Management of inferior dislocation of a StopLoss Jones tube after conjunctivodacryocystorhinostomy

Abstract

Persistent epiphora significantly worsens one’s quality of life. A commonly known method of treatment of complete obstruction of the lacrimal canaliculi is conjunctivodacryocystorhinostomy with placement of a glass Jones tube. Unfortunately, the use of such a prosthesis of the lacrimal tract often results in certain complications, the most frequent of which include extrusion or superior and inferior migration. For the last several years, a modified version of the Jones tube—the StopLoss Jones tube (SLJT)—has been available. It almost eliminates the possibility of extrusion. However, inferior migration still remains an important problem. When that happens, it is necessary to proceed surgically. In this paper, we describe an endoscopically-guided technique of management of an inferiorly dislocated SLJT.

Background

Epiphora conspicuously worsens one’s quality of life and is among the most frequent ophthalmological symptoms. This condition may be associated with improper patency of tear drainage pathways. In such a case, there is a structural obstacle in the lumen of the lacrimal canaliculus, lacrimal sac or nasolacrimal duct.

Complete proximal bicanalicular obstruction has been a significant diagnostic (often unclear causes) and therapeutic challenge for many years. When this occurs, the patients are usually treated with conjunctivodacryocystorhinostomy (CDCR) with placement of a bypass Jones tube, the use of which was first described by Lester Jones in a paper from 1962.^{1 2} The procedure involves inserting a glass prosthesis draining tears directly from the conjunctival sac to the nasal cavity. Placement of a Jones tube is possible via external CDCR or endoscopic CDCR approach. In both of these cases, the initial element of the procedure is the performance of dacryocystorhinostomy (DCR). The surgically created fistula allows placement of the glass prosthesis. Selected authors also describe a minimally invasive procedure of conjunctivorhinostomy (CR) with a Jones tube insertion.^{3 4} This surgery does not involve a DCR. Its basic steps include introducing a metal trocar through the lacrimal caruncle and lacrimal bone into the nasal cavity. Next, the created channel is expanded. Based on the measurement of its length, an appropriate tube size is selected. The prosthesis is introduced using a metal guide. A suture is placed to stabilise the proximal end of the tube. The suture is usually removed after a few weeks. Frequently, a reduction of the anterior part of the middle turbinate is necessary to create an adequate space for the distal end of the glass prosthesis.

In recent years, the use of a StopLoss Jones tube (SLJT) has been more widely accepted in the CDCR procedures (figure 1). It significantly lowers the risk of extrusion in the postoperative period. Thanks to the placement of a silicone flange near the distal end of the tube, it is unable to shift in the superior lateral direction. Unfortunately, the problem of inferior dislocation remains unsolved and is a frequent concern. In such cases, it is necessary to pursue surgical intervention to reposition the tube. The procedure can be challenging, especially if the patient reports so late that the conjunctival scar has already covered the proximal end of the tube.

Figure 1.

StopLoss Jones tube (red arrow: proximal flange; green arrow: distal silicone flange).

In this paper, we present the case of a 65-year-old female patient who reported to our eye department with the inferior migration of an SLJT combined with simultaneous closure of the conjunctiva over its proximal end. We used a minimally invasive, endoscopically guided approach to reposition the tube.

Case presentation

A 65-year-old woman reported to our ophthalmological ward for repositioning an inferiorly dislocated SLJT on the right side. Five months before, at our hospital, she had undergone endoscopic CR without a DCR. We had used an SLJT with the size of 20 mm/3.5 mm (length/proximal flange diameter).

The case history revealed that the suture had been removed 4 weeks after surgery. The patient was seen on the first day after surgery, after 1 week, after 1 month (suture removal) and after 2, 3 and 4 months, respectively. During follow-up visits, we assessed the patient’s level of satisfaction, severity of symptoms and tube patency (on irrigation), and performed nasal endoscopy. If necessary, the tube was cleaned with a micro brush.

At the 2-month follow-up, a lower tube location and conjunctival overgrowth surrounding the proximal outlet were noted. At follow-up after 3 months, the patient reported epiphora and the conjunctival folds practically covered the outlet. In-office repositioning of the tube was performed by gently pulling it upward with forceps. The patient was advised to report sooner in the event of symptoms recurrence. At 4 months after surgery, the patient reported with epiphora again. Inferior tube migration with complete conjunctival scarring over its proximal outlet was found. The patient was informed of the need for surgical repositioning of the tube, which was performed after a month.

Medical history showed that the patient had not undergone any surgery before. In terms of general diseases, she had received treatment for hypertension and hypothyroidism.

