【摘要】 目的 自主设计制作一种取材、制作简易的泪道插管圈套器，用于辅助泪道阻塞再通术、泪小管断裂吻合术时协助泪道插管、挂线或扩张器的植入。方法 随机选择慢性鼻泪管阻塞或合并慢性泪囊炎、急性外伤后泪小管断裂、鼻腔泪囊吻合术后吻合口狭窄阻塞患者206例，其中慢性鼻泪管阻塞或合并慢性泪囊炎者198例，鼻腔泪囊吻合术后吻合口狭窄阻塞者2例，泪小管断裂者6例;男性38例，女性168例;年龄5~82岁，平均年龄为(48.0±5.8)岁。用自制泪道插管圈套器辅助泪道插管完成泪道挂线，并观察评价其耗时、成功率及并发症。具体方法：用一根内置有钢丝的硬脊膜外导管，将其分成两段，有标记刻度带侧孔的头部一段作为泪道插管;另一段硬脊膜外导管的两端绞合，制成带柄的长轴约为7~8 cm、短轴约为5~6 cm的类椭圆形环状圈(取名为泪道插管圈套器)。在泪道插管前将泪道插管圈套器的环状段预先从前鼻孔向后部鼻腔插入，使环状段放置于鼻腔至鼻咽部内，再行上或下泪点泪道插管，插入泪道达鼻泪管下鼻道开口以下，穿入预先放置于下鼻道至后鼻孔区域的圈套器圆环中;继之牵引圈套器拉出前鼻孔，将套取的泪道插管牵引拉出前鼻孔;再将丝线固定于泪道插管头端，随后泪道插管逆行退出泪道，丝线即随泪道插管退出而穿入泪道完成泪道挂线术。最后可再与其他各种泪道扩张器连接完成泪道扩张器植入。结果 用泪道插管圈套器圈套拉出泪道插管的206例完成泪道挂线的成功率为100%，平均时间92 s。自制泪道插管圈套器辅助泪道插管完成泪道挂线术中部分病例有泪道和鼻腔少量出血，全部在5 min内自止;术中术后无泪小点及泪小管撕裂或其他并发症。结论 泪道插管圈套器可以简单有效地辅助完成硬脊膜外导管泪道插管、挂线或扩张器植入，使泪道插管、挂线或扩张器植入更为简易、快捷、无痛。

　　【关键词】 鼻泪管阻塞;泪小管断裂;插管法;圈套器

　　A custom-made lacrimal duct intubation snare and its clinical application for implanting a tube， a hanging suture or a dilator in the lacrimal duct is described

　　ZHOU Jianqiang， WANG Yi， CHEN Jie， et al.

　　Department of Ophthalmology， Jiaxing First Hospital， Jiaxing China， 314000

　　[Abstract] Objective To design a simple lacrimal duct intubation snare that can be used as a supplementary instrument for intubation， for a hanging suture or for the implantation of a dilator in the lacrimal duct. Methods One eye of each of 206 cases with an obstruction of the naso-lacrimal duct with or without chronic dacryocystitis， laceration of the canaliculus or stroma stenosis after dacryocystorhinostomy were randomly selected for the study. Of the 206 cases， 198 were diagnosed with chronic obstruction of the naso-lacrimal duct or chronic dacryocystitisin， 2 cases were diagnosed with stroma stenosis after dacryocystorhinostomy， and 6 cases were diagnosed with laceration of the canaliculus. The mean age of the 38 men and 168 women was (48.0±5.8)years (range 5 to 82 years). The operation to hang a line in the lacrimal duct was performed with a custom-made lacrimal duct intubation snare. The amount of time needed， the success rate， and the complications were evaluated. The procedures were as follows： an epidural tube enclosing a steel wire was cut into two sections. The head of the epidural tube was scaled with lateral holes and used for the nasolacrimal duct intubation. The two ends of another piece of epidural tube were twisted and the extra section was cut off， creating an oval annular ring with a diameter of 5×7 cm (called a lacrimal duct intubation snare). The annular ring of the lacrimal duct intubation snare was inserted first from the anterior nares to the posterior nares nasal septum， setting it between the nasal cavity and nasopharynx nasalis. The epidural tube entered the lacrimal duct through the superior or inferior lacrimal punctum and was inserted into the nasolacrimal duct under the inferior nasal meatus. The annular ring of the lacrimal duct intubation snare was then inserted. With the traction of the twisted section of the snare， the epidural tube entered the annular ring of the lacrimal duct intubation snare and was pulled out of the anterior nares. After a silk suture was fixated to the head end of the epidural tube， the epidural tube was moved back toward the lacrimal punctum and the silk thread entered the lacrimal duct. The operation to hang a line was then completed. With the connection to the silk suture， the dilator can be implanted into the lacrimal duct. Results The one-time success rate of pulling out the epidural tube with the lacrimal duct intubation snare in 206 cases was 100%. The procedure took an average of 92 seconds. In some cases， there was a small amount of bleeding in the lacrimal duct and nasal cavity during the operation. No puncture or canaliculus tear or other complications occurred. Conclusion The lacrimal duct intubation snare effectively aids the intubation， hanging line and implantation of the dilator in the lacrimal duct， and deserves further clinical application.

