TRANSCANALICULAR LASER TRANSCANALICULAR LASER DACRYOCYSTORHINOSTOMY.DACRYOCYSTORHINOSTOMY.MEDIUM-LONG TERM RESULTS MEDIUM-LONG TERM RESULTS AFTER 4 YEARS of PRACTICE.AFTER 4 YEARS of PRACTICE.

• 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.

Mailing adressess:Mailing adressess:- 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: 24024jmr@comb.cat- 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)

INTRODUCTIONINTRODUCTION

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’

STANDARD 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.

Observational prospective non-randomized studyObservational prospective non-randomized studyJanuary 2004 – January 2008January 2004 – January 2008

426 eyes426 eyes394 patients (32 bilat)394 patients (32 bilat)

279 (70.81%) women / 115 (29.19%) men279 (70.81%) women / 115 (29.19%) men

Mean age: 65,17 years (61,5 men – 68,84 women)Mean age: 65,17 years (61,5 men – 68,84 women)Range: 31 – 89 yearsRange: 31 – 89 years

Minimum follow-up: 1 year / Mean time of follow-up: 21 monthsMinimum follow-up: 1 year / Mean time of follow-up: 21 months

MATERIAL and METHODMATERIAL and METHOD

Postoperative treatmentPostoperative treatment

Eye drops: antibiotic + corticoids 15 days; after, non-esteroidal antinflammatoriesEye drops: antibiotic + corticoids 15 days; after, non-esteroidal antinflammatoriesNasal corticoidsNasal corticoids

Nasal SF cleaningsNasal SF cleanings

Follow upFollow up

24 hours postop24 hours postopEvery 7-10 days first month Every 7-10 days first month

(1 month: removing of silicone intubation)(1 month: removing of silicone intubation)3, 6, 12 months3, 6, 12 months

Every 6-12 monthsEvery 6-12 months

- Clinical evaluation symtoms (tearing)- Clinical evaluation symtoms (tearing)- Nasal endoscopy (ostium follow up, and crusts, fibrine,... cleaning)- Nasal endoscopy (ostium follow up, and crusts, fibrine,... cleaning)

- Lachrymal irrigation- Lachrymal irrigation

MATERIAL and METHODMATERIAL and METHOD

RESULTSRESULTSMean of total energy used: 378.65 J (range 165-618)Mean of total energy used: 378.65 J (range 165-618)

Mean of ostium diameter achieved: 11.23mm (8-15)Mean of ostium diameter achieved: 11.23mm (8-15)

Mean surgical time: Mean surgical time: 26.37 min26.37 min (8-55)(8-55)

COMPLICATIONSCOMPLICATIONS

- SURGICAL: NONESURGICAL: NONE

- POSTOPERATIVE:POSTOPERATIVE:* light cantal haematomas (local anesthesia)* light cantal haematomas (local anesthesia)

* minimum pain* minimum pain* minimum self-limited nasal bleeding (2)* minimum self-limited nasal bleeding (2)

* lachrymal intubation mobilisation (3)* lachrymal intubation mobilisation (3)

RESULTSRESULTSANATOMICAL RESULTSANATOMICAL RESULTS

(Fluorescein clearance / positive irrigation / endonasal confirmation)(Fluorescein clearance / positive irrigation / endonasal confirmation)

FUNCTIONAL CLOSEDFUNCTIONAL CLOSED 382 / 426 4 / 426382 / 426 4 / 426

(89.67%) (10.33%)(89.67%) (10.33%)

CLINICAL RESULTSCLINICAL RESULTS(disappearance / improvement symptoms)(disappearance / improvement symptoms)

COMPLETE IMPROVEMENTCOMPLETE IMPROVEMENT377 / 426377 / 426(88.49%)(88.49%)

PARTIAL IMPROVEMENT NO CHANGESPARTIAL IMPROVEMENT NO CHANGES 20 / 426 29 / 42620 / 426 29 / 426

(4.69%) (6.81%)(4.69%) (6.81%)

DISCUSIONDISCUSION From our experience, transcanalicular diode laser DCR (TC-DCR) has given us great From our experience, transcanalicular diode laser DCR (TC-DCR) has given us great advantatges, with perfectly acceptable medium and long term results, shared with advantatges, with perfectly acceptable medium and long term results, shared with other authors for primary surgeries or for revision of failures of previous other authors for primary surgeries or for revision of failures of previous procedures(1,2,3,4).procedures(1,2,3,4).

