Assisted local anaesthesia for endoscopic dacryocystorhinostomy

BACKGROUND: Endoscopic dacryocystorhinostomy is traditionally performed under general anaesthesia. However, there are reports in the literature of various local anaesthetic techniques with or without sedation for this procedure. An effective and acceptable local anaesthetic technique enables the avoidance of the risks associated with general anaesthesia, particularly for elderly patients, with the added benefit of reduced bleeding, reduced nausea and vomiting, and reduced length of hospital stay and thus health care cost savings. This study aims to evaluate the safety and patient acceptance of a minimally invasive assisted local anaesthetic technique for endoscopic dacryocystorhinostomy. METHODS: A prospective questionnaire-based study is presented of 24 consecutive adult patients who underwent 26 endoscopic dacryocystorhinostomies in a day surgery including 22 primary and four revision procedures performed by one surgeon under local anaesthesia and sedation over a 4-month period. RESULTS: Apart from persistent postoperative vomiting in one patient there were no anaesthetic complications. There were no instances of epistaxis. The mean pain score on a visual analogue scale of 0-10 was 1.56 and 56% reported no pain. Ninety-two per cent would recommend the procedure to others. CONCLUSION: This assisted local anaesthetic technique for endoscopic dacryocystorhinostomy is safe and acceptable to patients.     

Techniques to minimize skin incision scar for external dacryocystorhinostomy

Although there has been a narrowing in the gap in successful functional outcomes between external and endonasal DCR, external DCR is still being frequently performed when cost, availability of additional surgical instruments and visual systems, surgeon’s experience and preference are concerned. Nonetheless, skin incisions at the lateral nasal sidewall of the lower eyelid inevitably leave cutaneous scars. The purpose of this review is to evaluate the outcomes of current modified surgical practices that prevent a conspicuous scar in external DCR.     

改良泪囊鼻腔黏膜吻合术临床观察

目的 总结和分析改良泪囊鼻腔黏膜吻合术的效果。方法 在常规泪囊鼻腔黏膜吻合术的基础上进行改进和简化，不切断内眦韧带，鼻黏膜做一“U”形大前叶瓣，泪囊做宽大的“U”形后叶瓣，将后叶瓣推向鼻孔，鼻黏膜瓣与泪囊前叶瓣间断缝合。结果 本组78例（78眼），术后观察随访5个月～2年，77眼获得满意效果，溢泪消失，泪道冲洗通畅，1眼手术失败，成功率98．72％。结论 改良手术方法简单，容易掌握和操作，手术成功率高，较为实用，便于普及。     

改良泪囊鼻腔吻合术疗效观察

目的总结和分析改良泪囊鼻腔吻合手术的效果。方法在常规泪囊鼻腔吻合术的基础上进行改进和简化，不切断内眦韧带，鼻黏膜作一“U”形瓣，泪囊亦作宽大的前叶瓣，两瓣连续缝合，后叶不加处理。结果本组58例60眼，术后观察随访2月～1年，60眼均获得满意效果，患者溢泪消失，泪道冲洗通畅，成功率100％。结论改良手术方法简单，容易掌握和操作，手术成功率高，较为实用，便于普及。     

Bicanalicular double silicone intubation in external dacryocystorhinostomy and canaliculoplasty for distal canalicular obstruction

