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Inflammation in the nasal mucosa may lead to epiphora by causing edema around the orifice of the nasolacrimal duct. We present and discuss three cases where simple treatment of rhinitis led to the resolution of the presenting symptom of epiphora, avoiding the need for surgery. A randomized prospective trial of topical nasal corticosteroids in the management of epiphora associated with rhinitis is in progress.
BACKGROUND: Recently, modified endoscopic medial maxillectomy (MEMM) has been described as an alternative technique to open maxillectomy for benign sinonasal neoplasms. However, few reports discuss the efficacy of MEMM for treatment of inflammatory disease of the maxillary sinus. We evaluate the efficacy of MEMM in treating chronic maxillary sinusitis. METHODS: A retrospective review of patients who underwent MEMM for refractory inflammatory disease between December 2002 and September 2004 was performed. All patients were treated with MEMM alone or as part of an endoscopic sinus surgery procedure. Standard demographic data, operative technique, and postoperative follow-up times were collected. RESULTS: Nineteen patients (average age, 57 years) underwent 24 EMMs for chronic maxillary sinusitis refractory to middle meatal antrostomy. All patients failed prior sinus surgery, including 14 Caldwell-Luc procedures. Average follow-up was 19.5 months (range, 10-27 months). One patient has persistent hyperplastic sinusitis that currently requires monthly follow-up and medical treatment. Our only complication was one nasolacrimal duct injury. CONCLUSION: MEMM is both a safe and an effective treatment for chronic maxillary sinusitis refractory to standard medical and endoscopic surgical management.
The aim of this study was to determine the type of phospholipase A2 (PLA2) in nasal fluid and to demonstrate its cellular origin. The concentration of group II PLA2 was high (591.5 micrograms/l) in nasal fluid compared with serum level (10.8 micrograms/l) and the fluid of paranasal sinuses (10.6 micrograms/l). Methacholine stimulated nasal fluid contained only small amounts (19.1 micrograms/l) of group II PLA2 when the flow of tear fluid through the nasolacrimal duct was obstructed. Occasional glands secreting group II PLA2 were found in nasal and paranasal mucosa by immunohistochemistry. Lysozyme was found in the majority of mucosal glands. It was concluded that nasal and paranasal mucosal glands contain group II PLA2. In nasal fluid, however, PLA2 is mainly derived from tear fluid.
The authors report the case of a male infant who presented with growth retardation and multiple congenital anomalies including bilateral cleft lip and palate, large glabella and broad nasal bridge. Eye examination revealed Rieger anomaly, nasolacrimal duct obstruction and mild microphthalmia bilaterally. In addition, shawl scrotum, nail hypoplasia and linear skin hypoplasia of the lower extremities were noted. Two G-banded chromosome studies were normal; prophase analysis showed 4p monosomy and 10q trisomy derived from a paternal balanced translocation. The clinical recognition of Wolf-Hirschhorn syndrome in this child, despite the two normal chromosome studies, allowed for the recognition of the cytogenetic aberration and identification of other family members who carry the balanced translocation.
Fifty-five patients with Down's syndrome were examined to evaluate the characteristics and frequency of ocular findings. Of these patients, 29 (52.7%) were hypermetropes, 7 (12.7%) were emmetropes, and 7 (12.7%) were myopes; astigmatism of more than 3.00 diopters was present in 7(12.7%) patients. Strabismus was observed in 12 (21.8%) patients. All but one of these 12 patients also had esotropia. Congenital nasolacrimal duct obstruction was present in 12 subjects (21.8%). Blepharitis was found in 19 (34.5%) cases. Nystagmus occurred in 7 (12.7%) patients. Brushfield spots were detected in only 20 (36.3%) of the patients and were more common in light-colored irides. Lens opacities were diagnosed in 11 (20%) patients, and two underwent successful cataract surgery. On fundus examination, an increased number of retinal vessels crossing the optic nerve head was detected in 21 (38.1%) cases. One of the patients had a retinal detachment. Significant but correctable ocular problems are present in patients with Down's syndrome and may interfere with the quality of life of the patient and with binocular vision. Surgical intervention may be needed for strabismus and for cataracts.
PURPOSE: The success rate of endoscopic dacryocystorhinostomy has been increasing with the development of better instruments and techniques. We conducted this study to evaluate the clinical results of endoscopic dacryocystorhinostomy using a Microdebrider, which has also been used for functional endoscopic sinus surgery. METHODS: We selected 76 patients (with a total of 84 affected eyes) who had been diagnosed with a nasolacrimal duct obstruction. These patients underwent an endoscopic dacryocystorhinostomy using a Microdebrider, which removed both nasal mucosa and lacrimal sac mucosa and also trimmed the margins of the ostotomy site. We assessed patients' outcomes on an anatomical basis using a dye test and endoscopy, which were used to define the anatomical success. We also arbitrarily defined functional success as whether the subjective epiphora was absent. At a four to 18 month follow-up, we monitored the clinical course to examine any recurrent episodes. RESULTS: The symptoms were alleviated in 72 eyes, with a primary success rate of 85.7%. On nasal endoscopy, a functional failure was seen in four eyes. In these four eyes, the orifice was narrowed by the presence of either granulation tissue or conjunctivochalasis. By contrast, surgical outcomes were the anatomical failure in eight eyes. In these eight eyes, the orifice was obstructed by the presence of granulation tissue as well as the adhesion of nasal mucosa. CONCLUSIONS: Endoscopic dacryocystorhinostomy using a Microdebrider enabled us to make the large fistula while minimizing the damage of adjacent tissue. It might be the recommended surgery that reduces the complications and enhances the success rate.
