Ординатура / Офтальмология / Английские материалы / Oculoplasty and Reconstructive Surgery Made Easy_Garg,Touky, Nasralla_2009
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cutaneous fistula. Early syringing and probing is indicated once the acute stage subsides.
If lacrimal sac abscess is developed, surgical drainage is required.
Syringing and Probing
Timing of probing is controversial, most of the surgeons now prefer to wait till one year of age, while some surgeons advocate early probing.
Anesthesia—It is performed under general anesthesia with protected airway. Laryngeal mask may be used instead of Endotracheal intubation depending on the choice of the anesthesiologist.
Technique—Before starting the procedure it, the lacrimal sac needs to be evacuated either by performing massage over the sac area or syringing with saline (Figure 6).
Upper punctum is generally preferred for probing to prevent any damage to the lower punctum during the manipulation. Punctum is dilated with Nettleship dilator (Figure 7A) and then Bowman probe (size 0 or 00) is introduced into the punctum perpendicular to the eyelid
Figure 6: Syringing is performed prior to probing of the nasolacrimal duct to evacuate the lacrimal sac
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margin (Figure 7B). It first traverses the vertical 2 mm of the canaliculus and then the horizontal part while maintaining a lateral traction of eyelid ismaintained (Figure 7C). The lateral traction of skin stretches the canaliculus and avoids any chance of damage to the canalicular mucosa and decreases the probability of creation of a false passage. If one feels the resistance while passing the probe medially, it may be due to kink of the canaliculus. Surgeon should withdraw the probe slightly and then proceed medially maintaining the lateral traction. As the tip reaches the medial wall of lacrimal sac and lacrimal bone, surgeon will feel a hard stop.
The probe is then slightly withdrawn and rotated superiorly against the brow and should come to rest over the supraorbital notch at the superior orbital rim (Figure 7D). The probe is then passed downwards, posteriorly and slight laterally down the nasolacrimal duct. The probe should slide down smoothly. In case of any feel of resistance, withdraw the probe slightly and proceed forward. If the surgeon feels the firm stop at a distance of about 12 mm (distance fom punctum to nasolacrimal duct) and cannot manipulate further, it indicates a bony obstruction and absence of nasolacrimal duct. Dacryocystorhinostomy is indicated in such a situation. If probe pass down the nasolacrimal duct to about 20 mm, it indicates that it has reached the inferior meatus. Some resistance is felt due to membranous obstruction. Firm pressure passes the probe into the nasal cavity with a slight “ pop up” sensation. Successful probing is verified by syringing (Figure 7E). Some surgeons confirm the patency by passing a spatula under the inferior turbinate to have a metal on metal feel.
Availability of nasal endoscopes, may also assist in verifying the correct passage of probe. It aids rupturing of the membrane under direct visualization and thus avoids
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Figures 7A to E: (A) A Nettleship dilator is used to gently dilate the punctum. (B) Bowman Probe size 00 is introduced into upper punctum perpendicular to eyelid margin. (C) Bowman probe is advanced horizontally while maintaining lateral traction of eyelid. (D) Probe lies over the supraorbital notch at superior orbital rim and is advanced into the nasolacrimal duct. (E) Syringing of nasolacrimal system is done to check the patency
creation of false passage. Postion of inferior turbinate can be visualized and infracture of the turbinate can be done if inferior turbinate is impacted at the ostium.
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Postoperatively, steroid—antibiotic drops four times a day for 2 weeks along with nasal decongesant drops are prescribed.
Failure
Probing may fail due to formation of small opening through the membrane, leading to closure postoperatively or due to impaction of inferior turbinate.
Repeat probing is attempted at least 6 weeks after the initial one.
Inferior Turbinate Infracture
It is performed under general anesthesia. The nasal cavity is packed before proceeding for turbinate infracture (Figure 8A).
Lens spatula is passed under the inferior turbinate, the anterior end of turbinate is rotated medially and superiorly towards the septum. Then the spatula is passed backwards and then the middle and the posterior part of turbinate are fractured (Figures 8B and C). Patency is checked by syringing (Figure 8D). Nasal cavity is packed for 24 hours as there may be a risk of slight bleed.
Postoperatively, steroid-antibiotic drops and nasal decongestants are prescribed.
Silicone Intubation
Indication—Silicone intubation is indicated in cases of recurrent failed probing with or without inferior turbinate infracture or in older children.
Various types of intubation sets like Crawford, Ritleng and others are available for the purpose.
It is performed under general anesthesia. Before intubation nasal packing is done to constrict the mucosa of the inferior turbinate. These silicone tubings have metal bodkins attached
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Figures 8A to D: (A) Nasal cavity is packed before proceeding for inferior turbinate infracture. (B and C) Inferior turbinate infracture with use of blunt spatula. (D) Syringing through inferior canaliculus to check patency
at each end. Punctum is dilated. If metal tube cannot be easily passed through the punctum, one or three snip procedure may be performed. The metal tubings are passed through each canaliculus into the nasolacrimal duct. They can be pulled into the nasal cavity with the help of an artery forceps. The silicone tubings are tied together in the nose near inferior meatus after removing the metal bodkins (Figures 9A and B).
The procedure can be combined with inferior turbinate infracture. Stents are left in position for atleast six months.
Ballon Dacryoplasty
This is a new technique of management, where collapsed catheterisintroducedintothenasolacrimalductbyaprocedure
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Figures 9A and B: (A) Silicone tube is passed through the canaliculus into the nasolacrimal duct. (B) Silicone tubing are tied together in the nose
similar to probing. The balloon is inflated with saline to 8 atm for 90 seconds, deflated, and then reinflated for 60 seconds with the catheter at the sacNasolacrimal duct junction and at thelowernasolacrimalduct.Theballoonshouldnotbeinflated in the lacrimal sac as it may rupture the system. The procedure is not so popular due to dependence on the requirement of a catheter and its high cost.
