CDCR with Jones Tube

Goals

Primary

• Re-establish patent outflow of tears from the ocular surface into the oropharyngeal cavity.

Secondary

• Minimize visibility of Jones tube to maximize aesthetic outcome.
• Ideally position in a location to minimize discomfort with blinking and/or foreign body sensation.
• Secure to prevent postoperative migration and extrusion.

Technical Details of the Jones Tube

• Pyrex glass tube with a cuff at end near ocular surface and a bevel at the end in nasal cavity.
• There are multiple cuff sizes (3, 4, 5 mm…) and lengths.
• There are frosted Jones tubes that are coated with porous polyethylene to increase adherence to surrounding tissue (Ophthal Plast Reconstr Surg 2009 25:42).

Indications

• Canalicular Obstruction – when dilation of the upper tear drainage system has been unsuccessful or is not possible (Am J Ophthalmol 2004 137:101)
• Previous canalicular trauma
• History of chemotherapy (ie taxotere) 
• History of Radiation Therapy
• History of I131 Therapy (Ophthal Plast Reconstr Surg 2004 20:126)
• History of Herpes Zoster Ophthalmicus
• Loss of upper tear drain during tumor excision
• Common canalicular stenosis without improvement by previous intubation with stent 
• Congenital absence of canaliculi
• Functional nasolacrimal duct obstruction
• Patent outflow but symptomatic epiphora secondary to reduced pump function

Contraindications

Absolute

• History of recent skin cancer in the surrounding area
• Theoretical risk of introducing carcinomatous cells into nasal cavity

Relative

• If reliable postoperative follow-up is a concern, consider alternatives or conservative measures.

Patient history

• Duration of tearing
• Previous trauma
• Chronic eye drop use
• Previous eye infections
• Chemotherapy or radiotherapy
• Punctal plug placement
• Tear-duct surgery
• Skin cancer near medial canthus
• Sinus or nasal surgery

Clinical examination

• Dye disappearance test
• Probe and irrigate nasolacrimal system to evaluate for punctal occlusion, canalicular obstruction, or nasolacrimal duct obstruction.
• Evaluate for conjunctival or subconjunctival scarring, inflammation.

Preoperative assessment

• Evaluate concomitant use of continuous positive airway pressure due to concern of postoperative air regurgitation.
• Discuss postoperative care required for Jones tube
• Yearly cleanings in office
• Potential need for removal, replacement, and repositioning

• Dacryocystorhinostomy
• Tear duct probe with silicone intubation
• Plastic repair of canaliculi

Prepare nasal cavity and surgical site

• Local anesthesia infiltration of nasal cavity and medial canthus
• Afrin or cocaine soaked neurosurgical cottonoids to pack nasal cavity

Prepare medial canthus

• Can perform primarily through conjunctival incision (Am J Ophthalmol 2000 129:244) or in conjunction with dacryocystorhinostomy incision (Am J Ophthalmol 1965 59:773)
• Partially excise caruncle to create space for Jones tube cuff.
• Considerations of desired path of Jones Tube
• Consider going through osteotomy path from previous dacryocystorhinostomy.
• Otherwise, consider vector that permits increased bony purchase in pathway.
• Use solid-bore needle (lacrimal trephine) or 14-gauge angiocath to puncture through site of resected caruncle into nasal passageway by your desired pathway (Ophthal Plast Reconstr Surg 2006 22:253).
• Remove needle and consider dilating passageway by bluntly spreading with Stevens or iris scissors
• Determine need for partial turbinectomy if turbinate lies in path of desired Jones tube placement. (Am J Otolaryngol 2015 36:330-3)
• Replace with probe to estimate desired length of Jones Tube.
• Choose cuff size and length and introduce into new pathway over a probe to determine position.
• Replace Jones tube with different sizes until happy with positioning.
• Examine nasal cavity for position of the Jones Tube.
• Adjust vector until satisfied with position in nasal cavity.
• Can use endoscope to monitor position.
• Secure into place with suture.
• Some tubes have a hole in cuff to secure cuff to medial canthus tissue.
• 5-0 vicryl suture or 6-0 prolene as a purse string or encircling Jones tube neck, respectively
• Tube malpositions were 7.7% in the vicryl group and 21.6%–31% in the prolene group (Br J Ophthalmol 2012 96:674).
• Place suction without tip and irrigate balanced salt solution or fluorescein solution on ocular surface to assure patency of the Jones tube passageway.

Published results

1991–2003 publications cited success rates of 91%–98.5% and satisfaction rates of 70%–91% (Am J Ophthalmol 2004 137:101).

Most publications report none or minimal complications of the procedure.

