Ectopic lacrimal gland in the lacrimal sac mimicking tumour: literature review

An 80-year-old man referred with repeated episode of dacryocystitis from the left lacrimal drainage system and palpable swelling. For many years, he has being presented with epiphora unilaterally with chronic dacryocystitis. Investigations with dye-test revealed subocclusion of the natural passage of the tears, and CT and MRI scans revealed solid mass in the lacrimal sac. The lacrimal sac was opened by endonasal endoscopic approach, the sacral mass was identified and completely removed. The histopathological examination showed lacrimal gland in ectopic position. Patient followed for 18 months with complete recovery of symptoms. In our differential diagnosis, the ectopic lacrimal gland is also identified, when a mass in the lacrimal sac and duct is present. Successful surgical excision required considerable multidisciplinary teamwork between ophtalmologist-ENT (Otolaryngologist) and radiologist. Endonasal endoscopic approach is perfectly safe with direct control and ensures a smooth postoperative recovery.

Amblyopia risk factors in congenital nasolacrimal duct obstruction: A longitudinal case-control study

Purpose

To investigate longitudinal changes in risk factors for amblyopia in children treated with congenital nasolacrimal duct obstruction (CNLDO).

Methods

Retrospective observational case control study. A total of 446 children under 4 years of age who underwent probing and/or intubation for CNLDO between January 2004 and January 2018, and 446 age-matched controls were included. Cycloplegic refraction and ocular alignment were investigated at the time of treatment and after at least one year of symptom improvement. Children were classified as having amblyopia risk factors on the basis of the American Association for Pediatric Ophthalmology and Strabismus guideline in 2013.

Main outcome measures

The prevalence of amblyogenic refractive errors, and determinants associated with the presence of amblyogenic refractive errors in CNLDO patients.

Results

The prevalence of amblyogenic refractive errors in CNLDO patients (5.4%) was similar to that of the control group (6.5%) (P = 0.571). After one year of symptom improvement in CNLDO patients, the prevalence of amblyogenic refractive errors was 4.7%. There was no difference in the prevalence of amblyogenic refractive errors between unilateral and bilateral CNLDO patients. Multivariate analysis revealed that manifest strabismus was the only risk factor related with the presence of amblyogenic refractive errors (odds ratio = 6.383, confidence interval = 1.205–33.826, P = 0.029).

Conclusions

This study found no evidence to suggest that the prevalence of amblyopia risk factors is higher in CNLDO patients compared with normal controls. Manifest strabismus was the only determinant associated with the presence of amblyogenic refractive errors.

Evaluation of the effect of inferior turbinate outfracture on nasolacrimal transit time by saccharin test

AIM

To evaluate the effect of inferior turbinate outfracture on nasolacrimal transit time by saccharin test.

MATERIALS AND METHODS

Twenty patients who underwent septoplasty + unilateral radiofrequency ablation and outfracture of inferior turbinate were enrolled into study. They had no complaints about their eyes and denied previous ocular surgery. Their nasolacrimal saccharin transit times (NSTTs) were estimated preoperatively and postoperatively in the 1st and 2nd months. The non-fractured side eye was measured only once preoperatively. The fractured-side eye was measured three times. These times were compared statistically.

RESULTS

There were 8 men and 12 women. Mean age was 29.04. Killian incision was used in 14 and hemitransfixion incision was used in 6 patients. Median NSTT was 484, 461, 490 and 446 s for the non-fracture side, preoperatively and postoperatively in the 1st and 2nd months, respectively. There was no statistically significant difference between the two eyes preoperatively, and in the fractured side preoperatively and postoperatively in the 2nd month. There were significant differences between median NSTT in postoperative 1st month and median NSTT in the preoperative measure, and between postoperative 1st and 2nd months (p < 0.05). Median NSST in the 1st month was longer than the others.

CONCLUSION

Outfracture of inferior turbinate had no permanent effect on NSTT 2 months after surgery in patients that had a healthy nasolacrimal system.

Pediatric endonasal dacryocystorhinostomy: A multicenter series of 116 cases

We report our experience with pediatric endonasal dacryocystorhinostomy (DCR). Multicenter, retrospective, noncomparative study. Cases of pediatric endonasal DCR during 2006-2011 were included from six oculoplastic units. Patients over the age of 16 years were excluded. The outcomes of pediatric endonasal DCR are presented. Indication for surgery, demographics, previous interventions, intraoperative or postoperative complications, follow-up duration, and success rate (defined as significant improvement of epiphora) were evaluated. In total, 116 endonasal DCRs were performed for 103 patients. The mean follow-up period was 8 months (range 3 months to 4 years), with 1 patient lost to follow-up. There were 48 males (mean age 5 years and 9 months) and 50 females (range of 4 months to 16 years), with a total of 98 cases of congenital nasolacrimal duct obstruction (CNLDO) (84.5%) and 18 cases of acquired nasolacrimal duct obstruction (ANLDO) (15.5%). Previous interventions included probing 75.9% (88/116), massaging 43.1% (50/116), and intubation 39.7% (46/116). There were no intraoperative complications. There was one case of postoperative pyogenic granuloma. There were no cases of postoperative infection and postoperative hemorrhage. Ninety percent of procedures were considered successful. Complete symptom resolution was observed in 78% (90/116), significant improvement in 12% (14/116), partial improvement in 2% (2/116), and no improvement in 8% (9/116). In our series, we demonstrated that endonasal DCR is a safe operation and has an overall success rate of 90% for pediatric NLDO.

