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Endoscopic Laser-Assisted Lacrimal Surgery
Endoscopic Laser-Assisted Lacrimal Surgery Russell S. Gonnering, M.D., David B. Lyon, M . D . , and John C, Fisher, Sc.D.
S i n c e S e p t . 1, 1 9 8 9 , w e h a v e s u c c e s s f u l l y performed 20 video-endoscopic, transnasal, l a s e r - a s s i s t e d l a c r i m a l p r o c e d u r e s o n 18 p a t i e n t s r a n g i n g in a g e f r o m 3 to 8 8 y e a r s . T h i s technique avoided a cutaneous scar and caused less surgical t r a u m a and bleeding t h a n t h a t s e e n in c o n v e n t i o n a l l a c r i m a l s u r g e r y , which shortened postoperative recovery time and l e s s e n e d p o s t o p e r a t i v e p a i n . W i t h m i n o r m o d i f i c a t i o n s in s u r g i c a l t e c h n i q u e , b o t h d a c ryocystorhinostomy and conjunctivodacryocystorhinostomy were performed with either the p o t a s s i u m t i t a n y l p h o s p h a t e or c a r b o n d i o x i d e l a s e r s . T h e u s e of t h e v i d e o e n d o s c o p e allowed laser surgery to be p e r f o r m e d across a b r o a d r a n g e of i n t r a n a s a l s t r u c t u r a l v a r i a t i o n s and p r o v i d e d a n e x c e l l e n t m e d i u m for t e a c h ing this new t e c h n i q u e .
S I N C E T H E D E S C R I P T I O N of e x t e r n a l d a c r y o c y s t o r h i n o s t o m y b y T o t i ' in 1 9 0 4 , s u b s e q u e n t m o d i fications by D u p u y - D u t e m p a n d Bourguet^'^ in 1920 and 1 9 2 1 , and conjunctivodacryocystor h i n o s t o m y w i t h t u b e p l a c e m e n t b y J o n e s " in 1962, these two surgical procedures have p r o v i d e d t h e m a i n s t a y o f t h e r a p y for p a t i e n t s with o b s t r u c t i o n o f t h e l a c r i m a l e x c r e t o r y s y s tem. Both procedures involve an external app r o a c h to t h e l a c r i m a l s y s t e m w i t h a t t e n d a n t s u r g i c a l t r a u m a to s u r r o u n d i n g s t r u c t u r e s to gain t h e n e c e s s a r y e x p o s u r e to p e r f o r m t h e bypass of the lacrimal system. M a s s a r o , G o n n e r i n g , a n d Harris^ d e s c r i b e d endonasal laser dacryocystorhinostomy using a high-energy argon laser and the operating mic r o s c o p e . We modified this t e c h n i q u e , e m ployed video endoscopy, and used either the c a r b o n d i o x i d e or p o t a s s i u m titanyl p h o s p h a t e
Accepted for publication Oct. 10, 1990. From the Department of Ophthalmology, University of Wisconsin, Madison, Wisconsin (Drs. Gonnering and Lyon); and St. Luke's Medical Center, Milwaukee, Wisconsin (Drs. Gonnering, Lyon, and Fisher). Reprint requests to Russell S. Gonnering, M.D., Ste. 950, 2600 N. Mayfair Rd., Milwaukee, WI 53226.
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l a s e r to p e r f o r m b o t h d a c r y o c y s t o r h i n o s t o m y and conjunctivodacryocystorhinostomy.
Patients and Methods S i n c e S e p t . 1, 1 9 8 9 , we h a v e p e r f o r m e d 2 0 endoscopic laser-assisted lacrimal procedures on 1 8 p a t i e n t s . D a t a c o n c e r n i n g t h e s e p a t i e n t s a r e f o u n d in the T a b l e . T h e a g e r a n g e o f t h e s e p a t i e n t s at t h e t i m e o f s u r g e r y w a s 3 to 8 8 y e a r s . T h e s u r g e r y w a s p e r f o r m e d in an o u t p a t i e n t setting with local anesthesia and intravenous s e d a t i o n , u n l e s s the p a t i e n t ' s a g e o r s t r o n g personal preferences necessitated general anest h e s i a . P a t i e n t s w e r e e x c l u d e d if t h e r e w a s s u s p i c i o n o f a l a c r i m a l s a c n e o p l a s m or if t h e r e was evidence of severe posttraumatic bony deformity of the lacrimal sac fossa. T h e p a t i e n t s w e r e g i v e n t w o sprays o f 0 . 0 5 % o x y m e t a z o l i n e h y d r o c h l o r i d e n a s a l spray in t h e affected n o s t r i l to b e g i n s h r i n k a g e o f t h e n a s a l m u c o s a . After a d e q u a t e i n t r a v e n o u s s e d a t i o n or i n t r o d u c t i o n of g e n e r a l a n e s t h e s i a , 4 % t o p i c a l c o c a i n e w a s a p p l i e d on p l e d g e t s to t h e a n t e r o nasal passages. Anesthesia of the medial c o m missure and lacrimal sac fossa was obtained by local anesthetic injection techniques. After at l e a s t s e v e n m i n u t e s , t h e c o c a i n e packing was removed and a 0-degree operating rod telescope with attached v i d e o c a m e r a was i n t r o d u c e d i n t o t h e n o s e . E x a m i n a t i o n of t h e a r e a a n t e r i o r to m i d d l e n a s a l t u r b i n a t e w a s t h e n performed. For d a c r y o c y s t o r h i n o s t o m y , a m o d i f i e d 2 0 g a u g e fiberoptic l i g h t p i p e w a s l u b r i c a t e d w i t h antibiotic ointment, inserted through the dilate d i n f e r i o r or s u p e r i o r c a n a l i c u l u s , a n d a d vanced into the lacrimal sac into contact with t h e m e d i a l wall o f t h e l a c r i m a l s a c f o s s a . T h e l i g h t p i p e w a s h e l d in p o s i t i o n w i t h s t e r i l e t a p e . For conjunctivodacryocystorhinostomy, a p a r t i a l c a r u n c u l e c t o m y w a s p e r f o r m e d if n e e d ed. N e x t , t h e 1 6 - g a u g e x ¿ V i - i n c h l o n g r a d i opaque catheter over a 2 0 - g a u g e introducer n e e d l e was d i r e c t e d from t h e c a r u n c l e , i n t o t h e l a c r i m a l s a c f o s s a , a n d up to t h e l a c r i m a l b o n e
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TABLE
DATA ON PATIENTS UNDERGOING LASER-ASSISTED LACRIMAL SURGERY* FOLLOW-UP (MOS) CASE NO., AGE (vns), SEX
PROCEDURE
LASER
1,66, F 2, 88, F 3, 50, F 4, 49, Μ 5. 59, Μ 6, 29, F 7. 80, F 8, 33, Μ 9, 75, F 10, 82, F 11.32, F 12, 59, F 13, 76, F 14, 68, F 15, 3, Μ 16, 46, F 17. 22, Μ 18. 77, F
Dacryocystortiinostomy Dacryocystortiinostomy Conjunctlvodacryocystortiinostomy Dacryocystortiinostomy Conjunctivodacryocystortiinostomy Conjunctivodacryocystortilnostomy (2) Conjunctivodacryocystorhinostomy Dacryocystortiinostomy Dacryocystortiinostomy Bilateral dacryocystortiinostomy Dacryocystortiinostomy Dacryocystortiinostomy Dacryocystorhinostomy Dacryocystorhinostomy Dacryocystorhinostomy Dacryocystorhinostomy Dacryocystorhinostomy Dacryocystorhinostomy
Carbon dioxide Carbon dioxide Carbon dioxide Carbon dioxide Carbon dioxide Potassium titanyl phosphate Potassium titanyl phosphate Potassium titanyl phosphate Potassium titanyl phosphate Potassium titanyl phosphate Potassium titanyl phosphate Potassium titanyl phosphate Potassium titanyl phosphate Potassium titanyl phosphate Potassium titanyl phosphate Potassium titanyl phosphate Potassium titanyl phosphate Potassium titanyl phosphate
FROM SURGERY FROM TUBE REMOVAL
13 13 12 12 11 6 6 6 6 4 4 4 4 3 3 2.5 2.5 2
7 7 NA 6 NA NA NA 2 1.5 0 0 Tube in place Tube in place Tutie in place Tube in place Tube In place Tutie in place Tube in place
*NA Indicates not applicable.
