Tricompartment model of the lacrimal pump mechanism

A major review of punctal stenosis: Updated anatomy, epidemiology, etiology, and clinical presentation

We aim to provide a detailed and updated literature review on the epidemiology, etiology, clinical presentations, histopathology, and ultrastructural features of punctal stenosis. There are inconsistencies in the definition and staging of punctal stenosis. While advanced optical coherence tomography imaging techniques have revolutionized the way the punctum and vertical canaliculi are assessed or monitored following treatment, the planes of measurement to characterize punctum anatomy need to evolve further. The current criteria for diagnosing and grading punctal stenosis are inadequate and based on empirical clinical findings. There is increasing evidence of the role of lymphocytes and myofibroblasts in the pathogenesis of punctal stenosis. There is a need for a uniform assessment of punctal stenosis and a uniform reporting of severity that would help standardize the several management options available in the lacrimal armamentarium.

Modified Horner-Duverney's muscle plication in the treatment of functional epiphora

BACKGROUND

The orbicularis oculi muscle, especially its part (Horner-Duverney's muscle), which is surrounded by the pericanalicular and located deep in the lacrimal sac, is of primary importance in all stages of tear fluid flow.

PURPOSE

This study aimed to demonstrate that tightening the pretarsal-preseptal orbicularis oculi and Horner-Duverney muscles may improve the function of the lacrimal pump and may be a surgical alternative for treating functional epiphora.

MATERIAL AND METHODS

This was a prospective interventional case series of 28 patients with functional epiphora. During surgery, sutures were used to perform the intervention, and these were first passed through the upper and lower eyelid pretarsal-preseptal orbicular muscles, through the Horner-Duverney's muscle, and finally, through the dacriocystorhinostomy incision and tightened. Each patient completed the Lac-Q questionnaire and Munk scale prior to surgery, as well as six weeks and six months later. Before surgery, a fluorescein dye disappearance test was performed, which was repeated at follow-up appointments. Pre- and post-operative data were analyzed and compared at the most recent visit.

RESULTS

Twenty-eight patients (10 males and 18 females) with a mean age of 59 ± 35 years were included in this study. The severity of epiphora and its tearing effect on daily life significantly improved following the operation. The fluorescein dye disappearance test result was significantly improved after 6 weeks of followup in %89.3 of eyes and at 6 months followup in 92.9% of eyes. The Lac-Q questionnaire's mean social impact scores improved significantly postoperatively, from 3.76 to 0.77 (p < 0.001). The changes in total scores (7.29 before surgery to 1.71 after 6 months) were statistically significant (p < 0.001). The Munk score success rate was 64.3% and 85.7%, respectively. No significant complications or adverse effects were observed.

CONCLUSION

Our findings suggest that a beneficial and seemingly simple, safe, and easy procedure to reduce functional epiphora is to tighten the preseptal-pretarsal orbicularis and Horner-Duverney's muscles.

Chronologic Analysis of Tear Dynamics on Blinking Using Quantitative Manometry in Healthy Humans

PURPOSE

To analyze the tear dynamics during blinking by measuring the inner pressure of the upper lacrimal drainage system.

METHODS

This observational study involved 11 healthy bi- or tricenarian volunteers. Direct manometry was performed using a fiber optic pressure sensor inserted into the conjunctival sac, upper/lower canaliculus (5 mm from punctum), and inferior lacrimal sac (15 mm from punctum) during both involuntary and intentional tight blinking. Pressure was measured 200 times/second during 3 separate blinks and then chronologically analyzed.

RESULTS

In all subjects of all locations during both types of blinking, the inner pressures during the stationary eyelid closing/opening were positive/approximately zero, while a positive/negative pressure spike was observed during the eyelid closing/opening movement. The averages of the maximum pressure in the spike during the intentional tight blinking (tPmax: mm Hg) in the conjunctival sac, upper/lower canaliculus, and lacrimal sac were 8.00, 12.39/12.93, and 10.59, respectively, while for the minimum (tPmin: mm Hg), the pressures were -3.18, -3.91/-3.43, and -3.31, respectively. The tPmax and tPmin in the lacrimal duct were positively correlated with that of the conjunctival sac, which suggested synchronism of the drainage system. However, the tPmax in the canaliculus was significantly higher than that of the conjunctival sac, which suggested that tears do not flow from the conjunctival sac into the lacrimal duct during eyelid closure.

CONCLUSIONS

The upper lacrimal drainage system functions as one united lumen in the lacrimal pump. The positive /negative pressure spike is essential for the lacrimal pump to efficiently eject/aspirate the tear from the lacrimal/conjunctival sac.

Objective assessment of eyelid position and tear meniscus in facial nerve palsy

PURPOSE

To evaluate lower lid position and tear meniscus in peripheral idiopathic facial nerve palsy (FNP).

METHODS

A prospective study enrolled patients with peripheral idiopathic FNP and epiphora. Data were collected on patient demographics, House-Brackmann (HB) scale, digital photographs of the face, and tear meniscus at the 1st, 30, and 90 day after onset of FNP. Marginal reflex distance to the upper (MRD1) and lower eyelid (MRD2) were evaluated using ImageJ software. Anterior segment optical coherence tomography (OCT) was performed to measure the tear menis- cus. P< .05 was considered statistically significant.

RESULTS

Sixteen patients were evaluated. The HB scale at presentation was grade III in six patients (37.5%). At 90 day, nine patients (56.25%) were grade I-normal. Three (18.7%) had upper lid retraction, three (18.7%) upper eyelid asymmetry and 7 (43.75%), lower eyelid retraction. The difference between MRD2-FNP with MRD2-healthy side was 0.51 ± 1.9 mm at the 1st visit, decreasing to 0.09 ± 1.47 mm at 90 days (P= .877). Tear meniscus measurements were significantly higher in FNP at the 1st visit (P= .001). The decrease in MRD2 was statistically correlated with the reduction of the tear meniscus area (TMA) (r = 0.67; P= .007) at 90 days. No correlation was found between HB and TMA. There is a difference in TMA between age groups at the 1st day(p= .009). Eldest group had higher HB scales.

