A Pilot Study of Dynamic Magnetic Resonance Dacryocystography Imaging to Assess Functional Epiphora

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 We compared measurements to asymptomatic fellow eyes and to historical reference values from asymptomatic eyes.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.

Fungal microbiome (mycobiome) and virome of the lacrimal sac in patients with PANDO: the lacriome paper 5

PURPOSE

To study the fungal microbiome (mycobiome) and the virome of the lacrimal sacs in patients with primary acquired nasolacrimal duct obstruction (PANDO).

METHODS

A prospective study was performed on 10 consecutive samples of the lacrimal sac contents obtained from patients with PANDO. The samples were obtained from the lacrimal sacs under endoscopy guidance and immediately transported on ice to the laboratory. Following DNA extraction and library preparation, a whole shotgun metagenome sequencing was performed on the Illumina platform (NOVASEQ 6000). The fungal internal transcript spacer analysis was performed using the PIPITS v2.7 . The viral taxonomy profiling was performed using Kraken2 against the virus database.

RESULTS

The taxonomic hit distribution across the lacrimal sac samples showed rich fungal diversity (4 phyla, 12 classed, 21 families and 26 genera). The major phyla were Ascomycota and Basidiomycota, and the key genera identified were Alternaria, Hyphopichia, Malassezia, Aspergillus and Epicoccum. The virome analysis identified 13 phyla, 15 classes and 27 families. The viruses were commonly from the families Poxviridae, Retroviridae, Siphoviridae and Myoviridae, Poxviridae being the most prevalent family. The BeAn 58058 virus, a member of the Poxviridae family, was the most abundant in all the samples.

CONCLUSION

The present study is the first whole metagenome sequencing exclusively of the fungal microbiome and virome from the lacrimal sacs of patients with PANDO. The lacrimal sacs harbour diverse fungal and viral communities with distinct ecosystem dynamics. Further studies of their functions and interactions with the hosts would provide valuable insights.

Dacryolithiasis diagnosis and treatment: a 25-year experience using nasal endoscopy

BACKGROUND

Dacryolith-induced epiphora is caused by a chronic obstruction of the nasolacrimal duct whose aetiology is often specified peroperatively. Dacryocystorhinostomy (DCR) has been often regarded as the gold standard to treat dacryolithiasis. Hasner's valve (HV) incision is a technique to evacuate lithiasis through its physiological track. The purpose of this study was to describe clinical and radiological findings associated with presence of dacryoliths in patients who underwent surgery and to assess the efficacy of these two procedures.

METHODS

This study was a comparative interventional multicentric retrospective study including patients referred for an epiphora. The primary endpoint was to determine clinical and endoscopic findings associated with dacryoliths. The secondary endpoints were to evaluate the performance of CT dacryocystography (CT-DG) in the diagnosis of dacryoliths and the success rate of the surgical treatment 6 months postoperatively.

RESULTS

4677 nasolacrimal ducts (NLDs) (78.0% female, mean age 59.2) were included in the study. 3913 underwent DCR, and 764 underwent HV incision. 291 out of 4677 NLDs (6.2%) were found to have dacryoliths. Presence of mucocele associated to a permeable lacrimal system (OR 8.17 (95% 4.62 to 14.44), p<0.01) was associated with presence of lithiasis peroperatively. Success rates at 6 months were 95.6% for endonasal DCR and 94.6% for incision of HV in dacryolithiasis group (p<0.01). CT-DG had a negative predictive value of 96.3% to detect lithiasis (p<0.01).

CONCLUSION

Strong clinical and endoscopic findings may improve the imputability of dacryoliths in epiphora. Evacuation of dacryolithiasis through its physiological track was first described in this study in adults with similar results to DCR in patients presenting with dacryolithiasis.

Metagenomics of the lacrimal sac in primary acquired nasolacrimal duct obstruction: the Lacriome paper 1

BACKGROUND

The purpose is to study the metagenomics of the microbes isolated from the lacrimal sac of patients with primary acquired nasolacrimal duct obstruction (PANDO).

METHODS

A prospective study was performed on ten consecutive lacrimal sac samples obtained for the metagenomic analysis from the patients with PANDO, who underwent endoscopic dacryocystorhinostomy at a tertiary care Dacryology service. The samples were collected intraoperatively soon after a full-length lacrimal sac marsupialisation and immediately transported on ice to the laboratory. Following DNA extraction and library preparation, a whole shotgun metagenome sequencing was performed on the Illumina platform. The downstream processing and bioinformatics of the samples were performed using multiple software packaged in the SqueezeMeta pipeline and MG-RAST pipeline.