(Fig. 1 ) . T h e n e e d l e w a s r e m o v e d , a n d t h e c a t h e t e r h u b w a s cut off w i t h s c i s s o r s to a l l o w passage of the light pipe through the catheter tip up to t h e l a c r i m a l b o n e . With the e n d o s c o p e , a discrete spot of transill u m i n a t e d l i g h t from t h e l i g h t p i p e c o u l d b e seen, which marked the site of intended r h i n o s tomy (Fig. 2 ) . To v i s u a l i z e t h i s s p o t , t h e l i g h t from the e n d o s c o p e w a s r e d u c e d to its l o w e s t s e t t i n g . I f a diffuse s p o t i n d i c a t e d l a c k o f c o n tact b e t w e e n t h e l i g h t p i p e a n d t h e l a c r i m a l bone, repositioning o f the light pipe was n e c e s sary. Local anesthetic with 1 : 1 0 0 , 0 0 0 epineph rine w a s t h e n i n j e c t e d u n d e r e n d o s c o p i c c o n trol i n t o t h e n a s a l m u c o s a o v e r l y i n g t h e s p o t . I f viewing of this area was awkward with the 0-degree telescope, a better view was possible by s u b s t i t u t i n g the 3 0 - d e g r e e t e l e s c o p e . B e c a u s e o f t h e p o t e n t i a l for o c u l a r d a m a g e , especially with visible light lasers, appropriate l a s e r s a f e t y p r e c a u t i o n s for t h e p a t i e n t a n d t h e operating team were taken. T h e patient's eyes were covered with a d o u b l e d strip o f a l u m i n u m foil, r e f l e c t i v e s i d e out, t a p e d in p l a c e , a n d further c o v e r e d w i t h a m o i s t e n e d s p o n g e . A l l m e m b e r s of the operating team wore appropri ately filtered p r o t e c t i v e g l a s s e s . I f o x y g e n w a s a d m i n i s t e r e d to an a w a k e p a t i e n t , it w a s
s t o p p e d d u r i n g l a s e r a d m i n i s t r a t i o n to p r e v e n t t h e d a n g e r o f flash fire in t h e o p e r a t i v e field. I f general anesthesia was used, the endotracheal t u b e w a s p r o t e c t e d w i t h a l u m i n u m foil. Laser rhinostomy was then performed with video-endoscopic visualization. With the po tassium titanyl p h o s p h a t e laser, the energy was d e l i v e r e d t h r o u g h a 3 0 0 - to 6 0 0 - μ m fiber that was passed through an angulated endoscopic laser suction tip. An electronically activated filter w a s fitted b e t w e e n t h e e n d o s c o p e a n d t h e v i d e o c a m e r a t o p r e v e n t d a m a g e to t h e c a m e r a and allow visualization during the intense green light of laser delivery. Half-second puls es o f 5 to 7 W o f l a s e r e n e r g y s e p a r a t e d b y h a l f - s e c o n d p a u s e s w e r e d e l i v e r e d in a n o n c o n tact mode to the m u c o s a surrounding the pro p o s e d r h i n o s t o m y . N e x t , in a n e a r - c o n t a c t m o d e , v a p o r i z a t i o n o f t i s s u e w a s p e r f o r m e d to p r o d u c e a 5 - to 6 - m m r h i n o s t o m y o v e r t h e a r e a o f t h e l i g h t p i p e for d a c r y o c y s t o r h i n o s t o m y a n d a 3 - t o 4 - m m r h i n o s t o m y for c o n j u n c t i v o d a c r y ocystorhinostomy. The carbon dioxide laser energy was deliv ered through an articulated arm of a 5 5 - W s u r g i c a l l a s e r a t t a c h e d to a s m a l l - w a v e g u i d e . Distal mirrors of varying angulation on the wave guide directed b o t h the h e l i u m - n e o n aim-
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Fig. 2 (Gonnering, Lyon, and Fisher). Video-endoscopic view of left nasal passage during laser-as sisted lacrimal surgery. (S, nasal septum; L, lateral nasal wall; MT, middle turbinate; arrowhead, dis crete transillumination from light pipe.)
Fig. 1 (Gonnering, Lyon, and Fisher). Placement of introducer needle and catheter from caruncle across lacrimal sac fossa to abut the lacrimal bone. ing b e a m a n d t h e c a r b o n d i o x i d e s u r g i c a l b e a m to t h e d e s i r e d a r e a . T h e s u p e r p u l s e m o d e w a s u s e d with 7 5 0 l a s e r p u l s e s p e r s e c o n d d e l i v e r ing 8 to 14 W of e n e r g y to c r e a t e r h i n o s t o m i e s s i m i l a r to t h o s e p r o d u c e d w i t h t h e p o t a s s i u m titanyl phosphate laser. With both lasers, the r h i n o s t o m y w a s p r o d u c e d in a p p r o x i m a t e l y t h r e e to five m i n u t e s of i n t e r m i t t e n t l a s e r t i m e with manipulation of the laser delivery b e a m a n d l i g h t p i p e to c r e a t e an o p e n i n g o f t h e desired size. W i t h d a c r y o c y s t o r h i n o s t o m y , after p r o d u c tion of the rhinostomy, silicone intubation was p e r f o r m e d a n d left in p l a c e for four to six months. With conjunctivodacryocystorhinos t o m y , after p r o d u c t i o n o f t h e r h i n o s t o m y , t h e light pipe was removed, the catheter was ad v a n c e d i n t o t h e n o s e , a n d t h e 0 . 0 3 5 - i n c h flex ible guide wire was inserted through the cathe ter, a c r o s s t h e r h i n o s t o m y , a n d out t h e n o s t r i l (Fig. 3 ) . T h e c a t h e t e r w a s t h e n v i e w e d e n d o s c o p i c a l l y , a n d an a p p r o x i m a t i o n of t h e p r o p e r Jones tube length was gauged by grasping the
c a t h e t e r w i t h f o r c e p s at t h e m e d i a l c o m m i s s u r e . The catheter was then withdrawn, leaving the g u i d e w i r e in p l a c e . By m e a s u r i n g from t h e tip of t h e c a t h e t e r to t h e f o r c e p s , an a p p r o x i m a t i o n of t h e l e n g t h of J o n e s t u b e r e q u i r e d c a n b e made. T h e v e s s e l d i l a t o r w a s t h e n cut a p p r o x i m a t e l y 4 c m from its distal e n d . T h i s c u t s e g m e n t o f d i l a t o r w a s t h r e a d e d o v e r t h e g u i d e w i r e to a c t as an i n t r o d u c e r for t h e J o n e s t u b e . T h e J o n e s tube was threaded on the guide wire b e h i n d the dilator s e g m e n t (Fig. 4 ) . With the vessel dilator a h e a d o f it, t h e J o n e s t u b e w a s t h e n e a s i l y advanced along the guide wire and into the n o s e . After p r o p e r J o n e s t u b e l e n g t h w a s c o n firmed, t h e v e s s e l d i l a t o r a n d g u i d e w i r e w e r e b o t h r e m o v e d from t h e n o s t r i l , a n d a s u t u r e w a s u s e d to fix t h e J o n e s t u b e at t h e m e d i a l c o m m i s s u r e for t h e i n i t i a l p o s t o p e r a t i v e h e a l i n g p h a s e . Bleeding was usually minimal, and no pack ing w a s r e q u i r e d u n l e s s t h e r e w a s an e x t e n s i v e t u r b i n e c t o m y . P o s t o p e r a t i v e m e d i c a t i o n s in c l u d e d t o p i c a l a n t i b i o t i c s a n d i n t r a n a s a l flunis o l i d e 0 . 0 2 5 % spray.
