Management of chronic dacryocystitis cases after failed external dacryocystorhinostomy using endoscopic technique with a novel lacrimal ostium stent.

AIM: To demonstrate the outcomes of endoscopic endonasal dacryocystorhinostomy (En-DCR) with an novel lacrimal ostium stent (LOS) which was performed in patients with recurrent epiphora after failed external dacryocystorhinostomy (Ex-DCR) and analyze the causes of failed Ex-DCR. METHODS: From September 2015 and December 2017, the clinic data of 29 cases suffered from recurrent epiphora after failed Ex-DCR was reviewed. The LOS were implanted into the ostium at the end of the revisional surgery. The causes of failed Ex-DCR were analyzed before revisional surgeries. Outcome of revisional surgeries with the new device were evaluated as well. RESULTS: The major causes of failure of the external approach were synechiae formation in the nasal ostium (29/29), followed by inadequate removal of the bony wall (21/29), nasal synechiae formation between lateral wall of nose and middle turbinate (11/29), and the bone opening was not in good location (7/29). The rate of success after revisional surgery was 82.76%. Re-obstruction of the ostiums were found in 5 failed cases. CONCLUSION: Endoscopic approach with a novel LOS may be an effective procedure to manage recurrent epiphora after previous failed Ex-DCR surgery. Synechiae formation in the nasal ostium and inadequate removal of the bony wall were the major causes of failure of Ex-DCR.

Endoscopic dacryocystorhinostomy with mucosal anastomosing in chronic dacryocystitis with three categories of ethmoid sinuses.

AIM: To evaluate the outcome of endoscopic dacryocystorhinostomy (En-DCR) with mucosal anastomosis in chronic dacryocystitis patients, with various categories of ethmoid sinuses. METHODS: Between July 2015 and September 2019, 1439 adult patients, representing 1623 affected eyes, presented with chronic dacryocystitis and were scheduled for En-DCR. The categories of ethmoid sinuses were preoperatively determined, using computed tomography-dacryocystography (CT-DCG), and were classified as category 1 (C1), category 2 (C2), and category 3 (C3). No sinuses anterior to the posterior lacrimal crest defined as C1. Sinuses found between the anterior edge of the lacrimal bone and the posterior lacrimal crest defined as C2. Sinuses found anterior to the lacrimal bone suture defined as C3. At the end of surgery, the dacryocyst and nasal mucosa were anastomosed in C1, and the dacryocyst mucosa and anterior ethmoid sinus were anastomosed in C2 and C3 ethmoid sinus patients. The surgical success rate and related complications, in patients with 3 categories of ethmoid cells, were monitored and documented. RESULTS: Postoperative data was obtained for 179 C1 affected eyes, 878 C2 affected eyes, and 432 C3 affected eyes. The overall success rate of En-DCR was 93.0% (1385/1489). Additionally, the success rates were comparable among the different ethmoid categories at 12mo post operation. We demonstrated that the major reason for surgical failure was intranasal ostial closure, due to granulation or scar tissue. CONCLUSION: En-DCR is a feasible and highly effective primary treatment for chronic dacryocystitis. To ensure surgical success, the surgery protocol must be designed in accordance with the category of ethmoid sinuses present in individual patient.

Surgical outcomes in acute dacryocystitis patients undergoing endonasal endoscopic dacryocystorhinostomy with or without silicone tube intubation.

AIM: To establish the necessity of silicone tube intubation in acute dacryocystitis (AD) patients undergoing endonasal endoscopic dacryocystorhinostomy (En-DCR). METHODS: Patients presenting with unilateral AD were randomly assigned to two treatment groups. En-DCR procedures were performed following lacrimal abscess formation, with the operation being performed with silicone intubation for patients in group B but not group A. Functional success was defined by an absence of additional AD episodes, no epiphora, and ostium patency as established via endoscopic evaluation or fluorescein irrigation. Operative success rates and demographic variables were compared between treatment groups. RESULTS: In total, 66 patients were analyzed in the present study (33 per group), with complete postoperative data having been successfully collected from 27 and 22 patients in group A and group B, respectively. All patients exhibited complete resolution of acute inflammation. Upon follow-up, granulation tissue was detected around the ostium at higher rates in group B (9/22, 40.9%) relative to group A (4/27, 14.8%). At the 12-month follow-up time point, patients in group A exhibited higher success rates (25/27, 92.6%) relative to patients in group B (20/22, 90.9%), but this difference was not significant. Cases of lacrimal passage reconstruction failure in both groups were attributed to excessive fibrous and/or granulation tissue formation proximal to the intranasal ostium. CONCLUSION: Given that these two operative approaches are associated with similar rates of operative success and in light of differences in granulation tissue formation, cost, and operative duration, these data do not support the routine silicone intubation of AD patients following En-DCR surgery.

Therapeutic difference between orbital decompression and glucocorticoids administration as the first-line treatment for dysthyroid optic neuropathy: a systematic review.

