[Microendoscopic minimally invasive techniques in lacrimal surgery]

BACKGROUND

Lacrimation of the eye is a relatively common problem, the cause of which must be clarified by differential diagnostics. The most important symptom of a dysfunction of lacrimal drainage is epiphora.

METHODS

Due to the enhancement and miniaturization of endoscopes, which were originally used in gastroduodenoscopy in the 1990s, it is possible to check the anatomical structure and visualize pathological changes of the lacrimal drainage system, which is only approximately 1 mm in diameter. As shown by the results, mechanical stenoses are often caused by recurrent chronic inflammation. A complete stenosis usually occurs only slowly due to dysregulation of the lacrimal unit.

CONCLUSION

In contrast to the assumptions that were valid before the implementation of microendoscopy, complete stenoses are often only punctate and do not stretch over long distances. Shortly after the introduction of microendoscopic diagnostics minimally invasive therapy techniques, such as laser dacryoplasty (LDP) and microdrill dacryoplasty (MDP) were established. These procedures have enabled for the first time preservation of the entire physiology of the lacrimal drainage pump system despite surgical intervention after recanalization.

[Minimally invasive lacrimal duct surgery with a multimodal concept for functional lacrimal stenosis]

PURPOSE

The aim of this study was to evaluate the long-term success rates of a multimodal concept for treating functional nasolacrimal duct obstruction (FNLDO) consisting of minimally invasive lacrimal duct surgery and additional treatment of the conjunctiva, the puncta or the lids if necessary.

METHODS

Clinical outcomes and subjective symptoms of 118 consecutive patients with the main diagnosis FNLDO were studied in a retrospective design.

RESULTS

Of the 118 cases 64 % were treated by microendoscopy and microdrill only while 36 % needed additional treatments. In 76 % of all cases (82 % in the group of patients who were treated by microdrill only) the patients reported their symptoms to have "improved" after a median follow-up of 14 months. Up to the age of 70 years more women were affected by FNLDO, while it was more common among male patients above this age. In older patients additional treatment especially tightening of the lids was required more frequently.

CONCLUSION

Transcanalicular microendoscopy of the lacrimal duct alone or in combination with additional treatments, if needed, showed satisfactory long-term outcomes in patients suffering from FNLDO and can be considered a valuable and minimally invasive option for these patients.

[Transcanalicular microendoscopic laser DCR: technique and results]

Transcanalicular microendoscopic diode laser DCR combined with 5-mm balloon dacryoplasty is an innovative procedure in lacrimal surgery. This procedure is minimally invasive and provides the possibility to fill the gap between the first step procedures (LDP, MDP) and external or internal DCR.

[Causes, diagnostics and therapy for paediatric ptosis]

BACKGROUND

The diagnosis of and therapy for paediatric ptosis present challenges because of difficulties in performing preoperative examinations and the inability of the patient to provide intraoperative cooperation for proper lid placement. The authors provide an overview of the different forms and findings in congenital ptosis patients and point out the difficulties of the surgical procedures.

DIAGNOSTICS AND THERAPY

The majority of paediatric ptosis cases is simple unilateral congenital ptosis with dysgenesis of the levator palpebrae superioris muscle. Other different forms exist due to neurological, neuro-myogenic, aponeurotic, sympathic, and mechanical reasons or syndromes. The relevant history is obtained, including birth history and family history, careful observation and full ophthalmological examination are necessary. Amblyopia because of ptosis, strabismus or anisometropia with corneal astigmatism should be recognised and treated early. The preoperative examination is vital for determining the appropriate diagnosis and is useful for selecting the appropriate procedure. Ptosis correction is based on ptosis severity, Bell phenomenon and levator function. The primary goal is symmetry of the upper lids. Most frequently a levator resection is performed between the 3rd and 5th year with a levator function of more than 3 mm. The most common complication is undercorrection, poor lid contour or amblyopia. Overcorrection may be associated with dry eye syndrome and keratopathy.

CONCLUSION

Levator resection is a useful procedure for the correction of mild to moderate ptosis. Frontalis suspension surgery is effective for congenital ptosis with poor levator function.

[How did lacrimal endoscopy influence lacrimal surgery?]