Results O f t h e 2 0 p r o c e d u r e s , five w e r e c o n j u n c t i vodacryocystorhinostomies. Five procedures were performed with the carbon dioxide laser, a n d 15 w e r e p e r f o r m e d w i t h t h e p o t a s s i u m t i t a n y l p h o s p h a t e l a s e r . T h e p a t i e n t in C a s e 1 0
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Fig. 3 (Gonnering, Lyon, and Fisher). Video-endoscopic view of passage of guide wire through catheter and into nose.
undervi^ent b i l a t e r a l dacryocystorhinostomy. T h e J o n e s t u b e in o n e p a t i e n t ( C a s e 6 ) d i s lodged one week postoperatively because she was rubbing her eye. T h r e e weeks later, repeat conjunctivodacryocystorhinostomy was n e c e s sary in t h i s p a t i e n t s i n c e t h e r h i n o s t o m y h a d c l o s e d . S i l i c o n e t u b i n g w a s r e m o v e d from p a tients who had had dacryocystorhinostomy four to six m o n t h s p o s t o p e r a t i v e l y . All p a t i e n t s had relief of symptoms with normal results of dye-disappearance tests.
Discussion Caldwell" described the intranasal approach to d a c r y o c y s t o r h i n o s t o m y in 1 8 9 3 , in w h i c h a portion of the inferior turbinate was removed a n d the n a s o l a c r i m a l c a n a l w a s f o l l o w e d to t h e l a c r i m a l s a c . W e s t ' s u b s e q u e n t l y refined t h i s technique by substituting a window resection over t h e l a c r i m a l s a c for w i d e r e s e c t i o n . A l though this m e t h o d was used extensively earli er in t h i s c e n t u r y , it h a s b e e n all b u t a b a n d o n e d b y o p h t h a l m o l o g i s t s , d e s p i t e an i n c r e a s e in i n t e r e s t in t h e o t o l a r y n g o l o g i c l i t e r a t u r e . ^ " W i t h i n t h e past five y e a r s , a m a r k e d shift t o endoscopic nasal and sinus surgery has o c c u r r e d in o t o l a r y n g o l o g y . ' ^ ' ^ T h e i n c r e a s e d v i s ualization allowed with this instrumentation h a s r e s u l t e d in p r e c i s e , m i c r o i n v a s i v e s u r g i c a l
Fig. 4 (Gonnering, Lyon, and Fisher). Use of vessel dilator for placement of Jones tube along guide wire.
t e c h n i q u e , a p p l i c a b l e to m o s t p a t i e n t s , w i t h high success and less morbidity than that seen w i t h e i t h e r o p e n p r o c e d u r e s or t r a n s n a s a l p r o cedures done without the endoscope. T h e e n d o s c o p e h a s b e e n u s e d b e f o r e in l a c r i m a l s u r g e r y to d o c u m e n t t h e p a t e n c y o f t h e r h i n o s t o m y , ' ^ as w e l l as to m a n a g e f a i l e d d a c r y o c y s t o r h i n o s t o m y surgery'^ a n d c o m p l i c a tions of conjunctivodacryocystorhinostomy.'" Four p a t i e n t s h a v e b e e n d e s c r i b e d b y R i c e " in whom conventional intranasal dacryocystorhi nostomy was performed with the endoscope. Although endonasal lacrimal surgery can be performed with the operating microscope, the e n d o s c o p e allows such procedures to be per f o r m e d w i t h o u t t h e n e e d for an o p e n l i n e o f s i g h t to t h e a r e a o f r h i n o s t o m y . S m a l l m o v e ments of the patient do not require complex repositioning of the p a t i e n t / m i c r o s c o p e axis. The addition of the v i d e o c a m e r a provides a m a g n i f i e d , o n - s c r e e n v i e w o f t h e p r o c e d u r e to t h e s u r g e o n a n d o p e r a t i n g t e a m , w h i c h is m o s t useful w h e n t h e s u r g i c a l t r a i n i n g o f r e s i d e n t s
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a n d fellows is a s e c o n d a r y g o a l o f t h e p r o c e dure. Although endonasal dacryocystorhinostomy was originally described with the argon laser, both dacryocystorhinostomy and conjunctivodacryocystorhinostomy can be performed with either the potassium titanyl phosphate or the carbon dioxide laser. Both of these lasers cur r e n t l y are a p p r o v e d for i n t r a n a s a l s u r g e r y . T h e p o t a s s i u m titanyl p h o s p h a t e l a s e r c o n s i s t s o f an N d : Y A G l a s e r s o u r c e , w h i c h is p a s s e d t h r o u g h a f r e q u e n c y - d o u b l i n g crystal of p o t a s s i u m t i t a n y l phosphate, producing a single output wave length of 5 3 2 . 0 n m . ' ' " When used with a quartz d e l i v e r y fiber, h e m o s t a s i s is p r o d u c e d in t h e n o n c o n t a c t mode, and tissue vaporization can b e a c c o m p l i s h e d with n e a r - c o n t a c t d e l i v e r y . W h e n u s e d in t h e c o n t a c t m o d e , p r e c i s e t i s s u e c u t t i n g is p o s s i b l e . A l t h o u g h t h e o u t p u t o f t h e a r g o n l a s e r is s i m i l a r at 4 8 8 . 0 a n d 5 1 4 . 5 n m , d i r e c t c o n t a c t o f t h e fiber w i t h t i s s u e c a n r e s u l t in fiber d a m a g e a n d t h e n e e d to c l e a v e t h e fiber to deliver precontact energy levels. The carbon dioxide laser has had a history o f s u c c e s s f u l u s e in t h e u p p e r airway.'^'^" T h i s i n frared l a s e r , at 1 0 , 6 0 0 n m , affords e x c e l l e n t vaporization of tissue with little thermal s p r e a d , e s p e c i a l l y w h e n u s e d in t h e s u p e r p u l s e mode. This wavelength, however, possesses only moderate hemostatic abilities and cannot as yet b e t r a n s m i t t e d effectively t h r o u g h a fiber. It must b e i n t e r n a l l y r e f l e c t e d or f o c u s e d from an a r t i c u l a t e d d e l i v e r y a r m d o w n a w a v e g u i d e , w h i c h m u s t b e flushed w i t h an i n e r t g a s s u c h as c a r b o n d i o x i d e to k e e p t h e distal r e f l e c t i v e m i r ror free from c h a r from t h e l a s e r p l u m e . W e found this more complicated delivery system, t h o u g h effective, to b e s o m e w h a t m o r e a w k w a r d t o u s e t h a n t h e q u a r t z d e l i v e r y fiber o f t h e p o t a s s i u m titanyl p h o s p h a t e l a s e r . O u r g u i d e wire a n d v e s s e l d i l a t o r c o m b i n a t i o n h a s b e e n d e s c r i b e d in t h e p e r c u t a n e o u s r e m o v a l of d a c r y o l i t h s in t h e s y n d r o m e o f n o n i n f e c t i o u s d a c r y o c y s t i c retention.^' T h e u s e o f t h i s c o m b i n a t i o n in p l a c e m e n t o f J o n e s t u b e s s i g n i f i c a n t l y r e d u c e s t h e i n t r a o p e r a t i v e frustra tion often a c c o m p a n y i n g a t t e m p t s to p a s s t h e Jones tube with conventional techniques.^ O t h e r a u t h o r s h a v e e m p h a s i z e d that t h e s u r g i c a l t r a u m a a n d a s y m m e t r i c r e d u c t i o n in t h e s i z e of t h e r h i n o s t o m y in t h e h e a l i n g p h a s e o f c o n j u n c t i v o d a c r y o c y s t o r h i n o s t o m y , as w e l l as h y p e r m o b i l i t y o f a t u b e in a l a r g e s u r g i c a l r h i n o s t o m y , m a y c o n t r i b u t e to p o s t o p e r a t i v e t u b e malposition.^^ In o u r t e c h n i q u e , t h e t u b e is a l r e a d y r e l a t i v e l y s n u g in t h e r h i n o s t o m y at t h e
