Intralacrimal migration of Masterka® stents

BACKGROUND

Tearing and conjunctivitis in children are commonly due to lacrimal drainage system obstruction. Congenital nasolacrimal obstruction is a common pathology treated by probing with or without silicone stent insertion, depending upon the age of the child. The silicone stent is self-retaining and placed for at least one month. Masterka^® is a recent version of Monoka^®, which may lead to the same surgical complications, such as intralacrimal migration.

SUBJECTS AND METHODS

The medical records of two patients surgically treated with the Masterka^® probe for nasolacrimal duct obstruction, who developed intralacrimal migration of the stent, were retrospectively reviewed and analyzed. A 41-month-old child and an 18-month-old child presented with disappearance of the silicone tube after 7 days and 2 years respectively. In the first case, the tube migrated completely within the lacrimal system and became externalized through the nose at 2 years, while in the second case, the Masterka^® was retrieved through a canalicular approach. In both cases, infants had no further tearing.

DISCUSSION

The frequency self-retaining stent disappearance is estimated at 15%. Among these cases, intralacrimal migration is only reported in 0.5% of cases. To prevent intralacrimal migration, the surgical technique must follow a certain number of rules. Management, based on residual epiphora, is discussed.

CONCLUSION

Prevention of intralacrimal migration of self-retaining stents involves a rigorous analysis of the relationship between the meatus and the fixation head at the time of placement. After lacrimal intubation, scheduled monitoring is necessary to screen for stent disappearance. Management is based on clinical findings, anterior rhinoscopy and even exploratory canaliculotomy.

[Minimally invasive bypass surgery for nasolacrimal duct obstruction : Transcanalicular laser-assisted dacryocystorhinostomy]

BACKGROUND

In recent years, the minimally invasive surgical procedure of transcanalicular laser-assisted dacryocystorhinostomy (TKL-DCR) has gained importance in the treatment of primary acquired nasolacrimal duct obstructions (PANDO).

OBJECTIVES

Surgical indications, functional success rates, potential advantages, and complications of TKL-DCR are presented and compared with the standard procedures external (EXT-DCR) and endonasal DCR (EN-DCR).

METHODS

The study comprises a PubMed literature review and our own clinical results.

RESULTS

Using TKL-DCR either as the primary surgical treatment for PANDO, or as a secondary procedure following failure (reobstruction of the surgical ostium) of previous EXT-DCR resulted in good functional success rates (60-90%). The duration of surgery (10-15 min) and the period of recovery are significantly shorter than in EXT-DCR. Visible cutaneous scars and significant postoperative nose bleeding are not among the complications of TKL-DCR, due to the lack of a skin incision and the coagulative ability of the diode laser. The smaller sized surgical ostium has been considered the main disadvantage of TKL-DCR, since it might be prone to earlier reobstruction. On the other hand, TKL-DCR spares the anatomical structures that form the physiological tear pump, which should favor tear drainage. In very few cases, thermal damage to the canaliculus has been observed as a complication.

CONCLUSIONS

Given the satisfying functional results, TKL-DCR is a valid alternative to the "gold standard" procedure EXT-DCR, especially in patients who particularly request speedy recovery and who do not want to take the risk of visible skin scaring. Future studies will have to investigate whether the smaller surgical ostia of TKL-DCR remain patent and whether functional success rates decrease during a longer follow-up period of >2 years.

[Success in probing for congenital nasolacrimal duct obstruction. Ten years experience]

INTRODUCTION

The congenital nasolacrimal duct obstruction is a common pathology, with low morbidity, but not exempt of complications without the correct diagnosis and management.

METHODS

Retrospective study from 2005 to 2015 in patients who were submitted to a probing procedure. We identified age at procedure, gender, laterality and presence or absence of success with the procedure.

RESULTS

One hundred thirty-seven eyes were analyzed. The median age was 17 months and the total success rate was 85.4%.

CONCLUSION

In congenital nasolacrimal duct obstruction there is a high rate of spontaneous resolution with the proper initial conservative management and, in patients older than 12 months, probing has a high rate of success.

Comparison of Polypropylene Sling with Combined Transconjunctival Retractor Plication and Lateral Tarsal Strip for Correction of Involutional Lower Eye Lid Ectropion

Purpose:

The study aims to compare the effectiveness and complications of transconjunctival retractor plication (TRP) with lateral tarsal strip (LTS) and the polypropylene sling (PS) surgery for treatment of involutional lower lid ectropion.

