TRANSCANALICULAR LASER TRANSCANALICULAR LASER DACRYOCYSTORHIONOSTOMY DACRYOCYSTORHIONOSTOMY

(TC – DCR): (TC – DCR): INITIAL RESULTS WITH INITIAL RESULTS WITH

INTRAOPERATIVE CORTICOIDSINTRAOPERATIVE CORTICOIDS

• Prof. Dra. Mª Teresa Sellarès (1,3) - Ophtalmology-Prof. Dra. Mª Teresa Sellarès (1,3) - Ophtalmology-• Dr. José Maeso (2,3) – ENT-Dr. José Maeso (2,3) – ENT-• (1) Fundació Parc Taulí.Instituto Universitario UAB (2) Centre Mèdic Delfos. Centro Internacional (1) Fundació Parc Taulí.Instituto Universitario UAB (2) Centre Mèdic Delfos. Centro Internacional

de Medicina Avanzada. (3) Centre Oftalmològic ORL d’Egara.de Medicina Avanzada. (3) Centre Oftalmològic ORL d’Egara.

Direcciones de correspondencia:Direcciones de correspondencia:- Prof. Dra. Mª Teresa Sellarès Fabrés. e-mail: Prof. Dra. Mª Teresa Sellarès Fabrés. e-mail: 18211msf@comb.cat-Dr. José Maeso Riera. e-mail: Dr. José Maeso Riera. e-mail: 24024jmr@comb.cat

INTRODUCTIONINTRODUCTION• Transcanalicular dacryocystorhinostomy (TC-DCR) with diode laser Transcanalicular dacryocystorhinostomy (TC-DCR) with diode laser

has given us a surgical technique with very low local and general has given us a surgical technique with very low local and general morbidity. Nowadays we can perform a lachrymal surgery under morbidity. Nowadays we can perform a lachrymal surgery under local anesthesia, in a short time, and on outcome basis. No local anesthesia, in a short time, and on outcome basis. No dissection nor external scars are needed.dissection nor external scars are needed.

• We use the lachrymal system itself for surgical approach.We use the lachrymal system itself for surgical approach.

• This surgery needs a certain learning curve in nasal endoscopy.This surgery needs a certain learning curve in nasal endoscopy.

• Inconvenience rests on equipment costs.Inconvenience rests on equipment costs.

• INDICATIONSINDICATIONS- Chronic Dachryocystitys.- Chronic Dachryocystitys.- Acquired lachrymal obstruction in patients before cataract surgery- Acquired lachrymal obstruction in patients before cataract surgery- Other ? (Revision surgery, Acute cases)- Other ? (Revision surgery, Acute cases)

INTRODUCCIONINTRODUCCIONSTANDARD TECHNIQUESTANDARD TECHNIQUE

* Conjunctival topical anesthesia (Eye drops tetracain + oxibuprocain).* Conjunctival topical anesthesia (Eye drops tetracain + oxibuprocain).* Nasal topical anesthesia (tetracain + adrenalin).* Nasal topical anesthesia (tetracain + adrenalin).* Local anesthesia of the internal cantus * Local anesthesia of the internal cantus (50% mix of 2% mepivacain + 0,5% bupivacain with adrenalin).(50% mix of 2% mepivacain + 0,5% bupivacain with adrenalin).

• Transcanalicular approach through upper canaliculus. Nasal endoscopic control.Transcanalicular approach through upper canaliculus. Nasal endoscopic control.

• Diode laser INTERmedic multidiode S15 OFT 980nm.Diode laser INTERmedic multidiode S15 OFT 980nm.• 600 microns Silica-fluopolimer-tefzel laser guide.600 microns Silica-fluopolimer-tefzel laser guide.• 10 watts; pulsed mode 500msec/500msec.10 watts; pulsed mode 500msec/500msec.

Dilatation of upper lachrymal punctum and laser guide placing, Dilatation of upper lachrymal punctum and laser guide placing, until contacting the lachrymal bone.until contacting the lachrymal bone.

Under nasal endoscopic control, Under nasal endoscopic control, confirmation of guide place and direction, confirmation of guide place and direction, beggining of the ostium, and widening until beggining of the ostium, and widening until achieving a large cystorhinostomy.achieving a large cystorhinostomy.

Silicone bicanalicular intubation placing.Silicone bicanalicular intubation placing.

Optional: C-Mitomicin 0,04% 5’Optional: C-Mitomicin 0,04% 5’

MATERIAL and METHODMATERIAL and METHOD• 41 eyes operated of TC-DCR, between September 2008 and January 200941 eyes operated of TC-DCR, between September 2008 and January 2009• Observational, prospective non randomized study. Observational, prospective non randomized study.

• Standard TC-DCR technique.Standard TC-DCR technique.

• Placing of a lentine of nasal packing (Merocel ®) soaked in triamcinolone Placing of a lentine of nasal packing (Merocel ®) soaked in triamcinolone acetonid (Trigon depot ®), maintained the first 24 hours postop.acetonid (Trigon depot ®), maintained the first 24 hours postop.