RESULTS

The taxonomic hit distribution across the samples showed that bacteria were the most common isolates (mean-97.56%), followed by viruses (mean-0.29%), archaea (0.04%) and others. The five major phyla identified across the samples of PANDO were proteobacteria, Bacteroidetes, Fusobacteria, Actinobacteria and Firmicutes. The prevalent organisms include Acinetobacter johnsonii, Porphyromonas catoniae, Cutibacterium acnes, Pseudomonas alcaliphila, Escherichia coli, Haemophilus influenzae, Enhydrobacter aerosaccus, Fusobacterium nucleatum, Moraxella osloensis, Butyricimonas virosa and Variovorax paradoxus, among few others. The alpha diversity of the ten sample datasets ranged from 60 to 175 species.

CONCLUSION

This is the first whole metagenome sequencing of the lacrimal sac contents from PANDO patients. Lacrimal sacs harbour diverse microbial communities, including bacteria, viruses, and archaea. Further Lacriome studies may provide clues for a better understanding of the disease aetiopathogenesis.

Prevalence and associated factors of symptomatic dry eye among undergraduate students in Hawassa University College of Medicine and Health Sciences, Hawassa, Ethiopia

Objective

This study aimed to assess the prevalence and associated factors of symptomatic dry eye (SDE) among undergraduate students at the College of Medicine and Health Science, Hawassa University, Ethiopia.

Methods and analysis

Institution-based cross-sectional study was conducted using a systematic random sampling technique. A total of 311 undergraduate students were recruited to execute the study. Ethical clearance was obtained from the ethical review committee of the school of Medicine and Health Science. A standardised self-administered questionnaire was used to collect the data. Data were entered using Epi Info V.7 and cleaned and analysed using SPSS V.23. Binary and multivariable logistic regression analysis was done to select candidate variables and to identify statistically significant factors. Variables with a p value of <0.05 on multivariable analysis were reported as statistically significant.

Results and conclusion

The overall prevalence of SDE was found to be 49.4% (95% CI 43.7% to 55.1%). In this study, the history of ophthalmic drop use (adjusted OR, AOR 2.063; 95% CI 1.073 to 3.957) and being second (AOR 5.99; 95% CI 1.10 to 32.56) and third (AOR 11.55; 95% CI 2.12 to 62.94) year student were factors that significantly associated with SDE.

In this study, the prevalence of SDE was significantly high. The factors associated with SDE were the use of ophthalmic drops and the class year of students. Therefore, public health education about protective measures should be considered to minimise the effects of SDE on the quality of life of students.

Should Silicone Lacrimal Stenting be a Better Choice for Primary Endoscopic Powered Dacryocystorhinostomy?

Objective: To compare endoscopic dacryocystorhinostomy (EnDCR) with and without silicone lacrimal stenting through subjective (patients’) and objective (surgeons’) outcome parameters. Methodology: Following defined selection criteria, EnDCR was performed on patients with primary chronic dacryocystitis with post-saccal stenosis. Every alternate patient had silicone lacrimal stenting (group A: no stenting; group B: with stenting); stents were removed at three months. At six months (minimum follow-up period), patients’ responses on symptom relief (through a five-point score) and naso-endoscopic evaluation (visualization of rhinostome; presence of granulations and synechiae; lacrimal drainage patency by estimating methylene blue flow pattern) were compared between the groups. Results: Each group had 20 patients. There was no statistically significant difference in group-wise follow-up periods. Five-point score at six months revealed 85% and 95% of patients in groups A and B, respectively, experienced “success”; among them, 60% and 75% were “symptom-free”. The majority (75%) in group B experienced no discomfort from stenting. Naso-endoscopy revealed 80% patients in group A and 65% in group B had well-delineated rhinostome, albeit with granulations in 25% and 50%, respectively. Spontaneous dye flow was achieved, respectively, in 75% and 90%. The difference in none of the subjective and endoscopic parameters achieved statistical significance. None had synechia; fibrosis was seen in the four patients with no dye flow even with pressure/massaging. Conclusion: There was no statistically significant difference in EnDCR with and without silicone lacrimal stenting in the overall outcome of symptomatic improvement and endoscopic assessment of the surgical site.

Spontaneous resolution rates in congenital nasolacrimal duct obstruction managed with massage or topical antibiotics compared with observation alone

BACKGROUND/AIMS

To determine if nasolacrimal massage or topical antibiotics are associated with higher rates of resolution compared with observation alone in a population-based cohort of infants with congenital nasolacrimal duct obstruction (CNLDO).

