Alsoudi, Amer; Copperman, Thomas S.; Idowu, Oluwatobi O.; Kersten, Robert C.
A 68-year-old man with known history of IgG4-related disease presented with a 1-year history of mucoid discharge OD and progressive proptosis OS. MRI showed diffuse enlargement of the left lacrimal gland along with prolonged infiltrative changes involving the left extraocular muscles, supraorbital nerve, and infraorbital nerve. No identifiable masses were noted in either nasolacrimal drainage system on MRI. Due to clinical evidence of nasolacrimal duct obstruction, a right external dacryocystorhinostomy was performed along with biopsies of the right lacrimal sac and left lacrimal gland. Immunohistochemical stains identified IgG4-positive plasma cells in the biopsy of the right lacrimal sac indicative of secondary acquired nasolacrimal duct obstruction despite the absence of mass forming lesions on exam and nasolacrimal imaging. This report is the first to describe nasolacrimal drainage system IgG4-related ophthalmic disease involvement in an otherwise clinically and radiographically normal appearing tear drainage system.
Rajabi, Mohammad Taher; Inanloo, Bahman; Salabati, Mirataollah; Rafizadeh, Mohsen; Tabatabaie, Seyed Ziaeddin; Bayat, Reza; Mahmoudzadeh, Raziyeh
Purpose: To evaluate the effect of inferior turbinate fracture in the treatment of congenital nasolacrimal obstruction combined with first attempt probing in children younger than 36 months.
Methods: This prospective case–control study was conducted on 230 eyes from 176 children aged 12 to 36 months with congenital nasolacrimal duct obstruction. All patients underwent simple probing under general anesthesia. Inferior turbinate fracture was performed in case group combined with first probing. Patients were followed up 1, 3, and 6 months after surgery.
Results: Total success rate was 91.2% for patients with turbinate fracture and 86.4% for patients without turbinate fracture. The difference between success rates was not statistically significant (p = 0.269). The authors did not find significant difference between cases and controls in age subgroups. Success rate in combined case and control groups in patients younger than 24 months (success rate: 91.7%) was significantly higher than those older than 24 months (success rate: 71.9%; p = 0.001). In univariate logistic regression analysis, age ≥24 months showed a negative association with the success rate (odds ratio = 0.232; 95% confidence interval: 0.91–0.59; p = 0.002). Other factors like sex, bilaterality of nasolacrimal duct obstruction, method of probing were not significantly associated with response to treatment.
Conclusions: Inferior turbinate fracture does not improve the outcomes of simple probing and is not recommended during the first attempt in treatment of congenital nasolacrimal duct obstruction. Late probing (after 24 months of age) may have a higher failure rate, and increased age is the important factor that predicts failure in probing simple congenital nasolacrimal duct obstruction.
Satchi, Khami; McNab, Alan A.
Purpose: Acquired lacrimal canalicular obstruction has a variety of causes. In a small proportion of patients, no cause can be identified. This article describes a cohort of 27 patients with idiopathic acquired lacrimal canalicular obstruction encountered over a 28-year period.
Methods: The diagnostic database of the senior author was analyzed to identify all cases of idiopathic acquired lacrimal canalicular obstruction seen from 1990 to 2017. Demographic, clinical, and treatment details were analyzed. Patients with primary lacrimal punctal stenosis or closure were excluded from the analysis.
Results: The authors encountered 27 patients with idiopathic acquired lacrimal canalicular obstruction (17 female, 63%) aged 34 to 91 years (median: 65 years). The level of canalicular obstruction ranged from 1 to 10 mm from the punctum. Canalicular obstruction involved 1 canaliculus in 4 patients, 2 in 14 (ipsilateral in all except one), 3 in 3, and all 4 in 6. One patient who presented with ipsilateral upper and lower canalicular obstructions developed contralateral upper and lower obstructions several years later, and another patient redeveloped obstructions after initial successful surgical repair. In all cases, there were no features on history or examination to suggest a cause for the canalicular obstruction. Follow up ranged from 1 to 260 months (mean: 39 months). Sixteen patients underwent surgical repair, 11 with a dacryocystorhinostomy and placement of a Lester Jones glass bypass tube, 2 had a canaliculo-dacryocystorhinostomy (anastomosis of the canaliculus to the nose), 2 had dacryocystorhinostomy and trephination of the canalicular obstruction with silicone intubation, and 1 had a dacryocystorhinostomy alone to try and improve drainage through a single patent canaliculus.
Conclusion: Idiopathic acquired lacrimal canalicular obstruction is uncommon and occurs more frequently in older women. The condition may be slowly progressive and can affect one or more canaliculi at any level. Treatment is the same as for any other cause of acquired lacrimal canalicular obstruction.
Stewart, Christopher M.; Luthert, Philip J.; Rose, Geoffrey E.
Purpose: To review the histological findings in the lacrimal sac and nasal mucosa from patients with sarcoidosis undergoing external lacrimal drainage surgery.
