The initial experience of using the drain implant to eliminate epiphora in patients with rhinogenous pathology

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INTRODUCTION

Epiphora is a significant health problem caused by disorders of the vertical portion of the lacrimal drainage system (LDS), including inflammation in the lacrimal sac mucosa or nasolacrimal duct and narrowing or other anatomical changes in this area [6]. Diseases of the nasal cavity and paranasal sinuses (PNS) play an important role in the pathogenesis of such lacrimation [4]. The role of nasal disorders in LDS pathology is now widely discussed. According to the literature, the most-frequent rhinogenic disorders are vasomotor rhinitis (14.5%) and nasal septal deviation (7.4%) [4]. Indeed, rhinitis with concomitant edematous nasal mucosa can cause mechanical compression of the lower segment of the nasolacrimal duct, which is possible if the nasolacrimal duct ends below the bony nasolacrimal canal [4, 6]. Later, other authors also demonstrated an association between excessive lacrimation and rhinogenic disorders, which was diagnosed in 60%–70% of cases [4]. There are several case reports describing the development of epiphora after nasal cavity and PNS surgeries, including those after endoscopic surgery. The risk of injury is closely associated with anatomical characteristics, disease stage and severity, results of previous surgeries, and experiences of the surgeons [3]. Cicatricial strictures and postoperative obliterations often develop in the nasolacrimal duct, becoming the main cause of dacryocystitis and dacryostenosis. Therefore, searching for new methods to prevent or eliminate rhinogenic epiphora (including those caused by surgical injury) is relevant.

This study aimed to assess the efficacy of the Healaflow^® drainage implant (Aptissen, Switzerland) in patients with excessive lacrimation and various concomitant nasal disorders.

MATERIALS AND METHODS

The study included 29 patients (50 eyes) complaining of permanent (for >6 months) excessive lacrimation. The study population comprised of 9 males and 20 females aged between 20 and 63 years. All study participants had already undergone long-term treatment for lacrimation, ranging from instillation of various eye drops (including antibiotics, non-steroidal anti-inflammatory, lubricant, and hormonal drops) to multiple LDS probings and irrigations (2 patients had undergone surgical extension of the lower lacrimal points). All patients underwent conventional ophthalmological and dacryological examinations, including color nasolacrimal test, tubular test, diagnostic LDS flushing, biomicroscopy of the anterior segment, and consultation of an otorhinolaryngologist with endoscopic examination of the nasal cavity. In addition, all patients underwent contrast-enhanced cone-beam computed tomography using the Gali leos Comfort System (Sirona Dental Systems GmbH, Bensheim Germany) and Galaxis software. We used the Ultravist Contrast Media. The scanning parameters were as follows: 85 kV, 4 mА, 28 mA/s, isotropic voxel size of 0.15 mm, and effective dose of 70 µSv. The assessed volume was 15 cm³. We used positioning along the orbitomeatal line. The scans were evaluated in the “MPR/X-ray examination” mode in 3 planes. We performed qualitative and quantitative assessment of the nasal structures, PNS, and LDS.

The results of LDS examination in 29 patients (50 eyes) are given in Table 1.

 

Table 1. The results of dacryology samples

Таблица 1. Результаты проведения дакриологических проб

Test	Results			Total (eyes)
	positive	delayed	negative
Fluorescein dye disappearance test	44	6	–	50
Jones test I	14	26	10	50
Lacrimal syringing test	50	–	–	50

 

All 29 participants (50 eyes) demonstrated normal passive permeability of the LDS with minimal lacrimal dysfunction, as evidenced by delayed or negative results of the tests investigating active permeability.

All participants also complained on difficulty in nasal breathing and reduced olfaction. The following disorders were identified by an otorhinolaryngologist:

• nasal septum deviation (functionally significant): 5 patients (Fig. 1, a);
• swell body: 4 patients (Fig. 1, b);
• Соncha bullosa: 2 patients (Fig. 1, c);
• vasomotor rhinitis: 18 patients (Fig. 1, d).

 

Fig. 1. CBCT of the patient: concha bullosa right (a); nasal septum deflection to the right. Bilateral inferior nasal concha increase. Right maxillary sinus' cyst (b); Swell-body (c); bilateral middle and superior nasal concha increase (d)

 

After nasal surgery, all patients underwent a control lacrimal syringing test. In the postoperative period, patients received 2 sprays of nasonex in each nostril for 1 month with gradual dosage decrease.

Next, all patients were divided into 2 groups: group I (study group) including 15 patients (28 eyes), and group II (control one) including 14 patients (22 eyes).

Patients from the study group were implanted with the Healaflow® drainage implant within 1 day of surgery (Figs. 2, а, b)

 

Fig. 2. Drain implant HELAFLOW (Aptissen, Switzerland): а – syringe with cannula; b – introduction of the drug in the tear-off pathways

 

The control group participants received tobradex eye drops for 2 weeks, followed by lubricating eye drops for 1 month.