Investigations

The severity of symptoms was assessed using the Nasolacrimal Duct Obstruction Symptom Score (NLDO-SS) questionnaire (table 1).⁵ Tube drainage was evaluated using four categories enclosed in (table 2).⁶ Preoperative endoscopy of the right nasal cavity revealed an inferiorly dislocated SLJT with its distal end leaning on the nasal septum (figure 2). The dislocation was evaluated with a piece (15 mm) of a disposable sterile paper ruler. It revealed that the position of the distal silicone flange shifted 8 mm inferiorly. The middle turbinate showed a reduction in the front.

Table 1.

The Nasolacrimal Duct Obstruction Symptom Score questionnaire before surgery (0–10 scale scoring for each parameter)

1	Tearing	8
2	Irritation	5
3	Pain	1
4	Discharge	2
5	Swelling	0
6	Visual acuity	5

Table 2.

The objective assessment of tube functions

Class I drainage	Spontaneous fluid drainage
Class II drainage	There is no spontaneous fluid drainage but the fluid disappears on exaggerated nasal respiration
Class III drainage	Fluid does not drain with respiration but the tube can be irrigated
Class IV drainage	The tube cannot be irrigated

Figure 2.

Nasal endoscopy before surgery.

Treatment

The surgery was performed under general anaesthesia. The nasal mucosa was decongested by a limited 5 min nasal packing with a solution of epinephrine and 2% lignocaine in a ratio of 1:10 000. The distal end of the SLJT was cleared of discharge with suction. Next, an ear hook was inserted into the nasal cavity. The hook’s tip was introduced into the distal outlet of the tube, and upward lateral pressure was exerted on it. The conjunctiva was dissected with Castroviejo scissors in the medial canthal area. The scissors tip was used to find the proximal outlet lumen of the SLJT, while the ear hook was continuously exerting pressure on the distal end. Next, an intravenous cannula was introduced into the lumen of the SLJT proximal end. It further served as a guide wire for the tube. This was followed by increased pressure on the distal end of the tube. As a result, the proximal flange came out of the conjunctival wound in the medial canthus. Next, a suture was placed to fix the proximal end of the prosthesis. The tube was checked for patency, and the procedure was completed (videos 1 and 2).

Video 1.

Download video file ^{(13.4MB, mp4)}

DOI: 10.1136/bcr-2020-236003.video01

Video 2.

Download video file ^{(13MB, mp4)}

DOI: 10.1136/bcr-2020-236003.video02

Outcome and follow-up

Follow-up took place 1 day, 1 week, 1 month (change of suture), 3 months, 6 months and 12 months after surgery. During follow-up visits, symptom severity was assessed using the NLDO-SS questionnaire, and patient satisfaction was evaluated based on the Jones tube satisfaction questionnaire (tables 3 and 4). Tube patency was checked, and endoscopy of the nasal cavity was performed. The patency was in class II during all postoperative visits (table 2). If necessary, the tube was cleaned with a micro brush. During the 12 months covered by the research, the glass prosthesis remained unobstructed. The level of symptom severity in the postoperative period is shown in table 3, while the level of satisfaction is presented in table 4.

Table 3.

Nasolacrimal Duct Obstruction Symptom Score after surgery at subsequent follow-up visits

		1 week	1 month	3 months	6 months	12 months
1	Tearing	2	2	2	2	2
2	Irritation	1	1	1	1	1
3	Pain	2	1	1	1	1
4	Discharge	0	0	1	0	1
5	Swelling	1	0	1	0	0
6	Visual acuity	2	2	2	1	2

Table 4.

The Jones Tube Satisfaction Questionnaire

		1 week	1 month	3 months	6 months	12 months
1	Fully satisfied
2	Moderately satisfied	●	●	●	●	●
3	Acceptable
4	Dissatisfied

Fully satisfied: the problem disappeared, the eye is healthy; moderately satisfied: most symptoms occurring prior to the surgery resolved; acceptable: there is improvement, but most of the ailments have not gone away; however, if the patient could go back in time to the decision about surgery, having the current knowledge, he/she would have still made the same decision to undergo surgery; dissatisfied: absence of improvement; if the patient could go back in time to the decision about surgery (with current experience), he/she would not have undergone surgery.

