Endonasal dacryocystorhinostomy: a report by the American Academy of Ophthalmology.

OBJECTIVE: This document describes endonasal dacryocystorhinostomy (DCR) and examines the evidence to answer key questions about the effectiveness of the procedure compared with external DCR; the relative indications, contraindications, advantages, and limitations of the procedure; and patient selection, surgical technique, postoperative care, and complications. METHODS: A literature search conducted for the years 1968 to 2000 retrieved 93 citations. The panel members reviewed 71 of these articles and selected 64 for the panel methodologist to review and rate according to the strength of evidence. A level I rating is assigned to properly conducted, well-designed, randomized clinical trials; a level II rating is assigned to well-designed cohort and case-control studies; and a level III rating is assigned to case series and poorly designed prospective and retrospective studies, including case-control studies. RESULTS: The published literature includes two reports that describe clinical trials comparing endonasal with external DCR with a 1-year follow-up. The success rate was 91% for the external DCR group in both reports and 63% and 75% for the endonasal DCR groups, defined by patency to irrigation. A longitudinal cohort study included a control group of age-matched external DCR patients who were compared with a study group of endonasal DCR patients. The reported success rate at 9 months following surgery for the endonasal cohort was 90% and was not statistically significantly different from the 94% success rate noted in the external DCR control group. Remaining data on reported success rates of primary and revision endonasal DCR were obtained from a collection of uncontrolled observational case studies with varying periods of follow-up and success rates ranging from 59% to 100%. CONCLUSIONS: It is difficult to make definite evidence-based determinations about the relative efficacy of endonasal and external DCR because of the deficiencies in the reported literature. Based on level III evidence, the available data suggest that endonasal DCR may be a viable option for the correction of acquired nasolacrimal duct obstruction and complex forms of congenital dacryostenosis in selected patients. This procedure may be indicated on a primary basis or as revisional surgery following failed external or endonasal DCR. Some studies comparing endonasal DCR with external DCR suggested lower success rates in the endonasal group; other studies yielded success rates comparable with or exceeding those of external surgery. Reported complications of endonasal DCR do not generally appear to be greater in frequency or magnitude than those associated with external DCR. Disadvantages of endonasal DCR include the preferred use of general anesthesia by many surgeons, the high cost of expensive equipment and instrumentation, and the relatively steep learning curve for this procedure. Depending on the preference of the surgeon, more postoperative care may be required for patients undergoing endonasal DCR than external DCR. Both the advantages and the limitations of endonasal DCR relative to external DCR should be carefully discussed with patients who are contemplating endonasal surgery.

The use of a computer-assisted image-guided system (InstaTrak) in orbital surgery.

PURPOSE: To assess the usefulness of a computer-assisted image-guided system (CAIGS) as an intraoperative anatomical guide in performing orbital surgery. METHODS: Noncomparative interventional case series of 30 consecutive orbital procedures performed by one surgeon (J.G.C.) using the CAIGS (InstaTrak) for intraoperative anatomical guidance. RESULTS: The series consisted of 8 cases of orbital decompression, 8 cases of orbital fracture, 11 cases of tumor excision, 2 cases of orbital reconstruction for severe enophthalmos, and 1 case of drainage of an orbital abscess. The CAIGS (InstaTrak) was useful in providing adjunctive intraoperative guidance in all 30 orbital cases. CONCLUSION: The CAIGS (InstaTrak) system is a useful adjunctive tool in providing intraoperative anatomic guidance in a consecutive series of varied orbital operations.

Teleophthalmology: the use of real-time telementoring to remove an orbital tumor.

OBJECTIVE: To determine whether current telemedicine technology can support real-time surgical telementoring to remove an orbital tumor. DESIGN: Interventional case report METHODS: An orbital specialist guided a general ophthalmologist in the removal of a lateral orbital tumor from a site 210 miles away on another island. A 3-mm endoscope connected to a three-chip digital video camera attached to a Concorde 4500 Picture-Tel videoconferencing system was used to transmit images at a rate of 384 kb per second over integrated service digital network lines. MAIN OUTCOME MEASURES: Successful performance and outcome of the telementored procedure comparable to hands-on orbital surgery. RESULTS: The surgical procedure was successfully telementored with uncomplicated removal of the orbital tumor. CONCLUSIONS: Current telemedicine technology can support real-time telementoring to remove an orbital tumor.

The safety and efficacy of mitomycin C in endonasal endoscopic laser-assisted dacryocystorhinostomy.

