Patients and their families should be clear: lacrimal system disease is a complex and difficult eye and nose related diseases, mainly manifested as lacrimation, obstruction, pus flow, etc.! It is difficult to be cured by eye drops etc.! If left untreated, it may lead to acute inflammation, infection in case of trauma, and affect the implementation of ocular surgery, etc.! Some patients with simple upper or lower lacrimal duct obstruction, stenosis or common lacrimal duct obstruction, with mild lacrimal symptoms and no obvious discharge, especially older patients and those with combined conjunctival relaxation and lid gland insufficiency, may be considered for temporary observation without surgical treatment and conservative treatment first. The pathogenesis is unknown and is related to the living environment, genetics, anatomy, age (more common in children and 30-60 years old) and gender (more common in women), etc. Since part of the lacrimal duct is located in the nose and is closely related to nasal disease, a comprehensive evaluation of the eye and nose, and even the orbit and maxillofacial area, should be performed to come up with a better treatment plan. In the case of combined nasal or maxillofacial diseases, our hospital is limited by the lack of equipment, so these patients need to be treated by ENT and maxillofacial surgery. We hope that patients and their families will understand and cooperate with us. Inpatients should not take leave to go out! There is no single surgical procedure that can solve all lacrimal tract diseases, and therefore there are certain risks regardless of the surgical procedure. The first thing we do is to determine whether the disease is indicated for surgery, the second thing is whether the hospital has the technical level and equipment to perform the surgery, and the third thing is whether the patient and his family can understand and accept the surgery.
Pre-operative lacrimal sac imaging: pre-operative lacrimal sac imaging is needed to determine the size, location, obstruction site and the inner surface of the lacrimal sac (after opening the checklist and paying for the medication, first go to the treatment room on the 1st floor of the 1st floor of our hospital, and then go to the radiology department for examination), the larger the lacrimal sac is, the worse the effect of simple lacrimal laser surgery may be, other procedures can be taken.
(Pre-operative nasal examination: because our hospital is an ophthalmology hospital, there is no otorhinolaryngology, patients can take the principle of proximity to nearby tertiary hospitals (458 East Dongfeng Road Hospital “Air Force Hospital”, Zhongshan Second Road, the First Hospital of Sun Yat-sen University, the First People’s Hospital of Guangzhou, Guangdong Provincial People’s Hospital otorhinolaryngology nasal endoscopy + photos to understand the middle and lower turbinates, nasal tract, nasal septum, nasopharynx, except tumors!) If you have rhinitis and sinusitis, nasal polyps, enlarged turbinates, deviated nasal septum and other lesions, the results are poor!
Pre-operative CT examination: Some patients also need to perform orbital CT (coronal scan + plain scan) (imaging department of the above-mentioned tertiary hospital) to understand the internal and peri-orbital tissues of the lacrimal sac, such as the nasal bone, lacrimal bone and orbital bone, for trauma, recurrent, hard, elevated, poorly defined borders, abnormal secretions need to exclude the possible existence of lacrimal sac tumor and need to go to the ocular oncology department for further examination, in order to clarify the surgical methods and means, but However, some rare tumors are not clear in all preoperative examinations, so the diagnosis may need to be confirmed after intraoperative resection pathology examination (we do not have intraoperative frozen section pathology examination, so please forgive us, patients and families!)
Preoperative diagnosis: chronic dacryocystitis (primary, congenital, traumatic, recurrent), acute dacryocystitis, lacrimal duct stenosis, lacrimal duct obstruction, total lacrimal duct obstruction, lacrimal duct obstruction, lacrimal duct dissection (fresh, old), lacrimal duct agenesis secondary to ocular surface burn, lacrimal duct atresia, absent lacrimal duct, lacrimal ductitis, neonatal dacryocystitis, lacrimal foreign body, lacrimal sac swelling, lacrimal duct swelling, lacrimal duct ectropion (or combined lower lid ectropion), lacrimal sac fistula, etc.
