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Silicone intubation: an alternative to dacryocystorhinostomy.

Silicone intubation is an alternative to dacryocystorhinostomy in selected patients who have epiphora and obstruction of the nasolacrimal system. Silicone tubing may be passed through the nasolacrimal system and left in place for a prolonged period of time. In many instances, this obviates the need for a dacryocystorhinostomy. If the intubation is not completely successful, a dacryocystorhinostomy can always be carried out at a later date.

Dacryocystitis↗

Lacrimal gland and fossa lesions: an approach to diagnosis and management.

Lesions of the fossa of the lacrimal gland present special problems in diagnosis and management. Clinical recognition and differentiation of benign mixed cell lacrimal gland tumors from other inflammatory and neoplastic lesions of the lacrimal gland fossa are feasible and should provide the basis for the approach to proper management. Lesions conforming to the clinical picture of benign mixed cell lacrimal gland tumors need not undergo incisional biopsy, but require en bloc excision with adjacent tissues through a lateral orbitotomy to ensure complete excision and to prevent late recurrence. Incisional biopsy is indicated and should not be delayed in suspected infectious and noninfectious inflammatory lesions that have not responded rapidly to medical therapy, and in other lesions suspected of being neoplastic and not amenable to total local excision. An expedient approach to these lesions is essential if the prognosis of epithelial lacrimal gland neoplasms is to be improved.

Adult↗

Caruncular dacryops with extruded secretory globoid bodies.

A 52-year-old black man evaluated for a left cataract following an iritis was incidentally noted to have a vascularized, firm, inflammatory-appearing left caruncular mass. Removal of the cataract and of the left caruncular mass led to the discovery that the latter was composed of dilated channels containing secretory globoid bodies; the cyst wall was composed of a double layer of cuboidal epithelium, occasionally displaying apical cytoplasmic snouts. Lobules of lacrimal gland tissue were found in intimate association with the cystic spaces in multiple foci. The secretory globoid bodies had ruptured from the cystic cavity into the connective tissue of the caruncle, where a multinucleated foreign body-type granulomatous response had been elicited. This spontaneous rupture and the ensuing inflammation accounted for the inflammatory character of the lesion on clinical examination. The authors believe that secretory globoid bodies are a distinctive feature of dacryops, which normally occurs in the major lacrimal gland. When dacryops occurs in a minor lacrimal gland of the caruncle or fornices (glands of Krause or Wolfring), the presence of secretory globoid bodies may help to distinguish dacryops in these unusual locations from small conjunctival inclusion cysts, which sometimes have calcareous inclusions but lack the myriad spherical secretory bodies of dacryops.

Cytoplasmic Granules↗

Lacrimal gland enlargement in familial sarcoidosis.

Familial sarcoidosis is rare. It is unusual for lacrimal gland enlargement to be the initial manifestation of sarcoidosis. Two sisters are described with lacrimal gland enlargement as the initial manifestation of sarcoidosis. Gallium-67 scan was a useful adjunct to lacrimal biopsy in sarcoidosis. Sarcoid dacryoadenitis responded dramatically to a short term course of low dose prednisone.

Adult↗

Hemorrhage associated with dacryocystorhinostomy and the adjunctive use of desmopressin in selected patients.

Of 150 consecutive patients who underwent dacryocystorhinostomy, postoperative hemorrhage requiring treatment occurred in 2 patients, both of whom had endogenous platelet dysfunction without thrombocytopenia. The first patient had macroglobulinemia, and the second patient had congenital platelet hypofunction. Prophylactic 1-deamino-8-D-arginine vasopressin (desmopressin; DDAVP) was used successfully to decrease intraoperative bleeding in the second patient. Of the 15 patients with exogenous platelet dysfunction secondary to the use of aspirin or nonsteroidal anti-inflammatory agents within 1 week of operation, none had hemorrhaging. Dacryocystorhinostomy should be undertaken cautiously and with hematologic consultation in patients with blood dyscrasias.

Adult↗

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.

