Endoscopic dacryocystorhinostomy in cases of dacryocystitis due to atrophic rhinitis

Atrophic rhinitis is a chronic inflammatory disease of the nose, which is more common in India. Chronic dacryocystitis is its rare complication. The authors found four cases of chronic dacryocystitis from March 2002 to October 2003 due to atrophic rhinitis. It was diagnosed clinically by the regurgitation test and lacrimal syringing. These cases were treated conservatively for a period of six weeks to make the nasal mucosa healthier and were then subjected to endoscopic dacryocystorhinostomy (end-DCR) under local anaesthesia. The procedure was found to be more difficult due to bleeding and the healing time was prolonged as compared to other cases of end-DCR. After one to one and half years of follow-up the primary success rate was 75 per cent but after revision surgery in one case, all cases were successful. Hence it was concluded that atrophic rhinitis is no more a contraindication for end-DCR. However, meticulous initial preparation and post-operative follow-up is necessary to improve the result.

Dacryocystectomy: indications and results

BACKGROUND

After the advent of dacryocystorhinostomy (DCR), dacryocystectomy (DCT) was regarded as mutilant surgery and reserved for lacrimal sac tumors.

PURPOSE

To present current indications for dacryocystectomy.

METHODS

Eighteen eyes from 11 patients subjected to DCT were reviewed retrospectively. Nine patients had chronic dacryocystitis confirmed by dacryocystography and two patients had lacrimal sac tumors.

RESULTS

The indications for DCT were: three patients with systemic medical problems, three patients with dry eye, two cases of lacrimal sac tumors, two cases of traumatic dacryocystitis and one case of cutaneous leishmaniasis. Dacryocystitis was resolved in 17 of 18 eyes; the two cases of tumor evolved without epiphora. One patient (traumatic dacryocystitis) had recurrence of dacryocystitis.

CONCLUSIONS

DCT is mainly performed when a lacrimal sac tumor is suspected but, since it avoids the intra- and postoperative complications related to dacryocystorhinostomy, it can be indicated in cases of dacryocystitis with significant lacrimal discharge and an enlarged or altered lacrimal sac.

Repeated probing results in the treatment of congenital nasolacrimal duct obstruction

PURPOSE

To assess the results of our protocol of repeated probing for the treatment of congenital nasolacrimal duct obstruction in various presentations.

METHODS

A total of 1600 patients (1748 eyes) with congenital dacryocystitis (850 boys, 750 girls; age range, 1 month to 48 months [mean 16.54 +/- 12.21 months]) were included. Diagnosis was confirmed by history of tearing, crusting of lids, and a boggy swelling over inner canthal region, which on pressure ejected mucopurulent discharge through punctum. Antibiotic eye drops were instilled five times a day for a week in affected eyes after the mother pressed the sac area and cleaned the discharge. The cases that were not relieved were subjected to sequential probing dilating with an increasing diameter probe repeated in failed cases second and third times at 1-week interval.

RESULTS

Medical treatment was effective in only 60 eyes (3.43%). Probing and syringing achieved successful results in 790 eyes (100%) aged 1 month to 12 months; 330 eyes (99.40%) aged 12 months to 18 months; 200 eyes (98%) aged 18 months to 24 months; 150 eyes (95.24%) aged 24 months to 36 months; and 158 eyes (89.87%) aged 36 months to 48 months. The cure rate with first probing was 98.10%, second probing was 99.64%, and third probing was 100%.

CONCLUSIONS

Our protocol of medical regime and early probing repeated two to three times was very effective in the treatment of nasolacrimal duct obstruction at all ages. A second and third probing was recommended after 1 week of the first probing with successful results if first probing failed.

Actinomyces canaliculitis: diagnosis of a masquerading disease

BACKGROUND

To review the diagnosis and management of seven cases of Actinomyces canaliculitis.

