Lacrimal scintigraphy in the diagnosis of epiphora

A Pilot Study of Dynamic Magnetic Resonance Dacryocystography Imaging to Assess Functional Epiphora

OBJECTIVE

To evaluate dynamic magnetic resonance dacryocystography (MRDCG) in eyes with functional epiphora.

METHODS

We included prospective eyes with epiphora if no alternative cause was found on clinical examination, were patent on syringing, had no obstruction or stenosis on DCG, and had an abnormal DSG. MRDCG was performed to qualitatively assess for block or patency and quantitatively measure tear transit time. We compared measurements to asymptomatic fellow eyes and to historical reference values from asymptomatic eyes.

RESULTS

We included 26 symptomatic eyes of 19 patients (median age 63 years). There was a block on MRDCG in 18 (69%) eyes and patency in 8 (31%) eyes. The block occurred at the sac-nasolacrimal duct (NLD) junction in 9 (50%), proximal NLD in 5 (28%), mid-NLD in 1 (5.6%), and distal NLD in 1 (5.6%) eye(s). No contrast was observed in the lacrimal system in two eyes. For eyes patent on MRDCG, median times to the sac, NLD, inferior meatus, first 25%, and first 50% of the fundus-to-nose distance (FND) were 22, 54, 118, 34, and 84 s, respectively. Times to the sac, NLD, and to fill the first 25% and 50% of the FND were significantly longer than historical values from asymptomatic lacrimal systems (p = 0.017, 0.050, 0.035, 0.017, respectively).

CONCLUSION

MRDCG shows a high rate of block in functional epiphora. However, DSG and MRDCG results may not always correlate. The improved temporal resolution of this emerging modality may be advantageous in the critical first 2 min of tear transit.

Diagnostic value of lacrimal scintigraphy in the evaluation of lacrimal drainage system obstruction: a systematic review and meta-analysis

PURPOSE

A systematic review and meta-analysis to evaluate the diagnostic performance of lacrimal scintigraphy (LS) versus anatomical methods in the evaluation of the nasolacrimal duct obstruction (NLDO).

MATERIALS AND METHODS

A systematic search was performed using electronic bibliographic databases until the end of May 2021. Inclusion criteria: (a) used LS as a diagnostic method to evaluate NLDO; (b) used anatomical studies [including syringing, irrigation, probing, and dacryocystography (DCG)] as reference tests; and (c) provided adequate crude data. A hierarchical method was used to pool the sensitivity and specificity. The hierarchical summary receiver-operating characteristic model was performed. Additionally, the studies' heterogeneity and publication bias were analyzed. All analyses were conducted by the 'Midas' module of STATA 16.

RESULTS

Twelve articles (with 14 separate populations) were considered eligible to enter the meta-analysis. They were divided into two groups based on the reference standard method, called irrigation and DCG groups. In the irrigation group, the pooled sensitivity and specificity were 89% [95% confidence interval (CI), 72-96%] and 25% (95% CI, 8-56%), respectively. In DCG group, the pooled sensitivity and specificity were 97% (95% CI, 85-100%) and 27% (95% CI, 0.12-0.49), in turn.

CONCLUSION

LS is a sensitive modality to evaluate the anatomical obstruction of NLD. In contrast, it shows low pooled specificity compared with anatomical methods. Thus, LS can be used as the first noninvasive modality for the evaluation of epiphora. However, in case of any abnormality, confirmatory procedures are required.

Clinical utility of SPECT/CT and CT-dacryocystography-enhanced dacryoscintigraphy in the imaging of lacrimal drainage system obstruction

Purpose

Epiphora is commonly caused by a relative or complete occlusion in the lacrimal drainage system (LDS), principally a nasolacrimal duct obstruction (NLDO). Dacryoscintigraphy (DSG), an extensively assessed imaging technique in diagnosing its abnormalities, can provide only planar images, according to which it needs to be improved. Our aim was to evaluate clinical utility of simultaneous DSG and single-photon emission computed tomography/computed tomography (SPECT/CT) combined with computed tomographic dacryocystography (CT-DCG) in the evaluation of LDS.

Methods

Dynamic imaging with DSG was performed, and tracer radioactivity was detected by a gamma camera. Successively, SPECT/CT images of the involved region were gained, followed by CT-DCG, during which a contrast medium was syringed into the affected LDS, and finally contrast CT scans were obtained again from the same region.