CONCLUSION

Quantitative evaluation of eyelid position and tear meniscus are effective to document the evolution of FNP and can serve as a clue of orbicularis recovery.

CLEAR - Anatomy and physiology of the anterior eye

A key element of contact lens practice involves clinical evaluation of anterior eye health, including the cornea and limbus, conjunctiva and sclera, eyelids and eyelashes, lacrimal system and tear film. This report reviews the fundamental anatomy and physiology of these structures, including the vascular supply, venous drainage, lymphatic drainage, sensory innervation, physiology and function. This is the foundation for considering the potential interactions with, and effects of, contact lens wear on the anterior eye. This information is not consistently published as academic research and this report provides a synthesis from all available sources. With respect to terminology, the report aims to promote the consistent use of nomenclature in the field, and generally adopts anatomical terms recommended by the Federative Committee for Anatomical Terminology. Techniques for the examination of the ocular surface are also discussed.

Adding myofibroblasts to the lacrimal pump

The lacrimal sac (LS) empties in the nasolacrimal duct to drain the tears in the inferior nasal meatus. Different studies indicated the role of the lacrimal pump in the lacrimal drainage. Although controversial, the lacrimal pump mechanism is an extrinsic one, either active, or passive. An intrinsic contractile potential of the LS was not documented previously. We thus aimed a retrospective immunohistochemical study to test the alpha-smooth muscle actin (α-SMA) and h-caldesmon expression in the LS wall. We used archived paraffin-embedded samples of LS from ten adult patients. The α-SMA + phenotype was detected in basal epithelial cells, in subepithelial ribbons of stromal cells, in vascular smooth muscle cells, as well as in pericytes. H-caldesmon was exclusively expressed in pericytes, vascular smooth muscle cells and myoepithelial cells of the subepithelial glands. The most striking feature we found in all samples was a consistent stromal network of α-SMA+/h-caldesmon- myofibroblasts. This finding supports an intrinsic scaffold useful for the lacrimal pump.

Lacrimal drainage function after cheese wiring of lacrimal passage intubation

PURPOSE

To investigate how cheese wiring affects lacrimal drainage function by quantitative assessment of tear function and punctal dimensions.

METHODS

Patients who underwent lacrimal passage intubation between January 2017 and September 2018 were enrolled prospectively. Among these patients, those with postoperative cheese wiring who received lacrimal passage intubation in one eye met the criteria for further investigation. The subjective symptoms of epiphora, dimensions of puncta, lower tear meniscus, and tear clearance were assessed postoperatively in both the involved eye and untreated contralateral eye. Punctum dimensions were analysed using the digital slit-lamp image. Tear meniscus and tear clearance were assessed by anterior segment optical coherence tomography.

RESULTS

Postoperative cheese wiring was observed in 68 of 314 eyes. Among these cases, 36 patients (age 70.5 ± 11.7 years) had cheese wiring only in one eye: with the involvement of both puncta in 15 patients (group A) and only the lower punctum in 21 patients (group B). There was no patient with the involvement of only the upper punctum. While tear function of the involved eyes in group B did not differ from that of the untreated eye, it was significantly decreased in group A compared with that in untreated control eyes (p < 0.05). The tear clearance rate correlated significantly with the upper punctum dimensions (p < 0.05), but not with the lower punctum.

CONCLUSION

Analysis of cheese wiring after lacrimal passage intubation with tear function demonstrated that the integrity of the puncta and the canaliculus is important for lacrimal drainage.

Endonasal endoscopic nasolacrimal duct dissection for primary nasolacrimal duct obstruction

PURPOSE:

The purpose of this study is to describe the results of endonasal endoscopic nasolacrimal duct dissection (EE-NLDD); a surgical technique used for the treatment of primary nasolacrimal duct obstruction (NLDO).

MATERIALS AND METHODS:

Before the operation, the patency of the nasolacrimal duct (NLD) was evaluated through irrigation and probing. The EE-NLDD surgical procedure involved the removal of the bony structure covering the NLD. The NLD mucosa was dissected and marsupialized with nasal mucosa, creating a mucosa-covered ostium. The bone surrounding the lacrimal fossa and lacrimal sac mucosa was preserved throughout procedure. The postoperative anatomical and functional outcomes were evaluated through irrigation, endonasal endoscopic fluorescein dye test, and subjective descriptions of the patients.

STUDY DESIGN:

This is a retrospective chart review study which included all patients with primary NLDO treated with EE-NLDD surgical technique from February 2012 to July 2016 in Taipei Medical University Shuang Ho Hospital by a single surgeon (YD, Shen).

RESULTS:

The mean follow-up time for the 39 patients (43 eyes) was 14.7 months (range: 0.5–46 months). Anatomical patency was achieved in all patients. Under endonasal endoscopy, fluorescein dye was observed at the internal orifice after the dye was instilled into the conjunctival sac in all patients. The complete resolution of the epiphora was reported in 36 patients (39 eyes) and two patients (2 eyes) exhibited an improvement of the epiphora after surgery. However, one patient (2 eyes) reported persistent bilateral epiphora without improvement even under solid evidence of anatomical patency. No major complications were noted intraoperatively or postoperatively.

CONCLUSIONS:

The results suggested that the EE-NLDD is a safe and effective procedure and has a success rate comparable with that of conventional endonasal dacryocystorhinostomy.

