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Indications
Thyroid Associated Orbitopathy ( M/c).Vasculitis .Lesions of posterior orbit & apex with compressiveoptic neuropathy .large myopic globes.
Problems associated with OrbitopathyExposure keratopathy.Diplopia.Optic Nerve Compression.
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In 1911, Dollinger = Kronlein's approach -
lateral wall decompression.In 1920, Moore = Intra orbital decompression.In 1931 , Naffziger = superior decompressionIn 1936 , Sewall = external ethmoidectomyapproach- medial orbital wall.In 1950 , Hirsch = orbital floor. ( caldwell-luc)In 1957, Walsh and Ogura = infero medialdecompressionIn 1990, Kennedy = Endoscopic transnasal
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Proptosis Corneal problems Diplopia
Eyelid retraction Optic nerve compression Most common cause of unilateral or bilateral proptosis in adult.
multisystem. autoimmune disorder hyperthyroid, hypothyroid, euthyroid
inflammation and enlargement EOM (MR>IR)
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Werners Classification: NOSPECS Class 0 ( No Signs)Class I ( Only Signs)
Class II (Soft tissue Swelling)Class III (Proptosis)Class IV (Extraocular muscle)Class V (Corneal Exposure)
Class VI (Sight Loss)
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For initial CAS, score only 7 items (1 for each)1. Spontaneous orbital pain2. Gaze evoked orbital pain3. Eyelid swelling that is considered to be due to
active phase4. Eyelid erythema5. Conjunctival redness that is considered to be
due to active phase6. Chemosis7. Inflammation of caruncle or plica
At follow up total score all 10 items8. Increase of 2mm in proptosis9. Decrease in ocular excursion in any one
direction 8 o
10.Decrease of acuity equivalent to 1 snellen line6
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CT scan classicalcoca cola bottlesign on axial view
( Hypertrophy ofmuscle sparing thetendon )
MRI Hypertrophyof Inferior Rectus.
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TreatmentMedical Management :
Medications targeting euthyroidstateCessation of Smoking (thiocyanate)Ophthalmic Management: LocalmeasuresCorticosteroidsRadiation therapy
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Surgical Management :
Indications : optic neuropathy, diplopia,corneal exposure, and cosmesisSurgical Procedures
Orbital DecompressionStrabismus repairCorrection of eyelid malpositions
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Strabismus Repair:
Extraocular muscle recessions preferredAlternative marginal myotomies
Eyelid Surgery :lateral tarsorrhaphylengthening of Mullers and levatormuscleslower lid elevationblepharoplasty with orbital fat removal
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Approaches :External
SUPERIORLATERALMEDIAL
TransantralOpen sublabialMicroscopicEndoscopic
Endoscopictransnasal
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Shell of bone which surroundsand protects the eyeRelations
Sup Ant cranial fossaMed Nasal cavity & ethmoidallabyrinthInf Maxillary sinusLat Infra temporal fossa & Middlecranial fossaApex Middle cranial fossa
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Shape quadrilateralpyramid with basefacing forwards,laterally and slightlyinferiorly. Height of orbitalmargin 35 mmWidth of orbitalmargin 40 mmDepth of orbit - 45-55mm
Volume of orbit - 30ml
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Seven bones formthe bony orbit
FrontalSphenoid (greater &lesser wing)MaxillaZygomaLacrimalEthmoidPalantine
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Formed by (from anterior to posterior):
Lacrimal bone Frontal process of maxilla Ethmoid (Lamina papyracea) Sphenoid (Body)
Extremely thinAnteromedially lacrimal fossa b/w ant& post lacrimal crestForamina for ant & post Ethmoidal
arteries & nerves in frontoethmoidsuture line. Rule of 24-12-6 is suggested.
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Formed by:
orbital plate of maxillaOrbital process of palatineZygomatic orbital plate
Infraorbital grooveLocation of infraorbital nerve
which supplies sensation to skin overmalar prominence, alveolus and teethThin (0.5 1 mm), dehiscent in 29%.Encountered in - orbital decompression
- orbital floor fracturerepair- maxillectomy
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Formed by:Orbital plate of frontal boneLesser wing of sphenoid
Supraorbital notch transmits the nerve &vesselsTrochlea = connective tissue sling anchors thetendinous part of the superior oblique muscleto the orbital wall.
