Name: transcanalicular diode laser-assisted dacryocystorhinostomy for the treatment of primary acquired nasolacrimal duct obstruction
Uploaded: 2017-10-13T12:30:00.000+00:00
Duration: 7 min 30 s
Description: Watch this Scientific Journal Video about Transcanalicular Diode Laser-assisted Dacryocystorhinostomy for the Treatment of Primary Acquired Nasolacrimal Duct Obstruction at JoVE.com

Deutsche Forschungsgemeinschaft (associação alemã de pesquisa; PARA 2240 "Angiogênese (linfa) e imunidade celular em doenças inflamatórias do olho" de LMH; Ele 6743/2-1 e ele 6743/3-1 para LMH), programa GEROK, da Universidade de Colónia para KRK e LMH. Nossa gratidão vai para Dr. Kühner para suporte técnico.

para este procedimento, o consentimento informado é necessário e tenha sido obtido para cada paciente que foi submetido a cirurgia no departamento de Oftalmologia, Universidade de Colónia, Colónia, Alemanha. Todos os exames e intervenções cirúrgicas foram executadas em conformidade com as legislações nacionais e a declaração de Helsínquia de 1975, na sua versão actual.
 Nota: salvo indicação em contrário, as instruções sempre só remeterá para o lado em que o procedimento está sendo executado. Usar equipamento esterilizado.
 1. preparação do paciente <ol><li>realizar um minucioso exame oftalmológico (com especial atenção para as pálpebras, punctum superior e inferior e drenagem da lágrima) incluindo irrigação e sondagem para testar para PANDO 10 .
	<ol><li>Para irrigação padronizada, inserir uma sonda Bangerter superior e, subsequentemente, menor punctum. Começar por inseri-lo na vertical e, em seguida, incline-a em direção ao templo em uma posição horizontal, a seguir a formação fisiológica do canalículo. Quando a sonda está em posição, cuidadosamente injetar soro fisiológico para testar a obstrução do ducto lacrimal. 
		Nota: Em infrasaccal PANDO, a cânula Bangerter facilmente atingirá a parede lateral nasal sem uma resistência saltitante (&#34; parada dura &#34;). Tentar irrigar resultará em refluxo contralateral através o punctum oposto sem qualquer líquido atingindo o paciente &#39; s faringe 10.</li>
	</ol></li> <li>Descartar infecções agudas, tumores do sistema de drenagem, bem como traumático, congênito ou obstrução de presaccal.
	<ol><li>Para descartar infecções agudas, olha para a dolorosa vermelhidão, inchaço ou purulenta descarga de drenagem da lágrima. Para descartar tumores, procure inchaço indolentes, ulceração ou pigmentação. Presaccal obstrução resulta em uma resistência saltitante ao tentar avançar a sonda Bangerter dentro do saco lacrimal (&#34; paragem suave &#34;). Obstrução congênita e traumática pode ser descartada, tendo o histórico do paciente 10 , 19 , 20.</li>
	</ol></li> <li>Descartar patologias rhinological intranasais, desvio de septo, por exemplo, grave. Isso deve ser feito tomando o paciente &#39; história s em combinação com uma rhinological inspeção da cavidade nasal 21.</li>
	<li>Coloca o paciente sob anestesia geral, por exemplo, por inalação de remifentanil desfluran mais intravenosa para manutenção, usando o padrão peso-adaptado de dosagem e injeção intravenosa de propofol e remifentanil atracúrio por indução 10. intubação deve ser realizada, mas também é possível a utilização de uma máscara de laringe. 
	Nota: Anestésicos, bem como as doses podem variar entre clínicas. Nenhum protocolo de anestesia específica é necessário para laser-assisted DCR.</li>
</ol> 2. Laser-assisted DCR <ol><li>Inserir o endoscópio de vídeo-assistida em nasal cavidade avançando com cuidado pela narina. Visualizar a margem anterior do corneto meio inclinando ligeiramente o endoscópio em direção à parede lateral nasal.</li>
	<li>Configurar o equipamento do laser e do laser de configurações para os valores corretos. Usar óculos de proteção.
	<ol><li>Conectar-se o laser de fibra óptica (diâmetro 400 µm) para o laser de diodo (comprimento de onda 810 nm). Definir o diodo laser configurações para 6-8 W, duração de pulso de 200 ms, pausa de exposição de 100 ms.</li>
		<li>a fibra óptica do laser se encaixam a peça de mão para manobras e através de uma cânula romba. Deixe 2 a 3 mm da fibra estique a ponta da cânula.</li>
		<li>Executar carbonização da ponta do laser da fibra, segurando-o em uma espátula de madeira e aplicação de energia de laser por alguns segundos até que a ponta é suficientemente escurecida. 
		Nota: Isto irá limitar a distribuição de energia indesejada no tecido do saco lacrimal.</li>
	</ol></li> <li>Posicionar a fibra laser corretamente na parede lateral nasal.