Comparison of Polypropylene Sling with Combined Transconjunctival Retractor Plication and Lateral Tarsal Strip for Correction of Involutional Lower Eye Lid Ectropion

Purpose:

The study aims to compare the effectiveness and complications of transconjunctival retractor plication (TRP) with lateral tarsal strip (LTS) and the polypropylene sling (PS) surgery for treatment of involutional lower lid ectropion.

Method:

A prospective randomised pilot study was conducted on 30 eyes of 30 patients suffering from epiphora having horizontal eyelid laxity >6mm and age >50 years at a tertiary care centre from December 2014 to March 2015. They were randomly divided into two equal groups for TRP with LTS (group A) and PS (group B). Success was defined as relief in epiphora and lid laxity ≤4mm at 12 months post operatively.

Result:

There were 19 male and 11 female patients with age ranging from 55-80 years. The mean grade of ectropion was 2.80±1.32 in group A and 2.87±1.60 in group B. The preoperative horizontal laxity increased with the grade of ectropion (p <0.001) while medial canthal laxity was variable. The average surgical time per procedure in group A was 66 minutes and in group B was 24 minutes. Group A had a success rate of 93.33%, while group B had a success rate of 87%. Post-operative complications occurred in 2 eyes in group B only.

Conclusion:

Both LTS with TRP and PS are effective in the management of involutional ectropion. LTS with TRP though more invasive has higher success rates and a lower incidence of complications as compared to PS. However, PS is an easy to perform out- patient procedure that is faster and better tolerated in old patients.

Punctal Ectropion repair using the Raus-Garito clamp

PURPOSE

To evaluate the results from the correction of ectropion of the punctum lacrimale in lower eyelids with a new surgical clamp.

DESIGN

Prospective study.

METHODS

Eighty eight eyelids in 55 patients with mild and moderate ectropion were included in the study. An excision of a diamond of tarso-conjunctiva with retractor reattachment and concomitant correction of horizontal lid laxity, if present, was performed.

RESULTS

Resolution of tearing was obtained in 77 eyes. In 11 eyes, persistent tearing was reported.

CONCLUSION

Conclusion:Conclusion: Repair of early to intermediate ectropion of the lacrimal punctum using the Raus-Garito clamp is associated with a good functional and cosmetic outcome.

[Treatment of nasolacrimal duct obstruction from the otorhinolaryngologist's perspective]

BACKGROUND

Epiphora is the classic symptom of nasolacrimal duct obstruction, particularly among elderly people. Dacryocystorhinostomy (DCR) via external (Toti) and endonasal (West) approaches are well-established surgical treatments.

OBJECTIVE

The aim of the present article is to describe the etiology and diagnostics of nasolacrimal duct obstruction. Furthermore, treatment modalities are discussed according to the current literature, with particular consideration of the otorhinolaryngologist's perspective.

MATERIALS AND METHODS

A search of the current literature focused on the past 5 years was performed in PubMed.

RESULTS

Several retrospective and prospective randomized studies describe the external and endonasal DCR approaches as safe surgical procedures, with high success rates of around 90 %. The endoscope is standardly used for visualization during the endonasal approach. Powered instruments such as diamond drills enable generation of a large rhinostomy, even in very hard bone. The application of silicone stents does not confer a significant additional advantage in terms of postoperative success rates.

CONCLUSION

DCR is a safe surgical procedure with high success rates. It can be strongly recommended for patients suffering from intra- or post-saccular nasolacrimal duct obstruction. Furthermore, the external and endonasal approaches (according to Toti and West, respectively) are comparable techniques. The use of silicone stents is indicated only in special cases.

The Pre-Sac Reflux Test (PSRT): a new diagnostic test for presaccal stenosis/obstruction

PURPOSE

To introduce a new procedure, the Pre-Sac Reflux Test (PSRT), to screen for epiphora caused by presaccal stenosis/obstruction, and to determine the reliability of this new test in the diagnosis of presaccal stenosis/obstruction.

METHODS

A nonrandomized, prospective, comparative case series of 280 eyes of 140 patients with unilateral presaccal stenosis/obstruction was performed. The PSRT was performed by a masked examiner on both eyes of each patient. After fluorescein staining, the lower lid was everted and lower punctum was observed using a cobalt-blue filter under slit-lamp magnification. After blotting excess fluorescein on the punbtum, the area of lacrimal ampulla was massaged with mild pressure with an index finger. The reflux (billowing of the fluorescein-stained tear) from each lower punctum were compared, and the bilateral symmetry was measured. In the same way, reflux from each upper punctum were compared for bilateral symmetry. The PSRT was considered positive if reflux from punctum was absent, or reduced asymmetrically, compared with that from contralateral punctum. If the test of either upper or lower punctum showed positive, the eye was considered positive. The validity of PSRT was measured by sensitivity and specificity, as well as positive- and negative-predictive values.

RESULTS

The PSRT used to diagnose presaccal stenosis/obstruction has a sensitivity of 92.9 % and a specificity of 97.1 %. It has a positive-predictive value of 97.0 % and a negative-predictive value of 93.2 %.

CONCLUSIONS

The PSRT is a reliable screening test for diagnosis of presaccal stenosis/obstruction.

Efficacy of tightening of orbicularis oculi muscle in patients with functional nasolacrimal duct obstruction

PURPOSE

To evaluate the efficacy of tightening of lateral portion of orbicularis oculi muscle in patients with functional nasolacrimal duct obstruction (FNLDO).

METHODS

This is an interventional cross-section study for evaluation of effect of orbicularis oculi tightening procedure in patients with FNLDO. Patients with unexplained epiphora, open lacrimal system in syringing and evidences of lacrimal pump weakness in lacrimal scintigraphy underwent surgery. In this procedure, a stripe of preseptal and pretarsal orbicularis muscle was dissected, slightly resected and secured to the periosteum of lateral orbital rim. Each subject completed a questionnaire about the intensity of epiphora before surgery and 1, 3 and 6 months after surgery. Furthermore, fluorescein dye disappearance test (FDDT) was performed before surgery and repeated in the follow-up visits. At last visit, the pre- and post-operative data were analyzed and compared.

