|Year : 2013 | Volume
| Issue : 2 | Page : 99-102
Transcanalicular endoscope combined laser-assisted dacryocystorhinostomy
Virendra K Pal, Ajai Agrawal, Suwarna Suman, Vir B Pratap
Department of Ophthalmology, Regional Institute of Ophthalmology, Sitapur Eye Hospital, Sitapur, India
|Date of Web Publication||19-Aug-2013|
Virendra K Pal
Regional Institute of Ophthalmology, Sitapur, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aims: In this study, we have tried to assess the success rate and difficulties that we came across while performing the transcanalicular endoscope combined laser-assisted dacryocystorhinostomy (T-ECLAD).
Materials and Methods: A prospective study of 60 patients suffering from nasolacrimal duct obstruction confirmed by preoperative syringing was carried out at the Regional Institute of Ophthalmology. T-ECLAD is a new minimally invasive dacryocystorhinostomy procedure, which is performed by diode laser (980 nm diode laser with power of 10 watts) through lacrimal canaliculi with the help of a cannula and fiber optic cable. The interior of the nasal cavity was visualized with the help of the nasal endoscope on a monitor. Success of procedure was assessed by patency of the lacrimal drainage system on irrigation.
Results: We performed 56 successive T-ECLAD. The average procedure time was 10 min, and on an average 235 Joules of laser energy was needed. We observed a patent nasolacrimal duct on irrigation in 39 out of 56 treated eyes. 1 patient had partial, 5 patients had blocked irrigation, and 10 patients did not return for follow up. This yields a success rate of 69.6% (if we exclude patients who did not return for follow up) with an average follow-up period of 6 months.
Conclusions: The 980-nm T-ECLAD is a new contribution to the field of lacrimal surgery. It is a minimally invasive and quick procedure.
Keywords: Diode laser, fiber optic cable, transcanalicular endoscope combined laser-assisted dacryocystorhinostomy
|How to cite this article:|
Pal VK, Agrawal A, Suman S, Pratap VB. Transcanalicular endoscope combined laser-assisted dacryocystorhinostomy. Oman J Ophthalmol 2013;6:99-102
|How to cite this URL:|
Pal VK, Agrawal A, Suman S, Pratap VB. Transcanalicular endoscope combined laser-assisted dacryocystorhinostomy. Oman J Ophthalmol [serial online] 2013 [cited 2020 Feb 21];6:99-102. Available from: http://www.ojoonline.org/text.asp?2013/6/2/99/116641
| Introduction|| |
External or conventional dacryocystorhinostomy (DCR) is the gold-standard surgical procedure for the management of nasolacrimal duct obstruction in adults with a high success rate (93%-95%). The Italian otolaryngologist A. Toti first described the method of external DCR for treating stenosis of the lacrimal sac in 1904.  External DCR, in which a communication is created between the lacrimal sac mucosa and nasal mucosa, is a widely acceptable treatment for nasolacrimal duct obstruction,  but it is a difficult and time-consuming procedure, with certain limitations. It may be performed under local/general anesthesia. Many times patients feel discomfort in local anesthesia, and they need extra sedation. An external incision nearly 7-8 mm is made on the side of nose and requires suturing. Excessive bleeding may occur during or after surgery. It is a difficult, more tissue handling, and time-taking procedure and needs hospitalization with delayed rehabilitation. Incision-related problems and scar may be formed after surgery.
The last step in the development of less traumatic DCR is the endocanalicular/transcanalicular approach. In this approach, first described in 1963 by Jack, a probe is inserted through the lower lacrimal punctum via the canaliculi into the lacrimal sac following the anatomical pathway of tear outflow.  Osteotomy is performed either by a mechanical drill or laser energy through an optic fiber, which is inserted within the probe.  The use of a diode laser for Endolaser-DCR (EL-DCR) has been first reported by Eloy et al. in 2000, followed by Fernandez et al. in 2004. , In this study, we have tried to assess the success rate and difficulties that we came across while performing the transcanalicular endoscope combined laser-assisted dacryocystorhinostomy (T-ECLAD).
| Materials and Methods|| |
A prospective study of 60 patients suffering from nasolacrimal duct obstruction, confirmed by preoperative syringing, was carried out at the Regional Institute of Ophthalmology and associated Sitapur Eye Hospital. The patients underwent transcanalicular endoscope combined laser-assisted DCR (T-ECLAD) during the period of 2008-2011. A preoperative evaluation of all patients, including syringing to confirm nasolacrimal duct obstruction and ENT check up for any nasal pathology or abnormality was done. Informed consent from all patients after explaining the surgical procedure was taken. Thereafter, the patients were operated by a single surgeon under local anesthesia. Nasal packing was done with 2% xylocaine with adrenaline at least 45 min prior to the surgery and removed just before use of the endoscope.