Encountered in - orbital decompression- orbital fracture repair- frontal sinus trephination- ext frontoethmoidectomy
- orbital exenteration20
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Formed by Zygomatic process of frontal bone Greater wing of sphenoid Orbital surface of zygoma
Whitnall`s tubercle deep to rim & abovemid point. Attachment of lateral canthaltendonEncountered in - orbital decompression
- Infratemporal fossa surgery- orbital fracture repair- lateral craniotomy- modified craniofacial
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Optic canal lesser
wing of sphenoidThickest part orbitaltubercle(4.8 mm wide)Isthmus (4.6 mm)Posterior ( 7.07 mm)Length 8 16mm (avg11,m>f)
Thickness of bone :0.79 mm avg (sphenoid)
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Optic foramenSuperior orbital
fissureInferior orbitalfissure
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Transmits :
- Optic nerve Ophthalmic artery
Medial & superior to geometric apex
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Separates lateral wall from roofTransmits the followingstructures:
Frontal NerveLacrimal nerveTrochlear nerve (CN IV)
Ophthalmic vein suf Oculomotor nerve (CN III)Abducens nerve (CN VI)Nasociliary nerve
Ophthalmic vein infOrbital branch of middlemeningeal arteryRecurrent branch oflacrimal artery
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Connects to orbit to infratemporal fossa andto pterygopalatine fossa in the medial mostpart
Located between floor and lateral wallTransmits:Infraorbital arteryMaxillary div of Trigeminal
Br of sphenopalatine ganglionBr of inferior ophthalmic V to pterygoid plexusOrbitalis muscle
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ORBITAL FASCIA
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Anesthesia : General Anesthesia orLocal Anesthesia 1 Position : Reverse Trendelenberg
positionHypotensive anaesthesia and topical1:1000 adrenaline ribbon gauze asroutinely used in ESS is used.
1 Metson et al.Laryngoscope;1994:104:904-908
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Which eye --?More severe eye first ( as there will befurther 1-2mm recession in first 3 months
post sx ).
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UNCINECTOMY INFUNDIBULOTOMY
ANTERIOR AND POSTERIOR ETHMOIDECTOMY
SKELETONIZATION OF LAMINA PAPYRACEA
LARGEST POSSIBLE MIDDLE MEATAL ANTROSTOMY
REMOVING BONE OF LAMINA PAPYRACEA
+/- MEDIAL ORBIT FLOOR
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middle turbinate
Lamina papyracea
Maxillary sinus roof
Maxillary line
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Endoscopic orbital Decompression
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INCISING PERIORBITA FAT PROLAPSE
HEMOSTASIS /NASAL PACKING
POST OP CARE
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Modified blepharoplasty incision /transconjunctival / anterior orbitotomy /bicoronal forehead flap
Horizontal canthotomy Incision(1.5 cm)Inferior cantholysisDivision of the conjunctiva, inferiorretractors and orbital septum
Periosteal incision placed about 7 8mm onlateral orbit outside the orbital
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osteotomy is made 3mm behind the lateralorbital rimlateral wall periosteum is openedFat made free ,anterior pole of the glandmade free and allowed to float into thebone lateral wall defect.Medial and floor decompression.Preserve ant2/3 rd of maxilloethmoidal bonestrut -> prevents block of max sinus aeration
with fat prolapse.
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Combined endoscopic and open approachTransconjunctival-endoscopic = allow dissection ofmedial wall beyond posterior ethmoid neurovascularbundle upto optic canal.Lateral wall decompression + endoscopic (avgdecompression 6.9mm)
Balanced orbital decompression = medial andlateral wall without floor ( reduce new onsetdiplopia)Two wall = superior + lateral wall.
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Mean reduction in axial proptosis = 3.2 5.1mm 2 (endoscopic approach)Endoscopic approach with a modifiedCaldwell Luc = 4.83mm 1
Conventional transantral approach = 4.8mm(3.4-5.3) 2
Three wall decompression = 7.2mm 1-7.5 2
Lateral wall decompression + endoscopic (avgdecompression 6.9mm) 2
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Orbital bruising (minor and temporary)Diplopia (pre-existing or de novo, improves postoperatively)
Particularly associated with inferomedialdecompressionsPts with restricted motility and diplopia within 20 0 ofthe primary position preoperatively are most likely torequire subsequent muscle surgery
Preservation of an inferomedial bony strut atjunction of medial wall and floor willminimize this complication.
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Epiphora ( de novo or exacerbated aftersurgery, improves except in NLD injury)Paraesthesia (in territory of infraorbital
nerve)OthersSecondary bacterial sinusitisimploding maxillary antrum
mucocoele
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Tumors /Fracture repair /Foreign bodyremoval /Orbitaldecompression/exenteration
Lateral / Inferior / Medial / SuperiorOrbitotomy/ EndoscopicEndoscopic =>
Orbital hematoma
Fronto-ethmoid mucoceleOrbital decompressionBenign orbital lesions especially of medial orbit
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Modified stallard-Wrightincision (Lazy S )Incision is deepened andthe periosteum exposedand incised 2 mm abovezygomatic frontalsuture.
Temporalis muscle isdissected and retractedposteriorly. Lateralorbital rim divided.Periorbita is incisedparallel to lateral rectus
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Indications: Orbital decompression, orbital biopsy & excision of orbital lesions.
