Ashi Morawala , Nandini Bothra , Dilip Kumar Mishra & Mohammad Javed Ali
Primary adenocarcinoma of the lacrimal drainage system is a rare malignancy. Poorly differentiated subtypes of this tumor demonstrate aggressive behaviors, and metastasis is not uncommon. We present a patient with poorly differentiated adenocarcinoma of the lacrimal sac and nasolacrimal duct with an orbital extension. The case was managed by a combined external and endoscopic approach excision followed by adjuvant radiotherapy.
Swati Singh & Mohammad Javed Ali
To provide a literature review on lymphoproliferative lesions involving the lacrimal drainage system.
The authors performed a pubmed search of all articles published in English on lymphoma/leukemia of lacrimal sac and the nasolacrimal duct. Data analyzed include prevalence, demographics, clinical presentations, treatment outcomes of primary versus secondary lacrimal involvement, and recurrence rates.
Lymphoma/leukemia of lacrimal sac presented at a mean age of 55 years. The majority of the tumors (63%) were primary involvement of lacrimal sac, bilateral involvement being more common in secondary than primary lacrimal sac lymphoma. Epiphora (96%, 98/102), swelling in the lacrimal sac region (75%, 77/102), and acute dacryocystitis (31%) were the most frequent presenting features. Thirty-six percent of the lesions were diagnosed incidentally while performing a dacryocystorhinostomy (DCR). Among primary sac lymphomas, diffuse large B-cell lymphoma (DLBCL) (43%) was the most common sub-type followed by MALToma (24%), unclassified B-cell lymphoma (21%), lymphoid hyperplasia (5%) and 3% each small lymphocytic lymphoma (SLL) and NK/T cell lymphoma. Management usually involves chemotherapy and/ or radiotherapy with or without surgical resection. Successful outcomes in terms of local disease control could be achieved in all the cases; however, 15% died of the systemic disease after a mean 18 months from the time of sac involvement. Aggressive lymphomas like NK/T-cell have the worst prognosis.
Lymphoproliferative involvement of lacrimal sac has a high incidence of acute dacryocystitis with a good response to chemotherapy. Epiphora in patients with leukemia/lymphoma should arouse suspicion of a lacrimal drainage involvement.
Maria Julia Orsolini , Silvana Artioli Schellini , Roberta Lilian Fernandes Souza Meneguim & Antônio José Maria Catâneo
To evaluate the effect of stents on the success of endoscopic dacryocystorhinostomy (DCR-EN) for treating primary acquired nasolacrimal duct obstruction (NLDO).
A systematic review of randomized clinical trials of DCR-EN for NLDO comparing outcomes of surgeries performed with and without the use of bicanalicular stents and the complications associated with each procedure. Two authors independently searched six databases (Scopus, PubMed, EMBASE, Google Scholar, Cochrane Central Register of Controlled Trials, and Web of Science) up to May 2019. Statistical analysis and meta-analysis were performed using RevMan 5.3 software provided by the Cochrane Collaboration.
Twelve studies involving 997 surgeries were included in this systematic review. The meta-analysis using a fixed-effects model showed a 94% success rate with stents versus 90.6% without stent. Although stent use favors greater success of DCR-EN, the confidence interval (CI) was wide and very close to nullity line (1.01), decreasing the strength of the recommendation for stent (odds ratio: 1.62, 95% CI: 1.01–2.59, I 2 = 0%). Meta-analysis of the adverse effects was not possible. A descriptive analysis was performed of the general complications related to the stents.
There is evidence that the use of bicanalicular stents slightly improves the success rate of DCR-EN, but the quality of evidence is low. Future prospective, randomized trials enrolling larger sample sizes may provide stronger evidence to determine whether the stent use influences the success of primary acquired DCR-EN.
Heather de Beaufort, MD; Alina V. Dumitrescu, MD; Michael A. Kipp, MD; Rudolph S. Wagner, MD
Bothra, Nandini; Gupta, Nishi; Nowak, Rafal; Ali, Mohammad Javed
To assess the efficacy of commonly available coronary angioplasty balloon catheters as a low-cost alternative to the traditional dacryoplasty catheters in select patients of congenital nasolacrimal duct obstruction.
A prospective, interventional study was performed between July 2018 and December 2018 in children with congenital nasolacrimal duct obstruction, who underwent balloon dacryoplasty using the coronary angioplasty balloon catheters (2.75 × 10 mm, SPALNO, Cardiomac, Haryana, India). The inclusion criteria were children ≥4 years of age, and/or previously failed probing and/or previous failed intubation. Parameters documented were demographics, techniques, costs, complications, and postoperative outcomes.
Twenty-three eyes of 22 children underwent balloon dacryoplasty using coronary angioplasty balloon catheters. The mean age of the patients was 4.33 years (range 1.5–10 years). The procedure was performed in 8 patients (8 eyes, 35%) as the primary procedure. The remaining 14 patients (15 eyes, 65%) had a history of probing, of which 4 eyes had it twice earlier. All eyes underwent balloon dacryoplasty as per standard protocols. The insertion profile and trackability of the coronary catheters were good. At a mean follow up of 6.17 months (range 1.5–9 months), anatomical and functional success was obtained in 87% cases (n = 20/23). No lacrimal passage trauma or injuries were noted during the procedure. The cost of coronary balloon catheter was approximately $60.
