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A case of bacterial endophthalmitis following suture removal after penetrating keratoplasty is presented. The sutures were removed 10 months postoperatively, and the endophthalmitis became apparent 2 days following suture removal. The patient was chronically immunosuppressed and was found to have a chronic dacryocystitis, which was felt to be the source of the bacterial infection.
Recently general anesthesia has become more popular than local for dacryocystorhinostomy, but the increasing bleeding tendency has hindered precise suturing of the nasal and lacrimal flaps. This paper describes a method of achieving controlled sedation with meperidine and chlorpromazine, postural sphenopalatine block with a mixture of cocaine and epinephrine, and nasociliary block with lidocaine. The dry field permits precise suturing of the mucosal flaps and has enabled the authors to gain experience with the miniature aneurysm needle of Reverdin, which facilitates suturing, and with Guibor's canaliculus intubation set, which is especially useful when flap suturing is not possible. Of 20 patients in whom this method was used, 16 obtained relief from dacryocystitis or tearing. Retrobulbar hemorrhage occurred in one patient during induction of the nasociliary block, necessitating cancellation of the operation, and pneumonitis occurred postoperatively in another patient. Respiratory gas exchange was normal when tested. The controlled sedation induced a fall in blood pressure and a rise in heart rate. No adverse effects of any of the drugs were noted. Thus, this method of controlled sedation and regional anesthesia is safe and effective, and because it reduces the bleeding tendency it makes the operation easier and shorter.
The Authors describe their method of treatment of congenital dacryocystitis. Up to 3-4 months of age the treatment consists in the use of antibiotic eye drops and message of the lacrimal sack. After this age and up to 8 months of age irrigation of the lacrimal passages is carried out. If this is unsuccessful or if the children are older a probing is performed. The Authors report the results of the probing in a series of 118 children (146 eyes). The best results are obtained when the probing is effectuated before 8 months of age. After this age the success decreases with the increase in age of the young children. There is no apprecciable difference between the unilateral and bilateral cases.
Seventy consecutive patients undergoing dacryocystorhinostomy for chronic dacryocystitis or dacryostenosis were analyzed. Lacrimal sac stones were found in 11 patients for an incidence of 16%. All stones were studied histopathologically and six of these stones demonstrated morphological characteristics compatible with fungus. Two stones were cultured and one of these grew aerobes with the other growing fungi only. A series of nine patients with canalicular dacryoliths was analyzed. All patients were studied clinically and bacteriologically. No fungus was found on any of these cases. Aerobic cultures were positive in two patients. All patients with canalicular stones grew anaerobes with arachnia propionica and fusobacterium species predominating. The treatment for both problems is recognition and removal of the stones.
The authors report two cases of postoperative lagophthalmos immediately following ab externo dacrycystorhinostomy (DCR). Two female patients, aged 67 and 62 years, underwent under general analgesia for chronic dacryocystitis with mucocele. An inferior surgical approach, sparing the inner canthal ligament was chosen in both cases. Lagophthalmos was observed on the operated side on the first postoperative day. Normal lid occlusion was present on the contralateral side. Impairement of palpebral occlusion was predominant in the nasal portion of the lid fissure. Upon voluntary and reflex blinking, a reduction in the downward movement of the superior lid was observed. This reduction was not as apparent when the patients were asked to produce a forced blink. Lagophthalmos disappeared progressively over 3 postoperative months in both cases. Neither epiphora nor any corneal complications were observed. Lagophthalmos following DCR via an inferior approach is a previously unreported complication and may be related to the disinsertion of the nasal portion of the orbicularis muscle and periosteum at the time of periosteal cleavage. Recovery of normal lid function may be due to reattachment of the periosteum.
The authors present a case of ethmo-spheno-maxillary mucocele revealed by the appearance of a giant unilateral exophthalmia with an important decrease of visual acuity and spectacular regression of symptomatology after surgical excision. We must note the initial location near the tear ductus, the slow progression (12 years) with a false aspect of chronic dacryocystitis.