Method:

A prospective randomised pilot study was conducted on 30 eyes of 30 patients suffering from epiphora having horizontal eyelid laxity >6mm and age >50 years at a tertiary care centre from December 2014 to March 2015. They were randomly divided into two equal groups for TRP with LTS (group A) and PS (group B). Success was defined as relief in epiphora and lid laxity ≤4mm at 12 months post operatively.

Result:

There were 19 male and 11 female patients with age ranging from 55-80 years. The mean grade of ectropion was 2.80±1.32 in group A and 2.87±1.60 in group B. The preoperative horizontal laxity increased with the grade of ectropion (p <0.001) while medial canthal laxity was variable. The average surgical time per procedure in group A was 66 minutes and in group B was 24 minutes. Group A had a success rate of 93.33%, while group B had a success rate of 87%. Post-operative complications occurred in 2 eyes in group B only.

Conclusion:

Both LTS with TRP and PS are effective in the management of involutional ectropion. LTS with TRP though more invasive has higher success rates and a lower incidence of complications as compared to PS. However, PS is an easy to perform out- patient procedure that is faster and better tolerated in old patients.

Chronic Lymphocytic Leukaemia/ Small-Cell Lymphocytic Lymphoma of the Lacrimal Sac: A Case Series

BACKGROUND

Lymphomas of the lacrimal sac are rare, accounting for less than 10% of lacrimal sac malignant tumours. They may present with symptoms typical of secondary acquired nasolacrimal duct obstruction and are thus often misdiagnosed.

METHODS

Case series and literature review.

RESULTS

Herein we describe 3 cases of chronic lymphocytic leukaemia (CLL)/small-cell lymphocytic lymphoma (SLL) of the lacrimal sac with immunohistochemical and in 1 case molecular confirmation.

CONCLUSION

Lymphomas of the lacrimal sac should be suspected in patients with known CLL presenting with epiphora and dacryocystitis. During dacryocystorhinostomy, an incisional biopsy of the lacrimal sac is essential for confirming CLL/SLL involvement and may guide treatment.

Botulinum neurotoxin injection for the treatment of epiphora in nasolacrimal duct obstruction

PURPOSE

Retrospective long-term study to evaluate the efficacy of botulinum neurotoxin A (BoNT/A) therapy for epiphora due to non-surgical nasolacrimal duct obstruction.

INTRODUCTION

BoNT/A has been used successfully since 2000 in axillary hyperhidrosis to reduce secretory disorders. Some isolated cases of hyperlacrimation or crocodile tear syndrome have been treated on this basis. We used BoNT/A to decrease lacrimal secretion in cases of epiphora.

METHODS

We reviewed the qualitative and quantitative degree of improvement of epiphora after botulinum neurotoxin injections in the palpebral lobe of the lacrimal gland, carried out in an ophthalmic centre between 2009 and 2016. Epiphora was graded using a questionnaire, Munk scores and Schirmer tests before and after injections. Severity of side effects was recorded.

RESULTS

Twenty-seven palpebral lacrimal glands of twenty patients with epiphora, mean age 65±13, were treated with BoNT/A (Botox^® or Xeomin^®) from April 2009 to April 2016. The epiphora was induced by persistent nasolacrimal duct stenosis after surgical treatment. No conventional medical nor surgical treatment was effective at this time. The technique of injection, dilution and dosage were specific. We re-injected 14/27 cases on an as-needed basis, 7/27 cases three times, 3/27 cases four times, and 2/27 cases (same patient both glands) five times. The Schirmer test measured a decrease of lacrimal secretion in 24/27 (89%) lacrimal glands after neurotoxin injection. Side effects were ptosis in 4 cases and transient esotropia in 2 cases. The authors describe the injection techniques, the dosage, the volume and concentration of BoNT/A.

CONCLUSION

Patients with epiphora can be treated effectively with BoNT/A to reduce lacrimal secretion of the principal lacrimal gland in its palpebral portion. Ninety percent of the patients were very satisfied, with few side effects (ptosis or mild diplopia lasting from 3 days to 3 weeks). More studies are needed to delineate which types of epiphora can be treated with BoNT/A.

