My SmartPlug 'situation'

[DCRdryeye]

Rebecca, regarding the possible DCR you may require. Firstly, insist on the least invasive “Endoscopic DCR”, please don’t let them do an “External DCR”. With regards to general or local anaesthetic, it depends if you don’t mind hearing them “drill” through bone. It’s a procedure that takes about an hour and you’d be very uncomfortable for that length of time. I’ve spoken to people whom have had it done with a local and all mention how painful it was. If you thought the local anaesthetic for your recent procedure was lengthy, imagine how much more you’d require for the more invasive DCR!!

It also depends on the surgeon. They have their own preferences, whilst one may always do a DCR with a general, others will use a local. I highly recommend you insist on a general anaesthetic.

It’s not surprising the assistant made the procedure sound like no big deal. The surgeon whom performed my DCR made it seem like a ‘scratch’ with nothing to be worried about other than ‘bruising’, ‘bleeding’ or a chance of it ‘failing’. Nothing else. He failed to list the other relevant complications which everyone having a DCR should be informed about. I hesitantly give you this link from my website with a comprehensive list of possible complications...

http://www.blockedtearductsurgeryadult.com/?p=158

Please don’t allow the list to detour you. It’s frightening but in all likelihood you won’t experience anything other than bruising and discomfort. It’s just our right to be fully informed.

[Rebecca Petris]

I had quite a good informed consent (written and verbal) from the surgeon before we started the canaliculotomy so no real complaints there - to be honest I just fault myself for not researching a bit more first.... we'll certainly be having some long conversations before heading to a DCR.

But re external versus endoscopic: What is your specific objection to the external approach? I haven't talked to the surgeon about it at all yet but I have read over and over in articles I've come across that external DCR has better overall clinical results than endoscopic. Had a long talk with another surgeon friend who was quite adamant about superior clinical results from external too. I don't care too much about aesthetic aspects - I already have a scar on that side of my nose and am not planning to apply for any modeling jobs....

Appreciate all the thoughts on anaesthetic. Purely from a comfort standpoint I'd rather do general but at the end of the day I want to go with whatever's got the best clinical results. I have lots of time so I'll be doing plenty more reading

[Rebecca Petris]

F/G - great to see you - almost missed your post! Thanks! Will look into the plantain leaves...

[DCRdryeye]

Rebecca, yes I agree External DCR has a reputation for having a higher success rate (92%) compared to Endoscopic DCR (about 86%). However, there are biases. Firstly, external DCR has been around for a lot longer (about a century, in fact) and thus has a longer history. Endoscopic DCR is the new kid on the block without the history to compare. Quite a few ophthalmologists don’t have the skills to perform endoscopic DCR and if a patient requests it, they require an otorhinolaryngologists to assist during surgery. So they have a personal investment in recommending external DCR.

For current figures found on the internet, difference in success rate is only very minimal, about 6% difference. When you weigh that up against the side effect profile, you’ll find the benefit to risk ratio leans in favour of Endoscopic DCR.

External DCR requires removal of bone in two locations (side of nose and in the nasal cavity), whilst Endoscopic DCR only creates one hole. It’s great you don’t mind an unsightly scar near your eye, but the real problem is post surgical complications where the wound isn’t healing. I’ve received numerous emails from External DCR complications where a bony ridge on the nose is not healing and it’s now difficult to wear glasses due to pain. This will be a problem for those needing to wear moisture chamber glasses.

I find it frightening that External DCR cuts part of the orbicularis muscle which is responsible for the pump mechanism for the excretion of tears (see paragraph below).
The success rates between External and Endoscopic DCR are questionable. A study finds Endoscopic DCR to be more successful: http://www.aaojournal.org/article/S0...05)00460-4/pdf

An extract from, “Endoscopic nasal dacryocystorhinostomy: results and advantages over the external approach”...

The choice of indication between external or endoscopic approach depends on the service where the patient is being seen, because normally external access is performed by Ophthalmologists whereas endoscopic access is preferred by Otorhinolaryngologists. The advantages of endoscopic DCR are quite a few compared to external approach:

Absence of external scars, maintenance of a lachrymal pump system through the orbicularis muscle (which is sectioned in the external approach), less bleeding, in addition to being easier in revision procedures, because the lachrymal sac is already exposed owing to the previous osteotomy. The possibility of performing repairs in the same surgical time for the association with nasal pathologies or those that are prone to recurrence (septal deformity, rhinosinusitis or synechiae of previous surgeries, patients with history or predisposition to formation of keloids), emphasize the endonasal indication. Endonasal approach may be preferred also in cases of acute dachryocystitis resistant to antibiotics.

Reference: http://www.ncbi.nlm.nih.gov/pubmed/16446941

[cristinalatina]

Rebecca, I am very sorry to hear of your situation as a Smart plug owner myself (I have 4, good God, were of little help but are still there threatening to cause problems!)

I didn't understand why the canaliculotomy was not enough and DCR was suggested? Just because the foreign object wasn't found?

Hope your problem gets resolved soon. What is your prognosis? Is lacrimal function compromised after those procedures in any way long term?

Hugs my dear friend x

[Rebecca Petris]

Hey CL! great to see you!!!

I didn't understand why the canaliculotomy was not enough and DCR was suggested? Just because the foreign object wasn't found?

Yeah. Basically canaliculotomy verified that nothing is in the canaliculi or the lacrimal sac. You can't get at the nasolacrimal duct though with canaliculotomy, have to go in through the bone (DCR) hence that really is the only approach to take *if* we think there may be a plug in the NLD. Certainly possible it's not there either. Plugs do strange things and wind up in strange places.

What is your prognosis? Is lacrimal function compromised after those procedures in any way long term?

