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Bermudez-Castellanos I, Malhotra R. The Light Switch and the Dimmer: Qualitative Observations to Improve Diagnostic Lacrimal Irrigation. Semin Ophthalmol 2024:1-10. [PMID: 39254309 DOI: 10.1080/08820538.2024.2397141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Revised: 08/13/2024] [Accepted: 08/19/2024] [Indexed: 09/11/2024]
Abstract
PURPOSE To emphasise the importance of "soft" observations during lacrimal irrigation in diagnosing lacrimal outflow dysfunction and reporting outcomes of soft factors post-DCR. METHODS A retrospective study of patients with ≤ 20% of regurgitation on lacrimal irrigation who underwent DCR surgery. A comparative analysis of percentage reflux of saline (RFX), initial mucus in reflux (IMR), patient-reported transit time of saline (PR-TTS), and resistance encountered (RES) during LS was performed. Validated TEARS score was used. Subjective success was defined as ≥ 2-point improvement in T subscale of TEARS score. Objective success, as a decrease in RFX, RES, PR-TTS and absence of IMR, post-operatively. RESULTS From a total of 253 patients who underwent DCR surgery, 8 patients met the inclusion criteria. All patients were T4 (wiping >10× daily) indoors and outdoors. TEARS score improved after surgery with a mean reduction of T = 2.62, E = 1.63 and A = 1.35 (p < .05) with no significant change in R scores (p = .10). A mean reduction in RFX of 11.75 ± 6.74% and a median improvement of 1 point in PR-TTS and 2 point in RES was observed (p < .05). No significant changes of these parameters occurred in the contralateral side during this period. Subjective and objective success of DCR was 75% and 100%, respectively. CONCLUSIONS This study is the first to attempt to combine qualitative "soft" observations during lacrimal irrigation such as IMR, RES and PR-TTS for identifying nasolacrimal outflow dysfunction and reporting outcomes using these parameters of DCR in patients with epiphora and ≤ 20% of fluid regurgitation. These parameters were greater in the more symptomatic side and successfully improved after DCR, making them a valuable tool to reach a provisional diagnosis.
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Affiliation(s)
| | - Raman Malhotra
- Corneo-Plastic Unit, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, UK
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C K Patel B, Ali MJ, Malhotra R. Finesse in Lacrimal Syringing: The Concept of Soft Observations During Lacrimal Irrigation. Semin Ophthalmol 2024:1-3. [PMID: 39033516 DOI: 10.1080/08820538.2024.2380576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/23/2024]
Affiliation(s)
- Bhupendra C K Patel
- Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA
| | - Mohammad Javed Ali
- Govindram Seksaria Institute of Dacryology, L.V. Prasad Eye Institute, Hyderabad, India
| | - Raman Malhotra
- Corneoplastic unit, Queen Victoria Hospital, East Grinstead, UK
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Kim D, Lew H. Clinical characteristics and cytological changes in mucinous obstruction diagnosed by dacryoendoscopy. Sci Rep 2024; 14:8891. [PMID: 38632478 PMCID: PMC11024180 DOI: 10.1038/s41598-024-59580-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 04/12/2024] [Indexed: 04/19/2024] Open
Abstract
To analyze the clinical characteristics of mucinous obstruction diagnosed by dacryoendoscopy and compared the cytological changes with membranous obstruction using a modified liquid-based thin prep cytology method. A retrospective chart review was conducted on 53 eyes of 51 patients with mucus obstruction based on dacryoendoscopic findings from January 2022 to October 2022. Liquid-based thin-prep cytology was performed by irrigating the inside of the nasolacrimal drainage system with saline during dacryoendoscopy-guided silicone tube intubation. Pathological findings were analyzed through a comparison of mucinous obstruction with membranous obstruction as determined by dacryoendoscopic findings. The modified liquid-based thin prep cytology technique had a higher cytology detection rate across all cases. Mucinous obstruction exhibited a significantly higher number of successful canalicular irrigation test cases compared to membranous obstruction. In mucinous obstruction, epithelial squamous cells were more frequently detected in pre-sac obstruction, whereas columnar epithelial cells were predominant in post-sac obstruction. Inflammatory cells showed a stronger correlation with primary change and post-sac obstruction. Bacterial colonies were observed exclusively in cases of mucinous obstruction. The use of a modified liquid-based thin prep cytology method enables the examination of histopathological changes in the lacrimal passage in primary acquired nasolacrimal duct obstruction (PANDO), particularly in cases of mucinous obstruction, without the need for invasive biopsies. These findings enhance the understanding of the etiopathogenesis of mucinous obstruction, complementing knowledge of membranous obstruction in PANDO.
