*Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts; †Ophthalmic Plastic and Reconstructive Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A.; ‡International Eye Institute, St. Luke's Medical Center, Quezon City, Philippines; §Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts; and ‖Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts; and ¶Department of Otolaryngology, Boston Children's Hospital, Boston, Massachusetts, U.S.A.
Ophthalmic Plast Reconstr Surg. 2013 Sep-Oct;29(5):367-72. doi: 10.1097/IOP.0b013e31829a72d4.
The reported 5% of patients with nasolacrimal duct obstruction who fail dacryocystorhinostomy likely include patients with severe mucosal disease or anatomical anomalies. The technique described herein avoids mucosal anastomosis and minimizes mucosal manipulation by inserting a permanent silicone conduit from the lacrimal sac into the nasal cavity.
This retrospective review of 9 surgical cases was performed with institutional review board approval. Six patients underwent 9 surgeries (3 sequentially bilateral) for dacryocystitis. Two patients had Wegener granulomatosis, 1 had pemphigoid, 1 sarcoidosis, 1 Rosai-Dorfman disease, and 1 congenital choanal atresia with chronic neonatal dacryocystitis. In each case, a modified Rains sinus stent was inserted through an external lacrimal sac incision with the draining end positioned in the nasal cavity. Two patients underwent concurrent canalicular intubation with Guibor silicone stents to prevent internal punctum obstruction by the lacrimal sac implant. Recurrence of symptoms, patient comfort, and modified Rains stent stability and patency were evaluated.
Mean follow up was 30 months (range 7-59 months). The modified Rains stent remained stable and patent in 7 of 9 cases, and symptoms resolved in 8 of 9 cases. In 1 patient with sarcoidosis, the modified Rains stent became repeatedly obstructed with nasal secretions and ultimately dislodged after intranasal manipulation by a physician unfamiliar with the surgery. In no other case did the patient experience recurrent infection, and in those cases, epiphora resolved entirely. In the patient with pemphigoid, one of the modified Rains stents extruded 6 months postoperatively, but his symptoms remained controlled. No adverse reaction to the implant material was seen.
A Rains silicone frontal sinus stent can be modified for implantation into the lacrimal sac and can safely and effectively drain the lacrimal sac into the nose in patients with severe mucosal disease or anatomical anomalies. Additional study and a stent specifically designed for this application will likely improve outcomes.
据报道，5%的鼻泪管阻塞患者在接受泪囊鼻腔吻合术后失败，其中可能包括患有严重黏膜疾病或解剖异常的患者。本文所述的技术通过将永久性硅胶导管从泪囊插入鼻腔，避免了黏膜吻合，并最大限度地减少了对黏膜的操作。
本研究回顾性分析了 9 例手术病例，该研究获得了机构审查委员会的批准。6 例患者因泪囊炎接受了 9 次手术（3 例先后双侧手术）。2 例患者患有韦格纳肉芽肿，1 例患有天疱疮，1 例患有结节病，1 例患有罗斯 - 多夫曼病，1 例患有先天性后鼻孔闭锁伴慢性新生儿泪囊炎。在每例患者中，通过外部泪囊切开术插入改良的 Rains 窦支架，使引流端位于鼻腔内。2 例患者同时进行了泪小管插管，插入 Guibor 硅胶支架，以防止泪囊植入物阻塞内眦。评估症状复发、患者舒适度以及改良 Rains 支架的稳定性和通畅性。
平均随访时间为 30 个月（7-59 个月）。7 例 9 例改良 Rains 支架稳定且通畅，8 例 9 例症状缓解。在 1 例结节病患者中，改良的 Rains 支架多次被鼻分泌物堵塞，最终在一位不熟悉手术的医生进行鼻腔内操作后脱落。在其他病例中，患者未发生复发性感染，在这些病例中，溢泪完全缓解。在患有天疱疮的患者中，1 个改良 Rains 支架在术后 6 个月时脱出，但他的症状仍得到控制。未观察到对植入物材料的不良反应。
Rains 硅胶额窦支架可进行改良，植入到泪囊中，在患有严重黏膜疾病或解剖异常的患者中，可安全有效地将泪囊引流至鼻腔。进一步的研究和专门为此应用设计的支架可能会改善结果。
