|Year : 2018 | Volume
| Issue : 1 | Page : 78-82
Evaluation of intraoperative mitomycin C in surgical management of adult lacrimal sac mucocele
Rabi M.M. Hassenien1, Ahmad M Eid1, Mohamed F.K. Ibrahiem MD 2, Noha N Shehata3
1 Department of Ophthalmology, Minia University Hospital, 98 Korneesh El Nile Street, Minia, Egypt
2 Oculoplastic Unit, Department of Ophthalmology, Minia University Hospital, 98 Korneesh El Nile Street, Minia, Egypt
3 Department of Ophthalmology, Minia Ophthalmology Hospital, Saad Zaghloul Street, Minia, Egypt
|Date of Submission||12-Jun-2017|
|Date of Acceptance||31-Aug-2017|
|Date of Web Publication||1-Feb-2018|
Mohamed F.K. Ibrahiem
Oculoplastic Unit, Department of Ophthalmology, Minia University Hospital, 98 Korneesh El Nile Street, Minia 61111
Source of Support: None, Conflict of Interest: None
The purpose of this study was to evaluate the effectiveness of intraoperative mitomycin C (MMC) with canaliculodacryocystorhinostomy (DCR) and bicanalicular silicone intubation for the management of adult lacrimal sac mucocele.
Patients and methods
In a 3-year period, 30 eyes of 28 adult patients with acquired lacrimal sac mucocele were enrolled in the study after thorough evaluation and if required computed tomography imaging was taken. All patients had at least 8 mm of patent proximal canaliculi. Under general anesthesia, all patients underwent canaliculo-DCR with bicanalicular silicone intubation and intraoperative MMC 0.2 mg/ml solution applied for 5 min to the lacrimal passages. All patients were followed up for at least 12 months postoperatively.
The mean age of the patients was 48.90±12.28 years and 78.6% of the cases were women. After a follow-up period of an average of 16 months, 93.3% of the patients reported successful results (disappearance of epiphora and lacrimal sac swelling and patent lacrimal passages) and only 6.7% presented with recurrent epiphora and obstructed lacrimal passages. No case of recurrent lacrimal sac mucocele was reported.
Canaliculo-DCR with bicanalicular silicone intubation and intraoperative MMC yielded satisfactory results in 93.3% of adult patients with acquired lacrimal sac mucocele.
Keywords: acquired, adult, canaliculodacryocystorhinostomy, mitomycin C, mucocele
|How to cite this article:|
Hassenien RM, Eid AM, Ibrahiem MF, Shehata NN. Evaluation of intraoperative mitomycin C in surgical management of adult lacrimal sac mucocele. Delta J Ophthalmol 2018;19:78-82
|How to cite this URL:|
Hassenien RM, Eid AM, Ibrahiem MF, Shehata NN. Evaluation of intraoperative mitomycin C in surgical management of adult lacrimal sac mucocele. Delta J Ophthalmol [serial online] 2018 [cited 2018 Feb 24];19:78-82. Available from: http://www.djo.eg.net/text.asp?2018/19/1/78/224567
| Introduction|| |
Lacrimal sac mucoceles usually occur in the pediatric age group . In adults, acquired lacrimal sac mucoceles are rare and usually follow dacryocystitis and form as a result of obstruction of the distal or common canaliculus in addition to nasolacrimal duct obstruction . They are almost always associated with epiphora or swelling in the medial canthal region . Dacryocystectomy is reserved for those with dry eye or patients who were poor candidates for surgery or if lacrimal sac malignancy is suspected . External or endoscopic dacryocystorhinostomy (DCR) can be the first surgical choice if there is no upper lacrimal system damage; otherwise conjunctivo-DCR is the choice .
| Patients and methods|| |
This is a prospective, interventional nonrandomized study that was carried out in the Ophthalmology Department, Minia University Hospital, in the period from March 2011 to January 2013 after getting the approval of our Research Ethics Committee. All procedures in the study were performed in accordance with the ethical standards of the Institutional Research Committee and with the 1964 Helsinki Declaration and its later amendments (registration number: NCT03176355 in clinicaltrials.gov).
Adult patients with acquired lacrimal sac mucocele ([Figure 1]) were evaluated by routine full ophthalmic examination in addition to evaluation of the lacrimal drainage system by probing and irrigation of the lacrimal passages and inspection, and palpation of the mucocele itself. Computed tomography scans were obtained for cases with heterogeneous consistency for fear of lacrimal sac malignancy.
After excluding cases with acute inflammation of the lacrimal sac mucocele, previous lacrimal surgery, and those with less than 8 mm of patent proximal canaliculi, 30 eyes of 28 patients fulfilled our criteria and were enrolled in the study after obtaining an informed written consent.
