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PubMed2006

Evaluation and management of congenital nasolacrimal duct obstruction.

Congenital nasolacrimal obstruction is a common disorder in infants that results in persistent tearing and may lead to infections, such as dacryocystitis, orbital cellulitis, and bacterial conjunctivitis. The true incidence of this disorder in healthy newborns remains controversial. The most frequently quoted number of 6% comes from a study of 200 consecutive live births in the 1940s in which nasolacrimal patency was assessed by the presence or absence of discharge on compression of the lacrimal sac. Estimates from other studies, which often use different criteria for diagnosis, vary considerably from 1.2% to 30%. The incidence of the disorder is higher in children who have craniofacial disorders and Down's syndrome. This article reviews the causes and treatment of congenital nasolacrimal obstruction.

Humans↗

PubMed2002

Balloon catheter dilation for treatment of persistent nasolacrimal duct obstruction.

PURPOSE: To report the outcome of balloon catheter dilation of the lacrimal duct for treatment of children with persistent nasolacrimal duct obstruction after previous surgery. DESIGN: Interventional case series. METHODS: Thirty-two consecutive children with a history of persistent nasolacrimal duct obstruction following previous surgery were treated with nasolacrimal duct probing with balloon catheter dilation of the distal nasolacrimal duct. Patients were excluded from this study if they had a history of facial trauma, systemic disorders that involved the lacrimal system, or nasolacrimal duct cysts. Outcomes were considered excellent if the patient had complete symptomatic 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, fair if the patient had moderate residual symptoms or delayed tear drainage, and poor if there was no improvement. RESULTS: Thirty-two children (20 with bilateral nasolacrimal duct obstruction and 12 with unilateral nasolacrimal duct obstruction) underwent balloon catheter dilation. Overall results were excellent in 9 (28%) patients, good in 15 (47%) patients, fair in 7 (22%) patients, and poor in 1 (3%) patient. Seven patients had undergone more than one previous procedure. Of these patients, 3 had excellent outcomes, 2 had good outcomes, 1 had a fair outcome, and 1 had a poor outcome following balloon catheter dilation. CONCLUSIONS: Balloon catheter dilation is a safe and generally effective treatment for children with persistent symptoms of nasolacrimal duct obstruction following previous surgery.

Catheterization↗

PubMed1990

Lacrimal drainage anomalies in mandibulofacial dysostosis.

Seven patients who had the complete form of mandibulofacial dysostosis were examined to determine the prevalence of nasolacrimal abnormalities. Bilateral inferior punctal atresia (and, by implication, accompanying inferior canalicular atresia) was identified in all seven patients; a 95% confidence interval for the true underlying rate of this finding in mandibulofacial dysostosis is 59% to 100%. Lacrimal surgery was required in only one patient who had coexistent bilateral nasolacrimal duct obstruction and chronic dacryocystitis and who responded well to bilateral dacryocystorhinostomy.

Adolescent↗

PubMed1994

Infection after insertion of alloplastic orbital floor implants.

Ten patients developed infections after alloplastic implantation (nine silicone, one gelatin film [Gelfilm] implant) for orbital floor fracture repair. Infection resulted from the following: (1) dental surgery, (2) upper respiratory infection, (3) inferior extrusion of a retained implant into the maxillary sinus with a fistulous tract into the inferior conjunctival fornix, (4) rhinoplasty, (5) snorting cocaine and other drugs, (6) postoperative infection after orbital floor repair, and (7) medial implant migration resulting in chronic dacryocystitis. In all ten patients, implants were removed because of orbital abscess, recurrent infection, or chronic low-grade infections. Microbiologic culture of removed implants disclosed Staphylococcus aureus, S. epidermidis, Serratia marcescens, and Pseudomonas aeruginosa as the offending organisms. The main complication of infection included severe cicatricial ectropion of the lower eyelid in three patients. The final globe position was not adversely affected by implant removal performed from five months to 20 years after insertion. Guidelines for prevention and management of orbital implant infections based on these ten patients are presented.

Adolescent↗

PubMed1993

Ocular manifestations of the lacrimo-auriculo-dento-digital syndrome.

We studied a mother and daughter with an extremely rare constellation of signs and symptoms. One or both had absent lacrimal puncta, nasolacrimal duct obstruction, chronic dacryocystitis, dry eyes, and epiphora. Systemic findings included salivary gland hyposecretion, dental hypoplasia and dysplasia, cup-shaped ears with hearing loss, and digital anomalies. These findings are consistent with those of the lacrimo-auriculo-dento-digital syndrome, a genetic disorder. Our study supports the autosomal dominant inheritance of this syndrome, delineates the ophthalmic manifestations, and provides evidence that renal anomalies are part of the disorder.

