Background
Conjunctivodacryocystorhinostomy (cDCR) using a glass bypass tube (Lester Jones tube, Gunther Weiss Scientific Glass Blowing Company, Portland, OR) can be used in the surgical management of proximal nasolacrimal obstruction. These tubes bypass the canaliculi, nasolacrimal sac and duct, forming a direct conduit for drainage of the conjunctival tear lake into the nose. The insertion and positioning of the bypass tubes can be challenging, as they are small, smooth surfaced and can fracture during insertion.
Technique
We describe the technique for endoscopic-directed Lester Jones tube insertion using a punctal dilator (Nettleship dilator, Accrington Surgical Instrument Suppliers, Accrington, Lancashire), lacrimal probe (Set Leibreichs probe, Altomed Limited, Tyne and Wear) and a Jobson Horne (Medisave UK, Dorset,) all instruments readily available to an ENT surgeon.
The caruncle is excised to allow space to accommodate bypass tube collars when in position. The Nettleship dilator is used to create a passageway into the nose (Figs 1 and 2). The lacrimal probe is inserted through the ring of the Jobson Horne (Fig 3) and the bypass tube is threaded over the remaining lacrimal probe. The bypass tube is inserted through the tract using the Jobson Horne to apply controlled pressure (Figs 4 and 5) until the tube is flush with the conjunctiva (Fig 6).
Figure 1.
Figure 2.
Figure 3.
Figure 4.
Figure 5.
Figure 6.
Discussion
The technique has proven to be a simple, reliable method for insertion of a bypass tube for both ear, nose and throat and ophthalmic surgeons practising endoscopic nasolacrimal procedures.