Are inflammation-related diseases risk factors for primary acquired nasolacrimal duct obstruction? A large scale, national case-control study

PURPOSE

To evaluate the incidence and risk factors for inflammatory conditions among patients with primary acquired nasolacrimal duct obstruction (PANDO).

METHODS

A retrospective case-control study was conducted among patients of Clalit Health Services (CHS) in Israel from 2001 to 2022. For each case, three controls were matched among all CHS patients according to year of birth, sex, and ethnicity. Differences in demographic characteristics, ocular surface, eyelid, upper airway, and systemic diseases were assessed between the groups, and odds ratios (OR) were calculated.

RESULTS

A total of 60,726 patients diagnosed with PANDO were included. The average age of PANDO patients was 63 ± 18 years, 63% were female. Significant associations were found between PANDO and various ocular surface and eyelid conditions, including chronic conjunctivitis (OR 2.96, 95% CI [2.73-3.20]), vernal keratoconjunctivitis (OR 2.89, 95% CI [2.45-3.29]), and blepharitis (OR 2.75, 95% CI [2.68-2.83]). There was a significant association with various upper airway conditions, including rhinitis (OR 1.62, 95% CI [1.58-1.66]), chronic sinusitis (OR 1.71, 95% CI [1.62-1.80]), and deviated nasal septum (OR 1.76, 95% CI [1.69-1.84]). Association was also observed with systemic conditions, including asthma (OR 1.34, 95% CI [1.27-1.41]) and atopic dermatitis (OR 1.36, 95% CI [1.32-1.41]).

CONCLUSION

Ocular surface, eyelid, upper airway, and systemic inflammatory-related diseases were found to be associated with PANDO, supporting the theory that inflammation has a prominent role in the pathophysiology of PANDO.

Early Endonasal Dacryocystorhinostomy for Acute Dacryocystitis: A Systematic Review and Meta-Analysis

OBJECTIVE

The aim of this meta-analysis is to compare the outcomes of early endonasal dacryocystorhinostomy (DCR) with delayed DCR in the treatment of acute dacryocystitis (AD).

METHODS

A comprehensive electronic search of PubMed, Embase, Web of Science, and the Cochrane Library databases was conducted up to November 11, 2023. Data synthesis was performed using Review Manager 5.4, and forest plots were generated for each outcome measure. Potential publication bias was assessed using funnel plots and Egger's test.

RESULTS

Six studies involving 288 patients were included in the meta-analysis. Overall, the success rate of early endonasal DCR was comparable to that in the delayed DCR group (odds ratio [OR] = 1.52, 95% confidence interval [CI]: 0.81-2.85, P = .19). Furthermore, in comparison with the delayed DCR group, early endonasal DCR significantly reduced the time for medial canthus swelling resolution (mean differences [MD] = -4.92, 95% CI: -5.46 to 4-.37, P < .00001) and complete resolution of symptoms (MD = -17.70, 95% CI: -23.88 to -11.52, P < .00001).

CONCLUSION

Primary early endonasal DCR seems to be a promising and favorable approach for managing AD with comparable efficacy and faster relief of symptoms compared to conventional delayed DCR.

Dynamic viscosity of the wall of the lacrimal sac in disorders of the patency of the lacrimal ducts

PURPOSE

To assess the dynamic viscosity of the lacrimal sac wall in patients with various origins of lacrimal duct obstruction.

METHODS

The study was performed in 35 cases: 21 cases with primary nasolacrimal duct obstruction (PANDO) and 14 cases with secondary nasolacrimal duct obstruction after radioiodine therapy (SALDO). The study of biomechanical properties of the lacrimal sac was carried out using a test bench. The principle of the study was to indent the sample at a given speed and record the data obtained from the sensor of the force transmitted to the sample. The area under the curve (AUC) and the peak viscosity were calculated. A qualitative characteristic of the obtained curve was given.

RESULTS

Median AUC in patients with PANDO was 17 × 106 [6 × 106; 19 × 106] N/m2 × s, in patients with SALDO 21 × 106 [13 × 106; 25 × 106] N/m2 × s. Intergroup differences were statistically significant (p = 0,048). The median peak viscosity in PANDO patients was 29 × 106 [25 × 106; 35 × 106] N/m2, in patients with SALDO 32 × 106 [21 × 106; 41 × 106] N/m2. The qualitative characteristics of the obtained curves differed.

CONCLUSION

Biomechanical properties of the lacrimal sac may vary depending on the cause of obliteration of the lacrimal ducts. The integrated dynamic viscosity is significantly higher in SALDO patients due to exposure to radioiodine compared to that in PANDO patients.

Is a bacterial biofilm in the lacrimal sac the cause of chronic refractory dacryocystitis? - A pilot study

PURPOSE

A pilot study to identify bacterial biofilm in the lacrimal sacs of patients with chronic dacryocystitis, and in patients with epiphora but without discharge, using scanning electron microscopy.

METHODS

Five patients: two with nasolacrimal duct obstruction without dacryocystitis, and three with dacryocystitis refractory to antibiotics, underwent external dacryocystorhinostomy. One control patient without infection was included. Bacterial cultures were obtained from the lumen of the lacrimal sac to analyze possible bacterial growth, including antibiotic resistance. Biopsies were taken from all lacrimal sacs and prepared for light and scanning electron microscopy.

RESULTS

Scanning electron microscopy of all the lacrimal sac samples revealed structures consistent with bacterial communities and adjacent extracellular material, indicating biofilm formation. This was most prominent in one of the patients with chronic dacryocystitis. Bacteria were found not only on the luminal surface of the sac, but also within the tissue of the sac. Bacterial growth was identified in samples from two patients with chronic dacryocystitis, whereas samples from the other three patients showed no bacterial growth.

CONCLUSION

Lack of patency of the lacrimal duct predisposes to bacterial growth, even in patients with no clinically confirmed infection of the lacrimal sac. The finding of a biofilm in patients with chronic dacryocystitis explains the lack of efficiency of antibiotic treatment at the concentrations used in clinical practice.

Surgeon Experience as Predictors of Outcome of Dacryocystorhinostomy Surgery

BACKGROUND

Dacryocystorhinostomy surgery aims to treat nasolacrimal duct obstruction and are often performed by general ophthalmologists in developing countries. The aim of this study is to estimate the clinical burden, surgeon's experience, and outcome of dacryocystorhinostomy surgery.

METHODS

A cross-sectional survey of Nepalese Ophthalmologists registered with the Nepal Ophthalmic Society was conducted after ethical clearance from Nepal Health Research Council. The survey form consisted of a single mail-shot questionnaire information including the age and experience, average case per month, and participant-reported post-operative complications and failures. Data were entered onto Microsoft excel (Microsoft Corp) and analyzed using SPSS 22.0. The data were presented in graphical and tabular format and appropriate statistical tools were employed for the analysis.