Lacrimal surgery has been characterised by multiple rapid changes within the last 20 years. The understanding of the development and existence of lacrimal stenoses has changed considerably. New morphological (endoscopy of the lacrimal system) and anatomic-functional aspects have been added. In the field of surgery the frequency of DCR has dropped within the last years, but still, with proper indications, this method has its significance, as well as irrigation of the lacrimal system. On the other hand microendoscopic canalicular surgery has been almost fully replaced by microendoscopic transcanalicular laser dacryoplasty and microdrill dacryoplasty. For the surgical treatment of injuries of the lacrimal system no changes have been implemented. As a spin-off effect from gastroduodenoscopy and ERCP superfine endoscopes have been developed, and have opened the possibility to inspect the mucosa and directly evaluate the lumen of the lacrimal system. Following the development of laser dacryoplasty and microdrill dacryoplasty as well as miniaturised drill systems, surgery can be performed less invasively today. Future developments of lacrimal surgery will be strongly influenced by the ongoing developments of microendoscopic transcanalicular techniques and modulation in wound healing.

[KTP laser in lacrimal duct surgery]

PURPOSE

The use of endoscopic methods of examination and treatment has brought new possibilities for non-invasive techniques in lacrimal surgery. The possibilities of the use of a PTP (potassium-titanium-phosphate) laser system are shown.

METHOD

The use of a PTP laser for external dacryocystorhinostomy (DCR) as well as for transcanicular methods when connected to an endoscope are shown.

RESULTS

With a PTP laser it is possible to make a very precise hole in the bone which simplifies the preparation of the nasal mucosal flap. Endocanalicular procedures for performing laser dacryoplasty with rechanneling of the lacrimal system is possible and examples are demonstrated.

DISCUSSION

The high output of a PTP laser of up to 10 W makes a precise preparation of the bone hole for DCR possible. The endoscopic connection opens the possibility of an endocanicular use but the high energy output means that increased scar tissue formation is to be expected.

[Laser canaliculoplasty]

BACKGROUND

Laser canalicular plastic surgery using the erbium-YAG laser is a new method for treating canaliculus stenosis. We compared results of this method with those of conventional surgical operations on canaliculi.

PATIENTS AND METHODS

Between 1996 and 1998 a total of 44 cases of symptomatic canaliculus stenosis were treated by laser. An erbium-YAG laser with a maximum power of 100 mJ was used in conjunction with a sapphire fiber 3 cm long and 325 microns in diameter. Endoscopic diagnosis of the other parts of the lacrimal passage was carried out before and after laser treatment and after tubular intubation. After an average of 12 months the results were assessed via questionnaires and follow-up examinations.

RESULTS

The success rate for reducing epiphora was 67%. Overall 86% of patients reported an improvement in canaliculus communis stenosis.

CONCLUSIONS

Laser canalicular plasty as minimally invasive surgical treatment is an excellent surgical method for treating point-focal, noninflammatory canalicular stenosis.

[Intraocular pressure response after administration of 3 different viscoelastic agents after cataract operation]

By using three different viscoelastics [Adatocel (methylhydroxypropylcellulose), Amvisc Plus (sodium hyaluronate) and Healon (sodium hyaluronate)] a prospective randomized study was conducted to investigate whether postoperative intraocular pressure shows significant differences according to the viscoelastics used after 150 cases of cataract surgery.

PATIENTS AND METHODS

The inclusion criteria for this study were: extracapsular cataract extraction via the usual small-incision techniques and endocapsular posterior-chamber lens implantation. A total of 150 eyes were operated upon. The patients were randomly assigned to three groups according to the viscoelastics, 50 cases used adatocel, 50 Amvisc Plus and 50 Healon. As far as possible, the viscoelastics were sucked out under visual control. Intraocular pressure (IOP) was measured after 6 and 24 h.

RESULTS

Six hours postoperatively, no statistically significant difference between the intraocular pressure after using different viscoelastics (adatocel: 19.6 +/- 9.7 mmHg, Amvisc Plus: 20.5 +/- 9.6 mmHg und Healon: 21.8 +/- 8.8 mmHg) was seen. At 24 h IOP was statistically significant higher for Healon than for adatocel and Amvisc Plus (adatocel: 16.3 +/- 4.8 mmHg, Amvisc Plus: 16.5 +/- 4.6 mmHg and Healon: 19.7 +/- 6.6 mmHg).

CONCLUSIONS

Six hours postoperatively after phacoemulsification there was no significant difference between the IOP using different viscoelastics adatocel, Amvisc Plus and Healon. Twenty-four hours postoperatively a significantly higher intraocular pressure was measured for Healon than for the other viscoelastics.

