[A clinical study of dacryocystorhinostomy per nasal endoscope guided by endo-ophthalmic optical fiber]

OBJECTIVE

To get a method of dacryocyst allocation for dacryocystorhinostomy per nasal endoscope.

METHOD

The dacryocyst of 7 chronic dacryocystitis cases(8 eyes) were located through nasal cavity guided by endo-ophthalmic optical fiber.

RESULT

All the 7 patients got successful operations, the bleeding was 10-20 ml during the operation , postoperative recovery was good, no infection occurred. Five patients received operations twice, all of them were detained anaesthetic tubes for 3 to 6 months, dacryocyst rinsing were conducted once per month after extubation. No obstructions and complications occurred after one year follow up.

CONCLUSION

Endo ophthalmic optical fiber can be used to locate dacryocyst in dacryocystorhinostomy per nasal endoscope.

Lodged Intracanalicular Plugs as a Cause of Lacrimal Obstruction

PURPOSE

To evaluate the complications and success of treatment of migrated or lodged intracanalicular and punctal plugs.

METHODS

A retrospective chart review of all cases having either a dacryocystorhinostomy or surgical removal of an intracanalicular or punctal plug from 1992 to 2006, in a single physician referral oculoplastics practice, was performed to identify cases in which a retained lacrimal plug required surgical intervention. Patients presented with symptoms of tearing, infection, or granuloma formation. The charts of 998 surgical cases were reviewed, from which 66 eyes (6.6%) were determined to have had lodged lacrimal plugs that required surgical removal, thus qualifying them for inclusion in this study. Patients were followed after surgery until reconstructive silicone tubing was removed (range, 6 weeks to 6 months), and each patient was questioned regarding symptoms. A comparison group of 336 eyes that had collared punctal plugs placed served as the control group.

RESULTS

All cases were noted to have complications from intracanalicular plugs. No complications were noted from other forms of lacrimal plugs. All eyes in this series required a canaliculotomy or a dacryocystorhinostomy after office irrigation failed to dislodge the plug. Five eyes presented with canaliculitis, 28 eyes presented with epiphora, and 29 eyes presented with dacryocystitis. Four of 66 eyes (6%) in this cohort presented with a pyogenic granuloma. Five eyes (8%) presented with canaliculitis. Forty-nine of 66 eyes (74%) were asymptomatic following treatment, with no observable infection or epiphora. Seven of 66 eyes (11%) had some improvement in symptoms and another 10 of 66 eyes (15%) had no change in symptoms after treatment. No complications requiring surgical intervention were encountered in the control group of collared punctal plugs.

CONCLUSIONS

Intracanalicular-type plugs may lodge in the lacrimal outflow system. This may result in epiphora, canaliculitis, or dacryocystitis that may require major reconstructive surgery. Despite surgical intervention, these symptoms do not always resolve (26% of eyes in this study had persistent epiphora). Intracanalicular plugs were observed to be associated with a higher rate of granulation tissue formation in the lacrimal outflow tract when compared with other forms of punctal plugs. As a result of the increased number of complications seen with intracanalicular plugs, caution is advised with respect to use of these devices. The relative infrequency of complications seen with collared punctal plugs suggests a safer alternative. Data from this study lead the authors to advocate the consideration of other forms of lacrimal occlusion due to the high number of complications noted with intracanalicular plugs, and the availability of other reversible forms of punctal occlusion.

Endoscopic study of the intranasal ostium in external dacryocystorhinostomy postoperative. Influence of saline solution and 5-fluorouracil

PURPOSE

To study, through endoscopy, the postoperative structural changes of the intranasal ostium following external dacryocystorhinostomy and to evaluate the influence of saline solution and 5-fluorouracil.

METHODS

Fifty patients were distributed into the following groups: Group SS-dacryocystorhinostomy and an injection of saline solution during surgery (13 patients); Group 5--FU1-dacryocystorhinostomy and an injection of 5 fluorouracil during surgery (17 patients); Group C--dacryocystorhinostomy only (11 patients); Group 5--FU3-dacryocystorhinostomy and 3 injections, 1 during surgery and 1 on the third and fifth postsurgical days (9 patients).

