Preloaded Monoka (Lacrijet) and congenital nasolacrimal duct obstruction: Initial results.

STUDY OBJECTIVE: To study the performance of a pre-loaded Monoka stent in the management of congenital nasolacrimal duct obstruction (CNLDO). STUDY DESIGN: Non-randomized study of consecutive cases. MATERIALS AND METHODS: A preloaded classic Monoka silicone stent contained entirely inside its introducer (Lacrijet) was used to treat a consecutive series of subjects with CNLDO over an 11-month period (May 2019-March 2020). Only subjects with chronic symptomatic CNLDO were included. Subjects with intermittent tearing, canalicular pathology, trisomy 21, facial cleft, or history of lacrimal surgery were excluded. Intraoperative findings were recorded, including the degree and location of the nasolacrimal obstruction, successful metal to metal contact with the probe, any difficulties encountered by the Lacrijet device itself, procedure duration, tolerability of the fixation punctal plug, and finally, inspection of the stent after withdrawal of the inserter. Functional success was defined as disappearance of all symptoms of epiphora. RESULTS: A total of 45 preloaded Monoka Lacrijet stents (Lcj) were placed consecutively in 38 children. The mean age was 27.9 months (12-78 months). The mean procedural duration was 2.8minutes (range: 1-10min). The overall success with disappearance of all symptoms of epiphora was 88.8% (40/45). Surgery in cases of simple mucosal stenosis was successful in 92.2% (35/38) of cases, with a mean follow-up time of 7.9 months (range: 1 to 12 months). The duration of stent intubation was for this group was 32 days (range: 1-103). The surgical outcomes for the other 7 cases with more complex intraoperative findings are summarized in the publication. All withdrawn probes were intact. CONCLUSIONS: The Lacrijet stent system is a simple and reliable pushed intubation device for CNLDO in appropriately selected cases where bony stenosis of the canal is minimal.

Insertion of a preloaded Monoka™ stent for congenital nasolacrimal obstruction: Intraoperative observations. A preliminary study.

STUDY OBJECTIVE: To study the intraoperative deployment of a pre-loaded probe for a "pushed" monocanalicular nasolacrimal intubation. STUDY DESIGN: Non-randomized study of consecutive cases. MATERIALS AND METHODS: Description: A classical Monoka™ silicone stent with the silicone tube attached at right angles to the punctal plug is contained entirely inside an introducer connected to a piston. Insertion: The procedure begins with intubation of the nasolacrimal duct with the metallic introducer. Traction on the piston retracts the metallic introducer inside the handpiece. This relative shortening progressively ejects the stent, starting with its free end at the bottom of the introducer. The operation was observed endoscopically under single-blind conditions. RESULTS: Twenty-eight preloaded Monoka™ stents were placed consecutively, in 28 congenital nasolacrimal duct intubations in 22 patients (28 sides). Endoscopic examination showed that the free part of the stent was progressively ejected from the introducer during retraction of the piston. Insertion of this pushed stent into the nasal cavity was effective in 23/28 cases (82.1%). A total of 28 preloaded stent insertions were attempted and 23 were correctly deployed. DIFFICULTIES ENCOUNTERED: At the end of nasolacrimal duct intubation, contact between the punctal plug and the lacrimal punctum was problematic in four cases (4/28=14.2%). At the beginning of stent placement, premature ejection of the punctal plug within the end of the introducer occurred in five cases (5/28=17.8%). These five stents failed to insert properly into the nasal cavity. At the end of insertion, retention of the punctal plug in the introducer occurred in two cases (2/28=7.1%). COMPLICATIONS: No cases of intraoperative or postoperative epistaxis were observed. CONCLUSIONS: Intraoperative nasal endoscopy validated the concept of the preloaded Monoka stent and its deployment. Reproducibility and improved reliability may require a change in stenting technique and a design modification.

Intralacrimal migration of Masterka® stents.

