Clinical science
Br J Ophthalmol: first published as 10.1136/bjophthalmol-2018-313039 on 5 November 2018. Downloaded from http://bjo.bmj.com/ on 19 December 2018 by guest. Protected by copyright.
Department of Ophthalmology,
University Hospitals Leuven,
Leuven, Belgium
Correspondence to
Professor Ilse Mombaerts,
Department of Ophthalmology,
University Hospitals Leuven,
Leuven 3000, Belgium; ​ilse.​
mombaerts@​uzleuven.​be
Received 6 August 2018
Revised 30 August 2018
Accepted 21 October 2018
© Author(s) (or their
employer(s)) 2018. No
commercial re-use. See rights
and permissions. Published
by BMJ.
To cite: Mombaerts I,
Witters E. Br J Ophthalmol
Epub ahead of print: [please
include Day Month Year].
doi:10.1136/
bjophthalmol-2018-313039
Jones lacrimal bypass tubes in children and adults
Ilse Mombaerts, Elodie Witters
Abstract
Background/aims  Although a Jones tube is considered
the mainstay for epiphora in patients with total blockage
of the canalicular system, it has been discouraged
in children for reasons of inadequate self-care and
maintenance. The purpose of this study is to compare the
long-term outcome of Jones tube surgery in paediatric
versus adult patients.
Methods  Retrospective, interventional case series of
a single academic institution. The medical records of
all children (≤16 years old) and adults (>16 years old)
who underwent conjunctivorhinostomy with placement
of a 130° angled extended Jones tube were reviewed.
The outcome measures were patency and anatomical
position of the tube, type and frequency of complications
and subjective relief of epiphora.
Results  The study included 10 children (11 eyes) (range,
5.1–16.0 years old) and 102 adults (127 eyes) (range,
19.7–82.4 years old). The success and complication
rate did not differ between the two age groups. Tube
dislodgement and obstruction occurred in 4 (36.4%) of
the paediatric tubes with an incidence rate of 6.1%/year
and in 47 (37.0%) of the adult tubes with an incidence
rate of 9.3%/year (p=0.3867). Two adults required
routine self-irrigation of the tube. The median follow-
up was 6.7 years for the children and 8.7 years for the
adults (p=0.3430).
Conclusion  With a similar outcome profile and minimal
self-care, young age is not a prognostic nor limiting
factor for surgery with angled Jones tubes. Exchange
with tubes of a longer length is not required during
growth.
Lacrimal canalicular bypass surgery with a Jones
tube is the standard treatment for epiphora
secondary to total proximal and midcanalicular
obstruction or absence of both upper and lower
canalicular systems.1 The Jones tube can be inserted
through external or endonasal conjunctivodacryo-
cystorhinostomy (CDCR), or through conjunc-
tivorhinostomy (CR) with direct puncture from
the caruncle to the nasal cavity with or without
endoscopic guidance.1 Although success rates
are high, complications such as tube migration,
tube obstruction and conjunctival granuloma may
frequently occur.2 3 This has prompted the develop-
ment of modifications to tube design (material, size,
shape), technique of securing and positioning of the
fistula.4–13 The angled extended tube, porous poly-
ethylene-coated tube and tube with a large collar
size are associated with relatively superior long-
term tube stability.5 10 11
The outcome of Jones tube surgery is believed to
rely on adequate self-care and maintenance of the
tube at regular intervals, such as forceful aspiration
Mombaerts I, Witters E. Br J Ophthalmol 2018;0:1–5. doi:10.1136/bjophthalmol-2018-313039
and in-office irrigation and clearing of accumu-
lated mucus. For these compliance requirements,
Jones tubes are considered less suitable for chil-
dren.2 14 15 In addition, tubes in young children may
have increased complication rates and may require
exchange of a longer length tube at later age due to
nasal growth. We present our longitudinal experi-
ence with the angled extended Jones tube in a series
of 112 patients, of whom 10 are children under the
age of 16 years old.