	<ol><li>Uso um lacrimal sonda para dilatar o punctum inferior ( Figura 2a). Introduzir a sonda em uma orientação vertical no início e depois trazer para uma orientação horizontal antes de avançá-lo ainda mais para o saco lacrimal. Isto permitirá a fibra de laser ser inserido sem problemas na próxima etapa.</li>
		A fibra de laser <li>Inserir o canalículo inferior ( Fig. 2b , 2C). Começar por inseri-lo na vertical e, em seguida, incline-a em direção ao templo em uma posição horizontal para seguir a formação fisiológica do canalículo inferior.</li>
		<li>Avance cuidadosamente a fibra de laser para o saco lacrimal até que toca a parede nasal lateral, ou seja, a parede medial saccal lacrimal. Lá, aponta a ponta no sentido ântero-inferior, para que ele aponta para a margem anterior do corneto meio.</li>
		<li>Verificar o posicionamento correto através do endoscópio, monitorando a transluminescence do feixe visando à altura da margem anterior do corneto meio ( Figura 2d).</li>
	</ol></li> <li>Criar uma suficiente nasolacrimal ultrapassar por aplicação de energia de laser pulsado a parede nasal.
	<ol><li>Aplicar energia de laser (usando o conjunto de parâmetros acima), mantendo contato constante na parede sem pressão, apontando para a margem anterior do corneto no meio. O laser vai vaporizar o tecido diretamente na frente dele, criando um desvio nasolacrimal ( Figura 2d , 2e). 
		Nota: A energia total necessária varia entre 0,9 - 1,8 kJ e tende a variar entre pacientes.</li>
		<li>, Certifique-se de que a ponta de fibra não é ativamente pressionada contra a parede. Tenha cuidado para não deixar a ponta entrar volta a cânula de metal porque isso poderá provocar lesões térmicas devido ao aquecimento do metal. Também evitar movimentos laterais, como a ponta pode quebrar fora</li>
		<li>Após penetrar a parede nasal lateral, puxe um pouco a fibra de laser e ampliar o óstio vaporizando cuidadosamente as margens em uma forma circular. Tente criar um desvio tão grande quanto possível ( Figura 2f).</li>
		<li>Aponta para um diâmetro total de 5 mm para o óstio.</li>
		<li>Parar de aplicar energia e retire a fibra de laser, juntamente com a peça de mão e a cânula, retirando cuidadosamente o equipamento.</li>
	</ol></li> <li>Para verificar a patência do óstio da irrigação salina usando uma sonda Bangerter, conforme descrito em 1.1.1. Se um óstio patente foi criado, irrigação bem sucedida deve ser visível através do endoscópio.</li>
	<li>Remover a sonda Bangerter.</li>
	<li>Colocar o tubo de silicone ( Figura 2 g).
	<ol><li>Através do punctum inferior, inserir um tubo de silicone monocanalicular e avançá-lo cuidadosamente até que a ponta de metal líder passa o óstio ossudo e se projeta para a cavidade nasal.</li>
		<li>Pinça Blakesley uso para pegar a ponta de dentro da cavidade nasal e puxe o tubo de silicone, o nariz e para a posição ( Figura 2h).</li>
		<li>Usar um par de tesouras para encurtar o tubo de silicone. Final não deve estar saindo do nariz.</li>
		<li>Realizar intubação de silício através o canalículo superior também (seguinte percorre 2.7.1 2.7.3) ( Figura 2 h).</li>
	</ol></li> <li>Do endoscópio nasal.</li></ol>
 3. cuidados no pós-operatório e seguimento <ol><li>após a cirurgia, iniciar o tratamento com antibiótico eye cai (por exemplo, ofloxacina), descongestionante colírio (por exemplo, xylometazolin) e colírio de esteroides (por exemplo, acetato de prednisolona). Antibióticos podem ser interrompidos depois de uma semana, enquanto esteroides e colírio descongestionante lentamente deve ser desmamado fora ao longo de um mês.</li>
	<li>De acompanhamento em seis semanas e três meses após a cirurgia. Olha para a resolução dos sintomas, prolapso de tubo de silicone, infecção e secreção.</li>
	<li>Remover tubos de silicone em três meses após a cirurgia, simplesmente agarrar a extremidade em forma de T na altura da partitura e cuidadosamente a tirá-los.</li>
</ol>

<ol>
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Transcanalicular laser-assisted DCR conforme descrito acima é uma maneira bastante rápida, minimamente invasiva para tratar infrasaccal absoluta obstrução de ducto nasolacrimal eficazmente sem a necessidade de incisão na pele, poupando assim não só a pele, mas também a medial tendão Cantal e o mecanismo fisiológico bomba canalicular. Enquanto o procedimento é adequado para pacientes com obstrução do ducto nasolacrimal adquirida primária, patologias que não sejam estenose idiopática não se qualificam para...

