Prolene: a novel, cheap, and effective material in dacryocystorhinostomy S ASLAN, H OKSUZ, S OKUYUCU, E AKOGLU & S DAGLI Acta Oto-Laryngologica, Volume 129, Number 7, August 2009, pp (5)

ABSTRACT Objective : To evaluate the clinical efficacy and results of stenting with polypropylene suture material instead of silicone tube in endoscopic dacryocystorhinostomy Methods:  Forty-two endoscopic DCR operations were performed in 36 patients between 2007 and  2/0 Prolene was inserted through the canaliculi into the sac. The Prolene was left in the lacrimal sac for 3 months.  The patients were followed up for between 6 and 18 months (mean 8.193months).  The improvement in epiphora was grouped as very good, good, or no change

Results:  The improvement in 34 eyes (81%) - very good, 5 eyes (11.9%) - good, 3 eyes (7.1%) - no change  Granulation tissue formation around the Prolene in two patients ABSTRACT

Conclusion:  Prolene is cheap, effective, and readily available in almost all operating theaters.  It might be used successfully in endoscopic DCR  It is an alternative to silicone stent intubations

INTRODUCTION  Dacryocystorhinostomy (DCR) has been performed in patients with chronic stenosis of the lacrimal drainage system.  It is based on the formation of a fistula on the lateral nasal wall between the nasal cavity and the lacrimal sac.  The operation can be carried out using either an external or endonasal surgical approach.  The external approach was popularized first and became the surgery of choice for most ophthalmologists.

INTRODUCTION  Since its first description by McDonough and Meiring, endoscopic DCR gained popularity  Consequently, endoscopic DCR became an accepted technique for the management of nasolacrimal obstruction.  Advantages of intranasal endoscopic approach Avoidance of scar formation Avoidance of injury to the medial canthus Preservation of the pumping fucn of the lacrimal sac Correction of septum deviation or chronic sinusitis

INTRODUCTION  The commonest reason for failure of DCR is attributed to stenosis of the rhinostomy.  Insertion of silicone stents is almost universally employed to prevent rhinostomy stenosis and to help to stabilize epithelialization  The authors describe a technique using a polypropylene suture materialas an alternative to silicone stent  It is a cheap material (US$3) and is readily available when compared with bicanalicular silicone tube (US$70)

PATIENTS AND METHODS  Thirty-six patients (25 females and 11 males)underwent 42 endoscopic DCR operations for complaints of continuous epiphora and recurrent swelling in the medial canthal  The study was conducted at the Ophthalmology and Ear Nose Throat Clinics, Mustafa Kemal University, between 2007 and 2008  Ages ranged from 16 to 60 yrs, with a mean age of 34.79± 9.5 years  Preoperatively all patients underwent routine ophthalmologic and otorhinolaryngologic examination  NLD obstructions were confirmed by the results of lacrimal irrigation and dacryocystographies

Surgical technique  All surgeries were performed under general anesthesia  Nasal cavity was decongested for 5 min using cottonoid pledgets soaked in lidocaine 2% with epinephrine 1:  Anesthetic solution was injected submucosally to the lat nasal wall  A nasal endoscope of 4 mm diameter and 0 O angle was used  A reverse C-shaped incision, 10 X10 mm, was made at the lateral nasal wall mucosa  Forceps were used to remove the mucosa in this area

SURGICAL TECHNIQUE  Then the bony structure was elevated using a chisel and hammer and removed with forceps.  Identification of the sac was aided by passing a lacrimal probe through the inferior canaliculus into the sac  The lacrimal sac opening was widened using Blakesley-Wilde forceps and through cutting punches  The patency of the lacrimal drainage system was checked with saline irrigation

SURGICAL TECHNIQUE  Then 2/0 polypropylene (Prolene) was inserted into the sac through the canaliculi with the Ritleng probe. The Ritleng probe is a rigid, hollow, polished stainless steel tube  Both ends of the Prolene were then fastened with several knots and sutured with 5/0 silk to the lateral nasal vestibul

Postoperative care and follow-up  The patients were generally discharged on the day of the procedure, and given oral antibiotics for 1 week.  Nasal irrigation and topical eye drops were given four times a day for 2 weeks  Patients were examined endonasally in the otorhinolaryngology clinic in first, second, and fourth week in the first month and then once a month until Prolene removal  The stenting lasted for 3 months  Patients were asked to fill in a questionnaire on their subjective epiphora complaint

Postoperative care and follow-up  The eyes with no epiphora were accepted as very good  The eyes which experienced epiphora occationally were designated as good  The eyes that still had epiphora with mild improvement or no change were placed in the no change group  The size of the ostium and patency of the lacrimal system were assessed by rigid nasal endoscopy and fluorescein eye drops and/or irrigation with saline  The resolution of epiphora with patent ostium during nasal endoscopy was accepted as a successful result

RESULTS  The age range of our patients was between 16 and 60(mean age 34.79±9.5)  42 endoscopic DCR, 6 pts were optd bilat.  Follow-up period varied from 6 to 18 months (mean 8.19 ± 3.6 months)  Success was def as anatomical patency with fluorescein flow on endoscopy and patency to lacrimal syringing

RESULTS AND ANALYSIS

RESULTS  Endoscopic DCR was successful in 39 of the 42 cases (92.9%).  There were no major surgical complications, such as bleeding, orbital injury, or diplopia  During the Prolene insertion, two patients had a tear at the canaliculi  Granulation tissue formation near the Prolene suture was observed in two patients

DISCUSSION  Endoscopic DCR was first performed by McDonough and Meiring in 1989  Endoscopic DCR is becoming popular as a relatively quick and easy surgery for post-saccal obstruction of the NLD  The success rate depends on providing a wide intranasal stoma with removal of adequate bone around the stomal area, reducing the chances of postoperative stenosis and adhesions  The diameter of a functional DCR fistula after wound healing may be as small as 1- 2 mm  Mann and Wormald demonstrated that the DCR ostium might show a significant shrinkage from surgery to 4 weeks but no statistical difference from 4 weeks to 6 or 12 months

DISCUSSION  A bicanalicular silicone tube is the stent most often used in DCR procedures to prevent obliteration of the rhinostomy  Many surgeons prefer to place bicanalicular silicone tubing stent with a reported success rate of 87% to 94.4%  Ciftci et al. and Snead et al. concluded that the silicone tubes had no effect on the pericanalicular inflammation or fibrosis  In the literature several other materials have been used to retain the lacrimal aperture following endoscopic DCR  Tamura et al. used T-sheet made from a penrose drain tube  Kishore et al. and Erkan et al. used standard otologic T-tubes

DISCUSSION  To authors knowledge, the use of Prolene for stenting purposes has not been reported in the literature  Main advantages - Strength Inertness Retention of strength after application Minimum tissue reactivity Resistance to bacterial contamination  A silicone tube,spontaneous prolapse or lateral displacement of silicone tubes at the medial canthus can be a problem  Silicone tube may cause ocular irritation, conjunctivitis, and corneal erosion

DISCUSSION  The Royal College of Ophthalmologists (1999) published guideline for clinical governance suggesting that freedom from epiphora 3 months after surgery is the marker for a satisfactory procedure  the overall success of Prolene insertion into the canaliculi in endoscopic DCR procedures was 92.9%.

CONCLUSION  This method is effective in primary cases with lacrimal sac or nasolacrimal duct obstruction  Prolene is also a cheap material and is readily available in almost all operating theaters and it permits tear flow into the nose following surgery  It represents a good alternative to silicone, especially in settings with limited resources

ANALYSIS OF THE STUDY 1.Large sample size, 2.New techinique, requires further validation