RESULTS

Out of 300 practicing ophthalmologist, 135 (45%) comprising male 60 (44.4%) and female 75(55.6%) responded to the survey. Majority of respondents were general ophthalmologists (37 ,41.6%) followed by oculoplastic surgeons (27,30.3%) and other subspecialties (25,28.1%). More than 70% respondents perform 1-10 surgeries /month and only 3% perform >50 surgeries /month. The success rate of 75-90% was reported by 45(50%) respondents whereas > 90% success rate by 41 (46.1%). More than 80% surgeons experienced an infection rate of <1% regardless of the intubation status.

CONCLUSIONS

This survey revealed huge differences in surgery practice patterns among ophthalmologists in Nepal. The surgical success rate and post-operative infection rate depends upon surgeon experience. Moreover, uniform surgery protocols and training budding ophthalmologists/ young Oculoplastic surgeons in the best modern dacryocystorhinostomy surgery are required.

Lacrimal gland activity in lacrimal drainage obstruction: exploring the potential cross-talk between the tear secretion and outflow

PURPOSE

To investigate the effects of lacrimal drainage obstructions on the lacrimal gland activity and if there exists a potential link between the two.

METHODS

Direct assessment of the lacrimal gland activity from the palpebral lobe was performed in consecutive patients diagnosed with unilateral primary acquired nasolacrimal duct obstruction (PANDO), along with Ocular Surface Disease Index (OSDI), non-invasive tear break up time (NIBUT; Oculus K5M), tear meniscus height and Schirmer I. The primary outcome measure was the difference in the tear flow rate between the eye with PANDO and the contralateral uninvolved eye.

RESULTS

Thirty patients (median age, 45.5 years; 25 females) with unilateral PANDO had epiphora for a mean duration of 20 months. The mean OSDI score was 6.3. NIBUT (mean 11.56 vs 11.58 s; p=0.49) and Schirmer I values (mean 18.83 vs 19.4 mm; p=0.313) were not significantly different between PANDO and non-PANDO eyes. The morphology of the palpebral lobe (size 29.3 vs 28.6 mm2, p=0.41) and the number of lacrimal ductular openings (median 2 vs 2.5) were similar between the two eyes. The mean tear flow from the lacrimal glands of the PANDO side was significantly reduced compared with the contralateral uninvolved side (0.8 vs 0.99 µL/min; p=0.014)).

CONCLUSION

Tear flow rate from palpebral lobes of patients with unilateral lacrimal outflow obstruction shows a significant reduction compared with the contralateral side. The potential ways of communications between the tear drainage and the tear production mechanisms need to be explored further.

Higher incidence of meibomian gland dysfunction in postmenopausal women with primary acquired nasolacrimal duct obstruction

PURPOSE

This study aimed to investigate the incidence of meibomian gland dysfunction (MGD) in postmenopausal women with primary acquired nasolacrimal duct obstruction (PANDO) and enables ophthalmologists to pay attention to ocular surface damage before surgery.

METHODS

165 postmenopausal women with PANDO and 115 postmenopausal women with a normal lacrimal drainage system were enrolled in this prospective study. Based on the results of lacrimal duct irrigation and age, the participants were further subdivided. The incidence of different severities of MGD in different groups was calculated and analyzed by the chi-squared test.

RESULTS

The incidence of MGD in the PANDO group was 81.21%, and in the control group, it was 46.96%, which was significantly higher in the presence of PANDO (p < 0.001). The incidence of severe MGD in the complete and incomplete PANDO groups was higher than that in the control group (all p < 0.05), and no significant differences were observed between the complete and incomplete PANDO groups. The incidence of moderate MGD was significantly higher in the complete PANDO group than in the control group (p < 0.001). When age was considered an independent variable, the results revealed a significant value for patients aged < 70 years (p < 0.001).

CONCLUSIONS

Our study revealed a prodominantly high incidence of MGD in postmenopausal women with PANDO, especially in a complete PANDO or aged < 70 years. Ophthalmologists need to pay close attention to MGD in postmenopausal women with PANDO.

Post-traumatic canalicular fistula: description and review of literature - SALDO update study (SUP) - paper II

PURPOSE

To discuss the clinical spectrum and management strategies in patients with post-traumatic canalicular fistula (PTCF).

METHODS

Retrospective, interventional case series of consecutive patients diagnosed with PTCF over a 6-year study period between June 2016 and June 2022. The demographics, mode of injury, location, and communication of the canalicular fistula were noted. The outcomes of several management modalities including dacryocystorhinostomy, lacrimal gland therapies, and conservative approaches were assessed.

RESULTS

Eleven cases with PTCF over the study period were included. The mean age at presentation was 23.5 years (range: 6-71 years), with male: female ratio of 8:3. The median time interval between trauma to presentation at the Dacryology clinic was 3 years (range: 1 week to 12 years). Seven had iatrogenic trauma and four had the canalicular fistula following primary trauma. Management modalities pursued include conservative approach for minimal symptoms, and dacryocystorhinostomy, dacryocystectomy, and lacrimal gland botulinum toxin injection. The mean follow-up period was 30 months (range: 3-months-6 years).

CONCLUSION

PTCF is a complex lacrimal condition and the management of the PTCF needs a tailored approach guided by its nature and location and patient symptomatology.

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.

Orbital Abscess Secondary to Nasolacrimal Duct Obstruction in an Extremely Preterm Infant

Orbital abscesses are rarely encountered in children younger than 1 year. The literature is limited to isolated case reports and a few case series. Most such cases are reported in infants born at term, with the earliest reported gestational birth age at 34 weeks. Children are more prone to orbital cellulitis compared with adults due to their underdeveloped sinuses and immature immune systems, and the origin is most commonly an ethmoid sinus infection. Orbital cellulitis secondary to dacryocystitis is even less common, with only a few isolated cases reported in infants and children. Herein, the authors present a case of a large extraconal and intraconal orbital abscess secondary to nasolacrimal duct obstruction and dacryocystitis in an extremely preterm infant. We discuss the diagnosis and multidisciplinary management of this challenging case.

Canalicular obstruction associated with dupilumab

PURPOSE

Dupilumab is a novel treatment for severe atopic dermatitis and is associated with a range of ocular complications such as blepharoconjunctivitis, keratitis, cicatricial ectropion and punctal stenosis.

METHODS

We report 4 patients with canalicular obstruction in association with dupilumab therapy, and we describe their treatment and outcomes in each case.

RESULTS

Canalicular obstruction was diagnosed by an oculoplastic consultant between 3 years and 3 months and 4 years and 9 months after the commencement of dupilumab therapy. Case 1 underwent nasolacrimal intubation, case 2 was treated conservatively, and case 4 underwent endonasal dacryocystorhinostomy and these patients' symptoms resolved. Unfortunately, in case 3 despite endonasal dacryocystorhinostomy with stenting they remained symptomatic.