Methods
Following institutional review board approval,
we retrospectively reviewed the medical records
of all patients who received an angled Jones tube
with CR in the period between 1996 and 2017
at the University Hospitals Leuven. Patients were
considered paediatric when 16 years old or less
at time of the first Jones tube insertion and adult
when >16 years old. The design and technique of
placement of the tube with a 130° angled middle
and standard length of 24 mm have been described
in previous reports.7 11 Before surgery and at
follow-up, the children were examined for tooth
development and their facial photographs were
reviewed for symmetry of the face. Patients older
than 6 years underwent proximal tube irrigation at
standard follow-up visits during the first 6 months
after surgery. The follow-up time comprised the
last visit of the patient with a functioning tube in
position, or, with a recently dislodged tube and the
patient not electing revision surgery. Patients were
contacted for a visit when the follow-up was less
than 3 years. The study is in compliance with the
tenets of the Declaration of Helsinki.
The data collected included patient demo-
graphics, aetiology of the canalicular obstruction,
patency and anatomical position of the tube, type
and time lapse of the complications, subjective relief
of epiphora and length of follow-up. The following
complications were included: tube displacement,
tube obstruction, conjunctival overgrowth and
granuloma formation at the proximal end of the
tube, dacryocystitis and restricted abduction. Tube
displacement is defined as lateral when migrated
towards the eye and nasal when submerged into the
fistula. A well-positioned tube is obstructed when
not amenable to be cleared with forceful proximal
irrigation. Successful outcome implies subjective
relief of epiphora in a patent well-positioned tube
and may include intermittent episodes of epiphora
arising from reversible mucus plugging or nasal
mucosal swelling associated with infectious or
allergic rhinitis.
Results
During the study period, 112 (138 eyes) patients
received a first 24 mm Jones tube, of whom 10 were
1
 Clinical science
Figure 1  Incidence of initial complication. Conjunctival issues comprise overgrowth and granuloma formation blocking the proximal entrance of the
tube. There is no statistically significant difference for each complication between the age groups (Fisher exact test).
children (11 eyes) and 102 adults (127 eyes), with 26 patients
who had bilateral surgery. General anaesthesia was used for
initial insertion of all paediatric and 105 adult tubes (82.7%)
and local anaesthesia for 22 adult tubes (17.3%). Of the 22
patients (19 adults and 3 children) with a follow-up of less than
3 years, 7 adults had died. There were 4 patients (4 adults) with
a follow-up of less than 4 months, of whom one had died.
There was no significant difference of the follow-up and
outcome between the age groups (table 1). The incidence and
type of complication, at first and cumulative, did not differ
between the age groups (figures 1 and 2). After the first complica-
tion, 5 (83.3%) of 6 eyes in the paediatric group and 38 (67.8%)
of 56 eyes in the adult group developed recurring or different
complications (Fisher exact test, p=0.6567). Major tube compli-
cations (displacement and obstruction) occurred in 4 (36.4%)
of 11 paediatric tubes with an incidence rate during the entire
length of follow-up of 6.1%/year and in 47 (37.0%) of 127 adult
tubes with an incidence rate of 9.3% (Χ2 test, p=0.3867). Five
adult patients, of whom two with canalicular blockage from
radiation for malignancy in the medial canthal area, and one
child, developed diplopia in lateral gaze from restricted abduc-
tion as a result of conjunctival scarring at the proximal end of the
tube. Two adult patients required frequent self-irrigation with
saline solution for recurrent mucus plugging. Table 2 lists the
complications and the management in the paediatric group. In
all children, the midface normally developed without marked
asymmetry (figure 3).
Revision surgery was similar for both age groups. For tube
displacement and obstruction, we inserted a new tube in a new
tunnel more anteriorly to the previous one, and used a tube of a
longer length, that is, 28 mm, in the case of nasal displacement.
Conjunctival overgrowth and granuloma was excised. One adult
with prior radiation retained severily restricted ocular motility in
abduction despite conjunctival adhesiolysis with 5-fluorouracil,
2 Mombaerts I, Witters E. Br J Ophthalmol 2018;0:1–5. doi:10.1136/bjophthalmol-2018-313039
Br J Ophthalmol: first published as 10.1136/bjophthalmol-2018-313039 on 5 November 2018. Downloaded from http://bjo.bmj.com/ on 19 December 2018 by guest. Protected by copyright.
botulinum toxin A injection to the medial rectus muscle and
conjunctival and buccal mucosal graft interposition. In patients
who developed dacryocystitis during follow-up, additional
external DCR was performed leaving the Jones tube in situ. Dry
eye was managed with topical ocular lubricants and vitamin A
ointment.
