Modified endoscopic dacryocystorhinostomy with posterior lacrimal sac flap for nasolacrimal duct obstruction.

OBJECTIVES: To evaluate a new technique of modified endoscopic dacryocystorhinostomy involving the creation of a large posterior flap at the lacrimal sac and to compare its success rate with that of the conventional endoscopic method of excising the entire medial lacrimal sac wall as a surgical treatment for epiphora caused by nasolacrimal duct obstruction. DESIGN: Retrospective, interventional, and comparative case series. SETTING: University teaching hospital, Hong Kong. PATIENTS AND METHODS: Only adults with primary nasolacrimal duct obstruction were included. Consecutive endoscopic dacryocystorhinostomy was performed using two different techniques from July 1999 to June 2001. The new technique involved the creation of a large posterior flap at the medial lacrimal sac wall, reflecting it posteriorly, followed by removal of the remaining small anterior flap (the LSF group). Other patients had the entire medial lacrimal sac wall excised (the ELS group). MAIN OUTCOME MEASURES: Surgical success was defined by free fluorescein drainage from the conjunctival sac into the rhinostomy site at least 3 months after silicone stent removal. RESULTS: Ninety-nine procedures were performed in 99 patients. The success rate was 89.1% (41/46) in the LSF group and 71.7% (38/53) in the ELS group. The difference between the two groups was statistically significant (Chi squared test, P=0.031). CONCLUSIONS: Our new and modified technique of endonasal dacryocystorhinostomy has a greater success rate than conventional endonasal dacryocystorhinostomy. A large-scale prospective randomised controlled trial to further evaluate the efficacy and safety of this surgical technique is under way.

Treatment of severe acute respiratory syndrome with lopinavir/ritonavir: a multicentre retrospective matched cohort study.

OBJECTIVES: To investigate the possible benefits and adverse effects of the addition of lopinavir/ritonavir to a standard treatment protocol for the treatment of severe acute respiratory syndrome. DESIGN: Retrospective matched cohort study. SETTING: Four acute regional hospitals in Hong Kong. PATIENTS AND METHODS: Seventy-five patients with severe acute respiratory syndrome treated with lopinavir/ritonavir in addition to a standard treatment protocol adopted by the Hospital Authority were matched with controls retrieved from the Hospital Authority severe acute respiratory syndrome central database. Matching was done with respect to age, sex, the presence of co-morbidities, lactate dehydrogenase level and the use of pulse steroid therapy. The 75 patients treated with lopinavir/ritonavir were divided into two subgroups for analysis: lopinavir/ritonavir as initial treatment, and lopinavir/ritonavir as rescue therapy. These groups were compared with matched cohorts of 634 and 343 patients, respectively. Outcomes including overall death rate, oxygen desaturation, intubation rate, and use of pulse methylprednisolone were reviewed. RESULTS: The addition of lopinavir/ritonavir as initial treatment was associated with a reduction in the overall death rate (2.3%) and intubation rate (0%), when compared with a matched cohort who received standard treatment (15.6% and 11.0% respectively, P<0.05) and a lower rate of use of methylprednisolone at a lower mean dose. The subgroup who had received lopinavir/ritonavir as rescue therapy, showed no difference in overall death rate and rates of oxygen desaturation and intubation compared with the matched cohort, and received a higher mean dose of methylprednisolone. CONCLUSION: The addition of lopinavir/ritonavir to a standard treatment protocol as an initial treatment for severe acute respiratory syndrome appeared to be associated with improved clinical outcome. A randomised double-blind placebo-controlled trial is recommended during future epidemics to further evaluate this treatment.

Peribulbar anaesthesia with 1% ropivacaine and hyaluronidase 300 IU ml-1: comparison with 0.5% bupivacaine/2% lidocaine and hyaluronidase 50 IU ml-1.

The low toxicity of ropivacaine makes it attractive for peribulbar anaesthesia. However, its motor-sparing properties are undesirable when akinesia is important. Hyaluronidase (300 IU ml-1) promotes the onset and quality of peribulbar blockade when used with other agents. We investigated the onset and quality of ocular akinesia in 80 patients randomized to receive 1% ropivacaine plus hyaluronidase 300 IU ml-1 (group 1), or bupivacaine 0.5%/Lidocaine 2% plus 50 IU ml-1 hyaluronidase (group 2). Ocular akinesia was scored from 0 (no movement) to 8 (full movement) every 2 min for 20 min. The groups showed no difference in the rate of onset or degree of akinesia achieved (analysis of variance with repeated measures; P = 0.34). Sixty per cent of patients in group 1 and 55% in group 2 achieved akinesia scores of < or = 4 by 6 min (chi 2 test; P = 0.5). We conclude that both peribulbar solutions produce equivalent onset and quality of ocular akinesia.