February, 1991
conclusion of surgery, and minimal postopera tive d i s p l a c e m e n t , d e s p i t e t h e e a r l y e x t r u s i o n s e e n in o n e o f o u r p a t i e n t s , s h o u l d b e e x p e c t e d . A v a l i d c o m p a r i s o n in r a t e s o f p o s t o p e r a t i v e extrusion will require several years of observa tion. Physicians must now evaluate not only the safety, but the cost and effectiveness o f n ew technology and w h e t h e r that new t e c h n o l o g y r e s u l t s in t a n g i b l e b e n e f i t s to t h e p a t i e n t a n d society.^'·^* W e b e l i e v e t h a t e n d o s c o p i c l a s e r a s s i s t e d l a c r i m a l s u r g e r y is a n e w t e c h n o l o g y with significant individual and societal benefits for t h e f o l l o w i n g r e a s o n s : a c u t a n e o u s s c a r is a v o i d e d ; s u r g i c a l t r a u m a is l i m i t e d w i t h l e s s b l e e d i n g a n d p o s t o p e r a t i v e p a i n ; v i r t u a l l y all p a t i e n t s a r e t r e a t e d as o u t p a t i e n t s w i t h m o s t procedures performed under local anesthesia; p o s t o p e r a t i v e r e c o v e r y is s h o r t e n e d w i t h m o s t p a t i e n t s a b l e to r e s u m e n o r m a l a c t i v i t i e s t h e n e x t day. T h e e q u i p m e n t u s e d , t h o u g h e x p e n s i v e , is shared by many surgical s e r v i c e s in a hospital. A d a p t a t i o n for l a c r i m a l s u r g e r y a l l o w s i n creased utilization of this equipment and thus i n c r e a s e s its c o s t - e f f e c t i v e n e s s . At o u r h o s p i t a l , t h e u s e o f t h e l a s e r a d d s a p p r o x i m a t e l y $ 3 0 0 to t h e o p e r a t i v e c o s t s o f l a c r i m a l s u r g e r y . We b e l i e v e t h i s c o s t is m o r e t h a n b a l a n c e d b y t h e a b i l i t y to p e r f o r m all our l a c r i m a l s u r g e r y o n an outpatient basis and the much more rapid re turn o f t h e p a t i e n t to w o r k , s c h o o l , or o t h e r normal activities. C o n t r a i n d i c a t i o n s to t h i s t e c h n i q u e i n c l u d e suspicion of lacrimal sac malignancy and severe bony deformity of the lacrimal sac fossa, w h i c h prevent accurate transillumination through the lacrimal bone. Because the anterior lacrimal c r e s t is n o t r e m o v e d w i t h t h i s t e c h n i q u e , r h i n o s t o m y s i t e s t e n d to b e m o r e i n f e r i o r a n d p o s t e r i o r t h a n t h o s e p e r f o r m e d in c o n v e n t i o n a l external approaches. Consequently, many pa t i e n t s r e q u i r e at l e a s t a p a r t i a l t u r b i n e c t o m y , especially when conjunctivodacryocystorhinos t o m y is p e r f o r m e d . ^ ' A l t h o u g h t u r b i n a t e m u c o sa c a n s a f e l y b e e x c i s e d w i t h t h e l a s e r , c a r e must b e used w h e n resecting c o n c h a l b o n e with t h e l a s e r to avoid o v e r h e a t i n g a n d p o s s i b l e n e c r o s i s a n d sequestration.^" L o n g e r J o n e s t u b e s are often n e c e s s a r y , w i t h m o s t p a t i e n t s r e q u i r i n g a t u b e a p p r o x i m a t e l y 2 0 to 2 2 m m in l e n g t h . A d e q u a t e s u p p l i e s of l o n g t u b e s m u s t b e a v a i l a b l e for t h i s p r o c e d u r e . A l t h o u g h t h e l e a r n i n g c u r v e for v i d e o e n d o s c o p y is s o m e w h a t s t e e p , t h e o u t c o m e s t o d a t e have been uniformly positive. T h e increased
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experience of multiple surgeons, however, will be necessary to evaluate the clinical usefulness of t h e s e p r o c e d u r e s a d e q u a t e l y .
References 1. Toti, Α.: Nuovo método conservatóre di cura radicale delle suppurazioni croniche del sacco lacrí male (dacriocistorhinostomia). Clin. Moderna (Firenza) 10:385, 1 9 0 4 . 2. Dupuy-Dutemp, L., and Bourguet, M.: Note preliminaire sur en procede de dacryocystorhinostomie. Ann. Ocul. 157:445, 1 9 2 0 . 3. : Procede plastíque de dacryocystorhinostomie et ses resultats. Ann. Ocul. 1 5 8 : 2 4 1 , 1921. 4. Jones, L. T.: The eure of epiphora due to canalic ular disorders, trauma and surgical failures on the lacrimal passages. Trans. Am. Acad. Ophthalmol. Otolaryngol. 66:506, 1962. 5. Massaro, B. M., Gonnering, R. S., and Harris, G. J.: Endonasal laser dacryocystorhinostomy. A new approach to nasolacrimal duct obstruction. Arch. Ophthalmol. 108:1172, 1 9 9 0 . 6. Caldwell, G. W.: Two new operations for ob struction of the nasal duct with preservation of the canaliculi and an incidental description of a new lachrymal probe. N. Y. Med. J. 5 7 : 5 8 1 , 1 8 9 3 . 7. West, J. M.: A window resection of the nasal duct in cases of stenosis. Trans. Am. Ophthalmol. Soc. 12:654, 1 9 1 4 . 8. Jokinen, K., and Karjä, J.: Endonasal dacryocys torhinostomy. Arch. Otolaryngol. Head Neck Surg. 100:41, 1 9 7 4 . 9. Steadman, G. M.: Transnasal dacryocystorhi nostomy. Otolaryngol. Clin. North Am. 18:107, 1985. 10. Rice, D. H.: Endoscopic intranasal dacryocys torhinostomy. A cadaver study. Am. J. Rhinol. 2:127, 1988. 11. : Endoscopic intranasal dacryocystorhi nostomy results in four patients. Arch. Otolaryngol. Head Neck Surg. 116:1061, 1 9 9 0 . 12. Stammberger, H.: Endoscopic endonasal sur gery. Concepts in treatment of recurring rhinosinusitis. Part L Anatomic and pathophysiologic consider ations. Otolaryngol. Head Neck Surg. 9 4 : 1 4 3 , 1 9 8 6 .
