dos-mar-2011

Figure 6: Lacrimal sac abscess can be safely operated by Figure 7: Results of Endoscopic DCR can be assessed
endoscopic approach, where the abscess can be drained by examining the rhinostomy made in the nose as seen
into the nose with simultaneous opening of the sac and on nasal endoscopy. The patency of the rhinostomy can
marsupialzing it into the nasal cavity. External DCR is
contraindicated in such cases, as the skin is unhealthy be confirmed by irrigating it with betadine
and it is not possible to suture the flaps in such cases.
Therefore the abscess has to be drained first and then the laser fibre is that it is too thick to enter the canaliculi and thus has
skin wound is allowed to heal for a week. Only after that limitations. The cases with narrow puncta or canaliculi have to
an external DCR can be planned. Times have changed be operated by the conventional endoscopic technique. The third
now, patient’s time, money and resources can be saved disadvantage is the availability of cheap lasers in the market. The
laser fibres have insertion cannula through which the laser fibre
by adopting the latest technology passes. This cannula gets heated up when the laser fire slips into the
canula and laser is fired without the surgeon realizing the actual
• Poor results position of fibres in the canula. Further the metallic sheath is not
insulated enough to stop the transmission of heat to the skin and
• Inability to pass the probe in cases with narrow punctum and tissue outside the canula. Severe cases of lid burn and canalicular
canaliculi. burn have reported to us following such an attempt.

• Stenting is mandatory adding to the complications of stents It is therefore very important to buy a laser that has a good
itself insulation sheath over the metallic canula and also there is
provision of locking the flexible laser fibre into the canula so that
Steps of Transcanalicular DCR it does not slip.

Once the sac is opened all along its length, a bicanalicular stent is Discussion
passed through the upper and the lower punctum to maintain the
patency. Some people use mitomycin C, but its role in improving Endoscopic DCR was not at all popular in India in 1996. We then
the results has not been established. acquired the endoscope and camera unit. The unavailability of
oculopastic surgeon served as an opportunity for us. We were able
Transcanalicular laser DCR is picking up but the documented
results are low even with the use of mitomycin C. This is due to the
fact that the hard bone is difficult to burn and inadequate opening
up of the sac leads to poor results. The other problem with flexible

www.dosonline.org 67

Figure 8: A 20 guaze vitreoretinal diode laser probe is
inserted through the lower punctum

Figure 9: Thransillumination of the
lacrimal sac is seen through the nose

to open up all the cases of NLD block endoscopically. In a short
span we were able to build a series of our own, since all the patients
undergoing cataract surgery required a patent NLD the volume
of cases was proportionate to the number of cataract surgeries.

Satisfied with the success of endoscopic DCR in 1999, we thought
of doing the first live surgery conference exclusively on endoscopic
DCR. Gradually the popularity of endoscopic DCR increased
amongst ENT surgeons and later amongst eye surgeons. We were
under lot of pressure as people were asking for the literature on
the subject and there was not much available on this topic. We
then thought of publishing our book on this topic under the title
Endoscopic Endonasal DCR – a Revolution. We have come a
long way from 1996 and I can say with confidence that besides
giving good results there is very less morbidity with endoscopic
technique.

Conclusion

It was found that external DCR no longer remains the gold Figure 10: As the laser is fired from
standard as the results of endoscopic DCR are as good as of transcanalicular route thick pus can be seen
external DCR. In the hands of trained surgeon results are at par coming out of the nose as the sac is opened
with both the procedures. The question remains today is after all
whose domain is it. In our set up we succeeded in doing so many
cases because initial cases referred to us for examination of nose
prior to external DCR revealed many abnormalities in the nose
that had to be corrected before the external DCR. Initial cases
of endonasal DCR were done with the help of microscope in
collaboration with oculopastic surgeon.

Dacryocystitis is primarily an eye disease and cooperation between It is important to base our decision on the debility associated
eye and ENT surgeon is utmost important. Once we realize the with the symptoms in a child. Thick purulent discharge smearing
intricacies of nasal anatomy it is amazing to know how many the eyelashes compromising the vision of the child needs urgent
structures are intimately related to the lacrimal sac. surgical intervention.