Endoscopic modified medial maxillectomy for odontogenic cysts and tumours

BACKGROUND

Odontogenic maxillary cysts and tumours originate from the tooth root and have traditionally been treated through an intraoral approach. Here, we report the efficacy and utility of endoscopic modified medial maxillectomy (EMMM) for the treatment of odontogenic maxillary cysts and a tumour.

METHODOLOGY

We undertook EMMM under general anaesthesia in six patients: four had radicular cysts, one had a dentigerous cyst, and one had a keratocystic odontogenic tumour.

RESULTS

The cysts and tumours were completely excised and the inferior turbinate and nasolacrimal duct were preserved in all patients. There were no peri- or postoperative complications, and no incidences of recurrence.

CONCLUSION

Endoscopic modified medial maxillectomy appears to be an effective and safe technique for treating odontogenic cysts and tumours.

Comparison of Anisometropia and Refractive Status in Children With Unilateral and Bilateral Congenital Nasolacrimal Duct Obstruction

PURPOSE

To evaluate and compare the refractive state in children diagnosed as having unilateral or bilateral congenital nasolacrimal duct obstruction (CNLDO). This study also compares how the laterality of CNLDO affects the refractive state of the patients.

METHODS

This descriptive cross-sectional study includes consecutive children with unilateral and bilateral CNLDO over a period of 1 year. Cycloplegic refraction was performed on each child who presented with CNLDO followed by appropriate plans for treatment. The refractive errors of patients with unilateral and bilateral CNLDO were compared.

RESULTS

One hundred sixty-one patients with unilateral CNLDO (mean age: 29 ± 19.93 months) and 46 with bilateral CNLDO (mean age: 30 ± 16.21 months) were enrolled from August 2013 to July 2014. The rate of the anisometropia (≥ 1 diopters [D] difference between the two eyes) was 13.7% (n = 22) and 8.6% (n = 4) in patients with unilateral and bilateral CNLDO, respectively. Interocular difference was significant in terms of spherical equivalent (P < .01) but not cylindrical refractive error in patients with unilateral CNLDO. Patients with bilateral CNLDO had insignificant interocular differences in terms of spherical equivalent and cylindrical refractive errors (P > .05).

CONCLUSIONS

Unilateral CNLDO is associated with statistically significant anisometropia compared to bilateral CNLDO, which predisposes children with unilateral CNLDO to amblyopia. It is vital to perform cycloplegic refraction routinely and counsel parents regarding regular follow-ups. [J Pediatr Ophthalmol Strabismus. 2016;53(3):168-172.].

Endoscopic dacryocystorhinostomy for acquired nasolacrimal duct obstruction: long-term results in 91 procedures

BACKGROUND

The purpose of the present study was to evaluate long-term outcomes of endoscopic dacryocystorhinostomy (DCR) using a drill without the use of mucosal flaps. Ninety one procedures in eighty seven patients were reviewed. All patients showed epiphora, caused by primary or secondary nasolacrimal obstruction.

METHODOLOGY

All patients underwent preoperative evaluation (irrigation and probing of the lacrimal drainage system, fluorescein tests, computerized tomography scan of the paranasal sinuses, dacryocystography and endoscopic examination of the nasal cavity). In 19 patients further intranasal procedures were conducted simultaneously with DCR (10 FESS, 2 septoplasties, 5 functional endoscopic sinus surgery (FESS) and septoplasties, 2 septoplasties and turbinoplasties). Stents were placed intraoperatively and removed 4 to 12 weeks, postoperatively. Postoperative follow-up ranged between 12 and 24 months.

RESULTS

Long-term success was achieved in 87/91 procedures. No major complications were observed. Failure was caused by granulation tissue formation in three patients and inappropriate stent removal in one patient.

CONCLUSION

The success rate achieved is comparable to success rates of external DCR.

Associated factors of functional failure of external dacryocystorhinostomy

OBJECTIVE

To evaluate the incidence and associated factors of functional failure of anatomically patent external dacryocystorhinostomy (DCR).

DESIGN

Prospective, nonrandomized case series.

PARTICIPANTS

Thirty-four consecutive patients who underwent external DCR at the oculoplasty clinic in the Department of Ophthalmology, Seoul National University Hospital between December 2008 and July 2009.

