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By using a PE-catheter for catheterising the tear ducts, dacrocystography becomes a simple and rapid investigation. It permits excellent morphological demonstration of pathological changes, since films can be obtained under screening control. A water-soluble, low viscosity contrast medium is recommended. Amongst more than 100 dacrocystograms, there were no serious complications.
The nasolacrymal duct of Discoglossus pictus is able to differentiate in vitro from prometamorphosis, without thyroxine added to the culture medium if it is taken off late or with thyroxine added to the culture medium if it is taken off earlier (presumptive anlage).
The topography and morphology of the lacrimal ducts in newborn infants was demonstrated by means of post mortem dacryocystograms and microphotograms of histologic slides. Because of bends in the course of the lower tear duct, a percentage of probings will fail to effect satisfactory perforation of the Hasner membrane. In most cases, the soft texture of this membrane requires no more than syringing under pressure, using a hollow probe as described by Bangerter (1953).
Intranasal operations on the lacrimal duct developed in 1910 by G. West are rarely used now. The author analyzes his experience gained in 5000 endonasal dacryocystorhinostomies (96.7% of which were effective) and the advantages of intranasal approach to the lacrimal duct and presents a working classification of dacryocystitis. Indications for endonasal surgery on the lacrimal duct and contraindications precluding it are defined and a table for selecting the appropriate intranasal intervention in cases with abnormal discharge of tears offered. The author emphasizes the efficacy of endonasal operations and advocates wide use of this method in dacryology.
We will refer to lacrimal system pathologies involving the outflow pathways, as well as to the recent advances in the management of canalicular and lacrimonasal duct anomalies, including modifications to dacrycystorhinostomy technique, treatment for congenital obstructions, and lacrimal intubations. Special emphasis will be placed on the usefulness of nasal and canalicular endoscopy for the examination and treatment of congenital obstructions and endonasal pathologies, as an aid for intubations and lacrimal surgery, as well as on reasons for failed procedures.
Diseases of the lacrimal system are optimally evaluated by dacryocystography, CT, MR imaging, and nuclear scintigraphy. Dacryocystography is selected to define the lumen of the lacrimal drainage system in inflammatory disease (dacryocystitis), dacryoceles, dacryoliths, and developmental abnormalities. Dacryocystography provides supplemental information in benign and malignant tumors, principally to differentiate an intrinsic lesion from an extrinsic lesion. CT is indicated for delineation of palpable mass lesions such as cysts, benign and malignant tumors, and diseases, especially in the paranasal sinuses, affecting the lacrimal apparatus secondarily. MR imaging has limited application but is useful to differentiate fluid from solid masses within the sac and to define tumor extension from the sac into the duct and anatomic regions outside the sac and duct. MR imaging with gadolinium enhancement should be used in suspected tumors and to separate a cyst from a solid mass. Radiologic methods fail to identify the histopathology of benign and malignant tumors. Nuclear scintigraphy is helpful in patients with epiphora with no demonstrable anatomic abnormality on dacryocystography.
The authors describe longer than two-year experience with the use of permanent intracanalicular silicone plugs in the treatment of the dry eye syndrome. Between August 1997 and November 1999 the authors selected by means of the test with dissolvable collagen plugs 50 patients to whom permanent silicone intracanalicular plugs were inserted. During the follow up period (1-28 months) no complications were recorded associated with the insertion of permanent intracanalicular silicone plugs.
The dacryocystorhinostomy is an operation that connects directly the lacrymal sac to the nasal cavity. In 1904, Toti described the external approach but one had to wait until the development of the sinus surgery to have a new interest in the endonasal approach. It appears to be a safe, efficacious and a less traumatizing procedure preserving the lacrymal function without skin incision. It allows a procedure in a non-scarred field. A good relationship between the ENT and the ophthalmologist is required.