Methods: All patients undergoing external dacryocystorhinostomy at Moorfields Eye Hospital with a known history of sarcoidosis had biopsies taken from the lacrimal sac and/or nasal mucosa during surgery. These patients were identified from databases at Moorfields Eye Hospital and the Institute of Ophthalmology, and their clinical notes were reviewed retrospectively for intraoperative findings with a view to identifying common trends. The histological findings of each biopsy were reviewed and classified as showing granulomas, nongranulomatous inflammation, or nonspecific fibrosis.
Results: Forty patients (29 females; 72%) were known to have systemic sarcoidosis prior to surgery, and they underwent 60 external dacryocystorhinostomies. Paired histological samples were available from 49/60 (82%) procedures, nasal biopsies alone in 3 dacryocystorhinostomies (5%), and solely lacrimal sac biopsies in 8 (13%). The main site of systemic sarcoidosis was pulmonary involvement (19 patients; 48%). Recorded operative findings included 9 large lacrimal sac mucoceles (29%), a “thick” (26%) or “inflamed” (9.7%) lacrimal sac mucosa, and “thick” (36%) or “friable” (32%) nasal mucosa. Noncaseating granulomas were identified in 34/57 (60%) sacs, and 45/52 (87%) nasal tissues—this being in 31/49 (63%) of paired tissues. Chronic inflammation, without granulomas, was present in 20/57 (35%) lacrimal sacs but only in 5/52 (9.6%) of nasal biopsies.
Conclusions: In patients with sarcoidosis undergoing external dacryocystorhinostomy, the characteristic histological feature—noncaseating granulomas—is present in most patients’ lacrimal sac mucosa and in almost all of their nasal mucosae. The lacrimal sac and nasal mucosa often appears abnormal—thickened or friable—during surgery.
Lemaitre, Stéphanie; Sarandeses Diez, Teresa; Gonzalez-Candial, Miguel
A 16-year-old girl diagnosed with velocardiofacial syndrome complained of occasional bilateral ocular discharge. Examination revealed an agenesia of the inferior puncti and canaliculi, while the irrigation through the superior puncta was patent on both sides. Dacryocystorhinostomy with insertion of Lester Jones tubes is not considered for the time being because of the absence of epiphora. To the best of the authors’ knowledge, this is the second reported case of lacrimal system agenesia in velocardiofacial syndrome.
Tran, Jeffrey; Allen, Richard C.
Agenesis of the lacrimal and salivary glands is an autosomal dominant disorder associated with mutations in the fibroblast growth factor 10 (FGF10) gene. Agenesis of lacrimal and salivary glands has variable expressivity, and the clinical findings include both lacrimal outflow abnormalities and aplasia or hypoplasia of the parotid, submandibular, sublingual, and lacrimal glands. From the absence of lacrimal glands, patients may present with ocular irritation and recurrent eye infections. Patients with nasolacrimal duct obstruction may also note increased ocular irritation and discharge, which is optimally treated with dacryocystectomy. The authors’ patient is a 30-year-old male who presented with a chief complaint of bilateral “blocked tear ducts.” Palpation of the lacrimal sac demonstrated dacryocystocele with reflux bilaterally. A coronal view (Fig. 1A) and axial view (Fig. 1B) of the patient’s computed tomography maxillofacial demonstrates bilateral dacryocystoceles without intranasal cysts (blue arrows) and absence of both lacrimal glands (yellow arrows). Absence of the paLrotid glands (red arrows) and teeth (green arrows) can be seen in Figure 2A. The parotid gland is normally seen as a hypoattenuating region surrounding the muscle of mastication, and the absence of the parotid gland can be appreciated by the homogenous appearance of the soft tissues surrounding the mandible. The absence of the salivary glands can lead to dental caries, dental erosions, and loss of dentition, which can be further seen in the 3-dimensional rendering of the computed tomography scan (Fig. 2B).
Bothra, Nandini; Nayak, Arpita; Ali, Mohammad Javed
A 32-year-old male presented with a history of swelling in the right lacrimal sac region extending into the medial orbital region (Fig. A) of 18 months duration. He was a known case of fungal sinusitis (Aspergillus) and had undergone functional endoscopic sinus surgery 3 years ago with a suboptimal response. Subsequently, he had undergone a right external dacryocystorhinostomy (DCR) elsewhere 3 years ago. Endoscopic evaluation showed retained discharge with focal whitish lesions within the sinuses suggestive of a severe maxillary and ethmoid sinusitis. Dacryocystorhinostomy ostium was filled with a similar whitish lesion with discharge in the vicinity (Fig. B). CT scan of the orbits showed bilateral sinusitis involving the ethmoid, maxillary, and partly frontal sinuses with isodense mass lesion extending into the medial orbit through the DCR ostium and displacing the globe temporally (Fig. C,D). Biopsy of the sinus lesions, ostium cicatrix, and orbital lesion were similar on histopathology, which showed epitheloid granulomas formed of multinucleated giant cells, epitheloid histiocytes, and lymphoplasmacytic cells (Fig. E). Gomori methanamine stains showed the presence of fungal filaments (Fig. F). Because the orbital lesion was displacing the globe, it was debulked along with a concurrent treatment for fungal sinusitis.
