Double stent intubation for canalicular obstruction
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This is Richard Allen at the University of Iowa.
This video demonstrates repair of an upper and lower canalicular obstruction via a cut down of the canaliculus followed by double Crawford stent placement.
The lower punctum is dilated followed by placement of a Bowman probe where the obstruction is palpated. A hemostat is placed on the Bowman probe so that the area of the obstruction can be marked. The same is then done on the upper eyelid. The obstruction in the upper canaliculus is palpated and then marked with a marking pen. Westcott scissors are then used to perform a canalicular cut down. The scissors are used to incise the area over the obstruction. The Bowman probe is then placed and the area is open. The patent portion of the canaliculus is then identified and a hard stop is palpated. There was some concern for a nasolacrimal duct obstruction; therefore the system is irrigated which reveals no obstruction. A Crawford stent is then placed through the punctum and retrieved from the cut end of the canaliculus. The stent is then placed through the proximal cut end of the canaliculus which is visualized. This is then placed down the nasolacrimal duct and retrieved from the nose. The same is then performed on the upper lid. The canalicular cut down is performed with the Westcott scissors. The Bowman is placed, but the obstruction is still palpated. Additional cut down is performed to excise the area of the obstruction. The Crawford stent can then be placed through the canaliculus. This is then placed through the cut end of the canaliculus and then retrieved from the nose.
Due to the fact that this was a recurrent obstruction, it was determined that a double intubation would be performed. I favor this is patients who are at a high risk for failure. An additional stent is placed in the same fashion and retrieved from the nose. The same is done for the upper canaliculus as well. Thus this results in having two stents through the system, which can keep the system more patent, compared to one stent, as it heals. We can see the position of the stents here. The canaliculus is then repaired over the stents, just as one would repair a canalicular laceration. I will usually keep both stents in for four months, then I may remove one stent, and then have the patient return in another four months to remove the remaining stent. Again, the repair is performed with a 7-0 vicryl suture, similar to the way one would perform repair of a canalicular laceration. This is then performed on the upper eyelid as well. Again, placing sutures around the stents to reappose the cut ends of the canaliculus, followed by closure of the eyelid margin and skin. At the conclusion of the case, the stents appear to be in good position. There is no tension on the stents. The patient will use antibiotic ointment over the area three times per day and return in one week for reevaluation.