Zuzana Sipkova , Ebube E. Obi , Oyinka Olurin , Peter M. Mota , Oana Vonica & Andrew R. Pearson
Assessment of lacrimal resistance in patients with patent lacrimal systems is important in determining whether dacryocystorhinostomy (DCR) surgery is appropriate. Current techniques, including lacrimal syringing and dacryoscintigraphy (DSG), can be unreliable. We compare the results of a manometric tear duct test (mTDT) irrigation technique with DSG in these patients.
All symptomatic patients in a specialist lacrimal clinic had full work-up apart from syringing. Lacrimal resistance was assessed using mTDT which applies a fixed head of fluid pressure via a cannula sealed to punctum. Conventional syringing was also performed in cases with abnormal mTDT. Symptomatic patients with delayed tear clearance, no external cause for watering and patent lacrimal systems had DSG. MTDT and DSG results were compared, including in asymptomatic fellow eyes.
105 tear ducts were examined, 85 symptomatic. Symptomatic eyes had a significantly higher mean mTDT resistance (p = .0003) and more had abnormal mTDT (52%) compared to asymptomatic eyes (10%). Although mean tear duct resistance was higher in those with nasolacrimal duct stenosis (NLDS) than freely patent (FP) on syringing (8.5 vs 10.8 dpm), this was not significant (p = .6). High proportions of both FP and NLDS groups had no flow at all on mTDT (60% and 53%, respectively). DSG showed no significant difference in the symptomatic versus asymptomatic eyes (p = .36), nor between those with a normal or abnormal mTDT (p = .25), nor between FP and NLDS groups (p = .25).
In contrast to DSG, the mTDT provides valuable, objective information on lacrimal resistance that can guide a decision to DCR surgery.
Elin Bohman Maria Kugelberg Eva Dafgård Kopp
To investigate long‐term outcome and report reoperation rate of non‐infected, complete acquired lacrimal drainage obstruction (ALDO ) treated with canaliculodacryocystoplasty (CDCP ) depending on site of stenosis.
Consecutive adult patients with non‐infected, complete ALDO treated with CDCP were followed for 76 months. Location of stenosis at preoperative visit and intraoperative probing was recorded, and during follow‐up, recurrence of stenosis prompting additional surgery and complications were noted. Survival analysis was applied to compare reoperation rate depending on site of stenosis. A follow‐up questionnaire was sent to patients not requiring reoperation asking to grade current epiphora problems.
Among 85 included cases (71 patients), 57 were classified as canalicular stenosis and 28 as nasolacrimal duct obstruction (NLDO ) preoperatively. At the end of follow‐up, 39% (33/85) of cases had required additional surgery due to persistent/recurrent symptoms. No statistical difference was found between these groups.
During CDCP , 25 of the 57 preoperatively classified canalicular stenosis were found to have an additional obstruction below the sac. The group with only canalicular stenosis had a statistically significant higher survival compared with cases with NLDO or multiple obstructions (p = 0.03). Of patients responding to the follow‐up questionnaire, 11/37 cases experienced epiphora often or constant.
Treating complete NLDO with CDCP results in a high reoperation rate and seems an insufficient alternative. Canaliculodacryocystoplasty (CDCP ) may be discussed if preoperative examination indicates canalicular stenosis and dacryocystorhinostomy is not desirable. However, the patient needs to be aware of the higher risk for additional surgery, especially if a second stenosis is found during probing.
Imran Haq, Hardeep Singh Mudhar, Zanna Currie, Showkat Mirza & Sachin Salvi
This case report deals with two patients with lacrimal sac swellings. Case 1 presented with bilateral sac swelling and Case 2 with a unilateral presentation. Dacrocystorhinostomy (DCR) followed by biopsies of both sacs in Case 1 revealed inflammatory polyps of the sac mucosa, identical in appearance to typical nasal allergic inflammatory polyps. The biopsies were accompanied by typical allergic mucin, featuring tiered mucin layers between which were numerous eosinophils, accompanied by Charcot–Leyden crystals. The histology of the dacryocystectomy specimen for Case 2 showed identical histopathological changes with the additional feature of prominent numbers of Immunoglobulin G (IgG)4-positive plasma cells in the stroma of the lacrimal sac inflammatory polyps. These features extend the sites affected by allergic inflammatory polyps and allergic mucin and possible pathogenesis is discussed.
Kaveh Vahdani, Geoffrey E. Rose
Continued “flow” symptoms after lacrimal drainage surgery are either due to physiologic failure, when flow through a patent anastomosis is insufficient relative to tear production, or anatomic obstruction, which is generally due to fibrosis at the valve of Rosenmuller. Thin common canalicular membranes may be treated by intranasal or transcanalicular1 trephination or by transcanalicular laser ablation. By a retrospective case-note review, we present the anatomic and symptomatic outcome after canalicular trephination and intubation in patients with medial canalicular obstruction after various open lacrimal surgeries; particular attention was directed at surgical difficulties and the subsequent control of symptoms.
