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Congenital lacrimal sinus (fistula/accessory punctum) excision

This narrated video demonstrates the excision of an accessory lacrimal sinus or fistula and the insertion of a mini Monoka stent to protect the normal canaliculus 배니쉬드. It discusses the different surgical options for this rare condition.



This procedure is being done under the operating microscope to aid visualisation 다운로드.

The normal punctum and canaliculus are assessed. The accessory punctum or sinus is assessed and in particular its direction and length

Saline syringed through the normal punctum emerges freely from the accessory sinus, as this is the path of least resistance 라따뚜이 영화 다운로드. Hence this patient has epiphora.

A Bowman probe is inserted into the normal canaliculus. The metal probe can be seen down the accessory, confirming that in this case, the sinus is relatively short and that great care will need to be taken to avoid damaging the normal canaliculus during excision of the sinus 다운로드.

A biopsy punch can be used to core out the accessory sinus. However, the 2mm punch is a little too large for this sinus.

A Bowman probe is inserted into the sinus and the sinus excised down to the level of the probe that is in the inferior canaliculus 다운로드. It is probably possible to excise it in one circular core, but it is difficult because of the mobility of the tissue, obscuration by blood and caution for the normal canaliculus 세인츠 로우 4 캐릭터 다운로드. It is excised piecemeal.

Dispersive viscoelastic gel is instilled from time to time to protect the cornea.

A mini Monoka stent is placed in the inferior canaliculus 다운로드. It has been cut to around 20mm and with a tapered end. Siting them can be frustrating as they keep bouncing back off the medial wall of the lacrimal sac 인텔 mkl 다운로드. However, with repeated attempts at different orientations it almost always will turn the corner in the lacrimal sac and not bounce back. The plug at the proximal end is pushed into the punctum 다운로드.

The defect created by the excision of the sinus is closed. Here we are using a 7-0 vicryl horizontal mattress suture.

The mini Monoka was removed 2 months later and there was no evidence of recurrence of the sinus 6 months post-operatively 다운로드.

Alternative surgical interventions have been used for accessory lacrimal sinus excision. Excision of the mouth of the sinus and then closure of the conjunctiva across the sinus is the least interventional has minimal risk of damaging the normal canaliculus but probably has high recurrence rates because of tears passing into the residual portion of the sinus and gradually the sinus re-epithelialising towards the surface. DCR surgery with sinus excision is also described. The DCR is actually downstream of the aberrant anatomy, but the reduced resistance to flow of the shortened drainage system may facilitate tears passing down the normal canaliculus and help prevent recurrent of the sinus.



Satchi K, McNab AA. Double lacrimal puncta: clinical presentation and potential mechanisms of epiphora. Ophthalmology. 2010;117(1):180-3 e2.

Sullivan TJ, Clarke MP, Morin JD, Pashby RC. The surgical management of congenital lacrimal fistulae. Aust N Z J Ophthalmol. 1992;20(2):109-


Congenital ptosis levator advance surgery

This narrated video demonstrates an anterior approach levator advance procedure for the correction of congenital ptosis. It discusses relevant aspects of the anatomy of the levator muscle as well as skin crease reformation.



Congenital Ptosis, Levator Advance



In congenital ptosis, the skin crease is often less pronounced or absent as in this case, presumably because of the reduced function or insertions of the muscle 다운로드. The crease is marked at 8mm centrally, 5mm above the lateral canthus and 4mm above the medial canthus

A blepharoplasty is not being undertaken as there is no skin redundancy.


The skin is incised.

A high temperature cautery or hot wire is being used for dissection.

The tarsal plate is exposed 다운로드. Identifying the dissection plane to the tarsal plate can be more difficult with the cautery than scissors, but the haemostatic effect is a big advantage. If the skin and orbicularis are grasped and retracted inferiorly and away from the globe, one can usually see a small pucker deep to the orbicularis, through where dissection will lead to the tarsal plate 복음성가 무료.


Dissection at the lower end of septum exposes the inferior end of the levator aponeurosis. This is inferior to the pre-aponeurotic fat pad which although a useful landmark for ptosis surgery does not need to be exposed to identify the inferior end of the aponeurosis.


The posterior surface of the retractors is dissected free from the underlying conjunctiva. One can either dissect between levator and Mullers to create a levator flap or between Mullers and conjunctiva to create a flap consisting of both retractors 윈도우10 1803 다운로드. While there is no evidence to guide the choice, intuitively it seems prudent to use both retractors in congenital ptoses given the reduced levator function and sometimes a levator only flap does not appear to adequately elevate the lid.


The lateral horn is the fan like extension of levator aponeurosis that attaches to the lateral retinaculum and lateral tubercle just inside the orbital rim 다운로드. It is transected at angle of 45 degrees medially and superiorly which avoids the lacrimal ductules. This allows levator to advance more freely

Similarly the medial horn which passes over superior oblique tendon and attaches to the posterior portion of the medial canthal tendon and the posterior lacrimal crest, is partially transected.


A quick check of the lid contour and the position of its peak aids suture placement.

A double ended 6-0 vicryl suture is passed partially thickness in the tarsal plate 다운로드. The lid is everted to ensure it is not full thickness.

Each of the two needles is passed from the posterior to the anterior surface of the levator.

The suture is tied on a bow and the lid position checked.


The lid is marginally too high. The sutures are placed a couple of millimetres lower on the levator aponeurosis 다운로드. The lid position is better. The levator has not been advanced a huge amount and just a small amount of its terminal end and adjoining orbicularis is resected.


This patient had no skin crease on this side. In this case, the orbicularis of the inferior incision edge is being sutured to the terminal end of the levator aponeurosis in a few places 다운로드. This is thought to create a soft or less dense skin crease. This contrasts with the more widely used technique in Caucasian eyes of including a small bite of levator in the skin closure. There is very limited evidence for different skin crease reformation techniques and their outcomes in Caucasian eyes, but there are theoretical downsides to including levator in the skin closure 다운로드. Firstly it may be at greater risk of slipping with resultant loss of the skin crease or change in its position because of the repeated pull on the closure from blinking. Secondly it is contrary to usual surgical teaching to include some internal tissues between skin edges. Finally, electron microscopy studies have questioned whether there are indeed slips of levator that attach to skin slui exe. The skin is closed with a running 6-0 suture.