RESULTS

Fifteen eyes of 12 patients (5 males and 7 females) with the mean age of 56.7 years included in the study. Severity of epiphora and tearing effect on daily life were significantly improved following the operation. FDDT result was improved significantly after 1 month follow-up in all eyes (15 eyes), at 3 months follow-up in 80% of eyes (12 eyes) and at the end of the 6th month in 66.7% of eyes (10 eyes). Subjective and objective success rates were 87% and 80%, respectively. No significant complications or side-effects were observed.

CONCLUSION

Tightening of lateral portion of preseptal and pretarsal orbicularis muscle seems an effective, safe, and easy procedure to decrease epiphora in patients with FNLDO.

The effectiveness of a simultaneous medial spindle procedure for involutional punctal ectropion with lid laxity in patients who require endonasal dacryocystorhinostomy instead of external dacryocystorhinostomy to prevent pump failure

PURPOSE

The aim of this study was to determine the effectiveness of a concurrent medial spindle procedure (MS) to address involutional punctal ectropion and the proportion of combined surgery in patients who need endonasal dacryocystorhinostomy (DCR) instead of external dacryocystorhinostomy to prevent pump failure.

METHODS

We conducted a retrospective, interventional study on endonasal DCR and MS procedures performed between March 2004 and January 2009 by a single surgeon (S.H.B.). Patient age, sex, the results of a medial distraction test, the surgical procedure, follow-up duration, and cause of failed surgery were recorded. The indication for the medial spindle procedure was punctal eversion on slit lamp biomicroscopic examination with classifications of grades 2 and 3 on the medial distraction test.

RESULTS

Endonasal DCRs were performed on 169 eyes in 121 patients, and DCR and MS (D + M) were performed on 23 eyes in 17 patients. The proportion of combined surgery to total DCR was 13.6%. Our primary success rate was 86.9% in the combined surgery group and 87.2% in the DCR group (P = 0.39).

CONCLUSIONS

The MS for correction of punctal ectropion concurrently performed with endonasal DCR will be an effective tool to manage epiphora caused by complex situations, such as nasolacrimal duct obstruction and involutional punctal ectropion. We recommend careful examination of the punctum, which is invisible in normal conditions, under slit lamp biomicroscopy before endonasal DCR.

The BLICK mnemonic for clinical-anatomical assessment of patients with epiphora

PURPOSE

Evaluation of the tearing patient is often distilled to a search for ocular surface problems causing reflex hypersecretion versus lacrimal drainage problems. The literature does not typically emphasize conditions affecting the function of the tear distribution system, but neglect of these important factors can lead to suboptimal treatment outcomes. The intent of this review is to provide a systemic evaluation of frequently overlooked conditions that can influence the distribution system and to offer a mnemonic to ensure an orderly sequence of inspection during clinical examination.

METHODS

Review of clinical literature and experience from 1957 to 2014.

RESULTS

Tearing complaints attributable to problems with the distribution system can be evaluated, classified, and managed according to the mnemonic BLICK, which stands for Blink dynamics, Lid malposition, Imbrication, Conjunctivochalasis, and Kissing puncta.

CONCLUSION

The BLICK mnemonic is a useful adjunct to the workup of epiphora.

Supernumerary punctum: an unusual case of seeing double

Supernumerary punctum is an under-reported congenital anomaly, in which there is more than one lacrimal punctum. Although usually asymptomatic, supernumerary puncta have been reported to cause dry eye or epiphora (excessive tearing) and should be included in their differential diagnosis. Tearing is often associated with dry eyes and can lead to discontinuation of contact lens wear. A comprehensive evaluation of the causes of tearing may uncover other contributory factors of epiphora. This case report highlights unilateral inferior double puncta in an otherwise asymptomatic patient. Due to increased evacuation of tears in the affected eye, manual occlusion of the puncta was advocated to allow topical medication to be more efficacious.

Lacrimal outflow mechanisms and the role of scintigraphy: current trends

Lacrimal outflow can be compromised by anatomical obstructions or stenoses (nonfunctional epiphora) or by defective lacrimal “pump” function (functional epiphora). Although classic imaging modalities, such as X-ray dacryocystography, computed tomography, or magnetic resonance imaging can effectively evaluate the former, their success is much less in the evaluation of the latter. This is largely due to the fact that forced diagnostic injection of fluid into the canalicular system can overcome partial obstruction sites. On the other hand, lacrimal scintigraphy mimicks “physiological” lacrimal outflow, being performed under pressure gradients present in everyday life. This is why it is considered more suitable for the study of functional epiphora. Furthermore, quantitative lacrimal scintigraphy (with time-activity curves) enables the accurate measurement of lacrimal clearance from the conjunctival fornices and may be used to study the physiology of the lacrimal “pump.” Data obtained from the scintigraphic study of lacrimal outflow may be used to design more effective procedures in the management of functional and nonfunctional epiphora. This is a review article, based on a literature search with emphasis on recent publications and on those supporting interdisciplinary cooperation between ophthalmology and nuclear medicine.

Elastic nature of the lacrimal canalicular wall

PURPOSE

To examine the elastic nature of the lacrimal canalicular wall.

METHODS

Fifteen postmortem specimens of 11 Japanese individuals (8 right, 7 left; age range, 45-89 years at death) fixed in 10% buffered formalin were axially sliced parallel to the lower eyelid margin to include all 3 portions of the lacrimal canaliculi (intrasac, extrasac-extramuscular, and intramuscular portions). All specimens were stained with Elastica van Gieson. Microscopic photographs were taken and converted to white (elastic fibers) and black (the other tissues) images to measure the elastic fibers in an area in each portion.

