Lacrimal bypass surgery in patients with sarcoidosis

Ocular manifestations of common pulmonary diseases: a narrative review

Several pulmonary disorders can cause ocular involvement. Understanding these manifestations is critical for early diagnosis and treatment. Hence, we set out to examine the most common ocular manifestations of asthma, chronic obstructive pulmonary disease (COPD), sarcoidosis, obstructive sleep apnea (OSA), and lung cancer. Allergic keratoconjunctivitis and dry eye are two ocular manifestations of bronchial asthma. The inhaled corticosteroids used to treat asthma can cause cataract formation. COPD is associated with ocular microvascular changes as a result of chronic hypoxia and systemic inflammation spillover into the eyes. Its clinical significance, however, is unknown. Ocular involvement is common in sarcoidosis, occurring in 20% of cases of pulmonary sarcoidosis. It can affect nearly any anatomical structure of the eye. Obstructive sleep apnea has been linked to floppy eye syndrome, glaucoma, non-arteritic anterior ischemic optic neuropathy, keratoconus, retinal vein occlusion, and central serous retinopathy, according to research. However, while an association has been established, causality has yet to be established. The effect of positive airway pressure (PAP) therapy used to treat OSA on the aforementioned ocular conditions is unknown. PAP therapy can cause eye irritation and dryness. Lung cancer can affect the eyes through direct nerve invasion, ocular metastasis, or as part of a paraneoplastic syndrome. The goal of this narrative review is to raise awareness about the link between ocular and pulmonary disorders in order to aid in the early detection and treatment of these conditions.

Outcomes of Endoscopic Dacryocystorhinostomy in Secondary Acquired Nasolacrimal Duct Obstruction: A Case-Control Study

INTRODUCTION

Secondary acquired nasolacrimal duct obstruction (SANDO), where the obstruction is caused by a known process, is becoming more commonly treated by endoscopic dacryocystorhinostomy (endoDCR). This study evaluates outcomes of endoDCR for cases of SANDO in comparison to endoDCR outcomes treating primary acquired nasolacrimal duct obstruction (PANDO).

METHODS

All patients undergoing endoDCR from 2006 to 2015 at a tertiary referral center were reviewed for etiology of nasolacrimal duct obstruction (NLDO) and success of procedure. Inclusion criteria were preoperative determination of NLDO via probing and irrigation, greater than 60-day follow up with assessment of duct patency via probing and irrigation after silicone tube removal, and postoperative survey for recurrent epiphora. Exclusion criteria were cases treating partial NLDO, patients undergoing concurrent conjunctivodacryocystorhinostomy, and patients lost to follow up or with incomplete records. Preanalysis stratification was performed for the following preexisting conditions: PANDO, granulomatosis with polyangiitis, sarcoidosis, midfacial radiotherapy, radioactive iodine therapy, severe prolonged sinusitis, prior failed DCR, and midface trauma. The primary outcome was postoperative anatomical patency of the nasolacrimal system with resolution of epiphora. Fisher-Freeman-Halton exact tests were performed comparing each SANDO group to the PANDO group with statistical significance set at p < 0.05.

RESULTS

Fifty-nine cases of NLDO underwent endoDCR in this series, 21 of which had a diagnosis consistent with SANDO. All patients treated with the aggressive perioperative management protocol the authors describe achieved anatomical patency. Patients with history of radioactive iodine therapy and radiotherapy had statistically worse outcomes compared with patients with PANDO, p = 0.011, p = 0.045, respectively. Stratified groups with increased intranasal sinus inflammation trended toward worse outcomes, but were not statistically different.

CONCLUSIONS

EndoDCR is a viable approach for the treatment of SANDO. In patients with history of radiotherapy or radioactive iodine therapy, however, endoDCR demonstrated decreased success rates as compared with patients with PANDO. Modifications of operative and postoperative management based on underlying etiology of NLDO may improve outcomes of endoDCR in SANDO cases. The authors describe an aggressive protocol for perioperative management of patients with pathologic nasal inflammation undergoing endoDCR.