A review on use of botulinum toxin for intractable lacrimal drainage disorders

PURPOSE

To review the published literature on botulinum toxin (BTX) for epiphora secondary to refractory lacrimal drainage disorders.

METHODS

The authors performed a Pub Med search of all articles published in English on BTX injection into lacrimal gland for epiphora secondary to lacrimal drainage disorders. Relevant cross-references were obtained from the resultant studies. Data reviewed included demographics, indications, dose of BTX, number of injections, transconjunctival or transcutaneous route, outcomes and complications. Animal experiments of BTX into lacrimal gland were included and analyzed separately.

RESULTS

Botulinum toxin injection into lacrimal gland, in animal studies, has shown to reduce the tear volume significantly lasting for approximately a month without any histological changes. The major indications have been refractory canalicular obstructions and functional epiphora. The commonly used dose was 2.5 U. Outcomes in the few studies published are encouraging with transient ptosis being the most common complication.

CONCLUSIONS

Botulinum toxin into the lacrimal gland is a minimally invasive alternative in cases of refractory epiphora secondary to lacrimal drainage disorders. In these subsets of patients, the reported concentrations, dosage and outcome measures are variable and need larger studies for standardization.

External Dacryocystorhinostomy; Success Rate and Causes of Failure in Endoscopic and Pathologic Evaluations

BACKGROUND AND OBJECTIVES

External dacryocystorhinostomy (DCR) is the method of choice to treat nasolacrimal duct (NLD) obstruction and the other approaches are compared with it, with a failure rate of 4% to 13%. The current study aimed to assess the causes of failure in external DCR by postoperative endoscopic and pathological evaluation.

METHODS

The current retrospective cross sectional study followed-up113 patients with external DCR and silicone intubation for three months. Silicone tubes were removed after the third months. Failure was confirmed based on the clinical findings and irrigation test. Paranasal sinus computed tomography (CT) scanning, and endoscopic and pathological evaluations were performed in the failed cases.

RESULTS

Totally, 113 patients underwent external DCR. The patients included 71 females and 42 males. The mean age of the patients was 55.91 years; ranged from 18 to 86. Epiphora was the most common complaint before surgery (90.3%). Clinically, epiphora continued in 17 cases (15%), of which 94.11% had at least one sinus CT abnormality and 82.35% had at least one endoscopic abnormality. The most common endoscopic findings were deviated septum (70.6%), scar tissue (52.94%), concha bullosa (46.9%), septal adhesion (47.05%), enlarged middle turbinate (41.2%), and sump syndrome (11.7%). The failure was significantly associated with the chronicity of the initial symptoms (P-value=0.00). Pathologically, there were significant relationship amongst the failure rate, scar formation, and allergic rhinitis (P-values =0.00 and <0.05, respectively).

CONCLUSION

Preoperative endonasal evaluation and consultation with an otolaryngologist can improve surgical outcomes and help to have a better conscious to intranasal abnormalities before external DCR surgery.

Success rate of placement of a bicanalicular stent for partial nasolacrimal obstruction in adults under local, monitored anesthesia care and general anesthesia

Purpose

To study The Kaneka Lacriflow Stent, a self-retaining bicanalicular intubation set that can be placed under local anesthetic, providing a new option to treat epiphora and partial NLDO.

Design

Retrospective chart review.

Subjects

93 adult patients requiring treatment for a partial NLDO were evaluated. Stents were placed in office setting under local/topical anesthetic or in OR (MAC or GEN). The stent is placed with a stylet, and self-retains due to a widened portion sitting distal to the common canaliculis. It does not require recovery from the nose.

Methods:

Outcomes analyzed to evaluate success of stent placement.

Main outcome measure

Success rate of placement of the stent in adults.

Results

Stents left in place for 3 months. Results recorded 1 month after removal. Stents successfully placed in 124 of 136 (91%) eyes. Under local anesthesia in the office setting, 83 of 92 (90%) were placed successfully. Records were complete in 59 patients (78 eyes) and were analyzed further. 33 patients (52 eyes) had stents retained for the full 90 days and had follow-up recorded one-month post removal. Of the patients who retained the stents for 90 days and had full follow-up, 32 patients (51 eyes, 98%) reported improvement in their symptoms, while 1 patient reported no improvement.