Discussion
The outcome of conjunctivonasally inserted angled extended
Jones tubes in 10 children who were followed over a maximal
period of 15 years is comparable to similar tubes placed in
adults. Likewise, the incidence of complications such as tube
displacement was 36%–37% for both age groups. For compar-
ison, the standard Jones tube with a straight design is associated
with a displacement rate of 26%–82% and an obstruction rate
of 1%–13%.10 16 17 Although original tubes can be tolerated for
decades, frequent early and late complications emphasise the
need of longitudinal follow-up.17
The use of Jones tubes in children is hardly documented in
the literature, with a few reports on CDCR with a straight Jones
tube in mainly older children. Rosen et al found a low efficacy
and subjective satisfaction in 7 children operated between 10 and
19 years old.2 Lim et al described, without detail, the outcome
of 7 patients between 5 and 25 years old, of whom 6 children
had incomplete relief of epiphora and 1 complete relief.16 Using
endonasal CDCR for Jones tubes in 15 children between 9 and
15 years, Kominek et al reported on a high tube displacement
rate, with 47% of children requiring reoperations.18
Follow-up tube maintenance through forceful aspiration,
nasal hygiene, avoiding violent nose blowing and sneezing and
in-office tube washing and cleaning is considered the most chal-
lenging and critical aspect to maintain tube patency and posi-
tioning. For these reasons, Jones tube surgery is usually deferred
 Clinical science

Br J Ophthalmol: first published as 10.1136/bjophthalmol-2018-313039 on 5 November 2018. Downloaded from http://bjo.bmj.com/ on 19 December 2018 by guest. Protected by copyright.
Figure 2  Cumulative incidence of complications, using the total number of events encountered for the entire follow-up time interval. Conjunctival
issues comprise overgrowth and granuloma formation blocking the proximal entrance of the tube. There is no statistically significant difference for
each complication between the age groups (Fisher exact test).

Figure 3  Patient with pediatric Jones tube at the left site. (Left) Girl of 7 years old, 2 years after placement of an angled extended Jones tube
via conjunctivorhinostomy for postherpetic proximal bicanalicular stenosis. (Right) Same patient at the age of 18 years old. She had normal and
symmetric development of the face without complications of the original tube (insert).
Mombaerts I, Witters E. Br J Ophthalmol 2018;0:1–5. doi:10.1136/bjophthalmol-2018-313039 3
 Clinical science

Br J Ophthalmol: first published as 10.1136/bjophthalmol-2018-313039 on 5 November 2018. Downloaded from http://bjo.bmj.com/ on 19 December 2018 by guest. Protected by copyright.
in-office cleaning of the tube was not required and only two
Table 1  Demographics and characteristics of paediatric and adult
adults needed regular self-irrigation.
patients with an angled Jones tube
To reduce tube motility, a fistula created from CR is preferred
Paediatric Adult P values*
to that from CDCR for the minimal osteotomy and hence tighter
Patients, no. (eyes, no.) 10 (11) 102 (127) tissue around the tube in the former. The vertical positioning
Female, no./male, no. (female, %/male, %) 4/6 64/38 0.1870 of an angled tube in the nasal cavity prevents the nasal opening
(40.0/60.0) (62.7/37.3)
touching the septum, for which reason routine endoscopic
Laterality
assessment may not be required. Despite the narrow nasal vest-
 Right, no. (%) 5 (50.0) 46 (45.1) 0.5646
ible and small vertical height of the nasal cavity in children, we
 Left, no. (%) 4 (40.0) 31 (30.4) (Χ2)
found no technical difference in performing the procedure as
 Bilateral, no. (%) 1 (10.0) 25 (24.5)
compared with adults. Given the vertical positioning in the nasal
Age
cavity parallel to the nasal septum, angled tubes with a standard
 Mean (years) 10.8 58.5 0.0001
length of 24 mm fit most of the patients, even young children.