METHODS

All patients underwent external DCR for primary acquired nasolacrimal duct obstruction. The silicone tubes were removed around 6 months after the DCRs, and patients were examined 1 month after tube removal. Anatomical patency was evaluated by a nasal endoscopic dye test and lacrimal syringing test. Tearing symptoms were evaluated using Munk's scoring system. Patients were divided into 2 groups according to the presence of epiphora symptom; a functional success and functional failure group, and the incidence of functional failure were calculated. Potential associated factors were also compared between 2 groups.

RESULTS

This study involved 50 eyes of 34 patients, and 8 eyes of 6 patients showed significant epiphora in spite of anatomical patency (16% functional failure). We compared associated factors between 42 functionally successful and 8 functionally failed DCRs. Among variables studied, demographic factors and intraoperative surgical findings were not statistically different between the 2 groups. With respect to intranasal endoscopic findings, the shape of the rhinostomy showed significant differences between the 2 groups (p = 0.03, Fisher's exact test). In the functional failure group, there were no flat shape rhinostomies. Three showed alcove shape rhinostomies, and the other 5 showed cavern shape rhinostomies.

CONCLUSIONS

Among anatomically patent DCRs, the incidence of persistent epiphora was 16%. The shape of rhinostomy is a possible associated factor for functional failure after external DCR.

Validation of a symptom-score questionnaire and long- term results of endoscopic dacryocystorhinostomy

BACKGROUND

Endoscopic dacryocystorhinostomy (EN-DCR) is a commonly used procedure in the treatment of nasolacrimal duct obstruction (NLDO). However, there is no generally accepted disease-specific questionnaire for assessing outcomes.

METHODOLOGY

We conducted a prospective study to initially validate a Nasolacrimal Duct Obstruction Symptom Score questionnaire(NLDO-SS) and to evaluate the long-term success of EN-DCR procedures. Seventy-six patients (86 eyes) were evaluated in follow-up visits at 1-8 years after EN-DCR. The patients completed the NLDO-SS questionnaire twice, first, at home and, second,after receiving information from the otorhinolaryngologist, during the visit. The surgical outcome was considered successful if the irrigation succeeded and if the patient symptoms were relieved as assessed with the NLDO-SS.

RESULTS

The diagnostic accuracy of the NLDO-SS was 84%, sensitivity 82%, specificity 85%, positive predictive value 58%, negative predictive value 95%, odds ratio 26, risk ratio 11 and usefulness index 0.55. Cronbach's alpha was 0.85, and the test-retest reliability coefficient was 0.87. The long-term success rate after EN-DCR was 79%.

CONCLUSION

The NLDO-SS iss a feasible clinical tool in assessing the success of EN-DCR. The success rate was found to decrease EN-DCR at long-term follow-up.

Transcanalicular Dacryocystorhinostomy With Diode Laser: Long-term Results

PURPOSE

To evaluate the effectiveness of transcanalicular dacryocystorhinostomy with diode laser in treatment of epiphora in adults.

METHODS

A prospective, noncomparative, interventional case series of transcanalicular dacryocystorhinostomy in 25 patients presenting with epiphora due to nasolacrimal obstruction. Patient age ranged from 32 to 72 years. Patients were evaluated postoperatively at 12, 24, and 36 months. Patients were evaluated for symptom improvement through a visual analog scale, and patency of osteotomy by lacrimal system irrigation with fluorescein and direct visualization by nasal endoscopy. Success was defined as resolution of epiphora.

RESULTS

Transcanalicular dacryocystorhinostomy was able to re-establish patency of the lacrimal system in 88% of cases after 36 months of surgery. No differences were found between patients older than 65 years and younger patients (chi-square, p > 0.05). Early (12 months) and late (36 months) results were similar (chi-square, p > 0.05).

CONCLUSIONS

In this prospective series, transcanalicular dacryocystorhinostomy was effective in treatment of epiphora in adults with little morbidity.

Inferior turbinate fracture and congenital nasolacrimal duct obstruction

PURPOSE

To evaluate the success rate of probing combined with inferior turbinate fracture in comparison with simple probing as a first attempt in the treatment of congenital nasolacrimal duct obstruction in children.

METHODS

In a prospective interventional case-control study, 86 eyes from 61 children older than 6 months with congenital nasolacrimal duct obstruction underwent surgical intervention. Forty-two eyes of 33 patients underwent probing combined with infracturing of the inferior turbinate and 44 eyes of 28 patients underwent simple probing. The outcome evaluation included a standard ophthalmologic examination plus a dye disappearance test 2 months after the surgical intervention.

RESULTS

In the case group (probing + infracture of the inferior turbinate), the results were good in 22 (66.7%) patients, fair in 8 (24.2%), and poor in 3 (9.1%). In the control group (simple probing), the results were good in 20 (71.4%) patients, fair in 3 (10.7%), and poor in 5 (17.9%) (p=0.9). Success rates were 91% and 82% in the case and control groups, respectively (p=0.4).