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Affiliation(s)
- Doah Kim
- Department of Ophthalmology, CHA Bundang Medical Center, CHA University, #59 Yatap-Ro, Bundang-Gu, Seongnam, 13496, Republic of Korea
| | - Helen Lew
- Department of Ophthalmology, CHA Bundang Medical Center, CHA University, #59 Yatap-Ro, Bundang-Gu, Seongnam, 13496, Republic of Korea.
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Macri CZ, Shapira Y, Tong J, Hood K, Drivas P, Patel S, Selva D. A Pilot Study of Dynamic Magnetic Resonance Dacryocystography Imaging to Assess Functional Epiphora. Semin Ophthalmol 2024; 39:158-164. [PMID: 37697818 DOI: 10.1080/08820538.2023.2256842] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 09/01/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVE To evaluate dynamic magnetic resonance dacryocystography (MRDCG) in eyes with functional epiphora. METHODS We included prospective eyes with epiphora if no alternative cause was found on clinical examination, were patent on syringing, had no obstruction or stenosis on DCG, and had an abnormal DSG. MRDCG was performed to qualitatively assess for block or patency and quantitatively measure tear transit time. We compared measurements to asymptomatic fellow eyes and to historical reference values from asymptomatic eyes. RESULTS We included 26 symptomatic eyes of 19 patients (median age 63 years). There was a block on MRDCG in 18 (69%) eyes and patency in 8 (31%) eyes. The block occurred at the sac-nasolacrimal duct (NLD) junction in 9 (50%), proximal NLD in 5 (28%), mid-NLD in 1 (5.6%), and distal NLD in 1 (5.6%) eye(s). No contrast was observed in the lacrimal system in two eyes. For eyes patent on MRDCG, median times to the sac, NLD, inferior meatus, first 25%, and first 50% of the fundus-to-nose distance (FND) were 22, 54, 118, 34, and 84 s, respectively. Times to the sac, NLD, and to fill the first 25% and 50% of the FND were significantly longer than historical values from asymptomatic lacrimal systems (p = 0.017, 0.050, 0.035, 0.017, respectively). CONCLUSION MRDCG shows a high rate of block in functional epiphora. However, DSG and MRDCG results may not always correlate. The improved temporal resolution of this emerging modality may be advantageous in the critical first 2 min of tear transit.
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Affiliation(s)
- Carmelo Zak Macri
- The Discipline of Ophthalmology and Visual Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Ophthalmology, The Royal Adelaide Hospital Adelaide, Adelaide, South Australia, Australia
| | - Yinon Shapira
- Department of Ophthalmology, The Royal Adelaide Hospital Adelaide, Adelaide, South Australia, Australia
| | - Jessica Tong
- The Discipline of Ophthalmology and Visual Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Ophthalmology, The Royal Adelaide Hospital Adelaide, Adelaide, South Australia, Australia
| | - Kylie Hood
- Department of Radiology, The Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Peter Drivas
- Department of Radiology, The Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Sandy Patel
- Department of Radiology, The Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Dinesh Selva
- The Discipline of Ophthalmology and Visual Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Ophthalmology, The Royal Adelaide Hospital Adelaide, Adelaide, South Australia, Australia
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Usmani E, Shapira Y, Selva D. Functional epiphora: an under-reported entity. Int Ophthalmol 2023; 43:2687-2693. [PMID: 36952153 PMCID: PMC10371897 DOI: 10.1007/s10792-023-02668-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 02/19/2023] [Indexed: 03/24/2023]
Abstract
PURPOSE To determine the etiology of epiphora in a tertiary Australian lacrimal clinic and highlight the high proportion of 'functional' cases. METHODS Single-center retrospective review: Records of adult patients presenting to a tertiary lacrimal clinic from January 2011 to February 2021 with epiphora were reviewed. Patients underwent testing with syringing/probing and lacrimal imaging to reach a diagnosis of functional epiphora. Functional epiphora was diagnosed based on the exclusion of alternate causes of epiphora on clinical examination, patent lacrimal syringing, normal dacryocystography, and delay on dacryoscintigraphy. RESULTS Five hundred and seventy-six symptomatic eyes of 372 adult patients (mean 66.2 ± 15.5 years, 63.4% females) with epiphora were evaluated for causes. Post-sac obstruction (stenosis/complete obstruction) and functional epiphora (non-anatomical delay) were the most common causes of presentations to the lacrimal clinic (26% each). Functional epiphora with post-sac delay was substantially more common than functional epiphora with pre-sac delay (89% vs. 11% of functional epiphora cases). In 16% of the cases, no cause for the epiphora was found while more than one cause (multifactorial) was present 11% of the time. CONCLUSION Functional epiphora was found to be as common as a nasolacrimal anatomical obstruction when lacrimal imaging is utilized.
