TRANSCANALICULAR LASER DACRYOCYSTORHINOSTOMY. MEDIUM-LONG TERM RESULTS 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 de Medicina Avanzada. (3) Centre Oftalmològic ORL d’Egara. (1) Fundació Parc Taulí.Instituto Universitario UAB (2) Centre Mèdic Delfos. Centro Internacional de Medicina Avanzada. (3) Centre Oftalmològic ORL d’Egara. Mailing adressess: - Prof. Dra. Mª Teresa Sellarès Fabrés Dr. José Maeso Riera.

INTRODUCTION Transcanalicular dacryocystorhinostomy (TC-DCR) with diode laser has given us a surgical technique with very low local and general morbidity. Nowadays we can perform a lachrymal surgery under local anesthesia, in a short time, and on outcome basis. No dissection nor external scars are needed. Transcanalicular dacryocystorhinostomy (TC-DCR) with diode laser has given us a surgical technique with very low local and general morbidity. Nowadays we can perform a lachrymal surgery under local anesthesia, in a short time, and on outcome basis. No 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. INDICATIONS INDICATIONS - Chronic Dachryocystitys. - Acquired lachrymal obstruction in patients before cataract surgery - Other ? (Revision surgery, Acute cases)

INTRODUCTION Dilatation of upper lachrymal punctum and laser guide placing, until contacting the lachrymal bone. Under nasal endoscopic control, confirmation of guide place and direction, beggining of the ostium, and widening until achieving a large cystorhinostomy. Silicone bicanalicular intubation placing. Optional: C-Mitomicin 0,04% 5’ STANDARD TECHNIQUE * Conjunctival topical anesthesia (Eye drops tetracain + oxibuprocain). * Nasal topical anesthesia (tetracain + adrenalin). * 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 study January 2004 – January eyes 394 patients (32 bilat) 279 (70.81%) women / 115 (29.19%) men Mean age: 65,17 years (61,5 men – 68,84 women) Range: 31 – 89 years Minimum follow-up: 1 year / Mean time of follow-up: 21 months MATERIAL and METHOD

Postoperative treatment Eye drops: antibiotic + corticoids 15 days; after, non-esteroidal antinflammatories Nasal corticoids Nasal SF cleanings Follow up 24 hours postop Every 7-10 days first month (1 month: removing of silicone intubation) 3, 6, 12 months Every 6-12 months - Clinical evaluation symtoms (tearing) - Nasal endoscopy (ostium follow up, and crusts, fibrine,... cleaning) - Lachrymal irrigation MATERIAL and METHOD

RESULTS Mean of total energy used: J (range ) Mean of ostium diameter achieved: 11.23mm (8-15) Mean surgical time: min(8-55) Mean surgical time: min (8-55)COMPLICATIONS - SURGICAL: NONE - POSTOPERATIVE: * light cantal haematomas (local anesthesia) * minimum pain * minimum self-limited nasal bleeding (2) * lachrymal intubation mobilisation (3)

RESULTS ANATOMICAL RESULTS (Fluorescein clearance / positive irrigation / endonasal confirmation) FUNCTIONAL CLOSED FUNCTIONAL CLOSED 382 / / / / 426 (89.67%) (10.33%) (89.67%) (10.33%) CLINICAL RESULTS (disappearance / improvement symptoms) COMPLETE IMPROVEMENT 377 / 426 (88.49%) PARTIAL IMPROVEMENT NO CHANGES PARTIAL IMPROVEMENT NO CHANGES 20 / / / / 426 (4.69%) (6.81%) (4.69%) (6.81%)

DISCUSION From our experience, transcanalicular diode laser DCR (TC-DCR) has given us great advantatges, with perfectly acceptable medium and long term results, shared with other authors for primary surgeries or for revision of failures of previous procedures(1,2,3,4). From our experience, transcanalicular diode laser DCR (TC-DCR) has given us great advantatges, with perfectly acceptable medium and long term results, shared with other authors for primary surgeries or for revision of failures of previous procedures(1,2,3,4). 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 with other approaches. 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 with other approaches. Nowadays is a procedure with short experience, compared to external and endonasal endoscopic approaches. But, its respect for nasal structures, no need for 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 in cases in whom it could not be possible recommend a functional treatment. Nowadays is a procedure with short experience, compared to external and endonasal endoscopic approaches. But, its respect for nasal structures, no need for 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 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 post-sacal non acute cases), to revision surgeries, acute cases, or pre-sacal obstructions. 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 obstructions. 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, KTP,...), with different physics and behavior (5,6,7) 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, 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): Alañón Fernández FJ, Alañón Fernández MA, Martinez Fernández A, Cárdenas Lara M. Dacriocsitorinostomia Transcanalicular con láser diodo. Resultados Preliminares. Acta Otorrinolariongol Esp 2004; 55: Alañón Fernández FJ, Alañón Fernández MA, Martinez Fernández A, Cárdenas Lara M. Dacriocsitorinostomia Transcanalicular con láser diodo. Arch. Soc. Esp. Oftalmol 2004; 79 (7): Plaza G, Beteré F. Efectividad de la dacriocistorinostomia transcanalicular en el tratamiento del lagrimeo del anciano. Mapfre Medicina, 2005; 16 (2): 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): Thomas Ressiniotis, Gerasimos M Voros, Vasilios T Kostakis et al. Clinical outcome of endonasal KTP laser assisted dacryocystorhinostomy. BMC Ophthalmology 2005, 5:2 7 Thiemo Hofmann, Andreas Lackner, Klaus Muellner et al. Endolacrimal KTP Laser-assisted Dacryocystorhinostomy. Arch Otolaryngol Head Neck Surg. 2003; 129:

CONCLUSIONS Easy and fast technique Easy and fast technique Minimum local and general trauma Minimum local and general trauma Minimum operative and postoperative morbidity Minimum operative and postoperative morbidity Good medium and long term resuls Good medium and long term resuls Can be repeated Can be repeated Initial indication: Initial indication: primary post-sacal non inflammatory cases primary post-sacal non inflammatory cases