Diagnosis and therapy of lacrimal system diseases by micro lacrimal endoscope

Abstract

The lacrimal endoscope is applied to the diagnosis and therapy of the disorders of the lacrimal system in combination with laser or micro drills under orthophoria. The changes of mucous membranes, the characteristics of pathological changes and the predilection sites of lacrimal system diseases were initially approached. One hundred and forty six pairs of eyes of 128 patients with lacrimal system disease were observed by the lacrimal endoscope in the Ophthalmology Department of Tongji Hospital from June 2006 to March 2007. The dynamic changes in mucous membranes, lesion sites, secreted substances and formation of membrane could be observed under orthophoria. Combined with laser or micro drill, the endoscope was applied to the therapy of lacrimal system disorders and the difference before and after the treatment was observed. Results are as follows: (1) The examination and therapy using the lacrimal endoscope were completed under topical anesthesia in 122 patients, and 6 patients of neonatorum dacryocystitis were examined and treated under general anaesthesia. All patients reported painless. (2) Sharp images of the lacrimal system were obtained by the endoscope. Normal lacrimal mucosal membrane was smooth and light pink, expanded and unobstructed during irrigation. In chronic dacryocystitis patients, the inhomogeneous colour of mucosal membranes was red and white, with different degrees of fibrotic membranes at the superior, middle and inferior parts of the nasolacrimal canals and secreted substances at sac could be observed. The lacrimal ducts could not be expanded and obstructed during irrigation. The patients with lacrimal system obstruction had different extents of membrane formation, and stenosis or complete obstruction of the lacrimal duct could be observed, and the corresponding mucosal membrane was not smooth which could not be expanded and obstructed during irrigation. (3) After the treatment by the endoscope combined with laser or micro drill, the major proliferation of the membrane disappeared and the lacrimal duct was unobstructed during irrigation. The cure rate and effective rate were 80.1% and 93.1%, respectively. The lacrimal endoscope is a new method in the diagnosis of lacrimal system diseases. Through a combination with laser or micro drill to carry out the therapy under orthophoria, it will bring a great change to the diagnosis and therapy of lacrimal system diseases.

Keywords

lacrimal apparatus diseases / endoscopes

Introduction

Lacrimal disease is a common disease of ophthalmology, but there is difficulty in the diagnosis and treatment for lacrimal disease in ophthalmology, because of the high incidence and low cure rate of the disease, and no substantively new ideas in the long term. Clinically, primary diagnosis is carried out only through the irrigation of the lacrimal passage. The pathological sites of lacrimal system diseases can be identified by a lacrimal visualization and imaging system, but the patients would not accept that kind of examination because of complicated operation, high cost and the fact that it could not be treated simultaneously. As a traditional lacrimal surgery, dacryocystorhinostomy is not accepted by young patients because of comparatively more damage, easy bleeding and facial scar that result from the operation. In recent years in other countries, especially in Germany, the micro lacrimal endoscope has been applied for exact diagnosis and treatment of the disorders of lacrimal system at the same time because the structure of lacrimal system and the changes of mucous membranes can be observed under orthophoria. With the improvement and development of technology, new types of lacrimal endoscope brings about great improvement in the diagnosis and therapy of lacrimal disorders [1-7]. The micro lacrimal endoscope was first applied in our hospital to observe disorders of the lacrimal system, analyze the pathological characteristics and treat the disease by a combination of laser or micro drill under orthophoria. The changes of the mucous membranes, pathological characteristics and the predilection sites of lacrimal system diseases are discussed first in this paper.

Data and methods

Clinical data

From June 2006 to March 2007, 146 eyes of 128 patients with lacrimal system disease (32 males, 96 females) were observed by the micro lacrimal endoscope in the Ophthalmology Department of the Tongji Hospital in Wuhan, China. The average age was (32.4 ± 7.6) years old, ranging from 3 months to 73 years. There were 6 cases (6 eyes) with neonatorum dacryocystitis, 20 cases (28 eyes) with chronic dacryocystitis, and 102 cases (112 eyes) with obstruction of lacrimal ducts.