All cases were operated upon under general anesthesia, with a nasal pack using gauze soaked in saline containing epinephrine 1 : 200 000 for hemostasis.
A vertical 15 mm long skin incision was made 10 mm nasal to the inner canthus; then blunt scissors were used to dissect the underling tissues and periosteum was incised parallel to the skin incision. The mucoid content of the enlarged lacrimal sac was aspirated using a 10 ml syringe to allow for more space and better exposure of the lacrimal sac fossa. Lacrimal sac mucocele ([Figure 2]) was retracted for better exposure of the bony lacrimal sac fossa to attain adequate bone exposure. A small hole was made in the weakest point of the lacrimal bone by an artery forceps; then the osteotomy opening was enlarged to about 15×15 mm by Kerrison Rongeur. The medial wall of the sac was opened vertically from the fundus to the neck using a phaco knife to create small anterior and large posterior flaps. A Bowman’s probe was then inserted through the punctum and advanced toward the sac till it stopped at the distal or common canalicular obstruction. The probe was pushed medially ([Figure 3]) and the obstructing fibrous tissue was grasped with fine-toothed forceps and excised ([Figure 4]) to allow the probe to freely enter into the opened sac. The nasal mucosa was incised to fashion a large anterior and a small posterior flap. In most cases of lacrimal sac mucocele, the posterior flap of the sac was so big that it needed trimming and shortening to avoid redundant folded posterior flaps. Both posterior flaps of the sac and nasal mucosa were sutured together using 6/0 vicryl sutures. A bicanalicular silicone tube was passed from the upper and lower puncti and advanced till the ends came out of the opened sac. Then both ends of the silicone tube were tied together at the level of the lacrimal sac to prevent retrograde migration of the tubes toward the cornea. The free ends of the tubes were passed into the ipsilateral nasal cavity to retrieve both ends out of the nostril. Then the anterior flaps of the lacrimal sac and nasal mucosa were sutured edge to edge over the tubes using three 6/0 vicryl sutures.
|Figure 3: Fibrous obstruction of common canaliculus pushed medially by Bowman’s probe.|
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|Figure 4: Excision of the fibrous tissue using microscissors and fine-toothed forceps.|
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To apply mitomycin C (MMC) 0.2 mg/ml solution to the area of distal canaliculi and common canaliculus after excision of the fibrous obstruction and to the space of the newly formed tract, a 5 ml syringe with # 27 G cannula was introduced through the lower punctum and advanced for 8 mm; then the MMC fluid was flushed gently to irrigate the desired site. After 5 min, MMC was washed out with copious amounts of normal saline solution that was aspirated away by suction from the nasal cavity.
A tenting 6/0 vicryl suture was used to keep the anterior flaps tented up and adherent to the overlying periosteum and orbicularis muscle The orbicularis muscle was sutured by interrupted 6/0 vicryl sutures whereas the skin incision was closed using 6/0 nylon sutures.
Postoperative treatment included oral broad spectrum antibiotic for 1 week and topical steroid antibiotic combination eye drops and ointment applied for 2 weeks; then tapered off over the following 2 weeks.
Skin sutures were removed after 7–10 days and the silicone tube was removed after 6 months.
The follow-up schedule was after 1 week, 1 month, then every month till the 6th month, then every month for another 6 months after silicone tube removal.
After removal of the tubes, the monthly patient visit included evaluation of the patency of the lacrimal passages by dye disappearance test and syringing of the passages with saline and if obstruction was noted nasal endoscopy was done.
Signs of success after removal of the silicone tube:
- Subjective relief of symptoms (watering, discharge, and mucocele).
- Dye disappearance test was within 5 min.
- Patent passages on probing and syringing where saline was flushed to the nasal cavity smoothly without reflux from the puncti.
The data were recorded and statistical analysis was done by SPSS statistical program for windows (version 19; SPSS Inc., IBM Corp., Armonk, New York, USA).
| Results|| |
The mean age of the patients was 48.90±12.28 years with a range between 20 and 70 years.
The female patients predominated in the present study by 78.6% in comparison to only 21.4% of male patients. The average follow-up period was 16 months.
All cases reported disappearance of the lacrimal sac mucocele, with 28 (93.3%) cases showing successful results. Only two (6.7%) cases presented with recurrent epiphora and delayed dye disappearance test and on probing soft stop was encountered and on syringing fluid regurgitated through the other punctum indicating reobstruction of the common canaliculus which was confirmed by probing of the lacrimal passages under direct visualization using nasal endoscopy. One patient refused reoperation and was satisfied with the disappearance of the mucocele and the other was candidate for endoscopic revision. No case of recurrent lacrimal sac mucocele was reported ([Figure 5] and [Figure 6]).
|Figure 6: The same patient in Fig. 5 with postoperative disappearance of swelling.|
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Early postoperative complications included postoperative nasal bleeding that was reported after 6 h in only one (3.57%) case who was hypertensive but under medical control and he was treated with posterior nasal pack.
