Self-irrigating piezoelectric device in orbital surgery

Outcomes of 8 × 8 mm osteotomy in powered external dacryocystorhinostomy

Purpose

To study the endoscopic ostium characteristics and outcome of 8 × 8 mm osteotomy in external dacryocystorhinostomy (DCR) using the microdrill system.

Methods

This prospective interventional pilot study was performed on 40 eyes of 40 patients with primary acquired nasolacrimal duct obstruction (NLDO) from June 2021 to September 2021 in patients undergoing external DCR. An 8 × 8 mm osteotomy was performed using round, cutting burr attached to a microdrill system. Success was defined as patent ostium on lacrimal syringing (anatomical) and a Munk score <3 (functional) at 12 months. Postoperative endoscopic ostium evaluation was done using a modified DCR ostium (DOS) scoring system at 12 months.

Results

The mean age of the study participants was 42.41 ± 11.77 years and the male-to-female ratio was 1:4. The mean duration of surgery was 34.15 ± 1.66 minutes and that for osteotomy creation was 2.5 ± 0.69 minutes. The mean intraoperative blood loss was 83.37 ± 11.89 ml. Anatomical and functional success rates were 95% and 85%, respectively. The mean modified DOS score was "excellent" in 34 patients (85%), "good" in 1 patient (2.5%), "fair" in 4 patients (10%), and "poor" in 1 patient (2.5%). Complications included nasal mucosal injury in 10% (4/40) of patients, complete cicatricial closure of ostium in 2.5% (1/40), incomplete cicatricial closure in 10% (4/40), nasal synechiae in 5% (2/40), and canalicular stenosis in 2.5% (1/40).

Conclusion

An 8 × 8 mm-sized osteotomy created by powered drill and covered by lacrimal sac-nasal mucosal flap anastomosis in external DCR is an effective technique that has minimal complications and shorter surgical time.

Ultrasonic instruments in orbital surgery: a major review

PURPOSE

Ultrasonic instrumentation has recently emerged as an important modality in orbital surgery. This review was designed to assess the current literature and potential advantages of this technology.

METHODS

A PubMed search was performed to identify relevant articles. These manuscripts were reviewed, and their data was abstracted.

RESULTS

Three variants of ultrasonic devices are gaining popularity in orbital surgery, including piezoelectric saws, the cavitron system, and ultrasonic bone aspirators and curettes. Previous manuscripts have described a variety of uses for these technologies, and the purported benefits include enhanced intraoperative visualization, improved facility in tight spaces, less damage to the surrounding parenchyma and vasculature, and excellent intraoperative dissection.

CONCLUSIONS

The emerging body of literature strongly supports the use of these devices in orbital surgery, and these instruments carry the promise of providing smoother, more precise, safer surgery.

External Dacryocystorhinostomy: A Comparison Of Ultrasonic Bone Aspiration To High-Speed Drilling

Purpose

Piezosurgical tools utilize high-frequency ultrasonic oscillations to selectively cut mineralized bone and minimize damage to soft tissue and mucosa. The purpose of this study was to directly compare outcomes in external dacryocystorhinostomy (DCR) using a piezoelectric ultrasonic bone aspirator (UBA) versus a high-speed electric drill with a diamond burr.

Methods

A retrospective chart review was conducted on 145 consecutive patients who underwent external DCR by a single oculoplastic surgeon between 2012 and 2017. Collected data included baseline patient characteristics, presenting symptoms, operative details and complications, and postoperative symptoms.

Results

One hundred and seventy-three primary external DCRs performed on 145 patients were included in this study. In total, 61.3% of cases were performed with the UBA and 38.7% with the high-speed drill. Most patients were white (92.4%) and female (67.6%), with a mean age of 57.6 years (range 1–93). Surgical success was achieved in 94.3% of patients in the UBA group and 94.0% in the drill group, with no significant differences between the two arms (p=0.36). Patients who experienced persistent nasolacrimal duct obstruction after surgery underwent endoscopic revision. Operative time was shortened for cases utilizing the UBA (38.9 mins) instead of the high-speed drill (44.7 mins; p=0.01). No significant intraoperative complications occurred in either group.