Methods

Lacrimal endoscopy (PolyDiagnost Endognost LS200, Germany) was applied to all patients to observe the changes of the mucous membranes, diseased regions, secreted substances and formation of membrane under orthophoria and the difference before and after the treatment. The probe of the endoscope has three tubes, including light, photographing and working tubes. One tube goes through the fibers of the endoscope, one links to irrigation equipment, and the intermediate tube is the working tube that can link to the laser fiber or micro drill.

The procedures are as follows: the upper punctum was dilated by a punctum dilator, and a micro endoscope was inserted into the canaliculus and the dacryocyst, and then resisted by the nasal bone and rotated into the nasal cavity. Persistent irrigation was required during the whole process to maintain a clear picture. All lacrimal system mucous membranes in the punctum, canaliculus, dacryocyst and canalis nasolacrimalis could be observed clearly, the inflammatory changes of mucous membranes, stenosis and scars could be defined or located exactly under orthophoria, and recorded and saved at the same time.

Results

Diagnosis and therapy of lacrimal disease by lacrimal endoscope

The examination and therapy using the lacrimal endoscope were completed under topical anesthesia in 122 patients, and 6 patients of neonatorum dacryocystitis were examined and treated under general anesthesia. Because of the advantages of quickness, minimal injury, and easy operation, all patients reported painlessness, and clear images could be obtained under the endoscope. We examined 2 chronic dacryocystitis cases with recurrence after dacryocystorhinostomy. In one case, we found under orthophoria that the scar and proliferation membrane had formed in the stoma, and moved like a flap during irrigation. The patient was cured after laser treatment, the scar disappeared and lacrimal duct was smooth and easy to irrigate. In another case, stoma could not be seen during the surgery, and the bone structure filled in the stoma under endoscopic examination. Then, the patient was treated by laser probing combined with tube insertion.

Mucosa membrane image of lacrimal system in lacrimal endoscope

The sharp images of lacrimal system could be achieved by endoscopy. The normal mucosal membrane in the lacrimal duct was smooth and light pink. The lacrimal duct could be expanded and was unobstructed during irrigation, and a ring-shaped reductus could be seen in a part of the canaliculus lacrimalis and canalis nasolacrimalis. In the patients with lacrimal passage obstruction, different extents of the membrane formation, stenosis or complete obstruction could be observed, and the corresponding mucosa membrane was unsmooth, which could not be expanded and was obstructed during irrigation. In patients with chronic dacryocystitis, the nonhomogeneous color of mucosa membranes was red and white, membranes of different degrees in the superior, middle and inferior of nasolacrimal canals could be found, and secreted substances moving obviously during irrigation could be observed. The lacrimal ducts could not be expanded and was obstructed during irrigation (Fig. 1).

Lesion sites of lacrimal system diseases and effect analysis after therapy by lacrimal endoscope

We found obstruction of the lacrimal canaliculus in 33 eyes of lacrimal obstruction patients (33/146, 22.6%), which were all treated by laser lacrimal system plasty and partly combined with tube insertion. One hundred and thirteen eyes in patients with obstruction of canalis nasolacrimalis (113/146, 77.4%), including 68 eyes of superior segment obstruction (68/146, 46.2%), 17 eyes of middle segment obstruction (17/146, 11.8%), and 28 eyes of inferior segment obstruction (28/146, 19.4%), were all treated by lacrimal passage plasty with laser or micro drill and combined with TobraDex Gel insertion into lacrimal system, and partly combined with tube insertion. Observation before and after the treatment in lacrimal endoscope showed: most fibrotic membranes disappeared and lacrimal duct was unobstructed during irrigation after treatment with laser or micro drill in lacrimal endoscope (Fig. 2).

Effect analysis on patients with lacrimal passage obstruction was performed six months (or more) after the therapy (Table 1). The cure rate and effective rate were 80.1% and 93.1%, respectively. Therapeutic effect judgment standard is as follows: (1) cure: there was no complaint of epiphora and purulent secretion, and it was easy and to wash lacrimal passages and they were smooth; (2) improvement: there was no purulent secretion; it was difficult to wash lacrimal passages but they were unobstructed; (3) invalid: there was no improvement in symptom; it was difficult to wash lacrimal passages and they are obstructed. Effective rate was cure rate plus improvement rate.