Subciliary incision through skin andorbicularis muscle with direction along orbitalseptum
Orbital periosteum is incised approximately2mm inferior to orbital rim.
Orbital floor is exposed, identification of intraorbital N vessels
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Given by Dandy 1921Compound trauma of orbitDecompression of opticcanalRemoval of apical andcombined apical intracraniallesion.Infra brow incisionDeepend till periosteum.Which is incised 2-3 mmsuperior to the orbital rim. periorbita is separated fromthe orbital roof periorbitaincised if required
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Described in 1973 by Galbraithand SullivanEffective in the management ofsmall, medial orbital tumorssuch as cavernoushemangiomas, schwannomas,
hemangiopericytomas, andisolated neurofibromas. 180 0 conjunctival peritomy atcorneoscleral limbus from 12 0 to 6 0 clock
Medial rectus retracted &disinserted from globe ,withcareful blunt dissection &retraction, orbital mass isidentified
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BleedingOrbital hematomaInfection of globe
DiplopiaLoss of vision excess pressure on globe,compression of Central Retinal ArteryInadvertant Intracranial injuryDirect perforation of globe
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IndicationsTrauma;Thyroid eye disease;
Neoplastic compression e.g. meningioma;Fibrosis due to chronic inflammation e.g.Wegeners granulomatosis.
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Intraorbital, 25 mm length
Intracanalicular, 9 mm length
Intracranial, 16 mm length
Intraocular disk, 1 mm length
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Visual impairment following trauma withevidence of Afferent Pupillary defect with outevidence of any injury to eye.Diagnosis = RAPD supported by disc edema,
congestion of vessels+ CT/MRI scan + VEP
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PrimaryDirect contusion on optic canal/Nerve orDeformation of Sphenoid with transfer of force intointracanalicular nerve
Secondary compression of nerveBony fragmentsHemorrhage nerve swells with in canal compression of blood supply Ischemia
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SURGERY IF# of optic canal on CT with vision6/60 butvision deteriorates on steroidVision deterioration (or
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Uncinectomy
Anterior and Posterior Ethmoidecotmy Sphenoidotomy Identify Lamina Papyracea, Fovea Ethmoidalis,
Posterior EthmoidsAnterior face of sphenoid widely opened [ until
roof of sphenoid and post.ethmoids iscontinuous]
Identify Optic Nerve,Carotid artery, Orbital apex
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Blunt Freer elevator pushed through laminapapyracea (1.5 cm ) ant to junction ofpost.ethmoid & Sphenoid.Carefully keep orbital periosteum intact.Bone over posterior orbital apex flaked off.Bone of optic canal flaked off.Incise optic sheath ( use sharp sickle knife )in upper medial quadrant.
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Optic tubercle thick bone overlyingjunction of orbital apex and sphenoid sinus.Incision continued over orbital periosteum ofposterior orbital apexNo pack placed on nerve or in sinuses.
Length of decompression = Orbital apex -1cm posterior to face of sphenoid sinus
Cranio facial approach (upto optic chiasm)
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Transorbital Pringle (1916)Extranasal transethmoid SewallTransantral KennerdellIntranasal microscopic
Craniotomy DandyEndoscopic Endonasal Kountakis (1993)
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1 VA > 6/60 ; no posterior orbit/optic canal#2 VA 6/60 ; no posterior orbit/optic canal#3 VA >PL - ve & # post.orbit/optic canal(or)
VA PL - ve but no #
4 VA PL - ve with # displaced
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GOOD PROGNOSIS BAD PROGNOSIS
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Blunt injury Sharp injury
PL +ve PL ve
Early presentation & Sx Late presentation & late Sx
Acute injury (trauma ) Progressive vision loss
Compressive diseases of
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Good landmark is the anterior portion ofmiddle turbinate, sac lies just lateral toit.The maxillary line is a mucosal projectionalong the lateral nasal wall .
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Lacrimal pump
=> Movements of the lids cause the punctato close against each other.
=> Tears pushed into the lacrimal sac.
=> Tears accumulating in the sac (lacrimallake)
=> Tears pushed down into the NLD wheneyes open because of the relativenegative pressure caused in the lacrimallake.
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1 . Unilateral or bilateral .
2 . Nature of the discharge (clear / purulent )3 . H/o Allergy4 . H/o Medication / Trauma / Surgery.5. History to rule out infective/Non-infective
granulomatous conditions.6 . On physical examination Palpate the region of the naso-lacrimal sac andsee for any reflex from the puncta.7 . Eyelids to look for excessive laxity, punctumfor evidence of obstruction or inflammation.
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Syringing = through the inferior canaliculus.
Inability to flush = obstruction at the site of thepunctum or inferior canaliculus while reflux ofsaline = obstruction is more distal.Gentle skilled Probing with a 0 Bowmans probe
Hard obstruction = bone or calculiSoft obstruction = soft tissue.