Latest concept in Endoscopic treatment of lacrimal sac disorders
of children:

In children stenting of the nasolacrimal duct to obviate the need First Author
of endoscopic DCR gives results. The selection of case should be Nishi Gupta MS, ENT
proper. Time has come to review our management style in cases
of children presenting with epiphora. The time of intervention,
the type of intervention and the need for less invasive technique
needs to be formulated.

68 DOS Times - Vol. 16, No. 9, March, 2011

Neuro-Ophthalmological Manifestations in Trauma Clinical Meeting: Clinical Talk

J.L .Goyal MD, DNB

Neurophthalmological deficits commonly follow craniofacial and nerve sheath hematoma. In contrast, indirect injury results
trauma. The anterior and posterior visual pathways are from transmission of forces to the nerve. In setting of closed
affected by both direct and indirect mechanisms. Craniofacial traumatic head injury, its incidence varies between 0.5-5%.
trauma may also affect the pupillo-motor pathways, the cranial Vast majority seen in males (85%) mean age being 34yrs. Motor
nerves and the inter-nuclear and supra-nuclear gaze pathways. vehicles and bicycle accidents account for the majority of causes
About 1/3rd to ½ of patients of head trauma have abnormal neuro- followed by falls and assaults. TON has also been associated
ophthalmological examination. Head trauma is more common with penetrating trauma(stab wounds, gunshot wounds, foreign
in males, especially in 2nd - 3rd decades of life. Motor vehicle bodies) and recreational sports (e.g. paintball injury). Violent
accidents fall& assaults account for 90% cases followed by sports/ rotations of globe produce avulsion of optic nerve leading to
occupational hazard injuries. Ocular injuries are commonly a picture of partial ring of haemorrhage at optic nerve head.
associated with orbital fractures. Trauma in intra-orbital region is mainly because of intra-orbital
haemorrhage or emphysema causing either ischemia or elevated
Complete ophthalmic evaluation should be done for all the intra-orbital pressure compromising the circulation of optic nerve
patients with head trauma including assessment of visual acuity, known as orbital compartmental syndrome. Haemorrhage may
color vision, visual fields (for clue to the site of lesion), fundus occur directly, surgically induced, post thrombolytic therapy,
(for papilloedema/ optic atrophy), motility testing (important injection of local anaesthetics or even following retro-bulbar
in cranial nerve injury / orbital trauma), FDT (in suspected block (0.4-3%). Optic nerve in intra-orbital compartment runs a
muscle entrapment due to orbital #), Electrophysiological sinuous course which can withstand stretching upto 9mm. Hence,
tests like VEP (in unconscious patient for both diagnostic and indirect injuries are commoner whilst direct injuries are rare.
prognostic value where VA testing is not possible), Neuro-imaging Intracanalicular optic nerve is the most common site of trauma
(to know extent of intracranial, craniofacial and ophthalmic characteristically associated with high momentum decelerating
injury). CT scan is essential to know the amount and extent of injuries especially in fronto-temporal region. Any blunt force
intracranial/craniofacial damage. Optic canal # are best visualised in the fronto-temporal area leading to elastic deformation of
in thin 1mm CT sections. CT is superior to MRI in evaluating sphenoid can transmit forces to the optic nerve which is tightly
bones and in cases with acute hemorrhage, more cost effective, fixed to the bony canal along with its sheath. (Figure 1)
lesser time consuming and easier to perform – takes 5min as
compared to 30 min for MRI. MRI is superior for evaluation of On presentation, Visual acuity ranges from 20/200 to no PL.
Orbital apex, vascular injuries (carotico-cavernous fistula), optic RAPD may be the only feature. APD >2.1 log units indicate poor
nerve haematoma, non metallic foreign bodies and previously prognosis. Fundus may be normal. Disc pallor might take 3-4
undetected brainstem lesions. USG may be helpful in detecting weeks to develop. VEP is required to document the presence of
Optic nerve sheath hemorrhage. Sometimes, neuro-ophthalmic TON in unresponsive patients / in cases with ocular injuries. In
deficits may be present despite normal imaging. unilateral cases, flash VEP amplitude ratio (affected side/normal
side) greater than 0.5 appears predictive of a favorable, long-term
Pupillary dysfunction in trauma: Pupillary size and reactivity visual outcome. Flat VEP indicates poor prognosis. (Figure2)
should be noted in every patient. Swinging flash light test to The main treatment options for traumatic optic neuropathy
be done to detect RAPD and neutral density filters are used to
quantify it. Traumatic mydriasis is the most common pupillary
abnormality in trauma. The pupil fails to constrict with 1%
pilocarpine. It should be differentiated from associated III N. palsy.
Bilateral miosed pupils are usually due to narcotic use or pontine
haemorrhage. Horner‘s Syndrome may be seen in penetrating/
blunt neck trauma. Its features are ipsilateral Ptosis (due to Muller
muscle Palsy), miosis, apparent enophthalmos, anhydrosis,
dilated conjunctival vessels. Pupillary reactions remain normal
in Horner’s syndrome.