Purpose: We aimed to evaluate the effectiveness of bicanalicular double silicone intubation in dacryocystorhinostomy (DCR) and canaliculoplasty for distal or common canalicular obstruction. Methods: We reviewed the medical records of patients with distal or common canalicular obstruction who had undergone bicanalicular double silicone intubation (insertion of two tubes into each canaliculus) during external DCR and canaliculoplasty. We reviewed the records of subjects who had undergone the same surgery with a bicanalicular single intubation as control material. The tubes were removed at around 6 months after surgery. Anatomical and functional success rates of patients who were followed up for > 2 months after the removal of tube(s) were evaluated. In addition, complications related to the silicone tube were evaluated. Results: Data for 60 eyes of 45 patients in the double‐intubation group and 69 eyes of 65 patients in the single‐intubation group were retrieved. The double‐intubation group showed higher anatomical success rates (96.5%) than the single‐intubation group (85.5%). Functional success was achieved by 53 (88.3%) of 60 eyes in the double‐intubation group and 56 (81.2%) of 69 eyes in the single‐intubation group. There was no significant difference in complication rates between the two groups. Conclusions: Bicanalicular double silicone intubation for DCR and canaliculoplasty may be an effective mode of treatment for patients with distal or common canalicular obstruction.     

Primary external dacryocystorhinostomy versus primary endonasal dacryocystorhinostomy: a review

This paper aims to compare the efficacy, mean operative time and adverse effects of primary external dacryocystorhinostomy (DCR) versus primary endonasal DCR in treating acquired nasolacrimal duct obstruction. Searches were performed for studies comparing the two procedures. Two reviewers independently extracted data from 14 eligible studies. A random effects model was used to analyse the studies. Outcome measures were defined as patency of the nasolacrimal canal and mean operative time, and adverse effects as cutaneous scarring and bleeding. Both procedures were comparable in efficacy in terms of full success, partial success and anatomic patency. Subgroup analysis showed no significant difference between prospective and retrospective studies as well as between non‐laser endonasal DCR versus external DCR and laser endonasal DCR versus external DCR. Endonasal DCR had a significantly shorter mean operative duration, be it laser endonasal DCR (mean difference: 37.65 min, 95% confidence intervals: 3.54–71.75 min, P: 0.03) or non‐laser endonasal DCR (mean difference: 19.22 min, 95% confidence intervals: 2.15–36.28 min, P: 0.03). The odds of postoperative bleeding was not significantly different between the two procedures, whereas postoperative cutaneous scarring was unique to external DCR and occurred in 50 out of 402 (12.44%) external DCRs recorded. Endonasal DCR has comparable success rates with external DCR and has a shorter operative time and no cutaneous scar. However, drawbacks include the steep learning curve and higher costs.     

Intubation in routine dacryocystorhinostomy: why we do what we do

The role of intubation in routine dacryocystorhinostomy (DCR) surgery is unclear, with there being little evidence in favour of this practice, which appears to have largely come about as a result of history, anecdote and the evolution of DCR surgery. In this paper, a brief history of intubation in DCR surgery is presented and the evidence base is analysed.     

泪囊鼻腔吻合术后再阻塞的支架植入治疗

目的:评价鼻泪管支架植入术在治疗泪囊鼻腔吻合术后再阻塞的应用价值。方法:对17例(17眼)泪囊鼻腔吻合术后阻塞患者行鼻泪管支架植入术,经逆行扩张鼻泪道后植入特制的鼻泪管支架,并于术前、术后行数字减影泪道造影检查。结果:17眼中15眼成功植入了支架,手术成功率为88%。成功植入支架的患者术后随访12～36(平均24.6)mo,有效率为100%。无严重并发症发生。结论:鼻泪管支架植入术治疗泪囊鼻腔吻合术后阻塞具有良好的效果,值得推广。     

Comparison of endoscopic revision for failed primary external versus endoscopic dacryocystorhinostomy