Surgical methods: there are many ways, mainly divided into the following categories, one is the “recanalization method”: tear laser shaping + prosthetic tube implantation, tear laser shaping, lacrimal duct exploration, lacrimal punctum exploration and shaping placement, lacrimal duct incision and shaping, lacrimal endoscopic tear laser ablation + prosthetic tube implantation, lacrimal duct exploration and anastomosis prosthetic tube implantation The second is the “rerouting method”: nasal endoscopic lacrimal sac rhinostomy + prosthetic tube implantation, transdermal lacrimal sac nasal anastomosis, nasal endoscopic laser lacrimal sac rhinostomy combined with lacrimal duct prosthetic tube implantation, the third is the “reconstruction method”: artificial lacrimal duct implantation, conjunctival lacrimal sac anastomosis, decellularized dermal conjunctival lacrimal sac (or conjunctival nasal) anastomosis lacrimal reconstruction, and lacrimal sac removal + upper and lower lacrimal duct incision + medial canthal ligament repair, lacrimal sac fistulotomy, lacrimal punctal ectasia correction, etc.
Post-operative recurrence: under the current medical conditions, they are not 100% curable! Not to mention that it cannot be cured! The general success rate is 70-90%, and the success rate of some patients is less than 30%! Especially some such as long obstruction range, age-related, recurrence, trauma, keloid, immune diseases, congenital genetic and functional aspects are more so!
Postoperative lacrimation: In the early postoperative period, due to poor drainage of the lacrimal duct, some patients will continue to have lacrimation, which may be better after removal of the tube, but some successful patients still have lacrimation due to poor lacrimal pump function or other ocular surface diseases, reduced tear aspiration or combined ocular surface diseases, not related to the surgery itself! (Each patient’s reaction is different, and it is obvious in case of wind and cold days), you can apply hot compresses or lightly massage the tear sac area! Some patients with failed surgery will have the same tearing and pus symptoms as before surgery!
Purulent secretions: mucus purulent, celiac-like secretions, yellow-white purulent, transparent gel-like secretions, cheese-like secretions, etc., each with different efficacy! The efficacy is worse for those with gel-like secretions and large and sticky amounts! A small number of patients still have a little mucus-like secretion even though the lacrimal duct is flushed smoothly after surgery, which is due to the patient’s reduced pumping ability of the lacrimal sac, so it is difficult to achieve a completely secretion-free state, and bacterial culture + drug sensitivity and fungal culture + identification of the conjunctival sac secretion can be considered to clarify whether there is a possible bacterial infection.
Postoperative scarring: postoperative scarring of the skin of the lacrimal sac area and lacrimal duct lacrimal dots will occur in patients with skin incisions or skin trauma (may be obvious if there is a keloid)
Pre-operative attention: cold, fever, cough, hypertension, severe diabetes, mental illness, blood clotting abnormalities, serious respiratory diseases such as asthma and other systemic diseases and early menstrual period of women are not allowed to operate. Jewelry and valuables should be removed and put at home. Pre-operative clothing should be center-buttoned! Please note that anticoagulant drugs should be stopped in advance in consultation with a cardiologist, and blood pressure drugs and blood sugar drugs should not be stopped.
Some patients may not be able to implant the prosthetic tube or implant the tube only from the lower/upper tear dots because of narrow tear ducts, bony obstruction, intraoperative bleeding, turbinate hypertrophy, and patient intolerance (which does not affect the efficacy of the treatment). It is normal to see a white silicone tube in the corner of the eye during the tube carrying period.
Age of surgery: Age is related to the procedure. Patients over 70 years of age have thinning and brittle nasal mucosa, declining tear duct function, brittle bone and easy bleeding, etc. Conventional surgery is less effective and often requires consideration of a different procedure.