Traumatic optic neuropathy: Traumatic optic neuropathy refers to
an acute injury of the optic nerve secondary to trauma. Injury may
be direct or indirect and visual loss may be partial or complete.
Direct TON result from an anatomical disruption of nerve fibres
by penetrating orbital trauma, bony fragments within the canal

Guru Nanak Eye Centre, Figure 1: Conclussional trauma to upper-temporal forehead,
Maulana Azad Medical College, most common site leading to traumatic optic neuropathy
Maharaja Ranjit Singh Marg, New Delhi
75
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the patients come late only neurotonics are given. In general visual
prognosis for traumatic optic neuropathy is poor.

Retrochoasmal injury: Refers to injury to optic tracts anywhere
beyond optic chiasm. Results in contra-lateral homonymous field
defects seen in more than 50% cases. VA is normal in unilateral
cases. Injury to temporal lobe produces homonymous superior
quadrantinopia (pie in the sky) and parietal lobe produces inferior
quadrantinopia (pie on the floor). More posterior lesions produce
more congruous visual field defects.

Figure 2: Flash VEP showing flat wave indicates bad Patients can have spastic gaze to the opposite side of the lesion &
prognosis in TON on OKN depressed pursuit when drum is rotated towards the side
of lesion in parietal lobe lesions and reverse happens in frontal
lobe lesions. Visual hallucinations can also occur. Typically, they
are formed in temporal lobe and unformed in occipital lobe.