Infrasaccal obstrução de ducto nasolacrimal adquirida primária (PANDO) é um distúrbio comum em pacientes de meia-idade e mais velhos, levando a epífora crônica e blefarite, bem como Dacriocistite crônica ou recorrente. Mais comumente, os pacientes desenvolvem uma obstrução infrasaccal de um ou ambos os ductos nasolacrimal, resultando em lágrima insuficiente drenagem.
No tratamento de PANDO, dacryocystorhinostomy externo (DCR) ainda é considerada o padrão-ouro, mesmo que este procedimento historicamente remonta mais de cem anos de quando foi apresentada pela primeira vez1. Após a incisão na pele e preparação da parede nasal do saco lacrimal, uma broca é usada para criar um óstio ósseo levando a cavidade nasal, ignorando assim o ducto obstruído. Taxas de sucesso funcional acima de 85% têm sido relatadas para este método2,3. Estes resultados, no entanto, vem ao custo de execução de um procedimento relativamente invasivo que coloca em risco as estruturas medial da pálpebra, incluindo o mecanismo de bomba canaliculares fisiológicas4,5 e pode deixar os pacientes com um indesejável cicatriz, embora moderno nasojugal incisões na pele melhoraram os resultados. Estes riscos são potencialmente evitáveis, realizando técnicas menos invasivas ou escolhendo uma abordagem endonasal.
A fim de contornar a cirurgia invasiva, tem sido feito muito trabalho no campo da recanalização de drenagem lacrimal minimamente invasiva. Dois métodos em particular se estabeleceram como potenciais primeiro passo procedimentos: microdrill dacryoplasty e dacryoplasty assistida por laser. Estes procedimentos são baseados na endoscopia transcanalicular do sistema de drenagem lacrimal e podem ser realizados para tratar para curto-segmento membranosas estenoses do ducto nasolacrimal. Embora apenas minimamente invasiva e caracterizada por rápida reconvalescence, um inconveniente comum destes recanalizing técnicas são as taxas de sucesso funcional relativamente baixo em relação a longo prazo os resultados6,7, 8 , 9.
Em um esforço para preencher o vazio entre esses procedimentos primeiro passo e DCR externa como um tratamento definitivo, recentemente foram desenvolvidas novas abordagens. A mais promissora do que é o DCR assistida por laser para o tratamento da infrasaccal absoluta PANDO. Como com todas as abordagens acima mencionadas, os pacientes são recomendados para ser colocado sob anestesia geral para este procedimento. Uma fibra de laser de diodo é inserida através de qualquer canalículo e então é avançada para o saco lacrimal. Em seguida, a energia do laser é aplicada na parede lateral nasal até que seja criado um óstio ósseo, conectando a cavidade nasal, na altura do margem anterior10,11 meio do corneto. Enquanto isso, o controle visual constante é mantido usando endoscopia endonasal. A anastomose recém-formado serve como um desvio para a drenagem da lágrima. Após a bem sucedida irrigação, intubação de silício bicanalicular é realizada para evitar cicatrizes no início do recém-formado óstio. Tratamento pós-operatório consiste de descongestionante, esteroide e antibiótico colírio para evitar inchaço, inflamação e infecção, respectivamente.
A duração da cirurgia, bem como reconvalescence é geralmente menor do que com o DCR externo (10-25 min em laser-assisted DCR vs 35-75 min em DCR externa). Taxas de complicação são relativamente baixas, o mais comum sendo discreto inchaço das pálpebras e prolapso de tubo de silicone. Canalicular infecção e lesões térmicas são eventos raros10. Um ano sucesso funcional taxas de 74-88% foram relatados10,11,12,13,14,15,16, 17,18, assim variando pròxima atrás dos DCR externa sem sofrer as desvantagens da abordagem cirúrgica externa. No entanto, os resultados a longo prazo permanecem ainda para ser fornecido. Além disso, mesmo depois de falha de laser-assisted DCR, DCR externa secundária ainda pode ser executada sem dificuldade. Consequentemente, assistida por laser DCR qualifica-se como um procedimento de segundo-passo viável que idealmente deve ser realizado após a falha da cirurgia de recanalização e antes DCR externa.