[CO2 laser in ophthalmology]

BACKGROUND

Baker et al. used a CO2 laser for blepharoplasty for the first time. The ultra-pulse CO2 laser provides a sophisticated instrument that makes more application alternatives possible in ophthalmology.

PATIENTS AND METHODS

From March 1997 to February 1998 surgical operations were performed in the eye clinics in Hagen and Darmstadt using the CO2 laser: 145 eyelid operations and 8 others (enucleation, evisceration, oral mucosa plastic surgery, secondary hydroxyapatite implantation, squint operation). In 34 patients in a total of 64 operations, after an average follow-up period of 7 (4-11) months, an examination was carried out.

RESULTS

There were serious complications in only one case. Three weeks after transconjunctival fat resection and resurfacing, one patient developed an inflammatory reaction with resulting ectropion on both sides. During steroid therapy the left lower lid flattened, but on the right side a slight ectropion remained.

CONCLUSION

The CO2 laser proved to be a very useful instrument for bloodless tissue-protective surgery without conspicuous scar formation.

Comparison of latanoprost monotherapy to dorzolamide combined with timolol in patients with glaucoma and ocular hypertension.A 3-month randomised study

BACKGROUND

The purpose of the study was to compare the effects on intraocular pressure (IOP) of adding dorzolamide to timolol or of switching from timolol to latanoprost monotherapy in glaucoma patients inadequately controlled on timolol.

METHODS

The study was designed as a 3-month randomised, open-label, multicentre study comprising 183 patients with primary open-angle glaucoma, capsular glaucoma with IOP above 22 mmHg on treatment with one or two ocular hypotensive drugs, or ocular hypertension with IOP above 27 mmHg. After a 2- to 4-week run-in period on timolol, 0.5% twice daily, the patients were randomised to treatment with either latanoprost, 0. 005% once daily, or the combination of timolol, 0.5% twice daily, and dorzolamide, 2% twice daily. The mean diurnal IOP after 3 months of treatment was compared with baseline.

RESULTS

Switching from timolol to latanoprost reduced mean diurnal IOP by 4.5+/-0.2 mmHg (mean+/-SEM, ANCOVA; 20%), and adding dorzolamide to timolol reduced mean diurnal by 4.4+/-0.2 mmHg (mean+/-SEM, ANCOVA; 20%). No serious side effects were observed with either treatment.

CONCLUSION

Latanoprost monotherapy can be an alternative to combined treatment with two aqueous flow suppressors in patients whose IOP is insufficiently controlled by timolol alone.

[Endoscopic laser dacryoplasty. Methodology and outcome after 3 months]

BACKGROUND

After performing endoscopy of the lacrimal passage, the endoscopic system can be connected to an erbium-YAG laser if the indications are appropriate.

MATERIALS AND METHODS

In a bi-center study we performed laser dacryoplasty in 53 cases out of 261 endoscopy procedures (18 stenoses of the canaliculi, 19 stenoses of the sac, 9 stenoses of the nasolacrimal duct, 9 restenoses following DCR). In 35 cases an examination was done and in all 53 cases the results were obtained by means of a questionnaire.

RESULTS

Epiphora and irrigation were improved in more than 75%.

CONCLUSION

Suitable indications are small stenoses in the sac or duct membranes following DCR. Laser dacryoplasty is a promising method, but more studies still need to be conducted to obtain long-term results. The technical system must also still be improved to make it easier to handle.

[Dacryoendoscopy--current status]

In the years from 1995 to 1997 in the eyeclinic of Darmstadt and the eyeclinic of the St. Josef Hospital Hagen 261 dacryoendoscopies were done in a bicentrical study.

PATIENTS AND METHODS

A dacryoendoscopy was done in 261 patients with an average age of 46.6 years (143 women, 93 men and 25 children). In dependance of the assessment of the mucosa conditions intraoperatively in all 261 cases the planed operative strategy was checked and if needed changed. As following surgical interventions of the lacrimal system were seen 70 cases of dacryocystorhinostomia externa, 138 cases of intubation of the lacrimal drainage system and 53 cases of laserdacryoplastic.

RESULTS

The dacryoendoscopy had succeeded as method for the assessment of the mucosa conditions [5, 6]. In a study of 261 dacryoendoscopies an examination of the mucosa was possible in every case. No complications were seen while dacryoendoscopy. With help of the dacryoendoscopy the planed operative strategy was determined. Therefore we had the possibility to choose a minimal invasive operation-procedure in 53 cases.