Discussion

CDCR with placement of a Jones tube is an accepted method of treating persistent epiphora due to complete obstruction of the lacrimal canaliculi.^{1 7–10} This procedure efficiency reaches 90%, where efficiency is understood as achieving a clear passage of tears to the nasal cavity.¹ The fact remains that the percentage of postoperative complications is high. In numerous publications, the rate of extrusion ranges from 28% to even 64%, and malposition from 22% to 28%.^{8 11–14} To avoid such adverse implications, various modifications of the Jones tube (different sizes of flanges, bent shape, expanded middle portion, porous surface and additional silicone flange at distal end) have been developed over the years.^15–19 Most of these innovations have not caused a radical reduction in the number of complications.

In recent years, some authors have indicated that the use of SLJT has significantly reduced or even eliminated the possibility of extrusion. Bagdonaite and Pearson report that the percentage of SLJT extrusions in the study group in the 20-month period after surgery was 0%.²⁰ In the latest publication from 2020, Timlin et al report a rate of tube extrusion of 3%.¹⁴ SLJT differs from a typical Jones tube by an additional silicone flange located 2 mm before the distal end. It prevents upward movement of the prosthesis. Unfortunately, this innovation does not reduce the number of complications in the form of inferior migration. A publication from 2015 comparing the results of treatment with three different types of Jones tubes—conventional, frosted and StopLoss—reports the percentage of inferior dislocation, respectively, at 18%, 20% and 14%.²⁰ Timlin et al report the percentage of 13% for plain Jones tube and 26% for SLJT.¹⁴ However, it seems natural that the possibility of inferior migration of the tube may be affected by the diameter of the proximal flange. Bagdonaite and Pearson report that in the group of tubes with a 3.5 mm flange diameter, this type of complication occurred in 25%, and in the group with a 4.0 mm diameter in 13%.²⁰

Timlin et al postulate the use of longer SLJT tubes than previously recommended.¹⁴ This notion comes out of a conviction about the significant role of variation in thickness of the nasal mucosa due to its periodic swelling resulting from various factors. The thickness of the nasal mucosa may vary from 0.3 mm to 5 mm as a consequence of changes in air temperature, humidity, physiological nasal cycle, infection, allergies and more.^{21 22} Previously, it was recommended to choose such an SLJT length to enable a 2 mm gap between the silicone flange and the nasal mucosa surface.¹⁵ It seems reasonable to conclude that increasing mucosal swelling could put pressure on the silicone flange, followed by downward pulling of the entire tube. This is indicated by a higher percentage of inferior SLJT migrations in the range of shorter lengths used.^{14 15} Therefore, it is currently postulated to keep a 4.0 mm gap between the flange and nasal mucosa to leave space for fluctuation in its thickness.¹⁴ During the initial placement of SJLT 17 months earlier, we had used a 2 mm gap, because of the fact that the current data had not been yet available.

In the presented procedure of management of an interiorly dislocated SLJT, it is essential to find the lumen of the proximal outlet of the tube with scissors, while applying pressure to the distal end with a hook. Usually, searching for a lost tube in scar tissue located in the medial canthus demonstrates a problem. In our procedure, due to the pressure from inside the nasal cavity, hard resistance can be palpable in the medial canthus. Then, the tube lumen can be found by inserting closed scissors into the tissue. After feeling hard resistance (glass in the tissue), they can be opened gently. Again, the resistance that prevents their opening is a sign that the tip of the scissors is in the lumen of the tube. An intravenous cannula is then introduced as a guide wire for the tube. In this manner, the glass prosthesis is pushed out until the proximal flange is revealed on the conjunctival surface. By application of the principles described, the procedure becomes uncomplicated.

In the 12-month period after surgery, the symptoms associated with lacrimal tract obstruction significantly decreased, although they did not completely cease (table 3). The level of satisfaction throughout the study period was ‘moderately satisfied’. At our ophthalmological ward, we used our own assessment of patient satisfaction after a Jones tube placement (table 4). The moderate level of satisfaction may also be affected by leaving the suture affixing the tube in the medial canthus for the duration of the study. The suture did not cause discomfort, but the very fact of its presence could have affected the patient’s psyche. At our facility, due to the relatively high risk of downward SLJT migration, we leave the fixation suture for as long as it does not cause problems. In our estimation, the presented technique is useful in the management of an inferiorly dislocated SLJT.

Learning points.

• Jones tube is the treatment method of choice for complete proximal obstruction of both lacrimal canaliculi on the same side.

• The incidence of postoperative complications in the case of Jones tube placement is relatively high.

• StopLoss Jones tube significantly reduces complications in the form of extrusion but does not improve the issue of inferior dislocation.

• Repositioning of a migrated Jones tube can be performed in a relatively simple way under endoscopic control in the specified manner.