Backgound: To compare differences in endoscopic revision after previously failed lacrimal surgery that involved either external or endoscopic dacryocystorhinostomy. Design: Retrospective, comparative, nonrandomized clinical study. Participants: We assessed 77 patients (82 surgeries) treated for recurrent nasolacrimal duct obstruction. Methods: Electronic medical records for patients with recurrent epiphora who underwent endoscopic revisional dacryocystorhinostomy, after previous external or endoscopic dacryocystorhinostomy at Seoul St. Mary's Hospital from 2004 to 2010, were reviewed. Main Outcome Measures: Data regarding the lacrimal drainage system, comprehensive eye examination, surgical outcome and preoperative/perioperative transnasal endoscopy were analysed. Results: In total, 77 patients underwent 82 endoscopic revisional dacryocystorhinostomy procedures. A success rate of 84% was achieved for cases of previous external dacryocystorhinostomy and 80.7% for previous endoscopic dacryocystorhinostomy (P = 0.722). For preoperative nasal endoscopy, more of the patients who underwent previous external dacryocystorhinostomy exhibited a hypertrophic middle turbinate and severe septal deviation when compared with patients who underwent previous endoscopic dacryocystorhinostomy (P = 0.031, P = 0.001, respectively). For perioperative nasal endoscopy, more of the patients who underwent previous endoscopic DCR exhibited a smaller ostium when compared with patients who underwent previous external dacryocystorhinostomy (P = 0.031). Conclusions: The success rate of revisional dacryocystorhinostomy in the previous external dacryocystorhinostomy group was slightly higher than that in the previous endoscopic dacryocystorhinostomy group. Differences in preoperative and perioperative endoscopic findings were detected between the groups. Clarifying these differences in endoscopic revision will help improve the surgical outcomes of primary surgery involving either external or endoscopic dacryocystorhinostomy.     

泪道置管联合外路泪囊鼻腔吻合术治疗慢性泪囊炎合并上泪道狭窄

目的:探讨泪道置管联合外路泪囊鼻腔吻合术治疗慢性泪囊炎合并上泪道狭窄的临床疗效。方法:回顾性分析33例33眼慢性泪囊炎合并上泪道狭窄的患者资料,所有患者在进行外路泪囊鼻腔吻合术同时于上泪道留置硅胶泪道引流管,泪管留置时间为6mo。患者于术后1wk;1,3,6,9mo复查,观察术眼泪道通畅、溢泪、溢脓等情况。结果:术后1wk~6mo复查,冲洗泪道通畅率100%,均无溢泪;术后6mo取出泪道置管,取管后3mo复查,32例(97%)冲洗泪道通畅,无溢泪;1例(3%)冲洗阻力大,溢泪症状减轻。2例(6%)泪小点轻度撕裂,无其他并发症。结论:泪道置管联合外路泪囊鼻腔吻合术能够有效治疗慢性泪囊炎合并上泪道狭窄。     

Patients' preferences for positioning during phaco-emulsification under topical-intracameral anaesthesia

In many eye departments it is routine to ask patients to lie completely flat for cataract surgery. However, many patients prefer not to lie completely flat, if given the choice. It is our practice to ensure patients are in a comfortable position before commencing surgery. We conducted a prospective observational study of our routine practice comprising 125 consecutive cataract operations conducted by a single surgeon with local anaesthesia (occasional phaco under general anaesthetic was not included). All patients were initially positioned lying flat on the reclining chair and were given the option of staying in that position throughout the operation or having the chair-back raised until they were comfortable. Only 27% (34 patients of 125 total) were happy to lie flat (angle between 0° and 5°). The majority of our patients (62% – 78 patients) preferred to sit up slightly, with the chair-back 10° to 25° above the horizontal; 8% (10 patients) of the patients were sited at an angle of 30° to 35° and 2% (three patients) needed to be sited at 35° or more. Patients who sat up above 30° generally had a medical reason such as orthopnoea (3% – four patients), back pain (5% – six patients), anxiety (2% – two patients), Meniere's disease (1% – one patient). Patients who sat up below 25° chose this position for comfort or preference. Our results show that patient preferences for positioning during cataract phaco-emulsification under topical-intracameral anaesthesia should increase overall patient satisfaction without the need to compromise safety.     