CONCLUSION

This case series adds to the growing number of ocular complications associated with dupilumab therapy, and there is yet an optimal treatment strategy to mitigate these complications. It is possible that simple conservative measures such as discontinuation of dupilumab and topical treatments with steroids can eventually lead to some form of recovery and recanalisation of the canalicular system. Early referral to an ophthalmologist prior to the development of canalicular obstruction to control the inflammatory ocular surface could reduce the risks of cicatricial sequelae from dupilumab, and temporary stenting of the canalicular system could be attempted as a method to keep the canalicular system patent, whilst the patient remained on treatment.

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.

Spectrum of ocular disease in children aged between 0 and 3 years at an Australian paediatric tertiary hospital

BACKGROUND

Childhood ocular disease can be a significant health burden to the child, family and society. Previous studies have examined the spectrum of paediatric ocular disease presenting to tertiary hospitals; however, these studies have broader age ranges, smaller sample sizes, and are largely based in developing countries. This study aims to assess the spectrum of ocular disease in the first 3 years of life presenting to the eye department of an Australian tertiary paediatric hospital.

METHODS

The records of 3337 children who had their initial presentation at the eye clinic between the age of 0 and 36 months were reviewed, spanning 6.5 years from 1st July 2012 to 31st December 2018.

RESULTS

The most common primary diagnoses overall were strabismic amblyopia (6.0%), retinopathy of prematurity (5.0%) and nasolacrimal duct obstruction (4.5%). Bilateral visual impairment was more common in younger children, while unilateral visual impairment was more common in older children. The proportion of all children presenting with visual impairment was 10.3%, with 5.7% of all children presenting with bilateral visual impairment and 4.6% presenting with unilateral visual impairment. In children with visual impairment, the most common sites of primary abnormality were lens (21.4%), retina (17.3%), and cerebral and visual pathways (12.1%). The most common primary diagnoses in children with visual impairment were cataract (21.4%), strabismic amblyopia (9.3%) and retinoblastoma (6.5%).

CONCLUSIONS

The spectrum of eye disease and vision impairment presenting in the first 3 years of life facilitates health care planning, greater community education about vision impairment and importance of early intervention, and guidance for appropriate resource allocation. Health systems can apply these findings to aid in early identification and intervention to reduce preventable blindness and institute appropriate rehabilitation services.

Bilateral Nasolacrimal Duct Obstruction Managed With Probing and Irrigation in a Patient With FGF10-Associated Lacrimo-auriculo-dento-digital Syndrome

The authors report a case of lacrimo-auriculo-dento-digital syndrome in a 16-month-old boy with punctal agenesis, upper canalicular dysgenesis and polydactyly, presenting as bilateral congenital nasolacrimal duct obstruction and unilateral acute dacryocystitis. Genetic sequencing revealed a novel mutation in fibroblast growth factor 10. [J Pediatr Ophthalmol Strabismus. 2023;60(4):e38-e40.].

Incidence and distribution of ocular disorders in the first year of life

PURPOSE

To describe the incidence and distribution of eye diseases affecting children in the first year of life in Olmsted County, Minnesota.

METHODS

We conducted a population-based, retrospective medical record review of infants (≤1 year of age) residing in Olmsted County diagnosed with an ocular disorder from January 1, 2005, through December 31, 2014.

RESULTS

A total of 4,223 infants were diagnosed with an ocular disorder, yielding an incidence of 20,242/100,000 births per year, or 1 in 4.9 live births (95% CI, 19,632-20,853). The median age at diagnosis was 3 months, and 2,179 (51.5%) were female. The most common diagnoses included conjunctivitis, in 2,175 (51.5%), nasolacrimal duct obstruction, in 1,432 (33.6%), and pseudostrabismus, in 173 (4.1%). Visual acuity was decreased in one or both eyes in 23 (0.5%) infants because of strabismus in 10 (43.5%) and cerebral visual impairment in 3 (13.0%). A majority of the infants (3,674 [86.9%]) were diagnosed and managed by a primary care provider, and 549 (13.0%) were evaluated and/or managed by an eye care provider.

CONCLUSIONS

Although ocular disorders occurred in 1 in 5 infants in this cohort, most conditions were evaluated and managed by primary care providers. Understanding the incidence and distribution of ocular diseases among infants is useful for planning clinical resources.

Accuracy of the International Classification of Diseases, 9th Revision for Identifying Infantile Eye Disease

PURPOSE

To determine the predictive value of International Classification of Diseases, 9th Revision (ICD-9) codes for identifying infantile eye diagnoses.

METHODS

Population-based retrospective cohort study of all residents of Olmsted County, Minnesota diagnosed at ≤1 year of age with an ocular disorder. The medical records of all infants diagnosed with any ocular disorder from January 1, 2005, through December 31, 2014, were identified. To assess ICD-9 code accuracy, the medical records of all diagnoses with ≥20 cases were individually reviewed and compared to their corresponding ICD-9 codes. Main outcome measures included positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity of ICD-9 codes.

RESULTS

In a cohort of 5,109 infants with ≥1 eye-related ICD-9 code, 10 ocular diagnoses met study criteria. The most frequent diagnoses were conjunctivitis (N = 1,695) and congenital nasolacrimal duct obstruction (N = 1,250), while the least common was physiologic anisocoria (N = 23). The PPVs ranged from 8.3% to 88.0%, NPVs from 96.3% to 100%, sensitivity from 3.0% to 98.7%, and specificity from 72.6% to 99.9%. ICD-9 codes were most accurate at identifying physiologic anisocoria (PPV: 88.0%) and least accurate at identifying preseptal cellulitis (PPV: 8.3%). In eye specialists versus non-eye specialists, there was a significant difference in PPV of ICD-9 codes for conjunctivitis (26.8% vs. 63.9%, p < .001), pseudostrabismus (85.9% vs. 25.0%, p < .001), and physiologic anisocoria (95.5% vs. 33.3%, p = .002).

CONCLUSION

The predictive value of ICD-9 codes for capturing infantile ocular diagnoses varied widely in this cohort. These findings emphasize the limitations of database research methodologies that solely utilize claims data to identify pediatric eye diseases.Abbreviations/Acronyms PPV: positive predictive value; NPV: negative predictive value; CNLDO: congenital nasolacrimal duct obstruction.

Functional Versus Anatomical Nasolacrimal Obstruction: Are There Differences in Epiphora Severity, Symptoms, or Effects on Quality of Life?

PURPOSE

To elucidate whether the specific cause of nasolacrimal duct drainage impairment impacts the severity, symptoms, and implications on visual tasks and quality of life (QOL) in epiphora.