METHODS

Culture of discharge was performed in six of seven patients with Actinomyces canaliculitis using a PD Plus/F blood culture bottle. All patients were treated by canaliculotomy with curettage of dacryoliths, followed by treatment with systemic penicillin and Sulphacetamide drops over a period of 3-6 months. Part of the curetted concretions was fixed on a glass slide and part was sent to the laboratory for culture.

RESULTS

Four patients were women and three men with age ranging between 43 and 90 years. The average time lapse between onset of symptoms until diagnosis was 3 years. All cases presented with epiphora, chronic conjunctivitis, palpably thickened canaliculus, and yellow punctal discharge. Diagnosis was achieved by culture of discharge in three of six cases, culture of concretions in three of five cases, and staining of dacryoliths in all seven cases. Follow-up ranged between 12 and 48 months. The canaliculitis resolved completely and all patients have patent canalicula.

CONCLUSIONS

Actinomyces canaliculitis presents with epiphora, chronic purulent conjunctivitis, a palpably thickened canaliculus, and yellow punctual discharge. In suspect cases canuliculotomy and curettage should be performed, although canalicular reconstruction is generally unnecessary. Culture of discharge and concretions using PD Plus/F blood culture medium gave improved results over accepted norms. Fixation of smeared concretions on a slide in alcohol is simple and is diagnostic of the disease. We recommend long-term systemic penicillin treatment in Actinomyces canaliculitis.

Solid cast-forming actinomycotic canaliculitis: case report

Solid-cast forming actinomycotic canaliculitis is an uncommon cause of unilateral chronic red eye resistant to conventional topical medical therapy. The authors report the history of a 62-year old woman who was complaining of mucopurulent discharge from the right lower canaliculus for a period of 12 months. Culture yielded a few colonies of Actinomyces. Magnetic resonance imaging showed a dilation of the right lower canaliculus. The signal was hypointense and heterogeneous on both T1 and T2 weighted sequences. Surgery enabled removal of several solid yellowish casts and resulted in resolution of the disease. Histopathologic examination confirmed the presence of dense, basophilic conglomerates of filamentous organisms. Because rhinologists have more and more opportunities to perform surgery of the lachrymal pathway they need to be informed about this clinical entity.

Canaliculitis: the incidence of long-term epiphora following canaliculotomy

PURPOSE

To review the long-term outcome following surgical treatment for canaliculitis.

METHODS

All cases of canaliculitis treated surgically from January 1995 to December 2001 were identified from theatre records. Case notes were reviewed retrospectively looking specifically for delay in diagnosis (defined as two or more visits prior to diagnosis), culture results and outcome following surgical treatment. Telephonic questionnaires were used to assess the incidence of post-treatment epiphora. Symptomatic patients were offered clinic appointments for further assessment and management.

RESULTS

Fifteen eyes of 15 patients were identified, 13 were females and 2 males. Mean age was 69.6 years (range 45-87 years). One patient had both upper and lower canaliculitis. The remaining 14 (93.3%) had lower canaliculitis. Diagnosis was delayed in 7 of the 15 patients (46.6%). Culture results were positive in 66.6% with Staphylocococcus spp. being the most common isolate (26.6%). Actinomyces was isolated in only 2 of the 15 cases (13.3%). Conservative treatment had been tried in 5 cases (33.3%). All patients had resolution of symptoms following canaliculotomy. Epiphora was identified in four of the treated eyes on telephonic questionnaires. Of these, three eyes had preexisting lacrimal pathology. Average follow-up was 26 months (range 6-83 months).

CONCLUSION

Canaliculotomy is safe and efficacious in the treatment of lacrimal canaliculitis with no demonstrable risk of posttreatment epiphora.

The treatment of acute dacryocystitis using laser assisted endonasal dacryocystorhinostomy

AIMS

To determine whether acute dacryocystitis complicated by abscess formation can be successfully treated using laser assisted endonasal dacryocystorhinostomy.

METHODS

A protocol was adopted for the management of acute dacryocystitis presenting to an ophthalmology department. All patients were assessed jointly by an ophthalmologist and otolaryngologist for their suitability for primary internal drainage via a nasal endoscopic approach. All suitable patients during the study period August 1999 to November 2000 were managed by intravenous antibiotics and holmium:YAG laser dacryocystorhinostomy.