METHODS

The medical records of all children <5 years diagnosed with CNLDO while residing in Olmsted County, Minnesota from 1 January 1995 through 31 December 2004 were retrospectively reviewed for type of management and non-surgical resolution of tearing.

RESULTS

Among 1958 infants diagnosed and followed for CNLDO, 516 (26.4%) were merely observed, 506 (25.8%) were prescribed massage alone, 485 (24.8%) were prescribed at least one course of topical antibiotics, 397 (20.3%) were prescribed both topical antibiotics and massage, and 54 (2.8%) had no documented therapy. Non-surgical resolution, occurring in 1669 (85.2%) during a median follow-up of 3.1 months (range: 1 week-248 months), was 74.6% for the merely observed, 89.7% for those prescribed digital massage, 87.0% for those prescribed antibiotics and 90.7% for those treated with both. This comparison was significant in unadjusted (p<0.001) and multivariable comparisons (p<0.001).

CONCLUSION

Prescribing topical antibiotics or digital massage for infants with CNLDO in this cohort, individually or in combination, was associated with a higher rate of spontaneous resolution than observation alone.

Congenital nasolacrimal duct obstruction continues trend for spontaneous resolution beyond first year of life

PURPOSE

To investigate spontaneous resolution of congenital nasolacrimal duct obstruction (CNLDO) beyond 12 months of age in Japanese infants.

METHODS

Retrospective, observational case series. We retrospectively reviewed the clinical records of patients diagnosed with CNLDO beyond 12 months of age at Kyoto Prefectural University Hospital, Kyoto, Japan. This study involved 155 cases of CNLDO in 133 Japanese infants diagnosed with CNLDO. All patients chose intervention with either dacryoendoscopic guided probing and stenting or conservative management. The proportion and age of patients who had spontaneous CLNDO resolution were analysed.

RESULTS

The patients were divided into two groups: (1) 62 patients with 70 obstructed nasolacrimal ducts (45%) in whom spontaneous resolution occurred and (2) 71 patients with 85 obstructed nasolacrimal ducts (55%) who underwent dacryoendoscopic guided probing and stenting. The mean age of spontaneous resolution was 17.8±5.3 months (range: 12.0-35.4 months). Dacryoendoscopic guided probing and stenting were successful in 83/85 (97.6%) of cases.

CONCLUSIONS

Spontaneous resolution of CNLDO can occur in 45% of infants over the age of 12 months. Dacryoendoscopic guided stenting also has high success rates in this patient group, and both treatment options can be proposed to caregivers.

How reliable is the lacrimal scintigraphy report? An inter-observer agreement and reliability study

AIM

To assess the inter-observer agreement and reliability as well as intra-observer repeatability for lacrimal scintigraphy (LS) reports with and without considering the irrigation test results.

METHODS

A prospective, observational, cross sectional study. Two masked clinicians (lacrimal surgeon and nuclear medicine specialist) independently reported 100 LS images (50 patients of >6 years of age with unilateral anophthalmic socket) in a university hospital. The lacrimal surgeon performed a diagnostic irrigation test and repeated the report of the same LS images 2y after the first report (intra-observer agreement). A weighted Kappa analysis was performed to determine inter-observer agreement and reliability as well as intra-observer repeatability for the type (normal, partial and complete obstruction) and location (presac, preduct, and intraduct) of the obstruction. Subgroup analysis was also performed with consideration of irrigation test results.

RESULTS

A significantly moderate agreement was found between lacrimal surgeon and nuclear medicine specialist for both the type (Kappa=0.55) and location (Kappa=0.48) of obstruction. Agreement values were higher for the type (Kappa=0.61 vs 0.41) and location (Kappa=0.56 vs 0.31) of obstruction in cases with normal than abnormal irrigation test. Strong and significant intra-observer (lacrimal surgeon) repeatability was found for both the type (Kappa=0.66) and location (Kappa=0.69) of obstruction. LS showed no to slight reliability based on irrigation test.

CONCLUSION

A moderate agreement is found between lacrimal surgeon and nuclear medicine specialist regarding the interpretation of LS suggesting the importance of consensus groups among nuclear medicine specialists and lacrimal surgeons to create a common language for interpretation of LS. Intra-observer repeatability is strong for the lacrimal surgeon.