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13. Stammberger, H.: Endoscopic endonasal sur gery. Concepts in treatment of recurring rhinosinusitis. Part Π. Surgical technique. Otolaryngol. Head Neck Surg. 94:147, 1 9 8 6 . 14. Linberg, J . V., Anderson, R. L., Bumsted, R. M., and Barreres, R.: Study of intranasal ostium in external dacryocystorhinostomy. Arch. Ophthalmol. 100:1758, 1982. 15. Orcutt, J. C , Hillel, Α., and Weymuller, E. Α.: Endoscopic repair of failed dacryocystorhinostomy. Ophthalmol. Plast. Reconstr. Surg. 6:197, 1 9 9 0 . 16. Bartley, G. B., and Gustafson, R. O.: Compli cations of malpositioned Jones tubes. Am. J. Oph thalmol. 109:66, 1 9 9 0 . 17. Levine, H. L.: Endoscopy and the K T P / 5 3 2 laser for nasal sinus disease. Ann. Otol. Rhinol. Laryngol. 9 8 : 4 6 , 1 9 8 9 . 18. : Lasers and endoscopic rhinologic sur gery. Otolaryngol. Clin. North Am. 22:739, 1 9 8 9 . 19. Selkin, S. G.: Pitfalls in intranasal laser sur gery and how to avoid them. Arch. Otolaryngol. Head Neck Surg. 1 1 2 : 2 8 5 , 1 9 8 6 . 20. : Laser turbinectomy as an adjunct to rhinoseptoplasty. Arch Otolaryngol. Head Neck Surg. 111:446, 1 9 8 5 . 21. Gonnering, R. S., and Bosniak, S. L.: Recogni tion and management of acute noninfectious dacryocystic retention. Ophthalmol. Plast. Reconstr. Surg. 5:27, 1989. 22. Migliori, M. E., and Putterman, A. M.: Recur rent Jones tube extrusions successfully treated with a modified glass tube. Ophthalmol. Plast. Reconstr. Surg. 5:189, 1 9 8 9 . 2 3 . Steinsapir, K. D., Glatt, Η. J . , and Putterman, A. M.: A 16-year study of conjunctival dacryocysto rhinostomy. Am. J. Ophthalmol. 109:387, 1 9 9 0 . 24. Henderson, P. N.: A modified trephining tech nique for the insertion of Jones tube. Arch. Ophthal mol. 103:1582, 1 9 8 5 . 25. Banta, H. D., and Thacker, S. B.: The case for reassessment of health care technology. JAMA 264:235, 1990. 26. Foege, W. H.: Budgetary medical ethics. J. Pub lic Health Policy 4:249, 1983. 27. Kulwin, D. R., Tiradellis, H., Levartovsky, S., Kersten, R. C , and Shumrick, K. Α.: The value of intranasal surgery in assuring the success of a conjunctivodacryocystorhinostomy. Ophthalmol. Plast. Reconstr. Surg. 6:54, 1 9 9 0 .
S i n c e S e p t . 1, 1 9 8 9 , w e h a v e s u c c e s s f u l l y performed 20 video-endoscopic, transnasal, l a s e r - a s s i s t e d l a c r i m a l p r o c e d u r e s o n 18 p a t i e n t s r a n g i n g in a g e f r o m 3 to 8 8 y e a r s . T h i s technique avoided a cutaneous scar and caused less surgical t r a u m a and bleeding t h a n t h a t s e e n in c o n v e n t i o n a l l a c r i m a l s u r g e r y , which shortened postoperative recovery time and l e s s e n e d p o s t o p e r a t i v e p a i n . W i t h m i n o r m o d i f i c a t i o n s in s u r g i c a l t e c h n i q u e , b o t h d a c ryocystorhinostomy and conjunctivodacryocystorhinostomy were performed with either the p o t a s s i u m t i t a n y l p h o s p h a t e or c a r b o n d i o x i d e l a s e r s . T h e u s e of t h e v i d e o e n d o s c o p e allowed laser surgery to be p e r f o r m e d across a b r o a d r a n g e of i n t r a n a s a l s t r u c t u r a l v a r i a t i o n s and p r o v i d e d a n e x c e l l e n t m e d i u m for t e a c h ing this new t e c h n i q u e .
S I N C E T H E D E S C R I P T I O N of e x t e r n a l d a c r y o c y s t o r h i n o s t o m y b y T o t i ' in 1 9 0 4 , s u b s e q u e n t m o d i fications by D u p u y - D u t e m p a n d Bourguet^'^ in 1920 and 1 9 2 1 , and conjunctivodacryocystor h i n o s t o m y w i t h t u b e p l a c e m e n t b y J o n e s " in 1962, these two surgical procedures have p r o v i d e d t h e m a i n s t a y o f t h e r a p y for p a t i e n t s with o b s t r u c t i o n o f t h e l a c r i m a l e x c r e t o r y s y s tem. Both procedures involve an external app r o a c h to t h e l a c r i m a l s y s t e m w i t h a t t e n d a n t s u r g i c a l t r a u m a to s u r r o u n d i n g s t r u c t u r e s to gain t h e n e c e s s a r y e x p o s u r e to p e r f o r m t h e bypass of the lacrimal system. M a s s a r o , G o n n e r i n g , a n d Harris^ d e s c r i b e d endonasal laser dacryocystorhinostomy using a high-energy argon laser and the operating mic r o s c o p e . We modified this t e c h n i q u e , e m ployed video endoscopy, and used either the c a r b o n d i o x i d e or p o t a s s i u m titanyl p h o s p h a t e
Accepted for publication Oct. 10, 1990. From the Department of Ophthalmology, University of Wisconsin, Madison, Wisconsin (Drs. Gonnering and Lyon); and St. Luke's Medical Center, Milwaukee, Wisconsin (Drs. Gonnering, Lyon, and Fisher). Reprint requests to Russell S. Gonnering, M.D., Ste. 950, 2600 N. Mayfair Rd., Milwaukee, WI 53226.
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l a s e r to p e r f o r m b o t h d a c r y o c y s t o r h i n o s t o m y and conjunctivodacryocystorhinostomy.