CONCLUSIONS

Based on the results of this study, infracturing of the inferior turbinate does not increase the success rate of simple probing as a first attempt.

External versus endoscopic dacryocystorhinostomy for acquired nasolacrimal duct obstruction in a tertiary referral center

PURPOSE

To compare success rates of external dacryocystorhinostomy (DCR) and endoscopic endonasal DCR for acquired nasolacrimal duct obstruction (NLDO).

DESIGN

Retrospective, comparative, nonrandomized clinical study.

PARTICIPANTS

One hundred forty-three patients (176 surgeries) operated for acquired NLDO.

METHODS

A review of electronic medical records of patients with acquired NLDO who underwent DCR at the Jules Stein Eye Institute from 1999 to 2004 was performed. Data regarding the lacrimal drainage system, comprehensive eye examination, surgical outcome, and postoperative nasal endoscopy were analyzed.

MAIN OUTCOME MEASURES

Surgery failure was defined as (1) no marked improvement in tearing or any episode of postoperative dacryocystitis, (2) inability to irrigate the lacrimal system postoperatively, and (3) postoperative nasal endoscopy with scarring in the intranasal osteotomy or no visualization of fluorescein dye. Postoperative nasal endoscopy was performed in all failed cases and in >50% of all patients.

RESULTS

One hundred forty-three patients (48 male and 95 female; mean age, 63 years) underwent 176 DCR surgeries for acquired NLDO. Success was achieved in 135 cases (76.7%), and failure in 41 (23.3%). Of the 41 failed cases, anatomical obstruction at the fistula site was found in 20 (49% of failed cases), whereas functional failure with no evidence of obstruction was found in 21 (51%). Surgery revision was performed in 22 cases (12.5%), but it was successful in only 9 (5.1%); patients who failed the first revision were likely to fail additional revisions (P = 0.02). History of facial trauma was associated with surgery failure. In our patients, endoscopic DCR (86 cases) had a significantly higher success rate than external DCR (90 cases), 84% versus 70% (P = 0.03). Complications included 1 patient with nose bleeding on the first postoperative day that resolved with nasal packing and 2 patients with sump syndrome that resolved after endoscopic revision.

CONCLUSIONS

The success rate of DCR for acquired NLDO in our group of patients was 77%, lower than reported in previous studies, with endoscopic surgery showing better results. Success rates of revision surgery were relatively low (<50%), and patients who fail the first revision are not likely to benefit from additional revisions.

The course of epiphora after failure of silicone intubation for congenital nasolacrimal duct obstruction

BACKGROUND

One of the indications for dacryocystorhinostomy (DCR) in children with congenital nasolacrimal duct obstruction (CNLDO) is failure of silicone intubation. We evaluated the course of epiphora after failure of silicone intubation for CNLDO when DCR was not performed.

METHODS

In a comparative cohort study carried out at a tertiary referral center, ten eyes of seven consecutive children who had failure of silicone intubation manifested as persistent epiphora over 2 months and whose parents refused DCR were followed up for an average of 50.4 months (range 33-70 months). Three lacrimal drainage systems of three other children who had failure of silicone intubation underwent uneventful DCR.

RESULTS

In eight (80%) of the ten consecutive eyes with congenital nasolacrimal duct obstruction (six of the seven children, 86%), there was spontaneous complete resolution of the epiphora and normal dye disappearance test (DDT) at the end of the follow-up period. One child with Down's syndrome, allergic rhinitis, asthma and multiple site obstructions had improvement of symptoms but abnormal DDT. The epiphora in all three children who underwent DCR had disappeared by 6 months after surgery when the silicone tube was removed. No complications were noted during the follow-up.

CONCLUSIONS

Epiphora can spontaneously resolve after failure of silicone intubation in CNLDO, and DCR should no longer considered be compulsory in such cases unless complications evolve.

Videoreflective dacryomeniscometry in normal adults and in patients with functional or primary acquired nasolacrimal duct obstruction

PURPOSE

Videoreflective dacryomeniscometry (VRD) for evaluation of marginal tear film has not been performed in patients with watery eye or in a controlled study. We used VRD to evaluate the height of the central marginal lower lid tear film in normal adults and compared it with two watery-eye groups and a postoperative dacryocystorhinostomy (DCR) group.

DESIGN

Case-controlled interventional case series.

METHODS

We evaluated with VRD 20 subjects with normal lacrimal drainage function, 21 patients with primary acquired nasolacrimal duct obstruction (PANDO), 28 patients with functional nasolacrimal duct obstruction (FNLDO), and a postoperative group of 14 patients derived from the previous two pathologic groups. Comparison between the four groups was performed to determine statistically significant differences between tear film height.