Results

Fifty-seven patients, mean age 54.25 (± 18.26) years all with unilateral NLDO and 32 control subjects, all with patent LDS, mean age 49.88 (± 18.61) years were evaluated in the study. Delayed outflow of tearing eyes was exposed to DSG compared to the fellow and control eyes. The highest value for sensitivity was observed for SPECT/CT, followed by CT-DCG and DSG techniques, while combining DSG with SPECT/CT, DSG with CT-DCG, and SPECT/CT with CT-DCG, the sensitivity increased to 96.49%, 92.98%, and 94.73%, respectively.

Conclusions

Although DSG is a sensitive nuclear medicine method, it only provides useful clinical data when simultaneously supplemented with SPECT/CT and CT-DCG trials as they jointly can offer valuable information about the localization of an abnormality and verify stenosis or obstruction.

Dacryoscintigraphic findings in the children with tearing

Purpose

To investigate the diagnostic effectiveness of dacryoscintigraphy in children with tearing; to evaluate tear clearance rate as a diagnostic factor of dacryoscintigraphy in children with tearing; and to analyze the results of treatment according to dacryoscintigraphic findings in children with tearing.

Methods

Between January 2010 and April 2014, 176 eyes of 88 children with tearing (49 boys and 39 girls; mean age, 23.81 ±14.67 months; range, 12 to 72 months) were studied retrospectively. Of these, 37 of 88 children with tearing were bilateral cases, and 51 were unilateral cases. None of the patients had a history of craniofacial disorder or trauma. The chief complaint of tearing with or without eye discharge and delivery mode, past history of neonatal conjunctivitis, syringing, or probing were collected from parents, grandparents, or previous hospital data. The drainage pattern of the nasolacrimal duct was analyzed, and the clearance rate of 50 µCi 99m technetium pertechnetate was measured by dacryoscintigraphy.

Results

According to the dacryoscintigraphy results, 98 of 125 eyes (78.4%) with tearing showed nasolacrimal obstruction and 29 of 51 eyes (56.9%) without tearing showed patency. There was a significant difference between tearing eyes and normal eyes (p = 0.001). The clearance rate difference after 3 and 30 minutes was 16.41 ± 15.37% in tearing eyes and 23.57 ±14.15% in normal eyes. There was a significant difference between epiphoric eyes and normal eyes (p = 0.05). Based on the dacryoscintigraphic findings, nasolacrimal-duct obstruction was treated with probing or silicone-tube intubation. The majority of patients showed symptom improvement (75.2%) during the two months of follow-up.

Conclusions

Dacryoscintigraphy is a non-invasive method of qualitatively and quantitatively diagnosing nasolacrimal duct obstruction in children with tearing.

Lacrimal outflow mechanisms and the role of scintigraphy: current trends

Lacrimal outflow can be compromised by anatomical obstructions or stenoses (nonfunctional epiphora) or by defective lacrimal “pump” function (functional epiphora). Although classic imaging modalities, such as X-ray dacryocystography, computed tomography, or magnetic resonance imaging can effectively evaluate the former, their success is much less in the evaluation of the latter. This is largely due to the fact that forced diagnostic injection of fluid into the canalicular system can overcome partial obstruction sites. On the other hand, lacrimal scintigraphy mimicks “physiological” lacrimal outflow, being performed under pressure gradients present in everyday life. This is why it is considered more suitable for the study of functional epiphora. Furthermore, quantitative lacrimal scintigraphy (with time-activity curves) enables the accurate measurement of lacrimal clearance from the conjunctival fornices and may be used to study the physiology of the lacrimal “pump.” Data obtained from the scintigraphic study of lacrimal outflow may be used to design more effective procedures in the management of functional and nonfunctional epiphora. This is a review article, based on a literature search with emphasis on recent publications and on those supporting interdisciplinary cooperation between ophthalmology and nuclear medicine.

Assessment of the accuracy of lacrimal scintigraphy based on a prospective analysis of patients' symptomatology

BACKGROUND

Dacryoscintigraphy is a noninvasive method frequently used for assessment of the lacrimal drainage system. Sometimes conflicting results with patients' complaints are obtained, which have no clear explanation. In our hypothesis, follow-up of patients evaluated with dacryoscintigraphy could be helpful in determining possible explanations for these conflicting results.

