Austin Pharo, James Chelnis, Tara Goecks, Kendra C. DeAngelis, Brian Fowler, J. Chris Fleming & Thomas C. Naugle
Purpose: Traditional (tCDCR) and endoscopic conjunctivodacryocystorhinostomy (eCDCR) are challenging surgical techniques requiring general anesthesia, a facial incision, and a large osteotomy and mucosal flap. Minimally invasive CDCR (miCDCR) techniques eliminate the need for some of the steps in t/eCDCR. Introduced here is a variation of the miCDCR technique using a Naugle-Fleming knurled dilator (NKD) to create the osteotomy and instruments within a central line catheter kit to help easily place or replace a Jones’ tube into position within a bony conduit.
Methods: This IRB-approved retrospective chart review examined all patients who underwent this miCDCR technique performed by two oculoplastic surgeons at Hamilton Eye Institute at the University of Tennessee Health Sciences Center from 2014 to 2016. Inclusion criteria: need for CDCR (either primary or repeat). Exclusion criteria: loss to follow up prior to six months. Primary endpoints: operative time, incidence of tube migration and complications, and cessation of epiphora.
Results: Sixteen patients (nine men, seven women) were reviewed, with three undergoing bilateral procedure, totaling 19 cases. Age range: 47.0 to 84.0 years, average of 66.6 years (SD = 11.1). Ten patients had surgery under local/MAC augmented with IV sedation, and six had general anesthesia (38%). Average operative time was 17.4 min (SD = 10.9). One patient (5%) required revision in the six-month immediate post-operative period because of tube migration. All patients had cessation of epiphora.
Conclusions: This procedure can be done safely and quickly without general anesthesia, resulting in a satisfactorily lower rate of tube migration and cessation of epiphora rates.
David S. Curragh, Craig James & Dinesh Selva
Purpose: To report a case of a lacrimal sac tumour identified at the time of endoscopic dacryocystorhinostomy and describe a swinging inferior turbinate approach to the nasolacrimal duct (NLD) to facilitate an en-bloc excision of the lacrimal drainage apparatus.
Methods: An 88-year-old male presented with a 6-month history of epiphora and mucocele. Endonasal DCR was performed for nasolacrimal duct obstruction (NLDO). Intraoperatively, a biopsy was performed of abnormal appearing lacrimal sac mucosa, following opening of the lacrimal sac. Subsequent definitive management was performed via a combined external and endoscopic approach using a swinging inferior turbinate approach to the NLD to facilitate an en-bloc excision of the lacrimal drainage apparatus, without removal of the bony medial wall of the maxillary sinus.
Results: The excised lacrimal drainage showed insitu and invasive squamous cell carcinoma of the canaliculi and lacrimal sac with focal divergent neuroendocrine and sebaceous differentiation. There was no local tumour recurrence or metastatic spread at 3 months of follow-up.
Conclusions: We describe a swinging inferior turbinate approach to the NLD to facilitate an en-bloc excision of the lacrimal drainage apparatus, without entering the maxillary sinus. We believe this modified technique is a useful option to consider in the management of tumours of the lacrimal drainage apparatus.
Eri Ishikawa, Maria Suzanne Sabundayo, Shinjiro Kono, Hirohiko Kakizaki & Yasuhiro Takahashi
Purpose: To examine the patency or secondary obstruction of the lacrimal drainage system in patients with a peripunctal tumour.
Methods: This retrospective, observational, and comparative study included 10 patients with a peripunctal tumour. Lacrimal probing and syringing in all patients and dacryoendoscopic examinations in 5 patients were performed to check for patency of the lacrimal drainage system. Tear meniscus height (TMH) was measured bilaterally in the upper and lower eyelids using anterior segment optical coherence tomography and compared in relation to the affected side using one-way ANOVA.
Results: All patients did not complain of epiphora. Probing gave a hard stop and irrigation fluid passed into the nose. A patent punctum/canaliculus was also confirmed by dacryoendoscopy in all of the 5 patients. TMH was not significantly different among the sides (P = .900).
Conclusions: This study shows patency of the lacrimal drainage system in patients with a peripunctal tumour and no significant difference in TMH among the sides, resulting in absence of epiphora in all patients.
