Charles, Norman C.; Hoda, Syed T.; Patel, Payal; Kim, Eleanore T.; Belinsky, Irina
A 72-year-old woman who presented with right-sided epiphora and conjunctivitis underwent a probing and irrigation procedure with normal results. She improved with antibiotic-steroid drops. A swelling in the medial canthal region completely resolved. One year later, she returned with symptoms of dacryocystitis. An external dacryocystorhinostomy was performed. Characteristic dacryoliths were removed from the sac lumen, and biopsy of the sac wall showed spicules of lamellar bone within a fibrous stroma. Diagnosed as fibrous dysplasia of the lacrimal sac, this rare entity represents the second such case in the literature.
The histopathology of an ossified lacrimal sac resembled fibrous dysplasia of bone and exemplifies the second case of this rare entity in the literature.
Varajini Joganathan, Bhupendra C. K. Patel, Raman Malhotra & Jonathan H. Norris
‘Kissing puncta’ (KP) or punctal apposition is an anatomical phenomenon sparsely reported in the English literature. We describe our experience of managing chronic epiphora in patients with punctal apposition.
A retrospective audit of five patients (nine eyes) with KP associated with epiphora. Data including: presenting symptoms, physical signs and surgical outcomes were collected.
Five patients aged between 66 and 77 years were reviewed. Common clinical features were: chronic epiphora, involutional eyelid laxity, kissing puncta (present at all phases of the blink) and reduced upper and lower margin-reflex distances. Medial upper eyelid ptosis with orbital fat prolapse was a prominent feature.
Four patients (nine eyes underwent eyelid-tightening surgery to restore normal anatomical position of the puncta. Only one of the four patients achieved improvement in epiphora at 3 months. One patient with continued epiphora underwent subsequent dacrocystorhinostomy with improvement in symptoms. The fifth patient had mild laxity and underwent dacrocystorhinostomy at first instance, with no improvement in symptoms, despite surgical success.
The KP sign is commonly found in those with involutional eyelid changes. Epiphora is present in variable degrees in the presence of punctal apposition. Restoration of normal punctal position with eyelid-tightening surgery does not always confer an improvement in epiphora. Surgical management in the setting of KP is therefore challenging with a guarded prognosis. Symptomatic patients with KP should be counselled accordingly.
Michel J. Belliveau, MD, FRCSC
To the Editor:
Tooley and colleagues1 have shared their experience with dacryocystorhinostomy (DCR) in an elderly population. Surgical outcomes and complications were reported for 32 patients aged ≥80 years. Postoperative resolution of symptoms was less than that seen in a younger cohort (64% vs 86%; P = 0.02). A higher rate of serious complications was reported in the elderly group, although common postoperative issues were not more frequent.
The authors have overlooked the seminal work on this subject in their discussion. Hurwitz et al2 reported on the outcomes of lacrimal surgery in patients aged 70 to 90 years. They reviewed 120 patients who underwent primary (including cases of canaliculo-DCR and DCR with Jones tube) or revision DCR over a 1-year period (30% of all DCR surgeries in their center). Complete symptomatic relief was achieved in 91% of patients. Of the 120 patients, 1 was admitted overnight for observation of intraoperative nosebleed and 2 were observed overnight because of perioperative dysrhythmia. Five patients with a history of cardiac disease and anticipated postoperative hospital admission were deemed fit for discharge on the day of surgery. Of the 120 patients, 17 were aged 81 to 90 years. All patients in this older group had surgery performed under intravenous neuroleptic anesthesia.
Both studies1,2 are important to consider given the vast difference in reported success in groups of similar age (≥80 years1 vs 70–90 years2).
Ben Limbu, Sulaxmi Katwal, Nicole S. Lim, Michelle L. Faierman, Anna G. Gushchin & Rohit Saiju
We determine whether age is a prognostic factor for surgical outcomes of external dacryocystorhinostomy (Ex-DCR). This retrospective cohort study conducted at Tilganga Institute of Ophthalmology (Kathmandu, Nepal) compared pediatric Ex-DCR procedures (age ≤ 15 years) to adult Ex-DCR procedures (age > 15 years) and was performed between January 2013 and December 2013, with a minimum follow-up period of 6 months. Primary outcome measure was rate of success, defined as complete resolution of subjective symptom(s) of epiphora (subjective success), combined with patent lacrimal passage on syringing (anatomical success) at last follow-up visit. Other outcome measures included clinical presentation, diagnosis, intraoperative complications and post-operative complications. In total, 154 Ex-DCR procedures were included, with an age range of 8 months to 81 years (mean age 36.4 ± 21.0 years). In all, 38 pediatric Ex-DCR procedures were compared to 116 adult procedures. Success rates were 97% in the pediatric group and 95% in the adult group, with no clinically or statistically significant difference in success rate or complication rate between groups (p > 0.05). Our study yielded high success rates of Ex-DCR in both pediatric and adult age groups suggesting that Ex-DCR remains an optimal treatment choice for all age groups. With no difference in surgical outcomes between pediatric and adult patients, including complication rate, we conclude that age is not a prognostic factor for Ex-DCR failure. We do not recommend adjuvant therapy for pediatric patients.
Galindo-Ferreiro, Alicia M.D.; El-Khamary, Sahar M. M.D.; Al-Katan, Hind M.D.; Akaishi, Patricia M. M.D.; Cruz, Antonio A.V. M.D.
A 25-year-old man presented with a mass on the right medial canthus after a successful dacryo cys torhinostomy performed 3 years ago. On examination, there was a firm, nondepressible mass inferior to the medial canthal ligament and a linear vertical scar on the lateral wall of the nose. Syringing through the right lower punctum indicated his lacrimal system was patent. Computed tomography and magnetic resonance imaging disclosed a large cystic lesion in the lacrimal sac fossa. No bone erosion was detected. The mass was approached through a tear trough incision and completely resected. The lacrimal anastomosis that was highly placed remained patent after surgery. Histopathology of the specimen revealed a cystic lesion compatible with lacrimal origin (dacryocystocele).