RESULTS

Nine patients were studied (mean age 72 years (range 38-82 years), three men, six women). A history of chronic epiphora was found in 78% of patients, and recurrent nasolacrimal infections in the same 78%. Resolution of symptoms and signs of acute dacryocystitis occurred in all nine patients. No recurrence of acute dacryocystitis occurred during the median follow up period of 11 months (range 6-31 months). Ostium patency defined as the absence of epiphora and the observation of irrigated lacrimal fluorescein at the ostium was achieved in 67% of patients. Epiphora recurred in 33% of cases.

CONCLUSION

Laser assisted endonasal dacryocystorhinostomy is an effective primary treatment in cases of acute dacryocystitis complicated by abscess formation. In addition, pre-existing symptoms of epiphora and recurrent nasolacrimal infections are relieved in the majority of patients.

Endoscopic Transnasal Dacryocystorhinostomy and Bicanalicular Silicone Tube Intubation

PURPOSE

To evaluate the results of endoscopic transnasal dacryocystorhinostomy (ETDCR) combined with bicanalicular silicone tube intubation (BSTI) performed in 49 patients with nasolacrimal canal obstructions secondary to chronic dacryocystitis.

MATERIAL AND METHODS

ETDCR combined with BSTI was applied as a primary procedure in 47 cases, and as a secondary procedure in 2 cases. All patients underwent dacryocystography, and 41 patients underwent radionuclide dacryoscintigraphy before the surgery. Silicone tubes were left in place for about 6.2 months. The patency of the lacrimal passages was controlled with a clinical examination, nasolacrimal canal lavage, and dacryoscintigraphy.

RESULTS

Patients were followed up for a mean period of 25.1 months after the removal of the tubes. The epiphora symptom disappeared and a successful drainage could be maintained in 43 out of 49 cases (87.7%). The obstruction rate found in the dacryoscintigraphy performed 15 days after extubation was 22.9%, while it was found to be 14.2% in the nasolacrimal canal lavage.

CONCLUSION

ETDCR combined with BSTI proved to be an effective surgical method in chronic dacryocystitis. The sensitivity and specificity of the postoperative dacryoscintigraphy in determining the surgical success were lower than those of the nasolacrimal canal lavage.

Dacriocistorrinostomía endonasal y endocanalicular con láser diodo. resultados preliminares

AIM OF THE STUDY

To describe the surgical technique and to evaluate the clinical results after having performed the transcanalicular and endocanalicular dacryocystorhinostomies by diode laser, including the advantages and limits of this technique.

METHODS

34 were performed by diode laser in patients with clinical history of epiphora, with or without mucopurulent secretion, for nasolacrimal duct obstruction. The study was prospective, interventional, non randomized and non comparative. Diode laser was used to realize vaporization of lacrimal sac, osteotomy and vaporization with coagulation of nasal mucosa. The mean of surgical time was 15 minutes (range 7 to 29 minutes). Bicanalicular intubation was performed with a silicone tube and prolene filament for two months in all cases. Postsurgical follow-up was between 4 and 11 months. The degree of epiphora was evaluated by the Munk scale and lacrimal permeability was evaluated by endoscopic functional staining test in all cases.

RESULTS

Out of the 34 DCR-EDN+ENC that were performed, 32 cases (94.11%) remain asymptomatic. Two of them (5.88%) required endonasal dacryocystorhinostomies by drilling, because the bony perforation was impossible to achieve by laser fiber. Two cases (5.88%) presented fibrosis and lacrimal and lower canaliculi obstruction, without epiphora because the superior canaliculi was permeable.

CONCLUSION

Endonasal and endocanalicular dacryocystorhinostomy technique performed by diode laser is a valid method. It does not cause cutaneous scarring, it decreases thermic canalicular damage, it respects the lacrimal pump, it minimizes pain and bleeding, it needs less surgical time and it has turned into an out-patient procedure with a minimal surgical and postsurgical morbility.