BACKGROUND: Tearing and conjunctivitis in children are commonly due to lacrimal drainage system obstruction. Congenital nasolacrimal obstruction is a common pathology treated by probing with or without silicone stent insertion, depending upon the age of the child. The silicone stent is self-retaining and placed for at least one month. Masterka® is a recent version of Monoka®, which may lead to the same surgical complications, such as intralacrimal migration. SUBJECTS AND METHODS: The medical records of two patients surgically treated with the Masterka® probe for nasolacrimal duct obstruction, who developed intralacrimal migration of the stent, were retrospectively reviewed and analyzed. A 41-month-old child and an 18-month-old child presented with disappearance of the silicone tube after 7 days and 2 years respectively. In the first case, the tube migrated completely within the lacrimal system and became externalized through the nose at 2 years, while in the second case, the Masterka® was retrieved through a canalicular approach. In both cases, infants had no further tearing. DISCUSSION: The frequency self-retaining stent disappearance is estimated at 15%. Among these cases, intralacrimal migration is only reported in 0.5% of cases. To prevent intralacrimal migration, the surgical technique must follow a certain number of rules. Management, based on residual epiphora, is discussed. CONCLUSION: Prevention of intralacrimal migration of self-retaining stents involves a rigorous analysis of the relationship between the meatus and the fixation head at the time of placement. After lacrimal intubation, scheduled monitoring is necessary to screen for stent disappearance. Management is based on clinical findings, anterior rhinoscopy and even exploratory canaliculotomy.

[Cosmetic eyelid surgery]. / Chirurgie esthétique des paupières.

Cosmetic eyelid surgery is becoming increasingly popular. It can rejuvenate the patient's appearance with relatively minor side effects. Its risk/benefit ratio is one of the best in facial cosmetic surgery. However, the patient does not always accurately assess the aesthetic appearance of his or her eyelids. This underscores the importance of clinical examination in order to determine the patient's wishes, and then make an accurate diagnosis and potential surgical plan. We currently oppose, in general, surgical techniques involving tissue removal (skin-muscle and/or fat) in favor of those involving tissue repositioning and grafting (autologous fat pearl transposition, obtained by liposuction, and lipostructure). Furthermore, the place of adjuvant therapies to blepharoplasty is steadily increasing. They mainly include surface treatments (peels and lasers), dermal fillers and anti-wrinkle botulinum toxin injections. They are also increasingly used in isolation in novel ways. In all cases, a perfect knowledge of anatomy and relevant skills and experience remain necessary.

[Cosmetic blepharoplasty complicated by necrotizing periorbital fasciitis: a case report]. / Fasciite nécrosante périorbitaire compliquant une blépharoplastie esthétique : à propos d'un cas.

Necrotizing periorbital or palpebro-orbital fasciitis represents a unique anatomical site for necrotizing fasciitis, which is an extremely rare and very severe, potentially devastating bacterial infection, rapidly leading to facial necrosis with loss of vision and even death of the patient from toxic shock. In this paper, we report a case of necrotizing periorbital fasciitis as a complication of cosmetic lower eyelid blepharoplasty. Necrotizing fasciitis most often affects the upper and lower limbs, the trunk and the perineal area. It is rarely observed in the facial region due to the rich blood supply in this area. The most commonly implicated pathogen is group A, ß-hemolytic "pyogenic"Streptococcus, either alone or in combination with other bacteria, such as staphylococcus or pseudomonas. Mortality varies according to the series and anatomical site. The mortality rate for necrotizing fasciitis is approximately 28 %. It is slightly lower in the periorbital area (15 %). Risk factors for death include alcoholism, diabetes mellitus, immunocompromise, hematologic or pulmonary diseases, and the identity of the causative agent (group A Streptococcus), although approximately 50 % of patients have no predisposing conditions. Management of periorbital necrotizing fasciitis is based on early detection of initial symptoms and on aggressive multidisciplinary treatment including surgical debridement of necrotic areas and antibiotic coverage. The timeliness of treatment and the multidisciplinary approach are considered to be the two essential factors in influencing the mortality and morbidity of this condition.

Pushed monocanalicular intubation. Pitfalls, deleterious side effects, and complications.