A 2-year-old child presented with watering and discharge since birth in right eye (RE) with regurgitation of pus through the canaliculion on pressure over lacrimal sac. The child was posted for RE endoscopic guided probing and syringing. Intraoperatively, there was a thin membrane over valve of Hasner which was pierced with probe making the passage patent [Figure 1]a and [Figure 1]b. As a protocol, her left eye was checked for syringing, to look for patency, endoscope was introduced in left side and a foreign body was found impacted in the nostril [Figure 1]c. The foreign body was removed under endoscopic guidance [Figure 1]d. Parents were unaware about the impacted foreign body. A similar case has been reported where a vegetative foreign body caused obstruction at opening of nasolacrimal duct leading to symptoms of congenital nasolacrimal duct obstruction. In the presented case, the foreign body was impacted in the other nostril and hence shows importance of bilateral examination.
Norman C. Charles, Frederick A. Jakobiec, Jillian K. Chong, Kyle J. Godfrey, Payal Patel, Lina Ma
Bonafide cysts of the lacrimal sac are rare, with only a few reports in the literature.1, 2, 3 Most are probably congenital in origin while others may be acquired. The epithelial lining of these cysts can be squamous or ciliated-respiratory in type, depending on the region of the sac lining that spawns the lesion. Conjunctival cysts arising from the medial regions of the forniceal conjunctiva must be distinguished from cysts deriving from the lacrimal sac. Other cyst-like conditions may be formed by closure of a dacryocystocele as a result of trauma or inflammation.1, 3 (A dacryocystocele is a diverticulum, a saccular outpouching of an epithelial-lined cavity, often resulting from an obstruction and attendant increased intraluminal pressure.) A lacrimal sac cyst presents as a gradually enlarging inner canthal mass characterized by a soft, fluctuant, and irreducible nontender cystic structure. Surgical excision of the adherent cyst may produce a tear in the sac wall, which should be repaired intraoperatively. A conjunctival cyst may also produce external medial canthal swelling but be visible in the forniceal subconjunctival tissues. The authors illustrate herein the first immunohistochemical analysis of a cyst that displayed respiratory-type epithelium and explore 2 possibilities: a lacrimal sac origin or a choristomatous cyst of paranasal sinus origin.
Xiaoqin Yan, Nan Xiang, Weikun Hu, Rong Liu, Ban Luo
To investigate the microstructure of the lacrimal canaliculus and the characteristics of lacrimal canalicular diseases by 80-MHz ultrasound biomicroscopy (UBM).
This study included 33 participants: 20 normal subjects (40 eyes), 2 patients with chronic lacrimal canaliculitis (4 eyes), 10 patients with chronic dacryocystitis (16 eyes), and 1 patient with lacrimal punctum atresia (2 eyes). All participants underwent 80-MHz UBM; disease-specific features were noted.
On 80-MHz UBM of the lacrimal canaliculi (vertical section) in normal subjects, low echo of the lacrimal canalicular lumen and high echo of the lacrimal canalicular wall were observed. The uniform low echo near the wall was the mucosal epithelium. The outermost layer of medium-to-high echo was the subepithelial elastic fibrous layer. In the horizontal section, the lumen was continuous. Two linear high echoes parallel to the canalicular wall could be observed at the center of the lacrimal canaliculus, which were sometimes attached and sometimes separated. When separated, the center of the lacrimal canaliculus was a low echo area (lumen). Lacrimal canaliculitis (vertical section) showed obvious ectasia of the lacrimal canalicular lumen, with a high echo mass shadow, which might have been calculi, and uneven thickness of the mucosal epithelium with a slightly high echo shadow. In the horizontal section, the lumen varied in size with clear boundaries of medium and high echoes. The central linear high echoes of the lumen were absent, and the echoes of the mucosal epithelium were discontinuous. In chronic dacryocystitis, the lacrimal canalicular lumen was extensively enlarged, with continuous echoes and uniform thickness of the mucosal epithelium and homogeneous patches of slightly higher echoes. Lacrimal punctum atresia indicated that the lacrimal canaliculus existed in both eyes and its structure was normal.
The 80-MHz UBM is a new non-invasive technique that can be used for clear visualization of the fine structure of the lacrimal canaliculus, including the mucosal epithelium and subepithelial elastic fiber layer. The use of this approach will improve understanding of the hierarchical structure of the lacrimal canaliculi and provide a comprehensive basis for diagnosis, differential diagnosis, and treatment plan in patients with lacrimal passage diseases.