RESULTS

Six specimens in 4 individuals (2 right, 4 left; age range, 62-87 years) included all 3 portions. The area of elastic fibers in the intrasac portion (mean area, 125.8±93.6 white dot) was not significantly different from that in the extrasac-extramuscular portion (p=0.637: mean area, 268.5±150.2 white dots) but was significantly smaller than the areas in the intramuscular portion (p<0.001: mean area, 796.3±278.1 white dots) and Horner's muscle fascia (p<0.001: mean area, 1052.8±250.1 white dots). The area of elastic fibers in the extrasac-extramuscular portion was also significantly smaller than areas in the intramuscular portion (p=0.001) and Horner's muscle fascia (p<0.001). There was no significant difference in the area between the intramuscular portion and Horner's muscle fascia (p=0.172).

CONCLUSIONS

The elastic nature of the lacrimal canalicular wall was different in areas with or without Horner's muscle envelope.

Evaluation and treatment of failed nasolacrimal duct probing in Down syndrome

PURPOSE

To elucidate the mechanisms underlying failed nasolacrimal duct (NLD) probing in children with Down syndrome (DS) utilizing computed tomography (CT) scans and histopathology of nasal mucosa.

METHODS

The medical records of children with DS and NLD obstruction confirmed by dye disappearance testing who failed NLD surgery were retrospectively reviewed. Dimensions of the bony NLD and presence of postductal mucosal obstruction were obtained from CT scans. Histopathology of the nasal mucosa was performed in a subset of patients. Subsequent treatment was topical or intranasal corticosteroids or submucosal corticosteroids alone or combined with surgical reduction of the inferior turbinate.

RESULTS

A total of 9 subjects (age range, 8-10 years) and 43 age-matched controls were included. Both groups demonstrated a logarithmic increase in NLD and maxilla dimensions with increasing age; however, the transverse diameter of the NLD was consistently 1-2 mm smaller in children with DS ≤5 years age (n = 4) than in age-matched controls. The transverse diameter in DS children overlapped that of controls after 5 years age. Histopathology revealed abnormal lymphoplasmacytic inflammation of the mucosa in 4 of 5 biopsies of DS patients, consistent with chronic infection, allergic disease, or immune dysregulation. The postductal obstruction was successfully treated with topical or intranasal corticosteroids or by surgical reduction of the inferior turbinate submucosa with corticosteroid injection.

CONCLUSIONS

Before 5 years of age, NLD obstruction in children with DS was associated with reduced dimensions of the NLD and hypertrophic nasal mucosa. In DS children older than 5 years of age, the dimensions of the NLD are normal and postductal obstruction due to hypertrophic nasal mucosa should be considered.

Movement of internal canalicular orifice in association with blinking: direct observation after dacryocystorhinostomy

PURPOSE

To examine movement of the internal canalicular orifice with blinking and lacrimal drainage under endonasal endoscopic observation after dacryocystorhinostomy.

DESIGN

Observational anatomic study.

METHODS

Twenty internal canalicular orifices (right 9, left 11) from 15 patients (age range: 44-77 years) who underwent endoscopic endonasal dacryocystorhinostomy were prospectively examined. The patients sat on a chair with the chin projected slightly upward while digital images were taken. After examining the movement of the internal canalicular orifice with blinking, the patient's eye was stained with fluorescein dye, and diffusion from the orifice was examined with blinking.

RESULTS

The internal canalicular orifice closed during eyelid opening, although always incompletely. In eyelid closing, the orifice opened, and was pulled laterally without folds. All 20 internal canalicular orifices formed a diverticulum. Three specimens illustrated the upper and lower canalicular ends emptying into the diverticulum. The closing of these canalicular ends was always incomplete. Movement of the internal canalicular orifice was slight during normal blinking, but forced blinking resulted in more movement. Movement of the lacrimal sac wall was slight. During the first few seconds without blinking, no fluorescein dye flowed from the orifice. After several blinks, fluorescein dye flowed out slowly from the orifice, and increased in volume with more blinking. The fluorescein dye traveled inferiorly by gravity. A forced blinking was related to more dye inflow.

CONCLUSIONS

The internal canalicular orifice incompletely closed during eyelid opening, but this orifice largely opened during eyelid closing, with a slow gravitational inflow of lacrimal fluid.

The effectiveness of simultaneous medial spindle and/or lateral tarsal strip procedure in East Asian patients who need endonasal dacryocystorhinostomy

BACKGROUNDS

To evaluate the effectiveness of simultaneous medial spindle procedure (MS) and/or lateral tarsal strip procedure (TS) with an endonasal dacryocystorhinostomy (DCR) for treatment of involutional medial punctal ectropion, horizontal eyelid laxity, and nasolacrimal duct obstruction.

METHODS

We conducted a retrospective, interventional study of DCR performed from March 2009 to July 2011 by a single surgeon (Baek SH). Patient age, sex, results of medial and lateral distraction test, surgical procedure, time of tube removal, duration of follow-up, functional and anatomical success rate, and causes of failed surgeries were recorded. Lateral lower eyelid laxity was evaluated by a medial distraction test, and medial lid laxity was evaluated by a lateral distraction test.