CONCLUSIONS

The dacryoendoscopy is a new important diagnostic development in diagnosis of diseases of the lacrimal drainage system. With help of better developed endoscopy-systems a much better quality of the picture is attainable. The results of the dacryoendoscopy offer the possibility to check the preoperative indication and to optimate the surgical treatment. At last only with help of the dacryoendoscopy these findings could be ascertained in which case a laserdacryoplastic is senseful.

[Dacryoendoscopy and laser dacryoplasty: technique and results]

BACKGROUND

In a bicentrical study in the eye clinic of Darmstadt and the eye clinic of the St. Josef Hospital Hagen 261 dacryoendoscopies were performed until February 1997.

MATERIALS AND METHODS

In 261 dacryoendoscopies (143 women, 93 men and 25 children, the average age was 46.6 years). In dependence of the assessment of the mucosa conditions intraoperatively in all 261 cases the planed operative strategy was checked and if needed changed. After surgical interventions of the lacrimal system 70 cases of dacryocystorhinostomia externa were seen 138 cases of intubation of the lacrimal drainage system and 53 cases of laserdacryoplastic. Intubation of the lacrimal system was always performed after laserdacryoplastic and after a patency was produced (average age 58.3 years).

RESULTS

Suitable indications for a laserdacryoplastic are: circumscribed stenosis of the distal saccus, point-sized stenosis of the canaliculus, membranous restenosis after dacryocystorhinostomia externa. The method shows no important rate of intraoperative complications, only in one case there was intraoperatively a protrusion bulbi and a haematoma of the eyelid, which postoperatively eased fastly away. The postoperative convalescence is in comparence to conventional surgical interventions of the lacrimal drainage system enormously shortened. The follow-up after 3 months showed a subjective improvement of epiphora in more than 75% of the patients, the success of this intervention therefore could be compared with conventional surgical methods of the lacrimal drainage system.

CONCLUSION

The dacryoendoscopy is a new important diagnostic development, which shows with help of better developed endoscopy-systems compared to previous systems a much better quality of the image and is therefore a valuable diagnostic help. Due to the check of the preoperative indication it is intraoperatively possible to confirm or, if needed, to change the indication after dacryoendoscopy. The laserdacryoplastic is an important new therapeutical development of the dacryoendoscopy and shows in suitable indications a comparable success-rate of conventional surgical interventions of the lacrimal drainage system. Therefore the possibility exists to carry out minimal invasive interventions of the lacrimal drainage.

[Endoscopy of the lacrimal ducts]

The available picturing methods in the diagnosis of functional and mechanical stenosis of the lacrimal drainage system do not allow direct optical evaluation of the mucosa. With the help of dacryoendoscopy, for the first time there is the possibility of receiving a direct morphological picture of the tissue of the lacrimal drainage system.

PATIENTS AND METHODS

In a clinical study in the period January to June 1996, 76 dacryoendoscopies were done before an operative intervention in the lacrimal drainage system to find out what information can be obtained with dacryoendoscopy and what use this extra information is.

RESULTS

In all of the dacryoendoscopies performed, direct evaluation of the mucosa was possible. Normal findings could be clearly differentiated from mucosa of acute or chronical inflammatory processes. The choice of the operative strategy changed in part of the planned operations, although in 37 cases where the preoperative diagnosis was stenosis of the lacrimal sac, only in 26 cases was dacryocystorhinostomy performed. Dacryoendoscopy provides an additional means of guaranteeing the quality of operative procedures, e.g., after intubation.

CONCLUSIONS

Dacryoendoscopy provides an important additional diagnostic possibility in the diagnosis of diseases of the lacrimal drainage system. Dacryoendoscopy offers the possibility of direct evaluation of the mucosa, the choice of operative strategy is checked and, if necessary, changed, and with the connection of an erbium YAG Laser there is minimal invasive surgery with the aim of rechannelization of the lacrimal drainage system.

[Endonasal implantation of a silicon mold improves the long-term outcome of revision surgery in lacrimal duct stenoses]

BACKGROUND

Uncomplicated dacryocystorhinostomy after dacryocystitis with lacrimal sac obstruction has a success rate of 85%. However therapy of restenosis poses a problem. Vast destruction of lacrimal and nasal mucosa renders the drainage system susceptible for further stenosis. This article presents a new surgical procedure for the treatment of restenosis of the nasolacrimal apparatus. The major difference from other techniques is the endonasal implantation of a silicon foil. This counters the development of synechiae and promotes the epitheliasation of wound surfaces. As a result the nasal mucosa can easier gain access to lacrimal mucosa. A complete mucosal coating of the reconstructed lacrimal drainage system is an important condition for the sufficient drainage of the tear-film.