RESULTS

Pair-wise group comparisons using the nonparametric Mann-Whitney test revealed that there was a significant reduction of the ostium area only in Group 5-FU1 vs. Group SS on the 60th postoperative day (P <.01); however, a comparative study among the 4 groups using the Kruskal-Wallis test showed no significant changes in the ostium area on the 60th postoperative day. The ostium area within groups at the 30th vs 60th postoperative day was significantly reduced for Group C (P < .05; Mann-Whitney test); no significant changes were found for the other groups.

DISCUSSION

These results suggest that the use of 5-fluorouracil in external dacryocystorhinostomy does not significantly influence the final size of the surgical fistula as determined 2 months postsurgery.

Community-acquired methicillin-resistant Staphylococcus aureus in association with chronic dacryocystitis secondary to congenital nasolacrimal duct obstruction

Methicillin-resistant Staphylococcus aureus (MRSA) has emerged as an important pathogen responsible for serious ocular and systemic disease. MRSA has been reported to occur in dacryocystitis in the adult population. This is the first case report of community-acquired MRSA in the pediatric population in association with chronic dacryocystitis secondary to congenital nasolacrimal duct obstruction in an infant.

Bilateral canaliculitis following SmartPLUG insertion for dry eye syndrome post LASIK surgery

BACKGROUND

Dry eyes are a common symptom following LASIK corneal refractive surgery. Treatments include topical lubricants to supplement the tear film, and punctal occlusion to reduce tear outflow. Canaliculitis is a recognised complication of punctal plugs, but has not previously been described following insertion of newer generation semi-permanent intra-canalicular plugs, such as the SmartPLUG.

METHODS

Case report.

RESULTS

We describe a 60-year-old female who underwent bilateral LASIK surgery leading to aggravation of her dry eye syndrome. She was managed with the insertion of semi-permanent intra-canalicular moldable silicone SmartPLUGs. She subsequently developed bilateral canaliculitis requiring bilateral canaliculotomy.

CONCLUSIONS

To the best of our knowledge, this is the first report of bilateral canaliculitis following intra-canalicular SmartPLUG insertion. This case illustrates that punctal occlusion with the newer generation intra-canalicular plugs carries a risk of canaliculitis and that irrigation is not always effective in removing these devices.

The treatment of congenital dacryocystocele

PURPOSE

To determine the proper management of congenital dacryocystocele.

DESIGN

Retrospective interventional case series.

METHODS

SETTINGS

Clinical practice.

STUDY POPULATION

Twenty-seven consecutive patients with 29 congenital dacryocystoceles who presented from 1987 through 2006.

MAIN OUTCOME MEASURES

The charts were reviewed for the presence and age of onset of infection, methods and age of treatment, and response to treatment.

RESULTS

Dacryocystitis and preseptal cellulitis requiring intravenous antibiotic therapy were present in 11 lacrimal systems (37.9%), and dacryocystitis without cellulitis was present in an additional 10 lacrimal systems (34.5%). One or more probings were performed in 26 patients (89.7%). Resolution with conservative therapy occurred in three lacrimal systems. The initial probing was successful in seven of seven lacrimal systems (100%) that did not have infection, but was successful in only 10 of 19 lacrimal systems (53%) that had dacryocystitis with or without cellulitis. The mean age of probing in the surgical patients who did not develop infection was 5.9 days, whereas the mean age at first probing in surgical patients who developed infection was 17.3 days.

CONCLUSIONS

Patients with congenital dacryocystocele should have probing on an urgent basis and as early in life as possible, unless the lacrimal sac decompresses into the nose at the time of the initial examination. This approach will reduce the incidence of dacryocystitis and cellulitis, and improve the success rate of surgery.

Recurrent bilateral dacryocystoceles in Wegener's granulomatosis: a rhinologic perspective

Wegener's granulomatosis (WG) is a rare, idiopathic, systemic vasculitis of small vessels that manifests in multiple organ systems. Otorhinolaryngic manifestations of this disease include recurrent sinusitis and relapsing polychondritis. Periocular involvement is also a well-documented location of Wegener's disease. We present the case of a 13-year-old girl with severe WG who developed multiple recurrent orbital infections. She underwent multiple incision and drainage surgeries of each orbit and multiple courses of intravenous antibiotics. The patient persistently reaccumulated purulence in her nasolacrimal duct system and was referred to an oculoplastic surgeon for evaluation of these recurrent infections. The diagnosis of dacryocystitis as a complication of WG was made. This unique case represents a patient with severe WG developing bilateral dacryocystitis requiring bilateral dacryocystorhinostomies.