(TON) include systemic corticosteroids and surgical optic nerve Cranial nerve palsies: Damage to cranial nerves III, IV, V, VI and
decompression, either alone or in combination. NASCIS 2 trial VII is of neurophthalmological significance.
evaluated patients with acute spinal cord injury treated with
placebo, methyl-prednisolone, or naloxone. It showed that methyl- Occulomotor nerve: Injury can occur anywhere between midbrain
prednisolone (30 mg/kg loading dose, followed by 5.4 mg/kg/h to orbit. Localization can be on the basis of site of injury. Trauma to
for 24 hours) started within 8 hours of injury was associated with red nucleus leads to contralateral tremors, Cerebral peduncle leads
a significant improvement compared with patients treated with to contra-lateral hemiparesis and injury to Superior cerebellar
placebo. The findings of the NASCIS trials led to an increased use peduncle causes ataxia. Compression at edge of tentorium cerebelli
of steroids in treating TON. Corticosteroid Randomization after occurs due to cerebral edema, hemorrhage. Cavernous sinus
Significant Head Injury (CRASH) trial raised concerns regarding injury can result from a carotid artery aneurysm, Cavernous sinus
the use of mega dose steroids in traumatic brain injury in terms thrombosis, Carotico cavernous fistula. At Superior orbital fissure
of increased mortality. The International Optic Nerve Trauma third nerve can be involved by orbital apex fractures. Presents with
Study (IONTS) was a nonrandomized intervention trial that horizontal, vertical, oblique diplopia, difficulty near vision, light
compared visual outcomes for patients with TON treated with sensitivity, ptosis , mydriasis ,adduction, depression and elevation
observation, systemic steroids, or optic canal decompression. deficit. Aberrant innervations may be seen weeks to months after
Published in 1999, the study included 133 patients who were injury causing abnormal eyelid position, pupil size. Spontaneous
evaluated and treated within 7 days of the traumatic event, with recovery seen in 6-12 months. Prisms, strabismus surgery can be
most of the patients being treated with either corticosteroids used to maintain binocular single vision. Ptosis repair requires
(n=85) or surgical decompression of the optic canal (n=33). frontalis suspension in third nerve palsy. Recovery of 3rd nerve
Follow-up results showed that visual acuity increased by more palsy is always incomplete in trauma. Surgical planning is difficult
than 3 lines in 32% of the surgery group, 52% of the corticosteroid due to misdirection/regeneration syndrome.
group, and 57% of the observation group. However, the study
was nonrandomized and uncontrolled, and the small numbers Trochlear nerve: 4th cranial nerve has longest intracranial
of patients in the observation group (n=9) limited the strength course. Head trauma is the commonest cause of IVth nerve
of the study’s statistical power. The rationale for surgical therapy paresis in adults.It emerges from dorsal aspect of mid brain
in indirect TON is to decompress the optic nerve at the site of & circles anteriorly around the brainstem and runs forwards
injury, which is often the intra-canalicular segment. Surgical and enters cavernous sinus Finally it enters the orbit through
decompression is thought to help reduce optic nerve compression SOF and innervates the superior oblique.Injury occurs at free
and subsequent vascular compromise that may occur as a result edge of tentorium cerebelli where it enters cavernous sinus. In
of the indirect injury. Patients with bone fragment impinging Bilateral cases (1/3rd) site of injury is anterior medullary velum
on a segment of the intra-canalicular optic nerve are the best before exiting midbrain .Central damage to trochlear nucleus
candidates but other view says that damage by impinging bony affects contralateral eye. The nuclei of other cranial nerves affect
fragment is instantaneous and there is no use removing it once ipsilateral structures. Clinically, patients present with vertical and
the damage is done. torsional diplopia which is worse on down gaze, reading, walking
downstairs is a characteristic feature. Hypertropia in primary gaze
So the management protocol depends on surgeon’s choice. We and head tilt to the opposite side. Bielschowsky’s head tilt test
at our centre start high dose (1Gm/day) not mega dose steroids is used to test superior oblique palsy. Bilateral trochlear paresis
if the patient presents to us within a week for 3 days followed by presents with V- esotropia.
oral steroids for 11 days and then taper them off. Patients who
have visual acuity of 6/60 or better, those who have formed but Abducens nerve: The abducens nerve leaves the brainstem at
subnormal waveform on VEP, unassociated with orbital # and ponto-medullary junction of the pons medial to the facial nerve.
unconsciousness have better chances of improvement than those it runs upward and then bends forward over the tip of the petrous
who have no PL, flat VEP, orbital # and unconsciousness. In case temporal bone where it makes a sharp turn forward to enter the
cavernous sinus. Here it runs alongside the internal carotid artery
and enters the orbit through the superior orbital fissure and
innervates the lateral rectus. The long course of the nerve makes

76 DOS Times - Vol. 16, No. 9, March, 2011

Figure 3: Rt Medial longitudinal fascicular Figure 4: Traumatic lesion of
injury leading to Rt INO showing restriction of Rt Lt PPRF & MLF leading to one and

