Syndromic and Nonsyndromic Systemic Associations of Congenital Lacrimal Drainage Anomalies: A Major Review

Optimal Diagnostic and Treatment Practices for Facial Dysostosis Syndromes: A Clinical Consensus Statement Among European Experts

Facial dysostosis syndromes (FDS) are rare congenital conditions impacting facial development, often leading to diverse craniofacial abnormalities. This study addresses the scarcity of evidence on these syndromes about optimal diagnostic and treatment practices. To overcome this scarcity, European experts from ERN CRANIO collaborated to develop a clinical consensus statement through the Delphi consensus method. A systematic search of Embase, MEDLINE/PubMed, Cochrane, and Web of Science databases was conducted until February 2023. The quality of evidence was evaluated using various tools depending on the study design. Statements were subsequently formed based on literature and expert opinion, followed by a Delphi process with expert health care providers and patient representatives. In total, 92 experts from various specialties and three patient representatives were involved in the Delphi process. Over 3 voting rounds, consensus was achieved on 92 (46.9%), 58 (59.2%), and 19 (70.4%) statements, respectively. These statements cover the topics of general care; craniofacial reconstruction; the eyes and lacrimal system; upper airway management; genetics; hearing; speech; growth, feeding, and swallowing; dental treatment and orthodontics; extracranial anomalies; and psychology and cognition. The current clinical consensus statement provides valuable insights into optimal diagnostic and treatment practices and identifies key research opportunities for FDS. This consensus statement represents a significant advancement in FDS care, underlining the commitment of health care professionals to improve the understanding and management of these rare syndromes in Europe.

Punctal Atresia As a Clinical Indicator of Systemic Genetic Anomalies

BACKGROUND

Punctal atresia or agenesis (PA) is a rare congenital anomaly characterized by the absence or closure of the tear duct puncta, potentially linked to systemic genetic anomalies. The necessity of a genetic workup based solely on the presence of PA remains uncertain. This study investigates a cohort of PA patients, examining the prevalence and types of associated syndromes.

METHODS

A retrospective medical records review of all patients diagnosed with PA at the Children's Hospital of Philadelphia between 2009-2023 was conducted, analyzing medical histories and genetic testing results. Primary outcomes included the prevalence of systemic syndromes, while secondary outcomes focused on the variety of associated syndromes.

RESULTS

Forty-four patients were included, of which 31 were male (70%) with a mean ± SD age 3.3 ± 3.3 years. Overall, 87 puncta in the study cohort were affected, and 26 cases (59%) were bilateral. Systemic abnormalities or genetic syndromes were identified in 19 patients (43%), with the most common being Ectodermal Dysplasia and Down syndrome. Additional rare syndromes were demonstrated. No significant association was found between systemic abnormalities and gender, bilaterality, or the number of puncta involved.

CONCLUSIONS

A high incidence of systemic syndromes (43%) was observed in the study cohort. In individuals with PA who also exhibit extraocular disease, systemic evaluation and genetic workup should be considered. Syndromic diagnoses identified in our cohort also include: Branchio-oto-renal syndrome, 22q11.2 deletion syndrome, 1q21.1 microdeletion syndrome, NF1, monosomy 4q and trisomy 6q, which represent novel associations. The lack of correlation between PA's phenotypic severity and systemic abnormalities highlights the need to obtain a comprehensive medical history and consider a systemic workup in PA patients.

Is Ophthalmia Neonatorum Associated With Invasive Bacterial Infection? A Single-Center Retrospective Study

OBJECTIVE

Ophthalmia neonatorum (ON) is a conjunctivitis occurring in neonates and can be caused by multiple bacterial pathogens. The risk of invasive bacterial infection (IBI) in neonates with ON is poorly known. Our objectives were to document the association of ON with IBI in term neonates and to investigate practice variation.

METHODS

This was a retrospective observational study of all neonates who presented to a single emergency department (ED) between January 2018 and December 2019. Participants were all children with a final diagnosis of ON according to the treating physician as registered in the ED computerized database. Newborns with craniofacial malformations and premature infants were excluded. The primary outcome was IBI as defined by growth of any bacterial pathogen in the blood or cerebrospinal fluid. Perinatal risk factors, ED visit details (symptoms on presentation, management, and treatment plan) as well as complications (ocular morbidity, death, and unscheduled return visits) were collected. Data were analyzed using descriptive statistics.

RESULTS

Fifty-two term neonates were included. There were no cases of IBI associated with ON (0%; 95% confidence interval [CI], 0%-6.9%). Six ocular bacterial infections were identified, one of which was Chlamydia trachomatis . Although there were no IBIs, ocular complications, deaths, or unscheduled return visits to the ED, there was a wide variation in physician's management of ON. Physicians ordered investigations in 49% (95% CI, 34%-62%) of neonates, prescribed antibiotics to 87% (95% CI, 74%-94%), and involved specialists in 39% (95% CI, 27%-52%) of cases.

CONCLUSIONS

Emergency department presentations of term neonates with ON are associated with a low risk of IBI. A better understanding of the current practice variation is needed to inform clinical guidelines for the management of neonates with ON presenting to the ED.