RESULTS

A total of 241 eyes in 175 patients were included in this study. The proportion of combined surgeries to total DCR was 24.5% (59 of 241 eyes). DCR and MS (D + M) were performed on 23 eyes in 17 patients (9.5%) and DCR and TS (D + T) on 29 eyes in 17 patients (12.0%). Concurrent DCR, MS and TS (D + M + T) were performed on seven eyes in four patients (2.9%). Mean age was significantly higher in the combined surgery groups (63.8 ± 10.0 years) than in the DCR group (56.2 ± 10.6 years; p = 0.01, by Mann-Whitney U test). The anatomical success rates were 84.2% in D, 86.9% in D + M, 89.5% in D + T, and 85.7% in D + M + T (p = 0.61 by Kruskal-Wallis test). Functional success rates were 82.4% in D, 86.9% in D + M, 86.2% in D + T, and 85.7% in D + M + T (p = 0.91 by Kruskal-Wallis test).

CONCLUSIONS

MS and TS performed concurrently with a DCR may be an effective tool to deal with epiphora due to complex clinical situations such as nasolacrimal duct obstruction, lid laxity, and involutional medial ectropion. It is recommended to examine punctum and lid laxity carefully using slit-lamp biomicroscopy and lid distraction test in patients with epiphora, especially in elderly patients.

The effectiveness of simultaneous lateral tarsal strip with endonasal dacryocystorhinostomy for the treatment of nasolacrimal duct obstruction and lower lid laxity

PURPOSE

The aim of this study was to evaluate the effectiveness of simultaneous lateral tarsal strip procedure (LTS) and endonasal dacryocystorhinostomy (DCR) for the treatment of nasolacrimal duct obstruction and lower lid laxity.

METHODS

We conducted a retrospective, interventional study of concurrent DCR with LTS for patients with nasolacrimal duct obstruction and lower lid laxity performed between March 2009 and July 2011 by a single surgeon (S.H.B.). Patient age, sex, the results of dacryoscintigraphy, time of tube removal, follow-up duration, and cause of failed surgery were recorded. Lower eyelid laxity was evaluated by a medial distraction test.

RESULTS

A total of 29 eyes in 17 patients were included in the study. The mean age was 61.1 ± 11.8 years (range 41 to 81 years). The mean degree of lower lid laxity was 2.4 ± 0.5. Dacryoscintigraphy showed presac delay in 22 eyes (75.9%). The tube was removed after 11.3 ± 1.9 weeks. The primary anatomical success rate was 89.5% (27 eyes) and the functional success rate was 86.2% (25 eyes). Membranous obstructions were the cause of failed surgery in 2 patients, but both patients remained symptom free after revision surgery with a diode laser.

CONCLUSIONS

Concurrently performed DCR with LTS can be an effective tool for the treatment of nasolacrimal duct obstruction and lower lid laxity. It is recommended for examining lid laxity carefully using lid distraction test in patients with epiphora.

Tear drainage in traumatic canalicular fistula

PURPOSE

To evaluate the function of the canaliculus with fistula after canalicular laceration repair.

METHODS

Patients with monocanalicular fistula following canalicular laceration repair were evaluated with dye disappearance test (DDT). Temporary collagen plugs were used to occlude the uninvolved canaliculus in the ipsilateral eye and the corresponding canaliculus in the contralateral eye. After 24 hours of placement of the temporary plugs, the same evaluation was repeated.

RESULTS

Ten patients with unilateral monocanalicular fistulas were evaluated. None of the patients had epiphora before and after placement of temporary plugs and DDT, and tear meniscus continued to be normal both in the affected and the unaffected eyes after temporary plug placement.

CONCLUSIONS

In this series, the presence of canalicular fistula at the site of repair did not affect tear drainage.

Endoscopic dacryocystorhinostomy: outcomes using mucosal flap preserving technique

Currently, transnasal approaches are preferred widely for treating chronic dacryocystitis. Restenosis which count for the most common causes of failure in endoscopic dacryocystorhinostomy (EDCR) reduces the success rate. We intended to make a large fistula, potentially minimizing granulation tissue, and synechiae by means of creating a large bony ostium and preserving mucosal flaps and intubation with silicone tube (STI). In this study, long-term follow-up results of EDCR with mucosa preservation were discussed. 126 patients underwent endonasal DCRs from January 2004 to March 2009. A large ostium was created preserving mucosa; nasal and lacrimal flaps were approximated and the new ostium was stented with silicone tube. Surgical success rate was 93 % with STI and with preservation of nasal and lacrimal flaps. In conclusion, EDCR is an easy surgical procedure with low complication rates. Intranasal pathologies can also be corrected in the meantime. Success depends on creating a large bony ostium and preventing restenosis. EDCR preserving nasal and lacrimal flaps with STI is recommended as an alternative procedure in chronic dacryocystitis with high success rates.

Effect of mitomycin C on the tensile properties of the upper lacrimal canaliculi in a rabbit model

The upper lacrimal canaliculus consists of a tubular structure, and the tensile properties which in lacrimal tissues might contribute to structural integrity and tear drainage. We evaluated the characteristics of the tensile properties of the upper lacrimal canaliculi and the clinical implications of using a mitomycin C (MMC)-treated rabbit model. Mitomycin C (0.04%) was applied to the punctum of rabbits for 5 min, and the upper lacrimal tissues including the punctum were excised and attached to a forced transducer to record the tensile properties in a resting state 1 month later. The recording showed continuing decrement of basal tension with time in the lacrimal tissues treated with MMC in contrast with normal controls which maintained initial tension throughout the experiment. The rabbits were then randomly divided into the following 3 groups: vertical punctal incision with the MMC application group; vertical punctal incision with a balanced salt solution application group; and a balanced salt solution application only group. Four weeks after surgery, the puncta of rabbits treated with an incision and MMC application were more dilated clinically and showed less elasticity as compared with the other groups. Histological staining revealed that MMC treatment combined with incision decreased the amount of collagen and elastin fibers in the canaliculi. These results suggest that lacrimal canaliculi of rabbits have rheological basal tension and elasticity, which can be decreased by the use of MMC treatment.

