[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.

[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.