Abnormalities, Multiple↗

PubMed2001

The role of bacteriologic infection in the etiology of nasolacrimal duct obstruction.

BACKGROUND: In patients with nasolacrimal duct obstruction, the inflammation and fibrosis may be secondary to coexisting infectious colonization within the lumen of the lacrimal sac. We examined the bacterial flora within the lacrimal sac at the sac-duct junction to explore the possibility of a primary bacteriologic etiology of the inflammatory response. METHODS: The study included 114 consecutive patients (132 sides) with epiphora undergoing routine external dacryocystorhinostomy (DCR) at a tertiary care hospital in Toronto between November 1999 and April 2000. A lacrimal sac tissue biopsy specimen was acquired intraoperatively from the inferior posterior lacrimal sac near the sac-duct junction. Microbiologic analysis was carried out to determine the presence and identification of infectious organisms. RESULTS: Culture gave positive results in 51 patients (44.7%) (41.7% of specimens). A total of 65 isolates were cultured, of which 78.5% were gram-positive bacteria and 21.5% gram-negative bacteria. Of the gram-positive organisms 76.5% were Staphylococcus sp. The presence of a positive culture result was independent of a history of dacryocystitis or the presence of a mucocele. INTERPRETATION: Using direct biopsy methods, we found culture-positive lacrimal sac specimens in a large proportion of patients undergoing DCR surgery. These organisms were found to be present in patients with and without a history of infection.

Bacterial Typing Techniques↗

PubMedDate not supplied

The spectrum of orbital aspergillosis: a clinicopathological review.

Orbital aspergillosis is an uncommon but serious infection that may first present to the ophthalmologist. Usually arising from the paranasal sinuses, it may present in manifold ways within the orbit. Some presentations, such as optic nerve involvement, can respond to systemic corticosteroids, leading to delays in diagnosis and possibly iatrogenic potentiation of the infectious process. In this review, pertinent clinical and radiographic findings are discussed, and the literature is summarized. Classic approaches to therapy include local treatment, debridement, and systemic amphotericin B. We review novel approaches to treating orbital aspergillosis and detail a flow-chart for its management. Four patients from the spectrum of orbital aspergillosis are also described: initially presenting as an infection of an exenteration socket, a complex dacryocystitis, and optic nerve tumor, and post-operative periorbital swelling. Physicians should be familiar with the clinical spectrum of disease and the variable presentation of this infection, as early diagnosis and rapid institution of appropriate therapy are crucial elements in the management of invasive aspergillosis. In the neutropenic or otherwise immunocompromised patient, a high index of suspicion must be maintained as delays in diagnosis of fulminant aspergillosis may lead to overwhelming and rapidly progressive infection. Obtaining adequate diagnostic material for pathological and microbiological examination is critical. Newer methods of therapy, particularly itraconazole and liposomal amphotericin B, may be beneficial in selected patients.

Adult↗

PubMed2000

Clinical efficacy of the polyurethane stent without fluoroscopic guidance in the treatment of nasolacrimal duct obstruction.

PURPOSE: To evaluate the clinical efficacy of the polyurethane (Song) stent in the treatment of nasolacrimal duct obstruction without fluoroscopic guidance, especially at the junction between the lacrimal sac and nasolacrimal duct or at the nasolacrimal duct. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: This study evaluated 59 cases of nasolacrimal duct obstruction in 53 patients, with mean epiphora of 36 months (range, 2 months-17 years). METHODS: Without the assistance of a radiologist, a polyurethane nasolacrimal stent was placed by introducing a guidewire through the superior or inferior punctum into the canaliculus and advancing it across the obstruction into the opening of the inferior meatus of the nasal cavity. The mean follow-up period was 22 months (range, 12 months-48 months). MAIN OUTCOME MEASURES: Patency of the lacrimal passage to irrigation and the duration of this procedure. RESULTS: Complete resolution of epiphora was accomplished in 55 (93.2%) of the 59 eyes. There was recurrence of epiphora in four cases because of obstruction of the stent in three cases and obstruction of the common canaliculus by recurrent dacryocystitis in one case. CONCLUSIONS: Polyurethane stenting without fluoroscopic guidance seems to be a valuable technique for primary management of nasolacrimal duct obstruction before dacryocystorhinostomy.

Adult↗

PubMed2001

Lacrimal sac dacryoliths: predictive factors and clinical characteristics.