Late postoperative complications included delayed wound healing that was observed in two (7.14%) cases where the skin wound still be gaped after 10 days and we could not remove sutures up to 2 weeks, whereas in the other uncomplicated case sutures were removed after only 1 week. These two cases were old, aged and one of them was a diabetic woman who was not compliant to diabetes therapy in the first week postoperatively.
No significant complications such as abnormal nasal bleeding, mucosal necrosis, or infection were noted in any patient during the follow-up period.
[Table 1] illustrates the age and sex of the patients, postoperative period, and postoperative results.
|Table 1: Age and sex of the patients, postoperative period, and postoperative results|
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| Discussion|| |
Adult lacrimal sac mucocele is related to acquired nasolacrimal duct obstruction and the associated chronic dacryocystitis resulting in thickened mucosa in the area of the valve of Rosenmuller which with time becomes sealed and an encysted mucocele is formed .
Dacryocystectomy was used to remove the lacrimal sac mucocele, but the patients still complained of watering eyes so that this procedure was only used in old patients unfit for general anesthesia and in case of lacrimal sac malignancy.
As the lacrimal sac mucocele is associated with both common canalicular and nasolacrimal duct obstructions, simple DCR may not be a sufficient treatment. Conjunctivo-DCR with Jones tube, which has been commonly performed for the management of common canalicular obstruction, can be used to bypass both the proximal and distal lacrimal passage obstruction . Conjunctivo-DCR is less frequently used and is usually reserved as a last resort because it is a complex technique in addition to the frequent drawbacks of Jones tube as displacement, obstruction, and lifelong maintenance ,.
Canaliculo-DCR which is an effective and much simpler surgical procedure performed for common canalicular obstruction can be used to address both sites of obstructions in cases of lacrimal sac mucocele ,.
Most of the surgical failures of DCR and canaliculo-DCR are usually identified in the first 2 years, commonly within the first 6 months after surgery, because of granulation tissue formation and scarring that cause adhesion of the osteotomy to the turbinate and septum or induce obstruction of the common canaliculus . This was confirmed by histopathological examination of biopsies taken from the obstructing tissues during reoperation ,.
MMC is an antineoplastic agent that markedly prevents fibroblastic proliferation and so prevents excessive fibrosis and reobstruction of the lacrimal passage and thus maintains the patency of the lacrimal drainage system ,. It was first used with endoscopic endonasal DCR in 1995 and in external DCR in 1997 and yielded 90% and 100% success rate at the end of the follow-up period, respectively ,.
In 1999, Jeong et al.  applied intraoperative MMC 0.02% for 5 min during canaliculo-DCR for cases with severe stenotic canaliculi. After 6–18 months of follow-up the success rate was 93.1% in the skin approach and 92.3% in the endonasal approach .
In the present study, 30 lacrimal sac mucoceles were managed by canaliculo-DCR to overcome the two anatomical sites of obstruction. Intraoperative MMC (0.2 mg/ml solution) was applied for 5 min as an adjunctive therapy aiming to suppress fibrous proliferation and scar formation in the lacrimal passages, especially at the canalicular site to reduce reobstruction and enhance the success rate.
In the current study, the age of the patients ranged between 20 and 70 years with a mean of 48.90 years and 78.6% (22 out of 28) of the cases being women.
After a follow-up period of average of 16 months, the success rate was 93.3%, as 28 cases reported subjective relief of symptoms (disappearance of swelling and epiphora) and normal dye disappearance test in addition to patent lacrimal passages on lacrimal probing and syringing. No case of recurrent lacrimal sac mucocele was reported.
The results of the current study were very similar to what was reported by Jeong et al.  in 1999, who treated 29 cases with severe stenotic canaliculi with skin approach canaliculo-DCR and intraoperative MMC (0.02% concentration) applied for 5 min and the final success rate was 93.1% (27 out of 29). The canaliculo-DCR with intraoperative MMC seems to be more physiologic and yielded better results with less morbidity than dacryocystectomy and conjunctivo-DCR.In addition to dacryocystectomy and conjunctivo-DCR, Xiao et al.  in 2008 used a hollow polyurethane stent to manage 21 lacrimal sac mucoceles in adult patients, where epiphora resolved completely in 76% of the patients.
Although the stent can be placed under local anesthesia with no need for skin incision or osteotomy it may induce chronic inflammatory response in the lacrimal sac ,. The success rate decreases as follow-up lengthens ,,. In addition, the stent yields best results in case of isolated nasolacrimal duct obstruction, but if the canaliculi were obstructed the stent treatment is more likely to fail ,.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]