Nasolacrimal Duct Probing and Intubation Under Sedation Anesthesia, OU

Patient is an 18-month-old male with a history of Nasolacrimal Duct Obstruction (NLDO). He presented to the Children’s Hospital Outpatient Setting for NLD probing and stenting. After informed consent was performed, including consent for taking photos and video recordings, the patients underwent sedation without complication. The eyelids were cleaned of mucus and crusts using sterile water. The inferior puncta were dilated with a dilator. A Ritleng introducer was placed through the inferior puncta and guided along the canaliculus to a bony stop. The introducer was then rotated to coronal/vertical position and guided along the lacrimal sac through the NLD and valve of Hasner to be positioned under the inferior turbinate. Next, the introducer was removed, and the puncta was re-dilated. We used a Lacrijet 30 nasolacrimal duct stent, REF S1.1530 was opened and guided through the NLD. The inserter was removed gently, and the stent’s collarette was seated in the puncta using the disposable punctal plug inserter. The same procedure was performed on the fellow eye. Maxitrol drops were placed in the medial canthal region. The patient was awakened from sedation without complication and discharged home without complication.

Inferior Oblique Myectomy

Inferior oblique myectomy is a type of strabismus surgical procedure that aims to weaken an extraocular muscle by transecting it. The patient is a four old with a history of inferior oblique overaction and vertical strabismus, which can be corrected by resection of the inferior oblique muscle.

The ointment was applied to the cornea. Forced ductions were performed and identified restriction of the inferior oblique. A conjunctival incision is made in the fornix. Tenon’s capsule is dissected to expose the Inferior Oblique. The inferior oblique muscle is isolated using a Stevens tenotomy hook followed by Jameson muscle hooks. The inferior rectus was identified on a steven’s hook medially to the inferior oblique. The lateral rectus was then identified on a steven’s hook laterally to the inferior oblique. This was done to ensure that neither muscle was incorporated with the portions of the inferior oblique muscle to be cut. Wescott scissors were used to cut both ends of the muscle. Bipolar cautery forceps were used to cauterize the resected proximal and distal ends of the inferior oblique muscle. The two ends were released and the remaining muscle ends were allowed to retract into the orbit. The conjunctiva was closed using a plain gut suture.

No complications arose during the procedure. Postoperatively, the patient had a subconjunctival hemorrhage, injection, and pain that decreased over the following week. Neomycin-polymyxin-dexamethasone drops were applied daily to prevent infection and inflammation. At the one follow-up, the redness and pain had resolved.

Inferior oblique myectomy effectively treats inferior oblique overaction and vertical strabismus associated with this condition.

RV-PA Conduit Replacement in d-TGA

Replacement of a stenotic/irregular right ventricle to pulmonary artery Gore-Tex trileaflet graft with a novel KONECT RESILIA Aortic Valved Conduit. This is the only tissue valved conduit currently in use. This patient has d-transposition of the great arteries along with ASD, VSD, pulmonary stenosis, bovine left arch and aberrant right subclavian arteries.

His previous operations include MBTS 4mm Gore-Tex graft, urgent shunt revision secondary to thrombosis and subsequent conversion to a 4mm central shunt, right atrial thrombectomy secondary to indwelling right atrial catheter, takedown of central shunt, primary pledgeted closure of pulmonary valve, Gore-Tex patch closure of ASD/VSD, Rastelli procedure with 24mm Gore-Tex trileaflet with bulging sinuses graft.

Superior Rectus Recession

Introduction

Muscle recession is a type of strabismus surgical procedure that aims to weaken an extraocular muscle by adjusting its insertion posteriorly closer to its origin. The patient is a 14-year-old with dissociated vertical deviation, which can be corrected with recession of the superior rectus muscle.

Methods

A conjunctival incision is made in the fornix. Tenon’s capsule is dissected to expose the superior rectus muscle. The superior rectus muscle is isolated using a Stevens tenotomy hook followed by a Jameson muscle hook. After the remaining Tenon’s attachments are cleared, the muscle is secured at both poles with a double-armed 6-0 VicrylTM suture and double-locking bites. The muscle is then disinserted from the sclera with Manson-Aebli scissors. A caliper is used to mark the predetermined distance of muscle reinsertion. Next, the muscle is reattached to the sclera with partial thickness bites and then tied down to its new location. The conjunctival incision is closed with 6-0 plain gut sutures.

Results

No complications arose during the procedure. Postoperatively, the patient had subconjunctival hemorrhage, injection, and pain that decreased over the following week. Neomycin-polymyxin-dexamethasone drops were applied daily to prevent infection and inflammation. At the three-month follow up, the redness had resolved. The dissociated vertical deviation had improved.

Conclusion

Superior rectus recession is a safe procedure that can effectively treat vertical strabismus.

By: Michelle Huynh

College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA

mhuynh@uams.edu

Surgeons:

Brita Rook, MD

Arkansas Children’s Hospital – Department of Ophthalmology, Little Rock, Arkansas, USA

BSRook@uams.edu

Joseph Fong, MD

Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA

JFong@uams.edu

Video was performed at Arkansas Children’s Hospital, Little Rock, AR, USA.

Redo Posterior Fossa Decompression with Duraplasty for the Treatment of Chiari Type I Malformation

Chiari decompression is a common neurosurgical procedure.  Chiari malformations present with a number of symptoms including Valsalva-induced headaches, swallowing dysfunction, and sleep apnea.  Chiari malformations can also cause syringomyelia and syringobulbia.  Surgical procedures used for the treatment of Chiari malformation include bone-only decompression (posterior fossa craniectomy +/- cervical laminectomy), craniectomy/laminectomy with duraplasty, and craniectomy/laminectomy/duraplasty with shrinkage or resection of the cerebellar tonsils.  The procedure used depends on the specifics of the patient’s condition and the preference of the surgeon.

The patient presented here had undergone a prior Chiari decompression at the age of 20 months.  This was bone-only with posterior fossa craniectomy and C1-2 laminectomy.  The dura was not opened due to the presence of a venous lake.  He initially had improvement in his symptoms.  However, his headaches and snoring recurred, balance worsened, and dysphagia never improved.  Therefore, a repeat Chiari decompression at the age of 28 months was performed as presented here.

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