What treatment is recommended for a patient with a nasolacrimal duct obstruction after a nasolacrimal duct stent (NLD) fell out 2.5 years post-trauma?

Management of Nasolacrimal Duct Obstruction After Stent Dislodgement

Dacryocystorhinostomy (DCR) surgery is the recommended treatment for a patient with nasolacrimal duct obstruction after a stent has fallen out 2.5 years post-trauma.

Assessment of the Current Condition

When evaluating a patient whose nasolacrimal duct pin/stent has fallen out after 2.5 years, the following assessment should be performed:

• Functional evaluation of the nasolacrimal tear drainage system 1
• Assessment for symptoms of epiphora (excessive tearing)
• Examination for signs of infection or inflammation
• Evaluation of the puncta and canaliculi for patency

Treatment Algorithm

1. Confirm Nasolacrimal Duct Obstruction

   • Perform slit-lamp examination
   • Assess tear film and tear meniscus height
   • Consider diagnostic tests such as dye disappearance test or dacryocystography

2. Determine Treatment Approach

   • For confirmed nasolacrimal duct obstruction after stent loss:
     • Primary recommendation: Dacryocystorhinostomy (DCR)
     • This is superior to attempting replacement of the stent, which has lower long-term success rates 2

3. Surgical Considerations

   • External DCR has 85-95% success rate 2
   • Endonasal approaches may be considered to avoid external scarring
   • Concurrent management of any associated conditions (e.g., chronic dacryocystitis)

Rationale for DCR Over Stent Replacement

The evidence strongly favors DCR over stent replacement for several reasons:

• Long-term success rates with polyurethane nasolacrimal stents are low compared to external DCR 2
• Patients with stents often continue to experience tearing despite a patent lacrimal system 2
• The stent has already been in place for 2.5 years, suggesting the underlying condition is not likely to resolve without definitive surgery
• Many patients with nasolacrimal duct obstruction have concomitant conditions like chronic dacryocystitis that may need surgical addressing 1

Post-Operative Management

After DCR surgery:

• Follow-up within 1-2 weeks to assess surgical site
• Monitor for complete resolution of epiphora
• Evaluate for potential complications such as:
  • Infection
  • Scarring of the surgical ostium
  • Recurrent obstruction

Potential Complications and Pitfalls

• Stent Replacement Pitfalls: If stent replacement is attempted instead of DCR, be aware that:

  • Stent occlusion is a common complication 3
  • Blood-stained nasal discharge may occur 3
  • Long-term patency rates are lower than with DCR 2

• DCR Complications to Monitor:

  • Bleeding
  • Infection
  • Scarring of the surgical ostium
  • Failure to resolve symptoms

Special Considerations

For patients who absolutely refuse surgery or are poor surgical candidates:

• Consider balloon dacryoplasty as an intermediate option, though success rates are lower than DCR 4
• Be aware that interventional procedures with new stent designs show technical success rates of 97.1%, but long-term success rates decline to 91.4% after 12 months 5

The evidence clearly demonstrates that external DCR provides the most reliable and durable solution for nasolacrimal duct obstruction after stent dislodgement, with success rates of 85-95% compared to the more modest long-term outcomes with stent replacement.