Congenital dacryocystocele: diagnosis using ante and post-natal ultrasonography / Dacriocistocele congênita: diagnóstico ultrassonográfico ante e pós-natal

Congenital dacryocystocele is an unusual type of nasolacrimal obstruction. Treatment with antibiotics or surgical removal is practiced to reduce the risks of infection (acute dacryocystitis) and potentially lethal septicemia. Here, we report a case of congenital dacryocystocele, antenatal ultrasonographic diagnosis (intrauterine), and postnatal reassessment.

A dacriocistocele congênita é um tipo incomum de obstrução lacrimal. Devido ao risco de se tornar infectada (dacriocistite aguda) e potencialmente letal com septicemia, podemos tratá-la com antibióticos e remoção cirúrgica. Relatamos um caso de dacriocistocele congênita com diagnóstico ultrassonográfico antenatal (intrauterino) e reavaliação pós-natal.

Dacriocistorrinostomía endonasal: participación del oftalmólogo / Endoscopic dacryocystorhinostomy: Role of the ophthalmologist

OBJETIVO: Evaluar los resultados de la dacriocistorrinostomía (DCR) endoscópica con o sin apoyo del oftalmólogo. MATERIAL Y MÉTODOS: Estudio retrospectivo de 100 casos operados de DCR endoscópica por un otorrinolaringólogo entre junio de 2008 y diciembre de 2009. De las 100, 50 fueron intervenidas con apoyo quirúrgico de un oftalmólogo, que canalizaba los canalículos superior e inferior con sondas de Bowman, mientras que en los otros 50 casos fue el propio otorrinolaringólogo quién realizó esta canalización, sin apoyo del oftalmólogo. La evaluación de los resultados a 2 años incluyó la percepción subjetiva, la permeabilidad de la vía lagrimal tras lavado y la permeabilidad funcional de la vía lagrimal tras test de Jones modificado. RESULTADOS: De las 100 DCR revisadas, en más del 50% se realizó algún tratamiento complementario por el otorrinolaringólogo, sobre todo septoplastias. En cuanto a la resolución de la epífora, cuando no hubo oftalmólogo presente en el quirófano, los pacientes referían mejoría subjetiva total en 75%; sin embargo, en el grupo cuya canalización quirúrgica era realizada por el oftalmólogo, los resultados satisfactorios llegaban al 92% de forma subjetiva, diferencia estadísticamente significativa. CONCLUSIONES: La DCR endoscópica es efectiva en el tratamiento de la epífora, pero sus resultados mejoran cuando el oftalmólogo colabora en el procedimiento quirúrgico, canalizando la vía lagrimal

OBJECTIVE: To evaluate the results of endoscopic dacryocystorhinostomy (DCR) with or without support of the ophthalmologist. MATERIAL AND METHODS: A retrospective study of 100 cases of endoscopic DCR surgery conducted by an otolaryngologist between June 2008 and December 2009. Of the 100 cases, 50 were operated with surgical support of the ophthalmologist, who inserted Bowman probes in the upper and lower canaliculi, while in the other 50 cases it was the otolaryngologist who performed this, without support of the ophthalmologist. The evaluation of the results after 2 years included the subjective perception, the lacrimal patency after lacrimal syringing, and lacrimal functional test after modified Jones test. RESULTS: Of the 100 DCR reviewed, more than 50% required complementary treatment by the otolaryngologist, mainly septoplasty. As for the resolution of epiphora, without support of the ophthalmologist, 75% the patients reported an overall subjective improvement, but this reached 92% in the surgical group with support of the ophthalmologist, which was a statistically significant difference. CONCLUSIONS: Endoscopic DCR is effective in the treatment of epiphora, but its results improve when the ophthalmologist inserts the probes in the lacrimal canaliculi during the surgical procedure

Dacriocistorrinostoma externa. Nuestros resultados / External dacryocystorhinostomy. Our results

Objetivo. Evaluar la eficacia del tratamiento de la obstrucción del conducto nasolagrimal adquirida, por dacriocistorrinostomía (DCR) externa en el Servicio de Oftalmología del CHUC-HG. Material y Métodos. Se evaluaron retrospectivamente 58 DCR externas realizadas a 52 pacientes. Se estudiaron seis variables: edad, sexo, manifestaciones y síntomas iniciales (lagrimeo, secreciones, dacriocistitis); história oftalmológica (trauma lagrimal), complicaciones intra y post-operatorias (sangrado, infección, dehiscencia de sutura); re-intervención/ fracasode la primera cirugía; tratando de relacionarlos con los resultados quirúrgicos obtenidos: éxito o fracaso. Resultados. La edad media de los pacientes fue de 59 años, con un predominio del sexo femenino (75,00%). La queja más frecuente fue la epífora (94,83%). Las complicaciones intra y post-operatorias ocurrieron en 8,62% de los pacientes. En 4,26% de los pacientes fue necesaria una segunda intervención. Conclusión. La tasa de éxito de la DCR externa fue 93,62%. Consideramos esta técnica una buena opción para la corrección de las obstrucción del conducto nasolagrimal adquirida debido a la baja tasa de complicaciones y fracaso quirúrgico (AU)

Objective. Evaluate the efficacy of treatment of the nasolacrimal acquired obstructions, with external dacryocystorhinostomy (DCR) in the CHUC-HG Ophthalmology Service. Material and Methods. A retrospective study was made with 58 external DCR’s performed to 52 patients. Six variables were studied: age, sex, initial signs and symptoms (epiphora, secretions, dacryocystitis); past ophthalmic history (lacrimal trauma), intraoperative and postoperative complications (bleeding, infection, suture dehiscence); reoperations; trying to relate them with the surgery results: success or unsuccess. Results. The mean age of patients was 59 years old, with female predominance (75.00%). The most frequent complaint was epiphora (94.83%). The intraoperative and postoperative complications occurred in 8.62% of patients. In 4.26% of patients operated, a reintervention was necessary. Conclusion. The success rate with external DCR was 93.62%. We considered that this technique is a good option for the correction of the nasolacrimal acquired obstructions due to low rates of complications and surgical unsuccess (AU)

