Solving eye problems through the nose
Date: May 25, 2012
An expert in transnasal endoscopic surgery, Andrew Lane frequently shares duties with ophthalmologic surgeons in cases involving both the eye and nose, such as tear duct surgeries and resection of orbital masses, and also when Graves’ disease patients become candidates for decompression surgery. That’s due to the intimate anatomy shared between the nose and the eye. Because the medial and inferior walls of the eye socket border the nasal cavity, those areas can be easily accessed through the nose.
“Ophthalmologists have long managed these problems solo through external approaches, but there are several advantages to performing operations endoscopically through the nose,” Lane, a specialist in rhinology and sinus surgery, explains.
These benefits can include better access and views for surgeons and shorter procedures with decreased risks to patients. Transnasal procedures also leave no external scars, an added benefit that many patients appreciate.
When tear ducts become blocked, impeding drainage from the eye into the nose, tears run constantly out of the eye—an often debilitating scenario for patients. The source of the problem is often the tear sac, the first collecting point for tears on their way into the nose, or the duct that carries the tears from the sac into the nasal passage.
A common surgery to repair tearing is to bypass the duct by making an opening directly from the sac into the nose, a procedure called a dacryocystorhinostomy (DCR). Ophthalmologists typically perform DCRs through an incision on the face, an approach that sometimes leads to the nasal DCR opening becoming blocked or scarred due to factors that are not directly apparent, such as a septal deviation, unusual sinus anatomy or sinusitis.
However, Lane says, tearing can also be resolved by endoscopic rhinolgogic surgeons through the nose without incisions. Though both the ophthalmologic and endoscopic approaches have extremely high rates of success, a major advantage of being evaluated by a rhinologist and doing the procedure endoscopically through the nose is that these other issues can be found and addressed.
Graves’ disease is another area where an endoscopic approach can be helpful. In over 50 percent of cases, patients go on to develop a condition known as Graves’ ophthalmopathy, which includes bulging of the eyes that can lead to bothersome symptoms such as eye dryness, double vision or pain. Ophthalmologists primarily treat the eye manifestations of Graves’ disease, but rhinologists can also play an important role in managing these cases, Lane says.
With extreme cases, Lane removes bone from the medial and inferior walls of the socket, and then ophthalmology will continue on the lateral walls. This tag-team approach creates more volume for the enlarged eye to sink back to its normal position.
Lane also takes referrals from ophthalmology in urgent or emergent Graves’ disease cases in which a patient is rapidly losing vision because of pressure on the optic nerve. Lane’s transnasal approach allows him to reach the affected areas in the back of the eye directly, often saving a patient’s vision without affecting other nearby structures.
The close teamwork between ophthalmology and otolaryngology–head and neck surgery is not the usual protocol at many hospitals, Lane says, but offering this rare collaboration is one way Hopkins is able to improve outcomes for patients whose conditions affect the eye and the nose.
“Our success rates are very high,” he adds, “and our patients are extremely satisfied.”