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Partial lacrimal carunculectomy: a simple procedure for epiphora.
OBJECTIVE: To evaluate the effect of partial surgical excision of enlarged lacrimal caruncles, termed megalocaruncles, in patients with epiphora from functional lacrimal drainage obstruction. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: From May 1995 through December 1999, 88 patients (46 women and 42 men; mean age, 68 years) with epiphora, patent lacrimal drainage system on irrigation, and a megalocaruncle underwent a partial lacrimal carunculectomy procedure. In 26 patients, a bilateral partial lacrimal carunculectomy was performed. INTERVENTION: Lacrimal caruncular tissue, with its overlying mucosa, was partially excised, and the wound was closed with interrupted sutures. MAIN OUTCOME MEASURES: Symptomatology and patient satisfaction. RESULTS: After a partial lacrimal carunculectomy procedure, epiphora was subjectively improved in 77% of the patients, ranging from complete relief in 33% to significant improvement in 44% of the patients. Twenty-three percent of the patients had no change in symptoms. The mean follow-up was 12.7 months. CONCLUSIONS: Megalocaruncles can be the cause of epiphora in patients with functional lacrimal drainage obstruction, for whom a partial lacrimal carunculectomy is an effective surgical procedure in 77% of the cases.
Silicone punctal plug extrusion.
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Silicone punctal plug extrusion.
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Diagnosis and treatment of lacrimal sac cysts.
A case of lacrimal sac cyst is presented. The presenting symptoms, work-up, and differential diagnosis are discussed. We advocate excision of the cyst as the treatment of choice in an attempt to preserve the functional anatomy of the patient's lacrimal system.
Benign peripheral nerve sheath tumors (neurofibromas) of the lacrimal gland.
Two patients, a 43-year-old woman and a 62-year-old man, developed benign peripheral nerve sheath tumors (neurofibromas) of the lacrimal gland, in the former case of the deep orbital lobe, and in the latter of the palpebral lobe. A neurogenic tumor was not seriously considered clinically in either case, because of the paucity of previous reports on the occurrence of neural tumors in the lacrimal fossa region. Instead, in the first case a benign mixed tumor was considered the most likely clinical diagnosis, whereas in the second the coexistence of a swelling in the parotid gland raised the possibilities of a lymphoid tumor or a leukemia. Due to unusual light microscopic features, transmission electron microscopy was required to secure unequivocal diagnoses. In the orbital lobe tumor, an encapsulated spindle cell proliferation without nuclear palisading but with focal areas of myxoid change suggested either a cellular benign mixed tumor or a schwannoma. The palpebral lobe lesion displayed a myxoid spindle cell proliferation that had splayed apart the ducts and acinae of the lacrimal gland, to impart the overall appearance of a benign mixed tumor. The ducts, however, were multilaminar rather than possessing the usual double cellular layer seen in classical benign mixed tumors, and the glandular units contained zymogen granules, which are typically not seen in benign mixed tumors. Electron microscopy disclosed in both lesions the presence of interrupted basement membrane material partially surrounding the tumor cells, long spacing collagen (banded basement membrane material), and poorly developed desmosomes, features compatible with a neural tumor. Neither myofilaments, tonofilaments, nor ductal-type granules sometimes observed in benign mixed tumors were discovered. The tumor cells in these cases therefore failed to demonstrate clear-cut Schwann cell characteristics (eg, continuous basement membranes, pseudo-mesaxons, tangles of cell processes), and more closely resembled perineural cells that have been described in ultrastructural studies of peripheral nerve tumors including neurofibromas of other sites.
Squamous cell carcinoma of the lacrimal sac.
Diagnosis to differentiate successfully an uncommon epidermoid carcinoma of the lacrimal sac from the commoner acute inflammation of the lacrimal sac requires a good history and thorough physical examination. If epidermoid carcinoma of the lacrimal sac is suspected, additional procedures including a dacryocystogram, orbital tomograms, plain films and CAT scans, and otolaryngologic consultation are necessary. Such a successful diagnosis of an epidermoid carcinoma of the lacrimal sac is reported here. An aggressive surgical approach is described and strongly recommended because review of the literature shows that the prognosis for these tumors is very grave.
Medical management of congenital nasolacrimal duct obstruction.
One hundred thirteen consecutive children seen with congenital nasolacrimal duct obstruction were treated with local massage and topical antibiotic ointment. The obstruction was resolved in 107 patients within eight months of initiation of this form of management. Nearly all of the children were spared a surgical procedure that probably would have been performed if early probing of the nasolacrimal system had been advocated.
A clinicopathologic study of primary adenoid cystic carcinoma of the lacrimal gland.