Evaluation of lacrimal tear drainage mechanism using dynamic fluoroscopic dacryocystography

PURPOSE

To evaluate the dynamic change of the canaliculus and the lacrimal sac during blinking using fluoroscopic dacryocystography.

METHODS

Sixteen patients presenting with unilateral epiphora were enrolled in the study. Fluoroscopic dacryocystography was performed in both eyes, and sequential images of the lacrimal drainage system were acquired during blinking. On examination of the contralateral asymptomatic side, the length of the lower canaliculus and the width of the superior and inferior portions of the lacrimal sac were measured and compared between eyelid closure and opening.

RESULTS

The length of the lower canaliculus decreased with eyelid closure in 13 of 16 patients, and the change was statistically significant (p = 0.006, Wilcoxon signed rank test). The width of the superior portion of the lacrimal sac increased with eyelid closure (p = 0.033), but the width of the inferior part did not change significantly (p = 0.679).

CONCLUSIONS

With eyelid closure, the canalicular system contracts, and the superior portion of the lacrimal sac dilates; these may be important parts of the active lacrimal pump mechanism. These findings suggested that the canalicular system and the superior portion of the lacrimal sac play key roles in active tear drainage pump.

Watery eye following patent external DCR: an MR dacryocystography study

PURPOSE

To examine patients with persistent watery epiphora following patent external dacryocystorhinostomy (DCR) with magnetic resonance imaging dacryocystography (MR-DCG).

METHODS

Patients with unobstructed nasolacrimal irrigation following external DCR were included. Five patients with watery epiphora constituted the study group (SG). Five patients without epiphora constituted the control group (CG). All patients underwent MR-DCG following the instillation of artificial tears in the conjunctival fornix. The osteotomy site was identified in T1-weighted coronal images. Lacrimal flow was assessed with modified T2-weighted (True Fast Imaging Steady State Pulse, "TrueFISP") coronal images before and 10 min after repeated blinking. Signal intensities at three regions of interest (ROIs), corresponding to the eyeball (ROI-1), conjunctival sac (ROI-2), and anastomotic site (ROI-3) were measured.

RESULTS

Differences in the diameter of both osseous and soft tissue ostia between SG and CG were statistically not significant. A post-blink increase in signal intensity at ROI-3 was noted in both groups, whereas differences in signal intensity for ROI-1 and ROI-2 were statistically not significant. The post-blink signal intensity increase in ROI-3 was significantly more pronounced in the CG, compared with the SG.

CONCLUSIONS

The fact that signal intensity increase at ROI-3 was less pronounced in the SG, compared with CG, implies a compromised "lacrimal pump" mechanism in the former group. The methodology presented may be used for the evaluation of post-DCR epiphora.

The lacrimal bypass tube for lacrimal pump failure attributable to facial palsy

PURPOSE

To describe the use of a lacrimal bypass tube in the management of epiphora in patients with epiphora attributable to lacrimal pump failure in facial palsy.

DESIGN

Multicenter retrospective interventional study.

METHODS

Information regarding patient demographics, diagnoses, symptoms, oculoplastic interventions, dacryocystorhinostomy, and Jones tube insertion were collected from patient charts.

RESULTS

Eighteen patients were identified, in all of whom epiphora was clinically and/or radiologically assessed as being attributable to pump failure, lid laxity having been corrected. All had constant epiphora prior to Jones tube insertion. Dacryocystorhinostomy was performed in all; insertion of a Jones tube was performed simultaneously in 12, with delayed insertion in 6. Patients' subjective epiphora improved postoperatively in 15 of 18 (83.3%) and at final median follow-up of 27.5 months (range, 6 months to 31 years); symptoms were improved in 13 of 18 (72.2%). Complications occurred in 13 of 18 (72.2%), including tube extrusion and the need for repositioning.

CONCLUSIONS

In this highly selected group of patients, Jones tube insertion led to symptom improvement in 83.3% postoperatively and in 72.2% at median follow-up of 27.5 months. Tube extrusion and migration were common, although such complications were not unexpected and were treatable.

Efficacy of probing for children with congenital nasolacrimal duct obstruction: a retrospective study using fluorescein dye disappearance test and lacrimal sac echography

PURPOSE

To evaluate B-scan echography for the assessment of lacrimal sac (LS) in pediatric epiphora secondary to congenital nasolacrimal duct obstruction (CNLDO), and to verify its predictive role in functional efficacy of nasolacrimal duct probing.

PATIENTS AND METHODS

Thirty-nine eyes of 23 consecutive children, treated with a single probing for persistent CNLDO-related epiphora, were retrospectively studied. These cases were investigated both collectively and considering two sub-groups: group A (ten patients [20 eyes] <or=13 months) and group B (13 patients [19 eyes] >13 months. Fluorescein dye disappearance test at 10 minutes (FDDT-10) and ultrasound examination of LS were performed before and after probing. An echographic LS scoring system (grade 0 = no LS enlargement; grade 1 = slight longitudinal LS enlargement; grade 2 = longitudinal and slight transverse LS enlargement; grade 3 = marked longitudinal and transverse LS enlargement) was introduced as a predictor of probing efficacy, estimating FDDT-10 modification between pre- and post-operative checks.

RESULTS

Echographic LS evaluation was easily practicable without sedation. In the total cluster and in both age sub-groups, post-probing FDDT-10 decreased with respect to pre-probing value (p < 0.001). Post-probing LS score improved with respect to pre-probing check within the total cluster and group A (p < 0.05). Strong correlation between pre-probing LS alteration and functional probing failure was present in each studied cluster (all p values <0.0001). Within group B, a greater gain of post-probing FDDT-10 was more frequent in patients with a better pre-probing LS score, as well as in younger children (both p values <0.0001).

CONCLUSIONS

In children with CNLDO-related epiphora, B-scan echography of the LS can represent a reliable and useful examination for a better understanding of the functional prognosis after probing treatment.