OBJECTIVE: Lacrimal sac dacryoliths are often diagnosed during dacryocystorhinostomy (DCR), although their cause is unclear. Several factors have been suggested to predispose to dacryolith formation. The clinical presentation of nasolacrimal duct obstruction (NLDO) may differ if associated with a dacryolith. Our study evaluated specific risk factors related to dacryolith formation and how the clinical presentation of patients with dacryoliths differs from patients with primary acquired NLDO who undergo DCR. DESIGN: Retrospective, comparative, interventional case series. PARTICIPANTS/INTERVENTION: One hundred thirty-eight consecutive patients with NLDO who underwent DCR (163 total DCR cases) between 1993 and 1998. MAIN OUTCOME MEASURES: We evaluated the frequency of dacryolith formation for all DCR cases. For 115 patients with primary acquired NLDO, we statistically compared the patients with dacryoliths (n = 12) to those without (n = 103) for several variables related to clinical history and presentation. RESULTS: The overall frequency of dacryoliths was 12 of 163 (7.4%) for all DCR cases and 12 of 138 (8.7%) for all patients. All patients with dacryoliths were in the subgroup of 115 patients with primary acquired NLDO, and the frequency in that subgroup was 12 of 115 (10.4%). There was no statistical difference between the group of patients with dacryoliths and those without dacryoliths for age, duration of epiphora, history of acute dacryocystitis, or previous use of antiglaucomatous topical medications. Male gender was more likely to be associated with dacryoliths (P = 0.004), as was initial presentation with lacrimal sac distension (P < 0.001). Partial nasolacrimal obstruction on lacrimal irrigation approached statistical significance for dacryolith formation (P = 0.08), as did a history of cigarette smoking (P = 0.09). CONCLUSIONS: In patients with primary acquired NLDO who require DCR, male gender and presence of sac distension are more frequently associated with dacryoliths. Partial NLDO and history of cigarette smoking may also be relative risk factors for dacryolith formation. These observations may be helpful in the evaluation and surgical planning for patients with lacrimal obstruction.

Dacryocystorhinostomy↗

PubMed2001

Clinicopathologic analysis of 166 patients with primary acquired nasolacrimal duct obstruction.

OBJECTIVE: To determine the prevalence of lacrimal sac pathology in patients undergoing dacryocystorhinostomy (DCR) for primary acquired nasolacrimal duct obstruction (PANDO). DESIGN: Observational case series. PARTICIPANTS: One hundred sixty-six patients with symptoms of PANDO. METHODS: A total of 202 lacrimal sac biopsies were obtained from 166 patients undergoing external DCR procedures for symptoms of PANDO. MAIN OUTCOME MEASURES: Patient demographics, presenting symptoms and signs, relevant history, and assessment of the nasolacrimal system were recorded. All lacrimal biopsy specimens were examined histopathologically. RESULTS: A total of 118 patients (71%) were female and 48 patients (29%) were male. The mean age was 60.7 years (range, 21-93 years). All patients demonstrated epiphora, and 32 patients had dacryocystitis. Duration of symptoms ranged from 6 weeks to 50 years. No lacrimal sac tumors were detected. Sixty-five percent of specimens demonstrated chronic inflammation. CONCLUSIONS: No neoplasms were detected among 202 lacrimal sac specimens from 166 patients with symptoms of PANDO. Most lacrimal sac specimens demonstrated chronic inflammatory changes. We conclude that a lacrimal sac biopsy should be performed when there is suspicion of a neoplasm based on the clinical, historical, or intraoperative findings, rather than routine biopsy of all patients with PANDO.

Adult↗

PubMed1980

Lacrimal system complications in trachoma.

A clinical study of the lacrimal complications of trachoma was conducted in the eastern province of Saudi Arabia. Of the 579 Saudi Arabian patients examined, 446 (77%) showed clinical evidence of trachoma, 62 of whom had severe inactive trachoma. In this last group the following lacrimal complications were observed: dry eye syndrome, punctal phimosis, punctal occlusion, canalicular occlusion, nasolacrimal-duct obstruction, dacryocystitis, dacryocystocele, and dacryocutaneous fistula. Histopathologic examination of seven lacrimal-sac biopsies showed the same cicatrizing changes seen in 14 conjunctival biopsies.

Aged↗

PubMed1984

Eyelid and orbital treatment following radical maxillectomy.

