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Jones Tube Replacement with Endoscopic Endonasal Guidance

The procedure in this video demonstrates the removal and replacement of a malpositioned Jones tube with endoscopic endonasal guidance to ensure proper tube placement within the nose.

Procedure The procedure in this video demonstrates the removal and replacement of a malpositioned Jones tube with endoscopic endonasal guidance to ensure proper tube placement within the nose. Introduction Conjunctivodacryocystorhinostomy (CDCR) is a surgical technique which is performed in patients who have complete or nearly complete lacrimal canalicular obstruction causing epiphora. Using nasal endoscopy in CDCR placement allows for verification of correct positioning of the tube and can assist in cases in which partial turbinectomy is indicated. Drainage failure of Jones tubes is fairly common and requires trouble shooting including inspection, irrigation, and sometimes repositioning or replacement. Indications/Contraindications Indications for CDCR with Jones tube placement include epiphora due to obstruction or congenital absence of the lacrimal canalicular system. Contraindications include recent skin malignancy in the vicinity of the canalicular system, gross nasal deformities or eyelid abnormalities and scarred medial canthi. Materials/Methods: Standard eyelid surgical instrumentation, a nasal endoscopy set-up and a set of Jones tubes are required for this procedure. Results: Removal of malpositioned Jones tube and placement of a new Jones tube to ensure significant improvement or resolution of epiphora. Conclusion: CDCR allows for the placement of a glass Jones tube to promote direct drainage from the ocular surface without need for a functioning canalicular system. Occasionally, removal or repositioning of Jones tubes is required to ensure proper tear drainage.
Conjunctivodacryocystorhinostomy (CDCR) is a surgical technique that consists of placement of a glass (Jones) tube in the medial canthus of the eye to allow tear drainage from the ocular surface directly into the nasal cavity. This procedure is used in cases of complete or nearly complete lacrimal canalicular obstruction which may be the result of radiation exposure, systemic chemotherapy as in this patient, herpes zoster ophthalmicus, trauma to the canalicular system, recurrent failure of dacryocystorhinostomy (DCR) or congenital absence of canaliculi.1 Before the introduction of CDCR as a potential treatment for epiphora in these patients, stenting of the canalicular system with polyethylene tubes and reiterative probing were prominent, both of which have lower rates of success in comparison to CDCR.2 Despite CDCR having a high success rate, it is quite common for the position of the tube to shift resulting in drainage failure, hence repositioning or replacement such as in this patient are necessary.3,4 With the implementation of endoscopy in these procedures, correct placement can be verified throughout the procedure.5 In certain cases, partial turbinectomy is indicated to decrease the risk of the tube being becoming internally obstructed.6 Additional complications of this procedure include infection and proximal obstruction which would warrant further medical or surgical treatment.3 Contraindications for CDCR procedures include recent skin malignancy in the vicinity of the canalicular system resulting in concern for tumor seeding of the nasal cavity.  Additionally, gross nasal deformities, gross eyelid abnormalities or scarred medial canthi are relative contraindications for CDCR.  Also, because of the high risk of tube displacement, patients must be highly responsible and able to place a finger over the tube each time they sneeze, cough or blow their nose.  Additionally, Children and others with highly active lifestyles are at higher risk for tube displacement during strenuous physical activity.
Instrumentation/Setup: A standard eyelid surgical instrumentation kit is needed which should include Bowman lacrimal probes.  A set of Jones tubes is required, which should contain tubes of various lengths ranging from about 14 mm to 23 mm.  Jones tubes are hand blown Pyrex glass and come with a variety of options such as frosted glass and variations in shape, all in an effort to avoid tube extrusion and loss.  These Jones tube sets come with a set of dilators to aid in creation of the passage for their placement.  A nasal endoscopy set-up is recommended which should include standard camera, zero-degree endoscope and video screen. Preoperative workup: Before performing the procedure, a thorough history and a complete eye exam should be performed, paying particular attention to the evaluation of the lacrimal system. This includes visualization of the punctal size and position and the height of the tear lake.  Lacrimal probing and irrigation should be performed in the office to determine if there is a lacrimal obstruction, and if present, the location of the obstruction.  CDCR is useful when there is no functioning canalicular system, whereas DCR is used when the canaliculi are patent, but there is distal obstruction at the level of the lacrimal sac or nasolacrimal duct.  Additionally, any signs of conjunctival or subconjunctival scarring and inflammation should be noted prior to the procedure. In cases of replacement imaging can be helpful to identify whether the previous tube is embedded under the conjunctiva. Anatomy and landmarks: An understanding of the anatomy of the lacrimal system is critical for this procedure.  