Maria Araújo, Tânia Borges, Yolanda Mahia, Vânia Lages, António Pereira
The solitary fibrous tumor (STF) is a rare spindle cell tumor that most often occurs in the pleura, mediastinum and other serosal sites, but it can be found anywhere. The authors present a case report of a 35-year-old male who was submitted to an eventless left external dacryocystorhinostomy (DCR) due to epiphora. During the surgery no tumors or anomalous tissues were visualized. Five months later the patient presented a painless mass at the lower medial quadrant of the left orbit, near the lacrimal fossa. A computed tomography, a magnetic resonance imaging and an orbital ultrasound were performed. A round, very vascularized and highly contrast enhanced mass was found. An anterior orbitotomy was done. Histological aspects and immunohistochemical markers were consistent with STF. The tumor was not visualized during the DCR. The authors think that the growth of the tumor and the weakening of the tissues in the medial canthus after the DCR allowed the tumor to move anteriorly within the orbit.
Kashkouli, Mohsen B.; Karimi, Nasser; Khademi, Behzad
Purpose of review After failed conservative management, most clinicians treat congenital nasolacrimal duct obstruction (CNLDO) in a conventional stepwise fashion: starting with probing, then repeat probing, next silicone intubation and/or balloon dilatation, and finally dacryocystorhinostomy. This approach is based on the patient’s age and previously failed procedures and recruits ‘one procedure for all’ CNLDO. A newly introduced approach is based on the type of obstruction and recruits ‘all procedures for one’ CNLDO. The aim of this review is to examine the best available evidence regarding CNLDO management.
Recent findings Recent articles support the concept that through intraoperative evaluation of obstruction in CNLDO, clinicians may predict probing failure and instantaneously employ more appropriate treatment modalities. This review addresses whether an age-based approach should be changed into a one-stage obstruction-based approach.
Summary An age-based approach treats CNLDO as a homogeneous disease and thus treats all patients with one predetermined procedure. A one-stage obstruction-based approach, however, considers CNLDO to be a heterogeneous disease, and therefore allows recruitment of all procedures simultaneously and selects the best intraoperatively. It may allow replacement of the conventional stepwise approach to CNLDO treatment provided that randomized trials verify its efficacy, safety, and cost-effectiveness.
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.
Nandini Bothra, Suryasnata Rath, Ruchi Mittal, Devjyoti Tripathy
Purpose: To describe the outcome of external dacryocystorhinostomy (DCR) as a suitable alternative to dacryocystectomy (DCT) in cases of isolated lacrimal sac rhinosporidiosis. Methods: This was a retrospective, interventional case series. Institutional review board approval was obtained for the study. The chart review of 13 patients who underwent external DCR surgery for isolated lacrimal sac rhinosporidiosis between July 2012 and May 2018 was performed. Demographic details, clinical presentation, preoperative and intraoperative findings, surgical technique used, postoperative management, surgical outcome and duration of follow up were reviewed for each patient. Results: Thirteen patients were included in the study. Nine (69.2%) were male and four (30.8%) were female. The mean age was 22.1 years (range: 8–46 years). Involvement was unilateral in all cases. The commonest presenting complaint was epiphora with discharge seen in 10 cases (76.9%). An intrasac granuloma was grossly identified intraoperatively in 12 out of the 13 patients. Mean follow up was 26.9 months (range: 1.5–68 months). Till the last follow up, all cases were symptom free and did not have any evidence of recurrence of infection. Conclusion: From this series of cases reported by the authors, external DCR with appropriate precautions to prevent recurrence appears to be a suitable alternative to conventional DCT with excellent long-term outcomes without disease recurrence.
Jinhwan Park, Joohyun Kim & Sehyun Baek
To evaluate the clinical features and treatment outcomes of patients complaining of tearing after receiving chemotherapy.
The clinical records of patients who complained of tearing between August 2014 and February 2016, and underwent or were undergoing chemotherapy were retrospectively reviewed. Clinical measurements were as follows: LipiView® interferometer (lipid layer thickness and meibography), lacrimal drainage examinations (syringing), and outcomes at 6 months after treatment.
This study included 34 eyes of 17 patients with a mean age of 62.4 ± 14.82 years. The mean follow-up period was 9.6 months. On syringing, 10 eyes (29.4%) showed total regurgitation, 19 eyes (55.9%) showed partial regurgitation, and 5 eyes (14.7%) showed no regurgitation. On LipiView®, mean lipid layer thickness was 34.5 nm (range, 20–89 nm). Mean meiboscore was 2.15 ± 0.86 in upper eyelid and 2.53 ± 0.79 in lower eyelid. Patients were treated with silicon tube intubation (STI) (10 eyes, 29.4%), dacryocystorhinostomy (DCR) (4 eyes, 17.6%), conjunctivodacryocystorhinostomy (CDCR) (8 eyes, 11.8%), DCR combined with CDCR (1 eyes, 8.8%), and conservative care (11 eyes, 32.4%). Mean time interval from onset of tearing to first clinic visit was 1.4 months in the conservative care group, 2.9 months in the STI and DCR groups, and 6.0 months in the CDCR group.
Because of the high incidence of accompanying meibomian gland loss in cases of lacrimal drainage system (LDS) obstruction, reflex tearing by mebibomian gland dysfunction should also be considered for proper management of tearing. Early recognition and management of LDS stenosis could result in patients undergoing surgery with a lower burden.