 Median (years) 10.6 61.0 (unpaired
t-test) Specific anatomical landmarks are to be considered when
 Range (years) 5.1–16.0 19.7–82.4 performing Jones tube surgery in children. The cartilaginous
Follow-up nasal septum is regarded a dominant growth centre of the
 Mean (years) 7.2 8.4 0.3430 midface, with dimensions rapidly increasing to a maximum at
(unpaired
 Median (years) 6.7 8.7
t-test) the age of 2 years.21 Nasal septal perforation, a complication
 Range (years) 1.5–15.2 0.3–25.7 described in nasal displacement of a straight tube, is unlikely to
Aetiology for canalicular obstruction or dysfunction occur with an angled tube.16 On the other hand, the growth of
 Idiopathic, no. (%) 1 (10.0) 47 (46.0) 0.0415 the external nose and nasal cavity is only completed by the age of
 Viral (herpes simplex, herpes zoster, 4 (40.0) 15 (14.7) 0.0644 16 years.22 23 In patients who had received an angled Jones tube
adenovirus), no. (%)
at childhood, we did not observe asymmetry of the face at later
 Chemotherapy, no. (%) 0 (0.0) 12 (11.8) 0.5967
age. Moreover, nasofacial growth should not be considered a
 Trauma, no. (%) 1 (0.0) 10 (9.8) 0.9999
possible cause of nasal tube displacement. The two children with
 Congenital, no. (%) 4 (40.0) 5 (4.9) 0.0034
late complication of nasal displacement had the tube inserted in
 Postexcision of malignancy, no. (%) 0 (0.0) 5 (4.9) 0.9999
early adolescence. Despite the narrow nasal passage and high
 Postradiation of malignancy, no. (%) 0 (0.0) 4 (3.9) 0.9999
prevalence of allergic rhinitis in children, tube obstruction from
 Atopic dermatitis, no. (%) 0 (0.0) 3 (2.9) 0.9999
nasal mucus plugging was not more prevalent in the paediatric
 Facial palsy, no. (%) 0 (0.0) 1 (1.0) 0.9999
patient group than in the adult.
Prior operations, no. (%) 2 (18.2) 35 (27.5) 0.7270
Lacrimal outflow surgery with rhinostomy at early age may
 Dacryocystorhinostomy, no. (%) 1 (9.0) 27 (21.1) 0.4616
interfere with tooth development. Quaranta-Leoni et al observed
 Dacryocystorhinostomy with straight Jones 0 (0.0) 5 (3.9) 0.9999
tube, no. (%)
anodontia of the ipsilateral upper canine in two children who
 Silicone tube intubation, no. (%) 1 (9.0) 3 (2.3) 0.2854
underwent external DCR before the age of 3 years old.24 The
Successful final outcome, no. (%) 11 (100%) 110 (86.6%) 0.2162
morphogenesis of teeth and the lacrimal system initiate at the
Dry eye at final outcome, no. (%) 0 (0%) 11 (89.9%) 0.5960
sixth week of fetal development and arise from structures of the
*
first pharyngeal arch.25 Congenital syndromes affecting both
Fisher exact test, unless specified otherwise.