　　[Key words] obstruction of naso-lacrimal duct; laceration of the canaliculus; intubation; snare

　　泪道阻塞、泪小管断裂是眼科常见病。在泪道阻塞行挂线、插管、扩张物植入术、泪小管断裂吻合置管术时常须将插管或挂线从泪小点或泪小管断裂端置入泪道后自前鼻孔拉出一端，以防滑脱易位，或进一步完成较粗的泪道挂线、泪道扩张绳、泪道置管的硅胶管、泪道扩张器泪道逆行植入。以往，常先经药物下鼻道黏膜收缩麻醉后在鼻镜、枪状镊协助下完成，操作繁琐费时，容易出血，患者疼痛明显;也可用鼻腔内窥镜取出，但常需耳鼻喉科医师协助。我们自主设计制作一种泪道插管圈套器，具有取材制作极为容易，操作无痛、简易快捷、不需其他辅助器械设备、可由眼科医师简单独立完成等优点。

　　1 资料和方法

　　1.1 一般资料 随机选择2004年6月至2006年9月来本院就诊的慢性鼻泪管阻塞或合并慢性泪囊炎、急性外伤后泪小管断裂、鼻腔泪囊吻合术后吻合口狭窄阻塞患者206例。其中慢性鼻泪管阻塞或合并慢性泪囊炎者198例，鼻腔泪囊吻合术后吻合口狭窄阻塞者2例，泪小管断裂者6例;男性38例，女性168例;年龄5~82岁，平均年龄为(48.0±5.8)岁。

　　1.2 泪道插管圈套器的设计制作 仅需一根内置有钢丝的硬脊膜外导管(我们选用的为65 cm长硬脊膜外导管)，将其分成两段，剪取有标记刻度带侧孔的头部一段作为泪道插管，长约25 cm，并剪除远端2 mm导管使内置钢丝长于导管，以免因内置钢丝短于导管而在插管时导管头部硬度不够而致弯曲，不易插入泪道;余下的硬脊膜外导管用于制作圈套器：剪取余下的硬脊膜外导管25 cm，将这25 cm长内置有钢丝的硬脊膜外导管两个末梢2.0 cm处绞合，制成带柄的、长轴约为7~8 cm、短轴约为5~6 cm的类椭圆形环状圈，取名为泪道插管圈套器(见图1)。最后将作为泪道插管的硬脊膜外导管(简称泪道插管)和制成的泪道插管圈套器灭菌处理后备用。

　　1.3 圈套器套取泪道插管挂线法的操作方法 手术操作由眼科医师完成。术前行常规检查确定鼻泪管阻塞位置，行上或下泪点扩张、泪道探通术或找到泪小管断裂位置，在泪道插管前将泪道插管圈套器的环状段预先从前鼻孔向后部鼻腔的鼻中隔方向斜向插入(见图2)，使环状段放置于鼻腔至鼻咽部内，并使圈套器的环状段的下极紧贴鼻腔的下壁并尽量低于鼻泪管的下鼻道开口，圈套器绞合端留置在前鼻孔外以备手持圈套器牵拉套取泪道插管(见图3);再用备用的泪道插管行上或下泪点或泪小管断裂近泪囊段泪道插管，插入泪道5 cm，使其经泪小管、泪总管、泪囊、鼻泪管到达鼻泪管下鼻道开口以下(见图2、图3);继续插入5~8 cm，硬脊膜外导管即从鼻泪管下鼻道开口向下鼻道、后鼻孔、鼻咽部方向转向，硬脊膜外导管随即穿入预先放置于下鼻道至后鼻孔区域的鼻腔、鼻咽部内的泪道插管圈套器圆环中(见图4)。继之牵引圈套器绞合端将圈套器拉出前鼻孔，此时穿入圈套器圆环中的泪道插管随即随圈套器拉出前鼻孔(见图5)，再用缝合针穿上1号丝线后自泪道插管头端侧孔穿透导管对侧壁，将丝线固定于泪道插管头端(见图6)。随后将头端固定有丝线的泪道插管逆行退出泪道，丝线即随泪道插管退出而穿入泪道完成泪道挂线术。我们将这种方法取名为：圈套器套取泪道插管挂线法。完成泪道挂线后，即可以根据治疗需要在丝线前鼻孔端系上较粗的泪道挂线、硅胶管或其他多种更符合泪道解剖结构的扩张物泪道置入。手术过程不需要鼻镜、枪状镊或鼻腔内窥镜以及其他辅助器械设备。

　　1.4 泪道插管圈套器套取泪道插管挂线法适应证以及禁忌证 适应证：能用泪道探针泪道探通，进而能用带钢丝内芯的硬脊膜外导管自泪小点或泪小管插入至下鼻道的所有泪道阻塞、狭窄或合并慢性泪囊炎，泪小管断裂等需要行泪道插管、挂线或扩张器植入的病例。

　　禁忌证：有严重心脑血管疾病，严重出血性疾病，泪道、鼻腔恶性肿瘤以及泪道、鼻腔严重阻塞不能通过扩张物的病例为禁忌或应慎用。

　　2 结果

　　2.1 泪道插管圈套器套取泪道插管完成泪道挂线的观察指标及方法

　　2.1.1 观察指标 将泪道插管圈套器置入鼻腔，泪道插管，圈套拉出泪道插管的硬脊膜外导管至前鼻孔外，再连接丝线，退出泪道插管带动丝线完成泪道挂线术。记录每个病例完成此泪道挂线术全过程的时间，完成挂线病例为手术成功。

　　2.1.2 方法 计时器记录每个病例完成泪道挂线全过程时间，计算全部病例完成泪道挂线的平均时间和成功率。

　　2.2 成功率和手术时间 本组206例患者用泪道插管圈套器圈套拉出泪道插管的成功率为100%;圈套拉出硬脊膜外导管的手术时间：最短为32 s，最长为360 s，平均时间为92 s。

　　2.3 术中及术后并发症 部分病例有泪道和鼻腔少量出血，全部在5 min内自止。术中、术后无泪小点及泪小管撕裂或其他并发症。

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