Punctal Plug as a Treatment Option for Dry Eye Associated with Congenital Supernumary Puncta

This study aims to describe a case of double lower lacrimal punctum-canaliculi in a dry eye patient treated with a punctal plug. A 60-year-old healthy female presented with complaints of tearing, itchy eyes, and foreign body sensation in the right eye for many years. There was no history of trauma or inflammation. Two patent independent supernumerary puncta and canaliculi were present on the right lower eyelid. The Schirmer Test II (with anesthesia) was zero, the tear breakup time was 2 s, and superficial punctate erosions were present in the right eye. A long-term nonabsorbable punctal plug was inserted into one of the lower puncta. At 9-month follow-up, the dry eye symptoms decreased markedly, the Schirmer Test II improved and superficial keratitis resolved.

Lysosomal enzymes and mannose 6-phosphate receptors in the lacrimal drainage system: Evidence and its potential implications

Purpose

To investigate the presence and patterns of lysosomal enzymes and mannose 6-phosophate receptor (MPRs) in human lacrimal drainage system.

Methods

The study was performed on healthy lacrimal sacs and nasolacrimal ducts obtained from exenteration samples immediately after surgery and frozen at -80°C for subsequent analysis. Soluble proteins' extract was used for enzyme assays, sodium dodecyl sulfate-polyacrylamide gel electrophoresis (PAGE), native PAGE, activity staining, and western blot analysis. Membrane proteins were separately assessed for detection of mannose 6-phosphate receptors, MPR 46. Sepharose gels, 4-methylumbelliferyl substrates, and antibodies against common lysosomal enzymes and MPRs were used. Enzyme assays were carried out in triplicate to ascertain the results.

Results

Differential lysosomal enzyme activities were documented, and among them acid phosphatase and β-hexosaminidase were found to be high. Western blot analysis using enzyme antibodies and subsequent activity staining confirmed strong signals for moderately expressed enzymes such as fucosidase, glucuronidase, and mannosidase. Membrane extracts demonstrated the presence of MPR 46, which indicates the possible roles of cation-dependent MPRs in lysosomal targeting in human lacrimal drainage system.

Conclusion

This study provides a proof of principle for the presence of differential lysosomal activity and mannose 6-phosphate ligand transport receptors in human lacrimal drainage system and hypothesizes the potential implications of their dysfunctions.

Outcomes in pediatric powered endoscopic dacryocystorhinostomy: a single-center experience

PURPOSE

The purpose of the article is to report the outcomes of powered endoscopic dacryocystorhinostomy (PEnDCR) in pediatric patients.

METHODS

A single-center, single surgeon, retrospective, interventional, non-comparative case series was performed on all pediatric patients who underwent PEnDCR between July 2014 and July 2017. Patients with associated congenital anomalies like single punctum agenesis or lacrimal fistula were excluded. Surgery was performed as per standard protocols published earlier. Data collected include demographics, clinical presentations, past interventions, indications for the surgery, intraoperative and postoperative complications, postoperative ostium characteristics, and anatomical and functional success.

RESULTS

Ninety-one eyes of 83 children underwent PEnDCR during the study period. Mean age was 8.32 years and epiphora was the most common presentation (81%, 74/91). The most common indication for PEnDCR was persistent congenital nasolacrimal duct obstruction refractory to earlier interventions of probing or intubation. Postoperative ostium assessment at 4 weeks showed a well-healed ostium with a dynamic internal common opening in 86.8% of the eyes. Edge granulomas of the ostium were the most common abnormal finding in the postoperative period (9.8%, 9/91) and all except one could be managed conservatively. At 6 months follow-up, five eyes showed anatomical failure and additional two eyes showeXd functional failure. Two of anatomical failure group and one of functional failure underwent a second intervention. The final anatomical and functional success were noted in 96.7% (88/91) and 95.6% (87/91), respectively.

CONCLUSIONS

This study shows that PEnDCR is a safe surgery for pediatric populations with a high success rate of beyond 95%.

Lacrimal drainage anomalies in congenital rubella syndrome

Purpose

The objective of this study was to ascertain the lacrimal drainage anomalies in a cohort of patients suffering from congenital rubella syndrome (CRS).

Methods

This was a retrospective case series performed in patients with CRS presenting with associated lacrimal drainage anomalies (LDA) over 6 years from 2011 to 2016. All the patients were confirmed as having CRS after clinical and laboratory testing. Data collected include demographics; associated lacrimal, ocular, and systemic anomalies; interventions performed for lacrimal anomalies; and their anatomical and functional outcomes.

