Misplaced Intracystic Lacrimal Implant- An Unusual Cause of Failed External Dacryocystorhinostomy

Abstract

Background

Various techniques of dacryocystorhinostomy (DCR) by an external or endonasal endoscopic approaches are in practice of ophthalmologists and otorhinolaryngologists. The purpose of this paper is to report a case of misplaced intracystic implant in the orbit following external DCR leading to persistence of watering, diplopia and visual diminution.

Case Report

A thirty nine year old female patient presented with recurrent left eye pain, swelling over medial side of the left eye, watering, progressive blurring of vision and diplopia after revision external DCR. The ophthalmology examination revealed bilateral decreased vision, left side restricted extraocular eye movements, sub capsular cataract. The computed tomography dacryocystograph (CT-DCG) revealed tubular foreign body in the extra-conal space abutting the medial rectus with proximal block in the nasolacrimal duct.

Conclusion

This is the first reported case of misplaced implant following external DCR in the literature. It may be suggested that patients undergoing intracystic larimal implant shall be on close follow up for such an occurrence later for timely intervention.

Introduction

The dacryocystitis is an inflammatory condition of the lacrimal sac and nasolacrimal duct [1]. It leads to obstruction of nasolacrimal drainage system manifesting with watering from the eyes. The surgery of dacryocystorhinostomy (DCR) is the gold standard surgical treatment of blocked nasolacrimal duct (NLD) wherein a functional pathway is created surgically which allows drainage of tears from the lacrimal sac into the nose by means of an osteotomy and marsupialization in to lateral nasal wall mucosa [2–5].

It can be performed via an external or endonasal endoscopic approach. Various techniques of these surgeries are currently in practice of ophthalmologists and otorhinolaryngologists. One of these is external dacryocystorhinostomy (DCR) with intracystic implant placement. The placement of implant has been described with advantage as being small length incision (5–6 mm), minimal intra operative or postoperative bleeding. Avoidance of need for osteotomy and marsupialization of the sac in to lateral nasal wall are considered as advantages of the procedure, improving overall success rate [6].

The purpose of this paper is to present an uncommon misplacement of this implant in our patient causing multiple orbital and ocular problems leading to failed external dacryocystorhinostomy (DCR), diplopia and blurring of vision after the revision surgery.

Case Report

A thirty nine year old female patient presented to the ENT OPD with recurrent left eye pain, swelling over medial side of the left eye, watering, progressive blurring of vision and diplopia over five months. The patient had history of road traffic accident, she sustained facial trauma that required augmentation rhinoplasty and multiple reconstructive facial plastic surgeries.

The patient started complaining of left eye watering for which she underwent left endonasal dacryocystorhinostomy. She again developed left eye watering after few months for which she underwent left external DCR with intra cystic lacrimal implant placement. After few days of the surgery the patient started complaining of recurrent left eye pain, swelling over medial side of the left eye, watering and blurring of vision from left eye and diplopia (Table 1).

Table 1.

Preoperative and post operative eye examination

	Preoperative		Postoperative
	Right eye	Left eye	Right eye	Left eye
Vision	6/12	6/18	6/12	6/9
Extra ocular movements	Free and full	Levoversion, levoelevation, levodepression deficit present	Free and full	Free and full
Pupil	NSRL	NSRL	NSRL	NSRL
Lens	IMSC NS 1	IMSC NS, 2 + PSC	IMSC NS 1	IMSC NS 2 + PSC
Regurgitation ROPLAS* test	ROPLAS* -VE	ROPLAS + VE	ROPLAS -VE	ROPLAS -VE

NSRL-Normal size reacting to light

IMSC- Immature senile cataract, PSC- Posterior subcapsular cataract

ROPLAS* test- Positive test is regurgitation of mucus/ pus from punctum on giving digital pressure over lacrimal sac region

The ophthalmology examination revealed bilateral decreased vision, left side restricted extraocular eye movements, sub capsular cataract. On syringing and probing, there was regurgitation from left upper punctum on syringing and hard stop on probing. Nasal endoscopy was suggestive of lateral nasal wall scarring in the region of lacrimal sac (Fig. 1). The provisional diagnosis of left side acute on chronic dacryocystitis with sub capsular cataract with restrictive ophthalmopathy was made.

Fig. 1.

Preoperative nasal endoscopy showing scarring in lateral nasal wall

The computed tomography dacryocystograph (CT-DCG) was done (Fig. 2A and B). The lacrimal sac was opacified with regurgitation of contrast seen through the lower canaliculus on left side which was suggestive of proximal NLD obstruction. Also, there was evidence of tubular foreign body in the extra-conal space abutting the medial rectus.