Clinical description of a 12-year-old girl with a number of congenital abnormalities including retarded growth and an asymmetric facies. All the clinical features observed are compatible with the CHARGE association. Ocular anomalies are important bilateral colobomata associated with nystagmus and strabismus. Three among four of the lacrymal canaliculi are missing. This anomaly has not yet been described in the CHARGE syndrome. The discussion refers to all the clinical observations especially the ophthalmological features.
Conventional dacryocystorhinostomy (DCR) usually involves extensive removal of bone at the lacrimal fossa and hence risks disruption of the lacrimal pump mechanism. A physiological operation for nasal lacrimal blockage is described whereby only the inferior portion of the lacrimal sac and the adjacent duct are marsupialized into the nose. The operation is safe, quick and does not involve sophisticated instruments. Result of 81 consecutive endoscopic inferior DCRs reveals a success rate of over 90% which is maintained with time. Most patients had a wide lacrimal window with preserved lacrimal pump movement at the superior sac remnant.
Lacrimal gland duct cysts develop insidiously in the superotemporal cul de sac. They may be preceded by trauma, infection, or inflammation of the conjunctiva. They are often asymptomatic but may induce discomfort, a sensation of fullness, a visible mass, lid distortion or ectropion. Fluctuation in size with weeping or environmental stimuli is seen. Histopathology is variable. Six cases are described to demonstrate the features. Complete excision of each cyst by meticulous dissection through a conjunctival approach was performed. Total resection is the optimal technique to prevent recurrence.
The bony nasolacrimal fossa and canal, which protect the more distal excretory portion of the lacrimal apparatus, the nasolacrimal sac and duct, are contained within the medial portion of the orbit and lateral aspect of the nose, sites that are commonly injured in facial trauma. The CT scans of 25 patients who sustained fractures of the nasolacrimal fossa and/or canal as a result of motor vehicle accidents were reviewed to determine the appearance of the fractures and to determine types of facial fractures also present. The patients' clinical records were reviewed to determine the frequency of associated complications. Thirty-six fractures of the nasolacrimal fossa and canal were found in the 25 patients. In 20 patients these were associated with complex fractures of the midportion of the face; the other five patients had simple unilateral facial fractures. Three kinds of nasolacrimal fractures were identified: avulsion of the fossa, comminution of the fossa or canal, and linear fractures of the canal. Of the 19 fractures involving the nasolacrimal fossa, 15 consisted of an avulsed fragment of bone containing the nasolacrimal sac and four had comminution of the nasolacrimal fossa. The majority of the fractures of the nasolacrimal canal (15 patients) were comminuted. Our results show that nasolacrimal fractures occur in association with simple unilateral facial fractures and with more complex fractures of the midface and that the fractures follow certain patterns. Complications related to injury to the nasolacrimal sac and duct were documented in five patients. Although this number is significant, it is fewer than we expected, considering the severity of the injuries.