METHODS

A retrospective review of consecutive adult patients with epiphora attending a tertiary lacrimal clinic from June 2011 to March 2021 was conducted. Cases with evidence of canalicular stenosis, a mucocele, or other identifiable causes of epiphora were excluded. A structured interview assessed the epiphora severity (Munk), symptomatology, precipitating factors, and effects on visual tasks and QOL. Following lacrimal syringing, all eyes were investigated with dacryocystography and dacryoscintigraphy. The domains of the interview were compared between nasolacrimal duct obstruction (NLDO), stenosis (NLDS), and nonanatomical functional delay (FNLDO).

RESULTS

One hundred twenty-two symptomatic eyes (63 patients; mean age 63.3 ± 17.2 years; 59% females) were included. There was no difference in Munk score between the groups (NLDO = 3.71 ± 0.18, NLDS = 3.79 ± 2.0, FNLDO = 3.85 ± 0.15; p = 0.82). In all 3 groups, most cases had a Munk >2 (86.8%, 75.9%, and 89.1%, respectively; p = 0.25). Discharge was more common in NLDO (65.7%) compared with NLDS (30.0%) and FNLDO (36.4%, p = 0.006). Worsening in the cold/wind was more frequent in FNLDO (77.1%) compared with NLDO (48.5%, p = 0.029). Effects on visual tasks and QOL were not significantly different.

CONCLUSIONS

FNLDO patients experience a high severity of epiphora, comparable to patients with NLDS and those with complete NLDO. The distinction between FNLDO and NLDS had little consequence on reported symptoms, precipitating factors, visual tasks, and QOL. Discharge may be more specific to NLDO, whereas precipitating cold or wind is more specific to FNLDO.

Assessment of Perinatal Clinical Characteristics, Perinatal Risk Factors, and Microbial Profile in Congenital Nasolacrimal Duct Obstruction in a Tertiary Care Center: A Descriptive Study

Purpose

To assess the perinatal risk factors, clinical characteristics, and microbial profile in congenital nasolacrimal duct obstruction (CNLDO).

Methods

A prospective observational study was conducted in pediatric patients of age <5 years. After a thorough clinical evaluation, the diagnosis of the CNLDO was confirmed by a Jones dye test or fluorescein dye disappearance test. A microbiological culture of lacrimal sac resurge was done with a sterile swab stick without touching the lid margins. Antibiotic susceptibility was then performed for the standard antibiotics.

Results

Seventy-one eyes of 52 children were included in the study. The mean age was 3.4 months. Our research found an equal number of cases born via spontaneous vaginal delivery and Caesarean section. Nine children (17.3%) had associated systemic and ocular anomalies. The number of cultures that were positive for any growth was 19 (27%). The most common isolate was Streptococcus pneumoniae which constituted eight cases (42%), followed by Pseudomonas aeruginosa (15.8%), and Escherichia coli (10.5%). Other organisms that grew were Klebsiella pneumoniae, Staphylococcus aureus, Staphylococcus epidermidis and nonfermenting gram-negative bacilli. Gram-positive organisms were susceptible to ciprofloxacin, amoxiclav, and oxacillin, and most of them were resistant to erythromycin. In comparison, gram-negative organisms showed 62.5% resistance and 37.5% susceptibility to ciprofloxacin.

Conclusions

CNLDO was more commonly unilateral, in male, preterm, and normal birth weight infants. Bilateral CNLDO was more commonly associated with coexisting ocular or systemic anomalies. Prematurity, delivery by Caesarean section, and presence of congenital anomalies were associated with a prolonged course. S. pneumoniae was the predominant isolate in our patient population.

Acquired lacrimal fistula: classification and management

PURPOSE

To classify the acquired lacrimal fistulae (ALF) and assess the outcomes following surgical management.

METHODS

Retrospective, interventional study of all patients presenting with ALF over a 3.5-year period was performed. The fistulae were classified based on photographic evidence with respect to their location, size and nature. Primary outcome measures were complete healing of the fistulous opening and resolution of discharge or leakage from it. Secondary outcome measures were resolution of epiphora and patency of the lacrimal drainage system.

RESULTS

84 eyes of 82 patients who had acquired lacrimal fistulae were analysed. The mean duration of the fistulae presence was 10.12 months. The etiology of ALF was spontaneous following lacrimal abscess rupture in 79 eyes and was secondary to incision and drainage in the remaining 5 eyes. Thirty eyes had fistulectomy along with definitive surgery for the associated nasolacrimal duct obstruction (NLDO), 15 eyes underwent definitive surgery without an additional fistulectomy and 4 fistulae healed spontaneously prior to intervention for NLDO. The resolution of ALF did not differ in between those who underwent fistulectomy versus those who did not. The exceptions were 2 chronic large fistulae with cutaneous lining which needed a definite fistulectomy for resolution along with surgery for NLDO.

CONCLUSION

Most of the acquired fistulae heal by themselves irrespective of the nature, size and location and need no additional treatment in the form of fistulectomy. However, this is not true for those that are large and have a cutaneous lining.

A case of blepharophimosis: Freeman Sheldon syndrome

PURPOSE

Important implications exist for ophthalmologists when considering possible early surgical intervention for potential amblyogenic anatomical abnormalities. The authors discuss the risks and benefits from an ophthalmological perspective of different interventions and review the genetic testing that confirmed the diagnosis.

OBSERVATIONS

The authors describe the findings and management of an infant with Freeman Sheldon syndrome presenting with blepharophimosis of both eyelids resulting in inability to open both eyes during the first several days of life. Although the mode of inheritance for Freeman Sheldon syndrome (formerly known as Whistling Face Syndrome) is often autosomal dominant, our patient had no known family history of congenital abnormalities or consanguinity. However, genetic testing confirmed a heterozygous variant in MYH3, consistent with autosomal dominant Freeman Sheldon Syndrome. When our patient required gastrostomy (G-tube_placement, we performed an exam under anesthesia (EUA)). As is typical for Freeman Sheldon syndrome patients, intubation was difficult and complicated by pneumothorax. Eye-opening improved slightly after several weeks of life; however, the decision was made to proceed with eyelid surgery to prevent deprivation amblyopia. Surgery is scheduled for a future date. Additionally, the patient had congenital nasolacrimal duct obstruction of the left eye; however, a probing and irrigation failed because of obstruction from the abnormal facial anatomy.

CONCLUSIONS AND IMPORTANCE

Patients with Freeman Sheldon syndrome are at increased risk for complications from anesthesia and surgery. Risks and benefits should be strongly considered and discussed with parent(s)/guardian(s) prior to any surgical intervention. Genetic testing of the MYH3 gene can confirm the diagnosis.

Lymphoma of the Lacrimal Sac: The Massachusetts Eye and Ear Experience With a Comparison to the Previously Reported Literature

PURPOSE

To describe the frequency, clinical features, and histologic subtypes of biopsy proven lacrimal sac lymphomas, and to compare these results to the previously published literature.

METHODS

A retrospective chart review was performed at a single institution from 2004 to 2017. Pathology reports, operative notes, and patients' medical charts were reviewed.