RESULTS

PANDO and FNLDO groups were shown to have significantly greater median tear meniscus heights ([TMH] PANDO: 620 microm, interquartile range [IQR] 453 microm; FNLDO: 731 microm, IQR 529 microm) than normal subjects (296 microm, IQR 214 microm; P < .001) and postoperative PANDO patients (265 microm, IQR 159 microm). There was no significant difference in TMH between PANDO and FNLDO groups preoperatively (P = .275). There was a reduction in median TMH postoperatively of 355 microm (P = .008) in PANDO and 360 microm (P = .068) in FNLDO.

CONCLUSIONS

PANDO and FNLDO patients have similar preoperative TMH. In both these groups, TMH is significantly greater than in normal control subjects. Lacrimal drainage surgery substantially reduces TMH as measured using VRD in PANDO.

The human nasolacrimal ducts

The human nasolacrimal ducts are a borderland of the disciplines ophthalmology and otorhinolaryngology, which work close together in the treatment of nasolacrimal disorders. However, little knowledge exists concerning the physiology of the nasolacrimal system and, therefore, its pathophysiology. The aim of the present investigations was to obtain a better understanding of tear flow physiology, microbial defence strategies and pathophysiological processes by analysing the nasolacrimal system, thus opening new perspectives against existing therapeutical concepts of diseases of the nasolacrimal ducts. The human nasolacrimal ducts consist of the upper and the lower lacrimal canaliculus, the lacrimal sac and the nasolacrimal duct. They drain the tear fluid from the ocular surface into the lower meatus of the nose. The lining epithelium of the lacrimal sac and the nasolacrimal duct is faced by microvilli, and animal experiments in rabbits support the hypothesis that tear fluid components are absorbed in the human nasolacrimal system. Evidence of seromucous glands, intraepithelial lipids and a specific mucus layer leads to the conclusion that the normal three-layering of the tear film is also present in the nasolacrimal ducts. Based on its composition, the mucus layer, which is mainly synthesised by goblet cells and intraepithelial mucus glands, functionally serves as a simplified drainage of tear fluid, and it is attributed similar properties to epithelia of the gastrointestinal tract. Further defence mechanisms are represented by antimicrobial peptides IgA and immunocompetent cells (lymphocytes and macrophages) which show intraepithelially and subepithelially a special distribution. Moreover, organised lymphoid tissue is present, which reveals the cytomorphologic and immunophenotypic characteristics of mucosa-associated lymphoid tissue. The wall of the lacrimal sac and the nasolacrimal duct are made up of a helical system of different connective tissue fibres. Wide luminal vascular plexus are embedded in this helical system, which is comparable to a cavernous body. Caudally, the vascular system is connected to the cavernous body of the inferior turbinate. With distension the system may be "wrung out" due to its medial attachment and helically arranged fibrillar structures. Thereby, tear fluid is drained distally. The embedded blood vessels underlie vegetative control. By means of this innervation, the specialised blood vessels permit regulation of blood flow by opening and closing the lumen of the lacrimal passage as effected by the engorgement and subsidence of the cavernous body, at the same time regulating tear outflow. Related functions, such as a role in the occurrence of epiphora related to emotional responses, are relevant. Moreover, malfunctions in the cavernous body and in its innervation may lead to disturbances in the tear outflow cycle, ocular congestion or total occlusion of the lacrimal passage. Thus, the pathophysiology of primary acquired dacryostenosis can be explained: Descending inflammation from the eye or ascending inflammation from the nose initiates swelling of the mucous membrane, remodelling of the helical arrangement of connective tissue fibres, malfunctions in the subepithelial cavernous body with reactive hyperaemia, and temporary occlusion of the lacrimal passage. In the follow-up, repeated isolated occurrence of dacryocystitis leads to structural epithelial and sub-epithelial changes, which may lead either to a total fibrous closure of the lumen of the efferent tear duct or to a non-functional segment in the lacrimal passage that is manifest on syringing. The normally constant absorption of tear fluid components into the blood vessels of the surrounding cavernous body that are connected to the blood vessels of the outer eye could be a feedback signal for tear fluid production, which comes to a halt if these tear components are not absorbed. Thus, dry eye could be initiated. Defective stimulation of tear duct-associated lymphoid tissue (TALT) could result in abnormal immune deviation at the ocular surface leading to an autoimmunologic response that could cause dry eye pathology.

[Endonasal micro-dacryocystorhinostomy in nasolacrimal obstruction]

Disorders in lacrimal passage are often caused by anatomotopographic peculiarities of the nasolacrimal tract. Surgical treatments of such patients are reviewed. The authors made endoscopic endonasal dacryocystorhinostomy in 34 patients with good results. How to achieve good functional outcomes is described.

New insights into the pathophysiology of primary acquired dacryostenosis

OBJECTIVE

To obtain new insights into the pathophysiology of primary acquired dacryostenosis.