Utilidad de las curas locales tras dacriocistorrinostomía láser / Usefulness of local postoperative care after laser dacryocystorhinostomy

Introducción y objetivos: La epífora originada por la oclusión del drenaje nasolagrimal es la principal indicación de la dacriocistorrinostomía (DCR). Igualmente, lo son la conjuntivitis crónica y la dacriocistitis del mismo origen. La vía endoscópica nasal, y la introducción del láser (DCR láser) ha facilitado la realización de la técnica, aunque requiere un equipamiento complejo y costoso, por lo que siguen existiendo partidarios del procedimiento externo tradicional. El objetivo de este estudio es analizar la efectividad y utilidad de las curas posoperatorias de la DCR láser en el resultado final. Material y métodos: Estudiamos un grupo de 96 pacientes diagnosticados de epífora secundaria a estenosis-oclusión del conducto nasolagrimal. En 32 pacientes se realizó la intervención en ambos ojos, lo que hace un total de 128 casos. La cirugía se practicó en un ámbito privado entre enero de 1999 y diciembre de 2008. Los 128 casos se dividieron en 2 grupos: 59 casos en los que se realizaron entre 4 y 6 curas posoperatorias en los 2 meses siguientes a la cirugía. Otro grupo de 69 casos en los que se hizo una sola cura, aproximadamente a los 7 días de la intervención. La valoración definitiva del resultado de la intervención se hizo en todos los casos entre 24 y 30 meses tras la cirugía. Resultados: En 27 casos de los 128 (79% de éxitos) se produjo una reestenosis del drenaje lagrimal, sin encontrar diferencias estadísticamente significativas entre los 2 grupos. Conclusiones: En la muestra de pacientes que hemos intervenido mediante DCR láser, resulta irrelevante, en cuanto al éxito de la intervención, la realización o no de curas posoperatorias (AU)

Introduction and objectives: Epiphora caused by nasolacrimal drainage system obstruction is the main indication for dacryocystorhinostomy (DCR). So are chronic conjunctivitis and dacryocystitis from the same origin. Nasal endoscopy and the introduction of laser assisted DCR have facilitated the performance of the technique. However, it requires complex and expensive equipment, so there are still supporters of the traditional external procedure. The aim of this work was to study the effectiveness and usefulness of local postoperative care in laser DCR final result. Material and methods: We studied a group of 96 patients diagnosed with epiphora secondary to stenosis-occlusion of the nasolacrimal duct. Of these, 32 patients underwent surgery in both eyes, making a total of 128 cases. The surgery was performed in a private setting between January 1999 and December 2008. The 128 cases were divided into 2 groups: 59 cases in which between 4 and 6 postoperative cures were given in the 2 months following the surgery, and another group of 69 cases in which a single cure was given approximately 7 days after surgery. The final assessment of the outcome of the intervention was done in all cases between 24-30 months after surgery. Results: In 27 cases out of 128 (79% success), there was a restenosis of tear drainage. No statistically significant differences were found between the 2 groups. Conclusions: In the sample of patients that were intervened using laser assisted DCR, implementation of postoperative cure was irrelevant in the success of the intervention (AU)

Dacriocistorrinostomia endoscópica: nossa experiência e revisão de literatura / Endoscopic dacryocystorhinostomy: our experience and literature review

Objetivo: Apresentar nossa experiência em dacriocistorrinostomia endoscópica, discutindo os resultados com os encontrados na literatura. Métodos: O material desse estudo consistiu de 16 dacricistorrinostomias realizadas em 12 pacientes acompanhados no período de 2009 a 2011. Analisamos sexo, idade no momento da cirurgia, etiologia da dacriocistite, quadro clínico, número de cirurgias necessárias para a correção, seguimento pós-operatório. Resultados: Houve predomínio do sexo feminino em relação ao masculino (5:1) com idades entre 8 e 71 anos, com média de 35,2 anos. Com relação à etiologia, oito foram classificados como idiopáticos; três, pós-traumáticos e um iatrogênico. Os pacientes foram acompanhados em média durante o período de seis meses, com melhora dos sintomas. Apenas dois pacientes evoluíram com permanência de epífora, sendo um deles reoperado com êxito por via externa. Conclusão:A cirurgia endoscópica endonasal deve ser considerada nos pacientes com obstrução das vias lacrimais, devido ao seu alto índice de sucesso, além de ser um procedimento seguro, com menor morbidade e proporcionar melhor resultado estético.

Objective:To present our experience in endoscopic dacryocystorhinostomy, discussing the results with those found in the literature. Methods: The material in this study consisted of sixteen surgeries performed in twelve patients followed between 2009 to 2011. We analyzed gender, age at surgery, etiology of dacryocystitis, clinical features, number of surgeries required to repair, follow-up. Results: There was a predominance of females compared to males (5:1) aged between 8 and 71 years, mean35.2 years. With regard to etiology, eight were classified as idiopathic, three, posttraumatic, and one, iatrogenic. Patients were followed on average over the period of six months, with improvement of symptoms. Only two patients had persistence of epiphora, one being reoperated successfully by external approach. Conclusion: Endoscopic endonasal surgery should be considered in patients with lacrimal obstruction, due to its high success rate, besides being safe procedure with less morbidity and give better cosmetic results.