A review of 120 cases of dacryocystorhinostomies (Dupuy Dutemps and Bourguet technique)

BACKGROUND

The study was conducted at the DHQ hospital Lakki Marwat from Jan, 1999 to Dec, 2002 to assess the intra and postoperative complications and success rate of external dacryocystorhinostomy (DCR) with suturing of the bridge between anterior flaps of nasal mucosa and lacrimal sac with the muscle layer.

METHOD

We operated upon 120 patients suffering from chronic dacryocystitis (CDC). Females were 81 (67.5%) and males were 39 (32.5%). Majority of the patients were between the age group 40 to 60 years. Indications for dacryocystorhinostomy (DCR) were epiphora, acute on chronic dacryocystitis and a mucocele. All the cases were operated under local anaesthesia with external approach and only anterior flap suturing and engaging it in the muscle layer. These patients were followed for a period of six months.

RESULTS

The overall success rate was 98.33%. The successful outcome was defined as symptomatic relief from epiphora and dacryocystitis and a patent nasolacrimal duct upon syringing.

CONCLUSIONS

Dacryocystorhinstomy is a safe procedure under local anaesthesia. It is associated with minimal complications, which can be easily managed. This technique has a very high success rate and a short learning curve.

Late and very late initial probing for congenital nasolacrimal duct obstruction: what is the cause of failure?

AIMS

To find the cure rate of late (second year of age) and very late (3-5 years of age) initial probing for congenital nasolacrimal duct obstruction (CNLDO) and to identify the factors contributing to the failure rate of the probing in older children.

METHODS

In a prospective interventional case series study, 169 eyes of 125 consecutive patients (1-5 years old) with CNLDO underwent probing under general anaesthesia. Cure was defined as absence of tearing and discharge in the affected eye.

RESULTS

138 eyes of 101 patients aged 13-60 months (mean 23.4 (SD 10.2)) were included. Of 15 eyes (10.8%) with complex CNLDO, 80% presented after 24 months of age (p<0.0001). The cure rate was 89% in patients 13-24 months of age and 72% after the age of 24 months (p = 0.01). It was 90.2% in the membranous and 33.3% in the complex CNLDO in both late and very late probing (p<0.0001). There was a high correlation (r = 0.97) and no significant difference between the cure rate at 1 week and final follow up.

CONCLUSION

Accumulation of the complex CNLDO is the main risk factor for failure of probing in the older children. The outcome of the nasolacrimal duct probing at 1 week follow up is highly indicative of the final outcome.

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.

[Possibilities of using the method of crystallography of tears in pathologies of the lacrimal apparatus]

A total of 178 patients with pathologies in the lacrimal apparatus (including 81 patients with dacryocystitis, 51 patients with imperforation of the lacrimal canals' opening and 46 patients with dacryostenosis) were investigated. Crystallographic examination (CGE) of the lacrimal fluid was made for both eyes before and after surgery. 32 virtually healthy persons made up the control group. Normal types were defined and an operational scheme, which ensured the detection of 4 main types of crystals typical of the discussed pathologies, was elaborated. CGE was found to enable a reliable detection of relapses' threat, which can be a criterion in choosing the time for removing the intubation tube after canaliculardacryocystorhinostomy (CDCT) and an extra source of information in specifying a stage of dacryostenosis. CGE provides for determining indirectly the presence of an allergic or inflammatory component in the disease course. Finally, CGE is a simple and sufficiently informative method, which can turn into an additional tool in the diagnosis, differential diagnostics and evaluation of the efficiency of conducted therapy and in forecasting a clinical disease course in the lacrimal apparatus.

Experience with bicanalicular intubation of the lacrimal drainage apparatus combined with conventional external dacryocystorhinostomy

AIM

The aim of this study was to assess the success rate of bicanalicular intubation of lacrimal drainage apparatus in chronic dacryocystitis patients who were at high risk of failure of surgery of dacryocystorhinostomy.