The lower punctum was dilated with the punctum dilator. Probing (starting with lower number 0-0 and increased up to desired level) was done and hard stop was felt. Cannula along with stellate was passed in canaliculi, and cannula advanced up to hard stop. Stellate was removed, and cannula was rotated at 45 degrees. Laser fiber-optic cable was introduced into the cannula with aiming beam in "on" position. Another person held the nasal endoscope and introduced it in the nostril of the same side to be operated and focusing of the area of middle turbinate was done. Now inside of the nose was visualized on the monitor, aiming beam was localized and positioned between the turbinates and nasal septum. If localization was difficult, intensity of the beam was increased and blinking light was used. As the aiming beam was localized in the correct position, the "ready button" was pushed on to warm machine and foot pedal was pressed to deliver laser energy, simultaneously advancing fiber optics gently (not pushing cannula). Now bony opening was made and the aiming beam with laser optical fiber was visualized on the monitor. The osteum was enlarged up to the formation of sufficient size (5 mm) opening. Now syringing was done with normal saline, betadine 5% solution, and mitomycin-c (0.02%) solution. During syringing we looked for free flow of solution on the monitor. If it was sufficient, cannula was removed and a drop of antibiotic-steroid eye drop was placed in the cul-de-sac. Silicon tube was not placed in the osteotomy. No dressing or pad was applied. Postoperative treatment included - Tab - amoxycillin + cloxacillin TDS, Tab - diclofenac BD, and xylomatazoline nasal drop two drops TDS for 5 days, gatifloxacin-steroid eye drop six times daily for 1.5 months (on tapering regime), and inhalation by steam. The follow-up period was 6 months. During follow up, the next syringing was performed on 1 st day then after 1 week and then every month up to 6 months. During follow up, the syringing was performed with 10 ml normal saline through the lower canaliculi.
| Results|| |
The patients were in the age group of 15-65 years (mean age was 33 years). 28 patients (46.6%) were male and 32 (53.3%) were female [Table 1]. Two patients (3.3%) were of earlier failed conventional DCR. Preoperatively, all the patients had symptomatic epiphora and blocked syringing with regurgitation of mucopurulent fluid from the upper punctum. Mucocele was seen in four patients (6.6%). Three patients (5.0%) had a canalicular block and one patient (1.6%) had fistulous tract. These four patients (6.6%) were excluded from the study. Duration of symptoms ranged from 1 year to 10 years with mean duration of 4 years. Patency of passage after the procedure was confirmed by performing syringing and visualization of flow directly under endoscopic view on the monitor with 10 ml normal saline and 5ml betadine 5% solution. After the procedure, free flow of fluid was present in 55 patients. In one patient (1.6%) the procedure was not performed due to inability to pass the cannula. The results of syringing with passage of time have been included in [Table 2]. The difficulties we encountered during the procedure and complications have been listed in [Table 3] and discussed in the discussion section of this article.
| Discussion|| |
External DCR is the gold standard surgery for chronic dacryocystitis with nasolacrimal duct (NLD) obstruction, with the highest success rate. It requires limited follow up and is a cost-effective procedure. In conventional DCR, obliterated nasolacrimal duct is bypassed and the lacrimal sac is opened directly into the nasal cavity with the help of the lacrimal and nasal mucosal flap after making an osteum in the bone, but this operation has many limitations, like it is time taking and requires skill. There is bleeding, incision-related complications, postsurgical scarring, and disturbance of medial canthal tendon and muscles. Postoperative complications include hemorrhage (3.9%) and scarring (2.6%).  So during the modern era, when early rehabilitation and cosmetic appearance are of great importance, it is the need of the time that this surgery also crosses the need of incision without compromising on the success rate. The first intranasal approach was described in 1889 by Killian, and endoscopic DCR was first performed by Caldwell in 1893, but was soon abandoned due to difficult visualization and numerous complications.  The endonasal technique has gained popularity only in the past decade due to the developments in endoscopic surgery. The endonasal technique is performed endoscopically through the nose without the need for an external skin incision. The success rate is 70%-90%.  The advantages of transnasal endoscopic DCR (TNE-DCR) over external DCR are  that there is no outer skin incision with resulting scar, shorter procedure time, and shorter patient recovery time. The first cadaveric study in 1990 proved that osteotomy of the lacrimal bone can be achieved by laser energy delivered through an optic fiber by the transnasal or endocanalicular approach.  