DESIGN

Comparative autopsy tissue study with histopathologic correlations.

MATERIALS

Tissue specimens from the human nasolacrimal ducts of 36 patients undergoing endonasal dacryocystorhinostomy within a framework of primary acquired dacryostenosis were analyzed by histologic studies and electron microscopic examination. Six lacrimal systems of body donors served as controls.

TESTING

One group of tissue specimens from each lacrimal system was prepared and processed with paraffin, sectioned, stained by different methods, and finally examined by light microscopy. The other group was processed with araldite after preparation, sectioned semithin and ultrathin, and examined by transmission electron microscopy.

MAIN OUTCOME MEASURES

The degree of dacryostenosis was scored in each tissue specimen by grading the histologic sections as mild (active chronic inflammation), moderate (proliferative sclerotic forms of chronic fibrosis), or severe (total subepithelial fibrosis).

RESULTS

Of 36 patients with epiphora, 13 had functional obstruction with a patent lacrimal system on syringing; in 23 cases, the lacrimal passage was completely obstructed. Different pathologic stages correlating to duration of symptoms were found ranging from active chronic inflammation to proliferative sclerotic forms and total subepithelial fibrosis.

CONCLUSIONS

Descending inflammation from the eye or ascending inflammation from the nose initiates swelling of the mucous membrane, remodeling of the helical arrangement of connective tissue fibers, malfunctions in the subepithelial cavernous body with reactive hyperemia, and temporary occlusion of the lacrimal passage. In the follow-up, repeated isolated occurrence of dacryocystitis leads to structural epithelial and subepithelial changes, which may lead either to a total fibrous closure of the lumen of the efferent tear duct or to a nonfunctional segment in the lacrimal passage that is manifest on syringing.

Endoscopic dacryocystorhinostomy in children

BACKGROUND

Persistent nasolacrimal duct obstruction (NLDO) often requires treatment by probing, intubation, or balloon dacryoplasty. Refractory cases have been managed by external dacryocystorhinostomy (DCR), which leaves a scar; however, this procedure is generally avoided in young children. Endoscopic DCR has been successfully performed in adults and described in children. We report the success of this procedure in a series of pediatric patients.

METHODS

A retrospective review of all endoscopic lacrimal procedures performed in a 3-year period was undertaken. Seventeen children (22 ducts) with persistent NLDO after at least one failed probing, with or without silicone tube placement, underwent endoscopic DCR. Follow-up ranged from 6 to 36 months, and success was defined as resolution of tearing and discharge by follow-up clinical evaluation and by parental history.

RESULTS

All but 2 patients (88%) with NLDO showed complete resolution of tearing and discharge. These 2 patients had recurrent symptoms after the Crawford tubes were removed and required revision endoscopic DCR. No complications from this procedure were noted.

CONCLUSIONS

Endoscopic DCR is a safe and effective means of treating persistent NLDO in infants and young children when simple probing, intubation, or balloon procedures have failed. The team ophthalmology-otolaryngology endoscopic approach provides a highly successful alternative for patients with a persistent distal obstruction that might otherwise require an external procedure.

Dacryocystorhinostomy for epiphora in the presence of a patent lacrimal system

PURPOSE

To evaluate the success rate of dacryocystorhinostomy (DCR) for epiphora in patients with a clinically patent lacrmal drainage system.

METHODS

A series of 51 patients, 12 men and 39 women, who underwent DCR surgery for epiphora with a clinically patent lacrimal drainage system in the background of normal eyelid examination, were evaluated. All patients underwent fluorescein dye disappearance testing and Jones 1 and 2 testing with dacryocystograms in borderline cases. A standard DCR was performed with bicanalicular silicone tubing inserted in all cases. The average time for the removal of the silicone tubes was 9.6 weeks.

RESULTS

In 48 cases (94%) there was improvement in symptoms with minimal or no significant epiphora postoperatively.

CONCLUSIONS

Epiphora with a patent lacrimal drainage system obstruction can be successfully treated by DCR based on fluorescein dye disappearance tests and Jones 1 and 2 tests, with dacryocystography in borderline cases.

Reappraisal of probing of the congenital obstruction of the nasolacrimal system: is nasal endoscopy essential?

OBJECTIVE

The rate of false passages during probing for congenital nasolacrimal system obstruction (CNLO) is a major limiting factor for a successful outcome. This shortcoming may be decreased with the use of a nasal endoscope during probing. This approach is particularly important in the probing training of ophthalmology residents.

METHODS

An experienced pediatric ophthalmologist performed probings on 11 eyes, and a group of ophthalmology residents under his supervision performed probings on another 11 eyes for CNLO. Their claims of a successful or unsuccessful procedure were evaluated with nasal endoscopy by an ear--nose--throat (ENT) surgeon. The age range of the patients was 8-23 months.