MATERIAL AND METHODS

A total of 24 patients with chronic dacryocystitis (25 eyes) including 11 males and 13 females (age range 3-80 years) having high risk factors of failure of dacryocystorhinostomy were enrolled. Factors such as previous attacks of acute dacryocystitis, trauma in lacrimal sac region, previously failed dacryocystorhinostomies, formation of false passages in the lacrimal drainage apparatus were considered. Conventional dacryocystorhinostomy followed by bicanalicular intubation of the lacrimal drainage apparatus with Jain metal silicone the lacrimal intubation tube (20-23 gauge) was performed in all these patients. The patients were followed up at weekly intervals for two months, at 6 months and at 1 year post surgery.

RESULTS

A total of 25 eyes in 24 patients (including 11 males and 3 females) were operated upon using the technique of bicanalicular intubation of lacrimal drainage apparatus with conventional external dacryocystorhinostomy. The procedure was successfully performed in 22 out of the 25 eyes. Perioperative complications included punctual damage due to recurrent attempts at passing these probes in 2 patients and mild damage to nasal mucosa in 5 patients. The majority of patients did not experience any untoward symptoms from these silicone tubes. However, in three eyes there was felt a mild foreign body sensation and two patients had chronic conjunctival erythema. The tubes could not be retained in two of these three eyes. Additionally, in one eye there was spontaneous extrusion of tubes whilst sneezing 3 months after surgery. All these three eyes had a recurrence of symptoms due to non-retention of the tubes and needed re-operation. On average the tubes were retained for a period of six months before they were spontaneously extruded or removed. Fifteen patients retained the silicone tubes for more than 1 year. The procedure gave a success rate of 76% (19/25 eyes) and these were the eyes in which the tubes had been retained for more than 6 months. The success was not influenced by the age or sex of patient, laterality of eye, aetiology of chronic dacryocystitis, or evidence of bony deformity or abnormality of the sac.

CONCLUSIONS

Bicanalicular intubation for lacrimal drainage system is a simple, inexpensive and straight forward adjunct to conventional external dacryocystorhinostomy. The procedure is strongly indicated for patients with chronic dacryocystitis who are at high risk of surgical failure. Carefully performed, it gives a 76% success rate and is not influenced by the different variables examined.

[Surgical treatment with dacryocystitis and retinal detachment in a patient with Wegener granulomatosis]

BACKGROUND

We report surgical treatment of a patient with dacryocystitis and retinal detachment (RD), which are rare ophthalmic involvements of Wegener granulomatosis (WG).

CASE

The patient was a 26-year-old man with WG. He was diagnosed as having WG 4 years ago and he has been treated by maintenance doses of predonisolone and cyclophosphamide. Rheumatoid factor and serum antinuclear antibody were negative. Cytoplasmic pattern-antineutrophil cytoplasmic antibody (C-ANCA) and renal function were normal. He was found to have nasolacrimal duct obstruction and lattice degeneration bilaterally, retinal tear with RD in the left eye and tear without RD in the right eye. No sign of vasculitis was found in fluorescein angiography. Bilateral dacryocystorhinostomy was performed without any sign of postoperative necrosis of the wound. After the surgery, epiphora and eye discharge disappeared and lacrimal passage has been maintained without obstruction. The pathological findings of his nasal mucosa and lacrimal sac showed chronic inflammation and no typical changes of WG. There was no abnormal change in the conjunctiva and sclera after an uncomplicated scleral buckling surgery.

CONCLUSION

We conclude that operations such as dacryocystorhinostomy and scleral buckling surgery may be performed successfully when WG is controlled within the normal limits of C-ANCA.