Conclusion

The UBA offers comparable outcomes and complication rates to more conventional surgical tools for external DCR. Excellent outcomes, ease of adoption, and potential surgical time savings make the UBA an appealing option for both novice and experienced surgeons.

A comparative analysis of piezosurgery and oscillating saw for balanced orbital decompression

Introduction: Different minimally invasive surgical approaches to the orbit allow individualized bone resection to reduce proptosis and decompress the optic nerve in patients with Graves' orbitopathy (GO). This study aims to compare piezosurgery to an oscillating saw used to resect bone from the lateral orbital wall. Methods: In a retrospective study, we analyzed balanced orbital decompressions performed on 174 patients (318 cases) with GO. An oscillating saw was used in 165 cases (saw group) and piezosurgery in 153 cases (piezo group). Peri- and postoperative complications, reduction of proptosis, new onset of diplopia and improvement of visual acuity in cases of pre-operative optic nerve compression were analyzed. Results: We observed no significant differences in the surgical outcome between the two groups. Proptosis reduction was 4.6 mm in the saw group (p < 0.01) and 5.3 mm in the piezo group (p < 0.01). Intraoperative handling of the piezosurgery device was judged superior to the oscillating saw, due to soft tissue conservation and favourable cutting properties. Duration of the surgery did not differ between the groups. No serious adverse events were recorded in both groups. Conclusion: The application of piezosurgery in orbital decompression is more suitable than an oscillation saw due to superior cutting properties such as less damage to surrounding soft tissue or a thinner cutting grove.

Piezoelectric surgery versus mechanical drilling for orbital floor decompression: effect on infraorbital hypoaesthesia

Purpose: To compare efficacy and safety of mechanical drill and piezoelectric technology in the prevention of infraorbital nerve hypoaesthesia during orbital floor decompression. Methods: Single-centre, non-randomized prospective, interventional case series. We enrolled 24 patients who underwent 3-wall orbital decompression. A total of 13 patients underwent floor decompression using 5-mm diamond dusted Piezoelectric tip (Synthes GmbH, Oberdorf, Germany), whereas 11 patients underwent conventional mechanical decompression of the floor using Stryker Core handpiece with 5-mm diamond dusted tip (Stryker, USA) and a Kerrison's bone ronguer. All surgeries were performed by a single surgeon (MNN) using standard surgical technique. The infraorbital nerve hypoesthesia was measured pre-operatively, and post-operatively on day 1, at 1 week, 6 weeks, 3 months, and final follow-up by an independent observer. Hypoaesthesia was graded on a simple numerical scale: 0 defined as "normal", 1 defined as "minimally reduced", 2 defined as "grossly reduced but perceptible", and 3 defined as "total loss". Results: The average follow-up after surgery was 16 months (range 13-48 months). The average score in the mechanical drilling group at day 1, week 6, week 12 and final follow-up was 1.9, 1.2, 0.7, and 0.6, respectively (p < 0.001). For the Piezo group, the average scores were 0.3, 0.2, 0.1, and 0.1, respectively. No procedure related complications were noted, and the average surgical time for floor decompression was comparable (p > 0.5). Conclusions: Piezoelectric technology is effective in orbital floor removal by minimizing infraorbital nerve hypoaesthesia.

Minimally invasive surgery for thyroid eye disease

Thyroid eye disease (TED) can affect the eye in myriad ways: proptosis, strabismus, eyelid retraction, optic neuropathy, soft tissue changes around the eye and an unstable ocular surface. TED consists of two phases: active, and inactive. The active phase of TED is limited to a period of 12–18 months and is mainly managed medically with immunosuppression. The residual structural changes due to the resultant fibrosis are usually addressed with surgery, the mainstay of which is orbital decompression. These surgeries are performed during the inactive phase. The surgical rehabilitation of TED has evolved over the years: not only the surgical techniques, but also the concepts, and the surgical tools available. The indications for decompression surgery have also expanded in the recent past. This article discusses the technological and conceptual advances of minimally invasive surgery for TED that decrease complications and speed up recovery. Current surgical techniques offer predictable, consistent results with better esthetics.