Many patients with symptomatic eye conditions present initially to their primary care physician. Comprehensive treatment of such conditions as dry eye syndrome, blepharitis, styes, chalazia, conjunctivitis, congenital nasolacrimal duct obstruction, superficial foreign bodies, corneal abrasion, and subconjunctival hemorrhage can often be provided in the primary care setting. Patients with persistent or severe conditions, particularly those involving foreign bodies and corneal abrasions due to high-velocity injuries, should be referred for immediate care by an ophthalmologist.
Docetaxel is a highly effective chemotherapeutic agent for metastatic or locally advanced breast cancer as well as other malignancies. One of the side effects of weekly administration of docetaxel is epiphora (excessive tearing) caused by canalicular stenosis and nasolacrimal duct obstruction. This article summarizes experience with epiphora and canalicular stenosis as a side effect of docetaxel and provides specific recommendations for management of this side effect.
We present a case of a young child whose canalicular laceration was repaired with a Veirs rod. The repair was likely successful. However, some time between four and six weeks postoperative, the rod slid down the nasolacrimal duct and was ingested. Its presence in the digestive tract was verified by radiographic studies. No untoward problems ensued.
Twenty-two cases of acute lacrimal abscess in infancy seen between 1959 and 1976 have been presented. Twelve of them had more han one attack at the time of reporting to this hospital. Initial treatment of the condition was medical, utilizing local and systemic antibiotics. If this did not produce a prompt response, incision and drainage of the abscess was done. The cases showed a preponderance of infections by mixed organisms. In three cases, blocked lacrimal passages opened up spontaneously while on medical treatment. In the remaining 19 cases, probing in an attempt to remove the obstruction in the nasolacrimal duct was performed as soon as the acute inflammation was controlled. Reprobing was needed in nine cases. Only two cases eventually required surgery to achieve a cure. The study indicates that early probing is successful in a high percentage of cases of acute lacrimal abscess including those coming with recurrent attacks.
Cornelia de Lange Syndrome (CDLS) is characterized by mental retardation, growth retardation, skeletal anomalies, and a characteristic facies. We examined 22 children with CDLS to ascertain the relative frequencies of oculofacial and ophthalmologic abnormalities. We confirm prior reports of the frequent findings of brow hypertrichosis, synophrys, and long arcuate eyelashes. In addition we documented the association with ptosis, nystagmus, and high myopia. Contrary to previous reports, we did not find blue sclera or corneal, pupillary, or retinal disorders to be part of this syndrome. Hypertelorism and telecanthus were found, but they were dependent on the method of calculation. Two children had optic nerve pallor. We also report the new findings of poor macular reflex, chin lifts induced by ptosis, hypertropia, and nasolacrimal duct fistula.
Three children developed endophthalmitis after cataract surgery. Each had signs and symptoms of either nasolacrimal duct obstruction or upper respiratory infection at the time of surgery. The causative organisms were Staphylococcus aureus, Staphylococcus epidermidis, and Streptococcus pneumoniae. Final visual acuities were 6/24, LP, and NLP, respectively. Endophthalmitis after cataract surgery in infants has never been reported. These three cases drawn from two pediatric ophthalmology practices represent an incidence of postoperative endophthalmitis of 0.45%. Although this incidence report is potentially spurious, it indicates that postoperative endophthalmitis is a very real threat in infants. We recommend a thorough systems review and exam of upper airways and lacrimal system before undertaking intraocular surgery in young children. We also caution against simultaneous bilateral surgery.
The incidence of endophthalmitis following pediatric anterior segment surgery is currently unknown. The paucity of reports of this entity has led some observers to recommend simultaneous bilateral surgery for congenital cataracts or glaucoma. In this study, we surveyed over 500 pediatric ophthalmologists and glaucoma specialists concerning their knowledge of, or involvement with, endophthalmitis following pediatric intraocular surgery. Seventeen cases of endophthalmitis were documented to occur out of 24,000 reported surgical cases. This results in an incidence estimate of 0.071%, or 7 cases per 10,000, which is similar to that recently reported following adult extracapsular cataract extraction. The presence of infection was diagnosed by the 3rd postoperative day in 82% of cases. An organism was documented by culture in 65% of cases. The organism was gram positive in all cases. Visual outcome was generally poor with 65% having no light perception. The presence of possible concurrent risk factors for postoperative endophthalmitis, including nasolacrimal duct obstruction and upper respiratory infection, was noted in 8 of the 17 cases.