PATIENTS AND METHODS

In 30 patients with restenosis after one or multiple dacryocystorhinostomies a silicon foil was implanted endonasally as part of their surgical revision. After skin incision and removal of scar tissue the bony ostium was enlarged. The canaliculi were intubated with silastic tubing. Afterwards the endonasal synechiae were split and a 0.2-0.4 mm silicon foil was implanted endonasally und fixed. The silastic tubing was brought through a hole in the silicon foil and knotted inside the nose. Then the wound was closed. Postoperative evaluation of the surgical success ranged from 3 to 36 months (mean 16 months).

RESULTS

The postoperative result was good in 24 patients. Sixteen patients were without symptoms. 8 had epiphora only on stress. The latter felt their situation to be greatly improved. The long-term results were directly proportional to the amount of reconstructable mucosa and inversely proportional to the severity of canaliculus damage. Adverse reaction to the silicon foil were not noted.

CONCLUSION

Endonasal implantation of a silicon foil is a new, easy and successful technique for the treatment of endonasal synechiae and restenosis of the nasolacrimal apparatus.

[Dacryocystorhinostomia externa. Technique, indications and results]

In a retrospective study on the years 1978-1989, the data we obtained on 1014 operative procedures of external dacryocystorhinostomy at the University Eye Hospital in Münster showed an age distribution of 2-93 years with a maximum in the 5th to the 7th decade (average 53.2 years) and a sex relationship of 61% females and 39% males. In the etiology of dacryostenosis, 60% of the patients had recurrent chronic dacryocystitis, 32% history of acute dacryocystitis, 7% facial trauma and less than 1% of the cases (n = 5) tumor diseases. The functional success rate was 85% in a postoperative follow-up period of 1-11 years (average 35.6 months). No serious intra- or postoperative complications were seen.

[Cold dosage in retinal cryotherapy using echography]

In cases of obscured view of the fundus a precise timing of cryotherapy of the retina is not possible. In order to avoid complications from overtreatment we use the real time ultrasonography for monitoring the spreading ice in relation to the retina.

[Experimental transvitreal fibrin gluing of the retina]

The authors report on the transvitreal application of fibrin glue in retinal detachment surgery. Methods of application and the course of postoperative resorption are illustrated with reference to experimental studies on rabbit eyes. The prospects for this new method of creating chorioretinal adhesions are pointed out and discussed.

[Incidence of conjunctival and corneal changes in dialysis patients]

Deposits of calcium salts in the conjunctivas and corneas of 72 patients showed a statistically significant correlation to the duration of hemodialysis. The deposition of calcium salts is not influenced by other signs of disturbed calcium metabolism (Ca-PO4 product, alkalic phosphatase) or the patient's age.

[Recommendations for the evaluation of complicated aphakia in private accident insurance]

An evaluation of cases in which an expert opinion was obtained during the last 2 years shows that only one-third of patients with traumatic aphakia and a 20/30 loss of vision are adequately assessed. If there are further consequences of the accident (complicated aphakia) they should also be taken into account when assessing loss of vision. A simple method of doing this is described on the basis of three examples.

[Candida albicans endophthalmitis. Results of pars plana vitrectomy without intraocular antimycotic therapy]

An early pars plana vitrectomy was performed without any additional intravitreal antimycotic therapy in 8 eyes of 5 patients with candida endophthalmitis; anatomic healing with a good functional result was obtained. The good prognosis of vitrectomy without intravitreal antimycotic therapy in our patients is seen in (1) a total surgical extraction of the abscess and (2) the better intraocular ventilation obtained for endogenous resistance.

Malignant tumors after chronic exposure to vinyl chloride

Correlations between exposure to vinyl chloride and the development of malignant tumors in the liver have been know since 1974 and have been confirmed by many an experimental investigation. Based on the evaluation of mortality statistics from nine different countries an increased incidence of malignant tumors of the lung, the gastrointestinal tract, and the central nervous system (CNS), and of malignant lymphomas is documented in connection with exposure to vinyl chloride. Statistically significant increases, however, are only found in the incidence of malignant liver tumors. Metabolism and toxicology of vinyl chloride are discussed in detail.