Ocular Sarcoidosis

Sarcoidosis is one of the leading causes of inflammatory eye disease. Ocular sarcoidosis can involve any part of the eye and its adnexal tissues and may cause uveitis, episcleritis/scleritis, eyelid abnormalities, conjunctival granuloma, optic neuropathy, lacrimal gland enlargement, and orbital inflammation. Glaucoma and cataract can be complications from inflammation itself or adverse effects from therapy. Ophthalmic manifestations can be isolated or associated with other organ involvement. Patients with ocular sarcoidosis can present with a wide range of clinical presentations and severity. Multidisciplinary approaches are required to achieve the best treatment outcomes for both ocular and systemic manifestations.

A modified lacrimal sac implant for high-risk dacryocystorhinostomy

PURPOSE

The reported 5% of patients with nasolacrimal duct obstruction who fail dacryocystorhinostomy likely include patients with severe mucosal disease or anatomical anomalies. The technique described herein avoids mucosal anastomosis and minimizes mucosal manipulation by inserting a permanent silicone conduit from the lacrimal sac into the nasal cavity.

METHODS

This retrospective review of 9 surgical cases was performed with institutional review board approval. Six patients underwent 9 surgeries (3 sequentially bilateral) for dacryocystitis. Two patients had Wegener granulomatosis, 1 had pemphigoid, 1 sarcoidosis, 1 Rosai-Dorfman disease, and 1 congenital choanal atresia with chronic neonatal dacryocystitis. In each case, a modified Rains sinus stent was inserted through an external lacrimal sac incision with the draining end positioned in the nasal cavity. Two patients underwent concurrent canalicular intubation with Guibor silicone stents to prevent internal punctum obstruction by the lacrimal sac implant. Recurrence of symptoms, patient comfort, and modified Rains stent stability and patency were evaluated.

RESULTS

Mean follow up was 30 months (range 7-59 months). The modified Rains stent remained stable and patent in 7 of 9 cases, and symptoms resolved in 8 of 9 cases. In 1 patient with sarcoidosis, the modified Rains stent became repeatedly obstructed with nasal secretions and ultimately dislodged after intranasal manipulation by a physician unfamiliar with the surgery. In no other case did the patient experience recurrent infection, and in those cases, epiphora resolved entirely. In the patient with pemphigoid, one of the modified Rains stents extruded 6 months postoperatively, but his symptoms remained controlled. No adverse reaction to the implant material was seen.

CONCLUSIONS

A Rains silicone frontal sinus stent can be modified for implantation into the lacrimal sac and can safely and effectively drain the lacrimal sac into the nose in patients with severe mucosal disease or anatomical anomalies. Additional study and a stent specifically designed for this application will likely improve outcomes.

Endonasal dacryocystorhinostomy for nasolacrimal duct obstruction in patients with sarcoidosis

PURPOSE

To evaluate the outcomes of endonasal dacryocystorhinostomy (EN-DCR) surgery in patients with sarcoidosis.

METHODS

Retrospective chart review of all patients with sarcoidosis undergoing EN-DCR in 6 practices from 1999-2011.

RESULTS

We included 18 procedures in 14 patients (8 female, 6 male) who underwent EN-DCR for acquired NLDO secondary to sarcoidosis. The mean age was 53.7 (range 38-82). The presenting symptom in all cases was epiphora. Eight patients (57%) complained of having additional nasal congestion. Surgery was performed using endoscopic powered-type DCR with flaps in 12/18 (67%) and non-endoscopic mechanical EN-DCR in 6/18 (33%). In 15 (83%) cases the lacrimal sac and nasal mucosa appeared abnormally yellowish, crusty, oedematous and friable. Five patients were treated with pre-operative oral steroid and overall 8 patients had oral prednisolone post operatively, 30-60 mg tapered within 10 days-8 weeks. One patient had difficulties in tapering down the oral steroids at 6 months of follow-up. All patients were free of epiphora and patent to syringing, with nasal endoscopy revealing free flow of fluorescein through the ostium at a mean follow-up of 11.3 months (median follow-up 9 months).