Management of chronic dacryocystitis cases after failed external dacryocystorhinostomy using endoscopic technique with a novel lacrimal ostium stent

AIM: To demonstrate the outcomes of endoscopic endonasal dacryocystorhinostomy (En-DCR) with an novel lacrimal ostium stent (LOS) which was performed in patients with recurrent epiphora after failed external dacryocystorhinostomy (Ex-DCR) and analyze the causes of failed Ex-DCR. METHODS: From September 2015 and December 2017, the clinic data of 29 cases suffered from recurrent epiphora after failed Ex-DCR was reviewed. The LOS were implanted into the ostium at the end of the revisional surgery. The causes of failed Ex-DCR were analyzed before revisional surgeries. Outcome of revisional surgeries with the new device were evaluated as well. RESULTS: The major causes of failure of the external approach were synechiae formation in the nasal ostium (29/29), followed by inadequate removal of the bony wall (21/29), nasal synechiae formation between lateral wall of nose and middle turbinate (11/29), and the bone opening was not in good location (7/29). The rate of success after revisional surgery was 82.76%. Re-obstruction of the ostiums were found in 5 failed cases. CONCLUSION: Endoscopic approach with a novel LOS may be an effective procedure to manage recurrent epiphora after previous failed Ex-DCR surgery. Synechiae formation in the nasal ostium and inadequate removal of the bony wall were the major causes of failure of Ex-DCR.     

下泪小管插管泪囊鼻腔吻合治疗泪囊黏液囊肿

目的　探讨适合泪囊黏液囊肿的手术方法、围手术期处理。方法　对 19例 (2 1眼 )泪囊黏液囊肿行泪囊鼻腔吻合术 ,下泪小管留置硬膜外导管 ,围手术期进行相应的处理并回顾分析其疗效。结果　 2 1眼中有 18眼经 1次治疗治愈。 3眼冲洗泪道不通畅而再行第 2次插管 ,其中 2眼治愈。总的治愈率为 95 2 4%。 1眼无效。结论　下泪小管插管泪囊鼻腔吻合术是治疗泪囊黏液囊肿的较好的方法 ,围手术期处理与手术方法和技巧同样是手术成功的关键。     

聚四氟乙烯在泪囊炎鼻腔内窥镜手术中的应用

目的:使用聚四氟乙烯膜提高泪囊炎鼻腔内窥镜手术的成功率。方法:在常规鼻腔内窥镜泪囊炎手术的基础上使用聚四氟乙烯膜做造孔支撑物,不用银夹将泪囊和鼻黏膜夹持。结果:本组56例56眼,手术后1～3mo拔膜,随访1～6mo,泪溢、溢脓消失,泪小点无撕裂。结论:聚四氟乙烯膜做为泪囊炎手术后造孔支撑物有良好的组织相容性,其直径可控,留膜期间患者舒适,手术成功率高,易于普及。     

Conal anaesthesia: a new approach to retrobulbar anaesthesia

We have set out critically to assess the current percutaneous technique of retrobulbar anaesthesia. Access to the confined space within the muscle cone is limited by the globe itself and the medially directed lateral orbital wall. By approaching the retrobulbar muscle space with a curved needle through the inferior conjunctival sac these anatomical constraints are overcome. This technique is referred to as conal anaesthesia. A quantitative comparison of the two techniques demonstrates that the conal approach produces more reliable and effective muscle block with faster onset of action than conventional percutaneous anaesthesia. The conal approach is safe and offers advantages with its ease of application, excellent anaesthesia and akinesis and through its rapid and consistent results.     

