Ali, Mohammad Javed
Septate lacrimal sac diverticula are uncommon and can present with acute dacryocystitis. Their management can pose surgical challenges. A boy, aged 5 years, presented with swelling of the inner side of right lower lid with epiphora of 1-year duration with an acute pain of 2-days duration (Fig.A). There was a history of 2 such episodes of pain and redness; however, there was no history of trauma, discharge, or surgical interventions. Clinical examination showed a tender multilobulated, firm lesion on palpation. Ocular examination was normal. CT scan showed a hypodense and homogenous mass with multiple, well-defined internal septae, involving the medial lower lid and bony lacrimal fossa (Fig.B). The lesion also appeared to be in contiguity with the lacrimal sac and upper nasolacrimal duct without a clear plane of distinction (Fig.C). An impression of a possible lacrimal sac diverticulitis with multiple internal septae was made. Patient was started on conservative treatment to reduce inflammation, and a surgical exploration was planned. Lacrimal irrigation was suggestive of a right nasolacrimal duct obstruction while the left side was patent. Surgical exploration revealed the lesion to be a multilobulated dermoid cyst with focal areas of keratin leak (Fig.D). The medial aspect of the lesion was adherent to the lateral walls of lacrimal sac and upper nasolacrimal duct (Fig.E). The lesion was carefully separated along with the adherent perilacrimal fascia (Fig.F). Post excision, the lacrimal drainage irrigation was freely patent. The adherent nature of the dermoid cyst with the wall of lacrimal sac could be secondary to inflammation and hence appeared contiguous on imaging. This case demonstrates the differential diagnosis of a septate lacrimal fossa lesion, and both possibilities should be kept in mind when approaching such presentations.
Cheong, Timothy Z.; Davies, Rodger P.
An 81-year-old man with unilateral nasolacrimal duct obstruction underwent routine endonasal dacryocystorhinostomy and 2 days postoperatively developed a severe headache and rigors. Subsequent CT and MRI imaging demonstrated a defect in the floor of the right anterior cranial fossa, which possibly was damaged during the operation, and meningoencephalitis of the adjacent frontal lobe gyrus. Following intravenous antibiotic treatment, the patient made a full recovery with no ongoing sequelae, and his epiphora completely resolved. To the authors’ knowledge, this is the first report of meningoencephalitis following endonasal dacryocystorhinostomy. This complication should be considered in any patient with a febrile septic presentation or headache following endonasal dacryocystorhinostomy.
Yi Zhang, Yu Fan, Jinlu Fan, Yanhui Cui
To evaluate the surgical intervention and its effect on congenital dacryocystocele.
A total of 531 children with congenital dacryocystocele admitted to the Department of Ophthalmology of Beijing Children’s Hospital, Shanghai Aier Eye Hospital, Nanjing Aier Eye Hospital, and the First Affiliated Hospital of Jinzhou Medical University between January 2007 and January 2017 were retrospectively analyzed.
A total of 531 patients were followed up for 3–24 months, with an average of 13.3 months. No serious intraoperative complications (such as bleeding and tissue damage) and postoperative complications (bleeding, infection, and hole atresia) were found. We classified the outcomes into three categories based on the signs (overflowing tears and empyema) and objective routine follow-up by endoscopy. Cure indicated that mass, overflow of tears, and breathing difficulties disappeared, and 81.5% cases (433/531) were postoperatively cured. Improvement indicated disappearance of mass, overflow empyema, and the presence of residual tears (due to trocar and tears puncture), and 18.5% cases (98/531) were postoperatively improved. Unhealed indicated overflowing pus and tears, and 0% cases did not heal after surgery.
Nasal endoscopic surgery is relatively safe, with high success rate for treatment of congenital dacryocystocele. Systematic training is required to promote the application of nasal endoscopy, so that more ophthalmologists can learn this technique.