Malignant lesions of the nasopharynx and paranasal sinuses often encroach upon the orbit. A series of nineteen patients who underwent partial or radical maxillectomy is presented to summarize the eyelid and orbital findings that required further treatment. Fifteen of these patients were left with an intact globe and a visually useful eye, but the defects of epiphora, eyelid malposition, dacryocystitis, and diplopia were visually threatening and required treatment. The cosmetic deformities and diplopia following maxillectomy and radiation are partially amenable to treatment with late bone grafting. Lacrimal outflow deficiencies were successfully treated with dacryocystorhinostomy. Only patients with ocular complications following maxillectomy are included in this series; therefore, the range of problems and their treatment confronting the ophthalmologist is summarized.

Adenocarcinoma↗

PubMed1985

Keratopathy in a family with the ectrodactyly-ectodermal dysplasia-clefting syndrome.

Four members of a family with the ectrodactyly-ectodermal dysplasia-clefting (EEC) syndrome and associated keratopathy are presented. The main features of this syndrome include lobster-claw deformities of the hands and feet, abnormalities of the hair and teeth, cleft lip and palate, nasolacrimal abnormalities, and a progressive keratopathy ranging in severity from an asymptomatic pannus to bilateral dense corneal scarring and neovascularization. Despite congenital limb abnormalities, the major functional disability of three of these patients stems from severe photophobia and decreased visual acuity secondary to the corneal disease. Treatment with cycloplegics, topical steroids, and bandage soft contact lenses was unsuccessful. The EEC syndrome is transmitted in an autosomal dominant manner. The spectrum of keratopathy demonstrated in this family can be explained by the different ages of the patients, by variation in gene penetrance and expressivity and by differing durations and severity of dacryocystitis and related keratoconjunctivitis. The etiology of the keratopathy appears to be primarily a manifestation of the underlying ectodermal dysplasia with probable contributions from associated tearfilm abnormalities and external ocular infection.

Abnormalities, Multiple↗

PubMed1986

Primary acquired nasolacrimal duct obstruction. A clinicopathologic report and biopsy technique.

Primary acquired nasolacrimal duct obstruction (PANDO) of adults is a clinical syndrome of unknown cause, and the histopathology of the nasolacrimal duct has not been substantially studied. A technique of excisional biopsy of the soft tissue contents within the nasolacrimal canal during external dacryocystorhinostomy (DCR) is presented. No complications were associated with the biopsy technique in 14 cases. Two cases of lacrimal obstruction secondary to sarcoidosis and leukemia were discovered in biopsies of patients with the clinical syndrome of PANDO, demonstrating the value of routine biopsy during DCR. Biopsies revealed a spectrum of changes that correlated with duration of symptoms. Early cases revealed active chronic inflammation along the entire length of the narrowed nasolacrimal duct. Intermediate cases revealed focal resolution of the inflammatory process with fibrosis, while late cases showed fibrous obliteration of the entire duct. Although the first event in primary acquired nasolacrimal duct obstruction remains uncertain, clinicopathologic correlation suggests that compression of the duct by inflammatory infiltrates and edema precedes clinical chronic dacryocystitis.

Adult↗

PubMed1988

Silicone intubation for the treatment of congenital lacrimal duct obstruction: successful results removing the tubes after six weeks.

There is little agreement in the ophthalmic literature on the optimum length of time that silicone tubes should be left in place after lacrimal intubation for the treatment of congenital nasolacrimal duct obstruction. Various authors have recommended leaving the tubes in for 3 to 6 months. The authors of this article believe this to be an excessive amount of time. Lacrimal probing, inferior turbinate fracture, and silicone intubation were performed in children ranging in age from 3 months to 5 years. The tubes were removed after 6 weeks in all cases. Resolution of epiphora and dacryocystitis was achieved in all cases. Follow-up ranged from 4 to 81 months. The authors recommend that the silicone tubes be removed after 6 weeks. They also believe that fracture of the inferior turbinate should be performed along with silicone intubation.

Child, Preschool↗

PubMed1995

External dacryocystorhinostomy. Surgical success, patient satisfaction, and economic cost.