Nasal endoscopy in congenital dacryocystitis

PURPOSE

Controversy exists regarding the relationship between nasal pathology and congenital dacryocystitis. The recent advent of nasal endoscopes has greatly improved visualization of deep and hidden areas of nasal anatomy and has led to the elaboration of nasal anatomical variants and pathologies that were previously unknown. The current study aimed to evaluate for associations, if any, between anatomical abnormalities or variations in the lateral nasal wall and the presence and resolution of congenital dacryocystitis.

PATIENTS AND METHODS

Phase I was a case-control study that compared the incidence of a predefined set of nasal endoscopic variations in infants with congenital dacryocystitis versus normal infants. Phase II was a cohort study that evaluated the impact of nasal endoscopic variations on the effectiveness of conservative treatment for congenital dacryocystitis. "Failure" to respond to conservative treatment measures was defined as the persistence of symptoms at the first birthday.

RESULTS

Inferior turbinate hypertrophy and inferior meatal narrowing were significantly more frequent in the case group than in the control group. Conservative treatment measures resulted in 70 of 83 resolved cases on subsequent follow-up. The occurrence of inferior turbinate hypertrophy or inferior meatal narrowing at final examination was associated with non-resolution. The relative risk of non-resolution with inferior turbinate hypertrophy or inferior meatal narrowing was 7.7 (confidence interval, 2.32 to 25.72) and 12 (confidence interval, 3.7 to 39.2), respectively.

CONCLUSION

Inferior turbinate hypertrophy and inferior meatal narrowing are more frequent in cases of congenital dacryocystitis. They are predictive of a poor outcome when congenital dacryocystitis is treated with conservative measures. This information should be considered when making clinical decisions for patients with congenital dacryocystitis.

Management of Complications after Insertion of the SmartPlug Punctal Plug

PURPOSE

To characterize and describe the management of complications seen in patients who have undergone insertion of the SmartPlug permanent punctal plug.

DESIGN

Retrospective case series.

PARTICIPANTS

Patients who experienced complications after SmartPlug insertion and were treated by 1 of 18 ophthalmic plastic and reconstructive surgeons between January 2004 and October 2005.

METHODS

Presenting symptoms and signs and the management of complications were analyzed.

MAIN OUTCOME MEASURES

Prevalences of canaliculitis and dacryocystitis, tearing at presentation, and outcome of conservative and/or surgical management of the SmartPlug complications.

RESULTS

Twenty-eight patients were included in the study; 13 had bilateral involvement. On initial presentation, 18 patients had inflammation, including 17 with canaliculitis and 1 with recurrent acute dacryocystitis. Ten patients had little or no inflammation; all 10 had tearing of the involved eye(s). In 5 patients, complications resolved after office irrigation of the lacrimal drainage system; in a sixth patient, silicone intubation was performed as well. Canaliculotomy was performed in 13 patients (bilateral in 3) and combined with silicone intubation (3 patients). Canaliculotomy was planned in an additional 2 patients. Canaliculitis in 1 patient responded to a course of oral antibiotics; the plug was massaged out of the punctum in a retrograde fashion in another patient. In still another patient, the plugs expressed themselves at the time of planned canaliculotomy. In 4 patients, dacryocystorhinostomy (DCR) with silicone intubation was necessary. Two additional patients refused further treatment including DCR and canaliculotomy; both were lost to follow-up.

CONCLUSIONS

Canaliculitis, acute dacryocystitis, and tearing may be seen in patients who have had SmartPlugs and may be managed by removal of the plug. A trial of topical and oral broad-spectrum antibiotics followed by retrograde massage of the plug through the canaliculus may be helpful should plug removal be deemed appropriate. If conservative measures fail, canaliculotomy with removal of the plug may be considered; DCR may be necessary. Although lacrimal irrigation may resolve the problem, irrigation also may dislodge the plug from its canalicular position and cause permanent obstruction of the lacrimal drainage system.

Osteoid osteoma of the ethmoid bone associated with dacryocystitis

Background

Osteoid osteomas (OO) are small, benign osteoblastic lesions. Ethmoid bone OO has been very rarely reported so far.