Md. Shahid Alam, A.K. Amitava
Regurgitation on pressure over the lacrimal sac (ROPLAS) is a clinical test that aids in diagnosing nasolacrimal duct obstruction (NLDO) with a specificity as high as 99%.1 This implies that if the ROPLAS test is positive, a nasolacrimal duct obstruction is almost certainly present. During our encounter with patients of NLDO we found many patients complaining of regurgitant discharge from the medial side of the eye on lacrimal compression (self-ROPLAS), in addition to the routine complaints of watering (Fig. 1).The maneuver is often resorted to by patients to empty the nasolacrimal sac and may provide relief from purulent discharge for a few hours. We investigated the reliability of self-ROPLAS in diagnosing NLDO.
Raoul K. Khanna, Alix Fontaine, Jean-Marc Lemacon, Sylvain Moriniere, Pierre-Jean Pisella
A 67-year-old Caucasian woman was referred for left-sided intermittent bloody tears of 3 months’ duration. The initial ocular examination was normal except for blood discharge at lacrimal syringing without obstruction of the nasolacrimal pathway. In particular, bulbar and orbital conjunctiva, and the medial canthus did not present any mass or pigmentation. A computed tomography scan revealed a well-delimited 5mm mass extending from the left nasolacrimal duct into the nasal cavity with no bony erosion, masquerading as a nasal polyp. Contrary to clinical lacrimal syringing, dacryocystography demonstrated a complete obstruction of the left lacrimal apparatus. A magnetic resonance image revealed an enhancing mass of the left nasolacrimal duct with spontaneous T1 hyperintensity (Fig. 1). A polyp was found through a nasal endoscopy with a pigmented mass beside (Fig. 2). A biopsy was performed and histological analysis revealed a mucosal melanoma. The results of investigations for metastases were negative; that is, liver echography was normal and only positron emission tomography revealed a left nasolacrimal pathway uptake. The patient was referred to an otolaryngologist who performed an excision of the left nasolacrimal duct, the anteromedial part of the orbital floor, and the inferior turbinate through a lateral rhinotomy approach. Final pathology revealed a 15mm in greatest dimension mucosal melanoma restricted to the nasolacrimal pathway without bone invasion, perineural involvement, or vascular emboli (Fig. 3). CKIT, BRAF, and NRAS mutations were tested and returned negative. According to the American Joint Committee on Cancer, the tumor was pT3N0M0, stage III.4 Postoperative adjuvant fractionated radiotherapy was given in divided doses (60 Gy in 30 sessions). At 12 months follow-up, the patient remained free of disease…..
Kasturi Bhattacharjee, Manpreet Singh, Richa Shrivastava, Ganesh Chandra Kuri, Samir Serasiya, Harsha Bhattacharjee
To report the long-term outcomes of the conjunctivo-rhinostomy surgery with labial mucosal graft performed for the patients of proximal lacrimal drainage system disorders.
Retrospective, single surgeon (KB), non-comparative study including patients having complete obstruction of the superior and inferior proximal lacrimal drainage system. All patients underwent conjunctivo-rhinostomy with labial mucosal graft insertion. Preoperatively, tear film break-up time and a fluorescein dye disappearance test was performed for each patient. A phaco aspiration tubing segment was used for supporting the mucosal graft for first 4 weeks followed by its removal. Minimum follow-up was 12 months. fluorescein dye disappearance test and nasal endoscopy were performed at each follow-up visit. Total resolution of epiphora and negative fluorescein dye disappearance test was defined as complete success.
Eighteen patients (12 males, 6 females) with a mean age of 39.94 years (range 7–76 years) all had a unilateral presentation. The indication for surgery was trauma (n = 11), failed dacryocystorhinostomy (DCR) with canalicular obstruction (n = 4), chronic ocular inflammation with complete punctal occlusion (n = 2), and post-radiotherapy (n = 1). At a mean follow-up of 5.38 years, complete success was observed in 12 (66.67%), partial success in 4 (22.22%) while in 2 (11.11%) patients, the procedure failed.
Labial mucosal graft in conjunctivo-rhinostomy is a successful adjunct which provides satisfactory long-term outcomes. Our surgical technique of directly suturing the mucosal graft to surrounding muscle provides better functionality to the system with eyelid blinking.
Saraniya Sathiamoorthi, Ryan D Frank, Brian G Mohney
Background/aims The literature on the prevalence and demographics of congenital nasolacrimal duct obstruction (CNLDO) is 30–70 years old and largely comprises small sample sizes. This study provides epidemiological findings of this common disorder from the largest cohort reported to date.