Discussion

Application of lacrimal endoscope in lacrimal system diseases

Ophthalmology endoscope was patented in 1950, and has been applied in clinics. Lacrimal endoscope provides a new way in diagnosis and therapy of lacrimal system diseases, such as obstruction, inflammation, trauma, extraneous material, tumor　and　fistulae of lacrimal passage. By using lacrimal endoscope to observe the structure of lacrimal passage and mucosa, the lacrimal passage obstruction can be exactly located, diagnosed, and treated at the same time. It can almost be used for all of the lacrimal system diseases, to analyze the cause of recurrence after operation, and make the strategy of therapy. In two cases of relapse after dacryocystorhinostomy, the causes of recurrence were found by it, and then the different strategy of therapy was made. The operation of lacrimal endoscope was simple. Lacrimal endoscope has satisfying lighting and clear image. By using lacrimal endoscope, morphologic image of lacrimal passage could be observed, pathological tissue could be obtained and tube intubation could be performed, and therapy combined with laser and electrodrill could be completed under orthophoria. Because of the minimal damage and the optimal curative effect, it is the best way to treat the lacrimal system diseases up to now [8,9]. But it should be used carefully in acute dacrocystitis. The diameter of micro lacrimal endoscope detecting head is small in our research, and has three different types: 0.75 mm, 0.90 mm and 1.1 mm, which can be applied in patients at different ages. It can be inserted into lacrimal passage completely and reach anywhere of the lacrimal passage. Through the amplifying effect of displayer, we can see the tiny transform of lacrimal under orthophoria, and get the clear image of it. It can also be applied in clinic, teaching and research through making photographic recording.

Observation of mucous membrane under lacrimal endoscope

Under the lacrimal endoscope, we can see the normal image of mucous membrane. The normal mucous membrane is smooth and light red. The lacrimal ductule and lacrimal canal have circular round reductus. when they are flushed, the caliber of lacrimal passage are broaden, and unobstructed. Through lacrimal endoscope, lesion can be found easily, such as obstruction, stricture etc. Gray membrane, and lacrimal passage completely or partly obstructed by the gray membrane can be observed by lacrimal endoscope. The caliber of lacrimal passage can not be broadened when the lacrimal passage was flushed. The place of obstruction can be located exactly by lacrimal endoscope, and differentially diagnosed. The acute and chronic inflammation, complete and part obstruction can be identified. The lacrimal mucous membrane is apparently gray in the chronic inflammation and thickening, congested in the acute. The mucous membrane of lacrimal ductule and lacrimal canal is unsmooth, and gray membrane construction in different degree exists, the caliber of lacrimal passage cannot be broadened. Lacrimal sac is dilated obviously, and the colour of mucous membrane is uneven, presenting in red or congestion. When it is adhered with secreta, the secreta can move obviously if it is flushed. Through the lacrimal endoscope, the morphology image of lacrimal passage can be obtained in the first time, and the tissue can be taken under orthophoria. It provides a new method to research the occurrence and development of lacrimal system diseases [10].

Location and treatment by lacrimal endoscope under orthophoria

Lacrimal passage obstruction is the most common disease in ophthalmology. Machine or laser used to be chosen to probe the lacrimal passage obstruction before lacrimal sac. We found abnormal membrane was the most common reason of lacrimal passage obstruction before lacrimal sac under the lacrimal endoscope, scar took second place. Obstruction of membrane did not need over high treating energy of laser, the obstruction place can be observed straightly and the blasting or heat effect of laser was utilized to perform lacrimal system plasty and the damage was minimal. We choose holmium laser and Nd-YAG laser differently, finding that holmium laser was easier to break the membrane obstruction under the water. But, if we did it without visualization, the energy of laser was usually over high, and inclined to form a false passage, on the other hand, too high energy would damage more tissue, resulting in serious inflammation reaction, formation of many scars, re-obstruction of lacrimal passage. Lacrimal passage obstructed by scars needed more energy of laser, thus resulting in more damage to lacrimal passage, and numerous scar formations after operation, the increase of re-obstruction ratio. It is shown: the most important factor of success for treating lacrimal obstruction by laser of endoscope is not the place, but the length of obstruction. When there is slight membrane obstruction, the rate of success is up to 100%. When the length of obstruction is less than 2 mm, the rate of success is 84.2% only, otherwise, it is less than 50%, and meanwhile, it has more chances of bleeding and penetration of the wall of lacrimal ductule during the operation [11]. So, we choose micro-electrodrill lacrimal plasty with tube insertion.