adduction and Lt abduction nystagmus a half syndrome,
only movement preserved is

Rt Abduction

it vulnerable to injury. Fractures of the petrous temporal bone Internuclear ophthalmoplegia: Trauma to the inter-nuclear and
can cause selective 6th/with 5th &7th nerve damage. Aneurysms supranuclear pathways can lead to INO: lesions of MLF result
of the intra-cavernous carotid artery, post traumatic carotid in impaired adduction of the ipsilateral eye (RT), often with
cavernous fistulas with sympathetic palsy (Horner syndrome) contralateral abducting nystagamus. (Figure 3)
localises the lesion in cavernous sinus. Mass lesions that push
the brainstem downward can damage the nerve by stretching it Horizontal gaze palsy: lesions of pons with damage of horizontal
over the petrous temporal bone. Patient presents with horizontal gaze centre in PPRF results in paralysis of ipsilateral horizontal
diplopia, inability to abduct. Damage to the nucleus does not gaze
produce isolated sixth nerve palsy, but rather a horizontal gaze
palsy. The abducens nucleus contains interneurons that cross One and half syndrome: lesions of PPRF and ipsilateral MLF
the midline and connect to the contralateral oculomotor nucleus resulting in INO with horizontal gaze palsy. Only movement
through MLF (which controls the medial rectus muscle of the preserved is abduction of contralateral eye. Prognosis is good.
opposite eye).Accompanying INO or skew deviation may be there. (Figure 4)

Trigeminal nerve: Nucleus of trigeminal nerve is largest and Vertical gaze Palsy: Damage to rostral interstitial nucleus of
extends from midbrain to C2 level of spinal cord. It exits brainstem the MLF produces paralysis of down-gaze. Lesions in the area
at lateral aspect of pons. of posterior commisure leads to Dorsal midbrain syndrome
characterized by-
Ophthalmic and maxillary division course through cavernous
sinus within lateral wall and enter the orbit. Infraorbital branch • Impairment of up gaze
of maxillary division travels within infraorbital canal in orbital
floor cause upper lip and cheek numbness. Sensory testing of face • Light near dissociation
and cornea should be done in all the cases.
• Eyelid retraction
Facial nerve: Facial nerve arises at pons, passes through internal
auditory meatus and supplies the face. Paresis of orbicularis leads • Convergence retraction nystagmus, and
to incomplete eyelid closure, ectropion of lower lid. Neurotrophic
corneal ulceration occurs with concomitant 5th nerve involvement • Spasm of paralysis of convergence
in # base of skull. Assessment of bell’s phenomenon should be
done in all such cases. Treatment is mainly conservative which Management of neuro-ophthalmic trauma should have a
includes lubricaton, tarsorrhaphy, tightening of lower eyelid etc. team of neurosurgeon, head and neck surgeon and a neuro-
ophthalmologist for better evaluation and management.

Central disorders of ocular motility:

Skew deviation: Skew deviation results from disruption of Author
vestibular input to the oculomotor system lesions in midbrain, J.L. Goyal MD, DNB
pons, medulla or cerebellum.

It has no localising value. Skew deviation may be comitant or
incomitant and may be associated with cranial nerve palsies.

www.dosonline.org 77

Forthcoming Events: National

April 2011 October 2011
15-17 NEW DELHI 7-9th RISHIKESH, UTTARAKHAND

Annual Conference The VIII annual conference of UKSOS,
Delhi Ophthalmological Society UTTARA EYECON -11
Venue: Hotel Ashok, Chanakya Puri, New Delhi Himalayan Institute of Medical Sciences
Contact Person & Address Swami Ram Nagar, Rishikesh
Dr. Amit Khosla, Secretary DOS Contact Person
Room No. 2225, 2nd Floor, New Building, Dr. Renu Dhasmana,
Sir Ganga Ram Hospital, Uttara eyecon 11
Rajinder Nagar, New Delhi - 110 060 Department of Ophthalmology
Ph.: 011-65705229, E-mail: [email protected], Himalayan Institute of Medical Sciences
Website: www.dosonline.org Swami Ram Nagar, Dehradun
Mobile: 08954785343,
May 2011 Phone: 0135-2471355, 0135-2471440
29th PILIBHIT, UTTAR PRADESH Email: [email protected]

Mid-term Converence of UPSOS October 2011
UP State Ophthalmic Society 9th SITAPUR, U.P.
Conference Secretariat
Dr. Vipin Sahni 1st Meeting of “Association of Children Eye Specialists
Kaushalya Devi Eye Institute of India” Regional Institute of Ophthalmology
Near Chhatari Chauraha, Pilibhit, U.P. Contact Person
E-mail: [email protected] Dr. V.B. Pratap
Website: www.practicesolutions.in Sitapur Eye Hospital, Sitaput, U.P.
(M): 91-9897504744 Mobile: 09336838343
E-mail: [email protected]

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