Hammer-chisel technique in endoscopic dacryocystorhinostomy

We performed a prospective evaluation of endoscopic hammer-chisel dacryocystorhinostomy (DCR) procedures on 62 eyes of 44 patients (40 female and 4 male) with chronic epiphora or dacryocystitis (26 unilateral and 18 bilateral). The technique included chisel removal of bone over the lacrimal sac. The follow-up period was 12 to 54 months (mean, 28 months), and the patients' ages ranged from 17 to 67 years (mean, 35.5 years). The success rate of the consecutive endoscopic hammer-chisel DCR procedures was 87%. During operation, 8 patients had mild mucosal hemorrhage, which did not prevent the successful completion of the operation. Excellent patient tolerance was observed, with minimal morbidity and no major complications. As compared to the external approach, endoscopic hammer-chisel DCR is less traumatic, is less time-consuming, and is practical and cosmetically convenient, with minimal perioperative and postoperative complications. It also allows the simultaneous correction of any intranasal disease. It requires minimal instrumentation and is a relatively easy and fast technique.

Endolacrimal KTP laser-assisted dacryocystorhinostomy

OBJECTIVE

To describe our experience with potassium-titanyl-phosphate (KTP) laser-assisted dacryocystorhinostomy, controlled via endolacrimal and endonasal endoscopy. The development of miniendoscopes enables endoscopy of the lacrimal drainage system via the lacrimal puncta to visualize the exact site of a stenosis.

DESIGN

A case series of 78 patients, with 1-year postoperative follow-up.

SETTINGS

A university medical center.

PATIENTS

Consecutive sample of 78 adult patients who required surgery for dacryostenosis.

INTERVENTION

Endolacrimal use of a KTP laser to perform a bony osteotomy of the lacrimal sac into the nasal cavity. The position for the perforation was controlled by endonasal endoscopy. The procedure was performed under either general or local anesthesia.

RESULTS

One year after surgery, 65 (83%) of the 78 patients were free of symptoms. Seven patients experienced intermittent tearing, and 6 had revision surgery because of restenosis.

CONCLUSIONS

The success rate of 83% achieved with KTP laser-assisted dacryocystorhinostomy, using miniendoscopes for lacrimal endoscopy to visualize the exact site of obstruction, is better compared with that of prior studies without the use of miniendoscopes (with success rates of 47%-85%). The advantages of this technique are that it is a minimally invasive procedure, requires a short operating time, and avoids use of an external incision.

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.

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.

Intraoperative fluorouracil in endonasal laser dacryocystorhinostomy

BACKGROUND

Although endonasal laser dacryocystorhinostomy (ELDCR) offers many advantages compared with conventional techniques, postoperative scarring leading to occlusion of the rhinostomy is more common with ELDCR.

OBJECTIVE

To investigate whether fluorouracil applied to the rhinostomy site intraoperatively has an effect on the outcome.

PARTICIPANTS

We randomly allocated 155 consecutive patients (201 procedures) to a control group and a fluorouracil group. Patients and investigators were masked to the choice of treatment.

METHODS

All patients underwent ELDCR. A pledget soaked in isotonic sodium chloride solution or 0.5-mg/mL fluorouracil, randomly allocated by the pharmacy, was applied to the rhinostomy site for 5 minutes at the time of surgery. Patients were followed up for 12 months and their symptoms were assessed at each visit.

RESULTS

Among patients followed up for 12 months or longer, ELDCR procedures performed with topical application of fluorouracil to the rhinostomy site were successful in 65 (76%), compared with 52 (63%) for the control group. This was not statistically significant when patients who failed to attend follow-up at or after 12 months were not counted as successfully treated (P =.21, chi(2) test). Even if those who failed to attend for follow-up were counted as successes, the effect of fluorouracil did not reach significance at the.05 level (P =.08, chi(2) test).

CONCLUSION

The topical application of fluorouracil failed to increase the patency rates in ELDCR.

Pneumococcal keratitis: a clinical profile

AIM

To study the clinical features of pneumococcal keratitis and response to ciprofloxacin therapy.

METHODS

A retrospective analysis was undertaken of 58 patients with culture-proven pneumococcal keratitis seen over a period of 2 years.