Aldo Vagge, MD, PhD; Claudia Tulumello, MD; Marco Pellegrini, MD; Marco Di Maita, MD; Michele Iester, MD, PhD; Carlo Enrico Traverso, MD
To investigate the presence of amblyopia risk factors in newborns with congenital nasolacrimal duct obstruction (CNLDO) and age-matched healthy control subjects.
This retrospective case-control study involved newborns aged 30 to 60 days with CNLDO and age-matched healthy control subjects. Amblyopia risk factors were identified in accordance with the American Association for Pediatric Ophthalmology and Strabismus Vision Screening Committee recommendations. The prevalence of amblyopia risk factors was compared in newborns with CNLDO and age-matched healthy control subjects, newborns with unilateral and bilateral CNLDO, and the affected eye and fellow eye of newborns with unilateral CNLDO.
Amblyopia risk factors were found in 18 patients (11.9%) with CNLDO and 19 control subjects (8.7%) (P = .314). Eyes with CNLDO showed a significantly lower spherical equivalent compared to control eyes (2.01 ± 1.21 vs 2.79 ± 1.14 diopters, P < .001). No difference in amblyopia risk factors was found in eyes with unilateral and bilateral CNLDO (11.5% vs 12.1%; P = .908) or in eyes with unilateral CNLDO and fellow eyes (9.8% vs 12.3%; P = .540).
CNLDO does not seem to be associated with amblyopia risk factors in newborns. Because anisometropia might develop later on, all patients with CNLDO should be monitored for amblyopia.
Margaret Reynolds, MD; Gregg Lueder, MD
To report outcomes of nasolacrimal duct (NLD) probing in children 4 years and older with simple membranous NLD obstruction.
The records of all patients 4 years and older with congenital NLD obstruction who underwent surgery from 1997 to 2015 at Washington University School of Medicine were retrospectively reviewed. Of 47 patients reviewed, 18 (38.3%) were found to have simple membranous obstructions and were included in this study. Simple membranous obstruction was present at the distal duct and was relieved with passage of the probes in all patients. Children with canalicular or diffuse distal NLD stenosis (as defined by a tight, gritty feeling or multiple obstructions when passing the probe through the bony portion of the NLD), trisomy 21, lacrimal trauma, or craniofacial abnormalities were excluded. A successful outcome was determined by resolution of epiphora and periocular crusting.
Eighteen patients with ages ranging from 4.1 to 10.6 years with simple membranous NLD obstruction were treated. Sixteen of 18 (88.9%) patients had good outcomes following NLD probing. Two patients had persistent symptoms that resolved following balloon dilation and stent placement.
This study found that the success rate of probing in older patients with simple membranous NLD obstruction was comparable to that of younger patients. NLD probing alone is a good treatment option for older children with simple membranous NLD obstruction. Additional procedures such as balloon catheter dilation or stent placement may not be necessary at the time of initial probing.
Ali, Mohammad Javed F.R.C.S., Ph.D.
The aim of this study was to examine the endoscopic anatomy of the valve of Rosenmüller in real-time and its potential functional implications.
High-definition endoscopic documentation of the valve of Rosenmüller (VOR) during 50 powered endoscopic dacryocystorhinostomy over a period of 2 years were reviewed. The presence or absence of the valves were assessed and when present, each of the valves were studied for their anatomical configuration, shape, precise location, and changes with opening and closing of the internal common opening (ICO) and with the presence and absence of the probe.
VOR was noted in 68% of the subjects studied and 2 distinct subtypes were noted with type I being more common. The Type 1 VOR was a stand-alone, freely mobile, elliptical valve arising from the superior or postero-superior portion of the medial edge of the ICO. The Type II VOR was a group of a superior and inferior mucosal fold, arising from the superior and inferior portions of the medial edge of the ICO. When the ICO opens slowly, the valve tends to fall outwards towards the lacrimal sac. When the ICO slowly closes back, the valve moves inward towards the common canaliculus.
This is the first study to demonstrate the in-vivo presence of VOR. Two different types of VOR were noted with characteristic shapes, locations, and movements of each. Where present, VOR fulfills the criteria of a true valve. The study proposes that the term “valve of Huschke” is a misnomer and when present, is actually part of the overall anatomical and functional unit of VOR.
Detailed anatomical features of the valve of Rosenmϋller can help our understanding of the focal anatomy and tear rheology.
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.