Fig. 2.

A: Computed tomography dacryoscystograph axial section showing non opacified lacrimal sac on left side. B: Computed tomography dacryoscystograph axial section showing tubular intracystic implant in extraconal space

The patient was then posted for revision endonasal endoscopic DCR and implant removal under general anaesthesia after informed written consent. The mucoperiosteal flap based on uncinate process was raised, rhinostomy site was widened by punching the fronto-nasal process. The incision was made on medial lacrimal sac wall, thick mucus was aspirated from the lacrimal sac. A funnel shaped upper end of the implant was visualised inside the lacrimal sac (Fig. 3). The implant was stuck and found embedded with fibrotic tissue in the extraconal space. It was removed carefully after freeing it all around of its adhesions with orbital content (Fig. 4). The sac wall was everted and mucoperiosteal flap was reshaped to cover raw bony edges.

Fig. 3.

Intra operative endoscopic image showing in-situ intracystic implant inside the lacrimal sac*

Fig. 4.

Intracystic lacrimal implant after its removal

In the immediate follow up, the patient was completely relieved of symptoms of watering and diplopia. The nasal endoscopy showed patent sac region in post operative endoscopic examination (Fig. 5).

Fig. 5.

Post operative nasal endoscopy showing open lacrimal sac

Discussion

Prolong operative time, risk of intraoperative and postoperative haemorrhage and patient discomfort are the major issues concerning external DCR. To tide over these difficulties, a technique called “Implant Dacryocystorhinostomy” was introduced in 1985 by Pawar and Sutaria, with the aim to obtain and maintain a patent passage between lacrimal sac and the inferior meatus of the nose through the bony osteum without the need of rhinostomy and marsupialisation of sac in lateral nasal wall [7].

The Pawar’s intracystic implant is made up of medical grade silicone elastomer providing maximum tissue compatibility and minimum thrombogenicity. The length of implant varies from 12 to 17 mm with an external diameter 3 mm and an internal diameter of 2.5 mm. The implant is funnel shaped and has a collar of size 8 mm vertically and 5 mm horizontally, which rest on the lacrimal sac cavity (Fig. 4). The implants are provided with four holes at the upper end near collar and 6 holes at the lower ends 5 mm prior to distal end. They act as extra drainage channel having 1 mm diameter. The authors view for such design is to establish the flow of tears through the natural passage with additional drainage from the perforations on the stem even with luminal obstructions [7].

The proponents of this implant has outlined advantages over conventional DCR with few complications. In a prospective study by Chandravanshi et al. published in 2019 where 30 patients underwent external DCR alone and DCR with Pawar’s implant. They compared incidence of post-operative complications like lid oedema, incisional oedema, haemorrhage from nasal mucosa, sac infection, wound gape and hypertrophic scar. They concluded that the implant reduced occurrence of these complications. The authors attributed it to the minimally invasive nature of intracystic implant surgery [6]. However, complications like obstruction of passage and external extrusion are acknowledged.

In a study by Mishra et al. [7], where he compared conventional external DCR with DCR with Pawar’s implant placement, 33 patients underwent external DCR with Pawar’s implant placement there was a success rate of 97% at six months follow up [8]. The most common cause of failure of Pawar’s implant was mucus plug formation leading to obstruction of the tube, followed by sac infection, crust formation and extrusion of the implant through a skin wound.

In another study by Gupta et al., where she performed external DCR with Pawar’s Implant in 40 patients, the complications documented were bleeding per-operatively (5%), longer duration of surgery (7.5%), recurrence of symptoms (5%), pain at the incision site (2.5%) and mild ecchymosis (100%) [9].

This article reports a rare complication of implant migration in extraconal space after the surgery of external DCR leading to its failure. The fibrous adhesions between implant and orbital content lead to restriction of medial rectus muscle mobility further causing diplopia. The posterior sub capsular cataract was result of excess prescriptions of antibiotic steroid eye drops to treat acute exacerbations at the intervals. This unique presentation has never been reported in the literature.

Conclusion

This is first reported case of misplaced intracystic lacrimal implant following external DCR in the literature. The endonasal endoscopic DCR helped retrieve the implant without causing further morbidity to the patient and complete resolution of dacryocystitis. It may be suggested that patients undergoing such an implant shall be on close follow up for such an occurrence later.

Funding

Not funded.

Availability of data and material

(data transparency)

Code Availability

NA.

Declarations

Ethics Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration.

Consent to Participate

Verbal informed consent of participant taken.

Consent for Publication

All authors provide consent to publish.

Conflict of Interest

None.