Patients and Methods S i n c e S e p t . 1, 1 9 8 9 , we h a v e p e r f o r m e d 2 0 endoscopic laser-assisted lacrimal procedures on 1 8 p a t i e n t s . D a t a c o n c e r n i n g t h e s e p a t i e n t s a r e f o u n d in the T a b l e . T h e a g e r a n g e o f t h e s e p a t i e n t s at t h e t i m e o f s u r g e r y w a s 3 to 8 8 y e a r s . T h e s u r g e r y w a s p e r f o r m e d in an o u t p a t i e n t setting with local anesthesia and intravenous s e d a t i o n , u n l e s s the p a t i e n t ' s a g e o r s t r o n g personal preferences necessitated general anest h e s i a . P a t i e n t s w e r e e x c l u d e d if t h e r e w a s s u s p i c i o n o f a l a c r i m a l s a c n e o p l a s m or if t h e r e was evidence of severe posttraumatic bony deformity of the lacrimal sac fossa. T h e p a t i e n t s w e r e g i v e n t w o sprays o f 0 . 0 5 % o x y m e t a z o l i n e h y d r o c h l o r i d e n a s a l spray in t h e affected n o s t r i l to b e g i n s h r i n k a g e o f t h e n a s a l m u c o s a . After a d e q u a t e i n t r a v e n o u s s e d a t i o n or i n t r o d u c t i o n of g e n e r a l a n e s t h e s i a , 4 % t o p i c a l c o c a i n e w a s a p p l i e d on p l e d g e t s to t h e a n t e r o nasal passages. Anesthesia of the medial c o m missure and lacrimal sac fossa was obtained by local anesthetic injection techniques. After at l e a s t s e v e n m i n u t e s , t h e c o c a i n e packing was removed and a 0-degree operating rod telescope with attached v i d e o c a m e r a was i n t r o d u c e d i n t o t h e n o s e . E x a m i n a t i o n of t h e a r e a a n t e r i o r to m i d d l e n a s a l t u r b i n a t e w a s t h e n performed. For d a c r y o c y s t o r h i n o s t o m y , a m o d i f i e d 2 0 g a u g e fiberoptic l i g h t p i p e w a s l u b r i c a t e d w i t h antibiotic ointment, inserted through the dilate d i n f e r i o r or s u p e r i o r c a n a l i c u l u s , a n d a d vanced into the lacrimal sac into contact with t h e m e d i a l wall o f t h e l a c r i m a l s a c f o s s a . T h e l i g h t p i p e w a s h e l d in p o s i t i o n w i t h s t e r i l e t a p e . For conjunctivodacryocystorhinostomy, a p a r t i a l c a r u n c u l e c t o m y w a s p e r f o r m e d if n e e d ed. N e x t , t h e 1 6 - g a u g e x ¿ V i - i n c h l o n g r a d i opaque catheter over a 2 0 - g a u g e introducer n e e d l e was d i r e c t e d from t h e c a r u n c l e , i n t o t h e l a c r i m a l s a c f o s s a , a n d up to t h e l a c r i m a l b o n e
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TABLE
DATA ON PATIENTS UNDERGOING LASER-ASSISTED LACRIMAL SURGERY* FOLLOW-UP (MOS) CASE NO., AGE (vns), SEX
PROCEDURE
LASER
1,66, F 2, 88, F 3, 50, F 4, 49, Μ 5. 59, Μ 6, 29, F 7. 80, F 8, 33, Μ 9, 75, F 10, 82, F 11.32, F 12, 59, F 13, 76, F 14, 68, F 15, 3, Μ 16, 46, F 17. 22, Μ 18. 77, F
Dacryocystortiinostomy Dacryocystortiinostomy Conjunctlvodacryocystortiinostomy Dacryocystortiinostomy Conjunctivodacryocystortiinostomy Conjunctivodacryocystortilnostomy (2) Conjunctivodacryocystorhinostomy Dacryocystortiinostomy Dacryocystortiinostomy Bilateral dacryocystortiinostomy Dacryocystortiinostomy Dacryocystortiinostomy Dacryocystorhinostomy Dacryocystorhinostomy Dacryocystorhinostomy Dacryocystorhinostomy Dacryocystorhinostomy Dacryocystorhinostomy
Carbon dioxide Carbon dioxide Carbon dioxide Carbon dioxide Carbon dioxide Potassium titanyl phosphate Potassium titanyl phosphate Potassium titanyl phosphate Potassium titanyl phosphate Potassium titanyl phosphate Potassium titanyl phosphate Potassium titanyl phosphate Potassium titanyl phosphate Potassium titanyl phosphate Potassium titanyl phosphate Potassium titanyl phosphate Potassium titanyl phosphate Potassium titanyl phosphate
FROM SURGERY FROM TUBE REMOVAL
13 13 12 12 11 6 6 6 6 4 4 4 4 3 3 2.5 2.5 2
7 7 NA 6 NA NA NA 2 1.5 0 0 Tube in place Tube in place Tutie in place Tube in place Tube In place Tutie in place Tube in place
*NA Indicates not applicable.
(Fig. 1 ) . T h e n e e d l e w a s r e m o v e d , a n d t h e c a t h e t e r h u b w a s cut off w i t h s c i s s o r s to a l l o w passage of the light pipe through the catheter tip up to t h e l a c r i m a l b o n e . With the e n d o s c o p e , a discrete spot of transill u m i n a t e d l i g h t from t h e l i g h t p i p e c o u l d b e seen, which marked the site of intended r h i n o s tomy (Fig. 2 ) . To v i s u a l i z e t h i s s p o t , t h e l i g h t from the e n d o s c o p e w a s r e d u c e d to its l o w e s t s e t t i n g . I f a diffuse s p o t i n d i c a t e d l a c k o f c o n tact b e t w e e n t h e l i g h t p i p e a n d t h e l a c r i m a l bone, repositioning o f the light pipe was n e c e s sary. Local anesthetic with 1 : 1 0 0 , 0 0 0 epineph rine w a s t h e n i n j e c t e d u n d e r e n d o s c o p i c c o n trol i n t o t h e n a s a l m u c o s a o v e r l y i n g t h e s p o t . I f viewing of this area was awkward with the 0-degree telescope, a better view was possible by s u b s t i t u t i n g the 3 0 - d e g r e e t e l e s c o p e . B e c a u s e o f t h e p o t e n t i a l for o c u l a r d a m a g e , especially with visible light lasers, appropriate l a s e r s a f e t y p r e c a u t i o n s for t h e p a t i e n t a n d t h e operating team were taken. T h e patient's eyes were covered with a d o u b l e d strip o f a l u m i n u m foil, r e f l e c t i v e s i d e out, t a p e d in p l a c e , a n d further c o v e r e d w i t h a m o i s t e n e d s p o n g e . A l l m e m b e r s of the operating team wore appropri ately filtered p r o t e c t i v e g l a s s e s . I f o x y g e n w a s a d m i n i s t e r e d to an a w a k e p a t i e n t , it w a s
s t o p p e d d u r i n g l a s e r a d m i n i s t r a t i o n to p r e v e n t t h e d a n g e r o f flash fire in t h e o p e r a t i v e field. I f general anesthesia was used, the endotracheal t u b e w a s p r o t e c t e d w i t h a l u m i n u m foil. Laser rhinostomy was then performed with video-endoscopic visualization. With the po tassium titanyl p h o s p h a t e laser, the energy was d e l i v e r e d t h r o u g h a 3 0 0 - to 6 0 0 - μ m fiber that was passed through an angulated endoscopic laser suction tip. An electronically activated filter w a s fitted b e t w e e n t h e e n d o s c o p e a n d t h e v i d e o c a m e r a t o p r e v e n t d a m a g e to t h e c a m e r a and allow visualization during the intense green light of laser delivery. Half-second puls es o f 5 to 7 W o f l a s e r e n e r g y s e p a r a t e d b y h a l f - s e c o n d p a u s e s w e r e d e l i v e r e d in a n o n c o n tact mode to the m u c o s a surrounding the pro p o s e d r h i n o s t o m y . N e x t , in a n e a r - c o n t a c t m o d e , v a p o r i z a t i o n o f t i s s u e w a s p e r f o r m e d to p r o d u c e a 5 - to 6 - m m r h i n o s t o m y o v e r t h e a r e a o f t h e l i g h t p i p e for d a c r y o c y s t o r h i n o s t o m y a n d a 3 - t o 4 - m m r h i n o s t o m y for c o n j u n c t i v o d a c r y ocystorhinostomy. The carbon dioxide laser energy was deliv ered through an articulated arm of a 5 5 - W s u r g i c a l l a s e r a t t a c h e d to a s m a l l - w a v e g u i d e . Distal mirrors of varying angulation on the wave guide directed b o t h the h e l i u m - n e o n aim-
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Fig. 2 (Gonnering, Lyon, and Fisher). Video-endoscopic view of left nasal passage during laser-as sisted lacrimal surgery. (S, nasal septum; L, lateral nasal wall; MT, middle turbinate; arrowhead, dis crete transillumination from light pipe.)