<table><tbody><tr><td>C1.multi</td><td>LUT</td><td>05.0082h.1</td><td>Endoscope camera</td></tr><tr><td>HL 250</td><td>LUT</td><td>95.2048n</td><td>Endoscope light source</td></tr><tr><td>MD-19E</td><td>ACL GmbH</td><td>1119</td><td>Endoscope screen</td></tr><tr><td>FOX (laser)</td><td>A.R.C. Laser GmBH, N&amp;uuml;rnberg, Germany</td><td>n/a</td><td>Diode laser</td></tr><tr><td>Laser fiber</td><td>A.R.C. Laser GmBH, N&amp;uuml;rnberg, Germany</td><td>LL13001s</td><td>Laser fiber</td></tr><tr><td>Laser handpiece</td><td>A.R.C. Laser GmBH, N&amp;uuml;rnberg, Germany</td><td>n/a</td><td>Handpiece</td></tr><tr><td>Wide Collarette Monoka</td><td>Fa. FCL, Paris, France</td><td>S1.1630</td><td>monocanalicular silicon tube</td></tr><tr><td>Suction elevatorium</td><td>Storz</td><td>474015</td><td>For intranasal use</td></tr><tr><td>Forceps (Gr&amp;uuml;nwald)</td><td>Storz</td><td>426620</td><td>For intranasal use</td></tr><tr><td>Forceps (Blakesley-Wilde)</td><td>Storz</td><td>456502</td><td>To grab the silicon tube</td></tr><tr><td>Lacrimal canula</td><td>Storz</td><td>81071</td><td>Blunt cannula</td></tr><tr><td>Bangerter probe cannula</td><td>Storz</td><td>81055</td><td>Bangerter probe cannula</td></tr><tr><td>Wooden spatula</td><td>any</td><td>n/a</td><td>Wooden spatula</td></tr><tr><td>Xylometazolin 0.05% eye drops</td><td>GlaxoSmithKline Consumer Healthcare</td><td>n/a</td><td>Decongestant eye drops</td></tr><tr><td>Dexapos comod eye drops</td><td>Ursapharm</td><td>n/a</td><td>steroid eye drops</td></tr><tr><td>Floxal eye drops</td><td>Dr. Gerhard Mann</td><td>n/a</td><td>antibiotic eye drops</td></tr></tbody></table>

transcanalicular diode laser-assisted dacryocystorhinostomy for the treatment of primary acquired nasolacrimal duct obstruction

Padrão-ouro de hoje no tratamento de obstrução de ducto nasolacrimal adquirida primária infrasaccal (PANDO) é externo dacryocystorhinostomy (DCR), um procedimento relativamente invasivo que pode ser realizado após a falha de recanalizing tratamentos. No entanto, com o progresso no campo da tecnologia de laser de diodo, surgiram novas abordagens. Assistida por laser transcanalicular DCR com intubação de silício bicanalicular subsequente é uma nova opção mostrando grande promessa como um procedimento minimamente invasivo viável. Sob permanente controle visual endoscópico da cavidade nasal, uma fibra de laser de diodo é inserida no saco lacrimal e a energia do laser é aplicada para criar um óstio ósseo entre o saco lacrimal e a cavidade nasal. Uma vez que não há incisão de pele precisa ser feita, vantagens desse método compreendem os poupadores da pele, bem como as estruturas palpebrais medial e o mecanismo fisiológico da bomba palpebral-canalicular. A duração da cirurgia, bem como reconvalescence é geralmente menor do que com DCR externa. As complicações incluem o prolapso de tubo de silicone, inchaço leve e, raramente, infecção canalicular e lesões térmicas. Taxas de sucesso funcional de um ano, definidas como completa resolução dos sintomas e a patência do óstio, são altas, ainda assim gama atrás dos DCR externa. No entanto, DCR externa secundária após fracasso da DCR assistida por laser pode ser realizada sem dificuldade. Assim, assistida por laser transcanalicular DCR é uma opção válida e que deve ser considerada como um segundo passo após falha dos processos de recanalização e antes DCR externa.

Resultado ideal:
O procedimento conforme descrito acima leva cerca de 10-25 min e é geralmente tolerado muito bem. Ao exame no dia seguinte, um pequeno inchaço da pálpebra pode estar presente em cerca de 60% dos casos. Este pequeno inchaço sempre resolve completamente num prazo máximo de três dias. Pacientes não reclamar de dor, prolapso de silício ou sinais de lesão ou infecção. No entanto, devido a intubação de silí...