Results

Eighty five patients were diagnosed as having CRS during the study period, and of these 23 eyes of 12 patients with associated LDA were included in the study. The prevalence of LDA was 14% in CRS. The mean age at presentation was 15.5 weeks, and all except one had bilateral presentation. Seventeen eyes were diagnosed with simple congenital nasolacrimal duct obstruction (CNLDO) and the remaining six eyes had complex CNLDO with buried probes. Additional lacrimal anomalies noted in the six complex CNLDO cases included punctal agenesis (n=3), atonic sac (n=3), incomplete punctal canalization (n=2), and single canalicular wall hypoplasia (n=1). At a mean follow-up of 12.54 months, anatomical and functional success were noted in 91.3% (21/23 eyes).

Conclusion

Simple CNLDO was the most common of the LDA in CRS. Buried probe was universal among the cases with complex CNLDO. All CRS patients should be screened for lacrimal anomalies to initiate appropriate interventions for successful outcomes.

Interactive navigation-guided ophthalmic plastic surgery: the utility of 3D CT-DCG-guided dacryolocalization in secondary acquired lacrimal duct obstructions

Aim

The aim of this study was to report the preliminary experience with the techniques and utility of navigation-guided, 3D, computed tomography–dacryocystography (CT-DCG) in the management of secondary acquired lacrimal drainage obstructions.

Methods

Stereotactic surgeries using CT-DCG as the intraoperative image-guiding tool were performed in 3 patients. One patient had nasolacrimal duct obstruction (NLDO) following a complete maxillectomy for a sinus malignancy, and the other 2 had NLDO following extensive maxillofacial trauma. All patients underwent a 3D CT-DCG. Image-guided dacryolocalization (IGDL) was performed using the intraoperative image-guided StealthStation™ system in the electromagnetic mode. All patients underwent navigation-guided powered endoscopic dacryocystorhinostomy (DCR). The utility of intraoperative dacryocystographic guidance and the ability to localize the lacrimal drainage system in the altered endoscopic anatomical milieu were noted.

Results

Intraoperative geometric localization of the lacrimal sac and the nasolacrimal duct could be easily achieved. Constant orientation of the lacrimal drainage system was possible while navigating in the vicinity of altered endoscopic perilacrimal anatomy. Useful clues with regard to modifications while performing a powered endoscopic DCR could be obtained. Surgeries could be performed with utmost safety and precision, thereby avoiding complications. Detailed preoperative 3D CT-DCG reconstructions with constant intraoperative dacryolocalization were found to be essential for successful outcomes.

Conclusion

The 3D CT-DCG-guided navigation procedure is very useful while performing endoscopic DCRs in cases of secondary acquired and complex NLDOs.

New method for evaluation of early phase tear clearance by anterior segment optical coherence tomography

PURPOSE

To describe a new method of measuring early phase tear clearance by anterior segment optical coherence tomography (AS-OCT).

METHODS

Sixty normal subjects were divided into a young group (30 subjects; 29.6 ± 7.2 years) and an elder group (30 subjects; 71.4 ± 10.8 years). AS-OCT (CASIA SS-1000, Tomey, Japan) with customized software was used to record the tear meniscus at the centre of the lower eyelid. Five microlitres of lukewarm saline solution was dropped into the lower conjunctival sac, and an image of the tear meniscus was obtained immediately and again 30 seconds after natural blinking. The tear meniscus height (TMH) and tear meniscus area (TMA) were measured in the AS-OCT images, and the percentage decrease in the TMH and TMA was used as a measure of the tear clearance. Correlations between tear clearance and clinical features including degree of conjunctivochalasis, degree of protrusion of inferior lacrimal punctum, distance of lacrimal punctum from the Marx line and fluorescein clearance rates were also determined in another healthy population consisting of 30 subjects.

RESULTS

The OCT tear clearance rate was 35.2 ± 11% for TMH and 28.1 ± 12.4% for TMA in the young group, and 12.4 ± 7.3% and 6.2 ± 9.1%, respectively in the elder group. The differences were significant for both the TMH (p = 0.017) and the TMA (p = 0.024). The OCT-determined tear clearance was positively correlated with the fluorescein clearance rate, and negatively correlated with the distance between the lacrimal punctum and Marx line, degree of conjunctivochalasis and degree of lacrimal punctum protrusion.

CONCLUSION

AS-OCT can be used as a rapid, non-invasive and quantitative method of determining the early phase tear clearance rate in a normal healthy population.