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Orbital decompression, optic n decompression and EndoDCR

Jun 02, 2018

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    Indications

    Thyroid Associated Orbitopathy ( M/c).Vasculitis .Lesions of posterior orbit & apex with compressiveoptic neuropathy .large myopic globes.

    Problems associated with OrbitopathyExposure keratopathy.Diplopia.Optic Nerve Compression.

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    In 1911, Dollinger = Kronlein's approach -

    lateral wall decompression.In 1920, Moore = Intra orbital decompression.In 1931 , Naffziger = superior decompressionIn 1936 , Sewall = external ethmoidectomyapproach- medial orbital wall.In 1950 , Hirsch = orbital floor. ( caldwell-luc)In 1957, Walsh and Ogura = infero medialdecompressionIn 1990, Kennedy = Endoscopic transnasal

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    Proptosis Corneal problems Diplopia

    Eyelid retraction Optic nerve compression Most common cause of unilateral or bilateral proptosis in adult.

    multisystem. autoimmune disorder hyperthyroid, hypothyroid, euthyroid

    inflammation and enlargement EOM (MR>IR)

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    Werners Classification: NOSPECS Class 0 ( No Signs)Class I ( Only Signs)

    Class II (Soft tissue Swelling)Class III (Proptosis)Class IV (Extraocular muscle)Class V (Corneal Exposure)

    Class VI (Sight Loss)

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    For initial CAS, score only 7 items (1 for each)1. Spontaneous orbital pain2. Gaze evoked orbital pain3. Eyelid swelling that is considered to be due to

    active phase4. Eyelid erythema5. Conjunctival redness that is considered to be

    due to active phase6. Chemosis7. Inflammation of caruncle or plica

    At follow up total score all 10 items8. Increase of 2mm in proptosis9. Decrease in ocular excursion in any one

    direction 8 o

    10.Decrease of acuity equivalent to 1 snellen line6

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    CT scan classicalcoca cola bottlesign on axial view

    ( Hypertrophy ofmuscle sparing thetendon )

    MRI Hypertrophyof Inferior Rectus.

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    TreatmentMedical Management :

    Medications targeting euthyroidstateCessation of Smoking (thiocyanate)Ophthalmic Management: LocalmeasuresCorticosteroidsRadiation therapy

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    Surgical Management :

    Indications : optic neuropathy, diplopia,corneal exposure, and cosmesisSurgical Procedures

    Orbital DecompressionStrabismus repairCorrection of eyelid malpositions

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    Strabismus Repair:

    Extraocular muscle recessions preferredAlternative marginal myotomies

    Eyelid Surgery :lateral tarsorrhaphylengthening of Mullers and levatormuscleslower lid elevationblepharoplasty with orbital fat removal

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    Approaches :External

    SUPERIORLATERALMEDIAL

    TransantralOpen sublabialMicroscopicEndoscopic

    Endoscopictransnasal

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    Shell of bone which surroundsand protects the eyeRelations

    Sup Ant cranial fossaMed Nasal cavity & ethmoidallabyrinthInf Maxillary sinusLat Infra temporal fossa & Middlecranial fossaApex Middle cranial fossa

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    Shape quadrilateralpyramid with basefacing forwards,laterally and slightlyinferiorly. Height of orbitalmargin 35 mmWidth of orbitalmargin 40 mmDepth of orbit - 45-55mm

    Volume of orbit - 30ml

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    Seven bones formthe bony orbit

    FrontalSphenoid (greater &lesser wing)MaxillaZygomaLacrimalEthmoidPalantine

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    Formed by (from anterior to posterior):

    Lacrimal bone Frontal process of maxilla Ethmoid (Lamina papyracea) Sphenoid (Body)

    Extremely thinAnteromedially lacrimal fossa b/w ant& post lacrimal crestForamina for ant & post Ethmoidal

    arteries & nerves in frontoethmoidsuture line. Rule of 24-12-6 is suggested.