PURPOSE: To present our experience with pushed monocanalicular nasolacrimal intubation in the management of 90 consecutive cases of nasolacrimal outflow obstruction. MATERIALS AND METHOD: This paper reports a non-randomized study of 90 consecutive cases treated with a pushed Monoka intubation system (Masterka™). A metal guide is placed inside a silicone tube rather than being attached at the distal end of the tube, as done with traditional pulled intubations. Three probe lengths are available: 30, 35, and 40 mm. SURGICAL PROCEDURE: The silicone stent was pushed into a punctum, canaliculus, and nasolacrimal duct by means of the guide. After passing through the valve of Hasner and reaching the nasal floor, the guide was then delicately withdrawn while remaining oriented along the axis of the lacrimal sac and duct. Throughout this phase, the anchoring plug was held in contact with the punctum. Three study groups were set up chronologically: group 1: endo-DCR procedures done with Masterka insertions under endoscopic observation. Group 2: Masterka insertions done with endoscopic guidance. Group 3: blind Masterka insertions without endoscopic guidance. The patients in groups 2 and 3 were selected on the information obtained by lacrimal probing. Only cases with mucosal nasolacrimal stenoses were included. All patients had surgery under general anesthesia with mechanically assisted ventilation (groups 1 and 2) or spontaneous ventilation (group 3). The anchoring plug was inserted into the punctum and vertical canaliculus, either by pulling on the probe (group 1) or using an inserting instrument. RESULTS: A total of 90 pushed Monoka intubations were done. Endoscopic examination (groups 1 and 2) demonstrated visually that the pushed intubation method was effective. In none of the 28 cases did the silicone bunch up when the guide was withdrawn. DEGREE OF DIFFICULTY: This was dependent upon proper selection for pushed Monoka intubation; the length of the probe and confirmation that there no false passage was created. The pushed intubation technique was only slightly more difficult than a simple lacrimal probing. The average operating time, excluding the anesthetic procedures, was respectively 5 min (group 2) and 4 min (group 3). COMPLICATIONS DURING SURGERY: There were no anesthetic or general problems observed in the three groups. Epistaxis was also not noted. POSTOPERATIVE COMPLICATIONS: Fifteen percent (13/90). The 13 complications noted were: two cases of canaliculitis, one intracanalicular migration, eight probes that disappeared, one keratitis, and one case of involuntary removal by the patient. DELETERIOUS SIDE EFFECTS: Tearing with the probe was in place was noted in 21.1% of the cases (19/90). This tearing disappeared as soon as the probe was removed in 50% of these cases (10/19). FUNCTIONAL RESULTS: Overall, the success rate (absence of epiphora, absence of mucous discharge) was 90% (81/90) with an average follow-up period of 19 weeks (Range, 1 day to 60 weeks). Two cases were lost to follow-up at day 1 and day 7. Group 1: 90.9% (20/22 cases; average age: 65 years, with an average follow-up period of 24 weeks). Group 2: 100% (6/6 cases; average age: 3.1 years, with an average follow-up period of 14 weeks). Group 3: 88.3% (53/60 cases excluding the two cases that were lost to follow-up; mean age: 2.3 years, with an average follow-up period of 16 weeks). CONCLUSIONS: From a technical perspective, pushed nasolacrimal intubation is much simpler than the traditional pulled types of nasolacrimal intubation. The anesthetic procedure required is the same as that for a late probing procedure, but the functional results are better. The Masterka is an alternative to simple late probing in the treatment of mucosal nasolacrimal stenoses in patients of over 12 months of age.

"Pushed" monocanalicular intubation in children under general anesthesia with spontaneous ventilation. A preliminary report.

