Use of Triamcinolone Acetonide in External Dacryocystorhinostomy

Purpose: To study the effect of Triamcinolone Acetonide injection into the ostium through the external wound after one week of external Dacryocystorhinostomy. Study Design: Quasi experimental study. Place and Duration of Study: Khalid Eye Clinic, Karachi, from July 2018 to June 2019. Methods: This study included forty patients with age ranging between 18 to 36 years. All patients had obstruction of the nasolacrimal duct. Patients were categorized into two groups. Both groups underwent external dacryocystorhinostomy with silicone intubation, with the difference being that patients in group A were injected with 20 units of Triamcinolone acetonide 40 mg/ml into the ostium through wound using 27 gauge needle, one week after the surgery. Group B did not receive any injection. Both groups were followed for a period of four months, at which time the silicone tube was removed and patency of lacrimal system was ascertained via syringing with balanced salt solution through the lacrimal puncta. Main outcome measure was the success rate of procedure. Results: The mean age of the patients was 27.1 ± 5.48 years. Success rate was 100% among the patients of group A and 85% in the patients of group B at the end of the four months followup period. However, the results were statistically insignificant (p = 0.115). Conclusion: Although statistically insignificant but clinically Triamcinolone Acetonide proved helpful in reducing fibrosis and ostium granuloma formation in patients with Ex-DCR. Thus preventing failure of external Dacryocystorhinostomy. Key Words: Triamcinolone acetonide, external dacryocystorhinostomy, DCR.

Pulled versus Pushed Monocanalicular Silicone Intubation in Adults with Lacrimal Drainage System Stenosis: A Comparative Case Series

Purpose. To compare the success rate and complications of pulled versus pushed monocanalicular intubation in adults with incomplete lacrimal drainage system obstruction (lacrimal drainage system stenosis). Methods. Patients with lacrimal drainage system stenosis (Munk grade ≥3), including both nasolacrimal duct (NLD) stenosis and common canalicular stenosis, were recruited in this prospective comparative case series. Patients underwent probing and either Monoka (51 eyes) or Masterka (48 eyes) intubation under general or local anesthesia. Tubes were removed 4–14 weeks after the procedure. Six months after tube removal, Munk grades 0 and 1 were defined as a complete success, Munk grade 2 was defined as a partial success, and Munk grade ≥3 was defined as failure. All complications were recorded. Results. Ninety-nine eyes from 89 patients with lacrimal drainage system stenosis who underwent either Monoka (51 eyes) or Masterka (48 eyes) intubation were included. The mean (SD) age of the patients was 55.4 (12) years in the Monoka group and 53.5 (12.9) in the Masterka group. Groups were matched on demographics. Masterka intubation could not be performed in one eye. Complete and partial successes were observed in 52.9% (27/51) and 17.6% (9/51) of eyes in the Monoka group and 42.6% (20/47) and 12.8% (6/47) of eyes in the Masterka group, respectively ( p = 0.29 ). There was a trend toward a higher total success rate in patients with NLD stenosis treated with Monoka 66.7% (26/39) than Masterka 45.5% (15/33) intubation ( p = 0.07 ). This trend also existed in patients with common canalicular stenosis (83.3% (10/12) vs. 76.6% (11/14), p = 0.75 ). Age, sex, bilateral involvement, and duration of intubation did not have a significant impact on the success rate. Early tube loss, slit puncta, and temporary superficial punctate keratopathy were observed complications. Conclusion. Intubation with the pulled monocanalicular silicone tube was associated with a slightly but not significantly higher success rate in adults with lacrimal drainage system stenosis. Patients with NLD stenosis may achieve better results with pulled silicone tubes.

A rare presentation of orbital dermoid: A case study

Introduction: A dermoid cyst is a developmental choristoma lined with epithelium and filled with keratinized material arising from ectodermal rests pinched off at suture lines. These are the most common orbital tumors in childhood. They are categorized into superficial and deep. Superficial orbital dermoid tumors usually occur in the area of the lateral brow adjacent to the frontozygomatic suture. Infrequently a tumor may be encountered in the medial canthal area [1], which is the second most common site of orbital dermoids. We report a case where a swelling presented in the medial canthal area without involving the lacrimal system. Case report: A 43 year old lady presented with complaint of swelling near the (RE; Right eye) since 2 years duration. She presented with a solitary 1.5 cm x 1 cm ovoid, non-tender, non-pulsatile, firm, non-compressible mobile swelling with smooth surface over the medial canthus of right eye. (MRI; Magnetic Resonance Imaging) brain and orbit showed right periorbital extraconal lesion and the (FNAC; Fine Needle Aspiration Cytology) suggested of Dermoid Cyst. RE canthal dermoid cyst excision was done under Local Anasthesia. Conclusion: Complete surgical excision in to be treatment of choice for dermoids. Since medial canthal mass can involve the lacrimal system, it becomes necessary to perform preoperative assessments using (CT; Computed Tomography), MRI or dacryocystography while planning the surgical approach. Silicone intubation at the beginning of the surgery is an easy and effective way of identifying canaliculi and of preventing canalicular laceration during dermoid excision if the lacrimal system is found to be involved.