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    Formed by:

    orbital plate of maxillaOrbital process of palatineZygomatic orbital plate

    Infraorbital grooveLocation of infraorbital nerve

    which supplies sensation to skin overmalar prominence, alveolus and teethThin (0.5 1 mm), dehiscent in 29%.Encountered in - orbital decompression

    - orbital floor fracturerepair- maxillectomy

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    Formed by:Orbital plate of frontal boneLesser wing of sphenoid

    Supraorbital notch transmits the nerve &vesselsTrochlea = connective tissue sling anchors thetendinous part of the superior oblique muscleto the orbital wall.

    Encountered in - orbital decompression- orbital fracture repair- frontal sinus trephination- ext frontoethmoidectomy

    - orbital exenteration20

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    Formed by Zygomatic process of frontal bone Greater wing of sphenoid Orbital surface of zygoma

    Whitnall`s tubercle deep to rim & abovemid point. Attachment of lateral canthaltendonEncountered in - orbital decompression

    - Infratemporal fossa surgery- orbital fracture repair- lateral craniotomy- modified craniofacial

    resection 21

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    Optic canal lesser

    wing of sphenoidThickest part orbitaltubercle(4.8 mm wide)Isthmus (4.6 mm)Posterior ( 7.07 mm)Length 8 16mm (avg11,m>f)

    Thickness of bone :0.79 mm avg (sphenoid)

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    Optic foramenSuperior orbital

    fissureInferior orbitalfissure

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    Transmits :

    - Optic nerve Ophthalmic artery

    Medial & superior to geometric apex

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    Separates lateral wall from roofTransmits the followingstructures:

    Frontal NerveLacrimal nerveTrochlear nerve (CN IV)

    Ophthalmic vein suf Oculomotor nerve (CN III)Abducens nerve (CN VI)Nasociliary nerve

    Ophthalmic vein infOrbital branch of middlemeningeal arteryRecurrent branch oflacrimal artery

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    Connects to orbit to infratemporal fossa andto pterygopalatine fossa in the medial mostpart

    Located between floor and lateral wallTransmits:Infraorbital arteryMaxillary div of Trigeminal

    Br of sphenopalatine ganglionBr of inferior ophthalmic V to pterygoid plexusOrbitalis muscle

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    ORBITAL FASCIA

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    Anesthesia : General Anesthesia orLocal Anesthesia 1 Position : Reverse Trendelenberg

    positionHypotensive anaesthesia and topical1:1000 adrenaline ribbon gauze asroutinely used in ESS is used.

    1 Metson et al.Laryngoscope;1994:104:904-908

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    Which eye --?More severe eye first ( as there will befurther 1-2mm recession in first 3 months

    post sx ).

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    UNCINECTOMY INFUNDIBULOTOMY

    ANTERIOR AND POSTERIOR ETHMOIDECTOMY

    SKELETONIZATION OF LAMINA PAPYRACEA

    LARGEST POSSIBLE MIDDLE MEATAL ANTROSTOMY

    REMOVING BONE OF LAMINA PAPYRACEA

    +/- MEDIAL ORBIT FLOOR

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    middle turbinate

    Lamina papyracea

    Maxillary sinus roof

    Maxillary line

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    Endoscopic orbital Decompression

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    INCISING PERIORBITA FAT PROLAPSE

    HEMOSTASIS /NASAL PACKING

    POST OP CARE

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    Modified blepharoplasty incision /transconjunctival / anterior orbitotomy /bicoronal forehead flap

    Horizontal canthotomy Incision(1.5 cm)Inferior cantholysisDivision of the conjunctiva, inferiorretractors and orbital septum

    Periosteal incision placed about 7 8mm onlateral orbit outside the orbital

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    osteotomy is made 3mm behind the lateralorbital rimlateral wall periosteum is openedFat made free ,anterior pole of the glandmade free and allowed to float into thebone lateral wall defect.Medial and floor decompression.Preserve ant2/3 rd of maxilloethmoidal bonestrut -> prevents block of max sinus aeration

    with fat prolapse.