Problems related to surgery: If laser lacrimal surgery is performed, local nerve block anesthesia is used, and most patients can tolerate it, if nasal endoscopy is performed, general anesthesia is used, and there may be slight pressure pain in the inner corner of the eye in the early postoperative period. If bilateral surgery is required, it can be done in one visit, but if some patients cannot tolerate it, it can be done at least in separate visits on alternate days. Some elderly patients who experience a significant increase in blood pressure before or during surgery, resulting in significant intraoperative bleeding that cannot be easily stopped, may be considered for discontinuation of surgery until their blood pressure stabilizes. For outpatients, please register a general number at 8:00 a.m. on the day of surgery and go to the second section on the third floor of Building 1 to see the doctor to sign the consent form for surgery. The doctor will arrange the surgery time. The nurse will prepare for the surgery before the operation, and then go to the 9th floor of Building 2 for the surgery.
Related cost: General local block anesthesia usually costs about 4,000-5,000 RMB, while those who need general anesthesia for nasal endoscopy need about 10,000 RMB.
Post-operative treatment: Outpatients should take back their outpatient medical records after surgery and then return to the lobby seat of Zone 2 on the 3rd floor of Building 1 to rest for 2 hours. Please do not lower your head and blow your nose for a long time to avoid bleeding, observe nasal bleeding, and leave only after the nurse has checked that there is no abnormality. Postoperative local edema can be applied with cold compresses or ice packs when eyes are closed, and will generally subside after 1-2 weeks. Bloody nasal discharge may occur within 4 weeks after surgery.
Post-operative tear duct rinsing: register a general number for tear duct rinsing in the plastic laser room on the 1st floor of Building 1 before 10:00 a.m. within 3 days after surgery, and bring the rinsing medication compound neomycin and chymotrypsin drops with you. The clinic will not be open on weekends and holidays, and the nurse manager will arrange a follow-up appointment according to the rinsing situation after the rinsing. If you do not flush the tear duct on a regular basis, the postoperative outcome will be significantly affected! You should avoid flushing from the tear dots to prevent tearing of the tear dots, and then flush the tear dots at intervals of 1 week, 2 weeks, 3 weeks and 1 month. Please consult with the lacrimal flushing physician for the specific time of review and flushing. Post-operative lacrimal duct dissection routinely does not work for tear duct flushing!
If the duct comes out from the nasal cavity after surgery, you can clean it by yourself and push it back into the nostril with your pinky finger or cotton swab in front of the mirror, if it comes out from the corner of the eye, you can gently send it back to the side of the nose in front of the mirror (while blinking), usually you can send it back, if you cannot send it back, you need to come to the hospital, you cannot pull it out by yourself! Therefore, when wiping tears or washing your face, you should not wipe the corner of your eye with a towel to prevent the prosthetic tube from being taken out! Some patients have a smooth lacrimal duct lumen due to better epithelialization after surgery, especially when sneezing, the prosthetic tube may easily come out of the nostril.
Postoperative dialing: performed 2-5 months after surgery, some patients may dial earlier if they have tearing of tear dots, formation of granulation polyps, keratoconjunctival injury, prosthetic tube rejection, infection, and repeated prolapse. Patients with scarring or total lacrimal obstruction may delay the canal dialing until 1 year later. The specific decision will be made by the reviewing physician.
Postoperative medication: local medication is usually needed for about 4-6 weeks after surgery, and the secretions should be drained by gently pressing the tear sac area at the corner of the eye before ordering eye drops. The nasal spray medication should be sucked back when used! If systemic medication is needed, it will take about 1 week
Diet: It is recommended to eat a light diet, do not eat hard and tough food, for fried fire such as lychee, longan, spicy hot high-fat food to eat less or not, especially before and after surgery, avoid staying up late, excessive fatigue, avoid eating a lot of raw fish and seafood, leeks, soy products and Qi, blood food such as Astragalus, angelica, ginseng, deer antler, red dates, etc., can be appropriate to take some more heat, detoxification, dampness soup type and food such as Fu Ling or Wu Zi Mao Tao bones.