Lacrimal Sac Reconstruction With Virtual Reality
Virtual Reality and Telemedicine in Endoscopic Procedures for Treatment of
Lacrimal Drainage Obstruction
14 Feb, 2023
Rafal Nowak, MD, PhD
Department of Ophthalmology, Military Institute of Medicine, Warsaw, Poland
PublicationCase
A female of 43 years presented to the lacrimal clinic with a history of slow
growing lesion at the inner angle of the left eye associated with epiphora
of 5 years. The swelling was not associated with any discharge, pain, or
acute infections in the past.
Clinical examination revealed a left-sided firm, well-defined lesion in the
area of the lacrimal sac fossa. Lacrimal irrigation was suggestive of a
partial nasolacrimal duct obstruction. The right-side examination was
normal. Different modalities of imaging were performed, including
dacryocystography (DCG), computed tomography dacryocystography (CT-DCG) and
magnetic resonance imaging (MRI)(Fig.1).
Figure 1. MRI shows a well-defined lesion (cyst) in the left lacrimal fossa
(red arrow)
Medical Imaging XR
(Medicalholodeck AG, Zurich, Switzerland) three-dimensional reconstructions
obtained from CT-DCG DICOM files showed a well-defined lesion in the left
lacrimal sac fossa, extending up to the beginning of the nasolacrimal canal
(bony). The lacrimal sac appeared to be compressed against the posterior
wall of the lacrimal fossa (Fig. 2-4).
Nasal endoscopy examination was normal other than a deviated septum. Further
3D-dimensional reconstructions were performed from the CT-DCG data using the
Meshlab (Visual Computing Lab, CNR-ISTI, Pisa, Italy) and Blender software
tools (Blender Foundation, Amsterdam, Netherlands).
The reconstructions showed the intricate relationship of the lesion with the
compressed lacrimal system (Fig. 5). The surgical plan was a careful
excision.
Figure 2. Medical Imaging XR reconstruction shows contrast dye in the left
lacrimal passages (blue arrow) and a space referring to a lesion compressing
the lacrimal sac (pink arrow)
Figure 3. Medical Imaging XR reconstruction shows isolated contrast dye in
the left lacrimal passages (red) and significantly compressed lacrimal sac
Figure 4. Medical Imaging XR reconstruction shows vertical dimension of the
cyst (11.9mm)
Figure 5. Three-dimensional reconstruction shows relationship of the lesion
with the compressed lacrimal system (posterior-anterior view from the back
of the left orbit; 1- lacrimal system in blue color, the cyst in red color;
2-isolated, compressed lacrimal system)
Surgical Technique
A curvilinear skin incision was taken to approach the lacrimal sac fossa.
The lesion was round to oval, firm with a yellowish surface. The lesion was
found to adhere to the anterolateral wall of the lacrimal sac. A probe was
placed in the sac, and a careful dissection was performed.
Following the complete excision of the lesion (Fig. 6), a focal area (9 × 6
mm) of the lacrimal sac was found to be injured with loss of tissue. The
lacrimal drainage system was first intubated with a Crawford bicanalicular
intubation to secure the lacrimal drainage pathway (Fig. 7).
Nasal mucosa was harvested from the floor of the left nasal cavity following
a standard decongestion (Fig. 8). The graft was fashioned in a way to
deliberately oversize and achieve final dimensions of 12 × 9 mm (Fig. 9).
The graft was secured by an end-to-end suturing with 6-0 vicryl (Fig. 2C).
Lacrimal irrigation was performed to ascertain no leakage from the sac
wound.
Skin wound closure was then closed in a standard way. Histopathological
examination was consistent with a diagnosis of a dermoid cyst. The
postoperative period was uneventful. Skin sutures were removed at 1 week.
Stents were extubated at 3 months.
Figure 6. Excision of the cyst
Figure 7. Visible bare silicone stents within the lacrimal sac defect
Figure 8. Harvested nasal mucosa
Figure 9. Nasal mucosa graft covering lacrimal sac defect
Follow-up
Epiphora gradually improved over 3 months. Lacrimal irrigation at 3 months
was freely patent. A CT-DCG was performed at the 6-month visit, which showed
reversal of the lacrimal sac compression with patent lacrimal drainage (Fig.
10).
Although the shape of the lacrimal sac was a little irregular on the CT-DCG,
the sac integrity was good. Three-dimensional reconstructions from the
postoperative CT-DCG showed good anatomical integrity of the lacrimal
drainage system (Fig. 11).
The patient was asymptomatic within the follow-up time of 2 years. Also, the
cosmetic effect was excellent (Fig. 12-13).
Figure 10. Medical Imaging XR postoperative reconstruction shows well
contrasted and filled lacrimal sac and nasolacrimal duct
Figure 11. Postoperative three-dimensional reconstruction of the lacrimal
system (right – well filled lacrimal system with smooth walls; left – well
filled lacrimal system with irregularities within inferior part of the
lacrimal sac
Figure 12. Operated area at follow-up after 6 months
Figure 13. Operated area at follow-up after 1 year
*Important Notice Regarding Functionalities for Surgical Planning and Professional Clinical Usage
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