Ординатура / Офтальмология / Английские материалы / Oculoplasty and Reconstructive Surgery Made Easy_Garg,Touky, Nasralla_2009
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Eyelid Injuries and Reconstruction—An Update 129
Figure 9: Eyelid injury with zygoma fracture 4
Figure 10: Eyelid injury with zygoma fracture 7
CONCLUSION
Though eyelid trauma has myriad manifestations, general surgical principles are to be followed in repair. Repair is to be attempted once the general condition of the patient permits;
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meticulous cleaning of the injured area, maintenance of asepsis is essential. In most cases one can manage edge to edge apposition as the lids are fairly forgiving of minor tissue loss. However, in cases of major tissue loss or where there is concurrent injury to canaliculi or canthal tendons, plastic repair as outlined above will yield very satisfactory results in terms of function and cosmesis.
BIBLIOGRAPHY
1.Color Atlas of Ophthalmic Plastic Surgery: A.G.Tyers, J.R.O. Collins.
2.Oculoplastic Surgery: William P Chen.
3.Ophthalmic Plastic and Reconstructive Surgery: Frank A Nesi, Richard D Lisman, Mark Levine.
PATHOPHYSIOLOGY
A very common condition in which the extreme end of the nasolacrimal duct underneath the inferior turbinate fails to complete its canalization in the newborn period. Canalization of the nasolacrimal duct usually completed by eight month of gestation.
FREQUENCY
•Rate: 2-4% of newborn
•Race: no racial incidence
•Sex: no sexual difference.
CAUSES
Usually, these anomalies are sporadic, but genetics, prematurity, and maternal drug use can be possible influencing factors.
Ocular abnormalities are present in 20% of patients, and systemic abnormalities are present in almost 25% of patients with serious congenital nasolacrimal duct anomalies.
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PRESENTATION
Amniotocele
This condition occurs in neonates as a distention in the lacrimal sac. Amniotic fluid enters the sac, is retained by a nonpatent nasolacrimal duct, and is trapped in the sac by the valve at the common caaliculus, the valve of Rosenmüller. Probing the nasolacrimal duct as an office procedure usually is curative.
Dacryocystitis (Acute Mucocele or Pyocele)
This condition exhibits acute distention and inflammation in the lacrimal sac region and may occur in the neonatal period. Probing is necessary in newborns with acute dacryocystitis to establish drainage as soon as possible. This procedure is performed with topical or local anesthesia only.
Tearing
Newborns who have congenital nasolacrimal duct obstruction may not develop acute dacryocystitis with a mucocele or pyocele of the sac in the early neonatal period but may simply have tearing with a chronic mucopurulent discharge, which usually manifests at 2 weeks. Topical antibiotics should be administered, and the parents must be instructed in the proper technique of lacrimal sac compression and massage. More than 90% of these cases clear and become asymptomatic with conservative management. Under normal circumstances, these children with mild-to-moderate symptoms of epiphora and lid crusting can be monitored for the first nine months life without serious sequela. It is rarely necessary to make probing mandatory at an early age before 6 month.
Congenital Nasolacrimal Duct Obstruction 133
INVESTIGATIONS
•Fluorescein dye disappearance test—Grade as good, fair, or poor clearance
•Jones dye tests—Not as useful in practice with small children
•Imaging Studies:
•Intubation dacryocystography
•Scintillography
DIFFERENTIAL DIAGNOSIS
•Sinus mucocele
•Repeated conjunctivitis
TREATMENT
Medical Care
Congenital nasolacrimal duct obstructions resolves spontaneously in 90% of cases during the first year of life. Massage with digital pressure used as an aid to speeding up this natural resolution. Other than massage, topical antibiotics are useful for mucopurulent discharge, but the only treatment of efficacy for those patients who do not resolve spontaneously is surgery as follow.
Surgical Care
Probing
Probing cures 95% of congenital nasolacrimal obstructions. Prognosis for probing decreases with the increasing number of probings and the age of the patient. Rarely, it is successful after the third time or after 3 years.
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Nasolacrimal Intubation
Success rates of 80-95% have been reported, in patients have only been probed twice or less and are younger than 2 years. Prognosis is poor for those patients with previous dacryocystitis and for those patients in which an obstruction is encountered during the procedure. Increasing duration of intubation was not associated with increasing chance of success but with a significantly higher risk of failure if longer than 18 months. The retention of silicone tubes for longer than 12 months was associated with a significantly lower success rate (67%).
Balloon Catheter Dilatation
Balloon catheter dilatation of nasolacrimal system with or without silicone tubing: This procedure has slightly better results than intubation alone.
Dacryocystorhinostomy with or without Intubation
This treatment indicated when a patent canalicular system is present with failed previous treatment.
Conjunctival Dacryocystorhinostomy
If the upper system is scarred or atretic then it can be bypassed using a prosthesis, such as a Lester-Jones tube. This procedure probably should be avoided until the child is older than 10 years because the prosthesis requires care from the patient and often has minor complications and revisions.
Congenital Nasolacrimal Duct Obstruction 135
Figure 1: Massage technique for congenital nasolacrimal duct obstruction
Figure 2: Massage technique for congenital nasolacrimal duct obstruction
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Figure 3: Congenital lacrimal obstruction presenting with persistent watering and mucopurulent discharge observed from the first month of life
Figure 4: Important dimensions of the lacrimal drainage system
Congenital Nasolacrimal Duct Obstruction 137
Figure 5: Probing of nasolacrimal duct under general anesthesia by mask
Figure 6: Both ends of the silicone tubing have been passed through canaliculus, sac, and duct, and have been retrieved from the nose
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Figure 7: Catheter for patients older than 30 months of age (3 mm balloon diameter, 15 mm balloon length)
Figure 8: Balloon catheter for adults
(5 mm diameter, 8 mm balloon length)
Figure 9: The balloon catheter inflation device