RESULTS

Of 566 lacrimal sacs submitted for routine histopathologic evaluation, 16 cases of lymphoma were identified. All were low-grade, non-Hodgkin B-cell lymphomas, biopsied at an average age of 71 years. Thirteen patients (81.25%) had a pre-existing lymphoma diagnosis; the average interval between the diagnosis of systemic or nonocular adnexal lymphoma and lacrimal sac lymphoma was 7.9 years (range 2-26 years; median 5.5 years). Three cases of primary lacrimal sac lymphoma were identified. Histopathology showed 3 cases (18.75%) of follicular lymphoma, 3 (18.75%) of extranodal marginal zone lymphoma, and 10 (62.5%) of chronic lymphocytic leukemia/small lymphocytic lymphoma. Primary cases presented with epiphora and nasolacrimal duct obstruction, while secondary cases predominantly manifested as dacryocystitis. All lacrimal sac neoplasms were locally responsive (without local recurrence) to chemotherapy, radiation, or both.

CONCLUSIONS

Lacrimal sac lymphoma is uncommon but should be suspected among patients with known lymphoma who develop dacryocystitis. In this series, primary lacrimal sac lymphoma most often presented as a mass or nasolacrimal duct obstruction. Chronic lymphocytic leukemia/small lymphocytic lymphoma was the most commonly identified cause of secondary lacrimal sac lymphoma. Distinguishing primary from secondary lacrimal sac lymphomas is important, as the extent of disease and histopathologic subtypes differ, which may affect patient management.

Small Cell Neuroendocrine Carcinoma Presenting as Recurrent Dacryocystitis: Case Report of a Rare Entity

An 84-year-old man presented with a localized, firm, tender mass over the right lacrimal sac. He had a history of acute dacryocystitis in the same eye 6 months before presentation, which resolved with antibiotics followed by uneventful dacryocystorhinostomy. At repeat presentation, the patient underwent orbital imaging and excisional biopsy of the lesion. Histologic studies revealed a small cell neuroendocrine carcinoma. The patient was subsequently treated with chemotherapy and radiation. Although there are rare reports of small cell neuroendocrine carcinoma originating in the sino-orbital-lacrimal region, this is the first report of tumor presentation with acute dacryocystitis in a patient with prior dacryocystorhinostomy.

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.

Extension of Masses Involving the Lacrimal Sac to Above the Medial Canthal Tendon

PURPOSE

Retention mucoceles of the lacrimal sac almost always expand below the medial canthal tendon (MCT), whereas the very much rarer malignancies involving the lacrimal sac may progress to form a mass above the tendon. In this study, the incidence of malignancy was determined for patients with a preoperative decision to undergo biopsy for a clinically suspect, hard lacrimal sac mass, together with the proportion having a tumor extending above the MCT.

METHODS

Patients thought-on the basis of having a firm, immobile mass centered on the lacrimal sac fossa-to possibly have lacrimal sac malignancy were identified from a database of biopsies between 1989 and 2020. A retrospective review of their clinical, radiologic, and pathologic records was undertaken.

RESULTS

Fifty-three patients (24 male; 45%) underwent biopsy of atypical masses of the lacrimal sac, of which 47 of 53 (89%) extended above the MCT. Seventy-seven percent (41/53) patients had malignancy-26 primary carcinomas and 15 secondary tumors (14 lymphomas or hematopoietic and 1 neuroendocrine)-and 12 had benign conditions (6 transitional cell papillomatosis, 5 chronic inflammation, and 1 solitary fibrous tumor); all the benign pathologies extended above the MCT. The age at presentation and duration of symptoms was similar in patients with benign or malignant pathology. One-fifth of malignant lesions had pain, whereas all the benign conditions were painless, and acute dacryocystitis was relatively uncommon-occurring in only 13% of patients.

CONCLUSIONS

If a firm and immobile lacrimal sac mass extends above the MCT, it has about a 74% chance of being malignant and, if pain is present, the lesion is more likely to be so. Clinically suspicious masses in the lacrimal sac fossa, whether benign or malignant, appear to present at the same age and with a similar duration of symptoms.

Improvements in planning lacrimal surgery using DICOM Horos® viewer 3D images

INTRODUCTION AND OBJECTIVE

The individual anatomic variation of the course of the lacrimal duct and surrounding structures requires the thorough knowledge of its three-dimensional configuration in order to perform the surgery in the safest and most efficient way. The aim of this study was to consider virtual surgical planning in order to improve dacryocystorhinostomies.

METHODS

Horos® was used as a viewer and manager of DICOM-format images for multiplanar, three-dimensional (3D) reconstruction when planning 148 first-time lacrimal operations and 26 reoperations by laser endonasal and endocanalicular DCRs.

RESULTS

The 3D images of the CT dacryocystography were much better identified than the 2D ones, Horos® showing a statistically significant correlation (P < .0001). Over 98.27% of the images match the programme reconstruction. Less than 1.73% of them showed some discordance due to study distortion. These cases were related to trauma. The intraopearative location of the lacrimal system was very accurate, avoiding complications.

CONCLUSIONS

Viewing and studying 3D images, Horos® is a very useful tool for diagnosis and preoperative planning. It is very helpful in complex conditions by marking surgical references, locating the lacrimal sac and controlling the post-operative permeability of the lacrimal system. The information loss produced by the image selection is also avoided. Another great advantage is that the programme is free.

Stenotrophomonas maltophilia-Associated Dacryocystitis in Leukemia-Infiltrated Lacrimal Sacs: Case and Review of Literature

A 91-year-old female with a history of chronic lymphocytic leukemia developed recurrent bouts of bilateral dacryocystitis. She underwent incision and drainage of the lacrimal sac with culture demonstrating the rare bacteria Stenotrophomonas maltophilia. She underwent subsequent dacryocystectomy with biopsy revealing bilateral involvement of chronic lymphocytic leukemia in the lacrimal sac. Stenotrophomonas maltophilia has been associated with immune suppression and is rarely seen in dacryocystitis. Local and/or systemic immune deregulation or suppression may play a role in lacrimal sac infection with this bacterium in some patients.

Acute dacryocystitis retention syndrome due to Epstein-Barr virus

A 4 year-old boy with no previous history of eye or nasolacrimal disease was referred due to a painful mass on his left inner canthus, of three days onset, with no improvement in spite of oral antibiotics. On examination eyelid oedema with periocular hyperaemia was noted. Lacrimal sac palpation was painful and tonsillar exudation was reported. He was admitted and started on intravenous (iv) antibiotics. Four days later, lacrimal signs started to improve, but his general condition become worse. Head and neck Computed Tomography scan (CT scan) showed a left lacrimal sac enlargement, suggestive of acute dacryocystitis and swollen laterocervical lymph nodes. Epstein Barr Virus (EBV) serology and PCR testing were positive. The child responded well after eight days, and was discharged with oral antibiotics. Acute dacryocystic retention (ADR) associated with EBV was suspected. Six months later, the patient remained asymptomatic with no tearing or other lacrimal symptoms.