structures are unknown. Only rarely, dentigerous cysts of the
maxillary sinus may cause nasolacrimal duct obstruction and
in children until late adolescence is reached. As alternative unerupted or impacted teeth.26 In the series of Quaranta-Leoni
treatment options in children with epiphora from proximal et al, it is therefore assumed that the osteostomy was located in
obstruction, botulinum toxin injections in the palpebral part of the vicinity of the developing bud of the permanent canine. The
the lacrimal gland and retrograde intubation DCR have been critical period of teeth eruption extends from birth to about 3
used.19 20 With regard to tube maintenance in our study patients, years of age. Therefore, with regard to the risk to violate the

Table 2  Patient demographics, characteristics and outcome of Jones tube surgery in 10 children
Aetiology for canalicular Complications Management of complications Follow-up
Age (years) Sex Side obstruction (prior surgery) (time interval after last intervention) (type of anaesthesia) (years)
5.1 (figure 3) F L Herpetic None – 15.2
5.8 M L Herpetic None – 10.7
10.6 M R Herpetic None – 2.7
5.9 M R Congenital agenesis None – 9.1
8.7 F Bil Congenital agenesis None – 4.3
14.6 F L Congenital agenesis (DCR) Obstruction (1 week) New tract for 24 mm tube (GA) 1.6
10.7 M R Herpetic Conjunctival overgrowth (2.4 years) Excision (GA) 13.7
Nasal displacement (6.2 years) New tract for 28 mm tube (LA)
Mild restriction of abduction (1 week) Abduction exercises
14.1 M R Congenital Lateral displacement (5.9 years) New tract for 24 mm tube (LA) 10.2
(silicone intubation) Nasal displacement (3.3 years) New tract for 28 mm tube (GA)
15.9 M R Idiopathic Lateral displacement (9 days) New tract for 24 mm tube (LA) 1.5
Conjunctival overgrowth (1.2 years) Excision (LA)
16.0 F L Traumatic Conjunctival granuloma (0.1 years) Excision (LA) 2.2
Bil, bilateral; DCR, dacryocystorhinostomy; GA, general anaesthesia; L, left; LA, local anaesthesia; R, Right.

4 Mombaerts I, Witters E. Br J Ophthalmol 2018;0:1–5. doi:10.1136/bjophthalmol-2018-313039


canine bud, Jones tube surgery in very young children is safer via
CR than via CDCR.
The limitations of this study comprehend its retrospective
nature and inclusion of four adults with a follow-up of <4
months. However, with tube displacement frequently occurring
in the immediate postoperative months, we included patients
with a short follow-up too.2 3 11 In this study, we also included
a previously reported cohort of 71 patients with Jones tubes,
of whom six are children.7 11 However, for the purpose of the
study, we extended the follow-up of this cohort, added 41 more
patients and analysed the outcome of children separate from
adults. The strengths of the study include single surgeon data
from a large patient cohort of all ages.
In conclusion, lacrimal bypass surgery with an angled extended
Jones tube appears to be effective in patients as young as 5 years
old, without the need for replacement with longer tubes due to
nasofacial growth. The outcome and complications were similar
in children and adults. This study provides a basis for a lower
threshold for Jones tube surgery in children who have a high
morbidity from epiphora from total proximal and midcanalic-
ular blockage, although counselling about the possible complica-
tions remains mandatory.
Present affiliations  The present affiliation of Ilse Mombaerts is: Department of
Ophthalmology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
Contributors  IM, EW: data collection, data analysis and interpretation and
manuscript drafting. IM: manuscript editing and approval.
Funding  The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-for-profit sectors.
Competing interests  None declared.
Patient consent  Obtained.
Ethics approval  Ethical Committee UZLeuven.
Provenance and peer review  Not commissioned; externally peer reviewed.
Data sharing statement  No additional data available.
References
1 Athanasiov PA, Madge S, Kakizaki H, et al. A review of bypass tubes for proximal
lacrimal drainage obstruction. Surv Ophthalmol 2011;56:252–66.
2 Rosen N, Ashkenazi I, Rosner M. Patient dissatisfaction after functionally
successful conjunctivodacryocystorhinostomy with Jones tube. Am J Ophthalmol
1994;117:636–42.
3 Sekhar GC, Dortzbach RK, Gonnering RS, et al. Problems associated with
conjunctivodacryocystorhinostomy. Am J Ophthalmol 1991;112:502–6.
4 Ahn ES, Dailey RA, Radmall B. The effectiveness and long-term outcome of
conjunctivodacryocystorhinostomy with frosted jones tubes. Ophthalmic Plast
Reconstr Surg 2017;33:294–9.
Mombaerts I, Witters E. Br J Ophthalmol 2018;0:1–5. doi:10.1136/bjophthalmol-2018-313039
Clinical science
Br J Ophthalmol: first published as 10.1136/bjophthalmol-2018-313039 on 5 November 2018. Downloaded from http://bjo.bmj.com/ on 19 December 2018 by guest. Protected by copyright.
