title: A modified lacrimal sac implant for high-risk dacryocystorhinostomy.
abstract: OBJECTIVE
  The reported 5% of patients with nasolacrimal duct obstruction who fail dacryocystorhinostomy likely include patients with severe mucosal disease or anatomical anomalies. The technique described herein avoids mucosal anastomosis and minimizes mucosal manipulation by inserting a permanent silicone conduit from the lacrimal sac into the nasal cavity.
  
  
  METHODS
  This retrospective review of 9 surgical cases was performed with institutional review board approval. Six patients underwent 9 surgeries (3 sequentially bilateral) for dacryocystitis. Two patients had Wegener granulomatosis, 1 had pemphigoid, 1 sarcoidosis, 1 Rosai-Dorfman disease, and 1 congenital choanal atresia with chronic neonatal dacryocystitis. In each case, a modified Rains sinus stent was inserted through an external lacrimal sac incision with the draining end positioned in the nasal cavity. Two patients underwent concurrent canalicular intubation with Guibor silicone stents to prevent internal punctum obstruction by the lacrimal sac implant. Recurrence of symptoms, patient comfort, and modified Rains stent stability and patency were evaluated.
  
  
  RESULTS
  Mean follow up was 30 months (range 7-59 months). The modified Rains stent remained stable and patent in 7 of 9 cases, and symptoms resolved in 8 of 9 cases. In 1 patient with sarcoidosis, the modified Rains stent became repeatedly obstructed with nasal secretions and ultimately dislodged after intranasal manipulation by a physician unfamiliar with the surgery. In no other case did the patient experience recurrent infection, and in those cases, epiphora resolved entirely. In the patient with pemphigoid, one of the modified Rains stents extruded 6 months postoperatively, but his symptoms remained controlled. No adverse reaction to the implant material was seen.
  
  
  CONCLUSIONS
  A Rains silicone frontal sinus stent can be modified for implantation into the lacrimal sac and can safely and effectively drain the lacrimal sac into the nose in patients with severe mucosal disease or anatomical anomalies. Additional study and a stent specifically designed for this application will likely improve outcomes.
authors.affiliation: *Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts; †Ophthalmic Plastic and Reconstructive Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A.; ‡International Eye Institute, St. Luke's Medical Center, Quezon City, Philippines; §Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts; and ‖Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts; and ¶Department of Otolaryngology, Boston Children's Hospital, Boston, Massachusetts, U.S.A.
authors.forename: Dawn K
authors.initials: DK
authors.lastname: De Castro
authors.forename: Yvette Marie B
authors.initials: YM
authors.lastname: Santiago
authors.forename: Michael
authors.initials: M
authors.lastname: Cunningham
authors.forename: Stacey T
authors.initials: ST
authors.lastname: Gray
authors.forename: Ralph
authors.initials: R
authors.lastname: Metson
authors.forename: Aaron
authors.initials: A
authors.lastname: Fay
mesh_terms: D000328:Adult; D003608:Dacryocystorhinostomy / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007440:Intubation / Q000379:methods*; D007767:Lacrimal Duct Obstruction / Q000000981:diagnostic imaging / Q000628:therapy*; D008297:Male; D009301:Nasolacrimal Duct; D011859:Radiography; D012189:Retrospective Studies; D015607:Stents