PURPOSE: To describe a new endonasal dacryocystorhinostomy (DCR) technique and assess its efficacy. DESIGN: Prospective nonrandomized interventional case series. METHODS: A prospective series of 44 consecutive endonasal DCRs performed from January 1999 to December 2000 was entered into the study. The new technique involved creation of a large bony ostium and mucosal flaps to create an anastamosis between the lacrimal sac mucosa and nasal mucosa. Patients presenting with naso-lacrimal duct obstruction based on symptomatic, clinical, and radiologic grounds were included in the study. Patients who had undergone previous lacrimal surgery were excluded. Surgery was performed by two surgeons (A.T., P.J.W.) using a standardized operative technique. Patient demographics, presentation, examination findings, surgical and anesthetic data, postoperative success, complications, and follow-up were evaluated. Success was defined as anatomic patency as well as relief of symptoms as assessed by fluorescein flow on nasendoscopy, lacrimal syringing, and patient examination. Intubation of the lacrimal apparatus was performed in all operations and the tubes usually removed at 4 to 6 weeks postoperatively. After removal of the tubes follow-up was 13 months (mean, 12.9 months; range, 9-28 months; standard deviation [SD], 6.1 months). RESULTS: There were 36 patients (12 male/24 female) who underwent 44 endonasal DCRs. The average age of the patients was 62.9 years old (range, 15-86 years old; SD, 19.1 years) and the main presentation was with epiphora (93%) and/or mucocoele (33%). In 13 operations (30%) a septoplasty was required at the time of surgery, and in 10 operations (23%) further endoscopic sinus surgery was performed in conjunction with the DCR. Anatomic success with a patent nasolacrimal system was achieved in 40 of 44 operations (91%). Symptomatic and anatomic success was seen in 39 of 44 operations (89%). Five of the DCRs were classified as failures. In one DCR the patient was symptomatic despite a patent nasolacrimal system and well-healed ostium. In two DCRs preoperative medial canalicular problems were noted. In two DCRs scarring and fibrosis of ostium were noted. CONCLUSIONS: This new technique of endonasal DCR involves creation of a large ostium and construction of nasal and lacrimal sac mucosal flaps. Its anatomic success rate (91% or 40 of 44 DCRs) compares favorably with the success rate of other techniques for endonasal DCR and is also similar to the success of external DCR. Experience in endoscopic nasal surgery is important in endonasal DCR surgery, as other ancillary procedures may be required within the nose at the time of surgery.
BACKGROUND: There are few lacrimal surgeons in the field of clinical Ophthalmology, while the number of patients with an obstruction of tear duct increases. The success rate for the external dacryocystorhinostomy (DCR) procedure is approximately 90%. The outcome of external DCR using two new forceps and postoperative transnasal endoscopy was studied. MATERIAL/METHODS: 93 consecutive patients (100 cases) underwent external DCR. Two new forceps (a DCR slide forceps and a cleaning forceps in the nasal cavity) were used, and transnasal endoscopic examination postoperatively was done. The relatively small cutaneous incision (12-15 mm) was done. Two new forceps were used during and after the DCR procedure. RESULTS: All the cases showed round or oval ostia and patency on irrigation. Some amount of discharge adherent to the STs was observed in each case within one week after the external DCR procedure. CONCLUSIONS: The transnasal endoscopic examination performed postoperatively and the use of the two new forceps were of value for increasing the success rate of external DCR.
Spontaneous nasal tumors in ageing rats are very rare. Chronic irritation and disruption of nasal, paranasal, buccal, and dental tissues have been associated with the occurrence of tumors of the nasal and paranasal structures in rats. To find out whether there is a relationship between malocclusion (MO) and nasal squamous cell carcinoma (SCC) in Cpb:WU (Wistar random) rats, a total of 899 untreated control rats (548 males and 351 females) from eight long-term toxicity/carcinogenicity studies was screened for nasal tumors and MO. All relevant data and the histopathology of the nasal and paranasal structures of a sample of these rats (189 males and 197 females from three of the studies) and all rats bearing a nasal tumor were subjected to a detailed analysis. Of the 899 rats, 84 males (15%) and 78 females (22%) suffered from MO. Microscopic examination revealed an unexpectedly high incidence of lesions in the nasolachrymal duct (NLD): 64 out of 189 males (34%) and 68 out of 197 females (34.5%) showed inflammatory changes, with or without squamous metaplasia and/or hyperplasia of the lining epithelium of the NLD. The incidence of NLD lesions was much higher in the animals with than without MO, suggesting an interaction of both phenomena. Eight of the 899 untreated control rats had a nasal tumor; all were SCCs and all occurred in males. The origin of the tumors was as follows: 2 NLD, 2 most probably NLD, 2 presumably NLD, 1 of unknown origin but possibly NLD, and 1 probably a cutaneous epidermoid cyst. On the basis of these findings, it was concluded that nasal SCC in Cpb:WU (Wistar random) rats prevails in males and is primarily associated with chronic inflammation of the NLD rather than with MO, although MO probably is an (indirectly) contributing factor.