Piezosurgery in External Dacryocystorhinostomy

BACKGROUND

Dacryocystorhinostomy (DCR) can be performed via an external or endoscopic approach. The use of ultrasonic or piezosurgery has been well described for endoscopic DCRs but is lacking for external DCRs. This study presents a case series of external DCRs performed using piezosurgery evaluating results and complications.

METHODS

Prospective, consecutive case series of patients undergoing primary external DCR for lacrimal drainage insufficiency. A standard external DCR technique was used using 1 of 2 piezosurgery systems for all bone incision. All patients received silicone intubation to the lacrimal system. Surgical outcome was measured in terms of patient-reported epiphora as follows: 1) complete resolution, 2) improvement >50%, 3) improvement <50%, and 4) No improvement. Intra and postoperative complications were also recorded.

RESULTS

Fifty-two patients, 14 male and 38 female, were included in the study, with 2 patients having bilateral surgery. The average age of the patients was 55.8 years. The average length of follow up was 221 days. Surgical outcomes showed 72% of patients with complete resolution of epiphora and 21% with >50% improvement. There were 4 patients (7%) who had <50% improvement. There was 1 (2%) intraoperative complication and 2 (4%) postoperative complications recorded.

CONCLUSIONS

Piezourgery is a viable modality for performing external DCRs. The lack of surgical complications shows a potential for decreased soft tissues damage. The surgical success rate based on patient-reported epiphora is similar to those published for mechanical external DCRs. This modality may benefit the novice surgeon in the reduction of soft and mucosal tissue damage.

Novel Surgical Approaches to the Orbit

Determining safe surgical access to the orbit can be difficult given the complex anatomy and delicacy of the orbital structures. When considering biopsy or removal of an orbital tumor or repair of orbital fractures, careful planning is required to determine the ideal approach. Traditionally, this has at times necessitated invasive procedures with large incisions and extensive bone removal. The purpose of this review was to present newly techniques and devices in orbital surgery that have been reported over the past decade, with aims to provide better exposure and/or minimally invasive approaches and to improve morbidity and/or mortality.

Orbital Decompression in the Endoscopic Age

Objective

Postoperative diplopia occurs in up to 45% of patients following orbital decompression for exophthalmos associated with Graves’ orbitopathy. We sought to describe outcomes of our balanced orbital decompression strategy that includes the preservation of a modified inferomedial orbital strut (mIOS).

Study Design

Case series with chart review.

Setting

Academic medical center.

Subjects and Methods

A total of 115 consecutive orbital decompressions were performed on 73 patients (42 bilateral) with Graves’ orbitopathy. All patients underwent (1) a balanced decompression technique incorporating an endoscopic medial and external lateral decompression and (2) a mIOS technique with preservation of the anterior half of the inferomedial orbital strut. A periorbital periosteal (orbital) sling was utilized in patients (n = 54) without threatened vision loss, proptosis >28 mm, or periorbital disruption to prevent prolapse of the medial rectus muscle.

Results

Utilization of the mIOS technique with or without a sling did not adversely affect the reduction in proptosis (5.1 mm with sling vs 5.0 mm without sling; P = .85).The incidence of new-onset postoperative diplopia was 17% (n = 6). The sling was not associated with postoperative diplopia (odds ratio = 0.54, 95% confidence interval: 0.08-3.40, P = .51), while it was associated with resolution of preexisting diplopia (odds ratio = 6.67, 95% confidence interval: 1.06-42.06, P = .04). No intraoperative complications occurred, and no patients suffered a decrement in visual acuity.

Conclusion

Balanced orbital decompression utilizing a mIOS in patients with Graves’ orbitopathy provides a safe and effective reduction in proptosis with a low rate of new-onset diplopia as compared with historical values. Utilization of an orbital sling may be beneficial in reducing postoperative diplopia in select patients.