METHOD

Thirty-eight consecutive patients (76 eyes) who had not previously undergone dacryocystorhinostomy or probing were entered in the study. Following instillation of 4 MBq (99m)Tc-pertechnetate, a routine procedure of dacryoscintigraphy was performed. After a mean follow-up time of 1.2 +/- 0.3 years (range 0.9-1.6 years), all patients were reassessed clinically.

RESULTS

Using initial patients' symptoms as the gold standard, the sensitivity, specificity, NPV, and PPV of dacryoscintigraphy were calculated to be 82.1%, 75%, 60%, and 90.1%, respectively. The kappa value as a measure of agreement was 0.52. Considering the follow-up study as the gold standard, the sensitivity, specificity, NPV, and PPV were calculated as follows, respectively: 96.3%, 90.4%, 96.3%, and 90.4%. The kappa value was 0.86. There were three initially symptom-free eyes with obstructive pattern on the scans, which developed epiphora on the follow-up. In fact, these eyes were initially classified as false positive, but follow-up assessment showed that they were true-positive scans in a subclinical state.

CONCLUSION

Despite certain drawbacks inherent to the technique, dacryoscintigraphy provides valuable independent information and allows more accurate management decisions. In some patients, data obtained from lacrimal scintigraphy could be predictive, and it makes possible determination of subclinical nasolacrimal duct obstructions.

Lower Eyelid Laxity in Functional Acquired Epiphora: Evaluation With Quantitative Scintigraphy

PURPOSE

The examination of lacrimal drainage is often based on qualitative criteria. This study uses quantitative scintigraphy to evaluate "functional" epiphora.

METHODS

Thirty-two patients with functional epiphora (no morphologic abnormalities of the conjunctiva and eyelids, a patent nasolacrimal duct on irrigation, and no anatomical stenosis on dacryocystography) were studied (study group, SG). Twenty-two individuals without epiphora were also examined (control group, CG). Fifty microliters of Technetium-99m was instilled into the conjunctival cul-de-sac. Time-activity curves were then constructed, and conjunctival lacrimal clearance (CLC) at 2.5, 5, 7.5, and 10 minutes was calculated. Differences in CLC between the SG and the CG and correlations between CLC and horizontal and median tendon laxity and eyelid length in the SG were examined.

RESULTS

The SG had significantly reduced CLC at 2.5 and 5 minutes, compared with the CG (p = 0.01 and p = 0.04, respectively), whereas respective differences at 7.5 and 10 minutes were not statistically significant. In the SG, CLC at 2.5 and 5 minutes was significantly correlated with horizontal and median tendon laxity. The respective correlation with eyelid length was not statistically significant. Furthermore, in the SG, CLC at 2.5 and 5 minutes was significantly correlated with patient age (p = 0.03 and p = 0.04, respectively). Differences in CLC between men and women were not statistically significant at all intervals.

CONCLUSIONS

The correlation between eyelid laxity and CLC supports the role of the eyelid "pump" in lacrimal drainage. CLC at 2.5 and 5 minutes may be used to decide treatment methods for functional epiphora.

The clinical value of dacryoscintigraphy in the selection of surgical approach for patients with functional lacrimal duct obstruction

PURPOSE

Dacryoscintigraphy is widely known to be an effective modality in diagnosing abnormalities of the lacrimal system that cause epiphora (pathological overflow of tear). However, dacryoscintigraphy rarely serves beyond the simple diagnostic use for lacrimal duct obstruction. In our study, dacryoscintigraphy results of patients with functional lacrimal duct obstruction are newly classified into three types, the effects and prognoses of silicone tube intubation are noted according to each type, and the role of dacryoscintigraphy in determining appropriate surgical approaches is evaluated.

METHODS

Subjects were 36 eyes of 29 patients complaining of epiphora who had increased tear meniscus, but showed no sign of obstruction on duct syringing. Impression of functional lacrimal duct obstruction was made through dacryoscintigraphy, and silicone tubes were inserted.

RESULTS

Patients were classified according to the results of dacryoscintigraphy; those with delayed secretion in the distal nasolacrimal duct were typed as class I; those with delays in the proximal nasolacrimal duct class II; and delayed secretion from the pre-lacrimal sac to the lacrimal sac as class III. All patients had silicone tube intubations together with selective punctoplasty. Symptomatic improvement was observed in all 6 cases of distal nasolacrimal duct obstruction (100%), 14 of 18 proximal obstruction cases (77.8%), and 8 of 12 pre-lacrimal obstructions (66.7%).