CONCLUSIONS

All 18 cases of acquired nasolacrimal duct obstruction secondary to sarcoidosis were treated successfully with EN-DCR. An abnormal appearance of the nasal mucosa is an important sign. Nasal congestion is a frequent sign. A successful outcome may not depend on intensive long-term therapy with local or systemic steroids. Mechanical or powered EN-DCR for nasolacrimal duct obstruction secondary to sarcoidosis achieves encouraging medium-term outcomes.

[Sarcoidosis of the lacrimal sac as a cause of dacriostenosis]

Sarcoidosis is a systemic granulomatous disease of unknown aetiology. The course of sarcoidosis ranges from asymptomatic to severe. It could affect people of all ages. The disease affects predominantly the lungs and lymph nodes, skin, abdominal organs or eyes. Sarcoidosis of lacrimal sac is very uncommon. We describe a young man with lacrimal sac and nasal mucosa sarcoidosis present with epiphora. Few years before the onset of dacriocystitis the patient was treated because of lymph nodes sarcoidosis. The lacrimal sac sarcoidosis developed five years after systemic disease remission. An endoscopic dacriocystorhinostomy with intubation of nasolacrimal duct was performed. We used postoperatively systemic and local steroids for 3 months period. The patient is under observation for over four years with good health. The abnormal looking nasal or lacrimal sac mucosa could be associated with granulomatous disease as sarcoidosis and Wegener's or malignancies. If the sarcoidosis is established, it could be the first manifestation of sarcoidosis leading to future systemic sarcoidosis development or it may develop many years after the onset of systemic disease. Endoscopic dacriocystorhinostomy with intubation followed by intensive therapy with systemic and local corticosteroids may be helpful to maintain lacrimal drainage patency.

Recurrent dacryostenosis as initial presentation of sarcoidosis

Sarcoidosis is a multisystem granulomatous disease with an unknown etiology. It most commonly affects young and middle-aged females. It can affect any organ, but mostly lung, skin, and eyes. Up to half of patients are asymptomatic and the disease is often detected incidentally on abnormal chest radiography. We report the case of a 31-year-old male with bilateral recurrent dacryostenosis. The nasolacrimal obstruction was the initial manifestation of systemic sarcoidosis.

Acquired nasolacrimal duct obstruction

Acquired nasolacrimal duct obstruction is a common problem. Although tearing is the usual complaint, the clinical presentation can range from a patient having no symptoms to one with a life-threatening infection. Despite many studies providing useful clues, the exact pathophysiology of the obstructive process is incompletely understood. The clinician must be able to accurately make the diagnosis, which is often a clinical one, because many treatments with excellent success are available.

Lacrimal drainage surgery in patients with rare nasal diseases

AIM

To examine the results of open lacrimal drainage surgery in patients with rare nasal diseases.

METHOD

A retrospective review of a group of patients with rare nasal disease who underwent open lacrimal surgery over a 15-year period at Moorfields Eye Hospital. Three main groups of disease were identified: (I) patients with treated mid-face tumours; (II) patients with prior major midfacial injury or surgery; and (III) patients with congenital nasal anomalies, including nasal aplasia. The more common systemic conditions of Wegener's granulomatosis and sarcoidosis were specifically excluded.

RESULTS

Eighty-six patients (43 men; 50%) were identified with an age range between 1 and 82 years at the time of surgery. A total of 100 primary procedures were performed in 85 patients and symptomatic relief was achieved in 83/100 (83%) eyes, with 18/100 eyes (18%) requiring two or more lacrimal procedures. Lacrimal reconstructive surgery was considered impractical in two further patients. There were no intraoperative and few postoperative complications.

CONCLUSION

With adequate experience, open lacrimal surgery appears to be a safe and effective procedure in the majority of patients with rare nasal diseases or major nasofacial anomalies.

Is routine biopsy of the lacrimal sac wall indicated at dacryocystorhinostomy? A prospective study and literature review

OBJECTIVE

To determine whether routine biopsy of the lacrimal sac wall at dacryocystorhinostomy (DCR) is indicated.