Piezosurgery in implant dentistry

Piezosurgery, or the use of piezoelectric devices, is being applied increasingly in oral and maxillofacial surgery. The main advantages of this technique are precise and selective cuttings, the avoidance of thermal damage, and the preservation of soft-tissue structures. Through the application of piezoelectric surgery, implant-site preparation, bone grafting, sinus-floor elevation, edentulous ridge splitting or the lateralization of the inferior alveolar nerve are very technically feasible. This clinical overview gives a short summary of the current literature and outlines the advantages and disadvantages of piezoelectric bone surgery in implant dentistry. Overall, piezoelectric surgery is superior to other methods that utilize mechanical instruments. Handling of delicate or compromised hard- and soft-tissue conditions can be performed with less risk for the patient. With respect to current and future innovative surgical concepts, piezoelectric surgery offers a wide range of new possibilities to perform customized and minimally invasive osteotomies.

Endoscopic ultrasonic dacryocystorhinostomy: clinical profile and outcomes

Ultrasonic endoscopic dacryocystorhinostomy (UEnDCR) is emerging alternative modality of managing nasolacrimal duct obstructions. The aim of this study was to report the clinical profile and outcomes with a UEnDCR with mitomycin C and silicone intubation. Prospective interventional case series performed on all consecutive patients undergoing an ultrasonic endoscopic dacryocystorhinostomy over a 1-year period from September 2013 to October 2014. All surgeries were performed by a single surgeon (MJA). Data collected include demographics, presentation, indications for surgery, past interventions, intraoperative and post-operative complications and outcomes. The main outcome measures were anatomical and functional success of the surgery. 44 procedures were performed in 41 patients. The mean age was 31.6 years. Children with complex congenital nasolacrimal duct obstructions refractory to probing and intubation accounted for 17 % (7/41) of the cohort. Past history of acute dacryocystitis was noted in 35.6 % (15/41). Two patients (4.9 %, 2/41) had failed external DCR. A minimal follow-up of 6 months following surgery was taken for final analysis. Complications included intraoperative focal epithelial burn in one patient that healed spontaneously and post-operative ostium granulomas in 15.9 % (7/44) of the ostia. At the 6-month follow-up, anatomical and functional successes were noted in 93.1 % (41/44) and 88.6 % (39/44), respectively. Ultrasonic dacryocystorhinostomy is a safe and effective alternative modality in the management of nasolacrimal duct obstructions in pediatric and adult age groups. Setup was easy and no additional technical difficulties were observed.

Piezosurgery for orbital decompression surgery in thyroid associated orbitopathy

The purpose of this study was to assess a piezosurgical device as a novel tool for bony orbital decompression surgery. At a multidisciplinary orbital center, 62 surgeries were performed in 40 patients with thyroid associated orbitopathy (TAO). Within this retrospective case-series, we analyzed the medical records of these consecutive unselected patients. The reduction of proptosis was the main outcome measure. Indications for a two (n = 27, 44%) or three wall (35, 56%) decompression surgery were proptosis (n = 50 orbits, 81%) and optic neuropathy (n = 12, 19%). Piezosurgery enabled precise bone cuts without intraoperative complications. Proptosis decreased from 23.6 ± 2.8 mm (SD) by 3 mm (95% CI: -3.6 to -2.5 mm) after surgery and stayed stable at 3 months (-3 mm, 95% CI: -3.61 to -2.5 mm, p < 0.001, respectively). The effect was higher in those with preoperatively higher values (>24 mm versus ≤ 24 mm: -3.4 mm versus -2.81 mm before discharge from hospital and -4.1 mm versus -2.1 mm at 3 months: p < 0.001, respectively). After a mean long-term follow-up period of 14.6 ± 10.4 months proptosis decreased by further -0.7 ± 2.0 mm (p < 0.001). Signs of optic nerve compression improved after surgery. Infraorbital hypesthesia was present in 11 of 21 (52%) orbits 3 months after surgery. The piezosurgical device is a useful tool for orbital decompression surgery in TAO. By cutting bone selectively, it is precise and reduces the invasiveness of surgery. Nevertheless, no improvement in outcome or reduction in morbidity over conventional techniques has been shown so far.