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Affiliation(s)
- Eiman Usmani
- Discipline of Ophthalmology and Visual Science, University of Adelaide, Adelaide, South Australia, Australia.
- Department of Ophthalmology, Royal Adelaide Hospital and South Australian Institute of Ophthalmology, Adelaide, South Australia, Australia.
| | - Yinon Shapira
- Discipline of Ophthalmology and Visual Science, University of Adelaide, Adelaide, South Australia, Australia
- Department of Ophthalmology, Royal Adelaide Hospital and South Australian Institute of Ophthalmology, Adelaide, South Australia, Australia
| | - Dinesh Selva
- Discipline of Ophthalmology and Visual Science, University of Adelaide, Adelaide, South Australia, Australia
- Department of Ophthalmology, Royal Adelaide Hospital and South Australian Institute of Ophthalmology, Adelaide, South Australia, Australia
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Nakamura J, Kamao T, Mitani A, Mizuki N, Shiraishi A. Accuracy of the Lacrimal Syringing Test in Relation to Dacryocystography and Dacryoendoscopy. Clin Ophthalmol 2023; 17:1277-1285. [PMID: 37162802 PMCID: PMC10164386 DOI: 10.2147/opth.s409662] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 04/28/2023] [Indexed: 05/11/2023] Open
Abstract
Purpose This study aimed to evaluate the accuracy of the lacrimal syringing test (syringing) in relation to dacryocystography (DCG) and dacryoendoscopy (DE) in lacrimal pathway (LP) obstruction. Methods We retrospectively reviewed 101 patients (188 LPs) who underwent syringing, cone-beam computed tomography (CBCT)-DCG, and DE to diagnose the degree and site of LP obstruction. The degree of obstruction was classified into patent, partial obstruction, and complete obstruction. The degree of LP obstruction was determined by combining the findings of DE and CBCT-DCG and was designated as DCG+DE. When differentiating complete or partial obstruction on DE was uncertain, complete or partial obstruction was assigned if the DCG showed evidence of contrast media obstruction or passage, respectively. The consistency between syringing and DCG+DE was evaluated by calculating the weighted kappa coefficient. Results The sensitivity and specificity of syringing were 94% and 89%, respectively. The weighted Cohen's kappa value of agreement between syringing and DCG+DE was κ = 0.73 (SE = 0.04, 95% confidence interval [CI]: 0.66-0.80, p < 0.01). When divided into presaccal and postsaccal obstruction categories, the kappa values were κ = 0.40 (SE = 0.11, 95% CI: 0.19-0.62, p < 0.01) and 0.55 (SE = 0.09, 95% CI: 0.37-0.73, p < 0.01), respectively. Furthermore, when limited to common canaliculus obstruction (stenoses), which accounted for 78% (46 LPs) of the total presaccal obstructions, the kappa value was κ = 0.29 (SE = 0.12, 95% CI: 0.05-0.54, p = 0.021), which demonstrated the lowest consistency between syringing and DCG+DE. Conclusion Syringing was "substantially" in agreement with DCG+DE in detecting the degree of LP obstruction. Moreover, syringing was a sufficiently sensitive and specific test when performed by an experienced clinician. However, distinguishing between complete and partial obstructions by syringing was sometimes difficult, particularly in the common canaliculus obstruction (stenosis).
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Affiliation(s)
- Jutaro Nakamura
- Department of Ophthalmology, Ehime University Graduate School of Medicine, Toon, Ehime, 791-0295, Japan
- Department of Ophthalmology and Visual Science, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, 236-0004, Japan
- Correspondence: Jutaro Nakamura, Department of Ophthalmology, Ehime University Graduate School of Medicine, Toon, Ehime, 791-0295, Japan, Tel +8189-960-5361, Fax +8189-960-5364, Email
| | - Tomoyuki Kamao
- Department of Ophthalmology, Ehime University Graduate School of Medicine, Toon, Ehime, 791-0295, Japan
| | - Arisa Mitani
- Department of Ophthalmology, Ehime University Graduate School of Medicine, Toon, Ehime, 791-0295, Japan
| | - Nobuhisa Mizuki
- Department of Ophthalmology and Visual Science, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, 236-0004, Japan
| | - Atsushi Shiraishi
- Department of Ophthalmology, Ehime University Graduate School of Medicine, Toon, Ehime, 791-0295, Japan
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