The present pilot study has shown that outcomes of balloon dacryoplasty in patients with congenital nasolacrimal duct obstruction with coronary balloon catheters is comparable to that of traditional balloons and offers significant economic advantage for developing nations.
Trakos, Nikolaos; Singh, Swati; Mishra, Dilip Kumar; Ali, Mohammad Javed
To investigate the histopathological and ultrastructural changes in the lacrimal glands (LGs) of rabbits following either botulinum toxin (BTX) injection or simple glandular needling.
Twenty-four LGs of 24 eyes of 12 healthy New Zealand white rabbits were included in the study. Of these, 4 LGs of 4 eyes of 2 rabbits were used as controls. In the intervention group, all the right LG received 5 U in 0.1 ml of BTX-A (Botox, Allergan, Dublin, Ireland) and the left LG received simple glandular needling under general anesthesia. The BTX-A was injected directly into the LG via the transconjunctival route under direct visualization. For simple needling, 5 LG passes were made through a single-entry point using a 29-gauge needle mounted on an empty tuberculin syringe. The rabbits did not receive any postoperative medications other than lubricants. The rabbits were sacrificed at 8 weeks and the 20 treated and 4 control LG’s were retrieved for histopathological and transmission electron microscopic (TEM) analysis as per standard protocols.
In comparison to the control LG samples, both the treated groups showed pathological changes, which were more pronounced in the simple needling group. The BTX-A-treated LGs showed mild to moderate acinar atrophy, few degenerating acini and patchy chronic inflammatory infiltrates with thick hyalinized collagen within the glandular stroma. TEM analysis showed the cytosol of few acinar cells to contain vacuoles and autophagosomes with marginal chromatin condensation of the nucleus and an eccentric nucleolus. The LGs treated with simple needling showed marked pathological changes which include moderate to severe, focal, and diffuse acinar atrophy, dense stromal fibrosis, inflammatory infiltrates, and peri-vasculitis. TEM analysis showed focal disorganized acinar morphology, loss of intra-acinar and ductal architecture, and needle track zones with surrounding fibrotic areas.
Histopathological and ultrastructural changes were noted in the LGs treated with BTX-A and simple glandular needling. Simple needling of the LG has the prospect to be an effective and cheaper alternative to BTX-A.
Fedorov, Anatoly A.; Atkova, Eugenia L.; Yartsev, Vasily D.
To conduct a morphological study of structural changes in the nasolacrimal duct in secondary acquired nasolacrimal duct obstruction (SALDO) as a result of treatment with radioiodine.
Twenty patients (20 cases) were involved: 10 cases with secondary acquired nasolacrimal duct obstruction at Hasner’s valve level due to the treatment with radioiodine (group 1) and 10 cases with primary acquired nasolacrimal duct obstruction (group 2). During surgery, a biopsy of nasolacrimal duct tissue from Hasner’s valve area was taken. A morphological study was performed using semi-fine sections technique.
Patients of group 1 showed the following: desquamation of columnar epithelium, pinpoint ulceration of nasolacrimal duct wall, collapse of a significant part of the capillary bed, and absence of blood cells in their lumen. State of secretory cells of mucous glands varied from necrobiotic to the different stages of dystrophic, decreased lumens of acini with abundant microvesicles in cell cytoplasm were revealed. A specific sign noted in patients of group 2 was mixed inflammatory infiltration of the mucosa of the nasolacrimal duct. The picture corresponds to the exacerbation of a chronic inflammatory process.
Changes revealed in patients of group 1 include desquamation of nasolacrimal duct epithelium, mucous gland lesion, and moderate fibrosis that indicate a probable primary character of the lesion. In patients of group 2, fibrotic changes were more significant and were due to a chronic inflammatory process. Thus, secondary acquired nasolacrimal duct obstruction after treatment with radioactive iodine has a specific pathogenesis and should be classified as a separate nosological form.
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.
Nishi Gupta, Poonam Singla, Sunil Kumar, Suma Ganesh, Nidhi Dhawan, Parul Sobti & Shreya Aggarwal
Purpose: To highlight the importance of dacryoendoscopy in recognizing the factors responsible for failure with successful recanalization obviating the need for dacryocystorhinostomy in a few selective cases.
Method: A retrospective study of 13 children undergoing dacryoendoscopy for refractory congenital nasolacrimal duct obstruction (CNLDO) was carried out during a period of 3 years from 2016 to 2018. Children with single or multiple failed probings were included in the study.
Results: Out of the total 13 cases included in the study there 9 males and 4 females. The age ranged from 9 months to 36 months with the involvement of the right side in 7 cases and the left side in 6 cases. Four cases had dysgenesis of bony nasolacrimal duct (NLD), 4 cases had dacryolith, 3 cases had an intact membrane at the lower end of NLD and 2 cases had fibrosis of the lower end of NLD and the surrounding area in the inferior meatus (IM) following multiple interventions, (Table 1). Dacryoendoscopic recanalization was done in 7 cases while the endoscopic dacryocystorhinostomy (DCR) was done in 6 cases. A successful outcome was achieved in all the cases and at the end of 6 months, all the children remained asymptomatic.
Conclusions: Dacryoendoscopy (DEN) facilitates direct examination of the nasolacrimal system and thus has an added advantage over nasal endoscopy assisted probing in the refractory cases of CNLDO.