PURPOSE: The adjunctive use of mitomycin C (MMC) in glaucoma and pterygium surgery has been widely published, but there has not been any large long-term study of its use in endonasal endoscopic laser-assisted dacryocystorhinostomy (ELA-DCR). The purpose of this study was to examine the safety and efficacy of the adjunctive use of MMC in this procedure. METHODS: A nonrandomized, retrospective, single-masked, interventional case-controlled study was performed wherein 123 consecutive procedures using MMC in ELA-DCR procedures, using the Holmium:YAG laser, were compared with a historical control group consisting of 48 consecutive procedures in which MMC was not used. One surgeon performed all procedures. The two groups were compared with regard to complications as well as success rate. The main outcome measures for success were the resolution of epiphora and patency with lacrimal irrigation. Success rates were analyzed using the Fisher's exact test. The main outcome determinants for complications were the presence or absence of delayed wound healing, wound necrosis, infection, or excessive bleeding. Postoperative follow-up interval ranged from 30 months to 72 months. RESULTS: There were no complications in the group receiving MMC. One case of turbino-septal synechia formation occurred in the non-MMC group. The success rate of the MMC group was 99.2% compared with 89.6% in the control group. This difference (9.6%) was statistically significant using Fisher's exact test (p = 0.007). CONCLUSION: This study supports the safety and efficacy of the intraoperative use of MMC in endonasal ELA-DCR.

The Micro-Reflux Test: a new test to evaluate nasolacrimal duct obstruction.

OBJECTIVE: The authors describe a new and simple procedure, the Micro-Reflux Test (MRT), to screen for primary acquired nasolacrimal duct obstruction (PANDO). This study sought to determine the reliability of this new test in the diagnosis of complete nasolacrimal duct obstruction. DESIGN: A nonrandomized, prospective, self-controlled, comparative case series. PARTICIPANTS: Two hundred eyes of 100 patients with documented unilateral complete PANDO were examined. INTERVENTION: The MRT was performed by a masked examiner on both eyes of each patient. Two drops of 0.25% sodium fluorescein dye were instilled in the inferior cul-de-sac and the patient made to blink five times to activate the lacrimal pump mechanism. Excess fluorescein dye was blotted away using tissue paper. The patient was positioned at the slit lamp, and observation of the inferior punctum with the cobalt blue filter was done using 5x magnification. The tissue overlying the lacrimal sac was massaged in a counterclockwise direction with moderate pressure using the index finger. The test was considered positive if there was continued observed reflux of fluorescein-stained tears from the inferior punctum after the initial counterclockwise massage to empty the inferior canaliculus. The validity of the MRT was measured by sensitivity and specificity as well as positive- and negative-predictive values. MAIN OUTCOME MEASURE: The MRT was considered positive if there was continued reflux of fluorescein-stained tears from the inferior punctum after the initial digital massage to empty the dye from the inferior canaliculus. RESULTS: The MRT used for the evaluation of complete PANDO has a sensitivity of 97% and a specificity of 95%. It has a positive-predictive value of 95% and a negative-predictive value of 97%. CONCLUSION: The MRT is a reliable screening test for presence of complete nasolacrimal duct obstruction.

[Evaluation of the body composition by anthropometry and bioelectric impedance in a group of elderly patients recovering from cerebrovascular accidents]. / Evaluación de la composición corporal por antropometría e impedancia bioeléctrica en un grupo de ancianos en recuperación de accidentes cerebrovasculares.

Body composition was assessed by bioelectrical impedance and anthropometry in 25 subjects, 13 men and 12 women aged 68 +/- 9 with approximately 1 year of recovering from stroke. Most of them with a high independence in their diary activities. The main purpose of this study is to know the body composition of elderly patients with this pathology and how affects the two compartments, fat mass and fat free mass when they are measured by two different techniques anthropometry and BIA. Body Mass Index was higher in women than in men and correlation coefficient (r = 0.6) with body fat per cent was similar with both methods: BIA and anthropometry. The body fat per cent values obtained by BIA showed the same trend to be lower for men than for women and in general were higher than the anthropometric values; the high correlation between the body fat per cent by anthropometry and by BIA support this tendency (r = 0.748, p < 0.01). The comparative studies of ours results in elderly subjects recovered from stroke and the literature data in healthy elderly subjects suggests that this pathology do not lean to important changes in body composition. However, further research is necessary to confirm these results.

Real-time telementoring in ophthalmology.

PURPOSE: To determine if current telemedicine technology can support real-time telementoring to teach ophthalmologic surgical procedures in remote areas. METHOD: Using an integrated systems digital network (ISDN) line conveying information at a rate of 128 kbps, an endoscopic laser-assisted dacryocystorhinostomy (ELA-DCR) procedure was transmitted in real time from the Saint Francis Medical Center in Honolulu, Hawaii, to ophthalmologists at the Makati Medical Center in Manila, Philippines, more than 5000 miles away. Live surgical and endoscopic images were sent real time with explanations by the surgeon and with interactive questions and answers during and after the procedure. RESULTS: The ELA-DCR procedure was transmitted in real time from Honolulu to more than 100 ophthalmologists at the Makati Medical Center in the Philippines. CONCLUSION: Current technology in telemedicine can support the use of real-time surgical telementoring to teach complex ophthalmologic procedures.

Advances in ophthalmic plastic, reconstructive and orbital surgery in Hawaii.

Advances in ophthalmic plastic and reconstructive surgery continue to be made in the state of Hawaii. A new technique of dacryocystorhinostomy using the endoscope and the pulsed Holmium: YAG laser as well as a subconjunctival endoscopic assisted approach to orbital surgery for orbital decompression is described. The integrated hydroxyapatite implant replacing the enucleated eye gives excellent postoperative extraocular motility.