Lasers with several different wavelengths have been used to perform osteotomy as part of the DCR procedure, mostly as part of a transnasal approach: Holmium:Yttrium-Aluminum-Garnet (Ho:YAG) laser, potassium-titanyl-phosphate (KTP) laser, Neodymium:YAG (Nd:YAG) laser, Erbium:YAG (Er:YAG) laser, and diode laser. The use of a diode laser for EL-DCR has been first reported by Eloy et al. in 2000, followed by Fernandez et al. in 2004. , Diode laser-assisted DCR seems to offer specific advantages for DCR. ,, The main technical obstacles in EL-DCR are to deliver a sufficiently powerful laser beam via a relatively narrow optical fiber, which in turn fits into an endocanalicular probe. Several laser wavelengths successfully comply with this requirement. However, there are other considerations to take into account, mainly unwanted collateral heating of the probe and residual thermal damage to the target tissue. Based on theoretical and our own preclinical studies, the 980-nm diode laser seems to adequately fulfill all the above requirements.  In this study, diode laser, 980 nm (infrared) with optical power 10 watts (maximum), aiming beam 635 nm, 4 MW, brightness adjustable and operating mode Cw pulsed was used. Laser light was delivered through a 0.6 mm optic fiber with 0.36 mm core, which in turn was inserted into a canalicular probe. The last step in the development of less traumatic DCR is the endocanalicular/transcanalicular approach. In this approach, first described in 1963 by Jack, a probe is inserted through the lower lacrimal punctum via the canaliculus into the lacrimal sac following the anatomical pathway of tear outflow.  Osteotomy is performed either by a mechanical drill or laser energy through an optic fiber, which is inserted within the probe.  Successes in DCR surgery are compromised by a small osteum and blockage of the osteum by scarred tissue. Linberg et al. showed that an appropriately large osteotomy made during surgery can narrow down to a final size of approximately 2 mm due to tissue growth and scarring.  The small osteotomy size compromises the success rate of T-ECLAD. Many studies have reported a lower success rate of T-ECLAD in the primary acquired cases of nasolacrimal duct obstruction (NLDO). ,,, One of the main open questions is adequate osteotomy size, as restenosis at the site of osteotomy is one of the leading causes of long-term failure in DCR.  An osteotomy of more than 10 mm in diameter can be routinely achieved by the classic approach, and a slightly smaller osteotomy of 7-9 mm is achieved with the transnasal approach.  The osteotomy size in our series was on an average 5 mm. We believe this is sufficient when using our technique, as there is minimal trauma to the surrounding mucosa and connective tissue, resulting in less postoperative scarring.  An interesting computed tomography study by Yazici and Yazici showed that final nasal osteum size six months after surgery has no correlation with osteotomy size at the time of surgery and suturing of mucosal flaps and measured from 3.1 to 3.8 mm in height.  Other factors must play a more important role in the development of restenosis, and we believe this to be tissue trauma, with the subsequent inflammatory response and scarring.  In this study, we had tried to keep osteum size big enough >5.0 mm, but it was found that during the procedure, the formation of first opening was quite easy but during successive shots, when we tried to increase the osteum size, it became harder to achieve desired size of opening. Probably, it is because the cannula was passed through a narrow tube (canaliculi), so it had a limited range of movement. Other difficulties which we had faced during the procedure [Table 3] were that the patient felt discomfort or pain. To manage it, nasal packing was done at least 45 min before starting the procedure and 2% xylocaine was injected locally. The aiming beam was not localized in some cases. To localize it, the cannula was rotated in the correct direction at 45 degrees, intensity of light was increased, blinking light was used, and if the endoscope was not clean it was cleaned. If there was difficulty in making the osteotomy, the laser power was increased. In case of inability to enlarge opening, the optical fiber was pulled backward to clearly visualize the aiming beam at the tip of the optical fiber. Opening was localized again with aiming beam and procedure was continued till desired size of osteum was made. The success rate can be increased using intraoperative mitomycin-C, an antiproliferative agent.  In this study, syringing was done with normal saline, betadine 5% solution, and mitomycin-c (0.02%) solution. Of course, there are certain disadvantages of this procedure. Some concern handling of the laser and the cost. A second endoscope for endonasal control as well as basic rhinologic surgery training is strongly suggested.  In this study, sometimes we faced a problem in exact focusing of the endoscope. In conclusion, The 980-nm T-ECLAD is a new contribution to the field of lacrimal surgery. It is a minimally invasive quick procedure. Although the success rate is not good (69.6%), but it may be a hope for future with better results if we continuously improve upon and analyze the procedure.
| Acknowledgment|| |
The authors certify that all investigations concerning the ethical use of human volunteers were performed according to the "Declarations of Helsinki" during this research.
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[Table 1], [Table 2], [Table 3]