Case presentation

We report a case of a 16-year-old boy suffering from persistent epiphora and a mild pain in the area of median canthus, due to a bone density mass within the right ethmoid air cells extending to the ipsilateral right orbit. The mass was removed via an external ethmoidectomy approach. Histopathologic examination of the specimen set the diagnosis of OO. One year after the operation the patient is free of symptoms, while no recurrence occurred.

Conclusion

A case of ethmoid bone OO associated with dacryocystitis is reported. Although benign and rare, OO should be considered in differential diagnosis of the ethmoid bone osteoblastic lesions.

A silastic sheet found during endoscopic transnasal dacryocystorhinostomy for acute dacryocystitis

Purpose

To report the case of a silastic sheet that was found during an endoscopic transnasal dacryocystorhinostomy for treatment of acute dacryocystitis with necrosis of the lacrimal sac.

Methods

A thirty-two year old male presented with painful swelling on the nasal side of his left lower lid two weeks prior to visiting this clinic. Fourteen years ago, the patient was involved in a traffic accident and underwent surgery to reconstruct the ethmoidal sinus. Lacrimal sac massage showed a regurgitation of a purulent discharge from the left lower punctum. Therefore, the patient was diagnosed with acute dacryocystitis and an endoscopic transnasal dacryocystostomy was performed the next day.

Results

The surgical finding showed severe necrosis around the lacrimal sac and a 20 × 15-mm sized silastic sheet was found crumpled within the purulent discharge. The sheet was removed, the lacrimal sac was irrigated with an antibiotic solution, and a silicone tube was intubated into the lacrimal pathway. After surgery, the painful swelling on the nasal side of left lower lid resolved gradually, and there were no symptomatic complications three months later.

Conclusions

We report the first case where a silastic sheet applied during a facial reconstruction had migrated adjacent to the lacrimal sac resulting in severe inflammation.

[Endonasal anatomy of lacrimal sac and its clinical significance in dacryocystorhinostomy]

OBJECTIVE

To explore the intranasal surface localization of the lacrimal sac in endoscopic dacryocystorhinostomy.

METHODS

Fifteen adult cadavers (30 sides) were studied, the data of projection position of the lacrimal sac on the lateral wall of nasal cavity were measured.

RESULTS

In 2/3 cadavers, the lacrimal sac is located above the axilla of the middle turbinate, and 1/3 lies below it. A majority of the lacrimal sac (2/3) are located below the entry point of the common lacrimal canaliculus, about 1/3 lies above it. Inner canthal ligament projects on the middle of the lacrimal sac, almost equal to the level of common lacrimal canaliculus. Thirty-two cases (thirty-nine sides) of chronic dacryocystitis were followed-up > 6 months after operation. Thirty-five sides were cured, 2 sides improved and 2 sides ineffective. The cure rate was 89.8%, improve rate 5.1% and ineffective rate 5.1%, respectively, and the total effective rate was 94.9%.

CONCLUSIONS

The central position of dacryocystorhinostomy should be 0.2 cm above the front of the axilla of the middle turbinate, to make an curved mucous membrane incision 0.8 cm above and 0. 4 cm below the front of the axilla of the middle turbinate and bone ostium about 1.2 cm x 1.0 cm. It is the best position in endoscopic dacryocystorhinostomy. Locating the inner canthal ligament with a bayonet type forceps to find the projection of lacrimal sac is also a simple and easy method.

Maxillary frontal process fracture complicating acute dacryocystorhinostomy

A case of maxillary frontal process fracture complicating an acute endonasal dacryocystorhinostomy is presented. The management of this previously unrecorded complication and the corrective procedure that resulted in both patient and clinician satisfaction is described.

Pyogenic Granuloma Associated With Chronic Actinomyces Canaliculitis

A case of chronic Actinomyces canaliculitis with associated pyogenic granuloma formation and bloody tears is described. Although Actinomyces is a well-known cause of canaliculitis, the authors are not aware that it has been reported in association with pyogenic granulomas.

Dacryocystomaxillorhinostomy for chronic dacryocystitis in a dog

A 10-year-old female spayed Vizsla had intermittent mucoid ocular discharge from the right eye for 7 years. History, clinical findings, imaging studies, and culture and histopathology results confirmed chronic dacryocystitis with granuloma. A dacryocystomaxillorhinostomy was performed to preserve the functional portions of the nasolacrimal system remaining in this patient, as well as to promote healing of the lacrimal sac granuloma and secondary infection. Complete resolution of the clinical abnormalities was achieved, and the dog remains healthy 3 years postoperatively.