Watch this Scientific Journal Video about Transcanalicular Diode Laser-assisted Dacryocystorhinostomy for the Treatment of Primary Acquired Nasolacrimal Duct Obstruction at JoVE.com

Transcanalicular Diode Laser-assisted Dacryocystorhinostomy for the Treatment of Primary Acquired Nasolacrimal Duct Obstruction

O objetivo do presente protocolo é apresentar transcanalicular assistida por laser dacryocystorhinostomy como uma abordagem minimamente invasiva no tratamento da obstrução do ducto nasolacrimal adquirida primária.

Transcanalicular diodo Laser-assisted Dacryocystorhinostomy para o tratamento da primária adquiriu a obstrução do ducto Nasolacrimal

Today&#39;s gold standard in the treatment of infrasaccal primary acquired nasolacrimal duct obstruction (PANDO) is external dacryocystorhinostomy (DCR), ...

transcanalicular-diode-laser-assisted-dacryocystorhinostomy-for

Research

JoVE Journal

Medicine

10.9K visualizações.  University of Cologne. O objetivo do presente protocolo é apresentar transcanalicular assistida por laser dacryocystorhinostomy como uma abordagem minimamente invasiva no tratamento da obstrução do ducto nasolacrimal adquirida primária.

Vídeo: Transcanalicular Diode Laser-assisted Dacryocystorhinostomy for the Treatment of Primary Acquired Nasolacrimal Duct Obstruction

Canalostomy As a Surgical Approach to Local Drug Delivery into the Inner Ears of Adult and Neonatal Mice

Local delivery of therapeutic drugs into the inner ear is a promising therapy for inner ear diseases. Injection through semicircular canals (canalostomy) has been shown to be a useful approach to local drug delivery into the inner ear. The goal of this article is to describe, in detail, the surgical techniques involved in canalostomy in both adult and neonatal mice. As indicated by fast-green dye and adeno-associated virus serotype 8 with the green fluorescent protein gene, the canalostomy facilitated broad distribution of injected reagents in the cochlea and vestibular end-organs with minimal damage to hearing and vestibular function. The surgery was successfully implemented in both adult and neonatal mice; indeed, multiple surgeries could be performed if required. In conclusion, canalostomy is an effective and safe approach to drug delivery into the inner ears of adult and neonatal mice and may be used to treat human inner ear diseases in the future.

Here we describe canalostomy procedure which allows local drug delivery into the inner ears of adult and neonatal mice through the semicircular canal with minimum damage to hearing and vestibular function. This method can be used to inoculate viral vectors, pharmaceuticals, and small molecules into the mouse inner ear.

Canalostomy como uma abordagem cirúrgica para entrega de drogas para o ouvido interno de ratos adultos e Neonatal

Local delivery of therapeutic drugs into the inner ear is a promising therapy for inner ear diseases. Injection through semicircular canals (canalostomy) ...

Genética

Ultrasound Cyclo Plasty in Eyes with Glaucoma

Glaucoma is a chronic disease caused by the progressive degeneration of the optical nerve fibers, resulting in decreased visual field that can lead to severe visual impairment, and eventually blindness. This manuscript describes a simple, surgeon-friendly, non-incisional technique, named Ultrasound Cyclo Plasty (UCP), for reducing intraocular pressure (IOP) in glaucoma patients. The technique determines a selective coagulation necrosis of the ciliary body; in addition, the stimulation of supra-choroidal and trans-scleral portions of the uveo-scleral outflow pathway has been recently proposed. UCP shows several technical improvements in ultrasound technology compared to previous techniques, providing more precise focusing on the target zone. The procedure is performed in the operating room under peribulbar anesthesia. Briefly, the coupling cone is put in contact with the eye and the ring probe, that contains six piezoelectric transducers which produce the ultrasound beams, is inserted inside it. Their proper centering over the ocular surface represents a crucial step for the correct targeting of the ciliary body. Sterile balanced salt solution is used to fill the empty spaces to ensure ultrasound acoustic propagation. Surgical treatment consists in the sequential automatic activation of each of the six transducers, for a total duration of less than 3 min. The patient leaves the hospital 1 h after the procedure with the treated eye patched. In the present study, 10 patients with open-angle glaucoma were followed-up during at least 12 months after the procedure. IOP was reduced at each interval compared to pre-operative, as well as the number of hypotensive medications. Twenty percent of patients did not respond to the treatment, and needed subsequent surgery to better control IOP. Treatment tolerability was good, with no cases of hypotony or phthisis. The UCP procedure is simpler, faster, safer, and less invasive than traditional cyclodestructive procedures with similar results in reducing IOP.