Surgical outcomes in acute dacryocystitis patients undergoing endonasal endoscopic dacryocystorhinostomy with or without silicone tube intubation

AIM: To establish the necessity of silicone tube intubation in acute dacryocystitis (AD) patients undergoing endonasal endoscopic dacryocystorhinostomy (En-DCR). METHODS: Patients presenting with unilateral AD were randomly assigned to two treatment groups. En-DCR procedures were performed following lacrimal abscess formation, with the operation being performed with silicone intubation for patients in group B but not group A. Functional success was defined by an absence of additional AD episodes, no epiphora, and ostium patency as established via endoscopic evaluation or fluorescein irrigation. Operative success rates and demographic variables were compared between treatment groups. RESULTS: In total, 66 patients were analyzed in the present study (33 per group), with complete postoperative data having been successfully collected from 27 and 22 patients in group A and group B, respectively. All patients exhibited complete resolution of acute inflammation. Upon follow-up, granulation tissue was detected around the ostium at higher rates in group B (9/22, 40.9%) relative to group A (4/27, 14.8%). At the 12-month follow-up time point, patients in group A exhibited higher success rates (25/27, 92.6%) relative to patients in group B (20/22, 90.9%), but this difference was not significant. Cases of lacrimal passage reconstruction failure in both groups were attributed to excessive fibrous and/or granulation tissue formation proximal to the intranasal ostium. CONCLUSION: Given that these two operative approaches are associated with similar rates of operative success and in light of differences in granulation tissue formation, cost, and operative duration, these data do not support the routine silicone intubation of AD patients following En-DCR surgery.

Rectangular 3-snip punctoplasty versus punch punctoplasty with silicone intubation for acquired external punctal stenosis: a prospective randomized comparative study

AIM: To evaluate the effectiveness of rectangular 3-snip punctoplasty versus punch punctoplasty via Kelly punch with silicone intubation for the management of acquired external punctal stenosis (AEPS). METHODS: A prospective, randomized, comparative study was performed on 123 eyes of 94 patients with AEPS. Patients were recruited into either group of rectangular 3-snip punctoplasty (group A) or group of punch punctoplasty with silicone intubation (group B). Outcomes measured were Munk score, grade of punctal stenosis, fluorescein dye disappearance time test (FDDT) and tear meniscus height (TMH) 6 and 12mo after surgery. RESULTS: Twelve months after surgery, Munk score, FDDT and TMH significantly decreased in both groups compared with the baseline (all P<0.05), and grade of punctal stenosis increased significantly (P<0.05). The grade of punctal stenosis, Munk score, FDDT and TMH were better in group B compared with group A at 6 or 12mo (all P<0.05). There was a positive correlation between TMH and Munk score (R=0.655, P<0.001). At the last followed-up, anatomical success was noted in 96.7% eyes in group A and 98.4% eyes in group B (P=0.613). CONCLUSION: Punch punctoplasty via Kelly punch with silicone intubation achieves better outcomes than rectangular 3-snip punctoplasty. The new technique is a simple, minimally invasive, with high anatomical and functional success in patients with AEPS.

Delayed unilateral pneumocephalus after bilateral endoscopic dacryocystorhinostomy in an elderly patient

Dacryocystorhinostomy (DCR) is the ‘gold standard’ treatment for nasolacrimal duct obstruction (NLDO). However, despite its recent technical advancements, complications are possible. Herein, to the best of our knowledge, we present the first reported case of delayed unilateral pneumocephalus after bilateral endoscopic DCR. An 85-year-old man with bilateral NLDO underwent endoscopic DCR with silicone intubation. After 1 month, he became lethargic and was admitted to emergency room. Brain CT demonstrated left pneumocephalus and a suspected microfistula in left orbital wall. Intravenous antibiotic therapy was started, and cerebrospinal fluid studies showed no evidence of meningitis. After 13 days of antibiotic treatment, his mental state recovered with no signs of pneumocephalus. Although DCR has high success rate and is relatively safe, surgeons should be aware of the risk, although low, of pneumocephalus, especially in elderly patients who are vulnerable to fractures and who exhibit headache or mental status changes after endoscopic DCR.

OUTCOME OF INITIAL 100 CASES OF ENDOSCOPIC DACRYOCYSTORHINOSTOMY IN KIRKUK

This study aimed at determining the effect and safety of endoscopic dacryocystorhinostomy (ENDO-DCR) in initial 100 cases of nasolacrimal duct obstruction. This study was done in Kirkuk general hospital from 2010 to 2017 with a total of 100 cases. A standardized method was applied to all cases through employing an endonasal technique to the lachrymal sac. Then, an operative resection was applied to the mucosa of nose, lacrimal bone and a part of the anterior maxilla. Next, a complete removal of the medial wall of the lacrimal sac was done. A tube of canalicular silicone intubation was placed for 6 months after operation. The key results of such measures were epiphora resolution, lack of discharge and clearness of the ostium. The success of ENDO-DCR method with adjunctive tube of canalicular silicon intubation was demonstrated in 80 cases (80%) and 10 cases represented acceptable improvements. However, there were minor complications faced during or after operation period. Finaly Endoscopic dacryocystorhinostomy is a safe and effective method for treating nasolacrimal duct obstruction in adults and children with nasolacrimal duct obstruction and epiphora.