Visual Loss Following Dacryocystectomy

Dacryocystectomy is the surgery of choice for elderly patients with chronic dacryocystitis with a fibrotic sac. Although a simple procedure, it can cause serious complications (however rare) such as visual impairment. A 65-year-old woman who underwent bilateral dacryocystectomy is described. On the first postoperative day, she complained of pain in her left eye. Her visual acuity was light perception in the left eye. Computed tomography scan of the orbit revealed a retrobulbar hematoma on the left eye. The hematoma was drained, but the patient did not regain vision. A rare complication of visual loss following dacryocystectomy is described.

[Alternatives to recovery of lacrimal duct patency]

Based on his many years' experience in treating patients with lacrimal duct abnormalities and on his familiarity with the latest progress of endoscopic microsurgery of dacryocystitis, the author presents a historic analysis of the development of currently available surgical treatments of dacryocystitis in Russia and foreign countries. He reviews treatments divided into the following groups: 1) operations applying an external approach to the lacrimal sac, such as Toti's-type ones; 2) those applying an intranasal approach to the lacrimal sac, such as West's-type operations; 3) intranasal endoscopic microdacryocystorhinostomies; 4) intranasal laser microdacryocystorhinostomies; 5) transcanalicular endoscopic laser microdacryocystorhinostomies; 6) operations that recanalize the lacrimal duct; 7) medical treatments of dacryocystitis. The author emphases the merits and discloses the prospects of endoscopic microsurgical treatments for impaired lacrimal duct patency and dacryocystitis.

Epidemiology of chronic dacryocystitis and success rate of external dacryocystorhinostomy in Nepal

PURPOSE

To study the epidemiology of chronic dacryocystitis and the success rate of external dacryocystorhinostomy (DCR) in Nepal.

PATIENTS AND METHODS

This is a retrospective descriptive and interventional case series. A total of 662 records of patients with chronic dacryocystitis due to nasolacrimal duct obstruction, who were treated by means of external DCR without bicanalicular silastic tube intubation, were studied.

STATISTICS

Mean for age with standard deviation and confidence intervals were calculated. The significance of the difference in means was calculated using the unpaired t-test.

RESULTS

Of 662 patients, 67.6% were female. The mean age of the patients was 27.4 +/- 13.7 years (SE = 0.53, 95% CI = 26.34-28.46). Chronic dacryocystitis due to nasolacrimal duct obstruction was found in 86 patients (13.0%) from the high hills (mean age = 35.3 +/- 11.4 years, 95% CI = 32.85-37.75), but most patients (576, 87.0%) were from the subtropical lowlands with a monsoon climate (mean age = 26.9 +/- 13.3 years, 95% CI = 25.8-28.0; p = < 0.01). An overall success rate of 88.6% (89.8% for high-hill patients and 87.4% for those from the lowlands) was obtained after DCR.

CONCLUSION

Chronic dacryocystitis is more common in the subtropical plains of Nepal with a monsoon climate than in the high hills. It is predominantly found in pre-menopausal females. External DCR without bicanalicular silastic tube intubation is an effective method for treating chronic dacryocystitis due to NLDO in these patients.

[Modified dacryocystorhinostomy]

OBJECTIVE

To introduce a novelty-modified dacryocystorhinostomy.

METHODS

With the innovated scalpels, 11 patients (13 eyes) suffering from chronic dacryocystitis were performed with the newly modified surgical procedures derived from traditional dacryocystorhinostomy. The efficacy, efficiency, and complications were observed.

RESULTS

Thirteen operations for 11 patients were performed successfully and efficiently. The wound was during operation neat and with a slight hemorrhage which could be stanched easily. No serious complications were observed intra-operatively. The average time of follow-up was 7.8 months (6-12 months). All the dacryocysto-rhinal canals remained unblocked.

CONCLUSIONS

The modified dacryocystorhinostomy with the help of innovated mucous scalpel has high success rate, high efficiency and low complications. It deserves wide application as the first choice for chronic dacryocystitis.