PURPOSE: We studied the possibility of placing a new type of monocanalicular nasal intubation under general anesthesia with spontaneous mask ventilation in congenital nasolacrimal duct obstruction. PATIENTS AND METHOD: This was a non-randomized study of consecutive cases using a monocanalicular stent called the "pushed Monoka". The benefits of anchoring with meatus fixation are similar to the original Monoka device, but the probe guide or introducer is inside the silicone tube. The external diameter of the "pushed Monoka" is 0.96 mm (versus 0.64 mm in the traditional Monoka). There are three lengths: 30, 35, and 40 mm. General anesthesia was administered by inhalation of a halogen gas using a facial mask. The technique was selected by lacrimal exploration to evaluate the extent of the stenosis (simple or complex). The location and freedom of movement of the stent into the inferior nasal meatus was tested using a second lacrimal probe. Only simple stenosis cases with positive metal-to-metal contact were included in the study. INSERTION TECHNIQUE: The introducer pushes the stent into the lacrimal duct. The introducer should be removed from the silicone sleeve very carefully by gently pulling it out, millimeter by millimeter. This action is carried out while paying careful attention to keeping the stent aligned with the major axis of the lacrimal sac. Throughout this phase, the anchoring plug should remain in contact with the lacrimal punctum. Once the introducer is completely removed, the anchoring plug is secured into the vertical canaliculus. A single-use plug inserter was used. RESULTS: Fourteen children (18 sides) with congenital nasolacrimal duct obstruction were consecutively included in the study. The pushed intubations were all performed under general anesthesia with spontaneous ventilation. The average age of the children was 26.2 months (range: 14 to 46 months). The average duration of the procedure, measured between the moment that the facial mask was put into place and the child's awakening (crying, restlessness) was 14 minutes (range: 9 to 27 minutes). The most variable parameter was the use of the venous portal. The introduction of the pushed probe itself required an average 7 minutes (range: 3 to 11 minutes). None of the children showed epistaxis. In general terms, no intraoperative or postoperative complications were noted. The "pushed Monoka" tubes were withdrawn during postoperative appointments with a mean intubation duration of 34 days (range: 1 to 59 days). Postoperative success (absence of epiphora, absence of mucous discharge) was achieved in 88% of cases (16/18 sides). The average follow-up was 8.7 weeks (range: 3 to 26 weeks). Complications and side effects were minimal. One stent was withdrawn on day 1 due to a keratitis with respect to the anchoring plug. Three stents were spontaneously lost (16%) between day 2 and day 30. Anterior rhinoscopy found none of the stents in the inferior nasal meatus. These four cases were all considered successful as there was no postoperative epiphora noted. CONCLUSIONS: Pushed nasolacrimal intubation can be safely utilized under general anesthesia with spontaneous mask ventilation. This technique appears to be a simple and safe alternative to late and very late probing in the treatment of membranous congenital nasolacrimal duct obstruction in children older than 12 months.

[Tumoral exophthalmitis]. / Exophtalmies tumorales.

Proptosis due to intraorbital tumors is frequent and secondary to several etiologies. Generally, young people (0-20 years of age) will be affected mainly by benign diseases, such as angiomas or cysts (often dermoid cysts). Yet the ophthalmologist must never forget the possibility of rhabdomyosarcoma occurrence in a child. Adults (20-60 years of age) will for the most part develop benign tumors (cavernous hemangiomas, meningiomas) and inflammatory diseases. Last, malignant tumors, such as lymphomas and metastasized tumors, will mainly be observed in elderly people over 60 years of age.

[Cutaneous abnormalities of the eyelid and systemic diseases]. / Dermatoses palpébrales et maladies systémiques.

Systemic diseases are unknown diffuse inflammatory disorders. They include systemic and metabolic diseases and connective tissue diseases. Among them, lupus erythematosus, scleroderma, polymyositis and dermatomyositis, Sjögren syndrome, Wegener's granulomatosis, sarcoidosis, Vogt-Koyanagi-Harada's syndrome, and amyloidosis are the diseases encountered most frequently that can manifest cutaneous abnormalities of the eyelids. The main eyelid disorders involved in these diseases are described in this paper.

[Endoscopic diagnosis of the lacrimal drainage system]. / L'endoscopie lacrymale à visée diagnostique.