It is a likely possibility that preexisting fungal sinusitis followed by DCR allowed the fungus to spread to the orbit through the bony ostium. Therefore, any preexisting sinusitis especially of fungal origin should be well treated before advising a lacrimal bypass procedure.
Kapoor, Anasua Ganguly; Mishra, Dilip; VS, Vijitha; Ali, Mohammad Javed
Giant dacryoceles with proximal lacrimal agenesis is an uncommon entity. A 51-year-old male presented with a painless mass arising from the medial aspect of the OD which has been slowly progressive since childhood. There was no associated epiphora. Examination revealed a large cystic lesion involving the right lacrimal sac region and was obstructing the visual axis (Fig. 1A). All the four puncta were absent, and the canalicular area showed atrophic changes (Fig. 1B,C). Clinically, there was no evidence of any lacrimal gland in the superotemporal fornix (Fig. 1D,E). Best corrected visual acuity was 20/20 OU with normal ocular findings. CT showed giant right dacryo cele involving the lacrimal sac region and extending along the length of the nasolacrimal duct to the inferior meatus of the nose with complete absence of lacrimal glands on both sides (Fig. 1F). Patient was treated with right dacryocystectomy. Intraoperatively a giant sac (Fig. 2A), dilatation of bony nasolacrimal duct opening (Fig. 2B), and absence of canalicular opening of the sac were noted. Histopathology showed wide and irregular lumen lined by pseudostratified columnar epithelium with goblet cells (Fig. 2C,D). Bilateral dacryocele with punctal and canalicular agenesis and alacrimia form a part of lacrimo-auricular-dento-digital syndrome or Levy Hollister syndrome. However, the patient did not have any other abnormality and hence could either represent an isolated anomaly involving the entire lacrimal system or a forme-fruste variant of the lacrimo-auricular-dento-digital syndrome. He did not have dry mouth ruling out the diagnosis of aplasia of lacrimal and major salivary glands in this case.
Swati Singh, Akshay Gopinathan Nair, Md Shahid Alam, Bipasha Mukherjee
PURPOSE: The purpose of this study is to assess the outcomes of lacrimal gland injections of botulinum toxin A (BoNTA) for epiphora secondary to lacrimal drainage disorders and functional epiphora. METHODS: This was a retrospective interventional case series where cases were divided into functional and nonfunctional epiphora. RESULTS: A total of 37 eyes of 31 patients were identified: 13 males and 18 females. The mean age was 52 years (median = 53, range 29–86). The functional epiphora group had seven patients (8 eyes), subcategorized into hypersecretion (5), crocodile tears (1), and post seventh nerve palsy (1). Obstructive group (nonfunctional) had 24 patients (29 eyes), subcategorized into proximal canalicular block (12), common canalicular block (6), punctal stenosis (3), posttraumatic nasolacrimal duct obstruction (1), and partial nasolacrimal duct obstruction (1). Median preinjection Munk scores were similar in both groups (Grade 4). At 1 month, the median Munk score improved to 1 and 2 in functional and nonfunctional groups, respectively, after receiving a median dose of 4 units of BoNTA. Median reduction in Munk score was 75% in functional group versus 50% in nonfunctional group (P = 0.07). No difference in terms of complications was noted (transient ptosis). CONCLUSIONS: Reduction in epiphora after lacrimal gland injection of botulinum toxin is seen in cases with functional epiphora as well as those with a physical obstruction in the lacrimal drainage pathway. While the symptomatic improvement was more in functional epiphora, the difference between the two groups was not statistically significant.
Pradhnya Sen, MS; Elesh Jain, DOMS, DNB; Amit Mohan, MS; Amit Kumar, MD
To assess the success rate of external dacryocystorhinostomy (DCR) with silicone intubation for recurrent lacrimal abscess in children younger than 6 years.
A single-center retrospective analysis of 46 eyes of 40 children who underwent DCR with silicone tube intubation for recurrent lacrimal abscess was done. Probing done previously in these cases was unsuccessful. Only those children who underwent incision and drainage of the abscess at least once with antibiotic treatment were included in the study. In all cases, silicone tube removal was done after 3 months. A successful outcome was defined as the absence of subjective complaints of pain and swelling over the medial canthal area and watering and discharge at 6 months postoperatively. Objective assessment of patency of the lacrimal apparatus was done by sac syringing at 6 months postoperatively.
The mean age at surgery was 4.93 ± 0.93 years (range: 3 to 6 years) and the mean follow-up duration was 11.80 ± 11.87 months (range: 6 to 84 months). Intra-operative difficulties encountered were excessive perisac adhesion (n = 28) and severe bleeding/hemorrhage (n = 24). A total of 82.61% cases had a successful outcome after DCR with silicon tube intubation. One child had granuloma formation at the wound. Spontaneous tube extrusion occurred in three children.
DCR with silicone tube intubation is a safe and effective surgical approach with satisfactory outcomes for treating recurrent lacrimal abscess with congenital nasolacrimal duct obstruction in children younger than 6 years.