Transcanalicular-endonasal semiconductor diode laser-assisted revision surgery for failed external dacryocystorhinostomy

PURPOSE

To report the results of transcanalicular-endonasal revision dacryocystorhinostomy (DCR) with a semiconductor diode laser in cases of failed external DCR.

DESIGN

Prospective, nonrandomized, interventional case series.

METHODS

Fifteen cases in 13 patients with failed external DCR underwent transcanalicular-endonasal DCR with a semiconductor diode laser. A functional successful outcome was defined as a patent nasolacrimal drainage system in nasolacrimal irrigation and a resolution of the symptomatic epiphora and/or mucoid discharge.

RESULTS

The patients were followed for a mean postoperative period of 27.3 months (range, nine to 54 months). The mean duration of the surgery was 19.6 minutes. After the initial revision transcanalicular-endonasal DCR surgery, patency to irrigation was obtained in 12 cases (80%), and 15 cases (100%) after a second revision treatment. Three cases required repeated revision surgery, and three other cases were considered to be functional failures in spite of a patent lacrimal system after the final revision surgery. The overall functional success rate was 80% (12 cases) at the final examination (mean, 27.3 months after surgery), and there were no intraoperative and postoperative complications. The presence of a canalicular obstruction or granulation tissue was not significantly related to the success rates of the revision surgery. The length of time between the primary and revision surgery, gender, age, the duration of the first revision surgery, and the timing of stent removal were also not significantly related to the failed cases.

CONCLUSION

Transcanalicular-endonasal DCR is a minimally invasive procedure and is recommended for patients as an alternative procedure for failed external DCR.

Drainage of tears: impact on the ocular surface and lacrimal system

The human efferent tear ducts are part of the lacrimal system. Because little knowledge exists concerning the physiology of the nasolacrimal system, and hence its patho- physiology, the nasolacrimal system has received almost no consideration as a possible factor in dry eye. The human nasolacrimal ducts consist of the upper and the lower lacrimal canaliculus, the lacrimal sac, and the nasolacrimal duct. As a draining and secretory system, the efferent tear ducts play a role in tear transport and nonspecific immune defense. Moreover, components of tear fluid are absorbed in the nasolacrimal passage and are transported into a surrounding vascular system. This system is similar to a cavernous body that is subject to autonomic control and regulates tear outflow. Tear duct-associated lymphoid tissue (TALT) is present in the efferent tear ducts, displaying the cytomorphological and immunophenotypic features of mucosa-associated lymphoid tissue (MALT). Under normal conditions, tear fluid components are constantly absorbed into the blood vessels of the surrounding cavernous body. These vessels are connected to the blood vessels of the outer eye and could act as a feedback signal for tear fluid production, which ceases if these tear components are not absorbed. In this way, dry eye could be initiated. Defective stimulation of TALT could result in abnormal immune deviation at the ocular surface, leading to an autoimmunological response that causes dry eye pathology.

Lacrimal sac volume measurement during eyelid closure and opening

BACKGROUND

Jones' theory of tear drainage suggests that the lacrimal sac fills when the eyelids are closed and empties when the eyelids are opened. This study was undertaken to see if there is any change in the volume of the lacrimal sac during eyelid closure and opening using images obtained from magnetic resonance dacryocystography using a topical magnetic resonance contrast agent.

METHODS

This is a prospective non-randomized comparative study in a tertiary hospital setting. Magnetic resonance dacryocystography scans were performed on five volunteers using 0.5% topical gadolinium-DTPA (MagneVist, Schering AG, Berlin, Germany) as a contrast agent. A T1-weighted magnetic resonance imaging scan with 2-mm contiguous coronal cuts was performed after localizing the lacrimal sac and instilling the contrast agent. The scans were performed with eyelids closed and opened. Volumes of 10 lacrimal sacs of five volunteers were calculated using pixel calibration and computer graphics.

RESULTS

No statistical difference in size of the lacrimal sacs was demonstrable between when the eyes were opened and when they were shut.

CONCLUSION

The present study could not demonstrate any volume change in the sac between eyelid closure and opening. Magnetic resonance imaging dacryocystography measures sac volume at two static end-points, so it cannot show any transient volume change that might occur during blinking. Various factors that may be affecting tear flow through the nasolacrimal system are discussed.

Changes in lumen width of nasolacrimal drainage system after adrenergic and cholinergic stimulation

PURPOSE

To determine the effect of an adrenergic agonist and a cholinergic agonist on the lumen width of the nasolacrimal drainage system.

DESIGN

Prospective, nonrandomized, clinical trial.

METHODS

The asymptomatic sides of 33 patients (23 women, 10 men) with unilateral stenosis/obstruction of the nasolacrimal drainage system were studied. The tear meniscus height of the asymptomatic side was normal, with a patent lacrimal system as revealed by dacryocystography. The nasolacrimal drainage system of the asymptomatic side was infused with 100 microL of 5% phenylephrine hydrochloride (an alpha-1 adrenoceptor agonist) or 100 microL of 2% pilocarpine hydrochloride (a cholinergic agonist), and dacryocystography was performed to determine the lumen width of the nasolacrimal drainage system.

RESULTS

Phenylephrine caused a significant increase of the lumen width of the nasolacrimal drainage system, and the changes were more marked in the nasolacrimal duct (NLD), especially the upper and middle regions, than in the lacrimal sac. In contrast, pilocarpine reduced the lumen width of the NLD significantly, especially in the middle and lower regions, and the lumen width of the lacrimal sac was not significantly changed.

CONCLUSION

The alterations of the lumen width of the nasolacrimal drainage system, especially the lumen width of the NLD by adrenergic and cholinergic agonists, suggest that the lumen width can be changed by the autonomic nervous system.