5 Wojno T. Experience with a medpor-coated tear drain. Ophthalmic Plast Reconstr Surg
2010;26:327–9.
6 Steele EA, Dailey RA. Conjunctivodacryocystorhinostomy with the frosted jones pyrex
tube. Ophthalmic Plast Reconstr Surg 2009;25:42–3.
7 Mombaerts I, Colla B. Modified Jones’ lacrimal bypass surgery with an angled
extended Jones’ tube. Ophthalmology 2007;114:1403–8.
8 Bagdonaite L, Pearson AR. Early experience with the stoploss jones tube. Orbit
2015;34:132–6.
9 Perry CB, Dailey RA. Success rate of variable collar size frosted Jones tubes.
Ophthalmic Plast Reconstr Surg 2018;34:262–5.
10 Aakalu V, Groat RS, Putterman A. Sixteen-year experience with the Putterman-
Gladstone tube for conjunctival dacryocystorhinostomy. Ophthalmic Plast Reconstr
Surg 2012;28:393–5.
11 Witters E, Mombaerts I. The survival of an angled extended Jones’ tube. Br J
Ophthalmol 2015;99:1523–6.
12 Na J, Lee S, Park J, et al. Surgical Outcomes of endonasal
conjunctivodacryocystorhinostomy according to Jones tube location. J Craniofac Surg
2017;28:e500–e503.
13 Ma’luf RN, Bashshur ZF, Noureddin BN. Modified technique for tube fixation
in conjunctivodacryocystorhinostomy. Ophthalmic Plast Reconstr Surg
2004;20:240–1.
14 Rose GE, Welham RA. Jones’ lacrimal canalicular bypass tubes: twenty-five years’
experience. Eye 1991;5–13–19.
15 Nemet AY, Fung A, Martin PA, et al. Lacrimal drainage obstruction and
dacryocystorhinostomy in children. Eye 2008;22:918–24.
16 Lim C, Martin P, Benger R, et al. Lacrimal canalicular bypass surgery with the Lester
Jones tube. Am J Ophthalmol 2004;137:101–8.
17 Scawn RL, Verity DH, Rose GE. Can Lester Jones tubes be tolerated for decades? Eye
2018;32:142–5.
18 Komínek P, Cervenka S, Matousek P, et al. Conjunctivocystorhinostomy with
Jones tube--is it the surgery for children? Graefes Arch Clin Exp Ophthalmol
2010;248:1339–43.
19 Eustis HS, Babiuch A. Botulinum toxin injection into the lacrimal gland for treatment
of proximal nasolacrimal duct obstructions in children. J Pediatr Ophthalmol
Strabismus 2014;51 Online:e75–7.
20 Wearne MJ, Beigi B, Davis G, et al. Retrograde intubation dacryocystorhinostomy
for proximal and midcanalicular obstruction. Ophthalmology 1999;106:2325–8.
discussion 2328-9.
21 Verwoerd CD, Verwoerd-Verhoef HL. [Rhinosurgery in children: developmental
and surgical aspects of the growing nose]. Laryngorhinootologie 2010;89(Suppl
1):S46–71.
22 van der Heijden P, Korsten-Meijer AG, van der Laan BF, et al. Nasal growth and
maturation age in adolescents: a systematic review. Arch Otolaryngol Head Neck Surg
2008;134:1288–93.
23 Samoliński BK, Grzanka A, Gotlib T. Changes in nasal cavity dimensions in children
and adults by gender and age. Laryngoscope 2007;117:1429–33.
24 Quaranta-Leoni FM, Verrilli S, Leonardi A. Surgical outcome and unusual complications
of paediatric external dacryocystorhinostomy. Orbit;34:1–5.
25 Uğurbaş SH, Zilelioğlu G, Saatçi M. Otolaryngological findings in congenital
nasolacrimal duct obstruction and implications for prognosis. Br J Ophthalmol
2000;84:917–8.
26 Altas E, Karasen RM, Yilmaz AB, et al. A case of a large dentigerous cyst containing
a canine tooth in the maxillary antrum leading to epiphora. J Laryngol Otol
1997;111:641–3.
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