CONCLUSIONS

Functional lacrimal duct obstruction is easily diagnosed with dacryoscintigraphy. Furthermore, its may be classified by types of obstruction to predict post-operative results of silicone tube insertion. Cases suspicious of pre-lacrimal sac obstructions in particular may achieve better operative results with adjuvant treatments in addition to silicone tube insertion.

Silicone versus collagen plugs for treating dry eye: results of a prospective randomized trial including lacrimal scintigraphy

PURPOSE

To compare the short-term efficacy of collagen and silicone plugs for treating dry eye using quantitative lacrimal scintigraphy.

DESIGN

Prospective randomized clinical trial.

METHODS

In this institutional study, 24 dry eye patients were evaluated in two groups: group I (n = 22 eyes) received collagen plugs and group II (n = 26 eyes) received silicone plugs. Comparisons were made with normal control subjects (n = 22 eyes). Data for the Schirmer I test, tear break-up time, and ocular surface staining with rose bengal dye were recorded before and after punctal occlusion. Lacrimal scintigraphy was performed at each time point, and the time to half maximum activity on the ocular surface (T(1/2)), and the percentage retention of activity on the ocular surface at the end of the dynamic study (RI) were recorded.

RESULTS

In both patient groups, Schirmer I results, tear break-up times, and rose bengal staining scores improved significantly after plug insertion. Mean T(1/2) values and RI values increased significantly in both groups (P < .0001 for both). The differences for these values between groups I and II was statistically insignificant (P > .05).

CONCLUSIONS

Collagen and silicone plugs both resulted in significant increases in aqueous tear volume, half-life of nuclear material on the ocular surface, and percentage of nuclear material retention. The groups' post-insertion values for all parameters were similar. These results suggest that these two plug types have similar efficacy as treatments for dry eye in the short term. Further studies evaluating long-term results are required.

Clinical value of dacryoscintigraphy using a simplified analysis

PURPOSE

To study the discriminatory ability of dacryoscintigraphy in differentiating between patients with epiphora and volunteers using a simple method.

METHODS

Twenty eyes in ten volunteers and 66 eyes in 55 patients with severe epiphora were studied. Dacryoscintigraphy (15 frames of 1 min) was performed after administration of 4 MBq (99m)Tc-pertechnetate (10 mul) in both eyes. By mapping a single region of interest (ROI) over the conjunctival sac we determined T1 (%dose in first minute) and linear clearance rate (LCR, defined as [see text] from the tracer disappearance curve. Reproducibility was determined in volunteers. Conjunctival resorption was determined from completely obstructed systems. Sensitivity and specificity were calculated and receiver operating characteristics (ROC) analysis was conducted.

RESULTS

In volunteers mean T1 was 52.8+/-11.9% (95% CI 47.1-58.4%), and LCR was 74.2+/-11.1% (95% CI 69.0-79.4%). Reproducibility was good (mean difference 4.1+/-13.3% for T1 and 0.7+/-17% for LCR). Epiphora patients had clearly higher T1 (82.1+/-15.2%, P<0.0001) and lower LCR (38.9+/-22.5%, P<0.0001) values. Tracer resorption was 24%. Based on ROC analysis 70% for T1 and 50% for LCR were considered optimal cut-off levels to separate patients from volunteers. Sensitivity/specificity were 77/95% for T1 and 71/100% for LCR. T1 and LCR values did not correlate with symptom scores or Anel test results.

CONCLUSION

Dacryoscintigraphy, using LCR and T1 as parameters, is a reliable and objective method to detect tear-flow abnormalities.

Fluorescein dye disappearance test in patients with different degrees of epiphora

PURPOSE

To assess the diagnostic efficacy of a modification of the fluorescein dye disappearance test (DDT) in patients with different degrees of epiphora.

METHODS

DDT was performed by instilling a drop of 2% fluorescein in the eye. Schirmer tear test strips were placed in the lower conjunctival fornix, after 3 and 10 minutes. The colour dilution on the strips was compared to a scale with known standards and the most closely comparable colour dilution was chosen and recorded as the visual scale test (VST) grade of the strip. The grey-scale value (GV) of each strip was calculated by computer image analysis. The control group comprised 44 patients, mean age 44.8 years (SD 7.5, range 30-60). There were 13 patients in group 1 with moderate epiphora; mean age was 44.2 years (SD 9.5, range 30-60). There were 17 patients in group 2 with severe epiphora; mean age was 48.3 years (SD 7.7, range 37- 60).

