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ABSTRACTS OF PAPERS AT THE 83RD RESEARCH MEETING OF THE MEDICAL RESEARCH CENTRE OF BOMBAY HOSPITAL ON MONDAY, 8TH JANUARY 2001, 2.30 PM, SP JAIN CAFETERIA. (CONVENOR DR. HL DHAR)
1. ENDOSCOPIC HYPOPHYSECTOMY
Nishit J Shah, Vimal Hemani, Priyadarshini Naik
Pituitary surgery is performed for various types of pituitary tumours such as prolactinomas, gigantism or acromegaly. Cushing’s disease, non-secreting adenomas and for pituitary adenomas extending into the suprasellar region. The conventional surgical method for removal of pituitary adenomas involves incisions under the upper lip (sublabial trans-septal) or in the nostril (trans-septal). Occasionally, even a trans-cranial procedure is used. The endoscope has revolutionised surgery in all parts of the body, and so too in ENT and neurosurgery. Working as a team, we have developed a surgical procedure to tackle pituitary tumours, so that the patient has the maximum benefit from the expertise of ENT and Neurosurgery. Augmenting the operating microscope the endoscope provides the surgeon with a panoramic view of the pituitary gland and surrounding structures. It can also provide a very close view of the pituitary gland and tumour interface. After the patient undergoes general anaesthesia, the endoscope and surgical instruments are placed in the patient’s nostril, and the tumour is removed. No lip or nasal incisions are made, no occlusive packing is placed and patients are generally sent home few days after surgery. Patients can also usually return to work or school in four to six week’s time.There are numerous advantages to the endoscopic approach
1. Pituitary tumours can be removed through the patient’s nostril.
2. Does not require skin incisions and eliminates the need for occlusive postoperative packing used with the conventional procedure.
3. Is less invasive because it directly approaches the tumour through the patient’s nare, thus eliminating facial swelling, decreasing postoperative pain and making recovery quicker.
4. Chances of leaving residual tumour is minimal as the endoscope can look around corners, and remove tumour that may be missed by the microscope.
5. Most patients can go home in two to three days following their surgery.
6. Bleeding is considerably less.
7. By not having an incision under the lip, numbness of the upper lip and teeth is avoided completely and eating and drinking after surgery is not hindered.
8. By minimising the amount of nasal mucosal dissection, post-operative nasal irritation, dryness and nasal septal defects are virtually eliminated. All the complications associated with a sub-mucous resection of the spectrum are avoided.
9. Additionally, the endonasal approach generally takes a shorter amount of time than the traditional sublabial approach.
2. ENDOSCOPIC DACRYOCYSTORHINOSTOMY
Nishit J Shah, Priyadarshini Naik , Vimal Hemani
Conventional dacryocystorhinostomy (DCR) usually involves extensive removal of bone at the lacrimal fossa and hence risks disruption of the lacrimal pump mechanism. The lacrimal sac can alternatively be approached with ease through the nose with the help of the nasal endoscope. This is a more physiological approach for naso-lacrimal blockage where the lacrimal sac is marsupialised into the nose.In patients with apparent dacryocystitis, blockage of the nasolacrimal duct may be inferred by doing sac syringing. If the irrigation fluid flows out through the superior lacrimal punctum, it indicates that the canaliculi are patent, and the patient would benefit from an endoscopic DCR. However if there is a reflux of fluid through the lower punctum itself, it signifies a canalicular block, in which case a DCR is contraindicated. The diagnosis of chronic dacryocystitis can be confirmed with the help of a dacryocystogram wherein dye is seen in the sac with an obstructed naso-lacrimal duct through which the dye fails to flow.
The lacrimal bone and the frontal process of the maxilla form the anterior part of the lateral nasal wall. The mucosa of the lateral nasal wall anterior to the uncinate process is removed. The underlying bone is then exposed. With the help of a bone punch forceps, this bone is removed so that the sac can be visualized. Following exposure, the sac is then incised and the pus allowed to drain out. The opening in the sac is then widened. The patency can also be confirmed by injecting methylene blue dye through the lacrimal punctum and watching it trickle into the nose. A silicon stent may be kept in certain cases for a period of 4-6 weeks to prevent re-stenosis.
The endoscopic approach has various advantages. It is safe, quick and far less traumatic. There is minimal blood loss and easily accepted by the patient, as there is no skin incision and therefore no cosmetic problem. The results are better than those of the conventional approach, as there is no disruption of the medial canthal structures and the pumping mechanism of the canaliculi. However, post-operative care is extremely important for the patient until healing occurs.
3. HEIDERBERG RETINA TOMOGRAPH IN GLAUCOMA
Jayashree Ahir Rao, RC Patel
Heidelberg Retina Tomograph is a scanning laser ophthalmoscope which can evaluate quantitative morphological optic disc and peripapillary changes in patients before other parameters become detectable.It is an automated digital image acquisition and analysis system designed to acquire record and analyse the 3D topography of optic nerve. Uses diode laser at 670 nm in a confocal system.
Topography Image
The optic disc is superimposed on a red/green/blue everyday.
Red region-indicates cup
Green blue-Neuroretinal rim
Optic disc is divided into 6 sectors and stereometric parameters of which are compared to (N) values if within normal limits > > a green check mark outside (N) limits > > a red cross X borderline > > a yellow? mark. If any sector is outside normal limits sectors and any one is borderline then the eye is classified as "Borderline". If all 7 sectors are within normal limits then the eye is classified within normal limits.
Adv of HRT - detects RNFL defects prior to visual field defects. Helps in accurate detection of progress of glaucoma. Examination does not require dilatation. Fast (0.6 sec) Accurate, Recordable, Reproducible, Easier for patients and ophthalmologists
Thus gives a better understanding of glaucoma.
Other Application - Macular holes, CSR, Macular oedema, Papilloedema, Pseudoneuritic disc.
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