LAUSR

Dacryocystorhinostomy (DCR) is a surgical procedure that re-opens the nasolacrimal duct in patients with nasolacrimal duct obstruction and relieves symptoms of epiphora (watery eyes) by allowing tear drainage back to nasal mucosa. This procedure, however, can present a unique challenge for patients with obstructive sleep apnea (OSA) on continuous positive airway pressure (CPAP). We present a 65 year-old man with a history of nasolacrimal duct obstruction status-post DCR who initially presented with daytime hypersomnolence and multiple nighttime awakenings. He underwent polysomnography (PSG) demonstrating moderate OSA with Apnea-hypopnea index (AHI) 18.5 events per hour. After initiation of CPAP, he reported eye pain, dryness and a sensation of air blowing into his eye. Both mandibular advancement device and BPAP (bilevel positive airway pressure) were attempted, unfortunately neither was found to be sufficiently effective. This patient experienced a potential complication of DCR called lacrimal duct air regurgitation (LADR), which occurs due to the potential for reflux of air through the relatively dilated anastomosis from nasopharynx to puncta of the eye. By reducing end expiratory pressure, BPAP may in theory relieve expiratory LADR. A total-face mask was then employed as, covering the eyes allows for pressure equalization across the duct with resultant LADR improvement. This improved eye discomfort, but adherence was limited due to bulkiness of the mask. Lacrimal duct plugging may also be explored to reduce air reflux. This is an example of an uncommon complication of PAP therapy and highlights the unique challenges in maintaining adherence in this setting.