We evaluated the advantages and disadvantages of image-guided endoscopic endonasal surgery for various diseases. Thirty-three patients, including 8 with chronic sinusitis, 14 with paranasal cysts, 1 with paranasal tumor (biopsy), 1 with sellaturcial cyst (Rathke's cleft cyst) and 9 with pituitary tumors were endonasally operated on from September 1998 to May 1999, with an electromagnetic navigation system, The Insta Trak (Visualization Technology Inc. USA). The Insta Trak system is composed of a computer, a metal probe with a nonmetallic suction tube attachment, and a soft-type headset with an electromagnetic sensor. This freehand, armless system compensates well for patient's head movement during surgery, and precludes the need for head fixation. Either straight or curved suction tube (probe) can be used to access almost of all pathological sites in the sinus cavity. Location of the metal probe is displayed on the computer moniter as an intersection point on the axial, coronal and sagital CT images. In all cases, Insta Trak showed the surgeon the appropriate location and direction of each lesion. The Insta Trak also indicated the location of the orbit, optic canal, nasolacrimal duct and/or skull base, thus, preventing intraoperative complications. When the anatomy was distorted by previous surgery and/or when there was uncontrollable bleeding from a severe lesion so that the surgeon had difficulty finding the proper orientation, the usefulness of image-guided surgery was sufficiently recognized. However, the following disadvantages were also pointed out. An additional 15 to 20 minutes is needed for equipment set up and operation, unless the surgeon and the operation room staff are familiar with the machine. The patient's CT image used for navigation relies on data obtained preoperatively, that is to say, it can not reflect morphological changes produced during surgery. Moreover, the surgeon must consider possible errors of the navigational point that may result in the headset during surgery, as well as, errors the machine may originally possess. The image-guided system successfully integrated the most up-to-date computer technology with a surgeon's anatomical knowledge for improved treatment of endoscopic endonasal surgery. However, we also concluded that the system should be used as a surgical supporting device for safer and more adequate procedures.
Inverted papillomas in the nose and/or paranasal sinuses exhibit a high recurrence rate, and an association with malignancy. Early diagnosis and aggressive surgical therapy are thus essential. Seventeen cases of inverted papilloma seen at Saitama Cancer Center over a 17-year period were reviewed. Common presenting symptoms, the primary papilloma sites and the results of surgical treatment were as follows. 1) Almost all patients complained of nasal obstruction. The usefulness of nasal biopsy of the tumor was confirmed, with 12 cases being diagnosed as having inverted papilloma pre-operatively. Inverted papilloma without squamous cell carcinoma caused osseous thinning, but did not destroy the bone. 2) It was found that the primary site of the papilloma involved the lateral wall of the nasal cavity. Lateral Rhinotomy was therefore recommended as a standard treatment. 3) The recurrence rate was 1/12 after Lateral Rhinotomy. Two cases had complaints associated with the Lateral Rhinotomy, nasolacrimal duct stenosis, and a scar in the median corner of eye. 4) Only one case had concomitant squamous cell carcinoma in the nose and maxillary sinus. This patient received chemo therapy, radiation therapy and finally maxillectomy, but the inverted papilloma recurred several times. Six years later, squamous cell carcinoma recurred and lead to this patient's death.
A six-month-old basset hound was presented with unilateral right epiphora and medial canthal and maxillary bone swelling. Skull radiographs and dacryocystorhinography revealed a nasal cyst, right nasolacrimal duct dilatation, and obstruction. Laboratory examination of the cyst confirmed the diagnosis of dacryops, a cyst of lacrimal gland origin. The cyst was treated successfully with surgical drainage and curettage.
PURPOSE: To evaluate a new magnetic resonance imaging protocol for dynamic study of the lacrimal outflow system and to use this protocol to search for problems in patients with an assumed permeable outflow system who develop epiphora. PATIENTS AND METHODS: A prospective study of nine patients, including 2 asymptomatic controls was conducted. The magnetic resonance protocol included, gadolinium instillation into the conjunctival cul-de-sac, 3D gradient-echo T1-weighted acquisition, 2 mm thick images passing through the nasolacrimal duct, dynamic acquisition after gadolinium instillation for timing dye progression through the outflow system. RESULTS: Similar results were obtained for the two control subjects with lacrimal transit time of a median 100 seconds. Three distinct events were individualized gadolinium arrival in the lacrimal sac (t1), at the extremity of the bony portion of the lacrimal duct (té), and the extremity of the mucosal portion of the duct (t3). Patients with an assumed permeable outflow system who had epiphora show results intermediary between passed dye and total blockage of the dye within the lacrimal sac. CONCLUSION: The study of the lacrimal outflow system using this new magnetic resonance imaging protocol contributes to the physiological study of tear evacuation and could be useful for quantitative assessment of lacrimal stenosis, particularly interesting for therapeutic guidance.
We present a 3-year-old child with clinical features of ectodermal dysplasia comprising sparse hair, dystrophic and ridged nails and bilateral obstruction of the nasolacrimal ducts. Additional findings were unilateral choanal atresia, bilateral syndactyly of the feet and polydactyly. We discuss the differential diagnosis of these clinical findings.