RESULTS

VST and GV differed significantly between controls and group 1 patients at 3 minutes (p=0.002, p=0.001), and between controls and group 2 patients at 3 minutes (p<0.001, p<0.001). There was no difference between groups 1 and 2 patients in VST and GV at 3 minutes. The differences were highly significant between controls and group 1 at 10 minutes (p=0.001, p=0.007), and between controls and group 2 at 10 minutes (p<0.001, p<0.001). The differences in GV and VST between groups 1 and 2 were significant at 10 minutes (p=0.026, p=0.018).

CONCLUSIONS

This modified DDT permits identification of different degrees of epiphora in a non-invasive manner, it can therefore be used to evaluate the outcome of different treatment strategies.

Comparison between nasolacrimal syringing/probing, macrodacryocystography and surgical findings in the management of epiphora

AIMS

Macrodacryocystography (MDCG) has been shown to be highly sensitive in evaluating the lacrimal drainage system. We aimed to compare the results of syringing/ probing with MDCG, and with surgical findings where available. We also aimed to determine whether MDCG is advisable in addition to syringing/probing when investigating epiphora.

METHODS

In a retrospective study, we looked at the records of 76 consecutive patients (86 eyes) presenting with epiphora over a period of 2 years (January 1993 to December 1994). All patients underwent syringing/probing and subsequent MDCG to determine the presence and level of nasolacrimal block. The results were then compared with surgical findings where available (46 eyes, 53%).

RESULTS

Surgical findings were predicted by MDCG in 95.5% of cases but in only 54% by probing. Probing findings agreed with MDCG in only 51% of cases. The main areas of disagreement were the presence of canalicular blocks and the presence of more than one block at different levels.

CONCLUSION

A combination of syringing/ probing and MDCG provides the most accurate pre-operative lacrimal assessment and should predict all the canalicular stenoses requiring intubation. In addition, MDCG can predict physiological duct blocks beyond canalicular blocks and thus alter surgical management.

Clinical and radiologic lacrimal testing in patients with epiphora

OBJECTIVE

The purpose of the study is to assess the strengths and weaknesses of selected clinical and radiologic lacrimal tests in patients with epiphora.

DESIGN

The study design was a prospective clinical trial.

PARTICIPANTS

Fifteen patients with epiphora (N = 27 eyes) were studied.

METHODS

All patients underwent Jones testing, the dye disappearance test, canalicular probing, lacrimal scintigraphy, and macrodacryocystography.

MAIN OUTCOME MEASURES

The dye disappearance test was graded individually by three ophthalmologists. Lacrimal scintigraphy and macrodacryocystography were evaluated by a nuclear medicine specialist and a radiologist, respectively. A panel of three ophthalmologists evaluated the data using a scoring system that relied on the preponderance of evidence to arrive at a final assessment.

RESULTS

When the Jones I test results were negative (dye recovered from the nose), the epiphora was always from hypersecretion. When the Jones I test results were positive (no dye recovered from the nose), obstruction was not always present. When the dye disappearance test results were strongly abnormal, obstruction was always present. In contrast, when the dye disappearance test results were normal, the lacrimal drainage system was not always patent. Canalicular probing was more reliable than scintigraphy in identifying canalicular obstruction. Marked stenosis of the sac or duct on dacryocystography essentially confirmed nasolacrimal outflow obstruction; however, with the authors' technique, a normal study was found in some patients with functional or partial obstruction.

CONCLUSIONS

More than one lacrimal test may be required for a definitive diagnosis in patients with epiphora due to partial or functional nasolacrimal outflow obstruction.

Nuclear dacryoscintigraphy: its role in oral and maxillofacial surgery

Obstruction of the lacrimal drainage apparatus may result in excessive tearing or epiphora. This may occur as a result of a traumatic injury or accumulation of debris, mucus, or pus. In nuclear dacryoscintigraphy, a radioactive solution is introduced into the conjunctival sac by pipette and allowed to follow the flow of the tear solution through the lacrimal drainage system. This article will review normal lacrimal anatomy and indications for nuclear dacryoscintigraphy in oral and maxillofacial surgery.