Conclusion

Silicone intubation of the NLD in adults is rarely done due to need for general anesthesia. The Lacriflow stent can be successfully placed in the office under local anesthesia offering a new approach for tearing in adults.

A Case Series of Dacryoendoscopy in Childhood: A Diagnostic and Therapeutic Alternative for Complex Congenital Nasolacrimal Duct Obstruction Even in the First Year of Life

INTRODUCTION

Congenital nasolacrimal duct obstruction (CNLDO) is the most common cause of epiphora in infancy. Spontaneous resolution occurs in the majority of the cases by 1 year of age. Nevertheless, obstruction has a negative impact on the outcome of conservative or surgical therapy, especially in cases of complex CNLDO. When the condition persists beyond several months, early intervention with dacryoendoscopy (DE) around the age of 1 year could yield good results. The objective of the study is to analyze the success rate and effectiveness of early DE for complex CNLDO in the first year of life.

METHODS

A retrospective, non-comparative case series is presented. DE was performed under general anesthesia in patients between the age of 1 and 12 months with severe recurrent acute or chronic dacryocystitis. The medical histories, intraoperative and postoperative results after 3 months as well as via parents' interviews were analyzed to investigate the success rate.

RESULTS

A total of 18 consecutive DE in 16 patients between the age of 1 and 12 months (mean 7.3 ± 3.4 months) were studied. Nine lacrimal ducts were diagnosed with persistent chronic dacryocystitis refractory to probing/syringing. The remaining 9 presented recurrent acute dacryocystitis. Diagnostic DE was performed in 18 cases. A therapeutic DE was conducted in 15 lacrimal ducts (83.3%) with simultaneous correction of the associated stenosiswith the tip of the endoscope. A visual controlled opening of the stenosis was impossible in 3 cases due to a too narrow presaccal anatomy (n = 1), an osseous duct stenosis (n = 1), and a bulging membrane of Hasner into the inferior nasal meatus (n = 1). Postoperative findings were classified into four categories: poor, fair, good and excellent. Good results were documented in 16.7% (n = 3) and excellent results in 77.7% (n = 14). The bony obstruction was treated with dacryocystorhinostomy. A minimum follow-up of 3 months was considered for final clinical analysis. Ten patients' parents (12 surgeries) were interviewed by telephone (mean follow-up 24.8 months). No recurrence of stenosis and no further postoperative complications were observed.

CONCLUSION

DE is a diagnostic and therapeutic option for complex CNLDO in patients before the age of 1 year. The outcome of DE in the 3 months follow-up is highly indicative of positive final results in terms of patency of the lacrimal duct.

[Microendoscopic minimally invasive techniques in lacrimal surgery]

BACKGROUND

Lacrimation of the eye is a relatively common problem, the cause of which must be clarified by differential diagnostics. The most important symptom of a dysfunction of lacrimal drainage is epiphora.

METHODS

Due to the enhancement and miniaturization of endoscopes, which were originally used in gastroduodenoscopy in the 1990s, it is possible to check the anatomical structure and visualize pathological changes of the lacrimal drainage system, which is only approximately 1 mm in diameter. As shown by the results, mechanical stenoses are often caused by recurrent chronic inflammation. A complete stenosis usually occurs only slowly due to dysregulation of the lacrimal unit.

CONCLUSION

In contrast to the assumptions that were valid before the implementation of microendoscopy, complete stenoses are often only punctate and do not stretch over long distances. Shortly after the introduction of microendoscopic diagnostics minimally invasive therapy techniques, such as laser dacryoplasty (LDP) and microdrill dacryoplasty (MDP) were established. These procedures have enabled for the first time preservation of the entire physiology of the lacrimal drainage pump system despite surgical intervention after recanalization.