• Epistaxis
• Generous use of local anesthesia with epinephrine in nasal passageway and medial canthus
• Pack nasal cavity with afrin or cocaine-soaked neurosurgical cottonoids.
• Ruptured globe
• Corneal protectors
• Continued globe awareness throughout surgery
• Fragmentation of Jones tube
• Thoroughly examine tube prior to use.
• Strabismus
• Maintain anterior approach through lacrimal sac fossa to minimize damage to medial rectus.
• Injury to nasal septum
• Regularly explore nasal passageway to identify positioning of instrumentation.

Complications from Jones tube itself

• Migration/extrusion
• Tube can get buried medially under conjunctiva, obstructing inlet of Jones tube or migrating and pushing on globe.
• Extrusion rates in a review of 11 studies were 5%–51% (Am J Ophthalmol 2004 137:101).
• Among 5 patients who underwent CDCR frosted Jones Pyrex tube, all had complete resolution of tearing and no evidence of migration/extrusion at mean 31.2 weeks follow-up (Ophthal Plast Reconstr Surg 2009 25:42).
• Obstruction of outlet in nasal cavity
• Abutting turbinate
• Abutting nasal septum
• Medial conjunctival inflammation (Ophthal Plast Reconstr Surg 2003 19:309)

Ocular surface complications

• Dry eyes secondary increased tear clearance
• CPAP use can lead to air reflux onto ocular surface can lead to: (Ophthal Plast Reconstr Surg 2015 31:269)
• Dry eyes
• Punctate keratitis
• Eye pain
• Feeling of air blowing on eye surface

Lester Jones originally published the surgical technique of a conjunctivodacryocystorhinostomy in 1965. His initial technique used a glass tube temporarily to allow fibrosis to form and creation of a new conduit for tear drainage. This has evolved into more permanent tube options over the years. However, the core technique and idea behind CDCR has stood the test of time (Am J Ophthalmol 1965 59:773).

1. Jones LT. Conjunctivodacryocystorhinostomy. Am J Ophthalmology. 1965 59:773-83
2. AAO, Basic and Clinical Science Course. Section 7: Orbit, Eyelids, and Lacrimal System, 2010-11.
3. McLean CJ, Rose GE: Postherpetic Lacrimal Obstruction. Ophthalmology 2000 107:496-499
4. Putterman AM. Conjunctivodacryocystorhinostomy. In: Lindberg JV. Lacrimal Surgery. New York: Churchill Livingstone; 1988:281-296.
5. Shin DH et al. Restrictive Strabismus and Diplopia 2 Years After Conjunctivodacryocystorhinostomy With Medpor-Coated Tear Drain. Ophthal Plast Reconstr Surg. 2015; 31:159-162.
6. Rosen N, Ashkenazi I, Rosner M: Patient Dissatisfaction After Functionally Successful Conjunctivodacryocystorhinostomy with Jones Tube. Am J Ophthalmol 1994 117:636
7. Vicinanzo MG et al. The Prevalence of Air Regurgitation and Its Consequences After Conjunctivodacryocystorhinostomy and Dacryocystorhinostomy in Continuous Positive Airway Pressure Patients. Ophthal Plast Reconstr Surg. 2015 31:269-271
8. Bartley GB, Gustafson RO. Complications of Malpositioned Jones Tubes. AJO 1990 109:66
9. Steele EA, Dailey RA; Conjunctivodacryocystorhinostomy with the Frosted Jones Pyrex Tube. Ophthal Plast Reconstr Surg 2009 25:42-43.
10. Lim C, Martin P, Benger R, Kourt G, Ghabrial R. Am J Ophthalmol 2004 137:101-108
11. Liu D. Conjunctival Incision for Primary Conjunctivodacryocystorhinostomy with Jones Tube. Am J Ophthalmol 2000 129:244-245
12. Abel AD, Meyer DR; Refractory Medial Conjunctival Inflammation Associated with Jones Tubes. 2003 19:309-312
13. Chang M, Baek S, Lee TS. A New Lacrimal Bypass Tube Fixation Method to Prevent Tube Displacement in Conjunctivodacryocystorhinostomy (CDCR). Br J Ophthalmol 2012 96:6764-8.
14. Devoto MH, Bernardini FP, de Conciliis C; Minimally Invasive Conjunctivodacryocystorhinostomy with Jones Tube. 2006 22:253-55.
15. 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 36:330-3).
16. Burns JA, Morgenstern KE, Cahill KV, Foster JA, Jhiang SM, Kloos RT; Nasolacrimal Obstruction Secondary to I131 Therapy. Ophthal Plast Reconstr Surg; 2004 20:126-129.