For chronic dacrocystitis in which lacrimal passage obstruction is after lacrimal sac, the traditional treating method is dacryocystorhinostomy. But, in 113 eyes with obstruction of nasolacrimal duct, different degrees of stenosis and obstruction were found at different places of nasolacrimal duct, most of which were still membranous obstruction. We choose laser or micro-electrodrill lacrimal plasty with drug (TobraDex Gel) or tube insertion into lacrimal system. Furthermore, some researches [12-14] showed dacryocystorhinostomy can be replaced completely by dacryocystostomy through lacrimal passage with endoscope. It has some advantages: no cut in facial skin and scar after it; minimal damage in tissue, and less bleeding; corresponding easier operation, shorter persistence time; other lesions of lacrimal passage can be found simultaneously.

In summary, lacrimal endoscope is the most accurate method to diagnose the diseased region of lacrimal passage, and can evaluate the change of lacrimal membrane, judge the obstruction characteristics, and make the concrete treatment strategy.

References

[1] PifarettiJ M. Endoscopy of the lacrimal ducts. Klin Monatsbl Augenheilkd, 1998, 212(5): 259-260

[2] MullnerK. Opening of lacrimal duct stenoses with endoscope and laser. Ophthalmologe, 1998, 95(7): 490-493

[3] MullnerK, BodnerE, MannorG E. Endoscopy of the lacrimal system. Br J Ophthalmol, 1999, 83(8): 949-952

[4] SensF M, RolP O, YanarA, RobertY C. Rigid GRIN-endoscope for endoscopy of the tear ducts. Klin Monatsbl Augenheilkd, 2000, 216(5): 301-304

[5] SensF M, RolP O, YanarA, RobertY C. Lacrimal duct endoscopy with the rigid GRIN endoscopy. Ophthalmologe, 2000, 97(6): 418-421

[6] EmmerichK H, UngerechtsR, Meyer RusenbergH W. Possibilities and limits of minimal invasive lacrimal surgery. Orbit, 2000, 19(2): 67-71

[7] EmmerichK H, Meyer-RusenbergH W. Endoscopic lacrimal duct surgery. Ophthalmologe, 2001, 98(7): 607-612

[8] MaierM, SchmidtT, SchmidtM. Endoscopically controlled surgery with the micro-drill and intubation of the lacrimal ducts. Ophthalmologe, 2000, 97(12): 870-873

[9] MuellnerK, BodnerE, MannorG E, WolfG, HofmannT, LuxenbergerW. Endolacrimal laser assisted lacrimal surgery. Br J Ophthalmol, 2000, 84(1): 16-18

[10] HaefligerI O, PiffarettiJ M. Lacrimal drainage system endoscopic examination and surgery through the lacrimal punctum. Klin Monatsbl Augenheikd, 2001, 218(5): 384-387

[11] KucharA, NovakP, PiehS, FinkM, SteinkoglerF J. Endoscopic laser recanalisation of presaccal canalicular obstruction. Br J Ophthalmol, 1999, 83(4): 443-447

[12] MullnerK, WolfG. Endoscopic treatment of lacrimal duct stenoses using a KTP laser--report of initial experiences. Klin Monatsbl Augenheilkd, 1999, 215(1): 28-32

[13] EmmerichK H, UngerechtsR, Meyer-RusenbergH W. KTP laser in lacrimal duct surgery. Ophthalmology, 2002, 99(12): 933-935

[14] HofmannT, LacknerA, MuellnerK, LuxenbergerW, WolfG. Endolacrimal KTP laser-assisted dacryocystorhinostomy. Arch Otolaryngol Head Neck Surg, 2003, 129(3):3 29-332

RIGHTS & PERMISSIONS

Higher Education Press and Springer-Verlag Berlin Heidelberg