"TuNa-saving" endoscopic medial maxillectomy: a surgical technique for maxillary inverted papilloma

The maxillary sinus is the most common site of sinonasal inverted papilloma. Endoscopic sinus surgery, in particular endoscopic medial maxillectomy, is currently the gold standard for treatment of maxillary sinus papilloma. Although a common technique, complications such as stenosis of the lacrimal pathway and consequent development of epiphora are still possible. To avoid these problems, we propose a modification of this surgical technique that preserves the head of the inferior turbinate and the nasolacrimal duct. A retrospective analysis was performed on patients treated for maxillary inverted papilloma in three tertiary medical centres between 2006 and 2014. Pedicle-oriented endoscopic surgery principles were applied and, in select cases where the tumour pedicle was located on the anterior wall, a modified endoscopic medial maxillectomy was carried out as described in this paper. From 2006 to 2014 a total of 84 patients were treated. A standard endoscopic medial maxillectomy was performed in 55 patients (65.4%), while the remaining 29 (34.6%) had a modified technique performed. Three recurrences (3/84; 3.6%) were observed after a minimum follow-up of 24 months. A new surgical approach for select cases of maxillary sinus inverted papilloma is proposed in this paper. In this technique, the endoscopic medial maxillectomy was performed while preserving the head of the inferior turbinate and the nasolacrimal duct ("TuNa-saving"). This technique allowed for good visualization of the maxillary sinus, good oncological control and a reduction in the rate of complications.

Characteristics of orbital lymphoma: a clinicopathological study of 26 cases

OBJECTIVE

Evaluation of the medical data of patients with orbital and adnexal lymphoma.

DESIGN

Cohort study of all cases diagnosed with orbital or adnexal lymphoma at Meir Medical Center between 1993 and 2007.

PARTICIPANTS

Twenty-six patients, with intraorbital or subconjunctival masses with orbital involvement, were examined and followed up between 1 and 8 years.

MATERIALS AND METHODS

Examined data included: clinical presentation, age, gender, imaging, tumor location, surgical management, and pathological diagnosis.

RESULTS

Presenting signs and symptoms included proptosis, eyelid lesions, tearing, chemosis, decreased visual acuity, ptosis, pain, squint, and optic nerve compression. In five cases, lymphoma was misdiagnosed on neuroimaging. Bone changes were seen in four patients. All cases were B cell lymphomas; with the majority (22 cases) of small B cell type; consisting of primary extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue and two cases of small cell lymphoma. One small cell lymphomas was of follicular type on a background of CLL, and the other was CLL/SLL type. Fourteen cases were primary orbital disease, and 12 cases were systemic disease. Macroscopic appearance of lymphoma at open biopsy was characteristic in most cases. Flow cytometry phenotyping gave rapid reliable diagnosis of the disease.

CONCLUSIONS

Epiphora or chemosis in the presence of an orbital mass should alert the ophthalmologist to suspect lymphoma. Lymphoma may be easily misinterpreted on neuroimaging for other diseases. Bone changes seen on CT are more common than is generally perceived. Macroscopic appearance at open biopsy was characteristic.

Decreased interaction between ZO-1 and occludin is involved in alteration of tight junctions in transplanted epiphora submandibular glands

Tight junctions (TJs) in salivary epithelium play an important role in regulating saliva secretion. Autologous transplantation of submandibular glands (SMGs) is an effective method to treat severe dry eye syndrome. However, epiphora occurs in some patients 6 months after transplantation. We previously found that the acinar TJs are enlarged in rabbit SMGs after long-term transplantation, but the exact TJ components involved in the epiphora are still unknown. Here, we found that the mRNA and protein expression of ZO-1 and occludin were increased in the transplanted SMGs obtained from epiphora patients, while other TJs were unchanged. The intensity of ZO-1 and occludin at the apicolateral membranes as well as occludin in the cytoplasm were increased in epiphora SMGs, but the interaction between ZO-1 and occludin was decreased as evidenced by both co-immunoprecipitation assay and co-immunofluorescence staining. Mechanically, the expression of casein kinase 2α (CK2α) and CK2β, which was reported to affect occludin modification and the interaction of occludin with ZO-1 in previous literatures, were increased in epiphora glands. Moreover, activation of muscarinic acetylcholine receptor (mAChR) by carbachol directly decreased the interaction between ZO-1 and occludin and increased the acinar TJ width in the freshly isolated human SMGs, whereas these effects were abolished by pretreatment with CK2 inhibitor. Taken together, our findings suggest that decreased interaction between ZO-1 and occludin might contribute to the epiphora occurred in the transplanted SMGs, and mAChR together with the intracellular molecule CK2 might be responsible for the alteration of TJs in epiphora glands.

Conjunctival cytologic features in patients with unilateral primary acquired nasolacrimal duct obstruction

PURPOSE

To evaluate the cytologic features of conjunctival epithelium in patients with unilateral primary acquired nasolacrimal duct obstruction (PANDO) using impression cytology.