Glaucoma is a chronic disease with progressive degeneration of optic nerve fibers resulting in decreased visual field. Elevated intraocular pressure is considered the most important and the only treatable risk factor. This manuscript describes a simple, surgeon-friendly, non-incisional technique, named Ultrasound Cyclo Plasty, for reducing intraocular pressure in glaucoma patients.

Ultra-som Cyclo Plasty nos olhos com Glaucoma

Glaucoma is a chronic disease caused by the progressive degeneration of the optical nerve fibers, resulting in decreased visual field that can lead to ...

Comportamento

Surgical Induction of Endolymphatic Hydrops by Obliteration of the Endolymphatic Duct

Surgical induction of endolymphatic hydrops (ELH) in the guinea pig by obliteration and obstruction of the endolymphatic duct is a well-accepted animal model of the condition and an important correlate for human Meniere's disease. In 1965, Robert Kimura and Harold Schuknecht first described an intradural approach for obstruction of the endolymphatic duct (Kimura 1965). Although effective, this technique, which requires penetration of the brain's protective covering, incurred an undesirable level of morbidity and mortality in the animal subjects. Consequently, Andrews and Bohmer developed an extradural approach, which predictably produces fewer of the complications associated with central nervous system (CNS) penetration.(Andrews and Bohmer 1989) 
The extradural approach described here first requires a midline incision in the region of the occiput to expose the underlying muscular layer. We operate only on the right side. After appropriate retraction of the overlying tissue, a horizontal incision is made into the musculature of the right occiput to expose the right temporo-occipital suture line. The bone immediately inferio-lateral the suture line (Fig 1) is then drilled with an otologic drill until the sigmoid sinus becomes visible. Medial retraction of the sigmoid sinus reveals the operculum of the endolymphatic duct, which houses the endolymphatic sac. Drilling medial to the operculum into the area of the endolymphatic sac reveals the endolymphatic duct, which is then packed with bone wax to produce obstruction and ultimately ELH. 
In the following weeks, the animal will demonstrate the progressive, fluctuating hearing loss and histologic evidence of ELH.

This video shows how to surgically obstruct the guinea pig's endolymphatic duct to produce endolymphatic hydrops.

Indução cirúrgica da hidropisia endolinfática por obliteração do ducto endolinfático

Surgical induction of endolymphatic hydrops (ELH) in the guinea pig by obliteration and obstruction of the endolymphatic duct is a well-accepted animal ...

Biologia

An &#8220;All-laser&#8221; Endothelial Transplant

The &#8220;all laser&#8221; assisted endothelial keratoplasty is a procedure that is performed with a femtosecond laser used to cut the donor tissue at an intended depth, and a near infrared diode laser to weld the corneal tissue. The proposed technique enables to reach the three main goals in endothelial keratoplasty: a precise control in the thickness of the donor tissue; its easy insertion in the recipient bed and a reduced risk of donor lenticule dislocation. The donor cornea thickness is measured in the surgery room with optical coherence tomography (OCT), in order to correctly design the donor tissue dimensions. A femtosecond laser is used to cut the donor cornea. The recipient eye is prepared by manual stripping of the descemetic membrane. The donor endothelium is inserted into a Busin-injector, the peripheral inner side is stained with a proper chromophore (a water solution of Indocyanine Green) and then it is pulled in the anterior chamber. The transplanted tissue is placed in the final and correct location and then diode laser welding is induced from outside the eyeball. The procedure has been performed on more than 15 patients evidencing an improvement in surgery performances, with a good recovery of visual acuity and a reduced donor lenticule dislocation event.

An all laser procedure is proposed in the endothelial transplant. The surgical technique is based on the use of a femtosecond laser to prepare the donor tissue. Laser welding technique is then used to secure the donor endothelium in the correct position.

Um &quot;All-a laser&quot; Endotelial Transplant

The &#8220;all laser&#8221; assisted endothelial keratoplasty is a procedure that is performed with a femtosecond laser used to cut the donor tissue at an ...