Adolescent↗

Infectious mononucleosis presenting with dacryoadenitis.

BACKGROUND: A case of severe, bilateral, acute dacryoadenitis in a rarely reported association with infectious mononucleosis is described. METHODS: A 16-year-old girl had acute, bilateral, lacrimal gland enlargement demonstrated with computed tomographic scanning of the orbits. Clinical findings and laboratory investigations confirmed the diagnosis of infectious mononucleosis. Treatment with systemic steroids was initiated. RESULTS: There was rapid resolution of the clinical findings with systemic steroids. CONCLUSION: Dacryoadenitis is an uncommon presentation of infectious mononucleosis and may overshadow the other manifestations of this disease. The diagnosis of infectious mononucleosis should be considered in patients with acute dacryoadenitis. Systemic steroids play an important role in rapidly resolving the dacryoadenitis.

Acute Disease↗

Retained stenting material: an unusual cause of dacryocystorhinostomy failure.

OBJECTIVE: To highlight a troubling cause of dacryocystorhinostomy (DCR) failure and to alert ophthalmologists to the potential problems that can result when stenting material is not removed and becomes retained after DCR. DESIGN: Consecutive noncomparative case series. PARTICIPANTS: Twelve patients who underwent revision DCR from February 1994 to January 1997. INTERVENTION: Endoscopic DCR, pre- and postoperative nasal endoscopy, preoperative computerized tomography (CT), and pre- and postoperative Jones testing. RESULTS: Fourteen revision endoscopic procedures were performed on 12 patients with recurrent epiphora following DCR. Failure was due to retained stenting material in six patients, a small bony rhinostomy in three patients, excessive scar formation within the rhinostomy in two patients, and improper location of the rhinostomy in one patient. Preoperative endoscopy and CT scan each correctly identified the retained sponge or tubing in four of six patients. CONCLUSIONS: Fastening a small sponge to Silastic tubing and positioning it within the DCR site in an attempt to retard DCR stenosis can be associated with a poor outcome and should be avoided. The nasal endoscope provided excellent visualization of pathology within the lacrimal sac and was a valuable tool. Retained stenting material should be considered in patients with persistent epiphora following DCR or intubation prior to any decision to commit a patient to permanent Jones tube placement.

Adult↗

Nasal endoscopy in the treatment of congenital lacrimal sac mucoceles.

PURPOSE: To determine the incidence of intranasal cysts associated with lacrimal sac mucoceles and the cure rate with nasal endoscopic cyst marsupialization. DESIGN: Interventional case series. METHODS SETTING: University-affiliated teaching hospital. PATIENT POPULATION: Twenty-five infants with non infected or infected lacrimal sac mucoceles or dacrocystitis without obvious mucocele were consecutively enrolled. INTERVENTION PROCEDURES: Management included local lacrimal massage, parenteral antibiotics, and when still symptomatic, nasolacrimal duct probing with concomitant nasal endoscopy. Intranasal cysts identified were marsupialized until the distal end of the nasolacrimal duct probe was visualized. MAIN OUTCOME MEASURES: Presence of intranasal cyst identification and cure rate. RESULTS: Infants were 4 days to 10 weeks old (mean 19 days). Forty-eight percent had a bluish cutaneous mass inferior and lateral to the lacrimal sac. Twenty percent were bilateral. At presentation, 76 percent had dacrocystitis. Fourteen percent had respiratory distress. Only one child responded to medical management. At endoscopy, 23 of 24 infants had ipsilateral intranasal cysts. The one child without nasal cyst had recurrent dacrocystitis and no mucocele. All children with mucocele were cured except one child with residual nasolacrimal duct obstruction. CONCLUSIONS: Lacrimal sac mucoceles were almost always associated with intranasal cysts. Nasal endoscopy is a valuable addition to the treatment plan for lacrimal sac mucoceles not responding to a brief trial of massage or infantile dacrocystitis. To avoid potential complications, we recommend against waiting until infection occurs before proceeding with surgery.

