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RESULTS
The mean age in the study was 29.7 years (ranged 465 years). The ratio of male to female was 1∶2 (Table 1). The majority of patients (89%) were younger than 50 years of age. Review of complications demonstrates that only 7 cases had intraoperative hemorrhage more than 100cc, while 193 experienced less hemorrhage. Two patients had early postoperative hemorrhage in the form of epistaxis which stopped without need for nasal repacking. Another two patients had orbital hemorrhage without seriously elevating the intraocular pressure. There was no case of orbital emphysema, cerebrospinal fluid (CSF) leakage or wound sepsis in our study. Three cases had disfigured scars in the shape of epicanthus fold. Ten patients had postoperative epiphora in varying degrees. Probing and syringing was done for cases of epiphora, which led to cessation of symptoms in six of them leaving only four patients with persistent epiphora or failed DCR. The success rate of surgical procedure used in this study was 98%.
DISCUSSION
Age and gender distribution of patients in this study generally complies with figures in literature. The surgical outcome of single flap DCR in this study showed minimal complications. In the three cases with disfigured scars, intraoperative inadvertent extension of the skin incision was made. Epiphora was resolvable by simple probing and syringing. Persistent epiphora or failure of DCR is documented in only four cases; two of them were traumatic cases with distorted bone anatomy. The success rate is comparable with best results reported in previous studies using different flap designs.
Possible postoperative complications of DCR include hemorrhage, wound sepsis, surgical emphysema, CSF leakage and recurrence of epiphora[17]. Occlusion of the new tract, either by granulation tissue or by adhesions, is a drawback of DCR. This complication was evident in only two patients in this study. It has been widely suggested that creation and suturing of both anterior and posterior mucosal flaps increase the possibility of primary healing of the new tract and reduce the mucosal scarring, complying with the general surgical principle of edgetoedge approximation of tissues[922]. Although a sutured anastomosis of both anterior and posterior mucosal flaps appears to better achieve this goal, alternative techniques of external DCR with variations in the mucosal flap design have been described and success rates have been reported to be comparably high[1014]. However, there are only few randomized studies comparing the outcomes of DCR performed with different mucosal flap designs[1518].
Table 1 Age and gender distribution（略）
On the other hand, suturing the posterior flaps often constitutes a difficulty and may take a considerable amount of time, particularly in the presence of hemorrhage in DCR surgery. Several options have been described for management of the posterior flaps. The posterior flaps can be anastomosed, excised, or not fashioned at all. A study by Elwan[16] found statistically similar success rates by the end of a mean followup period of 11 months when comparing excision of the posterior flaps to posterior flaps not be fashioned at all.
In this study, only anterior single flap is sutured to the margin of periosteum at the anterior lacrimal crest. The Ushaped configuration of the created flap allows easier suturing of sac and periosteal flaps.
Although it is simpler and easier to master the surgical technique, anterior single flap DCR shows a success rate comparable to that obtained by the more complex conventional DCR. This gives this procedure an advantage over the conventional one. However, a randomized trial is needed to statistically compare between the two procedures and validate this conclusion.
【参考文献】
1 Tanenbaum M, McCord CD. The lacrimal drainage system. In: Tasman W, Jaeger EA, eds. Duanes clinical ophthalmology, Vol. 4. Philadelphia: Lippincott Williams & Wilkins;2001:134
2 Hirschbein MJ, Stasior GO. Lacrimal system. In: Chen WP, ed. Oculoplastic surgery: the essentials. 1st ed. New York: Thieme Medical Publishers;2001:263288
3 Older JJ. Routine use of a silicone stent in a dacryocystorhinostomy. Ophthalmic Surg1982;13:911915
4 Rosen N, Sharir M, Moverman DC, Rosner M. Dacryocystorhinostomy with silicone tubes: evaluation of 253 cases. Ophthalmic Surg1989;20:115119
5 Yu HH, Deng JY, Zheng XN, Lu L, Zeng D. Comparative study of silicone reverse intubation versus dacryocystorhinostomy for nasolacrimal drainage obstruction. Int J Ophthalmol(Guoji Yanke Zazhi)2007;7(5): 14561457
6 Ben Simon GJ,Joseph J,Lee S,Schwarcz RM,McCann JD,Goldberg RA.External versus endoscopic dacryocystorhinostomy for acquired nasolacrimal duct obstruction in a tertiary referral center. Ophthalmology 2005;112:14631468
7 Gonnering RS, Lyon DB, Fisher JC. Endoscopic laserassisted lacrimal surgery. Am J Ophthalmol1991;111:152157
8 Dolman PJ. Comparison of external dacryocystorhinostomy with nonlaser endonasal dacryocystorhinostomy. Ophthalmology2003;110:7884
9 Piaton JM, Limon S, Ounnas N, Keller P. Transcanalicular endodacryocystorhinostomy using Neodymium:YAG laser. J Fr Ophtalmol1994;17:555567
10 Burns JA, Cahill KV. Modified Kinosian dacryocystorhinostomy: a review of 122 cases. Ophthalmic Surg1985;16:710716
11 Zhang WQ, Zhou X, Zhou HZ. Clinical management of dacryocystorhinostomy in treatment of chronic dacryocystitis. Int J Ophthalmol(Guoji Yanke Zazhi)2006;6(4):953954
12 Mauriello JA Jr, Vadehra VK. External dacryocystorhinostomy without mucosal flaps: comparison of petroleum jelly gauze nasal packing with gelatin sponge nasal packing. Ophthalmic Surg Lasers1996;27:605611
13 Baldeschi L, Nardi M, Hintschich CR, Koornneef L. Anterior suspended flaps: a modified approach for external dacryocystorhinostomy. Br J Ophthalmol1998;82:790792 上一页 [1] [2] |