Fig. 1 (Gonnering, Lyon, and Fisher). Placement of introducer needle and catheter from caruncle across lacrimal sac fossa to abut the lacrimal bone. ing b e a m a n d t h e c a r b o n d i o x i d e s u r g i c a l b e a m to t h e d e s i r e d a r e a . T h e s u p e r p u l s e m o d e w a s u s e d with 7 5 0 l a s e r p u l s e s p e r s e c o n d d e l i v e r ing 8 to 14 W of e n e r g y to c r e a t e r h i n o s t o m i e s s i m i l a r to t h o s e p r o d u c e d w i t h t h e p o t a s s i u m titanyl phosphate laser. With both lasers, the r h i n o s t o m y w a s p r o d u c e d in a p p r o x i m a t e l y t h r e e to five m i n u t e s of i n t e r m i t t e n t l a s e r t i m e with manipulation of the laser delivery b e a m a n d l i g h t p i p e to c r e a t e an o p e n i n g o f t h e desired size. W i t h d a c r y o c y s t o r h i n o s t o m y , after p r o d u c tion of the rhinostomy, silicone intubation was p e r f o r m e d a n d left in p l a c e for four to six months. With conjunctivodacryocystorhinos t o m y , after p r o d u c t i o n o f t h e r h i n o s t o m y , t h e light pipe was removed, the catheter was ad v a n c e d i n t o t h e n o s e , a n d t h e 0 . 0 3 5 - i n c h flex ible guide wire was inserted through the cathe ter, a c r o s s t h e r h i n o s t o m y , a n d out t h e n o s t r i l (Fig. 3 ) . T h e c a t h e t e r w a s t h e n v i e w e d e n d o s c o p i c a l l y , a n d an a p p r o x i m a t i o n of t h e p r o p e r Jones tube length was gauged by grasping the
c a t h e t e r w i t h f o r c e p s at t h e m e d i a l c o m m i s s u r e . The catheter was then withdrawn, leaving the g u i d e w i r e in p l a c e . By m e a s u r i n g from t h e tip of t h e c a t h e t e r to t h e f o r c e p s , an a p p r o x i m a t i o n of t h e l e n g t h of J o n e s t u b e r e q u i r e d c a n b e made. T h e v e s s e l d i l a t o r w a s t h e n cut a p p r o x i m a t e l y 4 c m from its distal e n d . T h i s c u t s e g m e n t o f d i l a t o r w a s t h r e a d e d o v e r t h e g u i d e w i r e to a c t as an i n t r o d u c e r for t h e J o n e s t u b e . T h e J o n e s tube was threaded on the guide wire b e h i n d the dilator s e g m e n t (Fig. 4 ) . With the vessel dilator a h e a d o f it, t h e J o n e s t u b e w a s t h e n e a s i l y advanced along the guide wire and into the n o s e . After p r o p e r J o n e s t u b e l e n g t h w a s c o n firmed, t h e v e s s e l d i l a t o r a n d g u i d e w i r e w e r e b o t h r e m o v e d from t h e n o s t r i l , a n d a s u t u r e w a s u s e d to fix t h e J o n e s t u b e at t h e m e d i a l c o m m i s s u r e for t h e i n i t i a l p o s t o p e r a t i v e h e a l i n g p h a s e . Bleeding was usually minimal, and no pack ing w a s r e q u i r e d u n l e s s t h e r e w a s an e x t e n s i v e t u r b i n e c t o m y . P o s t o p e r a t i v e m e d i c a t i o n s in c l u d e d t o p i c a l a n t i b i o t i c s a n d i n t r a n a s a l flunis o l i d e 0 . 0 2 5 % spray.
Results O f t h e 2 0 p r o c e d u r e s , five w e r e c o n j u n c t i vodacryocystorhinostomies. Five procedures were performed with the carbon dioxide laser, a n d 15 w e r e p e r f o r m e d w i t h t h e p o t a s s i u m t i t a n y l p h o s p h a t e l a s e r . T h e p a t i e n t in C a s e 1 0
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Fig. 3 (Gonnering, Lyon, and Fisher). Video-endoscopic view of passage of guide wire through catheter and into nose.
undervi^ent b i l a t e r a l dacryocystorhinostomy. T h e J o n e s t u b e in o n e p a t i e n t ( C a s e 6 ) d i s lodged one week postoperatively because she was rubbing her eye. T h r e e weeks later, repeat conjunctivodacryocystorhinostomy was n e c e s sary in t h i s p a t i e n t s i n c e t h e r h i n o s t o m y h a d c l o s e d . S i l i c o n e t u b i n g w a s r e m o v e d from p a tients who had had dacryocystorhinostomy four to six m o n t h s p o s t o p e r a t i v e l y . All p a t i e n t s had relief of symptoms with normal results of dye-disappearance tests.
Discussion Caldwell" described the intranasal approach to d a c r y o c y s t o r h i n o s t o m y in 1 8 9 3 , in w h i c h a portion of the inferior turbinate was removed a n d the n a s o l a c r i m a l c a n a l w a s f o l l o w e d to t h e l a c r i m a l s a c . W e s t ' s u b s e q u e n t l y refined t h i s technique by substituting a window resection over t h e l a c r i m a l s a c for w i d e r e s e c t i o n . A l though this m e t h o d was used extensively earli er in t h i s c e n t u r y , it h a s b e e n all b u t a b a n d o n e d b y o p h t h a l m o l o g i s t s , d e s p i t e an i n c r e a s e in i n t e r e s t in t h e o t o l a r y n g o l o g i c l i t e r a t u r e . ^ " W i t h i n t h e past five y e a r s , a m a r k e d shift t o endoscopic nasal and sinus surgery has o c c u r r e d in o t o l a r y n g o l o g y . ' ^ ' ^ T h e i n c r e a s e d v i s ualization allowed with this instrumentation h a s r e s u l t e d in p r e c i s e , m i c r o i n v a s i v e s u r g i c a l
Fig. 4 (Gonnering, Lyon, and Fisher). Use of vessel dilator for placement of Jones tube along guide wire.
