Simple lid tightening or complex dacryocystorhinostomy?

Chicago-When failure of the tear pump upsets the dynamic equilibrium between tear production and tear loss, resulting in tearing, numerous options for correction are available.

In a debate at the oculofacial plastic surgery subspecialty day program of the annual meeting of the American Academy of Ophthalmology, two surgeons made the case for their preferred surgical approach: lid tightening or dacryocystorhinostomy (DCR).

"The case for this is that the lid tightening is a very simple procedure in contrast to the somewhat more complex DCR and something that many comprehensive ophthalmologists should be able to perform," Dr. Holds said. "It can resolve tearing with minimal morbidity.

"We're approaching the problem anatomically instead of taking an end-run around it by performing DCR surgery," he added. "A tarsal strip procedure can be easily combined with other lid procedures such as punctoplasty and medial spindle ectropion repair for punctal malposition."

While acknowledging the occasional need for DCR surgery to deal with a coexisting functional nasolacrimal duct obstruction or a lacrimal pump system that is still incompetent after eyelid tightening surgery, Dr. Holds believes that most patients with eyelid laxity and a diagnosis of lacrimal pump failure deserve a lid tightening with a lateral tarsal strip procedure as their initial surgical approach.

Disadvantages of a lateral tarsal strip procedure may include postoperative tenderness in the lateral canthus and a brief recovery period. About 10% of patients may require a second procedure. This contrasts with DCR surgery, which can have significant risks of discomfort and nosebleed as well as significant and prolonged swelling and bruising, Dr. Holds said.

Making a case for DCR

He suggested that just as lacrimal dynamics must be viewed in the context of the entire ocular environment, functional nasolacrimal duct obstruction should likewise be considered in relation to changes in the whole lacrimal pathway-including the production side, lid functions, and tear drainage pathways.

"After failed medical therapy, DCR is the treatment of choice for functional nasolacrimal duct obstruction," Dr. Rose added.

When treating patients with functional nasolacrimal duct obstruction, the first logical step is to quiet the inflammatory component of the obstruction. The second is to increase the pick-up of the tears, and then finally to bypass one of the main areas of physiological narrowing-the nasolacrimal duct. In practical terms, however, Dr. Rose suggested that the greatest symptomatic control in these patients comes from medical therapy, followed where necessary by DCR, with eyelid surgery being used later to address problems due to premature spillage of tears from the center or lateral part of the lower eyelid contour.

The underlying inflammation is tackled with a potent anti-inflammatory regimen. The next step is to increase tear pick-up, but not by performing surgery on the lids. In many cases, this results in tears being retained in the tear layer, which may actually make patients' symptoms worse, Dr. Rose said.

The final step is to bypass the nasolacrimal duct stenosis, which addresses a major component of the obstruction and opens avenues for secondary treatment if symptoms persist.

This is important because, as shown in a study by Dr. Rose and Sven Sahlin, MD, many patients with persistent watering after DCR for functional nasolacrimal duct obstruction in fact have a better conductance than the normal lacrimal system. This suggests that another factor, such as hypersecretion, was a significant component of their functional blockage and that a few patients may require lid surgery.

FYI

John Bryan Holds, MD, FACS
Phone: 314/567-3567
E-mail: eyelidmd@hotmail.com

Geoffrey E. Rose, FRCOphth
Phone: 02079 355385
E-mail: Geoff.Rose@moorfields.nhs.uk

Neither Dr. Holds nor Dr. Rose reported any relevant disclosures.