Effects of Nasopore Packing on Dacryocystorhinostomy

PURPOSE: To investigate the effects of placement of the absorbable packing material Nasopore at the anastomosis site of newly formed mucosal flaps on postoperative re-bleeding, discomfort, and on the success rate of dacryocystorhinostomy (DCR). METHODS: A review of the medical records of patients with primary acquired nasolacrimal duct obstruction that underwent external or endonasal DCR by a single surgeon was performed. The degree of re-bleeding, discomfort, and postoperative results, including anatomical success, functional success and postoperative nasal findings such as granulation, synechiae, and membrane formation were compared in patients whose anastomosis site was packed with either Nasopore or Merocel, a non-absorbable packing material. RESULTS: A total of 77 patients (101 eyes) were included. Of the 101 eyes, 30 were packed with Nasopore, while 71 were packed with Merocel. The Nasopore group showed significantly better results than the Merocel group in the degree of re-bleeding and the level of patient discomfort (p = 0.000, 0.039, respectively; Pearson's chi-square test), whereas there were no statistically significant differences between the two groups in postoperative anatomical and functional success (p > 0.05). CONCLUSIONS: Nasopore significantly reduced postoperative nasal re-bleeding and patient discomfort during the early post-surgical period, but failed to show an effect on the postoperative anatomical and functional success of DCR.

Effects of Nasopore Packing on Dacryocystorhinostomy

PURPOSE: To investigate the effects of placement of the absorbable packing material Nasopore at the anastomosis site of newly formed mucosal flaps on postoperative re-bleeding, discomfort, and on the success rate of dacryocystorhinostomy (DCR). METHODS: A review of the medical records of patients with primary acquired nasolacrimal duct obstruction that underwent external or endonasal DCR by a single surgeon was performed. The degree of re-bleeding, discomfort, and postoperative results, including anatomical success, functional success and postoperative nasal findings such as granulation, synechiae, and membrane formation were compared in patients whose anastomosis site was packed with either Nasopore or Merocel, a non-absorbable packing material. RESULTS: A total of 77 patients (101 eyes) were included. Of the 101 eyes, 30 were packed with Nasopore, while 71 were packed with Merocel. The Nasopore group showed significantly better results than the Merocel group in the degree of re-bleeding and the level of patient discomfort (p = 0.000, 0.039, respectively; Pearson's chi-square test), whereas there were no statistically significant differences between the two groups in postoperative anatomical and functional success (p > 0.05). CONCLUSIONS: Nasopore significantly reduced postoperative nasal re-bleeding and patient discomfort during the early post-surgical period, but failed to show an effect on the postoperative anatomical and functional success of DCR.

Dacriocistorrinostomia endoscópica / Endoscopic dacryocystorhinostomy

A abordagem cirúrgica do saco lacrimal por via intranasal assistida por videoendoscopia é, hoje, realizada com altos índices de sucesso. Apesar da técnica tradicional por via externa apresentar resultados bastante satisfatórios, tem a grande desvantagem de necessitar de uma incisão de pele e sua consequente cicatriz local. Com o desenvolvimento e aprimoramento do instrumental e das técnicas endonasais, a abordagem endoscópica é cada vez mais utilizada. OBJETIVO: Este artigo revisa a anatomia do sistema lacrimal, a avaliação pré-operatória e os detalhes técnicos da cirurgia assistida por endoscopia que podem proporcionar os desfechos cirúrgicos mais favoráveis ao paciente. As complicações e as causas de insucesso cirúrgico são também brevemente revisadas. METODOLOGIA: Trata-se de uma revisão da experiência dos autores nos últimos 10 anos de aplicação da técnica endoscópica para cirurgia do saco lacrimal. CONCLUSÃO: Os resultados da dacriocistorrinostomia endoscópica são, no mínimo, iguais aos da técnica tradicional externa. Apesar disto, o trabalho conjunto do oftalmologista e do otorrinolaringologista é muito vantajoso para o melhor manejo possível do paciente com epífora.

The endonasal surgical approach of the lacrymal sac assisted by video-endoscopy is carried out today with high success rates. Despite the satisfactory results reached with the traditional external approach, it has the disadvantage of requiring a skin incision and a consequent local scar. With the development and enhancement of the endonasal techniques, the endoscopic approach is increasingly preferred by surgeons. OBJECTIVE: This paper reviews the lacrymal system anatomy, the preoperative assessment and the technical details of the endoscopic assisted approach which may provide better surgical outcomes for patients. We will also briefly discuss complications and causes for surgical failure. METHODOLOGY: This is a review of the experience of the authors in the past 10 years of employing the endoscopic technique for the lacrymal sac surgery. CONCLUSION: Outcomes regarding the endoscopic dacryocystorhinostomy are, at leas, equal to those from the traditional external approach. Notwithstanding, the joint work between the otorhinolaryngologist and the ophthalmologist is of great benefit to patients with epiphora.

Recanalização do ducto nasolacrimal com radiofrequência: estudo preliminar / Recanalization of nasolacrimal duct with radio frequency: preliminary study

OBJETIVO: Avaliar a reconstituição do ducto nasolacrimal com o uso de radiofrequência para restabelecimento do fluxo lacrimal nos casos de obstrução da via lacrimal excretora. MÉTODOS: O procedimento foi realizado em 16 olhos de 16 pacientes (13 femininos e 3 masculinos) pelo mesmo cirurgião, utilizando aparelho de radiofrequência monopolar de 450 kHz e 150 W de potência, com anestesia local sob sedação. Os critérios de inclusão foram obstrução baixa da via lacrimal (confirmada por dacriocistografia) e idade superior a 18 anos. Os critérios de exclusão foram trauma prévio, dacriocistite aguda, fístula cutânea, mucocele, cirurgia prévia da via lacrimal e uso de marca-passo cardíaco. RESULTADOS: O seguimento mínimo foi de 120 dias, os pacientes realizaram retornos ambulatoriais para avaliação clínica (presença de epífora, secreção, refluxo à expressão do saco lacrimal, posicionamento do tubo de silicone) e teste de Milder. Aos 90 dias de pós-operatório, 13 pacientes apresentavam irrigação positiva (81,25%) com desobstrução do ducto nasolacrimal e 3 casos (18,75%) de insucesso com irrigação impossibilitada (sem passagem para cavidade nasal). CONCLUSÃO: A reconstituição do ducto nasolacrimal com radiofrequência mostrou-se eficaz no tratamento da obstrução da via lacrimal excretora.