The cosmetic outcome of external dacryocystorhinostomy scar and factors affecting it

Purpose:To study the cosmetic outcome of external dacryocystorhinostomy (Ex-DCR) and to detect the factors affecting it.Results:The mean scar grading was 0.98 ± 1.0 and 1.3 ± 1.0 in patients’ and examiner''s assessment. About 27.5% described their scars as cosmetically significant. The cosmetic outcome was significantly affected by the type of incision with only 5% significant scars in subciliary incision group. Prolene 6-0 suture was associated with better cosmetic results with 15% significant scars. 50% of dark-skinned patients showed cosmetically significant scars. Although no correlation was found between patients’ age and cosmetic outcome, pediatric patients showed higher tendency to scar visibility with mean scar grade 1.2 ± 1.0 and 1.5 ± 0.9 in patients’ and examiner''s assessment.Conclusion:Dark skinned and pediatric patients are more prone to visible Ex-DCR scar. The use of subciliary approach and prolene 6-0 skin sutures is associated with more favorable cosmetic outcome.     

基层医院开展改进的泪囊鼻腔吻合术疗效观察

目的观察简化改进的泪囊鼻腔吻合术的效果。方法在传统的泪囊鼻腔吻合术的基础上进行了4方面改良：内眦韧带不断离；做泪囊和鼻粘膜两个“U”型瓣，两瓣上面填充可止血和吸收的明胶海绵；两瓣间无需缝合；术中及术后不放置引流管。结果23例（26眼）观察2—10月，25眼恢复了汨道功能，无溢泪或溢泪减少。1例阻塞。结论改良的泪囊鼻腔吻合术方法简便，疗效确切，治愈率高，适用于基层医院。     

经鼻鼻腔泪囊吻合术治疗儿童复杂性泪道阻塞的临床观察

目的 探讨应用经鼻鼻腔泪囊吻合术（NES-DCR）治疗儿童复杂性泪道阻塞的安全性、可行性和临床疗效。设计 回顾性病例系列。研究对象 儿童复杂性泪道阻塞患者20例（25眼）,其中先天性泪道阻塞伴骨性泪道发育异常14例（19眼）,外伤性泪道阻塞6例（6眼）。方法 在鼻内窥镜直视下进行鼻腔泪囊吻合术联合或不联合泪道硅胶扩张管植入术,术后3个月后拔除泪道扩张管,随访观察6~18个月。观察术后症状改善、泪道冲洗通畅情况（泪液排放试验、泪道冲洗）,吻合口大小和开放情况以及并发症等,分析手术疗效。主要指标 有效率、治愈率、并发症。结果 本组患者术后总有效率达到96%,无效仅1例,为外伤性泪囊炎患儿。其中,先天性泪道阻塞伴骨性发良异常者效果最佳,有效率达100%,治愈率达94.4%;外伤性泪道阻塞者有效率83.3%,治愈率仅为50%。术后随访期内两组均未见明显并发症。结论 经鼻鼻腔泪囊吻合术为儿童复杂性泪道阻塞提供了较为安全有效的治疗手段,尤其对先天性泪道阻塞合并骨性鼻泪管发育异常患者疗效突出。     

Anterior suspended flaps: a modified approach for external dacryocystorhinostomy

BACKGROUND/AIMS—External dacryocystorhinostomy (DCR) is a reliable but difficult surgical technique for the treatment of any obstruction of the lacrimal drainage system lying distal to the internal opening of the common canaliculus. In this prospective study, a simplified external DCR procedure and the results obtained on a series of 45 consecutive patients, in which traditional external DCR was indicated, are described.
METHODS—In this modified procedure only very large and mobile anterior flaps of the lacrimal sac and nasal mucosa are created. Thanks to the large size and the great motility the two flaps can be easily sutured. Two double armed 6/0 polyglycolic acid sutures are used to join the two flaps, to elevate them anteriorly in order to avoid adhesions with underlying tissues, and to approximate the deep planes of the wound. The mean operative time was measured.
RESULTS—At the end of follow up period (mean 17 months, range 14-24 months) all patients had no sign or symptoms of tearing and normal Jones I dye test. The mean operative time was 28.6 minutes (range 23-44 minutes)
CONCLUSION—We believe that our modified technique can be used to simplify and speed up traditional external DCR without decreasing its well known reliability.

Keywords: external dacryocystorhinostomy; anterior mucosal flaps