The effect of silicone nasolacrimal intubation on epiphora after helium ion irradiation of uveal melanomas

Radiation-Induced Acquired Lacrimal Drainage Obstructions: Management and Outcomes

OBJECTIVE

To describe the management and outcomes of patients with radiation-induced acquired lacrimal duct obstructions (RALDO).

METHODS

A retrospective chart review from July 2018 to December 2023 of all cases undergoing surgical intervention for RALDO by a single surgeon. Data collected included demographics, tumor type and anatomic location, radiation treatment (including radiation type, dosage, and duration), interval between radiation and reported onset of epiphora, oculoplastic clinical examination, management, and outcomes. Lacrimal irrigation was done prior to surgery in all patients.

RESULTS

Seventeen eyes of 16 patients with a mean age at presentation of 63.3 years and over half the patients being females (56.3%) were included in the study. The right lacrimal drainage system (LDS) was involved in 4 (23.6%), and the left side was involved in 13 (76.4%). The mean onset of epiphora symptoms after radiation was 9.5 months. The underlying tumor type were intraocular having uveal melanoma in four, cutaneous squamous cell carcinoma in 2, basal cell carcinoma involving forehead and nose in one and sino-nasal indications present in 8 patients. One patient had metastasis to the orbit and eyelid. Four patients (25%) received external beam radiotherapy (XRT) (one case had bilateral LDS involvement), 6 patients (37.5%) received intensity-modulated radiation therapy (IMRT), 5 patients (31.25%) received proton beam irradiation (PBI), and one (6.25%) received stereotactic body radiotherapy (SBRT). Mean radiation dosage was 61.31 Gy in 15 patients (data was missing in 1 patient). Punctum was effaced in 3, canalicular stenosis in 1, proximal canalicular obstruction in 8, distal canalicular obstruction in 2, and nasolacrimal duct obstruction (NLDO) in 3. Treatment was based on the site and nature of obstruction and varied from minimally invasive techniques like serial dilatation with bicanalicular silicone tube or Guibor tube to surgical interventions like dacryocystorhinostomy (DCR) or conjunctivo-dacryocystorhinostomy (C-DCR). Only 10% with primary lacrimal intubation had good response. Of the six cases that underwent C-DCR with Jones tube either as primary or secondary procedure, four cases showed improvement in epiphora (67%). Three with NLDO did well after external DCR. In total, four patients had a secondary procedure after the first failed while 7 with failed initial surgery elected against secondary surgery. The mean follow-up was 9.6 months (range 2-24 months).

CONCLUSIONS

In patients with RALDO, salvage treatment with silicone lacrimal intubation has poor results, CDCR with Jones tube has better results, although imperfect and in cases with NLDO, DCR has good outcomes.

The use of prophylactic Nunchaku stents to reduce the risk of nasolacrimal duct obstruction in patients with midfacial tumours undergoing radiotherapy

The treatment of midfacial tumours with radiotherapy, chemotherapy and radio-iodine can cause nasolacrimal duct fibrosis resulting in epiphora. Nasolacrimal patency can be maintained by stenting. We report our experience of prophylatic Nunchaku stent insertion in 5 patients prior to midfacial radiotherapy. Four out of 5 patients (80%) had patent nasolacrimal ducts without any symptoms of epiphora following removal of the stents. One patient was initially asymptomatic with patent nasolacrimal duct, but subsequently developed epiphora. Nunchaku stents may provide a simple and effective way of preventing epiphora, obviate the need for nasal retrieval that is required for other nasolacrimal stents, and reduce the risk of requiring further lacrimal surgery.

Nasolacrimal duct obstruction after maxillary orthognathic surgery

PURPOSE

To report cases of nasolacrimal duct obstruction (NLDO) after maxillary orthognathic surgery.

MATERIALS AND METHODS

The authors reviewed the clinical manifestations, dacryocystographic images, and orbital computed tomographic scans of 10 patients who were diagnosed with NLDO after undergoing maxillary orthognathic surgery.

RESULTS

Six of the 10 patients (60%) complained of epiphora immediately after the surgery. Bilateral (n = 2, 20%) or unilateral (n = 8, 80%) NLDO occurred in all patients involved in the study. Twelve eyes of 10 patients were examined, and dacryocystography showed that the obstruction was present in the distal ostium in 7 eyes (58.3%), the junction between the sac and duct in 3 eyes (25%), and the common canaliculus in 2 eyes (16.7%). Computed tomographic scans of all subjects showed that mucosal swelling and congestion around the distal NLD opening narrowed the space between the lateral nasal wall and the inferior turbinate of the affected side. Dacryocystorhinostomy was performed in 9 eyes (8 patients), with a success rate of 100%.

CONCLUSIONS

The distal to proximal portion of the NLD can become obstructed after maxillary orthognathic surgery. This obstruction seems to be caused by secondary inflammatory changes associated with an indirect injury of the NLD. Therefore, clinicians should be aware of the possibility of NLDO after orthognathic surgery, which can be treated successfully with dacryocystorhinostomy.

[Late effects of radiation on the eye and ocular adnexa]

Late ocular effects after irradiation of the eyes and ocular adnexa are reviewed. Ocular and orbital injuries occur more often after irradiation of central nervous system neoplasms or treatment of paranasal sinus malignancies. The complete loss of vision is the major complication which is multifactorial. This paper describes the radiation effects and grading of ocular adnexa, lens, retina, optic nerves and orbit. The tolerance doses and treatment are described.

Late effects of radiation on the eye and ocular adnexa

A clinically useful classification system is suggested that can be used in prospective trials to evaluate the effects of radiation on the visual system. We review radiation-induced pathophysiological and clinical changes of the various ocular structures as well as dose-response data and management of ocular complications. The rationale for the classification scheme chosen is also discussed.

Lacrimal collecting system lymphomas: integration of magnetic resonance imaging and therapeutic irradiation

Lymphomas arising within the lacrimal collecting system are rare tumours and unusual causes of lacrimal obstructive symptoms. The presentation, diagnosis, and treatment of this disease in five patients are described, as well as a review of the existing literature. Emphasized in this series is the efficacy of magnetic resonance imaging of these presentations and the importance of irradiation in their treatment.