 

Table 2. Revealed pathology of the nasal cavity performed surgery to eliminate it

Таблица 2. Выявленная патология полости носа и оперативные вмешательства, выполненные для её устранения

Nasal disorder	Surgery
Nasal septum deviation (functionally significant)	Reconstruction of the nasal septum
Swell body	Laser surgery
Соncha bullosa	Partial middle turbinectomy
Vasomotor rhinitis	Laser coagulation of inferior turbinates; lower submucosal vasotomy with disintegration and lateropexy

 

RESULTS AND DISCUSSION

The Healaflow^® is a slowly absorbable drainage implant designed for glaucoma surgery. It is an isotonic, sterile, apyrogenic, viscoelastic, pure, colorless, and transparent gel containing reticular sodium hyaluronate and phosphate buffer (pH 7.0) [2]. It is an easy-to-handle seamless implant that is compatible with mitomycin C [1].

We used the following technique to place the Healaflow^® implant into the lacrimal ducts:

• the syringe was removed from the sterile packaging; the cannula from the package (similar to a disposable cannula used for lacrimal syringing test) was tightly fixed at the end of the syringe;
• an anesthetic (Inokain or Alcaine) was instilled into the conjunctival sac twice at an interval of 3 min;
• the patient was asked to sit down, look up, and press his chin to the chest. In this position, the cannula was introduced through the lower lacrimal point and then pushed forward through the lower lacrimal canal to the lateral wall of the nasal bone. Then, the gel was injected until it appeared in the lower nasal passage;
• the cannula was slowly removed from the lower lacrimal canal while injecting the gel. To control the process of gel injection, we checked filling of the lacrimal sac with gel (by palpation) and gel escape from the lower lacrimal point (gel drops could also come out from the upper lacrimal point).

In group 1, 9 patients reported increased lacrimation during the first day after the implantation. The procedure was well tolerated by all participants in general.

The results of the control examination performed at 3 months after treatment completion are shown in Table 3.

 

Table 3. The results of the control examination after 3 months after treatment

Таблица 3. Результаты контрольного осмотра через 3 месяца после проведённого лечения по группам

Excessive lacrimation	Group I	Group II
None	12	7
Reduced	3	6
No change	–	1
Total (patients)	15	14

 

Patients from both groups experienced improvement after nasal surgeries, including reduced lacrimation, improved nasal breathing, and better olfaction. The effect was more pronounced in patients from the study group. Out of 15 patients, 12 reported absence of excessive lacrimation, whereas remaining 3 patients reported reduced lacrimation. In the control group, 7 patients showed no excessive lacrimation, 6 patients showed reduced lacrimation, and 1 experienced no changes. The Healaflow^® implant could maintain the volume of the lacrimal ducts and prevent scarring due its long life-time in the LDS.

CONCLUSION

1. The use of the Healaflow^® drainage implant in the LDS of patients with epiphora after nasal surgery is a safe and well-tolerated procedure that ensures a good drainage effect. It reduces the patient complaints of excessive lacrimation and improves the quality-of-life.
2. This is a simple and easily available method, without any side-effects.
3. We recommend this method for patients with lacrimal disorders and epiphora to improve the drainage effect as well as to prevent scarring in the complex treatment of lacrimation system impairments.

• The authors declare no conflicts of interest related to the current manuscript.
• Authors’ contribution:

Research concept and study design: N.Yu. Beldovskaya, M.A. Shavgulidze, and S.A. Karpischenko.

Data collection and processing: N.Yu. Beldovskaya, M.A. Shavgulidze, and E.E. Farikova.

Data analysis and drafting the manuscript: N.Yu. Beldovskaya and E.E. Farikova.

About the authors

Natalya Y. Beldovskaya

Academician I.P. Pavlov First Saint Petersburg State Medical University

Author for correspondence.
Email: beldovskay@mail.ru

MD, PhD, Assistant Professor, Ophthalmology Department

Russian Federation, Saint Petersburg

Sergey A. Karpichenko

Academician I.P. Pavlov First Saint Petersburg State Medical University

Email: karpischencos@mail.ru

MD, PhD, Professor, Head of the Otorhinolaryngology Department

Russian Federation, Saint Petersburg

Marina A. Shavgulidze

Academician I.P. Pavlov First Saint Petersburg State Medical University

Email: soikomedplus@mail.ru

MD, PhD, Assistant Professor Otorhinolaryngology Department

Russian Federation, Saint Petersburg

Elmaz E. Farikova

Academician I.P. Pavlov First Saint Petersburg State Medical University

Email: Fortuna_s_krilami@mail.ru

Resident, Ophthalmology Department

Russian Federation, Saint Petersburg

References

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