Dacryocystitis↗

Lacrimal gland abscess complicating acute sinusitis.

Infections of the lacrimal gland are uncommon, with suppuration and abscess formation being exceedingly rare. Acute bacterial dacryoadenitis may develop secondary to an adjacent infection, from blood-borne spread or after trauma. We report a paediatric case of lacrimal gland abscess thought to be caused by spread of infection from the paranasal sinuses. The possible mechanisms of spread of infection to the lacrimal gland are discussed as well as the management of this unusual complication of sinusitis.

Abscess↗

[Pleomorphic adenoma mimicking dacryoadenitis].

A 56-year-old female patient displayed an increased volume of her left lacrimal gland with pain and inflammation. On CT scan, a hyperdense lacrimal mass was found in the left lacrimal fossa. Observation was the first course, for no steroid therapy could be applied because of evolving digestive ulcers. After 9 months of observation, the gland was surgically removed en bloc through a wide anterolateral approach. Pathological analysis of the gland showed a pleomorphic adenoma. This case illustrates the advantage of a wide surgical approach in treating lacrimal gland tumors, in order to avoid or limit the risk of recurrence.

Adenoma, Pleomorphic↗

[Actinomycotic lachrymal canaliculitis: a case report].

The authors report a case of unilateral chronic epiphora resistant to prolonged topical antibiotic treatment in a 62-year-old woman. Culture yielded some colonies of Actinomyces species. A dacryocystorhinostomy was found to be ineffective. Canaliculotomy with removal of cast resolved the chronic canaliculitis. Histological examination confirmed the diagnosis of solid cast of Actinomyces.

Actinomycosis↗

Lacrimal drainage system obstruction: management and results obtained in 70 patients.

Causes and types of acquired obstruction of the lacrimal drainage system are discussed in 70 patients, as well as the results of their surgical treatment. Obstruction of the lacrimal drainage pathway, according to frequency, was due to: trauma (mainly naso-orbital and LeFort II fractures), post-inflammatory stenosis of the nasolacrimal duct, tumours and latrogenic injuries of the naso-lacrimal drainage system often following Caldwell-Luc operations of the maxillary sinus. The ages of patients ranged from 3-70 years. Canalicular obstruction was diagnosed in 9 (12.9%), obstruction of the lacrimal sac in 2 (2.8%), while obstruction of the naso-lacrimal duct in 50 (71.4%) patients, including 3 bilaterally. And in 9 (12.9%) patients, injury to the lacrimal system following excision of tumours of the eyelids and the medial canthal region occurred. In patients with canalicular obstruction intubation of the canaliculi was carried out and both ends of the drain were inserted into the nasal cavity for 6 months via a dacryocystorhinostomy. Total recovery was obtained in 44.5%. In lacrimal sac and nasolacrimal duct obstruction Dupuy-Dutemp's dacryocystorhinostomy was performed and 90.4% of the patients recovered. When fibrosis or extensive damage of the lacrimal sac had occurred, wide anastomosis with the nasal duct was indicated. After tumour excision, the lacrimal pathways were reconstructed by conjunctivo-rhinostomy, conjunctivo-sinusostomy or conjunctivo-dacryocystorhinostomy. In 40% of the patients who underwent conjunctivo-dacryocystorhinostomy a successful outcome ensued.

Adolescent↗

Canalicular infection caused by Actinomyces.

We present 7 cases of canalicular involvement with Actinomyces collected over a 5-year period. All patients had involvement of one canaliculus, upper or lower, with lacrimal drainage patent to syringing. Curettings obtained by incising the involved canaliculi yielded Actinomyces species (5 cases) and Arachnia propionica (2 cases), typically in association with a mixed bacterial growth. Our results show that these patients often remain undiagnosed for months or even years, and are treated inappropriately for their recurrent symptoms. Despite sensitivity of Actinomyces to a broad spectrum of antibiotics, medical therapy alone does not eradicate the disease, and surgical evacuation of all concretions is essential to achieve a cure.

Actinomycosis↗