Operative Technique

Repair of the canalicular system is optimally done under general anesthesia. Microsurgical repair by surgical loops or operating microscope is necessary [6, 46]. Before starting repair, it is important to constrict the nasal mucosa with oxymethazoline or 0.25% phenylephrine on cotton pledgets placed inferiorly to the inferior turbinate. This will shrink the inferior turbinate and improve visualization. Following this, injection with 2% lidocaine with epinephrine 1:100,000 is done followed by repacking of the inferior meatus with the soaked cotton pledgets.

The punctal dilator is used to enlarge punctum and the lacrimal probe is used to navigate the proximal canaliculus until the cut canaliculus is identified laterally. Canalicular injuries should be repaired

within 24-48 h after injuries [6, 46], because the medial cut edge of canaliculus becomes progressively more difficult to identify as fibrin and granulation deposition occurs. The medial cut edge of canaliculus is identified successfully by direct inspection. The cut canaliculus is identified as white mucosal tissue with wall and lumens. Deliberate inspection with gentle traction of the crowded tissue is often necessary. If discovery of the lumen remains difficult, injection of air into the uncut canaliculus while observing the medial cut area submerged in saline may uncover its location with the appearance of air bubbles [47-49]. Also, skin hooks and silk traction sutures can be used to retract the medial eyelid tissue as necessary.

After identification of the medial cut edge of the canaliculus, a Crawford tube is used to intubate the distal canaliculus and the lacrimal sac and duct. Following this, a metallic probe attached to silicone tubing is insinuated into the proximal canaliculus, distal canaliculus, and then the lacrimal sack and duct. It is necessary to orient the probe to follow the anatomical course of the lacrimal system. Because visualization of the distal canaliculus is easily lost, it is useful to keep the Crawford tube in place until the moment of intubation with the silicone tubing. The hook or grooved dissector is used to deliver the probe from beneath the inferior turbinate and out the nostril. When a bicanilicular system is used, the opposite ca-nilicular system is insinuated in a similar way and retrieved through the nares.

The canaliculus can be approximated by two to three absorbable 8-0 sutures placed in the mucosal wall of cut canaliculus in order to achieve an end-to-end anastomosis of the tube [50, 51]. Some authors [52, 53] used single stitch repairs with 7-0 vicryl horizontal mattress sutures, which passed in the plane directly anterior to the canaliculus. The results [52] are excellent, although 4% still have epiphora and 13% still have delay outflow with dye disappearance test.

With compete avulsion of the medial canthus from its origin at the anterior lacrimal crest, reapproximation can be done with a double armed 4-0 silk suture. This suture should be placed through the lateral wound edge with a substantial bite followed by a deep medial bite which would ideally include periostium of the anterior lacrimal crest. The sutures should be tied over the skin using bolsters of foam or rubber.

With bicanilicular intubation, the distal tube ends are joined with five single throws of the silicone suture. The silicone should have enough tension on it to recess at least 1.5 cm into the nares after they are tied and released.

If the eyelid margin lacerated, 6-0 silk suture is placed through three layers, tarsus to tarsus via mei-bomian orifice, gray line, and lash line. These marginal sutures should be reflected away from the globe and tied to skin (Figs. 9.5-9.13).

Nasolacrimal Duct Avulsion

Fig. 9.5. A patient with complete avulsion of the upper and lower eyelids with canalicular injury. In the upper eyelid it is important to identify and repair the levator muscle that has been lacerated. The repair is done in three layers (the conjunctiva, the levator, and the skin). It is difficult in these cases to identify the distal lacerated common canaliculi. The use of the surgical microscope and painstaking repair is required to affect good result

Fig. 9.5. A patient with complete avulsion of the upper and lower eyelids with canalicular injury. In the upper eyelid it is important to identify and repair the levator muscle that has been lacerated. The repair is done in three layers (the conjunctiva, the levator, and the skin). It is difficult in these cases to identify the distal lacerated common canaliculi. The use of the surgical microscope and painstaking repair is required to affect good result

Fig. 9.6. Same patient. After punctal dilation, the Bowman probe 0-0 is passed through the upper canaliculus, through the naso lacrimal system, through the valve of Hasner, and then into the nose. The direction of the probe will be helpful when the Crawford intubation is done
Hasner Membran

Fig. 9.7. Same patient. One olive-piped rod of the double armed silastic tube is placed through the upper canalicular system while the other is placed through the lower canalicular system. Each rod is retrieved in the nares, leaving a loop of tubing between the upper and lower punctum (demonstrated here with Crawford tube system)

Fig. 9.7. Same patient. One olive-piped rod of the double armed silastic tube is placed through the upper canalicular system while the other is placed through the lower canalicular system. Each rod is retrieved in the nares, leaving a loop of tubing between the upper and lower punctum (demonstrated here with Crawford tube system)

Crawford Tube

Fig. 9.9. Same patient. An olive-tipped probe has been grasped by the hook to complete the bicanalicular intubation. Shrinkage of the inferior turbinate with the use of a vasoconstrictor is helpful in the identification of the Crawford probe prior to grasping it. Nasal endoscopy can be quite helpful in this step

Fig. 9.9. Same patient. An olive-tipped probe has been grasped by the hook to complete the bicanalicular intubation. Shrinkage of the inferior turbinate with the use of a vasoconstrictor is helpful in the identification of the Crawford probe prior to grasping it. Nasal endoscopy can be quite helpful in this step

Nasolacrimal Injury
Fig. 9.8. Same patient. The Crawford probe and tube is passed into and through the lacrimal system. After the Bowman probe has helped to define the direction of the angle into the nose. The Freer elevator is used to palpate the end of the probe in preparation for the retrieval of the Crawford tube

In conclusion, the principal techniques for repair canalicular laceration are:

1. Reanastomosis of the cut edge

2. Endocanalicular support with silicone tube

3. Use of direct catheterization if possible, or with an inexperienced surgeon, to avoid uninjured canaliculus injury

Nasolacrimal Duct Laceration
Fig. 9.10. Same patient. After intubation has been completed, the tissues are brought into position. Repair of the canalicula and eyelid laceration is then completed. A 4-0 double-armed silk suture is passed anterior and superior to the tube over a sponge bolster
Silicone Tube Intubation
Fig. 9.11. Same patient. A double-armed needle is passed anterior to the medial canthal tendon in a superior medial direction. The double arm suture is passed through a similar bolster and tied after the lacerated eyelid margins are repaired

Fig. 9.12. Same patient. The patient seen immediately after repair of eyelid injuries. The angle of the medial commissure is well defined and the silastic intubation is in good position

Exotic Piercings

Fig. 9.13. Same patient. The patient seen 2 months postopera-tively. The repair is successful with no epiphora despite the severe injury gery. If the patient has no stent-related problem, the stent is kept in place for 3-6 months.

Essentials of Human Physiology

Essentials of Human Physiology

This ebook provides an introductory explanation of the workings of the human body, with an effort to draw connections between the body systems and explain their interdependencies. A framework for the book is homeostasis and how the body maintains balance within each system. This is intended as a first introduction to physiology for a college-level course.

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