Etiology of tearing in patients seen in an oculoplastic clinic in Saudi Arabia

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.

Functional epiphora: an under-reported entity

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.

Comparative evaluation of dacryocystorhinostomy with retrograde intubation and conjunctivo-dacryocystorhinostomy

OBJECTIVE

To compare the surgical outcomes of dacryocystorhinostomy with retrograde intubation and conjunctivo-dacryocystorhinostomy for the management of proximal mid-bicanalicular lacrimal obstruction.

DESIGN

Randomized, controlled trial.

METHODS

The study was conducted in 50 eyes of 50 adult patients with bicanalicular obstruction ≤ 6 mm from the punctum. The etiology, duration of symptoms, and Munk scores were recorded. Group A underwent dacryocystorhinostomy with retrograde intubation, and in group B, conjunctivo-dacryocystorhinostomy was performed. Success was defined as anatomic patency on syringing, a negative fluorescein dye disappearance test, and a Munk score < 2 twelve months postoperatively.

RESULTS

There were 23 males and 27 females, 18-66 years of age, with a 6-month to 20-year duration of epiphora. The etiologies were idiopathic, trauma, and allergic conjunctivitis and ocular surface inflammation. In group A, the pseudopunctum was located medial to the diagnosed level of canalicular block by 1.28 ± 0.54 mm and 1.04 ± 0.88 mm in upper and lower canaliculi, respectively. Four post-traumatic cases required intervention following closure of the pseudopunctum, all being located ≥ 7 mm from the true punctum (p = 0.001). The complication rate was higher in group B than in group A (p = 0.001). At 12 months, the success rate was 100% in group A and 88% in group B (22 of 25; p = 0.74), with reduction in Munk scores from preoperative levels in both groups (p = 0.001).

CONCLUSION

Dacryocystorhinostomy with retrograde intubation and conjunctivo-dacryocystorhinostomy have comparable success rates in the management of proximal mid-bicanalicular obstructions. Dacryocystorhinostomy with retrograde intubation has lower complication rates and does not require long-term maintenance of the bypass tube, unlike conjunctivo-dacryocystorhinostomy.

Soft stop on syringing and probing may have a high false-positive rate in diagnosing pre-sac obstruction

Purpose

To determine the diagnostic value of 'soft stops' encountered during lacrimal syringing and probing.

Methods

Single-center retrospective review. Adult patients with epiphora attending a tertiary lacrimal clinic from May 2010 to April 2021 were reviewed. Cases with evidence of soft stop encountered during lacrimal syringing/probing were included, and patients with possible canaliculitis or a history of lacrimal surgery were excluded. Findings of syringing/probing consistent with pre-sac obstruction were correlated with dacryocystography (DCG) and surgical findings.

Results

53 (10.2%) canalicular systems had soft stops on syringing/probing and were included in the analysis. The mean age of the patients was 63.8 ± 15.6 (range 28–87) years, and 27 (65.9%) were females. Intraoperative examination findings were available for 27 of 30 cases that underwent lacrimal surgery and DCG was available for 40 systems. Pre-sac obstruction found on syringing/probing was confirmed in 40% and 37% of cases on DCG and surgery, respectively. The correlation between syringing/probing and DCG was stronger for canalicular than for common canalicular location (p = 0.016). Canalicular stenosis on syringing/probing manifested as pre-sac abnormality on DCG in 5/7 (71.4%) compared to 0/6 common canalicular stenosis cases (p = 0.021). Based on the surgical findings, the false-positive rate of a soft stop on syringing/probing was highest for common canalicular ‘stenosis’ (100%) and lowest for canalicular ‘block’ (45.5%; p = 0.093). Findings of pre-sac obstructions on DCG were confirmed in 85.7% of the cases intraoperatively (p = 0.035 compared to syringing/probing alone).

Conclusions

Soft stops on probing showed poor correlation with DCG and surgical findings, particularly in common canalicular location.

Etiology of Epiphora

Purpose

This study aimed to analyze the common causes of epiphora in Korean patients and their response to subsequent management.

Methods

We retrospectively analyzed the medical records of 180 patients who visited Kim’s Eye Hospital for epiphora between December 2017 and January 2019. This study included 320 eyes of 180 patients.

Results

In the 320 eyes of 180 patients, the most common etiology of epiphora was reflex tearing due to dry eye syndrome, which occurred in 167 eyes (52.19%). The other etiologies of epiphora included anatomical abnormality (68 eyes, 21.25%), multifactorial (60 eyes, 18.75%), functional epiphora (14 eyes, 4.38%), ocular surface disease (seven eyes, 2.19%), and eyelid abnormality (four eyes, 1.25%).

Conclusions

The most common etiology of epiphora in Korean patients was reflex tearing due to dry eye syndrome, followed by lacrimal passage abnormality, multifactorial, functional epiphora, anterior segment disease, and eyelid malposition. Most patients with reflex tearing reported improvement in their symptoms after lubrication.

Acquired symptomatic external punctal stenosis: a tertiary referral center study

Background

To report the prevalence of acquired symptomatic external punctal stenosis (EPS) in a tertiary referral center in Kuwait, and to study the associated risk factors, etiologies, and management outcomes.

Methods

This prospective interventional hospital-based study was performed at the Farwaniya governmental hospital in Kuwait between November 2018 and November 2019. All patients were referred to the oculoplastic clinic with symptomatic epiphora, age > 18 years, epiphora Munk score ≥ 0, tear film meniscus ≥ 2 mm, and punctum with grade ≤ 2 (smaller than normal size, but recognizable) were included. Eclusion criteria were congenital causes of epiphora, previous eyelid surgeries, and traumatic or neoplastic causes of punctal or canalicular obstruction.