PURPOSE: To evaluate the nasolacrimal duct reconstitution with radio frequency for restoration of lacrimal flow in cases of nasolacrimal duct obstruction. METHODS: The procedure was carried out in 16 eyes of 16 patients (13 women and 3 men) by the same surgeon, with monopolar high-frequency device at 450 kHz and 150 W, with local anesthesia under sedation. Inclusion criteria were lower lacrimal system obstruction (confirmed by dacryocystogram) and age over 18 years old. Exclusion criteria were previous trauma, acute dacryocystitis, cutaneous fistula, mucocele, previous lacrimal surgery and cardiac pacemaker. RESULTS: Patients were followed for at least 120 days, patients were clinically evaluated at outpatient clinics for the presence of secretion, epiphora, reflux at compression of the lacrimal sac, placement of silicone tube and Milder test. At the 90-day postoperative visit, 13 patients had positive irrigation (81.25%) with clearance of lacrimal duct and 3 cases (18.75%) presented irrigation failure. CONCLUSION: Nasolacrimal duct reconstitution with radio frequency was effective in treating nasolacrimal duct obstruction.

Uma nova abordagem para a dacriocistorrinostomia endoscópica / A new approach to endoscopic DCR

OBJETIVO: Comparar uma técnica composta de dacriocistorrinotomia (DCR) endoscópica à técnica convencional. MÉTODO: Foi realizado um estudo prospectivo no Departamento de Otorrinolaringologia da Faculdade de Medicina Maulana Azad. Trinta pacientes selecionados para DCR endoscópica foram divididos em dois grupos, um submetido à DCR endoscópica convencional e outro tratado com uma técnica mais nova com o uso de cautere, instrumentação fria e laser em diferentes etapas da DCR endoscópica. Os pacientes foram seguidos por nove meses. RESULTADOS/CONCLUSÃO: Com o uso do cautere, instrumentação fria e laser em diferentes etapas da DCR endoscópica, fomos capazes de obter taxa de sucesso de cerca de 94% com a técnica composta em comparação a 83,3% da DCR endoscópica convencional.

AIM: To compare a composite technique of Endoscopic Dacrocystorhinostomy with the conventional technique. METHODS: A randomised prospective study was carried in the department of Otolaryngology Maulana Azad Medical College. Thirty patient selected for Endoscopic DCR were divided into two groups, one of which underwent conventional Endoscopic DCR and the other group were treated with a newer technique using cautery, cold instrumentation and laser at different steps of Endoscopic DCR. The patients were followed up for Nine months. RESULTS/CONCLUSION: By using cautery, cold instrumentation and laser at different steps of Endoscopic DCR we were able to achieve a success rate of around 94% with this composite technique as compared to 83.3% in conventional Endoscopic DCR surgery.

Obstrução de vias lacrimais associada ao tratamento radioiodoterápico de carcinoma de tireoide / Lacrimal drainage system obstruction associated to radioactive iodine therapy for thyroid carcinoma

OBJETIVO: Descrever uma série de pacientes portadores de obstrução do sistema lacrimal associado à radioiodoterapia para tratamento de carcinoma de tireoide, revisar os dados clínicos e a resposta ao tratamento cirúrgico desta rara complicação. MÉTODOS: Foi realizada uma análise retrospectiva dos achados oftalmológicos de pacientes com histórico de carcinoma de tireoide previamente submetidos à tireoidectomia e à RIT que foram encaminhados para cirurgia de vias lacrimais. RESULTADOS: Dezessete pacientes com carcinoma de tireoide tratados com tireoidectomia e RIT apresentaram obstrução do ducto nasolacrimal sintomática após período médio de 13,2 meses do tratamento do câncer. Onze pacientes tiveram epífora bilateral, 8 com mucocele de saco lacrimal. A idade dos pacientes variou entre 30 e 80 anos, sendo 10 com idade menor ou igual a 49 anos. A dose cumulativa média de radioiodo administrada foi de 571 mCi (variação entre 200-1200 mCi). Sintomas de obstrução nasal e aumento de glândulas salivares ocorreram em 53% dos pacientes. Todos os pacientes foram submetidos à dacriocistorrinostomia. Observou-se ainda que nos 3 pacientes mais jovens houve maior sangramento intraoperatótio e dilatação de saco lacrimal. A resolução completa da epífora e da dacriocistite ocorreu em 82,4%, e foi parcial em 17,6% (3 pacientes mantiveram queixa unilateral após a correção da obstrução bilateralmente). O seguimento médio foi de 6 meses (intervalo: 2-24 meses). CONCLUSÕES: Alta dose cumulativa de radioiodo, disfunção nasal e de glândulas salivares estão associadas à obstrução das vias lacrimais. Observa-se uma maior porcentagem de pacientes mais jovens apresentando quadro de dacriocistite quando comparado à dacrioestenose idiopática. A absorção de iodo radioativo pela mucosa do ducto nasolacrimal com subsequente inflamação, edema e fibrose parece ter relação direta com a obstrução do ducto nasolacrimal. O conhecimento desta complicação é importante para o estudo e abordagem correta desses pacientes.