Methods The medical records of all children (<5 years of age) residing in Olmsted County, Minnesota, when diagnosed with CNLDO from 1 January 1995 through 31 December 2004, were reviewed.
Results Of 17 713 newborns born during the 10-year study period, 1998 were diagnosed with CNLDO, yielding a birth prevalence of one in nine live births. The diagnosis was made in approximately 90% by a primary care physician, at a median age of 5 weeks, with no gender predilection. Compared with the reference population, CNLDO was associated with premature birth (p=0.005) and was more prevalent among Caucasians (p<0.001). Two-thirds of patients initially presented with discharge alone, 18% with tearing alone and 15% with both discharge and tearing.
Conclusions In this large population-based cohort, CNLDO occurred in one in nine live births with no gender predilection. Prematurity and Caucasian race were associated with the development of CNLDO. Mucopurulent discharge was a much more common feature than tearing at initial presentation.
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.
Md. Shahid Alam, Nisar Sonam Poonam, Bipasha Mukherjee
To evaluate outcomes of canaliculotomy in cases of recalcitrant canaliculitis.
All cases diagnosed with canaliculitis who subsequently underwent canaliculotomy over a 15 year period were included in the study. We reviewed and analyzed demographic data, clinical presentation, microbiological profile and management outcomes.
Out of 40 patients, 21 (52.5%) were males. Age range was 17–89 years. Lower canaliculus was affected most commonly (53.81%). Mean duration of symptoms was 8 months (range- 0.5–60 months, median 6 months). The most common presenting symptom was watering (34, 85%) while pouting puncta (32, 80%) was the most frequently documented clinical sign. Concretions were seen in 20 (50%) patients and Actinomyces was the most commonly isolated micro organism in the concretion group. Polymicrobial growth was seen in 18 (45%) patients. Commonly isolated bacteria on culture were Staphylococcus epidermidis (16, 40%) followed by Actinomyces (14, 34%) and Corynebacterium species (5, 12.5%). Complete resolution was seen in 39 cases post-operatively (97.5%, p = 0.0002). Mean follow up period was 21 months (range- 3–180 months).
Recurrence was noted in 6(15%) cases, of which 4 were males (66.67%, p = 0.069) Four (66.67%, p = 0.069) patients had associated diabetes and 5 (83.33%, p = 0.046) had associated concretions. Six (15%) patients complained of persistent epiphora.
Canaliculotomy is a safe and effective method for management of recalcitrant canaliculitis with a success rate of 85%. Presence of concretions was associated with higher risk of recurrence in our study.
Jenil Sheth, Suryasnata Rath, Devjyoti Tripathy
Purpose: To compare the efficacy of a single perioperative bolus dose of intravenous antibiotic versus postoperative oral antibiotic prophylaxis for prevention of surgical site infection (SSI) in external dacryocystorhinostomy (DCR) for primary acquired nasolacrimal duct obstruction (PANDO). Methods: This was a prospective randomized controlled study with a noninferiority design. Patients undergoing external DCR surgery were randomized into two groups A and B. Patients in group A received a single bolus dose of intravenous cefazolin 1 g at surgery, whereas those in group B received oral cephalexin 500 mg postoperatively twice a day for 5 days. Allocation concealment was ensured by sequentially numbered opaque sealed envelopes (SNOSEs). Both groups were advised identical postoperative local wound care regimens. Any clinical evidence of SSI at 4 weeks of follow-up in either group was the main outcome measure. Results: In all, 338 patients randomized into two groups of 169 patients each participated in this study. At follow-up of 4 weeks, only one patient in group B developed postoperative SSI. None in group A developed postoperative SSI. Other potential risk factors for postoperative SSI were also analyzed by univariate and multivariate analyses but none achieved statistical significance in either group. Conclusion: Our results demonstrate that a single bolus dose of perioperative intravenous antibiotic offers adequate prophylaxis against postoperative SSI and compares favorably with the more commonly used oral antibiotic prophylaxis in external DCR for PANDO in our population and our practice scenario.