Endoscopic study of the lacrimal drainage system is the only way to directly observe the lacrimal sector of the lacrimal drainage system. The first experiments on this subject date from 1979. Recent technological progress has allowed us to test the latest instruments. These experiments have demonstrated the unquestionable progress of endoscopes and their potential contribution to diagnosing lacrimal pathology. However, certain factors still limit their everyday use. Image improvements and low cost will no doubt facilitate its integration in the diagnosis and therapy of the lacrimal drainage system.

[Examination and surgical indications for blepharoplasty]. / Examen et indications opératoires des blépharoplasties.

Cosmetic blepharoplasty has become very popular these last years and can easily be performed with local anesthesia. Its benefits are numerous and side effects minimal. Nevertheless, the different types of eyelid impairment are numerous and the patient is often not aware of them. This paper discusses the importance of the clinical examination targeting proper diagnosis of the type of eyelid impairment so as to recommend the most adapted surgical technique. The different types of cosmetic eyelid impairment are presented.

[Surgical treatment of congenital eyelid malpositions in children]. / Chirurgie des malpositions palpébrales congénitales de l'enfant.

Congenital eyelid malpositions can be isolated or associated with other structures such as the eyeball, ocular muscles, and lacrimal pathways. It is important to separate eyelid malpositions, which are topographical disorders, from eyelid malformations, which are constitutional morphological disorders. Only eyelid malpositions will be described in this paper, with a distinction made between static and dynamic disorders. Static disorders include epiblepharon, congenital ectropion and entropion, epicanthus, telecanthus, and centurion syndrome. Dynamic disorders group ptosis and congenital eyelid retractions. Epiblepharon is characterized by the absence of adhesion between the lower eyelid retractors and the orbicularis-skin layer, which allows the anterior lamella to roll over. Congenital entropion and ectropion are very rare. They most often require surgical treatment. Epicanthus involves a semi-lunar fold of skin extending from the upper eyelid across the medial canthal area to the margin of the lower eyelid. Four types (supra-ciliaris, palpebralis, tarsalis and inversus) of epicanthus are described. Treatment requires surgery. Telecanthus is defined as an increased distance between canthi. Primary telecanthus results from attenuation of the medial canthal tendons and is usually associated with other soft tIssue abnormalities such as epicanthus or blepharophimosis, or is seen after trauma. Secondary telecanthus is caused by underlying bony malpositions with an abnormal separation between the orbits because of an increased thickness of the interorbital bones such as that seen in hypertelorism or in other complex craniofacial syndromes. Euryblepharon is distinguished by an enlargement of the horizontal palpebral fissure associated with enlarged eyelids. The etiology is unknown and patients may benefit from surgery. Congenital ptosis is characterized by a deficiency of the levator muscle. They are most often unilateral and isolated. When associated with other abnormalities such as squint, synkinesis, blepharophimosis, or craniofacial syndromes, surgical treatment may require several-stage procedures. On the other hand, isolated congenital ptosis is usually treated in childhood (3-6 years) in a single stage. Congenital eyelid retractions may affect either the lower or the upper eyelid. They make up a rare condition and most cases are associated with craniofacial syndromes such as Crouzon or Apert syndromes. Upper eyelid retractions may spontaneously improve in some cases, but lower eyelid retractions do not. Treatment requires surgery, depending on the corneal consequences.

[Surgical treatment of upper lid trichiasis with partial tarsal rotation: a new procedure]. / Traitement du trichiasis localisé par rotation tarsale segmentaire: une nouvelle technique chirurgicale.

The authors' report a new surgical technique for partial isolated upper lid trichiasis. This ten minutes' time consuming procedure is easy to perform. It allows a fair cosmetic appearance of the operated eyelid and permits a reliable uneventful outcome. The technique consists to severe the lid margin and the tarsal plate on a distance of 3 to 4mm, at each part of it's trichiased area, in order to allow the pathological part of the eyelid to rotate like a shutter. The rotation of the ill eyelid segment is strengthen by a partial resection of the anterior lamella localizated here and there of the lid crease above the trichiased part of the eyelid, which allows to place everting sutures between the superior part of the tarsus and the two edges of the anterior lamella incision.

[Treatment of benign eyelid conditions with Argon laser]. / Traitement des affections palpébrales bénignes au laser à Argon.