PURPOSE: To report the finding of nasolacrimal drainage system obstruction associated with radio iodine therapy and to review clinical data and the surgical treatment outcome of this rare complication. METHODS: We retrospectively analyzed ophthalmological data of patients with history of thyroid carcinoma that underwent radioactive iodine I-131 therapy and were referred to lacrimal surgery. RESULTS: 17 patients with thyroid cancer treated with thyroidectomy and radioactive iodine I-131 therapy presented symptomatic nasolacrimal duct obstruction after 13.2 months following cancer treatment. 11 patients presented bilateral epiphora, 8 had lacrimal sac mucocele. Age range was 30 to 80 years, 10 patients had less than or equal to 49 years. The mean cumulative dose of radioiodine was 571mCi (range: 200-1200 mCi). Nasal obstruction symptoms and increased salivary glands were also present in 53% of patients. All subjects underwent dacryocystorhinostomy. Dilation of the lacrimal sac and increased intraoperative bleeding was also observed in 3 younger patients. Complete epiphora and dacryocystitis resolution after surgery occurred in 82.4%, and partial in 17.6% (3 patients that still presented unilateral relapse after correction of bilateral obstruction). Mean follow-up was 6 months (range: 2-24 months). CONCLUSIONS: Cumulative high dose of radioidine, nasal and salivary gland dysfunction are associated with lacrimal drainage obstruction. We observed a great percentage of younger patients presenting dacryocystitis when compared to the idiopathic dacryostenosis. Radioactive iodine uptake by nasolacrimal duct mucosa with subsequent inflammation, edema and fibrosis seems to have a relationship to lacrimal duct obstruction. The knowledge of this complication is important for the study and proper management of these patients.

Functional and cosmetic results of a lower eyelid crease approach for external dacryocystorhinostomy / Resultados cosméticos e funcionais na dacriocistorrinostomia com incisão transpalpebral

PURPOSE: External dacryocystorhinostomy is routinely performed through a cutaneous vertical incision placed on the lateral aspect of the nose. The lower eyelid crease approach has been seldom reported. The purpose of this study is to report the cosmetic and functional results of the lid crease approach for external dacryocystorhinostomy in a series of patients. METHODS: Prospective, interventional case series. Twenty-five consecutive patients (17 women) ranging in age from 3 to 85 years (mean ± SD= 44.84 ± 23.67) were included in the study. All patients but one underwent unilateral external dacryocystorhinostomy with a 10 to 15 mm horizontal incision placed on a subciliary relaxed eyelid tension line. The inner canthus was photographed with a Nikon D70S digital camera with a macrolens and resolution of 3008 x 2000 pixels at 1, 3 and 6 months after surgery. The resulting scar was judged from the photographs by 3 observers (ophthalmologist, plastic and head and neck surgeons) according to a four level scale (1= unapparent, 2= minimally visible, 3= moderately visible, 4= very visible). RESULTS: The surgery was easily performed in all patients with a 90.48 percent success. Three of the elderly patients (ages 61, 79 and 85 yr) developed mild lacrimal punctum ectropion, which resolved with conservative treatment. One patient had a hypometric blink which spontaneously recovered within one month. The mean score for scar visibility was 2.19 (1st mo), 1.65 (3th mo) and 1.44 (6th mo). CONCLUSIONS: The eyelid crease approach is an excellent option for external dacryocystorhinostomy. It leaves an unapparent scar since the first month after surgery, even in younger patients. The functional results are excellent and comparable to other techniques. Care should be taken in elderly patients with lower eyelid laxity in order to prevent lacrimal punctum ectropion.

OBJETIVOS: A dacriocistorrinostomia externa é classicamente realizada por meio de incisão cutânea nasal. Há poucos relatos sobre a incisão transpalpebral, posicionada no sulco infraciliar da pálpebra inferior. O presente estudo tem por objetivo relatar os aspectos cosméticos e funcionais utilizando a técnica transpalpebral. MÉTODOS: Série de casos, intervencional e prospectivo. Foram incluídos 25 pacientes consecutivos (17 mulheres) com idades variando de 3 a 85 anos (média ± dp= 44,84 ± 23,67), que apresentavam dacriocistite crônica. A dacriocistorrinostomia foi unilateral em 24 casos e bilateral em 1 caso. A incisão transpalpebral foi posicionada no sulco infraciliar medial, com extensão de 10 a 15 mm. Foram realizadas fotografias digitais do canto interno (Nikon D70S, lente macro, resolução de 3008 x 2000 pixels) nos tempos pós-operatórios 1, 3 e 6 meses. A visibilidade da cicatriz foi avaliada por 3 observadores (oftalmologista, cirurgião plástico e cirurgião de cabeça e pescoço) utilizando a seguinte escala: 1= imperceptível, 2= minimamente visível, 3= moderadamente visível, 4= muito visível. RESULTADOS: A DCR foi realizada sem dificuldades e com sucesso funcional em 90,48 por cento dos casos. A pontuação média para visibilidade da cicatriz foi de 2,19 (1º mês), 1,65 (3º mês) e 1,44 (6º mês). Houve 3 casos de ectrópio leve do ponto lacrimal que foram tratados conservadoramente. Um paciente apresentou piscar espontâneo incompleto, com resolução no primeiro mês de pós-operatório. CONCLUSÃO: A incisão transpalpebral é uma excelente via de acesso para realização da dacriocistorrinostomia. A cicatriz é pouco visível desde o primeiro mês após a cirurgia, mesmo em pacientes mais jovens. Os resultados funcionais são semelhantes ao das outras técnicas. Em pacientes mais idosos é necessário avaliação cuidadosa da frouxidão palpebral a fim de evitar a indução de ectrópio lacrimal.