Ostium finished with the Ostium finished with the silicone bicanalicular silicone bicanalicular intubation in place.intubation in place.

Placing of the lentine over the ostium.Placing of the lentine over the ostium.Verification of the position if the lentine, Verification of the position if the lentine, attached to a silk 0/0 suture to allow attached to a silk 0/0 suture to allow easy extraction after 24 hours.easy extraction after 24 hours.

Soaking of the lentine with Soaking of the lentine with triamcinolone.triamcinolone.NO C-MITOMICINE IS USEDNO C-MITOMICINE IS USED

• Lentine is removed after 24 hours, during the first Lentine is removed after 24 hours, during the first postoperative control.postoperative control.

• Follow-up every 7-15 days the first month, and after 3 and Follow-up every 7-15 days the first month, and after 3 and 6 months. 6 months.

• Clinical (tearing), nasal endoscopy (debrys removing, Clinical (tearing), nasal endoscopy (debrys removing, ostium revision, fluorescein test) and lachrymal irrigation.ostium revision, fluorescein test) and lachrymal irrigation.

MATERIAL and METHODMATERIAL and METHOD

RESULTSRESULTS• We have observed a reduction in local healing time, minimal local We have observed a reduction in local healing time, minimal local

imflammatory signs and a better y un mejor mantenimiento del imflammatory signs and a better y un mejor mantenimiento del diámetro del ostium inicial.diámetro del ostium inicial.

• Bicanalicular intubation is removed after 1 month.Bicanalicular intubation is removed after 1 month.

24 hours 7 days 15 days

1 month 6 months

1 monthIntubation removed

ANATOMICAL RESULTS - 6 months –ANATOMICAL RESULTS - 6 months –(Fluorescein clearance / Irrigation / Nasal endoscopy confirmation)(Fluorescein clearance / Irrigation / Nasal endoscopy confirmation)

FUNCTIONAL OSTIUMFUNCTIONAL OSTIUM40 / 4140 / 41

(97,56%)(97,56%)

CLOSED OSTIUMCLOSED OSTIUM1/411/41

CLINICAL RESULTS - 6 months -CLINICAL RESULTS - 6 months -(Improvement / desappearing of symptoms)(Improvement / desappearing of symptoms)

COMPLETE IMPROVEMENTCOMPLETE IMPROVEMENT37 / 4137 / 41

(90,24%)(90,24%)

PARTIAL IMPROVEMENTPARTIAL IMPROVEMENT3/413/41

(7,32%)(7,32%)

RESULTSRESULTS

DISCUSSIONDISCUSSIONIn our experience, TC-DCR with diode laser has become a simple In our experience, TC-DCR with diode laser has become a simple

approaching for the treatment of lachrymal obstructions, with a minimal approaching for the treatment of lachrymal obstructions, with a minimal morbidity, minimal general hazards and acceptable long-term results. morbidity, minimal general hazards and acceptable long-term results.

With the standard technique we have practiced since 2003, we had With the standard technique we have practiced since 2003, we had studied two groups of patients, with and without use of C-Mitomincine, studied two groups of patients, with and without use of C-Mitomincine, without finding any difference in postoperative outcome nor in long term without finding any difference in postoperative outcome nor in long term results (1), as found for other authors (2), in large groups.results (1), as found for other authors (2), in large groups.

Compared with our previous cases, the use of local steroids seem Compared with our previous cases, the use of local steroids seem to offer many advantages. Immediate postoperative reaction is less intense. to offer many advantages. Immediate postoperative reaction is less intense. The local recovery of the surgical ostium is faster, allowing an early The local recovery of the surgical ostium is faster, allowing an early removing of the intubation.removing of the intubation.

Finally, the diameter of the ostium at the end of the follow-up period Finally, the diameter of the ostium at the end of the follow-up period is maintained very stable, without significant reduction compared to that is maintained very stable, without significant reduction compared to that achieved with the surgery.achieved with the surgery.

1. Maeso Riera J, Sellares Fabres MT. Dacriocistorrinostomía transcanalicular con láser diodo: variaciones técnicas y resultados. Acta Otorrinolaringol Esp. 2007;58:10-5.2. Alañón Fernández FJ, Alañón Fernández MA, Martínez Fernández A, Cárdenas Lara M. Dacriocistorrinostomía transcanalicular con láser diodo. Arch Soc Esp Oftalmol. 2004;79:325-30.

CONCLUSIONSCONCLUSIONS

• The use of local depot corticoids at ht e end The use of local depot corticoids at ht e end of surgical procedure seem to improve the of surgical procedure seem to improve the prognosis of the lachrymal transcanalicular prognosis of the lachrymal transcanalicular surgery with diode laser.surgery with diode laser.

• Results observed after a first 6 months follow Results observed after a first 6 months follow up, have maintained in cases followed for up, have maintained in cases followed for longer periods.longer periods.