BACKGROUND: Treating injuries of the lacrimal system with a silicon intubation is an approved method to prevent post-traumatic epiphora. MATERIALS AND METHODS: Between 1990 and 1999, operations were carried out on 44 patients with injuries of the canaliculi with silicon ring intubations. Interesting for us were the age distribution, causes of injuries, localisation and mid- to long-term postoperative complications. RESULTS: The age of the patients was between 1.75 and 74 years, 48% of the injuries were caused by household accidents, 23% by violence, 20% by traffic accidents and 9% by job-related accidents. The canaliculus inferior was injured in 68% of all patients. We found 10 postoperative complications, e.g. ectropia, a too long silicon ring or granuloma. We found a positive anatomical readapted lacrimal system in 88% and 12% of our patients complained of distinct to severe epiphora. CONCLUSIONS: The treatment of lacrimal laceration with a silicon intubation is an excellent method but special care should be taken with correct positioning of the lid margin.
BACKGROUND: The mechanism of lacrimal drainage under physiological conditions is controversial. The aim of this study was to analyze the three-dimensional architecture of human efferent tear ducts from functional and clinical points of view. A new theory of tear outflow is discussed. METHODS: Thirty-two prepared lacrimal systems of adults were examined by histological, immunohistochemical and scanning electron microscopic techniques. RESULTS: The wall of the lacrimal sac is made up of collagen bundles, elastic and reticular fibers arranged in a helical pattern. Wide luminal vascular plexus are embedded in this helical system and connected to the cavernous tissue of the inferior turbinate in the region of Hasner's valve. Immunohistochemical analysis showed evidence of type I and type III collagen as well as chondroitin 4- and 6-sulfate. CONCLUSION: With blinking, the lacrimal part of the orbicularis muscle contracts. The fornix of the sac moves in a cranial-lateral direction. Thus the lacrimal sac distends and may be "wrung out" due to its medial attachment and helically arranged fibrillar structures. The vascular plexus may play an important role in the absorption and drainage of lacrimal fluid.
PURPOSE: To evaluate the utility of a new diagnostic radiologic technique for anatomic evaluation of the lacrimal outflow system in patients with epiphora and to delineate anatomic variations in the lacrimal systems of patients with both patent and obstructed systems. METHODS: This study retrospectively reviewed clinical and radiologic data in a series of 30 patients with epiphora who underwent our radiologic protocol. Imaging included fluoroscopic dacryocystography followed by helical CT dacryocystography after injection of lacrimal system contrast. Axial CT data was three-dimensionally reconstructed and rotated for viewing of images in multiple projections. Mean axial cross-sectional areas of the lacrimal sac and duct were determined. RESULTS: Sixty lacrimal systems in 30 patients were clinically and radiologically evaluated. The average mean cross-sectional area of the lacrimal sac and duct in the setting of complete obstruction was 0.153 cm2 and was statistically significantly larger (p=0.0286) when compared with average mean cross-sectional areas in unobstructed (0.045 cm2) and partially obstructed (0.052 cm2) lacrimal systems and were associated with lacrimal system dilation proximal to the level of obstruction. The difference in average mean cross-sectional area between patients with unobstructed and partially obstructed systems was not statistically significant. A number of lacrimal system abnormalities were noted in our series, including obstructions at various levels of the lacrimal outflow system, lacrimal sac masses, sinusitis, sarcoidosis, sinus carcinoma, and failed dacryocystorhinostomy. Twenty-three lacrimal systems were believed to be radiographically normal. Radiologic findings altered surgical treatment in 10 of 30 patients in this series. CONCLUSIONS: This relatively safe and well-tolerated radiologic technique provides detailed imaging of the lacrimal outflow system and surrounding structures. The information obtained from this technique may be helpful in clinical and surgical decision making.