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Retrograde silicone intubation of the nasolacrimal duct in children
SURVEY OF OPHTHALMOLOGY
VOLUME
24-
NUMBER
3. NOVEMBER-DECEMBER
1979
CURRENT OPHTHALMOLOGY
Retrograde Silicone Intubation of the Nasolacrimal Duct in Children, by K. Nagashima. Jpn J Ophthalmol22:449-459, 1978 On the basis of his successful experience with retrograde polyethylene intubation of the congenitally and persistently obstructed nasolacrimal duct in a 2-year-old male Lowland gorilla, the author performed the newer procedure using a silicone tube in a series of 8 patients, aged from 2 to 5 years, with obstruction of the nasolacrimal duct observed as a refractory condition. Two cases were congenital and 6 cases were acquired following epidemic keratoconjunctivitis. A set of intubating materials consisted of three parts as follows: Guide tube - The first 25 mm of a polyethylene tube, 80 cm long with an outside diameter of 0.9 mm and inside diameter of about 0.5 mm, was curled up into ten bends with notches. Dilution tubes - Each of five polyethylene tubes 7 cm long, 1.9 to 3.0 mm in outside diameter, was closed and rounded at one end. In this blind end, a new orifice was made just large enough to attach the guide tube. Retention tubes - Each of three silicone rubber tubes 7 cm long, 2.0, 2.4, and 3.0 mm in outside diameter, was fixed to guide threads for linking it with the guide tube. All surgical procedures could be carried out as office procedures under local anesthesia. The notched side of the guide tube was directed posteriorly while the tube was introduced into the nasal cavity through the upper punctum with the aid of a probe. Thus, its lower end came forward making a bend anteriorly of itself to be found on or over the floor of the nose near the vestibule past under the inferior turbinate; or, it coiled within the inferior meatus, but it could still easily be recovered by a blunt hook, because of its curliness. The occlusive part of the nasolacrimal duct was reamed by a knot of the guide tube first and by the dilation tubes connected with the guide tube afterwards. Depending on the outside diameter of the last dilation tube employed, one of the silicone tubes was chosen to remain in the nasolacrimal duct and lacrimal sac. The silicone tube was fixed by fitting the upper punctum with a glass bead with its guide threads coming out of the punctum. Its lower end was cut short in the vestibule. In the third week postoperatively, isotonic saline colored with fluorescein injected through the lower canaliculus flowed into the nasopharynx, not through the nasal end of the tube but around its surface. This was interpreted as establishment of some space between the nasolacrimal duct and the tube. So the tube was removed in the following week, about 4 weeks after the operation. Six of the 8 patients had very good results. The follow-up period ranged from 4 to 11 months after the removal of the tube. One of the other two patients was improved 9 months after the tube was extruded from the eye during a fight with her brother on the 17th postoperative day. The remaining patient progressed favorably for several weeks after the removal of the tube, but the nasolacrimal duct closed again following measles. Although the number of cases and the length of followup study are limited, and the lower limit of application as well as the upper limit of indication on a patient’s age remain to be clarified, the results of this method of intubation suggest a successful substitute for dacryocystorhinostomy in the very young without obstruction of the osseous nasolacrimal canal. (Abstract by K. Nagashima)
Comment To understand this method of treatment, “retrograde intubation with silicone tube,” one should read this article in its entirety to see the illustrations accompanying the paper. It is difficult to believe that a polyethylene tube three mm in diameter could be introduced into the inferior meatus of the nasolacrimal duct under local anesthesia especially in infants and small children. In our hands 6- to 8-month-old infants are often unmanageable without general anesthesia for simple prob194
CURRENTOPHYHALMOLOOY
195
ing of the nasolacrimal duct. In these small infants we have hesitated to use larger than #1 or #2 Bowman probes without traumatizing the duct mucosa. When we have used silicone canalization of the nasolacrimal duct we have left it in place for 2 to 4 months, but even then most of the ducts close after the silicone is removed. Nagashima was able to remove the tube after 4 weeks. The author notes that in 10 of 14 cases in adults where this same silicone intubation was employed, the ducts closed again in less than a week after removal of the tube. In our experience it has been the lower end .of the nasolacrimal duct in infants that fails to canalize into the nose, while in adults the site of the obstruction is usually higher at the upper end of the duct near the lacrimal sac. This may explain why Nagashima has been so much more successful in infants than in adults. Of 8 infants and young children treated by this method 7 were successful, but the followup period was from only 2 to 11 months. As Schaeffer has pointed out, the nasolacrimal ostium has various forms and locations sometimes slitlike, varying in size and location, high up or low down under the inferior turbinate. A single probing will usually suffice to establish this opening, but if it is slitlike or low down toward the nasal floor, perhaps a larger retrograde opening, as the author suggests, is better. J. V. CASSADY
Photocoagulation for Central Vein Occlusion, by G. Hiivener. Augenheilkd
173:392-401,
Kfin Monatsbl
1978