TC-DCR has become a real step to local, short, easy and outcome procedures, TC-DCR has become a real step to local, short, easy and outcome procedures, without resign to achieve a large final drainage, with a similar success rate compared without resign to achieve a large final drainage, with a similar success rate compared with other approaches.with other approaches.

Nowadays is a procedure with short experience, compared to external and Nowadays is a procedure with short experience, compared to external and endonasal endoscopic approaches. But, its respect for nasal structures, no need for endonasal endoscopic approaches. But, its respect for nasal structures, no need for external nor nasal dissections, brief and easy performance once finished learning external nor nasal dissections, brief and easy performance once finished learning curve and the real tolerance of the patients under local anesthesia, allow its indication curve and the real tolerance of the patients under local anesthesia, allow its indication in cases in whom it could not be possible recommend a functional treatment.in cases in whom it could not be possible recommend a functional treatment. In our hands, practice has made possible widen its initial indications (primary In our hands, practice has made possible widen its initial indications (primary post-sacal non acute cases), to revision surgeries, acute cases, or pre-sacal post-sacal non acute cases), to revision surgeries, acute cases, or pre-sacal obstructions.obstructions. The progressive use of diode lasers has to give us more series to validate the The progressive use of diode lasers has to give us more series to validate the results, avoiding comparisons with series done with other kind of lasers (Argon, results, avoiding comparisons with series done with other kind of lasers (Argon, KTP,...), with different physics and behavior (5,6,7)KTP,...), with different physics and behavior (5,6,7)

Initial inconvenience can be equipment costs, higher than the others.Initial inconvenience can be equipment costs, higher than the others.

References

1 J Maeso Riera, Mª T. Sellares Fabres. Dacriocistorinostomia Transcanalicular con laser diodo: Variaciones técnicas y resultados. Acta Otorrinolaringol Esp. 2007;58(1):10-5.2 Alañón Fernández FJ, Alañón Fernández MA, Martinez Fernández A, Cárdenas Lara M. Dacriocsitorinostomia Transcanalicular con láser diodo. Resultados Preliminares. Acta Otorrinolariongol Esp 2004; 55: 171-176.3 Alañón Fernández FJ, Alañón Fernández MA, Martinez Fernández A, Cárdenas Lara M. Dacriocsitorinostomia Transcanalicular con láser diodo. Arch. Soc. Esp. Oftalmol 2004; 79 (7): 325-330.4 Plaza G, Beteré F. Efectividad de la dacriocistorinostomia transcanalicular en el tratamiento del lagrimeo del anciano. Mapfre Medicina, 2005; 16 (2): 66-72.5 J Maeso Riera, Mª T. Sellares Fabres.Dacriocistorrinostomía endocanalicular (DCR-E): importancia de la estandarización de materiales en los resultados. Acta Otorrinolaringol Esp. 2008;59(8):371-6.6 Thomas Ressiniotis, Gerasimos M Voros, Vasilios T Kostakis et al. Clinical outcome of endonasal KTP laser assisted dacryocystorhinostomy. BMC Ophthalmology 2005, 5:27 Thiemo Hofmann, Andreas Lackner, Klaus Muellner et al. Endolacrimal KTP Laser-assisted Dacryocystorhinostomy. Arch Otolaryngol Head Neck Surg. 2003; 129:329-332.

CONCLUSIONSCONCLUSIONS

• Easy and fast techniqueEasy and fast technique

• Minimum local and general traumaMinimum local and general trauma

• Minimum operative and postoperative morbidityMinimum operative and postoperative morbidity

• Good medium and long term resulsGood medium and long term resuls

• Can be repeatedCan be repeated

• Initial indication: Initial indication: primary post-sacal non inflammatory casesprimary post-sacal non inflammatory cases