METHODS

Twenty-four patients with unilateral PANDO for at least 1 year were enrolled in this study. The healthy eyes of the patients are assessed as control group. All patients were subjected to ophthalmic surface examination with conjunctival impression cytology analysis. Squamous metaplasia and goblet cell density were graded according to Nelson grading system.

RESULTS

The mean age was 52.7 ± 16.3 (range 21-70) years. The mean period for complaints of epiphora was 3.2 ± 2.4 (range 1-8) years. The eye with PANDO had a mean squamous metaplasia grade of 2.38 ± 0.59 versus 1.91 ± 0.82 for control eyes (p = 0.011). The mean grade of goblet cell density was 2.0 ± 0.51 for eyes with PANDO and 2.38 ± 0.65 for control eyes (p = 0.013). There was no statistically significant correlation between conjunctival cytological features in terms of squamous metaplasia and goblet cell density grades and duration of epiphora complaint (r = -0.04, p = 0.82; r = 0.09, p = 0.66, respectively).

CONCLUSIONS

PANDO may cause alterations in conjunctival impression cytology. Successful dacryocystorhinostomy surgeries will help to protect ocular surface health.

Die Dakryozystographie (DZG) zur Diagnostik bei Epiphora

Dacryocystography is a radiological procedure for the examination and localisation of obstructions of the lacrimal ducts, the findings of which are decisive for the choice between conservative or invasive surgical measures and thus for treatment planning.

Primary Marginal Zone B-Cell Lymphoma of the Mucosa-Associated Lymphoid Tissue of the Lacrimal Sac Found with Epiphora: A Case Report

We report a case of a primary marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue of the lacrimal sac, which was found in a patient with epiphora without palpable mass. Magnetic resonance imaging demonstrated mucosal thickening of the lacrimal sac with a patent lumen, consistent with the intraoperative finding. Epiphora resolved, which was confirmed by smooth syringing, 1 month after starting the immunotherapy.

Chronic tarsal conjunctivitis

BACKGROUND

Toxicity is rarely considered in the differential diagnosis of conjunctivitis, but we present here a new form of toxic conjunctivitis with unusual clinical features. Between 2010 and 2013, a new clinical presentation of chronic conjunctivitis unresponsive to normal treatment was noted within a Primary Care Ophthalmology Service.

METHODS

Retrospective review of case records and histopathology results.

RESULTS

A total of 55 adult patients, all females, presented with epiphora and stickiness. They did not complain of itch and had had symptoms for an average of 9 months. Clinical examination showed bilateral moderate to severe upper and lower tarsal conjunctival papillary reaction, without corneal or eyelid changes and mild bulbar conjunctival hyperaemia in a third of cases. Biopsies were taken in 15 cases to exclude an atypical infection or lymphoma. Histologically, there was a variable superficial stromal lymphocytic infiltrate, involving the epithelium in more severe cases. The majority of the cells were CD3 positive T-lymphocytes and follicle formation was not noted. The clinical history in all cases included prolonged use of eye make- up and other facial cosmetic products. Clinical symptoms of epiphora settled with topical steroid drops, but the clinical signs of chronic tarsal inflammation persisted until withdrawal of the facial wipes thought to contain the inciting agent, though the exact nature of this remains unclear.

CONCLUSION

The presentation, appearances, histological features are consistent with a contact allergen-driven chronic conjunctivitis. Steroid treatment provided good relief of symptoms and patients were advised to avoid potential contact allergens. Management remains difficult. Further research into contact allergies of mucous membranes and identification of its allergens is required.