t e c h n i q u e , a p p l i c a b l e to m o s t p a t i e n t s , w i t h high success and less morbidity than that seen w i t h e i t h e r o p e n p r o c e d u r e s or t r a n s n a s a l p r o cedures done without the endoscope. T h e e n d o s c o p e h a s b e e n u s e d b e f o r e in l a c r i m a l s u r g e r y to d o c u m e n t t h e p a t e n c y o f t h e r h i n o s t o m y , ' ^ as w e l l as to m a n a g e f a i l e d d a c r y o c y s t o r h i n o s t o m y surgery'^ a n d c o m p l i c a tions of conjunctivodacryocystorhinostomy.'" Four p a t i e n t s h a v e b e e n d e s c r i b e d b y R i c e " in whom conventional intranasal dacryocystorhi nostomy was performed with the endoscope. Although endonasal lacrimal surgery can be performed with the operating microscope, the e n d o s c o p e allows such procedures to be per f o r m e d w i t h o u t t h e n e e d for an o p e n l i n e o f s i g h t to t h e a r e a o f r h i n o s t o m y . S m a l l m o v e ments of the patient do not require complex repositioning of the p a t i e n t / m i c r o s c o p e axis. The addition of the v i d e o c a m e r a provides a m a g n i f i e d , o n - s c r e e n v i e w o f t h e p r o c e d u r e to t h e s u r g e o n a n d o p e r a t i n g t e a m , w h i c h is m o s t useful w h e n t h e s u r g i c a l t r a i n i n g o f r e s i d e n t s
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a n d fellows is a s e c o n d a r y g o a l o f t h e p r o c e dure. Although endonasal dacryocystorhinostomy was originally described with the argon laser, both dacryocystorhinostomy and conjunctivodacryocystorhinostomy can be performed with either the potassium titanyl phosphate or the carbon dioxide laser. Both of these lasers cur r e n t l y are a p p r o v e d for i n t r a n a s a l s u r g e r y . T h e p o t a s s i u m titanyl p h o s p h a t e l a s e r c o n s i s t s o f an N d : Y A G l a s e r s o u r c e , w h i c h is p a s s e d t h r o u g h a f r e q u e n c y - d o u b l i n g crystal of p o t a s s i u m t i t a n y l phosphate, producing a single output wave length of 5 3 2 . 0 n m . ' ' " When used with a quartz d e l i v e r y fiber, h e m o s t a s i s is p r o d u c e d in t h e n o n c o n t a c t mode, and tissue vaporization can b e a c c o m p l i s h e d with n e a r - c o n t a c t d e l i v e r y . W h e n u s e d in t h e c o n t a c t m o d e , p r e c i s e t i s s u e c u t t i n g is p o s s i b l e . A l t h o u g h t h e o u t p u t o f t h e a r g o n l a s e r is s i m i l a r at 4 8 8 . 0 a n d 5 1 4 . 5 n m , d i r e c t c o n t a c t o f t h e fiber w i t h t i s s u e c a n r e s u l t in fiber d a m a g e a n d t h e n e e d to c l e a v e t h e fiber to deliver precontact energy levels. The carbon dioxide laser has had a history o f s u c c e s s f u l u s e in t h e u p p e r airway.'^'^" T h i s i n frared l a s e r , at 1 0 , 6 0 0 n m , affords e x c e l l e n t vaporization of tissue with little thermal s p r e a d , e s p e c i a l l y w h e n u s e d in t h e s u p e r p u l s e mode. This wavelength, however, possesses only moderate hemostatic abilities and cannot as yet b e t r a n s m i t t e d effectively t h r o u g h a fiber. It must b e i n t e r n a l l y r e f l e c t e d or f o c u s e d from an a r t i c u l a t e d d e l i v e r y a r m d o w n a w a v e g u i d e , w h i c h m u s t b e flushed w i t h an i n e r t g a s s u c h as c a r b o n d i o x i d e to k e e p t h e distal r e f l e c t i v e m i r ror free from c h a r from t h e l a s e r p l u m e . W e found this more complicated delivery system, t h o u g h effective, to b e s o m e w h a t m o r e a w k w a r d t o u s e t h a n t h e q u a r t z d e l i v e r y fiber o f t h e p o t a s s i u m titanyl p h o s p h a t e l a s e r . O u r g u i d e wire a n d v e s s e l d i l a t o r c o m b i n a t i o n h a s b e e n d e s c r i b e d in t h e p e r c u t a n e o u s r e m o v a l of d a c r y o l i t h s in t h e s y n d r o m e o f n o n i n f e c t i o u s d a c r y o c y s t i c retention.^' T h e u s e o f t h i s c o m b i n a t i o n in p l a c e m e n t o f J o n e s t u b e s s i g n i f i c a n t l y r e d u c e s t h e i n t r a o p e r a t i v e frustra tion often a c c o m p a n y i n g a t t e m p t s to p a s s t h e Jones tube with conventional techniques.^ O t h e r a u t h o r s h a v e e m p h a s i z e d that t h e s u r g i c a l t r a u m a a n d a s y m m e t r i c r e d u c t i o n in t h e s i z e of t h e r h i n o s t o m y in t h e h e a l i n g p h a s e o f c o n j u n c t i v o d a c r y o c y s t o r h i n o s t o m y , as w e l l as h y p e r m o b i l i t y o f a t u b e in a l a r g e s u r g i c a l r h i n o s t o m y , m a y c o n t r i b u t e to p o s t o p e r a t i v e t u b e malposition.^^ In o u r t e c h n i q u e , t h e t u b e is a l r e a d y r e l a t i v e l y s n u g in t h e r h i n o s t o m y at t h e
February, 1991
conclusion of surgery, and minimal postopera tive d i s p l a c e m e n t , d e s p i t e t h e e a r l y e x t r u s i o n s e e n in o n e o f o u r p a t i e n t s , s h o u l d b e e x p e c t e d . A v a l i d c o m p a r i s o n in r a t e s o f p o s t o p e r a t i v e extrusion will require several years of observa tion. Physicians must now evaluate not only the safety, but the cost and effectiveness o f n ew technology and w h e t h e r that new t e c h n o l o g y r e s u l t s in t a n g i b l e b e n e f i t s to t h e p a t i e n t a n d society.^'·^* W e b e l i e v e t h a t e n d o s c o p i c l a s e r a s s i s t e d l a c r i m a l s u r g e r y is a n e w t e c h n o l o g y with significant individual and societal benefits for t h e f o l l o w i n g r e a s o n s : a c u t a n e o u s s c a r is a v o i d e d ; s u r g i c a l t r a u m a is l i m i t e d w i t h l e s s b l e e d i n g a n d p o s t o p e r a t i v e p a i n ; v i r t u a l l y all p a t i e n t s a r e t r e a t e d as o u t p a t i e n t s w i t h m o s t procedures performed under local anesthesia; p o s t o p e r a t i v e r e c o v e r y is s h o r t e n e d w i t h m o s t p a t i e n t s a b l e to r e s u m e n o r m a l a c t i v i t i e s t h e n e x t day. T h e e q u i p m e n t u s e d , t h o u g h e x p e n s i v e , is shared by many surgical s e r v i c e s in a hospital. A d a p t a t i o n for l a c r i m a l s u r g e r y a l l o w s i n creased utilization of this equipment and thus i n c r e a s e s its c o s t - e f f e c t i v e n e s s . At o u r h o s p i t a l , t h e u s e o f t h e l a s e r a d d s a p p r o x i m a t e l y $ 3 0 0 to t h e o p e r a t i v e c o s t s o f l a c r i m a l s u r g e r y . We b e l i e v e t h i s c o s t is m o r e t h a n b a l a n c e d b y t h e a b i l i t y to p e r f o r m all our l a c r i m a l s u r g e r y o n an outpatient basis and the much more rapid re turn o f t h e p a t i e n t to w o r k , s c h o o l , or o t h e r normal activities. C o n t r a i n d i c a t i o n s to t h i s t e c h n i q u e i n c l u d e suspicion of lacrimal sac malignancy and severe bony deformity of the lacrimal sac fossa, w h i c h prevent accurate transillumination through the lacrimal bone. Because the anterior lacrimal c r e s t is n o t r e m o v e d w i t h t h i s t e c h n i q u e , r h i n o s t o m y s i t e s t e n d to b e m o r e i n f e r i o r a n d p o s t e r i o r t h a n t h o s e p e r f o r m e d in c o n v e n t i o n a l external approaches. Consequently, many pa t i e n t s r e q u i r e at l e a s t a p a r t i a l t u r b i n e c t o m y , especially when conjunctivodacryocystorhinos t o m y is p e r f o r m e d . ^ ' A l t h o u g h t u r b i n a t e m u c o sa c a n s a f e l y b e e x c i s e d w i t h t h e l a s e r , c a r e must b e used w h e n resecting c o n c h a l b o n e with t h e l a s e r to avoid o v e r h e a t i n g a n d p o s s i b l e n e c r o s i s a n d sequestration.^" L o n g e r J o n e s t u b e s are often n e c e s s a r y , w i t h m o s t p a t i e n t s r e q u i r i n g a t u b e a p p r o x i m a t e l y 2 0 to 2 2 m m in l e n g t h . A d e q u a t e s u p p l i e s of l o n g t u b e s m u s t b e a v a i l a b l e for t h i s p r o c e d u r e . A l t h o u g h t h e l e a r n i n g c u r v e for v i d e o e n d o s c o p y is s o m e w h a t s t e e p , t h e o u t c o m e s t o d a t e have been uniformly positive. T h e increased
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experience of multiple surgeons, however, will be necessary to evaluate the clinical usefulness of t h e s e p r o c e d u r e s a d e q u a t e l y .
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