Eyelid surgery is not always uneventful. Complications (punctal ectropion, retractile scars) can sometimes occur. Argon laser treatment is an interesting alternative technique, particularly in cases with cosmetic indications. The advantages of the procedure, compared to surgery are numerous: magnified view of tissue removal, enhancing complete excision; good hemostasis, avoiding wound sutures and bandage; fast and painless technique; outpatient office procedure with little post-operative care; good acceptance of the technique by most of the patients. The technique and the main indications are described in this paper.

[Etiologic causes of ptosis about a serie of 484 cases. To a new classification?]. / Etiopathogénie des ptôsis à propos d'une série de 484 cas. Vers une nouvelle classification?

We have analyzed the etiological causes of ptosis in a retrospective study of 484 cases undergoing operation. This study has confirmed how difficult it is to classify ptosis despite the different existing classifications. Some authors divide ptosis into two groups: congenital and acquired. These classifications seem to have been abandoned now for classifications based on the mechanism that instigates ptosis rather than the moment when the deficit developed. We chose to classify ptosis into five subgroups: myogenic (42% of the cases studied), aponeurotic (35.3%), neurogenic (6.8%), mixed (15.9%), and pseudoptosis (enophthalmos, eyelid tumor, hypotropia, etc.), the latter of which were removed from this series. This classification is based on clinical and surgical criteria. It has the advantages of unity, simplicity, and practicality in terms of establishing a treatment plan for a given ptosis patient. Indeed, each subgroup requires a particular clinical examination and a more stereotyped surgical treatment.

[A new instrument in eyelid surgery: ptosis forceps with a protected lock]. / Un nouvel instrument en chirurgie palpébrale: la pince à ptosis à cliquet protégé

We report on a new instrument in eyelid surgery: the ptosis forceps with a protected lock. This new device helps the surgeon to dissect the levator muscle to facilitate any type of levator surgery. It is particularly useful in the adjustment of the superior lid margin level towards the corneoscleral area in ptosis surgery with levator resection.

[Excessive tearing in infants and young children. Questions? Answers]. / Le larmoiement du petit enfant. Questions? Réponses...

Tearing in infants and young children is a subject of controversy. A logical succession of questions and answers is helpful in developing a consensual attitude.

[Analysis of the efficacy of early probing in the treatment of symptomatic congenital lacrimal duct obstruction in infants. Apropos of 92 cases]. / Analyse de l'efficacité du sondage précoce dans le traitement de l'obstruction congénitale des voies lacrymales symptomatique du nourrisson. A propos de 92 cases.

INTRODUCTION: Nasolacrimal duct obstruction (NLDO) is a common clinical problem (5 to 6% of newborns). Dacryostenosis is a partial or complete block in the nasolacrimal duct. PATIENTS AND METHODS: The records of 68 patients (92 cases) of NLDO with/without mucocele were reviewed. The probing was performed early and according to the same technique. RESULTS: The age at the time of probing ranged from 0 to 7 months (mean 4.6 months). The cure rate was 91.3% and the failure rate was 8.70%. DISCUSSION: Our results are consistent with other reports in the literature. The cure rate was higher with a earlier probing and was good after a second tentative of probing. A multiple obstruction of nasolacrimal system was cause of a failure. This was not the case with mucocele. The optimal timing of the probing is discussed in this report and we preferred to perform the probing to 4 at 6 months. CONCLUSION: We showed a high cure rate with early probing in our series. These results should be confirmed by a prospective randomised study (in process in our institution).

[Fetal anophthalmos. Problem of the prenatal diagnosis: a case report]. / L'anophtalmie foetale. Problème du diagnostic anténatal: à propos d'un cas.

We report a case of anophthalmia discovered after birth and discuss the need to resolve diagnostic difficulties and determine prognosis. This is an exceptional malformation which is particularly difficult to manage. It often occurs in the context of a complex malformation syndrome. Recent imaging techniques including magnetic resonance imaging help determine the degree of malformation and provide useful information for giving genetic advice to parents.