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    Combined endoscopic and open approachTransconjunctival-endoscopic = allow dissection ofmedial wall beyond posterior ethmoid neurovascularbundle upto optic canal.Lateral wall decompression + endoscopic (avgdecompression 6.9mm)

    Balanced orbital decompression = medial andlateral wall without floor ( reduce new onsetdiplopia)Two wall = superior + lateral wall.

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    Mean reduction in axial proptosis = 3.2 5.1mm 2 (endoscopic approach)Endoscopic approach with a modifiedCaldwell Luc = 4.83mm 1

    Conventional transantral approach = 4.8mm(3.4-5.3) 2

    Three wall decompression = 7.2mm 1-7.5 2

    Lateral wall decompression + endoscopic (avgdecompression 6.9mm) 2

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    Orbital bruising (minor and temporary)Diplopia (pre-existing or de novo, improves postoperatively)

    Particularly associated with inferomedialdecompressionsPts with restricted motility and diplopia within 20 0 ofthe primary position preoperatively are most likely torequire subsequent muscle surgery

    Preservation of an inferomedial bony strut atjunction of medial wall and floor willminimize this complication.

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    Epiphora ( de novo or exacerbated aftersurgery, improves except in NLD injury)Paraesthesia (in territory of infraorbital

    nerve)OthersSecondary bacterial sinusitisimploding maxillary antrum

    mucocoele

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    Tumors /Fracture repair /Foreign bodyremoval /Orbitaldecompression/exenteration

    Lateral / Inferior / Medial / SuperiorOrbitotomy/ EndoscopicEndoscopic =>

    Orbital hematoma

    Fronto-ethmoid mucoceleOrbital decompressionBenign orbital lesions especially of medial orbit

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    Modified stallard-Wrightincision (Lazy S )Incision is deepened andthe periosteum exposedand incised 2 mm abovezygomatic frontalsuture.

    Temporalis muscle isdissected and retractedposteriorly. Lateralorbital rim divided.Periorbita is incisedparallel to lateral rectus

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    Indications: Orbital decompression, orbital biopsy & excision of orbital lesions.

    Subciliary incision through skin andorbicularis muscle with direction along orbitalseptum

    Orbital periosteum is incised approximately2mm inferior to orbital rim.

    Orbital floor is exposed, identification of intraorbital N vessels

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    Given by Dandy 1921Compound trauma of orbitDecompression of opticcanalRemoval of apical andcombined apical intracraniallesion.Infra brow incisionDeepend till periosteum.Which is incised 2-3 mmsuperior to the orbital rim. periorbita is separated fromthe orbital roof periorbitaincised if required

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    Described in 1973 by Galbraithand SullivanEffective in the management ofsmall, medial orbital tumorssuch as cavernoushemangiomas, schwannomas,

    hemangiopericytomas, andisolated neurofibromas. 180 0 conjunctival peritomy atcorneoscleral limbus from 12 0 to 6 0 clock

    Medial rectus retracted &disinserted from globe ,withcareful blunt dissection &retraction, orbital mass isidentified

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    BleedingOrbital hematomaInfection of globe

    DiplopiaLoss of vision excess pressure on globe,compression of Central Retinal ArteryInadvertant Intracranial injuryDirect perforation of globe

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    IndicationsTrauma;Thyroid eye disease;

    Neoplastic compression e.g. meningioma;Fibrosis due to chronic inflammation e.g.Wegeners granulomatosis.