A retrospective study of 26 patients with the diagnosis of primary adenoid cystic carcinoma of the lacrimal gland was performed with use of randomly selected tissue from each tumor. An attempt was made to determine any associations among clinical presentation, survival, and tumor histologic patterns. We found that lower tumor grades were associated with a predominantly Swiss-cheese (cribriform) pattern. Both lower tumor grade and Swiss-cheese pattern were associated with longer survival. The basaloid (solid) pattern or bone invasion was not associated with a shorter survival. Between men and women, there were no differences in clinical presentation, histologic patterns, or survival. Survival was not affected by surgical or radiation therapy.
The autoimmune nature of aqueous tear deficiency.
Twenty-two patients with aqueous tear deficiency (ATD) were examined for the presence of the following autoantibodies: immunofluorescent antinuclear antibody (ANA) and Sjögren's syndrome antibodies A and B (SS-A and SS-B). These autoantibodies were found in 17 (82%) patients but not in control subjects, and they correlated with the severity of symptoms and ocular surface changes. Bacterial keratitis, often recurrent and bilateral, and progressive sterile corneal stromal melting developed in six autoantibody-positive ATD patients. Eight antibody-positive patients had labial salivary or lacrimal gland biopsies, and all showed similar histologic features with marked destruction of the glandular architecture by lymphocytic infiltration. Immunoglobulin and complement were not detected in the glandular tissue. Circumstantial evidence suggests that an abnormal immunologic reaction, possibly related to Epstein-Barr viral (EBV) infection, is the cause of the glandular destruction and tear deficiency.
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.
Results of late probing for congenital nasolacrimal duct obstruction.
One hundred four consecutive patients (138 eyes) with congenital nasolacrimal duct obstruction were probed after the age of 13 months. One hundred twenty-nine eyes (93.5) were cured after the first probing. Based on this study and others showing the effectiveness of medical management, it is the current practice of the authors to delay probing until the patient is at least 13 months of age.
Computerized survey of lacrimal surgery patients.
A computerized survey of 295 patients undergoing lacrimal drainage surgery within a three-year period where a six-month follow-up was possible was undertaken. The etiology and demographic information regarding tear duct obstruction was assessed. Dacryocystorhinostomy surgery was found to be highly successful (93%), in obstructions of the lacrimal sac and lacrimal duct. The overall success rate in patients with canalicular and common canalicular obstruction undergoing a reconstructive approach was 73%, and those cases where an attempt was made to relieve epiphora with the insertion of a Jones bypass tube had a success rate of 65% on one operation. Most of these Jones tube patients could ultimately be rendered tear-free.
Canaliculops.
Over a 1-year period, a cystic bluish coloration developed in the most medial aspect at the margin of the right upper eyelid of a 40-year-old man. The clinical diagnoses were either a conjunctival inclusion cyst or an adnexal cyst, possibly of the gland of Moll. The excised specimen was studied histopathologically and exhibited a lining that was virtually indistinguishable from that of the normal canaliculus, except for hyperplasia of the cellular wall and the focal presence of a superficial mucin-producing columnar cell monolayer at the lumen. The medial edge of the excised specimen showed a merging of the cyst into a nonectatic portion of the canaliculus. Inflammation in the wall of the cyst and in this terminal portion of the canaliculus was not identified. This is believed to be a unique entity of an idiopathic ectasia with mild epithelial proliferation of a segment of the canaliculus. The authors have termed this condition canaliculops, to draw a parallel between it and ectasia of the ducts of the lacrimal gland, so-called dacryops.
Epstein-Barr virus infection and immunologic dysfunction in patients with aqueous tear deficiency.
The authors tested their hypothesis that Epstein-Barr virus (EBV) infection is a risk factor for aqueous tear deficiency (ATD) by evaluating 38 ATD patients and 17 controls for serologic evidence of EBV infection. Aqueous tear deficiency was graded clinically as mild or severe. A linear trend toward elevated EBV capsid (P less than 0.05) and early antigen (P less than 0.001) titers was noted from control to severe ATD patients. Rubella and cytomegalovirus antibody titers were poorly correlated with EBV titers, suggesting that the elevated EBV antibodies in ATD patients were not due to nonspecific polyclonal B-cell activation. Epstein-Barr virus antigens were detected in two of six lacrimal gland biopsies from severe ATD patients with Sjögren's syndrome, but in none of the control glands. Aqueous tear deficiency patients were evaluated for immunologic dysfunction associated with EBV infection. Linear trends of elevated serum IgG (P less than 0.05), autoantibody and immune complex positivity (P less than 0.05), and reduced natural killer cell cytotoxicity (P less than 0.05) were found from controls to severe ATD patients. Furthermore, reduced T-helper lymphocyte counts (P less than 0.06) and an increased percentage of HLA-DR+ CD8 lymphocytes (P less than 0.05) were observed in severe ATD patients compared with the mild and control groups. A multivariate analysis of the data showed a significant correlation between severe ATD and elevated EBV early antigen titers, Sjögren's syndrome, and an increased percentage of HLA-DR+ CD8 lymphocytes. The authors' findings suggest that EBV infection may be a risk factor for development of ATD in a subset of ATD patients with greater disease severity, Sjögren's syndrome, and immunologic dysfunction.