I don't think what I just had done will hurt anything. I'm back to status quo at this point. I don't really know about the DCR... I have a lot of reading to do. Without any research I'd expect that I can't mess around in there too much without affecting something adversely - never having believed in free lunch. However, frankly I'm not too daunted by risks to the tear function... this is my better eye and if it ends up like my worse eye, it won't kill me. (Though I need to look into what DCRDryEye just mentioned about obicularis muscle... stuff affecting the lids for example would concern me) Since I have dry eyes, we don't need to bypass the NLD because frankly a duct blocked by scar tissue isn't going to bother me... wouldn't have to bother with cautery LOL... My real problem is the infections/canaliculitis which are not a good thing in general but in my case are keeping me out of a lens in that eye. If I could just *do nothing* right now, I absolutely would. Drippy eye won't kill me but constant infection pain and poor vision, harder to visualize tolerating that long term. So my only real non-financial concern about surgery thus far is, is the !#$ plug actually there in the NLD to be found. I *think* it is, but won't know till they lay it open. And if it ain't, well, that's another bridge for another day.

[cristinalatina]

My dear Rebecca, of course now I realise that your issue is being able to wear the lens. I thought at first you were concerned about worsening dry eye.

After reading about Smartplug complications at first I had contacted the optometrist who put them in, who said that in case of an infection I'd need antibiotics and irrigation, but most likely not surgery. I wonder whether you were one of the unlucky few, or whether its just a matter of time.

By the way, just wanted to let you know that my husband and I moved from Greece to Northern Ireland, where I had my wee boy (16 months old now!) I am grateful for the NHS. You might wait forever to be seen, but cost is never an issue. I remember you are British, would you not consider "medical tourism" if you plan to come see your family?

[Rebecca Petris]

Statistically it's very unlikely that yours will ever go wrong but just in case, if you ever get canaliculitis, please, don't let them irrigate... at least, not without research and a second opinion. There's actually some medical documentation on the harm that can come from irrigating this particular type because they can break or be driven unwanted places.

I had a few attempts at irrigation early in the year (my blockage first started last December) but at the time, I had no idea a plug might be the problem - I had these plugs put in so long ago I'd forgotten all about them and it never occurred to me till this summer that something so old might be there. If I had realized in time, I wouldn't have had the irrigations. I don't believe they actually did any harm, but everything about these plugs is guesswork - for all I know, an irrigation might have pushed it from the canaliculus all the way into the NLD.

Congrats on your little boy!!! I'm so happy for you. How fun to be in N. Ireland! That's a big move! I'm actually American, just lived abroad a lot - I must have been in England still when I first got to know you here? But yes, I loved the NHS, especially post-natal care... My goodness, they sent a midwife out to my house to check on me every day for something like two weeks. Then I come to the US where few subjects are as toxic as social medicine I had an emergency appendectomy last year at a time when I didn't happen to have insurance. $40,000 for about a day and a half. I'll be paying that one off forever.

[cristinalatina]

What? They're not supposed to irrigate? I don't understand that, how are they going to get the plug out otherwise?

Congrats on your little boy!!! I'm so happy for you. How fun to be in N. Ireland! That's a big move! I'm actually American, just lived abroad a lot - I must have been in England still when I first got to know you here? But yes, I loved the NHS, especially post-natal care... My goodness, they sent a midwife out to my house to check on me every day for something like two weeks. Then I come to the US where few subjects are as toxic as social medicine I had an emergency appendectomy last year at a time when I didn't happen to have insurance. $40,000 for about a day and a half. I'll be paying that one off forever.

They still do that! I gave birth with midwives at the hospital and walked out with baby, not having paid a quid. Then the midwife was over for a couple weeks to check on baby's weight, breastfeeding, my stitches etc. And then health visitor took over. I haven't paid anything for health care except for dental coverage and optometrist. Even my eye drops are free!!I'm happy to have had my baby here. I was helped to deliver naturally without drugs. They were very patient and helped me do the unthinkable.

Yes, I think when we met many moons ago you were still living here. Even though many are complaining about waiting times etc. I will forever be grateful for the NHS.

I hope you'll find relief soon and that you'll keep us posted! With 4 smart plugs in and a love of makeup I don't consider myself a statistical improbability!

How is your lovely daughter? Is she 11-12 now? I want to ask about her by name but will not for privacy reasons!

Hugs my friend, and apologies for hijacking the thread with personal details...

[Rebecca Petris]

What? They're not supposed to irrigate? I don't understand that, how are they going to get the plug out otherwise?

Check out this abstract. (Also more references in my blog post about SmartPlugs a couple years back here.) In many cases, surgery is required. That's why the SmartPlug study group basically called for a moratorium on the product. Hm, 8 years ago? Has it happened? No.

Hugs my friend, and apologies for hijacking the thread with personal details...

Right back at you! No apologies necessary just so great to 'see' you!

[Rebecca Petris]

How is your lovely daughter? Is she 11-12 now? I want to ask about her by name but will not for privacy reasons!

Oops missed that bit! She is doing wonderfully, thanks... You're right on, she will be 12 on Saturday... and she is almost as tall as me now! If you're on Facebook come find me!

[RFREITAS]

Today I found this at my doctor blog:

http://www.alvaro-sa.com/2014/01/dac...r-externa.HTML

Hope you are doing well!

[Rebecca Petris]

Hmmm the link didn't seem to work?

My eye's kind of tanked the last several days... heading back to Seattle to see the doc this afternoon... with all the goop oozing out I'm guessing the canaliculitis is raging again.

[Amanda]

Resolved?

Hmmm the link didn't seem to work?

My eye's kind of tanked the last several days... heading back to Seattle to see the doc this afternoon... with all the goop oozing out I'm guessing the canaliculitis is raging again.

Hi Rebecca,

Has your situation been resolved? If so, how?