Medicina

Establishment of a Severe Dry Eye Model Using Complete Dacryoadenectomy in Rabbits

Dry eye disease (DED) is a complex disease with multiple etiologies and variable symptoms, having ocular surface inflammation as its key pathophysiologic step. Despite advances in our understanding of DED, significant knowledge gaps remain. Advances are limited in part due to the lack of informative animal models. The authors recently reported on a method of DED induced by injecting all orbital lacrimal gland (LG) tissues with the lectin concanavalin A. Here, we report a novel model of aqueous-deficient DED based on the surgical resection of all orbital LG (dacryoadenectomy) tissues. Both methods use rabbits because of their similarity to human eyes in terms of the size and structure of the ocular surface. One week after removal of the nictitating membrane, the orbital superior LG was surgically removed under anesthesia, followed by removal of the palpebral superior LG, and finally removal of the inferior LG. Dacryoadenectomy induced severe DED, evidenced by a marked reduction in the tear break up time test and the Schirmer&#39;s tear test, and significantly increased tear osmolarity and rose bengal staining. Dacryoadenectomy-induced DED lasted at least eight weeks. There were no complications and animals tolerated the procedure well. The technique can be mastered relatively easily by those with adequate surgical experience and appreciation of the relevant rabbit anatomy. Since this model recapitulates the features of human aqueous-deficient DED, it is suitable for studies of ocular surface homeostasis, DED, and candidate therapeutics.

A novel approach is presented to induce chronic dry eye disease in rabbits by surgically removing all orbital lacrimal glands. This method, distinct from those previously reported, produces a stable, reproducible model of aqueous deficient dry eye well suited to study tear physiology and pathophysiology and ocular therapeutics.

Estabelecimento de um modelo severo do olho seco usando dacryoadenectomy completo nos coelhos

Dry eye disease (DED) is a complex disease with multiple etiologies and variable symptoms, having ocular surface inflammation as its key pathophysiologic ...

Endaural Endoscopic Atticoantrotomy (Retrograde Mastoidectomy) using a Constant Suction Bone-drilling Technique

Endoscopic middle ear surgery is a widely employed minimally invasive surgical technique to address middle ear and mastoid pathology. Bone drilling is the main technical challenge of endoscopic middle ear surgery. The accompanying video describes the detailed protocol of a constant-suction bone-drilling technique and the procedure of endaural exclusive endoscopic atticoantrotomy (retrograde mastoidectomy) using this technique. The main components of this bone-drilling technique include a soft and flexible suction tube, which is placed into the tympanic cavity to provide constant suction, and a soft sleeve, which is wrapped around the drill shaft to prevent the high-speed rotating shaft from damaging the lens of the endoscope. With these simple modifications, the traditional otological electrodrill can be used for drilling a tiny endaural incision in endoscopic middle ear surgery. Based on this bone-drilling technique, endaural endoscopic atticoantrotomy (retrograde mastoidectomy) can be successfully established for the removal of various amounts of bone, depending on the extent of the lesion. The short-term postoperative outcome seems promising.

Endaural Endoscopic Atticoantrotomy Retrograde Mastoidectomy using a Constant Suction Bone-drilling Technique

In this paper, we present the protocol and short-term outcomes of endaural exclusive endoscopic atticoantrotomy using a constant suction bone-drilling technique.

Atticoantrotomia endaural endoscópica (Mastoidectomia Retrógrada) usando uma técnica de perfuração óssea de sucção constante

Endoscopic middle ear surgery is a widely employed minimally invasive surgical technique to address middle ear and mastoid pathology. Bone drilling is the ...

The Microscopic Transcanal Approach in Stapes Surgery Revisited

The microscopic transcanal (aka transmeatal) surgical approach was first described in the 60s, offering a minimally invasive means of reaching the external auditory canal, the middle ear, and epitympanon. Such an approach avoids a retroauricular or endaural skin incision; however, working through a narrow space needs angled microsurgical instruments and specific training in otologic surgery. The transcanal approach restricts the working space; however, it offers a binocular microscopic vision into the middle ear without extended skin incisions and thus, reducing post-operative pain and bleeding. In addition, this minimally invasive approach avoids scar tissue complications, hypoesthesia of the auricle, and potential protrusion of the pinna. Despite its numerous advantages, this method is still not routinely performed by otologic surgeons. Since this minimally invasive technique is more challenging, there is a need for extensive training in order for it to be widely adopted by otologic surgeons. This article provides step-by-step surgical instructions for stapes surgery and reports possible indications, pitfalls, and limitations using this microscopic transcanal technique.

This article describes the microscopic transcanal technique for stapes surgery, providing step-by-step surgical instructions for familiarizing surgeons with this approach.

A Abordagem Transcanal Microscópica na Cirurgia do Estribo Revisitada

The microscopic transcanal (aka transmeatal) surgical approach was first described in the 60s, offering a minimally invasive means of reaching the ...