Dacryocystorhinostomy (DCR)
Indication—DCR is indicated in cases of repeated failed probing with inferior turbinate infracture or silicone intubation or in cases where on the initial probing a bony obstruction is diagnosed. It is also indicated in traumatic cases leading to canalicular scarring or injury to intraosseous part of nasolacrimal duct and in craniofacial abnormalities, associated with nasolacrimal abnormalities.
Timing—Surgery is usually not performed before 3 years of age except in cases of persistent episodes of acyte dacryocystitis.
Anesthesia—The procedure is performed under general anesthesia. Mild hypotensive anesthesia may be preferred to minimize blood loss intraoperatively.
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DCR in children is may be difficult owing to smaller size of the structures. The technique requires some modifications due to some anatomical differences from the adult lacrimal system. The anterior lacrimal crest and the lacrimal fossa are pooly developed and it is sometimes difficult to locate the site for osteotomy. Medial canthal tendon insertion provides an important landmark to identify the superior part of anterior lacrimal crest.
Due to thin bones, osteotomy is easily performed. One should prefer to have a larger osteotomy as there may be postoperative bony regrowth which may be a cause of failure.
Failures have been observed in the paediatric age group due to less well defined anatomy, postoperative bony growth and greater scarring.
Mitomycin C have also been tried intraoperatively by applying a soaked piece of cotton to the osteotomy site to reduce fibrosis and scarring postoperatively.
Endonasal DCR
Endonasal DCR, though technically difficult in young children offers a number of advantages over the external approach. It avoids the need for a skin incision and consequent scarring, enables creation of a large ostium even when the lacrimal sac is small and scarred. It has additional advantage of limited intraoperative bleeding.
SUMMARY
Abnormalities of lacrimal system are encountered frequently in the pediatric age group. Epiphora is a common condition in infancy and early childhood. Congenital nasolacrimal duct obstruction resolves spontaneously in 90-95% cases in first year of life. Inital management includes massage of lacrimal
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sac and application of topical antibiotics. Syringing and Probing alone or in combination with inferior turbinate infracture is performed in cases who does not respond to conservative therapy after one year of age. Silastic intubation is performed for repeated failed probing and finally DCR is indicated in cases of failed probing after 3 years of age.
BIBLIOGRAPHY
1.Chen PL, Hsiao CH. Balloon dacryocystoplasty as the primary treatment in older children with congenital nasolacrimal duct obstruction. J AAPOS 2005;9:546-9.
2.Chiesi C, Guerra R, Longanesi L, Fornaciari M, Morano RP. Congenital nasolacrimal duct obstruction: therapeutic management. J Paediatric Ophthalmol Strabismus 1999 Nov-Dec;36(6):326-30.
3.J E Marr, A Drake-Lee, HE Willshaw. Management of childhood epiphora. British Journal of Ophthalmology 2005;89:1123-26.
4.Jones LT, Wobig JL. Surgery of the eyelids and lacrimal system.Birmingham, Ala: Aesculapius Publishing Co; 1976
5.MacEwen CJ, Young JD, Barras CW, et al. Value of nasal endo-scopy and probing in the diagnosis and management of children with congenital epiphora. Br J Ophthalmol 2001;85:314-8.
6.Maheshwari R. Results of Probing for Congenital Nasolacrimal Duct Obstruction in Children Older than 13 Months of Age. Indian J Ophthalmol 2005;53:49-51
7.Nesi FA, Lisman RD, Levine MR, Brazzo BG, Gladstone GJ. Smith’s Ophthalmic Plastic and Reconstructive Surgery. 2nd ed. St Louis, MO: Mosby Year Book, Inc; 1998.
8.Sekhar GC. Practical approach to a patient with epiphora. Indian J Ophthalmol 1994;42:157-61
9.Wesley RE. Inferior turbinate fracture in the treatment of congenital nasolacrimal duct obstruction and congenital nasolacrimal duct anomaly. Ophthalmic Surg 1985;16:368.
PIGMENTED LESIONS
Nevi (Figure 1)
These are benign congenital tumors. They may vary in size and may be sessile or pedunculated. The commonest location is along the lid border. Risk of malignancy is low. However in large tumors, there will be 4-6% risk of malignant transformation. Sudden increase in size and increase in pigmentation suggests concern regarding malignant transformation and requires excision.
Figure 1: Showing nevus in upper eyelid
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Management
Shave off flush with the lid margin if it involves the lid margin or if nevus does not involve the lid margin excision with direct repair with margin repair can be done.
Nevus of Ota (Oculodermal Melanocytosis)
It is characterized by patchy bluish or brownish pigmentation of periocular skin and sclera. The lesion is composed of dermal melanocytes and has malignant potential. Increased intraocular pigmentation contributes to risk of glaucoma. It is occasionally associated with Sturge-Weber syndrome.
Management
Ruby laser has been tried to lighten the cutaneous component.
ANGIOMATOUS TUMORS
Portwine Stain (Nevus Flammeus)
This condition is characterized by telangiectasia of the deeper skin capillaries. It involves the part of the face which is innervated by the trigeminal nerve. It is often associated with Sturge-Weber syndrome. Congenital glaucoma and choroidal hemangioma have strong association.
Strawberry (Capillary) Hemangioma (Figure 2)
These are benign tumors present at birth. 90% of these clinically manifest by age of 1 month.
Symptoms and Signs
The child may present with ptosis, refractive error, amblyopia and proptosis.