Fig. 9.13. Same patient. The patient seen 2 months postopera-tively. The repair is successful with no epiphora despite the severe injury
In some very severe and extensive injuries, however, repair cannot be achieved the first time. Surgery should be obtained for the best possible repair of fracture and eyelids . Then a bypass tube procedure may be considered in the next step of management.
Generally, the silicone rods are well tolerated; however, if the tube is tied too tightly, or the lacrimal papilla is compromised, "cheese wiring" through the puncta and canaliculi may occur, necessitating the removal of the tube. A pyogenic granuloma may develop near the punctum in some cases and should be excised with cautery to its base.
The tube can irritate the cornea and conjunctiva with adduction of the eyes. Tear supplements should be used; however, if keratoconjunctivitis is persistent, the tube should be removed earlier. Commonly, the tube can prolapse and extrude. Often the tube can be replaced into proper position with forceps through an intranasal approach with the aid of an endoscope. If the surgeon cannot replace the tube, it can be removed.
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