METHODS

A prospective study and literature review. In 193 consecutive endoscopic DCRs performed on 164 patients (108 females and 56 males) part of the medial wall of the lacrimal sac was sent for histological examination. The mean age of the patients was 64 years with a range of 2.5-89 years. Previous reported series were reviewed.

RESULTS

Of the 193 specimens, 44 (23%) showed normal histology, 146 (76%) showed varying degrees of non-specific chronic inflammation, and three (1.2%) showed specific pathology. Of the three specimens that showed specific pathology two showed sarcoidosis and one showed transitional cell papilloma. The two specimens with sarcoidosis were obtained from one patient who underwent bilateral surgery. In this and the six previous reported series only seven of 1294 specimens (0.5%) showed specific pathology, which was definitely not suspected preoperatively or intraoperatively, and only one of these (0.08%) was found to be malignant (a lymphoma).

CONCLUSIONS

Biopsy of the lacrimal sac wall at DCR is not indicated routinely and is only indicated if there is a reason to suspect pathology other than chronic inflammation preoperatively or intraoperatively.

Pathology and Imaging of the Lacrimal Drainage System

The lacrimal drainage apparatus drains tears from the eye. The system is susceptible to a multitude of pathologic findings, including obstruction, infection, inflammation, and neoplasms. The diagnosis of several of these processes is aided by the use of radiologic studies. In conjunction with dacryocystography, cross-sectional modalities, such as CT and MR imaging have improved the ability of diagnostic imaging to characterize the obstructive nature and soft tissue or osseous changes of various disease processes.

Blind canalicular marsupialization in complete punctal absence as part of a systematic approach for classification and treatment of lacrimal system obstructions

The procedure of choice for epiphora caused by bipunctal and canalicular obstruction is conjunctivodacryocystorhinostomy. Despite its high success rate, it may result in multiple complications, such as extrusion, migration, and secondary obstruction. The author describes a simple alternative procedure to conjunctivodacryocystorhinostomy for patients with epiphora caused by bipunctal and proximal canaliculus complete occlusion and a systematic approach to treat lacrimal system obstructions. Ten instances of bipunctal and proximal canaliculus absence in five consecutive patients, caused in four patients by ocular surface disorders (topical drug toxicity, herpetic keratoconjunctivitis, and trachoma), were treated by blunt dissection of the presumed lower punctal site under a surgical microscope. The punctal site was determined by several landmarks, the peaked medial lid margin, a dimple at that site, or an area of relative avascularity. The canaliculus was exposed and expanded to create a pocket. After the procedure, the lacrimal drainage system was found patent in nine of the 10 procedures. After one additional procedure, irrigation of the lacrimal drainage system revealed a nasolacrimal duct obstruction that was treated with dacryocystorhinostomy and silicone tube insertion. After these procedures, an objective resolution of the epiphora was noted in all patients. Epiphora resulting from lack of punctal and proximal canaliculus caused by ocular surface diseases may be treated with blind exposure and marsupialization of the proximal canaliculus instead of conjunctivodacryocystorhinostomy. If, in addition, the nasolacrimal duct is obstructed, a dacryocystorhinostomy may be performed. If this proposed procedure fails, the patient can still undergo conjunctivodacryocystorhinostomy or other procedures. The procedure may be part of a systematic approach to treat lacrimal drainage obstructions that is based on an association between the location and the cause of the obstruction.

Routine histopathologic evaluation of the lacrimal sac during dacryocystorhinostomy: how useful is it?

OBJECTIVE

To determine the usefulness of "routine" lacrimal sac biopsy to evaluate unsuspected neoplasm or systemic disease in patients with acquired nasolacrimal duct obstruction.

DESIGN

Noncomparative, interventional case series with histopathologic correlation.

PARTICIPANTS

Review of charts revealed histopathologic reports on 302 specimens from 258 patients who had undergone routine dacryocystorhinostomy for clinical acquired nasolacrimal duct obstruction.

INTERVENTION

Dacryocystorhinostomy (DCR) with histopathologic evaluation of lacrimal sac.