Dacriocistorrinostomía en adolescentes, jóvenes y adultos / Dacryocystorhinostomy in adolescents and young adults

ObjetivoEstudiar la frecuencia relativa, causas, resultados anatómicos, funcionales y complicaciones de la dacriocistorrinostomía (DCR) en pacientes entre la segunda y quinta décadas de la vida.MétodoEstudio retrospectivo, no aleatorizado, intervencional de una serie de casos clínicos, de 12 pacientes intervenidos de DCR desde marzo de 2007 hasta marzo de 2009, realizadas por un cirujano único, con un rango de edad comprendido entre los 10 y los 48 años. Registrándose edad, día de cirugía, género lateralidad, causa de la obstrucción de conducto nasolagrimal (OCNLG), técnica quirúrgica, resultado de la intervención y complicaciones. Se calculó la frecuencia relativa de estos casos respecto del total.ResultadosLa DCR en pacientes entre 13 y 48 años representaba el 14,11% del total (12:85). En este grupo el 88,8% eran mujeres y en la cirugía el 75% estaba en el lado derecho. La causa más frecuente de obstrucción fue la obstrucción baja idiopática (58,33%), mientras que 41,66% eran secundarias. En el 66,67% de los pacientes una DCR externa se llevó a cabo y el resto fue DCR endonasal. En el 91,6% de los pacientes se logró éxito anatómico con la resolución de los síntomas. Un caso presentó cicatriz hipertrófica.ConclusiónLos adolescentes y adultos jóvenes representan un porcentaje significativo de casos que reciben cirugía DCR. Tanto el abordaje externo como el endoscópico representan una alternativa válida para el tratamiento de estos pacientes con buenos resultados y baja incidencia de complicaciones(AU)

ObjectiveTo study the relative frequency, causes, anatomical and functional outcomes and complications of dacryocystorhinostomy (DCR) in patients between the second and fifth decade of life.MethodA retrospective, nonrandomized, interventional study of a clinical series of 12 patients who underwent DCR from March 2007 to March 2009, performed by a single surgeon, with an age range between 10 and 48years. Recorded data included age at surgery, date of surgery, gender, affected side, cause of obstruction, surgical technique, outcome and complications. The relative frequency of such cases over the total was calculated.ResultsDCR in patients between 13-48years old represented 14.11% of the total (12:85). In this group 88.8% were females and in 75% surgery was on the right side. The most frequent cause of obstruction was low idiopathic obstruction (58.33%) whereas 41.66% were secondary. An external DCR was performed on 66.67% of patients and the rest were endonasal DCR. Anatomical success was achieved with resolution of symptoms in 91.6% of patients. One case had a hypertrophic scar.ConclusionAdolescents and young adults represent a significant percentage of cases undergoing DCR surgery. Both the external and endoscopic approach is shown to be a valid alternative for treating these patients, with good results and low incidence of complications(AU)

Dacriocistite aguda: relato de 2 casos / Acute dacryocystitis: two cases reports

A obstrução da via lacrimal no adulto pode ser congênita ou adquirida. No caso da forma adquirida, a etiologia se classifica em não específicas (o que envolve o epitélio de revestimento e/ou o plexo vascular submucoso do ducto lácrimo-nasal) e específicas (infecções, inflamações, traumatismos, tumores e iatrogenias). O diagnóstico é estabelecido por meio da anamnese, seguida de avaliação clínica baseada na semiologia das vias lacrimais. Os pacientes acometidos pela obstrução da via lacrimal apresentam epífora, dores agudas e tumefação, principalmente na região do saco lacrimal, ocasionando ainda ectasia do mesmo em grau variável, podendo culminar com fistulização cutânea. Ao exame por imagem, utilizamos rotineiramente a dacriocistografia, que representa um ótimo meio de indicar a técnica cirúrgica mais viável. A dacriocistorrinostomia é indicada assim que for tratado o quadro clínico agudo inflamatório.

The adult lacrimal obstruction can be congenital or acquired. In the case of the acquired form, the etiology classifies in not-specific (it involves the coating epithelium and/or the vascular plexus submucosae of the lacrimal duct) and specific (infections, inflammations, tumours and iatrogenies). The diagnosis is established by means of the anamnesis and clinical evaluation based on semiology of the lacrimal sack. The patients with lacrimal obstruction present epiphora, acute pains and swelling, mostly in the region of the lacrimal sack causing ectasye of various degrees whichn culminate with cutaneous fistulization. The image exams routinely proposed for dacryocysto-graphy, which represent a great help in showing the best surgical technique for dacryocystorhinostomy, will be indicated as soon as the acute inflammatory state is treated.

Disfunción ventricular y edema agudo de pulmón asociado a crisis hipertensiva intraoperatoria. Evaluación clínica y ecocardiográfica / Ventricular dysfunction and acute pulmonary edema related to intraoperative hypertensive crisis: a case report of clinical and echocardiographic assessment

Mujer de 39 años, obesa, sometida a cirugía de desobstrucción de la vía lagrimal con anestesia general, que tras la reversión del bloqueo neuromuscular presentó una elevación súbita y grave de la presión arterial asociado a taquicardia ventricular monomorfa no sostenida. Fue tratada con propanolol, labetalol y nitroglicerina, desarrollando a los pocos minutos un cuadro de edema agudo de pulmón y shock cardiogénico. La ecocardiografía transesofágica intraoperatoria mostró un ventrículo izquierdo difuso y severamente hipocinético, con fracción de eyección menor al 15%, iniciándose la infusión de drogas inotrópicas logrando estabilizar los parámetros hemodinámicos. El estudio angiográfico descartó la lesión de las arterias coronarias y el seguimiento ecocardiográfico mostró una mejoría progresiva de la función ventricular. Se analizan las posibilidades diagnósticas y se describe la utilidad de la ecocardiografía en el diagnóstico y tratamiento del fallo cardiaco agudo intraoperatorio (AU)