Primary Melanoma of the Lacrimal Sac Treated With Pembrolizumab

Primary melanoma of the lacrimal sac is a rare entity, with high mortality and a propensity for recurrence. This report details a patient with widely metastatic melanoma discovered after biopsy of abnormal lacrimal sac tissue during routine dacryocystorhinostomy. The patient subsequently underwent local excision and treatment with pembrolizumab. At the time of this writing, it has been 24 months since the original diagnosis with resolution of his lacrimal and orbital lesions and improvement in all metastatic lesions. This case highlights the growing use of cancer genomics and immunotherapeutic agents in orbital aspects of oncology and reinforces the role of a multidisciplinary approach in the treatment of such diseases.

Inverted Papilloma of the Orbit and Nasolacrimal System

PURPOSE

Periocular inverted papilloma (IP) is a rare, locally aggressive tumor with a propensity for recurrence and malignant transformation. Historically treated via wide excision, this study examines the characteristics and management of periocular IP, comparing those confined to the nasolacrimal system with those invading the orbit.

METHODS

An Institutional Review Board-approved, Health Insurance Portability and Accountability Act-compliant retrospective, comparative case series was conducted in patients with IP of the orbit or nasolacrimal system across 15 clinical sites.

RESULTS

Of 25 patients, 22 met inclusion criteria with 9 limited to the nasolacrimal system and 13 invading the orbit. Mean age was 60.4 years, 55% were women, all were unilateral. Mean follow-up was 48 months. Rates of smoking, dust and/or aerosol exposure, human papillomavirus (HPV) status, and inflammatory polyps were elevated compared to rates in the general population (45%, 18%, 18%, and 14%, respectively). Bony erosion on computed tomography scans was statistically significantly associated with orbit-invading IP (p = 0.002). Treatment involved all confined IP undergoing surgery alone while 39% of orbit-invading IP also received radiation therapy and/or chemotherapy (p = 0.054). Orbit-invading IP was more likely to be excised with wide margins than IP confined to the nasolacrimal system (85% vs. 22%, p = 0.007). Overall rates of malignancy, recurrence, and patient mortality from IP were found to be 27%, 23%, and 9%, respectively.

CONCLUSIONS

IP invading the orbit typically requires aggressive therapy, while IP confined to the nasolacrimal system may be treated more conservatively. Using risk factors, characteristics, and outcomes, a treatment algorithm was created to guide management.

Tear protein analysis in patients with primary acquired nasolacrimal duct obstruction treated with lacrimal passage intubation

PURPOSE

The pathophysiology of nasolacrimal duct obstruction (NLDO) may involve quantitative as well as qualitative changes in tears. We measured tear protein concentrations in patients with primary acquired NLDO and compared them with the tear proteins in healthy individuals and patients with dry eye disease.

STUDY DESIGN

Case-control study.

METHODS

Twenty-four patients diagnosed with primary acquired NLDO who underwent endoscopic lacrimal passage intubation were included in the study. Tear fluid was collected with Schirmer's test strips three times: before intubation, after intubation while the nasolacrimal tube was in place, and after extubation. At the same time, 24 age-matched normal controls and 24 patients with dry eye were selected from subjects whose tears were collected during the same study period. We measured the following components of tear fluid: total protein, lactoferrin, albumin, and interleukin 6 (IL-6) levels.

RESULTS

Total proteins and albumin levels in tears of the NLDO group were significantly lower than those of the control group (P < 0.001 and P = 0.014, respectively, Mann-Whitney U test). Total proteins, albumin, and lactoferrin levels were significantly increased after extubation of nasolacrimal tube (P < 0.001, P = 0.004, and P = 0.029, respectively, Wilcoxon matched-pairs signed-rank test). There were no statistically significant differences in total protein, albumin, lactoferrin and IL-6 levels between patients with NLDO after lacrimal passage extubation and controls.

CONCLUSIONS

Our study shows distinct differences in protein composition of tear fluid in NLDO eyes and demonstrates that these can be normalized by nasolacrimal tube placement.

Postoperative Quality of Life in Oculoplastic Patients

PURPOSE

To conduct a literature review on postoperative quality of life in oculoplastic patients.

METHODS

The authors conducted a database search to evaluate the evidence available for the change in quality of life after oculoplastic surgery.

RESULTS

There was a wide disparity of evidence available for different oculoplastic conditions. Certain conditions, such as nasolacrimal duct obstruction, were well-researched while other conditions, such as epiblepharon, had little to no research supporting improvement in quality of life after surgery. The scales used to measure quality of life displayed heterogeneity.

CONCLUSION

There is a lack of published evidence concerning postoperative quality of life in patients with certain oculoplastic conditions such as brow ptosis, entropion, ectropion, epiblepharon, and orbital wall fracture. There is a need to standardize the quality of life data collection tools and scoring systems to allow better comparison and scrutiny of the current literature.

Treatment outcomes after definitive radio(chemo)therapy for 17 lacrimal sac squamous cell carcinoma

OBJECTIVES

Tumors of the lacrimal sac are rare and life-threatening. Because of their rarity, no extensive clinical data on their management and prognosis exist. We investigated the application of definitive radiation therapy and its outcome in patients with lacrimal sac squamous cell carcinoma (LSSCC).

METHODS

We retrospectively studied 17 patients with LSSCC at a single institution between 2003 and 2017. All the patients were treated with definitive radiotherapy, and 11 patients were delivered with cisplatin-based chemotherapy. The patients' clinical records were reviewed for symptoms, pathological types, the volume and dosimetry of the tumors and their adjacent structures, radiation coverage of lymph node drainage areas, treatment outcomes, and complications from definitive radiotherapy.

RESULTS

Median follow-up was 38.9 months, and age at diagnosis was 48 years.The 2-year and 5-year overall survival, progression-free survival, locoregional control, and disease metastasis-free survival rates were 94.1 and 84.7%, 88.2 and 73.5%, 93.8%, 94.1, and 78.4%, respectively. A total dose of 6600-7000 cGy was prescribed to the tumor. Levels Ⅰb, Ⅶa, Ⅷ, and Ⅸ were covered with the clinical target volume regardless of lymph involvement. Acute Grade 3 radiation dermatitis occurred in seven patients (17.6%), but no acute Grade 4 or Grade 5 toxicity of any type occurred. Seven (41.2%, 7/17) of the treated eyes had moderated vision impairments; 17.6% (3/17) of patients developed cataracts, and glaucoma and radiation retinopathy were found in 5.9% (1/17) of patients.

CONCLUSIONS

Definitive radiotherapy could be a treatment option for those who refuse surgery or have unresectable LSSCC.

ADVANCES IN KNOWLEDGE

Radiation alone is a treatment option for LSSCC.