Massaging of the sac = discharge from the puncti=consistent with chronic dacrocystitis.Swelling inferolateral to the medial canthus Jones test
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Low Howarths incision Lacrimal sac with its attached periosteum isdissected free from the lacrimal fossa and isretracted laterallyRhinostomy of 1.5 cm is created taking care notto damage the nasal mucosa.A vertical slit is made in the exposed nasalmucosa and, similarly, a corresponding vertical
slit is made in the lacrimal sacFlaps created are sutured together.Epithelium lined rhinostomy created.
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Advantages.Consistently high success rates
Biopsy of the lacrimal sac possible if it looksabnormal. DisadvantagesMight require general anaesthesia with anovernight stay.Facial scar.Injury to normal lacrimal pump function.
Risk of haemorrhage.Revision surgery by the same approach difficult.
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Common causes of failure of external DCR(EXTDCR). Intranasal synechiae
Improper placement of the rhinostomy site[eg, into an agger nasi cell(8 percent ofcases) or the superolateral aspect of themiddle turbinate]
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Indications for Primary endoscopic DCR :
1. In the management of tearing associated withprimary acquired NLDO2. Infection of lacrimal sac associated withprimary acquired NLDO
3. NLDO secondary to specific inflammatory orinfiltrative disorders4. The level of obstruction should be distal tothe junction of the lacrimal sac and the duct.
5. In the management of lacrimal duct injuriesassociated with sinus surgeries
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An incision is made in the mucosa overlyingthe anterior lacrimal crest.Posteriorly based muco-perichondrial flap israised.Anterior lacrimal crest is removed using apunch.Just lateral to Uncinate process is the thin
lacrimal bone that forms the remainder ofthe medial aspect of the lacrimal fossa.
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1. There is no external scar.2. The lacrimal pump system is preserved.3. Any concomittant intranasal pathology causing
epiphora can be addressed4. Lacrimal sac mucosa is preserved5. The risk for cutaneous fistulas, of concern in
patients who had previous radiation therapy orcertain granulomatous disorders, also may bereduced, as there is no external incision
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1. Presence of a firm indurated mass at thelevel of medial canthus.2. Any swelling near medial canthus wheremalignancy is yet not excluded.3. Bloody epiphora4. Presence of bony destruction as seen inradiological films5. Pseudoepiphora( hyperlacrimation) : isessentially reflux tearing: the main gland oversecretes because of lack of secretion fromminor glands along the lid margin.
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The canaliculus is dilated to allow passage ofa vitreoretinal light probe, (ideally throughthe superior canaliculus) which is advancedinto lacrimal sac.Point of light seen endoscopically acting as aguide to fashion the rhinostomy.Use optimum power to ablate tissue.(???)
Once the sac is exposed, the light probe iswithdrawn, replaced by lacrimal probe.
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Rhinostomy is enlarged to 5 8mm diameter. A silicone stent may then be passed throughboth superior and inferior canaliculi and beretrieved from the nose.The loop should not be excessively tight as itcan cause granulations at the rhinostomy siteand can cheese -wire through the canaliculi.
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Ability to vaporize soft tissue and bone.Good haemostatic properties.Deliverable through a flexible laser fibre.
Co2, Argon,Nd:YAG not suitable.Ho:YAG, KTP/532 and diode laser aresuitable.
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Ho:YAG laser --Vaporizes bone /good haemostaticpropertiesDisadvantage -- tendency to spatterrequiring repeated cleansing of theendoscope lens.The KTP/532 star pulse laser has similaradvantages but avoids this problem.The diode laser has a single-use fibre --
Expensive The erbium:YAG laser-- ideal for this surgery,but as yet no suitable delivery system exists.
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Small/Improper placement ofrhinostomy.(Bony/Membranous)Sump syndrome/small cicatrized sacScar ( at rhinostomy/ canaliculi-sac Junction)
GranulomaBony spicules/Incomplete periosteum removalPump insufficiency/persistent sac diverticulum
Previuos Sx, RT, Chemo for PNS tumor
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Microscope with a 300-mm lens may be usedStent - Some do not insert a stent whileothers leave a stent in for several months.Size of the ostium -- affect success rates.Transcanalicular DCR -- laser fibre throughcanaliculus (600 micron optical fibre).Balloon dacryocystoplasty -- Dilates stenosis.
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Mitomycin C and 5-Fluorouracil have beentried.
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Insertion of Lester-Jones tube =a permanentindwelling ceramic tube between the nasalcavity and the conjunctival sac to drain tearsand completely bypass the lacrimal drainagesystem.Canaliculo DCR = resection of the stenosedregion of the common canaliculus withprimary anastomosis over a stent inconjunction with a DCR.
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