A 39-year-old obese woman underwent surgery to open an obstructed tear duct under general anesthesia. After reversal of the neuromuscular block, the patient had a sudden, severe increase in blood pressure related to nonsustained monomorphic ventricular tachycardia. Acute pulmonary edema and cardiogenic shock developed minutes after treatment with propranolol, labetalol, and nitroglycerin. Intraoperative transesophageal echocardiography showed severe diffuse left ventricular hypokinesis with an ejection fraction under 15%. Hemodynamic stability was achieved with inotropic infusions. Angiography ruled out coronary artery injury and echocardiographic follow-up revealed progressive improvement of ventricular function. We analyze diagnostic possibilities and describe the benefits of echocardiography in the diagnosis and treatment of intraoperative acute heart failure (AU)

Resultados de la dacriocistorrinostomía externa vía inferior realizada por médicos residentes / Outcomes of inferior access external dacryocystorhinostomy performed by residents

Objetivo: Analizar los resultados de la dacriocistorrinostomíaexterna (DCREx) realizada por losmédicos residentes del Hospital Universitari deBellvitge, estudiando las diferencias de sus cirugíasrespecto a los médicos adjuntos.Métodos: Realizamos un estudio retrospectivoestudiando todas las DCREx realizadas entre enerode 2006 y diciembre de 2007 en nuestro centro quecorrespondieron a 65 cirugías de 54 pacientes, delas cuales 16 fueron realizadas por médicos residentesy 49 por los médicos adjuntos.Se constituyen dos grupos: casos intervenidos porlos médicos residentes y casos intervenidos por losmédicos adjuntos, y se estudian las siguientes variables:características epidemiológicas de los pacientesintervenidos (edad, sexo), lado de intervención,antecedente de inflamación del saco lagrimal, tipode anestesia empleada, complicaciones intraquirúrgicas,postquirúrgicas y resultados de la cirugía. Sedefine como «éxito anatómico» cuando se compruebala permeabilidad de la vía lagrimal al irrigarsuero, y «éxito funcional» cuando además elpaciente no refiere síntomas de epífora.Resultados: En el 88% de los casos se obtuvieronbuenos resultados: en un 80% de los casos se alcanzó éxito funcional y en un 8% sólo anatómico. En lascirugías realizadas por los médicos residentes se consiguióun éxito global del 81% (75% funcional-6%anatómico), frente al 90% de éxito global alcanzadopor los adjuntos (82% funcional-8% anatómico).Conclusión: Los resultados indican que con el adecuadoentrenamiento y supervisión, en la DCRExlos residentes pueden obtener tasas de éxito satisfactorias,muy próximas a las alcanzadas por losadjuntos, sin que exista un incremento en las complicaciones(AU)

Purpose: To assess the outcomes of external dacryocystorhinostomy(DCREx) performed by residentsat the Hospital Universitari de Bellvitge, comparingthe cases operated on by residents and thecases operated on by staff surgeons.Methods:We performed a retrospective study betweenJanuary 2006 and December 2007 of all DCRExperformed at our hospital. The operations involved 65cases from 54 patients: 16 operations were performedby residents and 49 by staff surgeons.The cases were divided into two groups: cases operatedon by residents and cases operated on by staffsurgeons, and the following variables were studied:epidemiologic characteristics of the patients (age,sex), side of intervention, antecedents of lacrimalsac inflammation, type of anesthesia, intrasurgicaland postsurgical complications and results. «Anatomicsuccess» was defined as the possibility to passphysiologic serum through the lacrimal pathwayand «functional success» if the patient in additionwas without symptoms of epiphora.Results: The procedure was successful in 88% ofcases: 80% were classified as «functional success»while only 8% were considered «anatomic success». The operations performed by residents were successful in 81% of cases (75% «functional success» and 6% «anatomic success»), whereas staffsurgeons achieved success in 90% of cases (82%«functional success» – 8% «anatomic success»).Conclusion: The results show that residents withsuitable training and supervision can achieve goodsuccess rates approaching those of staff surgeonoutcomes, without additional complications(AU)

Tratamiento de la obstrucción del conducto lacrimal con el stent Tear-Leader / Treatment of lacrimal duct obstruction with a Tear-Leader stent

Objetivo: Describir los resultados clínicos y estudiarla permeabilidad del stent de Tear-Leader(PBN) en el tratamiento de la obstrucción del conductolacrimal.Método: Estudio prospectivo de 68 pacientes, remitidosdesde el Servicio de Oftalmología para estudiode epífora por sospecha de obstrucción del conductolacrimal. Hemos colocado un total de 74 stentsTear-Leader. Los criterios de inclusión fueron: obstruccióncompleta del conducto lacrimal con permeabilidadde canalículos y de puntos lacrimales asícomo ausencia de infección aguda. Hemos realizadoen todos los pacientes el control clínico y unaencuesta de satisfacción. Se realizó un estudio estadísticodescriptivo y se evaluó la permeabilidad de laprótesis usando las curvas de Kaplan Meier.Resultados: El seguimiento de los pacientes se realizódurante dos años. Se confirmó la resolucióntotal de la epífora en el 77%, (en el 23% persistióuna epífora grado I). Permeabilidad del stent: lamediana fue de 490 días (15 meses) con rango de11-730 días, al año la permeabilidad fue de 0,51 y a2 años de 0,31. Refieren implantación dolorosa el10% de los casos implantados. Aparecieron episodiosde dacriocistitis leve en el 18% de los casos.Encuesta de satisfacción a los 68 pacientes: con respectoa la técnica, procedimiento y prótesis estabansatisfechos un 41%. Mientras la prótesis se mantuvopermeable se encontraban satisfechos un 60,8%.Conclusión: La prótesis Tear-Leader es de fácilcolocación, con escasas molestias para el paciente.Presenta una permeabilidad similar al resto destents del mercado (AU)