To assess all available data to compare the efficacy of glucocorticoids treatment and orbital decompression for dysthyroid optic neuropathy (DON). PubMed, EMBASE, the Cochrane Library databases as well as other sources were searched by two independent reviewers followed by extensive hand-searching for the identification of relevant studies. The primary outcomes were the improvement in visual acuity and responder rate. Secondary outcomes were the proptosis reduction, change in diplopia, and clinical activity score (CAS). One randomized controlled trial, three retrospective case series and one prospective case series met the inclusion criteria. They were divided into intravenous high-dose glucocorticoids (ivGC) group and orbital decompression (OD) group. Both groups demonstrated improvement in visual acuity. In addition, the proportion of patients with improved vision in OD group was higher than that in ivGC group (P<0.001). Post-treatment proptosis reduction was also reported in both groups. Overall, weighted mean in proptosis reduction estimated at 1.64 and 5.45 mm in patients treated with ivGC and OD respectively. This study also presented results regarding pre-existing and new-onset diplopia. Apart from diplopia, a wide variety of minor and major complications were noted in 5 included studies. The most common complication in ivGC group and OD group was Cushing's syndrome and epistaxis respectively. The present systematic review shows that both glucocorticoids treatment and OD are effective in treating DON and OD may work better in improving visual acuity and reducing proptosis. However, high-quality, large-sample, controlled studies need to be performed in the future.

Newly onset indirect traumatic optic neuropathy-surgical treatment first versus steroid treatment first.

AIM: To investigate the efficacy and safety of the treatment of endoscopic trans-ethmosphenoid optic canal decompression (ETOCD) with combination of steroid in patients with newly onset indirect traumatic optic neuropathy (ITON) and compare the outcome between immediate ETOCD treatment and ETOCD with preoperative steroid treatment. METHODS: Patients presented as newly onset ITON (suffered trauma within 3d) at a tertiary medical center between Mar 1st, 2016 and Mar 1st, 2018 were enrolled in this study. All patients were equally and randomly divided into 2 groups. Cases in group A were performed ETOCD immediately after admition while cases in group B were prescribed by methylprednisolone (20 mg/kg · d) for 3d before ETOCD. Methylprednisolone (20 mg/kg · d) was used after surgery for 6d in group A and 3d in group B. Follow-up was up to 3mo in all cases. Visual acuity (VA) before and after treatment between the two groups were taken into comparison. RESULTS: Complete postoperative data were acquired from 34 patients in group A and from 32 patients in group B. Group A had significantly higher effective rate in VA than group B (χ 2=4.905, P=0.027). CONCLUSION: For patients with newly onset ITON, combination treatment of ETOCD with high-dose steroid is an effective and safe way. Immediate surgery will lead to better prognosis for these cases.

Predictive parameters on CT scan for dysthyroid optic neuropathy.

AIM: To evaluate the value of parameters on CT scan in predicting dysthyroid optic neuropathy (DON) and to provide guidance for early diagnosis of DON accordingly. METHODS: A total of 67 eyes of 35 patients with thyroid-associated ophthalmopathy (TAO) were included in this study. Patients were divided into 2 groups (DON group and non-DON group). Parameters were measured on high resolution CT, including muscle index (MI), superior ophthalmic vein (SOV) dilatation, extraocular muscle volume/orbit volume (MV/OV), and intracranial fat prolapsed, and be compared between these 2 groups. The relation between those parameters and visual function [visual acuity (VA) and visual field defect (VF defect)] were also evaluated. RESULTS: MI and MV/OV were significantly higher in DON group (P=0.00035 and P=0.00026). No significant difference was detected regarding intracranial fat prolapse existence and SOV dilatation (P=0.37 and P=0.15). MV/OV was found to have significant negative correlation with both VF defect (R=-0.332, P=0.0273) and VA (R=-0.635, P=0.00) while MI was found to have negative linear correlation with VA only (R=-0.456, P=0.00017). The area under receiver operating characteristic curves was 0.82 for MV/OV and 0.75 for MI. The best performance in detecting DON was achieved when MV/OV is set at 0.20 with 72% sensitivity and 87% specificity and MI is set at 0.52 with 64% sensitivity and 80% specificity. CONCLUSION: MI and MV/OV are predictive parameters for DON. Together with clinical manifestations, MV/OV≥0.2 can be used as a good indicator for DON in TAO patients.

Endoscopic transnasal canaliculorhinostomy for refractory common canalicular obstruction with an unidentifiable lacrimal sac.

AIM: To describe the role of endoscopic transnasal canaliculorhinostomy (ETC) in refractory common canalicular obstruction (CCO) associated with an absent or unidentifiable lacrimal sac. METHODS: The records of patients with refractory CCO who underwent ETC at the Eye Hospital of Wenzhou Medical University from October 2007 to December 2016 were retrospectively reviewed. RESULTS: Fifty-six patients (56 eyes) with refractory CCO were recruited into the study. Eight patients were excluded due to the presence of a residual lacrimal sac or failure to complete the follow-up duration. The anatomic and functional success rates were both 85.4% (41/48) at a mean follow-up of 18.6mo. Five cases failed as a result of ostial synechia and two failed because of ostial obstruction by granulation. Postoperative complications included mild nasal bleeding in 5 cases, dried nasal feeling in 8 cases, and olfactory dysfunction in 4 cases. CONCLUSION: Although being surgically challenging, ETC has comparable findings to its external approach counterpart or conjunctivodacryocystorhinostomy (CDCR) with Jones tube. And it may prove to be a novel alternate surgical technique for patients with refractory CCO without identifiable lacrimal sac.