RESULTS

The ophthalmologist made two false passages, one of which he was aware, out of 11 eyes. The residents had five false passages, two of which were unclear to them, out of another 11 eyes. No false passages occurred in obstructions at the level of the Hasner valve. None of the successful probings required more than a 30 mm probe introduction into the nasolacrimal canal from the inferior punctum.

CONCLUSION

It seems justified to have a nasal endoscopic evaluation, performed by an ENT surgeon, for probings during the training program of ophthalmology residents. Difficult cases with stenosis proximal to the inferior meatus, prior false passage experience on a particular case, and any indication for silicone tube implantation will benefit from the use of an endoscope during the procedure. In order to achieve the best results in CNLO, the collaborative teamwork of an ophthalmologist and an ENT specialist is necessary.

Nasolacrimal duct injury from microscopic sinus surgery: preliminary report

Nasolacrimal duct injury is a well established complication of functional endoscopic sinus surgery. In 1992, Bolger reported an incidence of nasolacrimal duct injuries in endoscopic sinus surgery of up to 15 per cent, but there is no documentation in microscopic sinus surgery. Fluorescein instillation into the lacrimal system via the punctum was done to determine the incidence of nasolacrimal duct injuries in 16 patients who underwent 32 microscopic sinus procedures. Only one patient exhibited nasolacrimal duct injury intraoperatively on the left side (0.3%). He had complete healing of the nasolacrimal duct at 2 months and no postoperative epiphora developed.

Monocanalicular lesions: to reconstruct or not

OBJECTIVE

To evaluate the success rate of a simple surgical method for the treatment of a monocanalicular lacrimal lesion.

DESIGN

Retrospective noncomparative case series.

PARTICIPANTS

Thirteen consecutive patients with monocanalicular trauma who were seen from August 1995 to March 1998. In six patients, the canaliculus was lacerated as a result of an external injury and in seven patients as a result of tumor removal (iatrogenic injury).

INTERVENTION

Reapproximation of the orbicularis muscle and skin overlying the torn canaliculus without reanastomosis of the lacerated canaliculus. In those patients in whom the canaliculus was sacrificed as part of the removal of an eyelid tumor, no attempt was made to reconstruct the canaliculus.

MAIN OUTCOME MEASURES

Symptomatology, patency of the lacrimal passage, fluorescein dye disappearance test, and patient satisfaction.

RESULTS

In all patients the injured canaliculus was totally blocked, but despite this none of the patients complained of inconvenient tearing either indoors or outdoors. The ipsilateral unharmed canaliculus was functioning normally in such a way that the fluorescein dye instillation test showed residual dye in six patients after 2 minutes and in none of the patients after 5 minutes. All patients were satisfied with the functional and cosmetic result.

CONCLUSION

Nonrepair of a monocanalicular lesion is a valid approach that results in little or no morbidity.

Clinical and radiologic lacrimal testing in patients with epiphora

OBJECTIVE

The purpose of the study is to assess the strengths and weaknesses of selected clinical and radiologic lacrimal tests in patients with epiphora.

DESIGN

The study design was a prospective clinical trial.

PARTICIPANTS

Fifteen patients with epiphora (N = 27 eyes) were studied.

METHODS

All patients underwent Jones testing, the dye disappearance test, canalicular probing, lacrimal scintigraphy, and macrodacryocystography.

MAIN OUTCOME MEASURES

The dye disappearance test was graded individually by three ophthalmologists. Lacrimal scintigraphy and macrodacryocystography were evaluated by a nuclear medicine specialist and a radiologist, respectively. A panel of three ophthalmologists evaluated the data using a scoring system that relied on the preponderance of evidence to arrive at a final assessment.

RESULTS

When the Jones I test results were negative (dye recovered from the nose), the epiphora was always from hypersecretion. When the Jones I test results were positive (no dye recovered from the nose), obstruction was not always present. When the dye disappearance test results were strongly abnormal, obstruction was always present. In contrast, when the dye disappearance test results were normal, the lacrimal drainage system was not always patent. Canalicular probing was more reliable than scintigraphy in identifying canalicular obstruction. Marked stenosis of the sac or duct on dacryocystography essentially confirmed nasolacrimal outflow obstruction; however, with the authors' technique, a normal study was found in some patients with functional or partial obstruction.

CONCLUSIONS

More than one lacrimal test may be required for a definitive diagnosis in patients with epiphora due to partial or functional nasolacrimal outflow obstruction.

The effect of nasolacrimal occlusion on drug-induced mydriasis

BACKGROUND

Nasolacrimal occlusion has been shown to improve the efficacy of some topically applied ocular drugs. The aim of this study was to investigate the effect of nasolacrimal occlusion on tropicamide-induced mydriasis.

METHODS

We compared pupillary dilatation by 0.125% tropicamide with and without nasolacrimal occlusion in 40 healthy volunteers.