Lesions of the lacrimal caruncle. Clinicopathologic features.
PURPOSE: The rarity of lesions of the lacrimal caruncle, in addition to their wide variety of histopathologic types, makes an accurate clinical diagnosis difficult. To comprehensively illustrate the clinical and histopathologic features of these lesions, the authors conducted a retrospective analysis of all caruncular lesions that underwent biopsy at a large referral ophthalmologic hospital during a 33-year period. METHODS: The files of the Laboratory of Pathologic Anatomy from July 1957 through July 1990 were reviewed. The slides of 113 cases were reviewed and classified in two main categories: (1) inflammatory lesions and (2) neoplasms and pseudoneoplasms. The age and sex of the patient as well as preoperative clinical diagnosis were analyzed. RESULTS: Among the 113 patients whose surgical specimens were evaluated, there were 44 males and 69 females. The mean age was 31 years. The clinical diagnosis was accurate in only 50% of the patients. The authors found 16 different histopathologic types of lesions. Nevi accounted for 34% and papillomas for 26% of the total analyzed lesions. Only 5.3% of the lesions were found to be malignant. CONCLUSION: In this series, the authors confirm the low frequency of caruncular lesions, as well as their wide variety of histopathologic types. The authors found a wide range of ages and a slight female predominance. Nevi and papillomas were the most frequent lesions, and clinically they were properly diagnosed in most of the cases. Although malignancy was uncommon, it was suspected in only half of the cases.
Magnetic resonance imaging of the lacrimal drainage system.
BACKGROUND: Magnetic resonance imaging (MRI) has excellent spatial and soft tissue resolution in the periocular and orbital region, especially when combined with surface coil techniques. Other methods, including computed tomography, dacryocystography, and dacryoscintigraphy provide limited information in the area of the lacrimal drainage system. Magnetic resonance imaging was used in conjunction with other imaging modalities to compare the anatomic detail and clinically relevant information obtained about various pathologic processes in the lacrimal drainage area. METHODS: Patients with a variety of lacrimal drainage disorders underwent MRI with either head or surface coils. Contrast agents also were used in selected cases. Seven case reports are presented. RESULTS: Magnetic resonance imaging provided detailed information about local anatomy, extent of pathology, and, in some cases, etiology of the pathology. CONCLUSIONS: Magnetic resonance imaging with surface coils provides detailed soft tissue information when compared with dacryocystography and computed tomography in the area of the lacrimal drainage system. In selected cases of lacrimal drainage system pathology, MRI may provide data that affect patient management.
Keratoconjunctivitis sicca associated with achalasia of the cardia, adrenocortical insufficiency, and lacrimal gland degeneration: Keratoconjunctivitis sicca secondary to lacrimal gland degeneration may parallel degenerative changes in esophageal and adrenocortical function.
OBJECTIVE/DESIGN: This study aimed to examine and describe three siblings with alacrima, the eldest of whom had associated achalasia and adrenocortical insufficiency. PARTICIPANTS: Three affected siblings and four age-matched control subjects participated. INTERVENTION/MAIN OUTCOME MEASURES: The three children underwent complete ophthalmologic examinations; computed tomographic scanning of brain, orbit, chest, and abdomen; and measurement of serum cortisol. All three were subjected to a short synacthen challenge. Lacrimal gland biopsies were performed on the two younger subjects, and specimens were studied by light and electron microscopy. RESULTS: All three children showed virtually absent tear secretion as tested by the Schirmer test. The resulting keratopathy was most severe in the oldest child, who developed bilateral corneal melting. The two younger children showed interpalpebral corneal staining with rose bengal. All three children improved after punctal occlusion. Addison's disease was present in the oldest child. Computed tomographic scanning showed absent lacrimal and shrunken adrenal glands in association with achalasia of the cardia in the oldest child. The lacrimal glands were found to be reduced in size in the next eldest child. When evaluated by electron microscopy, the lacrimal gland biopsy specimens from the two younger children showed neuronal degeneration associated with depletion of secretory granules in the acinar cells. CONCLUSION: In this disease, radiologic evidence of reducing lacrimal gland size with increasing age could represent a degenerative process. This may be paralleled by other signs and the possibility of adrenocortical insufficiency and achalasia of the cardia should be investigated in all children presenting with dry eyes. These children appear to have a progressive neuronal disease.