The natural process of congenital nasolacrimal duct obstruction and effect of lacrimal sac massage

This study aimed to examine the rate of symptomatic improvement of congenital nasolacrimal duct obstruction (CNLDO) in infants treated with conservative management within the first year of age. Other purpose of the study is to emphasize the relationship between spontaneous resolution time and effective lacrimal sac massage. Thirty-one infants were diagnosed to have CNLDO by an ophthalmologist prior to 3 months of age. In this study, 36 eyes of 31 patients were included with CNLDO. The patients were divided into two groups. Group 1 (28 eyes of 24 patients) was consisted of the patients who were applied effective lacrimal sac massage regularly during the follow-up period, and patients whose parents did not apply a regular lacrimal passage regularly were accepted as group 2 (8 eyes of 7 patients). Thirty-three eyes of 31 patients (18 rights and 15 left) successfully resolved with only conservative management (91.6 %). In these thirty-three eyes, one eye (3 %) resolved between 0 and 3 months, fourteen eyes (42.5 %) resolved between 4 and 6 months, eleven eyes (33.3 %) resolved between 7 and 9 months, and seven eyes (21.2 %) resolved between 10 and 12 months. CNLDO was resolved in 27 (96.2 %) of 28 eyes in group 1, and in group 2, six eyes (77.7 %) had resolvement. This difference was statistically significant (p = 0.001). The mean age of resolution was 6.8 ± 1.88 months in group 1, 10.3 ± 1.5 months in group 2 (p < 0.001). In light of our study, we believe that conservative management of CNLDO is highly successful. Our study provided a possible objective explanation for the efficacy of lacrimal sac massage. Emphasizing the importance of the massage to parents and describing in detail can reduce the risk of unnecessary surgical interventions.

Necrotizing sialometaplasia of the lacrimal sac mimicking squamous cell carcinoma: Necrotizing dacyocystometaplasia

INTRODUCTION

Necrotizing sialometaplasia is thought to represent an inflammatory reaction directed against an ischemic insult or local trauma within a glandular tissue and is most commonly observed in the minor salivary glands of the oral mucosa. The importance of this condition arises from the fact that its clinical and histological aspects may raise issues of differential diagnosis with malignant neoplasms. The authors present a case of necrotizing sialometaplasia involving the lacrimal sac simulating a well-differentiated squamous cell carcinoma.

CASE

A 52-year-old man presented with epiphora in the left eye after having sustained an orbital blowout fracture during a motor vehicle accident. During subsequent external dacryocystorhinostomy, an abnormal lacrimal sac mucosa was observed and analyzed histologically revealing a well-differentiated squamous cell carcinoma. However, the subsequent biopsies of the lacrimal sac were negative for malignancy; in view of these findings, two pathologists reviewed the first specimen and immunohistochemical staining was performed allowing us to arrive at a diagnosis of necrotizing sialometaplasia. We suggest the term necrotizing dacryocystometaplasia for the involvement at this site.

CONCLUSION

Although exceedingly unusual, necrotizing dacryocystomeplasia should be considered in patients presenting with epiphora in the appropriate clinical context. Notably, this condition can be mistaken for a malignant disease, presenting a diagnostic challenge both clinically and histopathologically.

Modified External Dacryocystorhinostomy in Primary Acquired Nasolacrimal Duct Obstruction

BACKGROUND

Epiphora secondary to acquired nasolacrimal duct obstruction is a common ophthalmic problem in adults requiring surgical management. External dacryocystorhinostomy (DCR) is a reliable but difficult surgical technique for the treatment of nasolacrimal duct obstruction.

PURPOSE

To evaluate the success rate and complications of modified external DCR in patients with primary acquired nasolacrimal duct obstruction.

MATERIALS AND METHODS

This hospital based prospective interventional study included 56 patients with primary acquired nasolacrimal duct obstruction. Diagnosis of nasolacrimal duct obstruction was made through irrigation of the nasolacrimal drainage system. All patients were operated by modified technique of external DCR with anastomosis of the anterior lacrimal and nasal mucosal flaps only, whereas posterior mucosal flaps were excised. Patients were followed up for a period of 6 months. During the follow up, success rate and complications if any were recorded. Success was defined objectively by a patent lacrimal passage on irrigation and subjectively by the absence of watering or discharge.

RESULTS

The mean age of the study population was 39.23 ± 10.66 years, and 78.6% of patients were females (male to female ratio 1:3.7). The average operation time was 36.48 ± 4.72 minutes. Objective and subjective success rates were 92.9% and 89.3%, respectively after a follow up period of 6 months. Intraoperatively, haemorrhage occurred in 3 patients (5.3%) and laceration of the nasal mucosa in 4 patients (7.1%). Postoperative complications included significant lid swelling and periorbital ecchymosis in 3 patients (5.3%), epistaxis in 2 patients (3.6%) and hypertrophic scar in 2 patients (3.6%).

