseled about the possibility beforehand.

Acknowledgments

Dr. OlmaVeena Noronha, MD (Radiology), VRR Scans, Chennai, India.

Dr. P. Anantnarayanan, MDS, DNB, MNAMS, FICS, MFDS RCPSGlasg, FDS RCSEd, Professor, Oral and Maxillofacial Surgery, Meenakshiammal Dental College and Hospital, Chennai, India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Kohn R, Romano PE, Puklin JE. Lacrimal obstruction after migration of orbital floor implant. Am J Ophthalmol 1976;82:934-6.  Back to cited text no. 1
    
2.
Mauriello JA Jr., Fiore PM, Kotch M. Dacryocystitis. Late complication of orbital floor fracture repair with implant. Ophthalmology 1987;94:248-50.  Back to cited text no. 2
    
3.
Chon BH, Zhang R, Bardenstein DS, Coffey M, Collins AC. Bloody epiphora (hemolacria) years after repair of orbital floor fracture. Ophthalmic Plast Reconstr Surg 2017;33:e118-20.  Back to cited text no. 3
    
4.
Zapala J, Bartkowski AM, Bartkowski SB. Lacrimal drainage system obstruction: Management and results obtained in 70 patients. J Craniomaxillofac Surg 1992;20:178-83.  Back to cited text no. 4
    
5.
Serdahl CL, Berris CE, Chole RA. Nasolacrimal duct obstruction after endoscopic sinus surgery. Arch Ophthalmol 1990;108:391-2.  Back to cited text no. 5
    
6.
Osguthorpe JD, Calcaterra TC. Nasolacrimal obstruction after maxillary sinus and rhinoplastic surgery. Arch Otolaryngol 1979;105:264-6.  Back to cited text no. 6
    
7.
Carpenter D, Shammas R, Honeybrook A, Brown CS, Chapurin N, Woodard CR. The role of postoperative imaging after orbital floor fracture repair. Craniomaxillafac Trauma Reconstr 2018;11:96-101.  Back to cited text no. 7
    
8.
Dhobekar M, Mukherjee B. Management of lacrimal system trauma. In: Mukherjee B, Yuen H, editors. Emergencies of the Orbit and Adnexa. India: Springer; 2017. p. 77-87.  Back to cited text no. 8
    
9.
Ali MJ, Singh S, Naik MN, Kaliki S, Dave TV. Interactive navigation-guided ophthalmic plastic surgery: The utility of 3D CT-DCG-guided dacryolocalization in secondary acquired lacrimal duct obstructions. Clin Ophthalmol 2017;11:127-33.  Back to cited text no. 9
    
10.
Uraloğlu M, Erkin Unlü R, Ortak T, Sensöz O. Delayed assessment of the nasolacrimal system at naso-orbito-ethmoid fractures and a modified technique of dacryocystorhinostomy. J Craniofac Surg 2006;17:184-9.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

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