Endolymphatic Duct Blockage as a Surgical Treatment Option for M&#233;ni&#232;re's Disease

Endolymphatic duct blockage is a relatively new treatment option for M&#233;ni&#232;re's disease, aiming to reduce vertigo attacks while sparing hearing and equilibrium. After a regular mastoidectomy, the posterior semicircular canal is identified, and Donaldson's line is determined. This is a line through the horizontal semicircular canal, crossing the posterior semicircular canal. The endolymphatic sac is usually found at this site under the posterior semicircular canal. The bone of the endolymphatic sac and the dura are thinned until the sac is skeletonized, after which the endolymphatic duct is identified. The duct is then blocked with a titanium clip. Using a computerized tomography (CT) scan, the position is confirmed. Follow-up visits take place 1 week, 6 weeks and 1 year after surgery. To this day, only one prospective trial assessing this method has been conducted, comparing this new method to endolymphatic sac decompression. Results of the duct blockage are promising, with 96.5% of the patients free of vertigo after 2 years. However, further research is required.

Endolymphatic duct blockage is a relatively new surgical method for patients suffering from M&#233;ni&#232;re's disease. Following a regular mastoidectomy, the endolymphatic duct is identified and ligated using a regular titanium hemoclip. The effectiveness of this procedure is currently being assessed in a randomized trial.

Bloqueio do Ducto Endolinfático como Opção de Tratamento Cirúrgico da Doença de Ménière

Endolymphatic duct blockage is a relatively new treatment option for M&#233;ni&#232;re's disease, aiming to reduce vertigo attacks while sparing hearing ...

Robot-Assisted Transcanal Endoscopic Ear Surgery for Congenital Cholesteatoma

Congenital cholesteatoma accounts for 25% of cholesteatoma cases in children. Transcanal Endoscopic Ear Surgery (TEES) is ideal for these patients because it offers a wide endoscopic view of the middle ear and a minimally invasive approach. The two main limitations are the loss of one operative hand and a narrow external auditory canal in younger children. Here, we present the case of a 3-year-old patient with a Potsic stage III congenital cholesteatoma adherent to the incus and branches of the stapes. A robotic-assisted TEES procedure was performed, during which a robotic arm with 6 degrees of freedom held a 0&#176;, 2.9 mm wide endoscope, enabling the surgeon to work in a narrow environment with both hands. The procedure's duration was 2 h and 9 min, including 16 min for the installation and draping of the robotic arm. After a trans-canal approach, the cholesteatoma was dissected from the ossicles using both a needle (or sickle knife) and suction to stabilize the ossicles and limit the risk of hearing trauma. The cholesteatoma was debulked to reduce its size, allowing it to be pushed under the malleus anteriorly and then separated from other adherences before removal. A tragal cartilage graft was used to reinforce the tympanic membrane.

This protocol describes the removal of congenital cholesteatoma using minimally invasive transcanal endoscopic ear surgery with a two-handed approach and a robotic endoscope holder.

Cirurgia Endoscópica Robótica Transcanal da Orelha para Colesteatoma Congênito

Congenital cholesteatoma accounts for 25% of cholesteatoma cases in children. Transcanal Endoscopic Ear Surgery (TEES) is ideal for these patients because ...

Nasolacrimal Lavage as a Treatment for Ocular Surface Toxic Soup Syndrome

Ocular surface toxic soup syndrome (OSTSS) is characterized by inadequate tear drainage through the nasolacrimal duct system, leading to the accumulation of inflammatory mediators in the tear film. This condition can result in toxic keratoconjunctivitis, with symptoms such as conjunctival hyperemia, itchiness, discomfort, and epiphora. Dilation and irrigation are common diagnostic procedures in both optometry and ophthalmology, used to assess nasolacrimal duct obstruction in cases of epiphora. This technique involves the injection of saline into the nasolacrimal duct system through the puncta, followed by the evaluation of reflux, which indicates obstruction. Although intended to be diagnostic, many patients report significant improvements in epiphora and ocular comfort after the procedure. In this paper, we present a case study in which a patient achieved complete resolution of epiphora and itchiness following therapeutic nasolacrimal lavage performed every 2 months. Subjective improvements in symptoms in 3 additional patients are also reported. We propose nasolacrimal lavage not only as a diagnostic tool but also as an effective therapeutic intervention for managing OSTSS.

OSTSS leads to pooled inflammatory mediators in the tear film, causing symptoms like epiphora and discomfort. Here, we present a case where therapeutic nasolacrimal lavage every 2 months resolved epiphora and itchiness, suggesting its efficacy as a therapeutic intervention for OSTSS. Additionally, we report subjective improvements in symptoms in 3 additional patients.

Lavagem nasolacrimal como tratamento para a síndrome da sopa tóxica da superfície ocular

Ocular surface toxic soup syndrome (OSTSS) is characterized by inadequate tear drainage through the nasolacrimal duct system, leading to the accumulation ...