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    Intraorbital, 25 mm length

    Intracanalicular, 9 mm length

    Intracranial, 16 mm length

    Intraocular disk, 1 mm length

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    Visual impairment following trauma withevidence of Afferent Pupillary defect with outevidence of any injury to eye.Diagnosis = RAPD supported by disc edema,

    congestion of vessels+ CT/MRI scan + VEP

    -

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    PrimaryDirect contusion on optic canal/Nerve orDeformation of Sphenoid with transfer of force intointracanalicular nerve

    Secondary compression of nerveBony fragmentsHemorrhage nerve swells with in canal compression of blood supply Ischemia

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    SURGERY IF# of optic canal on CT with vision6/60 butvision deteriorates on steroidVision deterioration (or

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    Uncinectomy

    Anterior and Posterior Ethmoidecotmy Sphenoidotomy Identify Lamina Papyracea, Fovea Ethmoidalis,

    Posterior EthmoidsAnterior face of sphenoid widely opened [ until

    roof of sphenoid and post.ethmoids iscontinuous]

    Identify Optic Nerve,Carotid artery, Orbital apex

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    Blunt Freer elevator pushed through laminapapyracea (1.5 cm ) ant to junction ofpost.ethmoid & Sphenoid.Carefully keep orbital periosteum intact.Bone over posterior orbital apex flaked off.Bone of optic canal flaked off.Incise optic sheath ( use sharp sickle knife )in upper medial quadrant.

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    Optic tubercle thick bone overlyingjunction of orbital apex and sphenoid sinus.Incision continued over orbital periosteum ofposterior orbital apexNo pack placed on nerve or in sinuses.

    Length of decompression = Orbital apex -1cm posterior to face of sphenoid sinus

    Cranio facial approach (upto optic chiasm)

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    Transorbital Pringle (1916)Extranasal transethmoid SewallTransantral KennerdellIntranasal microscopic

    Craniotomy DandyEndoscopic Endonasal Kountakis (1993)

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    1 VA > 6/60 ; no posterior orbit/optic canal#2 VA 6/60 ; no posterior orbit/optic canal#3 VA >PL - ve & # post.orbit/optic canal(or)

    VA PL - ve but no #

    4 VA PL - ve with # displaced

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    GOOD PROGNOSIS BAD PROGNOSIS

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    Blunt injury Sharp injury

    PL +ve PL ve

    Early presentation & Sx Late presentation & late Sx

    Acute injury (trauma ) Progressive vision loss

    Compressive diseases of

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    Good landmark is the anterior portion ofmiddle turbinate, sac lies just lateral toit.The maxillary line is a mucosal projectionalong the lateral nasal wall .

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    Lacrimal pump

    => Movements of the lids cause the punctato close against each other.

    => Tears pushed into the lacrimal sac.

    => Tears accumulating in the sac (lacrimallake)

    => Tears pushed down into the NLD wheneyes open because of the relativenegative pressure caused in the lacrimallake.

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    1 . Unilateral or bilateral .

    2 . Nature of the discharge (clear / purulent )3 . H/o Allergy4 . H/o Medication / Trauma / Surgery.5. History to rule out infective/Non-infective

    granulomatous conditions.6 . On physical examination Palpate the region of the naso-lacrimal sac andsee for any reflex from the puncta.7 . Eyelids to look for excessive laxity, punctumfor evidence of obstruction or inflammation.

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    Syringing = through the inferior canaliculus.

    Inability to flush = obstruction at the site of thepunctum or inferior canaliculus while reflux ofsaline = obstruction is more distal.Gentle skilled Probing with a 0 Bowmans probe

    Hard obstruction = bone or calculiSoft obstruction = soft tissue.

    Massaging of the sac = discharge from the puncti=consistent with chronic dacrocystitis.Swelling inferolateral to the medial canthus Jones test

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    Low Howarths incision Lacrimal sac with its attached periosteum isdissected free from the lacrimal fossa and isretracted laterallyRhinostomy of 1.5 cm is created taking care notto damage the nasal mucosa.A vertical slit is made in the exposed nasalmucosa and, similarly, a corresponding vertical

    slit is made in the lacrimal sacFlaps created are sutured together.Epithelium lined rhinostomy created.

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    Advantages.Consistently high success rates

    Biopsy of the lacrimal sac possible if it looksabnormal. DisadvantagesMight require general anaesthesia with anovernight stay.Facial scar.Injury to normal lacrimal pump function.

    Risk of haemorrhage.Revision surgery by the same approach difficult.