Purpose: To compare the effectiveness and patencyof the TearLeader stent (PBN) for treatment oflacrimal system obstruction.Methods: A prospective study of 68 patients referredfrom the ophthalmology department with suspicionof lacrimal system obstruction. We placed 74TearLeader PBN stents. Inclusion criteria were:complete obstruction of lacrimal duct with canaliculaand lacrimal puncta patency, and absence ofacute infection. We studied the clinical improvementby means of an opinion survey, and thepatency of stents was evaluated with Kaplan-Meiersurvival curves.Results: Follow-up of patients was two years. Apainful procedure was reported in 10% of cases.Minor dacryocystitis appeared in 18.9% of cases,while complete resolution of epiphora was confirmedin 77% of cases (23% of cases showed grade Iepiphora). Patency of stents: median patency 490days (15 months), range 11 to 730 days; 1 year afterstent placement patency was 0.51 and long termpatency rate for 2 years was 0.31. Opinion survey ofthe 68 patients: satisfaction with the technique, theprocedure and prosthesis placement was 41%; satisfactionwhilst the stent remained patent was 60.8%. Conclusion: Tearleader stent placement is easy toperform and comfortable for patients. TearLeaderplacement gave a patency outcome similar to otherstents(AU)

Complicações na dacriocistorrinostomia transcanalicular com laser diodo: complications / Transcanalicular dacryocystorhinostomy with diode laser: complications

OBJETIVO: Analisar as complicações da aplicação do laser de diodo para o tratamento da obstrução nasolacrimal adquirida. MÉTODOS: Foram realizados 44 procedimentos (dacriocistorrinostomia transcanalicular com laser de diodo com intubação bicanalicular de silicone sob anestesia local) entre fevereiro de 2002 a novembro de 2007 em 41 pacientes (3 bilateralmente), sendo 32 mulheres e 9 homens. RESULTADOS: As complicações mais frequentes no intraoperatório foram: dificuldade de passar a sonda de Crawford (13,6 por cento) e passagem da fibra óptica dificultada (11,3 por cento). No pós-operatório, a epífora foi a ocorrência mais frequente (15,9 por cento), seguida pela retirada acidental do silastic (11,3 por cento). CONCLUSÃO: Os índices de complicações intra e pós-operatórias se equivalem aos artigos publicados com a mesma técnica cirúrgica (e mesmo tipo de laser).

PURPOSE: To evaluate the complications of the use of diode laser in the treatment of acquired nasolacrimal obstruction. METHODS: Forty four procedures (transcanalicular dacryocystorhinostomy with diode laser with bicanalicular silicone tube intubation and local anesthesia) where performed from February 2002 to November 2007 in 41 patients (3 bilaterally), 32 women and 9 men. RESULTS: The most common intraoperative complications were disability to pass the Crawford probe (13.6 percent) and the laser probe (11.3 percent). Regarding postoperative complications, epiphora was the event of higher frequency (15.9 percent) followed by the non-intentional silastic extrusion by the patient (11.3 percent). CONCLUSION: Intraoperative and postoperative complications rate were similar of others articles that demonstrated the same surgical technique (with same laser).

Dacriocistorrinostomía endocanalicular (DCR-E): importancia de la estandarización de materiales en los resultados / Endocanalicular dacryocystorhinostomy (E-DCR): relevance of materials standardization for outcomes

Introducción y objetivos: Después de un periodo de 5 años de experiencia con la dacriocistorrinostomía endocanalicular (DCR-E) con láser diodo, la introducción de nuevos materiales ha originado diferencias técnicas significativas que motivan el presente trabajo para su evaluación. Material y método: Se compara el comportamiento de dos tipos distintos de fibra de guía de láser (sílice-fluoropolímero-tefzel y sílice-sílice-poliamida), usando un mismo generador, sobre tejido orgánico de cadáver animal fresco, y se resume el comportamiento clínico de los nuevos materiales en una serie de casos de cirugía lagrimal. Resultados: Hemos observado diferencias relevantes en el comportamiento clínico de dos tipos distintos de fibras de guía de láser, y se objetiva que los nuevos materiales propuestos tienen un comportamiento sobre tejido orgánico peor de lo que sus características físicas teóricas hacen suponer. Así, la utilización de diferentes materiales de guía puede implicar diferencias relevantes en los resultados de la cirugía, así como en el momento de evaluar estas técnicas en diferentes series realizadas por distintos cirujanos. Conclusiones: Debe buscarse una estandarización de los materiales recomendados para estas cirugías, tanto por su utilidad y efectividad clínica como en la comparación de resultados de diferentes series (AU)

Introduction and objectives: After 5 years’ experience with endocanalicular dacryocystorhinostomy (E-DCR) using diode laser, the introduction of new materials has led to significant technical differences, thus giving rise to this study to evaluate them. Material and method: We compare the behaviour of 2 different kinds of laser guide fibre (silica-fluoropolymer-tefzel and silica-silica-polyamide), using the same laser generator, on organic tissues from fresh animal carcases, and we summarize the clinical behaviour of the new materials in lachrymal surgery cases. Results: We have seen significant differences in the clinical behaviour of the two kinds of laser guides, namely the proposed new materials have a worse behaviour on organic tissues than their physical characteristics might theoretically have suggested. Thus, the use of different guide materials could lead to relevant differences in terms of surgical results, as well as in the comparison of the outcomes of series performed by different surgeons. Conclusions: It is necessary to determine standards for the materials recommended for this surgery, not only for easier technical performance and better effectiveness, but also to allow comparison of results from different authors (AU)