Revision dacryocystorhinostomy: a comparison of endoscopic and external techniques

BACKGROUND

Success rates for revision dacryocystorhinostomy (DCR) are lower than primary DCR. Scarring of the sac may limit the ability of the surgeon to achieve good nasal and lacrimal mucosa apposition. This study evaluates the comparative success rates of the external and endoscopic techniques for revision DCR.

METHODS

Seventeen consecutive revision endoscopic DCRs (average age, 60.9 years) and 13 revision external DCRs (average age, 65.1 years) performed from January 1999 to December 2000 performed by separate surgeons were entered into the study. Patients with functional nasolacrimal and canalicular obstruction were excluded. The average follow-up was 11.1 months for the endoscopic DCR group and 10 months for the external DCR group.

RESULTS

A successful DCR required complete relief of symptoms and an endoscopically determined anatomic patency of the nasolacrimal system. Revision endoscopic DCR surgery was successful in 76.5% of cases (13 of 17 cases) and external DCR surgery was successful in 84.6% (11 of 13 cases). This difference was not statistically significant. (p = 0.64, Fisher exact test with a two-tailed probability).

CONCLUSION

Revision endoscopic DCR has a success rate of 76.5%, which compares favorably with that of the revision external DCR (84.6%).

Dacryocystoceles in the aftermath of Stevens-Johnson syndrome

Although Stevens-Johnson syndrome has been reported to result in canalicular and nasolacrimal duct obstruction, reports of dacryocystocele formation are lacking. We describe the occurrence and management of bilateral dacryocystoceles related to Stevens-Johnson syndrome. A 45-year-old man, recovered from Stevens-Johnson syndrome, presented with bilateral medial canthal masses and intermittent overlying facial cellulitis. Examination revealed severe keratitis sicca with extensive corneal scarring, cicatricial occlusion of all puncta, and palpable medial canthal masses bilaterally. Computed tomography demonstrated bilateral cystic masses consistent with dacryocystoceles. Bilateral lacrimal sac/cyst excision was attempted, but the left cyst recurred within 6 months after surgery. A dacryocystorhinostomy was then performed, effectively marsupializing the cyst. The puncta were not canalized and stents were not placed. The masses have not recurred with 2 years of follow-up. Dacryocystoceles may arise in the setting of Stevens-Johnson syndrome. Successful management may be achieved with marsupialization to the nasal cavity (dacryocystorhinostomy).

[Domestic 1.44 mcm Nd:YAG laser in combined treatment of dacryocystitis complicated by abscess formation]

We have treated 12 patients with acute dacryocystitis complicated by abscess formation. All the patients were examined by an ophthalmologist and otolaryngologist. The patients received intravenous antibiotics followed by Nd:YAG laser dacryocystorhinostomy via transcanalicular approach under the endonasal endoscopic control. The treatment resulted in resolution of symptoms and signs of acute dacryocystitis complicated by abscess formation in all the patients. No recurrence of acute dacryocystitis occurred during the median follow-up period of 11 months. Ostium patency defined as the absence of epiphora and observation of irrigated lacrimal fluorescein at the ostium was achieved in 9 patients. Epiphora recurred in 3 cases. Use of Nd:YAG laser reduces the duration of the operation and provides maximal functional and cosmetic results.

Rhinolithiasis: a very late complication after dacryocystorhinostomy with rubber-gum and polyethylene stenting

PURPOSE

To describe a rare case of rhinolith formation 21 years after dacryocystorhinostomy (DCR) with rubber gum and polyethylene tubing surgery.

DESIGN

Interventional case report.

METHODS

A 23-year-old-woman underwent uneventful left DCR with rubber gum and polyethylene tubing for chronic dacryocystitis. Twenty-one years later, she presented with purulent rhinorrhea, nasal obstruction, and facial pain. Computed tomography revealed a radiopaque density in the left nasal cavity.

RESULTS

A rubber gum foreign body embedded with granulation tissue and a huge rhinolith was removed endoscopically through the anterior nares. After surgery, the patient reported immediate and complete relief of symptoms.

CONCLUSION

Rhinoliths can develop progressively several years after DCR as a result of foreign body reaction to rubber gum or polyethylene tubing. This rare complication should be ruled out in patients complaining of purulent rhinorrhea who underwent DCR with tubing before the early 1980s.