At birth, a thin membrane often remains at the distal end of the nasolacrimal duct in the inferior meatus. The rupture is spontaneous during the first month of life. Sometimes this impatency can lead to a symptomatology usually limited to an uni or bilateral dacryocystitis. Exceptionally a cyst can develop in the nasolacrimal passageways. The authors describe three cases of intranasal occurrences, two of which brought about an obstructive dyspnea. Twelve cases have been described in the literature. This affliction predominantly occurs in young girls. Whenever the nasal obstruction is isolated, it is important to eliminate any other cause of intranasal tumor, especially an encephalocele, before any surgical intervention. Computerized tomographic scan is indispensable in order to eliminate any connection with the intracranial space. Magnetic resonance imaging appears promising. For the authors, the treatment must be surgical and must be kept simple. It consists in a cyst excision.
During the last ten years 218 dacryocystorhinostomies were done, 8 of them on under 10-years-old children (3.7%). Dacryocystorhinostomy remains the only curative intervention which may be done on children even when the lacrimal ways sounding is inefficient. The surgical technique was the same as the one used for the adults, with some characteristic features imposed by the age of the patient. The intervention was some especially on children with congenital imperforations of the lacrimo-nasal channel, when the repermeability of the lacrimal ways could not be obtained by repeated soundings, but also in traumatic and congenital malformed dacryocystitis. The operation was made with good results even after the extirpation of the lacrimal sac, followed by the formation of a neosac. In the observations we presented the underlimit of the intervention has been 2 years and 4 months.
Canaliculitis is a relatively rare dacryocanal infection which occurs most unilateral. It can easily be misinterpreted and not sufficiently treated. Typical agents of the canaliculitis are actinomyces, that can cause infections of the hollow spaces with formation of concrements. The clinical courses of two patients are shown. One of them was treated for a dacryocystitis for 3 years and the other one had been referred to the eye hospital for chalazion removal. Only a microbiologic examination including cultivation of the surgically obtained dacryolithes and secretion enabled us to a reliable proof of the actinomyces and to an appropriate therapy for canaliculitis.
Primary care physicians have an important role in diagnosing and treating eye disorders--including dacryocystitis, blepharitis, and conjunctivitis--and in determining when ophthalmologic referral is needed. Fundus examination for diagnosis of glaucoma and diabetic eye complications should be a part of the routine examination in all adults. Patients with HIV or AIDS should be carefully monitored for cytomegalovirus retinitis. Children should be tested for amblyopia. Orbital cellulitis can have serious complications and must be vigorously treated. Finally, careful use of ophthalmologic topical agents, especially corticosteroid drops, is essential.
Magnetic Resonance Imaging of a dacryocystography and a watersoluble computed tomographic dacryocystography were compared in 13 prospective cases after facial traumas, infections or without previous history. All had either watering eyes, ephiphora or dacryocystitis. This study demonstrated the superiority of computed tomography which must be used in first intention for complexe problems of the lacrimal drainage system. Only tumoral pathology (very rare) requires Magnetic Resonance Imaging. Combined computed tomography and dacryocystography in the same time provide diagnostic precision and less radiation. Confortable for the patient by helicoidal acquisition, computed tomography is cheaper than a Magnetic Resonance Imaging.
A high index of suspicion is very important in the early diagnosis and treatment of potentially lethal tumors of the lacrimal sac. The triad of a mass above the medial canthal tendon, chronic dacryocystitis which irrigates freely and bloody reflux on irrigation should alert the ophthalmologist of this potentially fatal situation. Complete surgical excision and postoperative irradiation are important in the treatment of malignant tumors.
A case of malformation of the tear duct associated with clefts in the face is described. To our knowledge this combination has not been described before. The whole symptoms complex consisted of: bilateral cleft lip upper jaw and gum, choanalatresia, mucocele of the left nasal cavity from adhesions of the lower concha with the nasal septum, cystic dilatation of the tear sac at the connection to a bony naso-lacrimal duct. Right inguinal hernia, syndactyly of the first and second left toes, iris-chroid coloboma right with congenital cataract and unilateral right convergent squint. Because of the advanced dacryocystitis on the basis of the congenital dacryostenosis, and external dacryostorhinostomy (modified after Kaleff 1937) was performed after pre-treatment by instillation of antibiotic solutions in the tear ducts. At the same time the nasal cavity mucocele was opened by partial excision of the lower concha and opening the choanal atresia. After a post-operative course free of complications and with clear patency of the tear ducts the oral surgical operation was done--closure of the face clefts. The chromosome analysis was normal the only abnormal result here was an unexplained slow rate of multiplication of lymphocytes in four cultures inoculated at various points of time. Because we could not find any hereditary factors, this symptom complex is probably due to exogenous embryo damage during the early development phase.
