: a quick fix? S.A. SADIQ, R.N. DOWNES

Abstract Patients and methods

Purpose To assess whether any simple, easily Patients attending the adnexal clinic of our performed and minimally invasive procedure hospital with symptoms of epiphora only were may help the symptoms of patients with entered into the study after full information of functional nasolacrimal obstruction without their condition and procedures entailed was recourse to elaborate investigation or major provided. A full history was obtained from each surgery. A randomised study was performed patient, followed by slit lamp examination. to assess the success of retropunctal cautery Patients were excluded if they had any of the (RPC) and one-snip in this following: a history suggestive of allergy, condition. herpetic infection, trauma, facial palsy, previous Methods In the absence of any cause for excess nasal or lacrimal investigations / procedures, lacrimation, malposition or bleeding disorder, , , eyelid nasolacrimal obstruction, patients underwent malposition, scarring or laxity, punctal

either syringing alone (group A, n = 15) or abnormality, lacrimal fistula or mucocoele. A syringing with RPC and a one-snip dye disappearance test was then

punctoplasty (group B, n = 15). performed and, if positive, syringing of the Results Three months after treatment, six nasolacrimal system was carried out. If the patients in group A were improved, compared system was patent, randomisation was then with 13 in group B (Fisher's exact test, undertaken for either no further procedure

p = 0.0096). (group A), or minor surgery (group B). Conclusions We would recommend that Surgery comprised local infiltration of the patients who suffer from a pump or functional medial aspect of the eyelid with lignocaine 1% nasolacrimal obstruction should receive RPC with adrenaline (1:200 000) solution followed by and a one-snip punctoplasty following the a double horizontal line of retropunctal burns demonstration of a patent system on with a disposable monopolar cautery and a one­ syringing. These simple procedures would not snip vertical punctoplasty using a fine spring impair further investigation or lacrimal scissor. surgery if required in the future. Patients in each group were asked to use chloramphenicol drops four times daily for Key words Epiphora, One-snip punctoplasty, 7 days. All patients were reviewed at 3 months Retropunctal cautery, Syringe to assess their symptoms.

Results

We performed 15 cases of syringing alone Epiphora is a common symptom in both the (group A) and 15 cases of syringing combined young and the elderly. It may be functionally with RPC and a one-snip punctoplasty (group disabling, as well as cosmetically embarrassing. B). Sixty-three per cent of patients were female, Causes include excess lacrimation, eyelid and the average age was 69.2 years (range malposition, nasolacrimal obstruction, or a 30-89 years). Three months after treatment, six combination of these. The surgical management patients in group A were improved, compared in these cases is well known/ but epiphora in with 13 in group B (Fisher'S exact test,

the absence of these factors, presumed to be a p = 0.0096). functional nasolacrimal blockage, may be more difficult to cure. We wanted to assess whether any simple, easily performed and minimally Discussion invasive procedure would help the symptoms There is no doubt that obstruction of the of such patients without recourse to elaborate nasolacrimal system can be successfully investigation or major surgery. A randomised managed by surgery.2,3 However, the treatment SA Sadiq study was performed to assess the effect of of a functional or non-anatomical block is more R.N. Downes � Department of retropunctal cautery (RPC) and one-snip inconsistent. Further investigation of this type punctoplasty on the symptoms of patients with of problem in the form of either a Queen's Medical Centre a presumed functional blockage. dacryocystogram or, ideally, lacrimal Nottingham NG7 2UH, UK

Eye (1998) 12, 417-418 © 1998 Royal College of Ophthalmologists 417 scintillography is usually required, before resorting to aspect of the eyelid to a mild degree, but punctal surgical treatment. A recent survey has shown that only enlargement by itself would probably not result in an 41 % of surgeons with a lacrimal interest would perform a improvement, as patients in group A had also undergone (DCR) for a lacrimal pump punctal dilation (although not permanent) during the 'functional block'. It is for this reason of low surgical process of syringing. This improvement may be enough intervention that we wanted to investigate whether a to improve quality of life without resort to major surgery, simple acceptable technique (such as RPC and one-snip especially for older patients. punctoplasty) may offer some improvement for these In conclusion, we would recommend that patients patients. Although our study involved younger patients who suffer from a pump or functional nasolacrimal also, most patients with a functional block tend to be obstruction should receive RPC and a one-snip older (the median age of the patients in our study was 73 punctoplasty following the demonstration of a patent years). It may thus also be for reasons of age that a major system on syringing. These simple procedures would lacrimal procedure (which is usually performed under also not impair further investigation or lacrimal surgery general anaesthesia) is avoided. if required in the future. Although the follow-up is short at 3 months, we are confident that at least in the short term we are able to improve the symptoms of a substantial proportion of our References

patients with a functional nasolacrimal obstruction. This 1. Welham RAN. Lacrimal surgery. In: Collin JRO, editor. A short-term relief is achieved by relatively simple manual of systematic eyelid surgery. 2nd ed. Edinburgh: methods that can be performed during the initial Churchill Livingstone, 1989:109-20. outpatient assessment. We are unsure of the exact 2. Tarbet KJ, Custer PL. External dacryocystorhinostomy: surgical success, patient satisfaction and economic cost. mechanism whereby an RPC and one-snip punctoplasty Ophthalmology 1995;102:1065-70. actually improves tear outflow physiologically, but this 3. Zolli CL, Shannon GM. Dacryocystorhinostomy: a review of combination of procedures may help by encouraging 106 operations. Ophthalmic Surg 1982;13:905-10. to more easily enter the punctum and canaliculi. 4. Conway ST, Wobig J. Evaluation and management of The remainder of the lacrimal pump mechanism consists 'functional' nasolacrimal blockage: results of a survey of the of canalicular shortening and lacrimal sac expansion on American Society of Ophthalmic Plastic and Reconstructive Surgery. Ophthalmic Plastic Reconstr Surg 1994;10:185-8. eyelid closure, followed by lacrimal sac collapsing and 5. Jones LT, Wobig JL. Newer concepts of tear duct and eyelid the forcing of tears into the on eyelid anatomy and treatment. Trans Am Acad Ophthalmol opening.5 The RPC may cause tightening of the medial Otolaryngol 1977;83:603-16.

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