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.

Medial Orbital Dermoid Cyst Removal

Dermoid cysts are the most common orbital tumor in childhood. It is a developmental benign choristoma, arising from ectodermal sequestration along the lines of embryonic fusion of mesodermal processes. It is lined by keratinized stratified squamous epithelium and expands slowly due to constant desquamation and dermal glandular elements. They are usually smooth, painless, mobile, or partially mobile lesions mostly present at the fronto-zygomatic suture with proptosis, displacement, ptosis, or diplopia, depending on depth and extent1. 

Although lateral orbital dermoid cysts are common, medial orbital dermoid cysts are rare2. Our patient had a right medial orbital congenital dermoid cyst since birth. At the presentation, the patient was 2 years old. On CT, the cyst measured 5 mm at the upper lid/medial canthus of the right orbit with subtle bone remodeling. He had a mildly clogged tear duct on the left but was otherwise asymptomatic. The decision was made to surgically remove the dermoid cyst. 

In this video, we present a case of removal of a medial orbital dermoid cyst in a 2-year-old patient. 
An incision was planned directly over the lesion. It was marked following the natural skin tension lines of the face to give the most natural esthetic appearance.
A small amount of Local anesthetic (0.5 ml of Lidocaine and Epinephrine) was injected under the skin to promote hemostasis and postoperative pain control.
A continuous Incision was made with a #15 blade on the skin.
Westcott scissors were used to dissect further through the subcutaneous tissue to expose the cyst and slowly dissect it from the normal tissue surrounding it.
Extra care was made to protect the integrity and avoid the rupture of the cyst.
After the entire cyst was freed from the surrounding tissue,  it was carefully removed from its attachments to the periosteum using Westcott scissors.
The incision was closed in a two-layer fashion.
The deeper layer was closed by 6.0 Vicryl in a vertical mattress fashion with 2 interrupted sutures.
Next, wound edge eversion was achieved by placing two interrupted, superficial 5.0 fast-absorbing gut sutures. This will minimize the scar appearance.
Dermabond was applied next and the sutures were protected by a small piece of Tegaderm. This will be left in place until it spontaneously falls off.

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.

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.

Bilateral Dacryocystoceles Resection

Contributor: Tyler McElwee

Congenital dacryocystocele describe the distended lacrimal sac in neonates with or without associated intranasal cyst.  The prevalence is about 0.1% of infants with congenital nasolacrimal duct obstruction and a slight prevalence in female infants.  It refers to cystic distention of the lacrimal sac as a consequence of the nasolacrimal drainage system obstruction.  It typically presents as a bluish swelling inferomedial to the medial canthus in the neonates.  Unilateral congenital dacryocystocele is more common but 12-25% of patients affected have bilateral lesions.  Ultrasound, CT scan or MRI can be used for diagnosis.  About half of the patient with acute dacryocystitis can be management with conservative management such as digital massage of lacrimal sac or in-office lacrimal duct probing.  The other half of patients will require surgery under general anesthesia for removal of the dacryocystocele.   Endoscopic excision of the intranasal cysts has been used successfully as a treatment option with Crawford stent placement.  Post-operatively patients are treated empirically with antibiotics and nasal saline.  No second look is usually planned unless patients develop significant nasal obstrctuion.

Editor Recruited By: Sanjay Parikh, MD, FACS

DOI: http://dx.doi.org/10.17797/16rnuq8n0y

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