Periocular infantile hemangioma masquerading as dacryocele

A 2-month-old boy developed a protuberant, blue nodule inferomedial to the left medial canthus. It was unresponsive to oral and intramuscular antibiotics. After developing difficulty breathing, he was admitted, with the diagnosis of a dacryocele, and, after an inconclusive ultrasound, underwent probing and irrigation with nasal endoscopy. Intraoperatively, the lesion appeared discontinuous with the nasolacrimal system and could not be decompressed. Postoperative magnetic resonance imaging suggested a hemangioma or possible collapsed dacryocele. Doppler ultrasound confirmed a perinasolacrimal duct hemangioma. Systemic propranolol treatment was initiated.

Use of 3-dimensional printing in surgical exploration of a nasolacrimal duct obstruction in a dog

A 1.5-year-old spayed female English setter dog was presented because of mucopurulent discharge emanating from the left medial canthal region of 8-months duration despite medical management and repeated nasolacrimal flushing. Dacryocystorhinography demonstrated obstruction at the level of the lacrimal sac. Three-dimensional (3-D) modelling software was used to print a 3-D construct of the facial bones and a drill guide over the region of obstruction. The 3-D prints were sterilized and utilized during surgery to facilitate access to the lacrimal sac. The left lacrimal sac was identified, explored, and flushed. Patency was re-established, and the dog was asymptomatic 7 months after surgery.

[Endoscopic septoplasty as a stage of endonasal dacryocystorhinostomy]

Endoscopic endonasal dacryocystorhinostomy (EN-DCR) is a modern and effective method for the surgical treatment of distal part obstruction of lacrimal pathway. Unsuccessful outcome and dacryocystitis relapses may be associated with concomitant rhinological pathology. Deviation of the nasal septum in the surgical area can affect the operation and contribute to stenosis. Additional correction of the nasal septum is necessary to obtain free surgical approach to the lacrimal sac. Endoscopic septoplasty provides high-quality surgical approach to the lateral wall of the nasal cavity.

OBJECTIVE

To evaluate simultaneous endoscopic septoplasty when performing EN-DCR.

METHODS

A retrospective analysis patients clinical data was conducted who were operated at the ENT department of Pavlov First Saint Petersburg State Medical University between January 2014 and December 2019.

RESULTS

232 EN-DCR were performed in 212 patients (21 men, 191 women). The average age at the time of the operation was 54.3 years (range 19-87). Of the 212 people 192 underwent unilateral surgery, 20 - bilateral EN-DCR. Simultaneous endoscopic septoplasty was required in 36 (15.5%) cases.

CONCLUSION

Performing a simultaneous endoscopic septoplasty provides comfortable surgical access and contributes to the final successful outcome of EN-DCR.

A Rare Case of Nasolacrimal Duct Partial Obstruction After Extraction of an Impacted Maxillary Canine

The main complications of tooth extraction include jaw fracture, maxillary sinus damage, adjacent teeth damage, nerve damage, root fracture, infection, bleeding, and swelling. Despite the theoretical possibility that tooth extraction could result in nasolacrimal duct obstruction, to the best of our knowledge, no cases have yet been reported. In the present study, we describe a case in which the nasolacrimal duct was partially obstructed after extraction of an impacted maxillary canine, causing paranasal discomfort and lower eyelid swelling.

[Meatoplasty - an effective method for surgical treatment of patients with nasolacrimal duct ostium stenosis]

The authors proposed a novel approach to the surgical correction of distal nasolacrimal duct stenosis - the meatoplasty of the nasolacrimal duct.

AIM

To evaluate the effectiveness of the developed surgical technique in cases of nasolacrimal duct ostium stenosis.

METHODS

78 patients (90 cases) with nasolacrimal duct stenosis at the level of it's ostium were included and divided into three comparable groups depending on the type of performed surgery: - the meatoplasty of the nasolacrimal duct in group 1, the meatoplasty with concomitant recanalization and bicanalicular silicone intubation of nasolacrimal duct by Ritleng in group 2 and recanalization with bicanalicular silicone intubation of nasolacrimal duct by Ritleng in group 3. A comparative analysis of the surgical treatment effectiveness of the patients of three groups was carried out.

RESULTS

The best effectiveness of treatment was noted in group 2 (positive outcomes in 90.0% of cases). The positive outcomes were obtained in 76.7% of cases in group 1 and in 66.7% of cases in group 3.

CONCLUSION

The developed surgical technique of meatoplasty with concomitant recanalization and bicanalicular silicone intubation of nasolacrimal duct is a highly-efficient and safe minimally invasive method for treatment of nasolacrimal duct ostium stenosis and it can be recommended in a wide clinical practice.

Silicone Tubing after Endoscopic Dacryocystorhinostomy: Is it Necessary?

Background

Endoscopic dacryocystorhinostomy (EN-DCR) is increasing in popularity as a treatment of nasolacrimal obstructions because it has proven to be an effective and safe procedure. In this study the success of EN-DCR combined with or without bicanalicular silicone stents was evaluated in patients with nasolacrimal obstructions.

Methods

Forty-two consecutive EN-DCR procedures were performed in 36 patients during 2000–2004. The surgery was primary in 23 cases and revision in 19 cases. Bicanalicular silicone stents were inserted in 18 cases and in 24 cases stenting was avoided.

Results

The overall success rate after EN-DCR was 81%. The success rate of EN-DCR was 89% with silicone tubing and 75% without silicone tubing. The mean duration of postoperative follow-up was 4 months.

Conclusion

In our retrospective study no significant statistical differences were seen between the patients with stenting compared with patients without stenting. However, prospective, randomized studies are clearly needed to answer the question of whether the use of stents is advisable.

Endoscopically assisted Balloon Dacryocystoplasty and Silicone Intubation versus Silicone Intubation Alone in Adults with Incomplete Nasolacrimal Duct Obstruction

PURPOSE

To compare the success rate of endoscopically assisted balloon dacryocystoplasty (DCP) and silicone intubation (DCP-SI) with endoscopically assisted silicone intubation alone (SI) in adults with incomplete nasolacrimal duct (NLD) obstruction. METHODS. In a retrospective nonrandomized comparative case series, 62 eyes of 55 adult patients with incomplete NLD obstruction underwent endoscopic probing and either SI (n=39 eyes) or DCP-SI (n=23 eyes) under general anesthesia. The last follow-up examination included diagnostic probing and irrigation if there was not success. Success was defined as disappearance of the symptoms and failure as partial improvement or absence of improvement at last follow-up.

RESULTS

Patients ranged from 20 to 85 years of age (mean: 60.93, SD: 15.60). Tubes were removed between 6 and 20 weeks (mean: 7.49, SD: 2.25) postoperatively. Follow-up ranged from 6 to 63 months (mean: 14.60, SD: 10.33). Success rate of the eyes with SI (21/39, 53.84%) and DCP-SI (14/23, 60.86%) were not statistically different (p=0.60). Complications included slight nasal and canalicular bleeding in almost all eyes in both groups which was easily controlled, slit punctum in four eyes with bicanalicular intubation (4/50, 8%), and monocanalicular tube lost in three eyes prematurely.