RESULTS

Analysis of variance with repeated measures failed to show any advantage due to nasolacrimal occlusion in drug-induced mydriasis.

CONCLUSION

Nasolacrimal occlusion did not increase the mydriasis obtained with 0.125% tropicamide.

[Management of congenital nasolacrimal duct obstruction. Timing of probing]

In the management of congenital nasolacrimal duct obstruction (CNDO), there is not a well-established agreement about the proper time for probing. Some authors perform it prior to the first year of life, since after this age the relapse frequency would be very high; others prefer conservative management, since they deny this high frequency. In order to evaluate which one of these two opinions has to be considered more appropriate, the present study retrospectively reviewed the frequency of relapses at the 6-month-mark after surgery in 77 patients (40 males, 37 females) probed for CNDO at the Children's Hospital of Trieste in the 1990-1992 period. In our case-record relapses were found in 7.8% of all patients (8.8% of eyes), while the corresponding percentages were 10.8% of patients (14.3% of eyes) in those probed in the first year of life, 5% of patients (3.8% of eyes) in those probed after this time. These results show no worsening for late probing outcome, with respect to early probing. As a consequence of these findings, it can be recommended that for CNDO it is proper to start with a conservative management, represented by lacrimal sac massage and antibiotic eye drops instillation, if mucopurulent discharge is present, for a 4-6 weeks period. If symptoms do not disappear completely after this period, whether probing is the treatment of choice, possibly after the 6th month of life, or, when parents prefer this option, to resume the medical treatment, since also late probing guarantees a good outcome. The choice for probing is mandatory after second year of life.

Tricompartment model of the lacrimal pump mechanism

BACKGROUND

The role of the lacrimal sac in the lacrimal pump mechanism is controversial.

METHODS

Movements of the lateral wall of the lacrimal sac with blinking were videotaped through an endoscope in eight patients after dacryocystorhinostomy. In addition, movements of an air bubble at the opening of the nasolacrimal duct with blinking were studied in three patients with an incompetent valve of Hasner.

RESULTS

The superior half of the lateral wall of the lacrimal sac moved laterally with lid closure and medially with lid opening. The inferior half of the lateral wall of the lacrimal sac moved medially with lid closure and laterally with lid opening. In patients with an incompetent valve of Hasner, the air bubble at the opening of the nasolacrimal duct bulged into the nose with lid closure and retracted into the nasolacrimal duct with lid opening.

CONCLUSIONS

A tricompartment model of the lacrimal pump is presented that incorporates these findings. With lid closure, the orbicularis muscle contracts, compressing the canaliculi and pulling the superior half of the lateral wall of the lacrimal sac laterally. This creates a lower pressure in the superior sac, allowing tears to be propelled from the canaliculi into the sac. At the same time, the inferior half of the lateral sac wall moves medially, creating a positive pressure in the inferior sac and nasolacrimal duct, thus forcing tears down the duct into the nose. With lid opening, the orbicularis muscle relaxes, allowing the canaliculi to open and the superior half of the lateral sac wall to move medially. The resulting negative intracanalicular pressure allows tears to flow from the lacrimal lake into the canaliculi, and the higher pressure in the superior sac closes the valve of Rosenmueller and forces tears from the superior to inferior sac and proximal nasolacrimal duct. At the same time, the inferior half of the lateral sac wall moves laterally, resulting in a negative pressure in the inferior sac and nasolacrimal duct.

Canalicular function during herpetic keratoconjunctivitis in rabbits

Canalicular function during acute herpetic keratoconjunctivitis was investigated in rabbits. Evidence of partial obstruction of the duct was obtained in the infected as compared with the mock-infected eyes. Direct damage of the ductal epithelium by virus could not be demonstrated by histologic and immunofluorescent studies. Our findings suggest that canalicular dysfunction associated with viral infection may result from accompanying inflammatory changes.

Intermedius nerve involvement and testing in acoustic neuromas

The clinical findings in 125 patients with surgically confirmed acoustic neuromas are presented, with special regard to the involvement of the intermedius nerve in the diagnosis. In assessing the function of the intermedius nerve the examination of the nasolacrimal reflex and the sensation of taste on the anterior two-thirds of the tongue are used. The methods of investigation are described in detail. The material consisted of 20 medium-sized and 105 large tumours; no intracanalicular tumor was found. Hearing loss was the initial symptom in 85% of the patients, 10% had tinitus and 4% vertigo as the first symptom. Apart from the VIII cranial nerve symptoms, a defective nasolacrimal reflex was the most significant evidence of cerebellopontine angle pathology. The test was positive in 65% of the medium-sized tumours, in the entire material, 85%. The figures are higher than the incidence of trigeminal nerve symptoms. This in contrast to the reports of most authors. The tests described are simple and quick to perform, and it is emphasized that they should be applied to all patients with unilateral hearing loss of unknown origin.