The conservative treatment of fully developed central vein occlusion (CVO) has been disappointing. The improvement of visual acuity was slight, and often a hemorrhagic secondary glaucoma developed. Since this disease resembles some forms of diabetic retinopathy, in which photocoagulation improves retinal blood flow, we have also been using photocoagulation in CVO-cases since 1972. We did coagulation only in cases with fully developed CVO. So-called prethrombosis was not included. To clearly differentiate these two forms of CVO, we did fluorescein angiography in all cases. In prethrombosis one finds only small changes in the capillary tree of the retina: some microaneurisms, moderate capillary dilatation with slight dye leakage, some retinal hemorrhages and a papilledema. In fully developed CVO, the changes in the capillary tree are very pronounced: intensive dilatation of all capillaries, extensive dye leakage with edema of the macula, destruction of the macula-arcade; massive capillary occlusion, and retinal hemorrhages. Photocoagulation was done in 27 cases of CVO that were observed for more than 4 months thereafter. We used the xenon-arc lamp (Zeiss-Oberkochen) and the argon-laser (Coherent). The coagulations were done paravenously, with the xenon-arc 2UO-300 coagulations of 3” aperture and with the laser 600-1200 coagulations with 200 CCspot-size. 4.5-29 months later, the visual acuity had improved in 9 cases, was unchanged in 8 and had decreased in 8. The prognosis for visual acuity is better in patients under 70 years of age (5 cases better, 1 worse, 4 unchanged) than in those over 70 (4 better, 7 worse, 4 unchanged). In all cases, retinal hemorrhages regressed relatively quickly, the caliber of the veins normalized and the papilledema disappeared. However, a pronounced macula-edema remained in a number of cases. Photocoagulation did not cause any complications. A secondary hemorrhagic glaucoma did not occur in any of the cases; this develops with conservative therapy in 18-3696 (lOO-day-glaucoma) within the first 2-4 months. At present, we think this will be the main goal for photocoagulation therapy in CVO. In one case, a secondary glaucoma regressed after coagulation of the retina. We obtained the best results for visual acuity in cases where CVO had not lasted longer than a month. (Abstract by G. Hijvener)
Comment Hiivener has presented the findings on 27 patients with central retinal vein occlusion. Those cases suggest that photocoagulation therapy either using the argon laser or xenon arc was beneficial. It is significant that only four of the cases are under 60 years of age, suggesting that the majority fall into the classical central retinal vein occlusion category and not into the “papilla-phlebitis” that has been reported in younger patients and which carries a much more benign prognosis. This paper fails to document the role of photocoagulation as it lacks the design of a prospective controlled clinical trial. However, although lacking the statistical strength of a randomized controlled
VOLUME
24-
NUMBER
3. NOVEMBER-DECEMBER
1979
CURRENT OPHTHALMOLOGY
Retrograde Silicone Intubation of the Nasolacrimal Duct in Children, by K. Nagashima. Jpn J Ophthalmol22:449-459, 1978 On the basis of his successful experience with retrograde polyethylene intubation of the congenitally and persistently obstructed nasolacrimal duct in a 2-year-old male Lowland gorilla, the author performed the newer procedure using a silicone tube in a series of 8 patients, aged from 2 to 5 years, with obstruction of the nasolacrimal duct observed as a refractory condition. Two cases were congenital and 6 cases were acquired following epidemic keratoconjunctivitis. A set of intubating materials consisted of three parts as follows: Guide tube - The first 25 mm of a polyethylene tube, 80 cm long with an outside diameter of 0.9 mm and inside diameter of about 0.5 mm, was curled up into ten bends with notches. Dilution tubes - Each of five polyethylene tubes 7 cm long, 1.9 to 3.0 mm in outside diameter, was closed and rounded at one end. In this blind end, a new orifice was made just large enough to attach the guide tube. Retention tubes - Each of three silicone rubber tubes 7 cm long, 2.0, 2.4, and 3.0 mm in outside diameter, was fixed to guide threads for linking it with the guide tube. All surgical procedures could be carried out as office procedures under local anesthesia. The notched side of the guide tube was directed posteriorly while the tube was introduced into the nasal cavity through the upper punctum with the aid of a probe. Thus, its lower end came forward making a bend anteriorly of itself to be found on or over the floor of the nose near the vestibule past under the inferior turbinate; or, it coiled within the inferior meatus, but it could still easily be recovered by a blunt hook, because of its curliness. The occlusive part of the nasolacrimal duct was reamed by a knot of the guide tube first and by the dilation tubes connected with the guide tube afterwards. Depending on the outside diameter of the last dilation tube employed, one of the silicone tubes was chosen to remain in the nasolacrimal duct and lacrimal sac. The silicone tube was fixed by fitting the upper punctum with a glass bead with its guide threads coming out of the punctum. Its lower end was cut short in the vestibule. In the third week postoperatively, isotonic saline colored with fluorescein injected through the lower canaliculus flowed into the nasopharynx, not through the nasal end of the tube but around its surface. This was interpreted as establishment of some space between the nasolacrimal duct and the tube. So the tube was removed in the following week, about 4 weeks after the operation. Six of the 8 patients had very good results. The follow-up period ranged from 4 to 11 months after the removal of the tube. One of the other two patients was improved 9 months after the tube was extruded from the eye during a fight with her brother on the 17th postoperative day. The remaining patient progressed favorably for several weeks after the removal of the tube, but the nasolacrimal duct closed again following measles. Although the number of cases and the length of followup study are limited, and the lower limit of application as well as the upper limit of indication on a patient’s age remain to be clarified, the results of this method of intubation suggest a successful substitute for dacryocystorhinostomy in the very young without obstruction of the osseous nasolacrimal canal. (Abstract by K. Nagashima)