CONCLUSIONS

Success rate of endoscopic DCP-SI had no statistically significant difference from silicone intubation alone in treatment of incomplete NLD obstruction in adults.

Study of microbial growth on silicone tubes after transcanalicular laser-assisted dacryocystorhinostomy and correlation with patency

INTRODUCTION

Intubation in primary transcanalicular laser assisted dacryocystorhinostomy (TCLADCR) is performed to increase the success rates. However, the associated inflammation and infection can have adverse effects.

OBJECTIVE

To study the microbial infection and drug susceptibility of extubated silicone tubes and final anatomical patency in patients undergoing TCLADCR.

MATERIALS AND METHODS

A non-randomised prospective interventional study was conducted in a tertiary care eye centre. The study included twenty consecutive adult patients with primary nasolacrimal duct obstruction. They underwent TCLADCR with bicanalicular silicone intubation. The stents were removed at 2 months and subjected to culture sensitivity, followed by administration of appropriate antimicrobial agents. Main outcome measures studied were the microbial spectrum on the cultured tubes, their sensitivity profile and its correlation with final anatomical patency.

RESULTS

A positive culture was obtained in 100% cases, comprising of normal commensals and pathogenic organisms. Of the total 24 isolates, 16 (66.6%) Gram positive bacteria (75% Staphylococcus aureus) and 8 (33.3%) Gram negative bacteria (commonest E.coli) were found, with 4 tubes having more than one isolate. No fungal growth was seen. Ninety percent success rate was achieved at one year following appropriate antimicrobial therapy except in 2 patients with gram negative isolates who had failed to take the prescribed antibiotics following sensitivity reports. There was no correlation between multiple infections and success rate. However, by using the Fisher exact test, a positive correlation was obtained between appropriate antibiotic treatment and the final anatomical patency (p less than 0.05).

CONCLUSION

Silicone intubation predisposes to microbial growth, which if neglected, can lead to failure of TCLADCR.

Medical Devices; Ophthalmic Devices; Classification of Nasolacrimal Compression Device. Final order

The Food and Drug Administration (FDA) is classifying the nasolacrimal compression device into class I (general controls). The Agency is classifying the device into class I (general controls) in order to provide a reasonable assurance of safety and effectiveness of the device.

[Congenital lacrimonasal duct cyst: Do not forget this radiological and clinical entity]

Although obstruction of the lacrimonasal duct is a fairly common finding in newborns, development of a dacryocystocele (nasolacrimal duct cyst) is uncommon and is caused by stenosis in the proximal and distal area of the nasolacrimal duct leading to a cystic dilatation. Its diagnosis remains difficult for the pediatrician, the ENT specialist, the ophthalmologist, and the radiologist. The study of six cases of dacryocystocele and the review of the literature led the authors to describe the clinical and radiological features of this uncommon entity. The symptomatology includes nasal obstruction and, when bilateral, significant respiratory distress in the newborn (obligate nose-breather) and dilatation of the lacrimal duct with blue cystic swelling inferior to the medial canthus or with an inflammatory aspect of the lacrimal duct in case of infection. A careful endoscopic examination of the nasal cavities and CT or MRI imaging reveals a cystic tumor, which arises in the inferior meatus, inferolateral to the inferior turbinate, and can partly or completely obstruct the endonasal space, uni- or bilaterally. CT and MRI are equally sensitive in detecting dacryocystocele and are also useful for differential diagnosis for other cystic or tumoral nasal lesions such as meningoencephalocele, dermoid cyst, and glioma. To avoid the risk of potential complications (respiratory distress or even sudden infant death, infectious ophthalmologic complications), this radiological and clinical entity should not be forgotten. Endoscopic marsupialization leads to immediate and definitive healing recovery.

The Frequency of Concomitant Adjunctive Nasal Procedures in Powered Endoscopic Dacryocystorhinostomy

PURPOSE

To assess the frequency of concomitant adjunctive nasal procedures performed in powered endoscopic dacryocystorhinostomy (DCR).

METHODS

Retrospective review of 269 consecutive powered endoscopic DCR's performed in 202 patients over a period of 10 years from 2003 to 2013. Patient records were reviewed for demographic data, clinical profiles and surgical notes. Concomitant adjunctive procedures were studied with relation to number of patients, indications, types of procedures (septoplasty, middle turbinoplasty and functional endoscopic sinus surgery or FESS) and complications.

RESULTS

269 powered endoscopic DCR's were performed on 202 patients. The mean age at surgery was 58.4 years (range 20-91 years). Adjunctive nasal procedures were performed in 53.4% (108/202) of the patients. 47% (95/202) required a septoplasty. Among the 95 septoplasty patients, 85 required solo septoplasty and 10 had additional sinus procedure. Middle turbinoplasty was performed in 5.9% (12/202) and septal papilloma excision was performed in 0.49% (1/202). No additional morbidity was noticed with adjunctive procedures. Successful outcomes of DCR were achieved in 96.5% of patients.

CONCLUSION

Simultaneous adjunctive nasal procedures were commonly required with powered endoscopic DCR. Septoplasty and middle turbinoplasty when performed as needed, provides an additional access to lacrimal region and may facilitate successful outcomes.

Early Experience with the StopLoss Jones Tube

PURPOSE

Extrusion is the most common reason for failure after Jones tube placement. The StopLoss Jones tube (SLJT) is a new innovation in Jones tubes that incorporates a flexible silicone internal flange to resist extrusion. We present our early experience of using this new tube and associated introducer system.

METHODS

We retrospectively analysed the case notes of a single surgeon consecutive series of patients having SLJT placement from November 2011 to November 2013.

RESULTS

29 SLJTs were placed in 25 eyes of 19 patients. Tube follow-up ranged from 1-25 months (mean 10 months) with a total of 291 tube-months. The indications for SLJT placement were: previous LJT complications (52%), failed canalicular-DCR surgery (31%), primary placement for inoperable canalicular occlusion (14%) and patent non-functioning DCR (3%). Tube length ranged from 10-16 mm. The tube introducer system was simple and effective and there were no intra-operative complications. The tube extrusion rate was 0%. Complications occurred in 5 tubes: 1 was too long, and 4 others (14%) developed conjunctival overgrowth/medial tube migration. Patient satisfaction with the tube was: 86% fully satisfied, 10% was moderately satisfied, 3% not satisfied. The overall final surgical success rate at last follow-up was 92%.

CONCLUSIONS

In this short follow-up initial study the SLJT is simple to use and has a high rate of success and patient satisfaction. The addition of the internal silicone flange appears to prevent the previously common problem of extrusion.