CONCLUSION

These results suggest that modified external DCR with anterior flaps anastomosis only is a simple, safe, less time consuming surgical technique that is easy to perform, and the outcome is comparable to conventional DCR.

Management of nasolacrimal duct injuries in mid-facial advancement

Nasolacrimal duct (NLD) may be injured following trauma. During certain surgical procedure, inadvertent damage to the nasolacrimal apparatus may occur as well. Such instances should be immediately managed to prevent any subsequent complications. The management of such inadvertent injuries may be accomplished only with a thorough anatomic comprehension and surgical expertise in the field of operation. It also requires the presence of armamentarium required for its management in situations when complications arise. The case report discusses one such rare complication of NLD injury during Le Fort III osteotomy and advancement effectively managed by bicanalicular stenting.

Myasthenia gravis exacerbation with low dose ocular botulinum toxin for epiphoria

We present a man with clinically stable systemic myasthenia gravis (MG) which flared with a low dose of peripherally injected botulinum toxin type A (BTX-A). Botulinum toxin drugs generally have an excellent safety profile, however, they are contentious in patients with neuromuscular disorders. Despite this, there remain limited reports on the systemic effects of botulinum therapy in patients with MG. This man is one of less than 10 reported patients worldwide in whom MG was exacerbated by a peripheral BTX-A injection. This is an important reminder to Australian clinicians of the potential risks of this common place medication in patients with neuromuscular disorders, even those with stable disease.

The outcomes of endoscopic dacryocystorhinostomy in children: A systematic review

OBJECTIVES

To systematically review and discuss the published results about the application of endoscopic dacryocystorhinostomy in treating children with nasolacrimal duct obstruction.

METHODS

In October 2014 an appropriate string was run on PubMed to retrieve all relevant articles. A cross-check was performed by two of the authors on abstracts and full-text articles found using the selected inclusion and exclusion criteria. A non-comparative meta-analysis concerning the procedures' rate of success and failure was performed.

RESULTS

Fourteen studies were identified comprising a total of 346 subjects affected by nasolacrimal duct obstruction (unilateral or bilateral). Overall there were 393 surgical procedures, all performed with an exclusive endoscopic approach. The average length of follow-up was reported in twelve studies resulting 15.2 months and ranging from 3 to 27.1 months. On the basis of our statistical analysis the mean (95% CI) rate of failure was 0.14 (0.09-0.21). The mean (95% CI) rate of success resulted 0.87 (0.80-0.91).

CONCLUSIONS

Although in young patients the nasal anatomy is more complex and narrow than in adults our review showed as the endoscopic dacryocystorhinostomy allows similar results in terms of success compared to the external approach.

[Treatment of congenital lacrimal duct obstruction: A prospective clinical cohort study]

BACKGROUND

Pressurized probing and irrigation is the method of choice for congenital lacrimal duct obstruction after conservative therapeutic strategies have failed. The aim of this study was to evaluate age dependence and success rates of different therapeutic options.

MATERIAL AND METHODS

A prospective cohort study of children with congenital lacrimal duct obstruction was performed. All children treated during the period between May 2009 and June 2010 were included. Surgical success was defined as the absence of epiphora and mucous discharge for a postoperative follow-up of 3 months. Odds ratios (OR) and 95 % confidence intervals (CI) of different variables were estimated using logistic regression.

RESULTS

A total of 111 children (137 eyes) underwent treatment for congenital lacrimal duct obstruction. The mean age of the children was 7.7 months (range 1-30 months). The success rate of probing under local anesthesia was 85.5 % (n = 100). Probing under general anesthesia without intubation of the lacrimal pathway was successful in 28.6 % (n = 2). Treatment under general anesthesia with intubation of the lacrimal pathway had a success rate of 94.2 %. If the primary treatment was complicated the OR was 1.9 (95 % CI: 0.7-5.1), for males the OR was 1.7 (95 % CI: 0.8-3.5) and in cases of a positive family history the OR was 1.5 (95 % CI: 0.7-3.3). With every increasing month of age the risk not to be treated successfully increased (OR: 1.3, 95 % CI: 1.2-1.5).

CONCLUSION

Syringing under local anesthesia is an effective therapy. The highest success rates were found at the ages of 1-6 months. Therapy with additional silicone tube intubation was highly successful.