Comment To understand this method of treatment, “retrograde intubation with silicone tube,” one should read this article in its entirety to see the illustrations accompanying the paper. It is difficult to believe that a polyethylene tube three mm in diameter could be introduced into the inferior meatus of the nasolacrimal duct under local anesthesia especially in infants and small children. In our hands 6- to 8-month-old infants are often unmanageable without general anesthesia for simple prob194
CURRENTOPHYHALMOLOOY
195
ing of the nasolacrimal duct. In these small infants we have hesitated to use larger than #1 or #2 Bowman probes without traumatizing the duct mucosa. When we have used silicone canalization of the nasolacrimal duct we have left it in place for 2 to 4 months, but even then most of the ducts close after the silicone is removed. Nagashima was able to remove the tube after 4 weeks. The author notes that in 10 of 14 cases in adults where this same silicone intubation was employed, the ducts closed again in less than a week after removal of the tube. In our experience it has been the lower end .of the nasolacrimal duct in infants that fails to canalize into the nose, while in adults the site of the obstruction is usually higher at the upper end of the duct near the lacrimal sac. This may explain why Nagashima has been so much more successful in infants than in adults. Of 8 infants and young children treated by this method 7 were successful, but the followup period was from only 2 to 11 months. As Schaeffer has pointed out, the nasolacrimal ostium has various forms and locations sometimes slitlike, varying in size and location, high up or low down under the inferior turbinate. A single probing will usually suffice to establish this opening, but if it is slitlike or low down toward the nasal floor, perhaps a larger retrograde opening, as the author suggests, is better. J. V. CASSADY
Photocoagulation for Central Vein Occlusion, by G. Hiivener. Augenheilkd
173:392-401,
Kfin Monatsbl
1978
The conservative treatment of fully developed central vein occlusion (CVO) has been disappointing. The improvement of visual acuity was slight, and often a hemorrhagic secondary glaucoma developed. Since this disease resembles some forms of diabetic retinopathy, in which photocoagulation improves retinal blood flow, we have also been using photocoagulation in CVO-cases since 1972. We did coagulation only in cases with fully developed CVO. So-called prethrombosis was not included. To clearly differentiate these two forms of CVO, we did fluorescein angiography in all cases. In prethrombosis one finds only small changes in the capillary tree of the retina: some microaneurisms, moderate capillary dilatation with slight dye leakage, some retinal hemorrhages and a papilledema. In fully developed CVO, the changes in the capillary tree are very pronounced: intensive dilatation of all capillaries, extensive dye leakage with edema of the macula, destruction of the macula-arcade; massive capillary occlusion, and retinal hemorrhages. Photocoagulation was done in 27 cases of CVO that were observed for more than 4 months thereafter. We used the xenon-arc lamp (Zeiss-Oberkochen) and the argon-laser (Coherent). The coagulations were done paravenously, with the xenon-arc 2UO-300 coagulations of 3” aperture and with the laser 600-1200 coagulations with 200 CCspot-size. 4.5-29 months later, the visual acuity had improved in 9 cases, was unchanged in 8 and had decreased in 8. The prognosis for visual acuity is better in patients under 70 years of age (5 cases better, 1 worse, 4 unchanged) than in those over 70 (4 better, 7 worse, 4 unchanged). In all cases, retinal hemorrhages regressed relatively quickly, the caliber of the veins normalized and the papilledema disappeared. However, a pronounced macula-edema remained in a number of cases. Photocoagulation did not cause any complications. A secondary hemorrhagic glaucoma did not occur in any of the cases; this develops with conservative therapy in 18-3696 (lOO-day-glaucoma) within the first 2-4 months. At present, we think this will be the main goal for photocoagulation therapy in CVO. In one case, a secondary glaucoma regressed after coagulation of the retina. We obtained the best results for visual acuity in cases where CVO had not lasted longer than a month. (Abstract by G. Hijvener)
Comment Hiivener has presented the findings on 27 patients with central retinal vein occlusion. Those cases suggest that photocoagulation therapy either using the argon laser or xenon arc was beneficial. It is significant that only four of the cases are under 60 years of age, suggesting that the majority fall into the classical central retinal vein occlusion category and not into the “papilla-phlebitis” that has been reported in younger patients and which carries a much more benign prognosis. This paper fails to document the role of photocoagulation as it lacks the design of a prospective controlled clinical trial. However, although lacking the statistical strength of a randomized controlled