BACKGROUND: External dacryocystorhinostomy (DCR) is the standard treatment for nasolacrimal duct obstruction, with success rates consistently above 90%. This study reviews the demographics, success, cost, efficiency, and patient satisfaction in external DCR. This information will be useful as comparison criteria for evaluating new surgical techniques. METHODS: Records of 169 external DCR procedures performed over an 8.7-year period were reviewed. All patients had preoperative symptoms of tearing and/or dacryocystitis with a component of nasolacrimal obstruction. Patient demographics, history, examination findings, surgical and anesthesia information, postoperative success, complications, and follow-up course were recorded. Patient satisfaction and long-term success were evaluated by telephone survey. RESULTS: External DCR often required middle turbinectomy (17%), exposure of ethmoid sinuses (17%), and removal of dacryoliths (14%). Most patients (90%) underwent silicone intubation, with the tubes removed at an average of 3.7 weeks after surgery. A patent system was established in 95% of procedures, whereas 92% remained asymptomatic. Postoperative complications included hemorrhage (3.9%) and scarring (2.6%). Of the surveyed patients, 87% denied continued or recurrent symptoms; 97% rated their incision "good" to "excellent" in appearance; and all patients stated they would recommend the procedure to others. CONCLUSION: External DCR is highly successful, requires limited follow-up, and is a cost-effective procedure. Complications are uncommon, and patient satisfaction is high. New lacrimal surgical techniques must be evaluated against the long-proven success of the external approach.

Adolescent↗

PubMed1997

Computed tomography in lacrimal outflow obstruction.

BACKGROUND: Acquired nasolacrimal duct obstruction is a common ophthalmologic problem. Despite widespread understanding of treatments available for nasolacrimal duct obstruction, few authors have commented on its etiology. Because the nasolacrimal system is anatomically related to important nasal and sinus structures, the authors postulated that acquired nasolacrimal duct obstruction and its complications might occur simultaneous to, and possibly as a consequence of, rhinologic or sinus disease. MATERIALS AND METHODS: Twenty-three patients with acquired nasolacrimal duct obstruction and 100 control patients were evaluated by coronal computed tomography for evidence of sinus disease or nasal abnormalities. Specifically, five findings were noted: ostiomeatal complex disease, ethmoidal opacification, agger nasi cell opacification, concha bullosa, and nasal septal deviation. RESULTS: Overall, 20 (87%) patients with acquired nasolacrimal duct obstruction demonstrated one or more radiologic finding of sinus disease or rhinologic abnormality whereas 63 (63%) control subjects exhibited these findings. This difference was determined to be statistically significant (P < 0.05). A statistically significant higher incidence of ethmoidal opacification, agger nasi cell opacification, and nasal septal deviation was observed in patients with nasolacrimal outflow obstruction than in controls. Differences in the incidence of ostiomeatal complex disease and concha bullosa were not found to be statistically significant. CONCLUSION: These data demonstrate a correlation between computed tomography findings of sinus disease or nasal abnormality and the presence of acquired nasolacrimal outflow obstruction. This association between radiologic evidence of sinorhinologic disorders and lacrimal outflow obstruction may imply that dacryocystitis, like sinus disease, may be produced by disease of the lateral nasal wall. When evaluating a patient with acquired nasolacrimal duct obstruction, the physician should consider evaluation for concomitant nasal and sinus disease.

Humans↗

PubMed1998

Prospective randomized comparison of external dacryocystorhinostomy and endonasal laser dacryocystorhinostomy.

OBJECTIVE AND DESIGN: The introduction of endonasal laser dacryocystorhinostomy (ENL-DCR) in the early 1990s showed great promise of changing dacryocystorhinostomy into an elegant, minimally invasive procedure from the traditional external dacryocystorhinostomy (EXT-DCR). This prospective, randomized study compares these two operations, their success rates, surgical durations, and postoperative symptoms. PARTICIPANTS: A total of 64 cases in 61 patients with primary acquired nasolacrimal sac or duct obstruction were divided into 2 subgroups by symptoms (simple epiphora and chronic dacryocystitis). These patients were randomized within both subgroups into 2 operation groups with 32 cases in each group. INTERVENTION: Altogether, 32 EXT-DCRs and 32 ENL-DCRs were performed. The silicone tube was removed at 6 months after surgery. The final follow-up visit was at 1 year after surgery. The patency of the lacrimal passage was investigated by irrigation, and patients were questioned about their symptoms. MAIN OUTCOME MEASURES: The patency of the lacrimal passage to irrigation and the duration of surgery were measured. RESULTS: The success rate at 1 year after surgery was 91% for EXT-DCR and 63% for ENL-DCR after primary surgery. The difference was statistically significant (P = 0.016). The surgical duration for ENL-DCR was three times shorter than for EXT-DCR, the average duration being 23 minutes and 78 minutes, respectively (P < 0.0001). CONCLUSIONS: The EXT-DCR, when compared with ENL-DCR, seems to provide superior operation results in primary acquired nasolacrimal duct obstruction.

Adult↗