Prognostic factors of trans-ethmosphenoid optic canal decompression for indirect traumatic optic neuropathy.

AIM: To investigate a possible correlation between visual acuity (VA) prognosis and the presence at baseline of various orbital and ocular signs in patients affected by indirect traumatic optic neuropathy (ITON). METHODS: From July 1st, 2012 to July 1st, 2015, 224 adults diagnosed with ITON who underwent endoscopic trans-ethmosphenoid optic canal decompression (ETOCD) were reviewed. Visual outcome before and after treatment were taken into comparison. RESULTS: Accompanied older in age, longer time to medical treatment and existence of optic canal fracture (OCF) were the independent predictors for poor postoperative VA and lower improvement degree of visual acuity (IDVA), while worse preoperative VA was predictive factor for poor postoperative VA only. Mean value of IDVA in patients with OCF was 0.19±0.30. Mean value of IDVA in patients without OCF was 0.29±0.35. IDVA in cases without OCF was significant higher than those with OCF (t=2.272, P<0.05). CONCLUSION: Patients suffered from ITON without OCF before ETOCD have better surgical outcome than those with OCF. Older in age, longer time to medical treatment and existence of OCF are independent factors for poor VA prognosis and lower IDVA. Preoperative VA is independent factor for VA prognosis only.

New mucosal flap modification for endonasal endoscopic dacryocystorhinostomy in Asians.

AIM: To describe a simple modification of fashioning the mucosal flap for endonasal endoscopic dacryocystorhinostomy (EES-DCR) in Asians and investigate its efficacy. METHODS: A total of 120 patients with unilateral primary chronic dacryocystitis (PCD) were randomized into two groups: the new shaped nasal mucosal flap group (group A) and the removed nasal mucosal flap group (group B). All patients underwent standard EES-DCR. Patients in group A were performed a new shaped nasal mucosal flap covering the bared bone around the opened sac and those in group B was removed the nasal mucosal flap uncovering the bared bone. Patients were followed up for one year. The occurrence of granulation tissue, the proliferation of scar tissue and success rate of EES-DCR was compared. RESULTS: In the present study, complete postoperative data were acquired from 54 patients in group A and from 57 patients in group B. During process of review, the occurrence of granulation tissue was at the ostium margins account for 15% (8/54) in group A and 39% (22/57) in group B (P<0.05). At the one-year review, scar tissue was present in 5 patients in group A compared with 18 in group B (P<0.05). The success rate of EES-DCR was 98% (53/54) in group A and 84% (48/57) in group B (P<0.05). CONCLUSION: The simple modification of fashioning nasal mucosal flap can effectively cover the bared bone around the opened sac and reduce formation of granulation tissue, lessen the risk of scar tissue formation and closure of ostium, thus improve the success rate of EES-DCR in Asians.

[Endoscopic trans-ethmoid medial orbital wall decompression combined with intraconal fat decompression for Graves' ophthalmopathy].

OBJECTIVE: To present a new mini-invasive surgery for compressive optic neuropathy (CON) in Graves' ophthalmopathy (GO) by adequately decompressing the orbital apex and correcting proptosis, and to analyze its results. METHODS: A retrospective chart was reviewed in 29 patients receiving orbital decompression for the treatment of CON secondary to GO from October 2006 to May 2011. All patients diagnosed CON were in stable and inactive phase of GO at least for 6 months. All patients received endoscopic transethmoid medial orbital wall decompression to reduce the compression on the orbital apex. In the meanwhile, an endoscopic transethmoid intraconal fat-removal orbital decompression was performed to remove parts of intraconal fat with a special aspiration/cutting instrument to further reduce the proptosis. All patients were followed up periodically. RESULTS: of improvement of visual acuity (VA), color vision, and amount of proptosis reduction and incidence of induced diplopia 9 months after surgery was recorded for analysis its feasibility. RESULTS: Forty-five orbits of 29 patients were included in the study. At the 9 months review, 44 of 45 eyes (97.8%) improved their VA from -0.65±0.30 (x±s) preoperatively to -0.24±0.22, with a mean improvement of 0.55±0.17 (t=-13.012, P<0.001), 23 of 29 eyes (79.3%) had improved color vision (P<0.001), and the mean reduction in proptosis was (7.07±1.59) mm (range 4-11 mm). Postoperative symmetry to within 2 mm were achieved in all patients. Except 1 patient complaining of deterioration in diplopia following surgery, no patients presented new on-set diplopia postoperatively. CONCLUSION: The endoscopic transethmoid medial orbital wall decompression combined with the endoscopic transethmoid intraconal fat-removal orbital decompression is an effective treatment with minimal morbidity for both visional recovery and improvement of proptosis for CON in GO.