Endonasal dacryorhinocystostomy is a surgical procedure performed to re-establish continuity of the lacrimal duct by partial diversion followed by dilatation. A simultaneous rhinologic and ophthalmologic approach is used. This simple and elegant procedure that results in no residual scarring is indicated for any blockage of the lacrimal duct due to congenital or acquired causes. Except for children under 6 years of age and in patients in poor general condition, contra-indications are uncommon. Operative and postoperative complications are rare. After a review of the relevant anatomy the authors of this report describe the equipment and basic techniques used to perform dacryorhinocystostomy. Endonasal dacryorhinocystostomy was performed in 15 patients presenting chronic (n = 14) or acute (n = 1) dacryocystitis in Madagascar. At six months follow-up the procedure was successful in 14 cases and unsuccessful in one case due a cutaneous fistula. Because it is simple and well-tolerated and results in no residual scarring, endonasal dacryorhinocystostomy is the method of choice for treatment of lacrimal duct obstruction in tropical areas in general and in Black Africa in particular.
Several questions concerning the material to be used for surgical repair of fractures of the orbit are still under debate. Surgeons may choose between autologous or heterologous grafts or different biomaterials. We conducted a retrospective analysis of 137 patients treated in our unit for fractures of the floor of the orbit over the last 20 years who received a silastic implant. After 20 years, the rate of complications requiring removal of the implant was 13.8%. Complications observed were dacryocystitis, implant migration to the skin and the maxillary sinus, skin fistula, persistent diplopia, communication between the orbit and the sinus, periorbit cellulitis.
A new operative technique is described in which the lacrimal sac is drained into the maxillary sinus. The advantages of the procedure, especially of avoiding a facial incision, are emphasized. Five patients suffering from long-standing epiphora underwent surgery. Two patients had chronic dacryocystitis. Two other patients presented with a mucocele of the lacrimal sac. In the fifth patient, there was obstruction in the nasolacrimal duct. Short term follow-up results suggest its usefulness as a first line of surgical treatment in cases of epiphora due to obstruction in the lacrimal sac or the naso-lacrimal duct.
Contemporary advances in endoscopic surgery of the paranasal sinuses make it possible to identify and open the lacrimal system via the nasal sinus. The authors describe four cases of chronic dacryocystitis with obstruction of the nasolacrimal duct in three women and one man aged 22 to 56 years. In all four patients the lacrimal sac was opened endoscopically by the endonasal route and safeguarded by drainage. In the discussion the authors deal with contemporary views on this problem.
OBJECTIVES: To describe the outcomes of balloon catheter dilation of the lacrimal duct as the first surgical treatment for older children (>or=18 months) with nasolacrimal duct (NLD) obstruction and to examine the effect of the type of obstruction on outcome. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Seventy-six children 18 months or older with NLD obstruction who had not undergone previous surgery. INTERVENTION: The patients underwent NLD probing, infracturing of the inferior turbinate, and balloon catheter dilation of the distal NLD. The type of obstruction was noted at surgery. MAIN OUTCOME MEASURES: Outcomes were considered excellent if the patient had complete resolution of epiphora and dacryocystitis and normal tear drainage on examination, good if the patient had only minimal residual symptoms or a minimally delayed dye disappearance test result, fair if the patient had moderate residual symptoms or delayed tear drainage, and poor if there was no improvement. RESULTS: Seventy-six children were treated. Overall, results were excellent in 28 (37%) patients, good in 30 (39%), fair in 13 (17%), and poor in 5 (7%). Forty-eight (63%) of the patients had simple membranous obstruction at the Hasner valve. Results were good or excellent in 35 (73%) of these patients. Twenty-eight (37%) patients had stenosis that extended along the length of the distal NLD. Results were good or excellent in 23 (82%) of these patients. CONCLUSIONS: Balloon catheter dilation is probably more effective than simple probing for older children with NLD obstruction because of stenosis that extends along the distal NLD. The procedure does not provide a significant advantage over simple NLD probing in patients with typical membranous obstruction at the Hasner valve.