Diplopia Following the Insertion of a Canalicular Bypass Tube: Etiology, Risk Factors, Management, and Outcomes

Abstract

Purpose: To report the etiology, management, and possible risk factors for diplopia after canalicular bypass surgery. Methods: A multicenter retrospective, noncomparative case series of patients who developed diplopia following canalicular bypass surgery were assessed. Results: Twenty-four cases of diplopia were identified across 12 institutions. Tubes were inserted as a primary procedure with external dacryocystorhinostomy (DCR) (1; 4%) or without DCR (10; 42%) or as a secondary procedure after external (8; 33%) or endonasal (5; 21%) DCR. Factors predisposing to local damage were noted in 17 (71%): these factors included preexisting autoimmune/inflammatory condition (7 cases), medial canthal tumor resection (5 cases), preoperative radiotherapy (2 cases), 2 drug treatments (topical and systemic), and 1 local surgery. Horizontal diplopia was due to restriction of abduction and first noted at a median of 3.5 months (mean: 17.8 months, range: 1 day to 112 months) and persisted in 23 (96%) cases with a mean restriction of −2, affecting primary gaze in 4 patients and activities of daily living in 13 (42%). Seventeen patients received various treatments: 10 were operated on resulting in cure in 1 and improvement in 9. A stable degree of diplopia persisted in all but one patient. Conclusions: Restriction of abduction causing horizontal diplopia is a rare complication with canalicular bypass surgery and a notably high proportion occurred after tube placement without DCR; carunculectomy was not ubiquitous. Although in some the diplopia may be improved with intervention, the chance of cure is low. This complication should probably be included during informed consent for canalicular bypass tubes.

Proximal lacrimal obstructions: a review

“…Various modifications to the original technique have been proposed by the years, and recent studies have increased awareness about adverse effects and relatively common complications such as tube migration and extrusion, tube obstruction, granuloma formation, diplopia, discomfort, ocular irritation, retrograde airflow or development of bacterial biofilms (Welham & Guthoff 1985;Steinsapir et al 1990;Rose & Welham 1991;Rosen et al 1994;Trotter & Meyer 2000;Lim et al 2004;Choi & Yang 2006;Parsa et al 2010;Athanasiov et al 2011;Steele 2016;Bladen et al 2020). Serious complications are more frequent in the early postoperative period or in the first 3-6 months after surgery (Scawn et al 2018); a correlation between age of patients and success rates has also been suggested, and a higher failure rate in elderly people might be related to inadequate tube maintenance and failing to comply with postoperative consultations (Rosen et al 1994).…”