TRANSCANALICULAR LASER DACRYOCYSTORHIONOSTOMY (TC – DCR): INITIAL RESULTS WITH INTRAOPERATIVE CORTICOIDS 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. Direcciones de correspondencia: - 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)

INTRODUCCION 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. 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’

MATERIAL and METHOD 41 eyes operated of TC-DCR, between September 2008 and January eyes operated of TC-DCR, between September 2008 and January 2009 Observational, prospective non randomized study. Observational, prospective non randomized study. Standard TC-DCR technique. Standard TC-DCR technique. Placing of a lentine of nasal packing (Merocel ®) soaked in triamcinolone acetonid (Trigon depot ®), maintained the first 24 hours postop. Placing of a lentine of nasal packing (Merocel ®) soaked in triamcinolone acetonid (Trigon depot ®), maintained the first 24 hours postop. Ostium finished with the silicone bicanalicular intubation in place. Placing of the lentine over the ostium. Verification of the position if the lentine, attached to a silk 0/0 suture to allow easy extraction after 24 hours. Soaking of the lentine with triamcinolone. NO C-MITOMICINE IS USED

Lentine is removed after 24 hours, during the first postoperative control. Lentine is removed after 24 hours, during the first postoperative control. Follow-up every 7-15 days the first month, and after 3 and 6 months. Follow-up every 7-15 days the first month, and after 3 and 6 months. Clinical (tearing), nasal endoscopy (debrys removing, ostium revision, fluorescein test) and lachrymal irrigation. Clinical (tearing), nasal endoscopy (debrys removing, ostium revision, fluorescein test) and lachrymal irrigation. MATERIAL and METHOD

RESULTS We have observed a reduction in local healing time, minimal local imflammatory signs and a better y un mejor mantenimiento del diámetro del ostium inicial. We have observed a reduction in local healing time, minimal local imflammatory signs and a better y un mejor mantenimiento del diámetro del ostium inicial. Bicanalicular intubation is removed after 1 month. Bicanalicular intubation is removed after 1 month. 24 hours 7 days 15 days 1 month 6 months 1 month Intubation removed

ANATOMICAL RESULTS - 6 months – (Fluorescein clearance / Irrigation / Nasal endoscopy confirmation) FUNCTIONAL OSTIUM 40 / 41 (97,56%) CLOSED OSTIUM 1/41 CLINICAL RESULTS - 6 months - (Improvement / desappearing of symptoms) COMPLETE IMPROVEMENT 37 / 41 (90,24%) PARTIAL IMPROVEMENT 3/41(7,32%) RESULTS

DISCUSSION In our experience, TC-DCR with diode laser has become a simple approaching for the treatment of lachrymal obstructions, with a minimal morbidity, minimal general hazards and acceptable long-term results. With the standard technique we have practiced since 2003, we had studied two groups of patients, with and without use of C-Mitomincine, without finding any difference in postoperative outcome nor in long term results (1), as found for other authors (2), in large groups. Compared with our previous cases, the use of local steroids seem to offer many advantages. Immediate postoperative reaction is less intense. The local recovery of the surgical ostium is faster, allowing an early removing of the intubation. Finally, the diameter of the ostium at the end of the follow-up period is maintained very stable, without significant reduction compared to that achieved with the surgery. 1. Maeso Riera J, Sellares Fabres MT. Dacriocistorrinostomía transcanalicular con láser diodo: variaciones técnicas y resultados. Acta Otorrinolaringol Esp. 2007;58: Alañón Fernández FJ, Alañón Fernández MA, Martínez Fernández A, Cárdenas Lara M. Dacriocistorrinostomía transcanalicular con láser diodo. Arch Soc Esp Oftalmol. 2004;79:

CONCLUSIONS The use of local depot corticoids at ht e end of surgical procedure seem to improve the prognosis of the lachrymal transcanalicular surgery with diode laser. The use of local depot corticoids at ht e end of surgical procedure seem to improve the prognosis of the lachrymal transcanalicular surgery with diode laser. Results observed after a first 6 months follow up, have maintained in cases followed for longer periods. Results observed after a first 6 months follow up, have maintained in cases followed for longer periods.