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    Common causes of failure of external DCR(EXTDCR). Intranasal synechiae

    Improper placement of the rhinostomy site[eg, into an agger nasi cell(8 percent ofcases) or the superolateral aspect of themiddle turbinate]

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    Indications for Primary endoscopic DCR :

    1. In the management of tearing associated withprimary acquired NLDO2. Infection of lacrimal sac associated withprimary acquired NLDO

    3. NLDO secondary to specific inflammatory orinfiltrative disorders4. The level of obstruction should be distal tothe junction of the lacrimal sac and the duct.

    5. In the management of lacrimal duct injuriesassociated with sinus surgeries

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    An incision is made in the mucosa overlyingthe anterior lacrimal crest.Posteriorly based muco-perichondrial flap israised.Anterior lacrimal crest is removed using apunch.Just lateral to Uncinate process is the thin

    lacrimal bone that forms the remainder ofthe medial aspect of the lacrimal fossa.

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    1. There is no external scar.2. The lacrimal pump system is preserved.3. Any concomittant intranasal pathology causing

    epiphora can be addressed4. Lacrimal sac mucosa is preserved5. The risk for cutaneous fistulas, of concern in

    patients who had previous radiation therapy orcertain granulomatous disorders, also may bereduced, as there is no external incision

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    1. Presence of a firm indurated mass at thelevel of medial canthus.2. Any swelling near medial canthus wheremalignancy is yet not excluded.3. Bloody epiphora4. Presence of bony destruction as seen inradiological films5. Pseudoepiphora( hyperlacrimation) : isessentially reflux tearing: the main gland oversecretes because of lack of secretion fromminor glands along the lid margin.

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    The canaliculus is dilated to allow passage ofa vitreoretinal light probe, (ideally throughthe superior canaliculus) which is advancedinto lacrimal sac.Point of light seen endoscopically acting as aguide to fashion the rhinostomy.Use optimum power to ablate tissue.(???)

    Once the sac is exposed, the light probe iswithdrawn, replaced by lacrimal probe.

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    Rhinostomy is enlarged to 5 8mm diameter. A silicone stent may then be passed throughboth superior and inferior canaliculi and beretrieved from the nose.The loop should not be excessively tight as itcan cause granulations at the rhinostomy siteand can cheese -wire through the canaliculi.

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    Ability to vaporize soft tissue and bone.Good haemostatic properties.Deliverable through a flexible laser fibre.

    Co2, Argon,Nd:YAG not suitable.Ho:YAG, KTP/532 and diode laser aresuitable.

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    Ho:YAG laser --Vaporizes bone /good haemostaticpropertiesDisadvantage -- tendency to spatterrequiring repeated cleansing of theendoscope lens.The KTP/532 star pulse laser has similaradvantages but avoids this problem.The diode laser has a single-use fibre --

    Expensive The erbium:YAG laser-- ideal for this surgery,but as yet no suitable delivery system exists.

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    Small/Improper placement ofrhinostomy.(Bony/Membranous)Sump syndrome/small cicatrized sacScar ( at rhinostomy/ canaliculi-sac Junction)

    GranulomaBony spicules/Incomplete periosteum removalPump insufficiency/persistent sac diverticulum

    Previuos Sx, RT, Chemo for PNS tumor

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    Microscope with a 300-mm lens may be usedStent - Some do not insert a stent whileothers leave a stent in for several months.Size of the ostium -- affect success rates.Transcanalicular DCR -- laser fibre throughcanaliculus (600 micron optical fibre).Balloon dacryocystoplasty -- Dilates stenosis.

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    Mitomycin C and 5-Fluorouracil have beentried.

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    Insertion of Lester-Jones tube =a permanentindwelling ceramic tube between the nasalcavity and the conjunctival sac to drain tearsand completely bypass the lacrimal drainagesystem.Canaliculo DCR = resection of the stenosedregion of the common canaliculus withprimary anastomosis over a stent inconjunction with a DCR.

    96

  • 8/10/2019 Orbital decompression, optic n decompression and EndoDCR

    97/97

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