Results

A total of 418 patients with symptomatic epiphora, who were referred to our oculoplastic clinic, were enrolled in our study. The prevalence of EPS was 70.3%. Eamination of the puncta revealed different shapes, including tangential, pinpoint, elevated, slit-shaped, horse shoe-shaped, and membranous puncta, with the tangential type accounting for the greatest proportion (65.3%). Bilateral punctal stenosis was observed in 206 patients (70.1%) and unilateral involvement in 88 patients (29.9%). Dilatation and syringing were performed for all puncta upon diagnosis, and repeated dilatation was performed for 225 puncta (32.7%). Placement of a Mini-Monoka tube was performed in 11 puncta (1.6%).

Conclusions

EPS was a common cause of symptomatic epiphora in our study. Aging and female sex were identified as common risk factors. Most etiological factors of EPS were associated with a pathophysiological inflammatory mechanism. For exact estimates of its prevalence, a population-based study is necessary in future.

Terminology and Etymology in Oculoplastic Surgery

PURPOSE

To provide a collection of important terms in oculoplastic surgery, their etymology, current usage, and clarification of terms with overlapping or often misconstrued definitions.

METHODS

Commonly employed terms in oculoplastic surgery were collected, and their etymologies were determined. The authors then examined how these terms are being currently used in the published literature to determine how closely their usage matched the origin of the terms, if any terms had developed multiple meanings, or if multiple terms were being used to describe the same concept.

RESULTS

This article assembles in one area much of the important terms in oculoplastic surgery, highlighting how the etymology of the terms both links to their meanings as well as clarifies the appropriate usage of terms that have evolved to develop several different definitions. Special attention is placed on clarifying the correct definitions of closely related but distinct terms.

CONCLUSIONS

Most terms in ophthalmology are used in a uniform manner across the literature with definitions closely matching their etymology, but some terms in oculoplastic surgery are being used in a potentially confusing overlapping manner and warrant clarification.

Evaluation of planned bicanalicular nasolacrimal tube retention in treating punctal stenosis or occlusion secondary to trachoma

This article evaluates retaining bicanalicular silicone nasolacrimal tube in patients susceptible to restenosis after punctoplasty. Sixty-nine eyes (38 patients) suffering from epiphora due to stenosis or occlusion of both punctae were included in this prospective study. All had 3 snip punctoplasty and bicanalicular silicone nasolacrimal duct insertion. Cases associated with proximal canalicular stenosis or obstructions were excluded. Tolerance to tube presence until the time of loss or removal was evaluated using a score (0 to 2). Average age was 49.71 ± 11.09 years. Tachomatous lesions were detected in all cases of punctal stenosis (48 eyes/69.57%) and membranous occlusion (21 eyes/30.43%). Common canalicular obstruction was additionally found in 12 eyes (17.39%). Absolute improvement was detected in 85% of cases and mean time for tube retention was (29.6 ± 10.2 months) with no difference in presence of common canalicular obstruction (P value: 0.138). Isolated punctal affection favoured tube retention that was well tolerated throughout the follow-up period (P value <0.001). Silicone bicanalicular nasolacrimal tube is an available option for treating acquired punctal stenosis. It is tolerated especially in cases suffering from isolated punctal stenosis. Tube retention could be of value in patients who are at risk of re-occlusion following tube removal.

Magnitude of diabetes and hypertension among patients with Dry Eye Syndrome at a tertiary hospital of Riyadh, Saudi Arabia - A case series

Purpose

To study the magnitude of chronic diseases among patients suffering from Dry Eye Syndrome (DES) and compare them with published findings in the literature.

Methods

Patients diagnosed in 2016 suffering from DES based on presenting symptoms and findings of ocular examination were included in this study. The demographic information included age and gender. Chronic diseases among them were identified through case records, assessment and ongoing medications.

Results

This case series had 62 patients (58% males) of DES. The mean age was 60.2 ± 16.6 years. The prevalence of hypertension, dyslipidemia and diabetes among them was 48.5% (95% confidence interval (CI) 31.5–65.5), 55.9% (95% CI 40.1–71.7) and 47.1% (95% CI 29.8–64.4) respectively. The rate of thyroid diseases (16.2%), renal diseases (6.5%), and liver diseases (6.7%) was not significant in this series.

Conclusions

This series in central Saudi Arabia suggests that the magnitude of chronic diseases such as diabetes, hypertension, obesity and dyslipidemia seems to be higher in patients with DES compared to the population.

How Important Is the Etiology in the Treatment of Epiphora?

Purpose. There are several etiological factors that cause epiphora, and treatment differs according to the cause. We aimed to evaluate the etiology of epiphora and the treatment modalities of the affected patients. Materials and Methods. Data of patients who were referred to ophthalmology clinics for epiphora were retrospectively analyzed. All patients were evaluated for epiphora etiology, treatment modalities, and duration of complaints, after complete ophthalmologic examination. Results. This study consisted of 163 patients with a mean age of 64.61 ± 16.52 years (range 1-92 years). Lacrimal system disease (48.4% [79/163]) was the most common cause, followed by ocular surface disease (dry eye/blepharitis) (38.7% [63/163]). Among the patients included in this study, 69% (113/163) did not receive any treatment, whereas only 1.8% (3/163) were treated surgically. About 4.3% of the patients (7/163) had a complaint for more than 5 years (p = 0.012) and six of these had chronic dacryocystitis and one had ectropion. Conclusion. Epiphora not only has a negative impact on patients' comfort, but also puts them at risk for probable intraocular operations in the future. Therefore, the wide range of its etiology must be taken into consideration and adequate etiology-specific treatment options must be applied.