MAIN OUTCOME MEASURES

The following variables were extracted from the medical records: age, gender, presenting symptoms, history of predisposing conditions, lacrimal system abnormalities noted before surgery, dye disappearance test, dacryocystogram or dacryoscintillogram, appearance of the lacrimal sac during surgery, and histopathologic report of the lacrimal sac specimen.

RESULTS

Findings of histopathologic evaluation of 302 lacrimal sac specimens from 170 females and 88 males who had undergone routine DCR were reviewed. Evidence of systemic disease or neoplasia involving the lacrimal sac was present in 10 specimens. All 10 positive specimens had a grossly abnormal appearing sac at the time of surgery (n = 8), a known preexisting history of systemic diseases (n = 6), or both. The remaining 292 specimens showed chronic inflammation, fibrosis, or normal mucosa.

CONCLUSIONS

Only patients with known preexisting systemic disease or a grossly abnormal lacrimal sac had "positive" histopathologic findings. We recommend that lacrimal sac biopsy in patients undergoing DCR should be performed only in those with a positive history for systemic disease or an abnormal-appearing lacrimal sac during surgery.

Isolated sarcoidosis of the lacrimal sac without systemic manifestations

Sarcoidosis is a systemic chronic granulomatous disease of unknown etiology. Although it most commonly affects African-Americans, Scandinavians, and the Irish, individuals of all races and ethnicities are susceptible. The otolaryngologist will most frequently encounter sarcoidosis involving the sinonasal region; however, other sites in the head and neck may be involved. Head and neck affliction with sarcoidosis most frequently accompanies pulmonary involvement, although, in rare cases, it may present in the absence of any systemic manifestations. We present a patient of Eastern European origin treated for persistent epiphora and recurrent dacryocystitis without any other medical problems. Because medical therapy and canalicular intubation failed, an endoscopic dacryocystorhinostomy (DCR) was performed. Histologic examination of the lacrimal sac showed noncaseating granulomas. Further workup revealed an elevated angiotensin-converting enzyme (ACE) level and hilar adenopathy. At no time did the patient have any other signs or symptoms of sarcoidosis. This unique case highlights 4 important issues for the otolaryngologist: (1) sarcoidosis may occur almost anywhere in the head and neck and is not strictly limited to the upper respiratory tract; (2) sarcoidosis may occur in the head and neck even in the absence of any pulmonary or other systemic involvement; (3) sarcoidosis may affect persons of all races, both sexes, and all ages; and (4) routine histopathologic examination after excision of the nasolacrimal sac is recommended.

Advances in lacrimal surgery

For nearly a century the gold standard treatment for epiphora and nasolacrimal duct obstruction has been dacryocystorhinostomy (DCR). The definitive treatment of severe canalicular stricture remains conjunctivodacryocystorhinostomy. Although the high success rate of open external approaches continues to be confirmed in the literature, there have been promising advances for endocanalicular surgery and endonasal DCR. Despite a significant narrowing of the gap in outcomes, external DCR may hold the advantage in its ease of performance and lower economic impact. A minor controversy exists over the role of routine postoperative antibiotics. Intraoperative intravenous antibiotic dosing may be as effective as postoperative systemic antibiotics for patients at high risk of infection.

Lacrimal drainage surgery in Wegener's granulomatosis

AIM

To examine the results of open lacrimal surgery in patients with Wegener's granulomatosis.

METHODS

A retrospective review of patients with Wegener's granulomatosis who underwent lacrimal surgery over a 17 year period.

RESULTS

11 patients were identified and a total of 14 primary dacryocystorhinostomies (DCR) and one revisional DCR were performed; symptomatic relief was achieved in 13/14 operations and one patient required revisional surgery for persistent symptoms. There were no intraoperative and few postoperative complications.

CONCLUSIONS

In contrast with some previous reports, open DCR appears to be a safe procedure and it is recommended as a treatment for lacrimal obstruction in patients with Wegener's granulomatosis, but an increase of perioperative immunosuppression is recommended in certain cases.