RESULTS

Pneumococcal keratitis accounted for 33.3% of bacterial keratitis. Most cases presented with non-severe keratitis (77.5%). Co-existing sac pathology was more frequent in pneumococcal ulcers as compared to non-pneumococcal bacterial ulcers (50%vs 9%, P < 0.001). Characteristic clinical features enabling an accurate clinical diagnosis were found in 27.5% and lanceolate diplococci on Gram's stain were identified in 76% of cases. In vitro testing showed a high susceptibility to cephazolin and ciprofloxacin. All patients received ciprofloxacin as first-line therapy. Eighty per cent responded well with complete healing of the ulcer. A second drug was required in 8.5%.

CONCLUSION

Ciprofloxacin therapy can be effective in the treatment of pneumococcal keratitis.

Loss of tear duct-associated lymphoid tissue in association with the scarring of symptomatic dacryostenosis

OBJECTIVE

To determine whether organized mucosa-associated lymphoid tissue (MALT) is a normal component of the human efferent tear ducts or is acquired in reaction to chronic inflammation.

DESIGN

Nonrandomized comparative (cadaver controlled) study with histopathologic correlations.

MATERIALS

Tissue specimens from nasolacrimal ducts of 38 patients undergoing endonasal dacryocystorhinostomy in postinflammatory dacryostenosis with signs of chronic inflammation were analyzed using histologic examination and immunohistochemical studies. Only tissue specimens revealing proliferative sclerotic forms of chronic fibrosis were chosen for the study. Eighty specimens from the lacrimal systems of body donors served as controls.

TESTING

Tissue specimens from each lacrimal system were prepared and processed with paraffin, sectioned, stained using different histologic methods with an array of specific antibodies, and examined by light microscopy.

MAIN OUTCOME PARAMETERS

The distribution of intraepithelial and subepithelial defense cells was analyzed to identify plasma cells, secretory immunoglobulins, lymphocytes, dendritic cells, and organized mucosa-associated lymphoid tissue.

RESULTS

The presence of secretory immunoglobulin A was demonstrated in subepithelial plasma cells and in the cytoplasm of apical epithelial cells in both chronically inflamed and healthy lacrimal systems. In more than one third of cases from body donors, but in only a few biopsy specimens from patients, organized lymphoid tissue was found with the cytomorphologic and immunophenotypical features of MALT. All other cases showed a diffuse infiltrate of defense cells within the lamina propria.

CONCLUSIONS

The development of tear duct-associated lymphoid tissue (TALT) is a common feature that is often found in symptomatically normal nasolacrimal ducts. Because TALT seems to be lost associated with the scarring of symptomatic dacryostenosis, it is unlikely that the presence per se of TALT leads to scarring. Future studies are needed to explain the development of TALT.

Initial nasolacrimal duct probing in children under age 5: cure rate and factors affecting success

AIMS

To evaluate the success rate of initial probing and the factors affecting the success rate for congenital nasolacrimal duct obstruction (CNLDO)in children under the age of 5 years.

METHODS

In a prospective uncontrolled interventional case series, 207 eyes from 161 consecutive patients with CNLDO underwent nasolacrimal duct probing under brief general anesthesia. Based on exclusion criteria, 180 eyes from 139 patients were included in the study. Diagnoses were made according to the patients' histories, clinical examinations, and modified dye disappearance tests. The state of the punctum, the canaliculus, the sac, and the nasolacrimal duct were recorded. The main outcome measure was the complete disappearance of tearing and discharge in the affected eye. The patients were followed at 1 week, 1 month, and 3 months postoperatively.

RESULTS

The age range was 5 to 60 months (mean, 19.1 +/- 11.2 months). The cure rates were 92% in the first year, 84.5% in the second year, 65% in the third year, and 63.5 in the fourth and fifth years of age. The patient's age, nonmemberanous CNLDO, and canalicular stenosis were correlated with the success of initial nasolacrimal duct probing (P <.05).

CONCLUSIONS

Based on the results, simplicity of probing, and absence of significant complications, initial nasolacrimal duct probing is advised up to the age of 5 years. Increasing age, nonmembranous CNLDO, and canalicular stenosis increase the failure rate (P <.05).