The lacrimal puncta are located in the medial most aspect of the upper and lower eyelids and are about 1-2 mm in vertical height.  At this point, the lacrimal system makes a right angle turn into the canaliculus which is horizontal and about 8-10 mm in length.  The majority of people have the canaliculi meet to form a common canaliculus at the site of junction with the lacrimal sac.  The lacrimal sac is encircled by the medial canthal tendon and is about 12-15 mm in vertical height.  The outflow system then passes through the lacrimal duct which is 15-18 mm in length and encased in the maxillary bone. Detailed steps to procedure: The patient is placed under general anesthesia.  Local anesthetic is infiltrated into the caruncle and a corneal shied is placed over the eye. The middle meatus of the nose is packed with cottonoids soaked in vasoconstrictor prior to endoscopy. Westcott scissors are used to remove a small portion of the anterior caruncle. In this case, the retained Jones tube, which is covered with conjunctiva and not externally visible, is visualized in the nasal cavity using the endoscope and blunt dissection is performed to provide an exterior view of the fallen-in tube. A Freer elevator is used to dissect 360 degrees around the flange of the tube. Subsequently, toothed forceps are used to gently remove the Jones tube, ensuring that it does not fracture as its being pulled from the original ostium.  A Jones tube set dilator is then placed to create a new passage for the placement of the replacement Jones tube. If the same passageway is used where the previous tube was removed, the new tube will soon end up in a similar position as the previous one.  Using the endoscope to visualize the point of dilator entry into the nose, the middle turbinate is found to be obstructing the new vector of placement of the tube and a middle turbinectomy is performed. Local anesthetic is injected into the turbinate.  A turbinectomy scissors is used to cut the base of the turbinate and a straight or upbiting endoscopic forceps is used to grasp and remove the turbinate. After creating a new ostium using the dilator, the Jones tube is loaded onto a Bowman probe and gently placed into the newly created passage. Placement is reviewed using the endonasal scope to ensure that the tube is long enough to extend into the nasal cavity not too long to be up against the septum. Saline or fluorescein tinged saline is then dropped onto the ocular surface and drainage of fluid is visualized using the endoscope. A 6-0 silk suture is then lassoed around the tube several times and externalized through the skin of the medial canthus adjacent to the tube flange for fixation. The corneal shield is then removed, and antibiotic and steroid combination drops are prescribed.
The goal of Jones tube replacement surgery is removal of the malpositioned Jones tube (if present) and placement of a new tube via a new passageway to ensure proper drainage from the ocular surface in the case of lacrimal obstruction at the level of the canaliculi.  Post-operatively, there should be significant improvement or resolution of epiphora. The Jones tube must remain in good position and be unobstructed to ensure proper drainage. Potential negative outcomes include infection or tube migration, in which case conjunctival or nasal mucosa overgrowth can cause tube obstruction and recurrence of epiphora.3,4
CDCR allows for the placement of a glass Jones tube to promote direct drainage from the ocular surface without the need for a functioning canalicular system.  Jones tubes are at risk for migration and malposition, which may result in foreign body sensation and decreased functionality which makes replacement necessary. Critical steps during this procedure include removal of the previous Jones tube without causing it to break as well as correct positioning of the replacement tube without using the previous ostium, risking recurrent malposition. A common pitfall during the procedure is selection of a Jones tube which is not the correct length, which can be overcome by use of the nasal endoscopy to monitor tube placement.
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1. Ali MJ. In: Atlas of Lacrimal Drainage Disorders. Singapore, Singapore: Springer; 2018:499-515. 2. Jones LT. The cure of epiphora due to canalicular disorders, trauma and surgical failures on the lacrimal passages. Trans Am Acad Ophthalmol Otolaryngol. 1962;66:506-524. 3. Zilelioğlu G, Gündüz K. Conjunctivodacryocystorhinostomy with Jones tube. A 10-year study. Doc Ophthalmol. 1996;92(2):97-105. doi:10.1007/BF02583282 4. Rose GE, Welham RA. Jones' lacrimal canalicular bypass tubes: twenty-five years' experience. Eye (Lond). 1991;5 ( Pt 1):13-19. doi:10.1038/eye.1991.3 5. Trotter WL, Meyer DR. Endoscopic conjunctivodacryocystorhinostomy with Jones tube placement. Ophthalmology. 2000;107(6):1206-1209. doi:10.1016/s0161-6420(00)00119-6 6. Fang CH, Patel P, Huang G, Langer PD, Eloy JA. Selective partial middle turbinectomy to minimize postoperative obstruction following Lester Jones tube placement. Am J Otolaryngol. 2015;36(3):330-333. doi:10.1016/j.amjoto.2014.11.009

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