Bilateral Nasolacrimal Duct Obstruction Managed With Probing and Irrigation in a Patient With FGF10-Associated Lacrimo-auriculo-dento-digital Syndrome

The authors report a case of lacrimo-auriculo-dento-digital syndrome in a 16-month-old boy with punctal agenesis, upper canalicular dysgenesis and polydactyly, presenting as bilateral congenital nasolacrimal duct obstruction and unilateral acute dacryocystitis. Genetic sequencing revealed a novel mutation in fibroblast growth factor 10. [J Pediatr Ophthalmol Strabismus. 2023;60(4):e38-e40.].

[Congenital anomalies in lacrimal drainage]

Congenital dacryostenosis is the most common reason for ophthalmic consultation in childhood. It is most often caused by persisting of Hasner's membrane. However, congenital malformations of the lacrimal drainage system can also occur in rare cases. In the area of the proximal lacrimal drainage system, supernumerary lacrimal puncta and canaliculi can arise as well as diverticula, fistula, and atresia. The distal lacrimal drainage system can be affected by fistulas, amniotoceles, and cysts. Association of lacrimal malformations with congenital systemic diseases is reported in about 10% of cases. Depending on the severity of the symptoms, surgical rehabilitation can be performed, and endoscopic procedures and modern lacrimal drainage intubation systems may be employed.

Bilateral Congenital Nasolacrimal Duct Obstruction in Williams-Beuren Syndrome

A 23-year-old patient with Williams-Beuren syndrome presented with ocular irritation and bilateral persistent tearing. Despite probing as an infant which showed bilateral nasolacrimal duct obstruction, dacryocystorhinostomy had been avoided due to the patient's syndromic supravalvular stenosis and related anesthesia risk. As the known diminished production of elastin in Williams-Beuren syndrome causes an array of associated vascular diseases, this case report hypothesizes that the lacrimal duct becomes obstructed through a similar mechanism. This case presents the unique findings of bilateral congenital nasolacrimal duct stenosis in a Williams-Beuren syndrome patient.

Goldenhar syndrome associated with lacrimal system agenesis: A case report

Purpose

To report a case of lacrimal system agenesis in a patient with Goldenhar syndrome.

Observations

A one-month-old female preterm twin with Goldenhar syndrome presented with left upper eyelid coloboma, left central corneal ulcer and inferotemporal epibulbar dermoid. The corneal ulcer was treated and healed to a mild stromal scar. Examination under anesthesia prior to surgery revealed agenesis of the upper and lower eyelids canaliculi. Surgery was performed to correct left upper eyelid coloboma. At a second stage, the epibulbar dermoid was excised and ocular surface was repaired with amniotic membrane graft.

Conclusion and importance

Goldenhar syndrome is a rare congenital anomaly arising from the abnormal development of the first and second branchial arches. Anomalies of lacrimal drainage system are uncommon in Goldenhar including nasolacrimal duct obstruction and common canalicular obstruction. Agenesis of the lacrimal system has not been described in cases of Goldenhar syndrome. This case represents a unique and uncommonly seen feature.

Retrospective analysis of congenital nasolacrimal duct obstruction outcomes in a tertiary referral center

Background

The aim of this study was to profile patients with simple and complex congenital nasolacrimal duct obstruction (CNLDO) and to determine the success rates of interventions at a third-level referral center.

Methods

In this retrospective and comparative study, medical records of patients with CNLDO were reviewed. Demographic data, types of CNLDO, surgical approach, type of silicone intubation, as well as outcome were recorded up to 3 months after the intervention. Obstruction location was identified by probing and irrigation following the American Academy of Ophthalmology (AAO) approach. Success rates were calculated for treatment approach and age group.

Results

Based on the outcome of 130 eyes with CNLDO, the overall success rate was 96%. The mean age of patients was 2.5 ± 2.2 months; 73% of cases were simple and 27% were complex CNLDO. Five children had to undergo reoperation; consequently, there was a lower success rate in the complex CNLDO (91%) than in the simple CNLDO subgroup (97%). There was a male predominance (61.5%), which was also present in the simple and complex CNLDO subgroups. The most frequent type of CNLDO was complete nasolacrimal duct obstruction (NLDO, 55.4%), followed by partial (17.7%) and bony NLDO (11.5%). In 87% of eyes, initial probing was performed followed by dacryocystorhinostomy (10%). Mono- or bi-canalicular lacrimal drainage system intubation was used in 86% of eyes.

Conclusion

The AAO-based diagnostic approach followed by an individualized treatment regimen yielded excellent success rates of 96% in unselected patients with CNLDO. These success rates were independent of patient age or gender.

Congenital Anomalies in Lacrimal Drainage

Congenital dacryostenosis is the most common reason for ophthalmic consultation in childhood. It is most often caused by persisting of Hasner's membrane. However, congenital malformations of the lacrimal drainage system can also occur in rare cases. In the area of the proximal lacrimal drainage system, supernumerary lacrimal puncta and canaliculi can arise as well as diverticula, fistula, and atresia. The distal lacrimal drainage system can be affected by fistulas, amniotoceles, and cysts. Association of lacrimal malformations with congenital systemic diseases is reported in about 10% of cases. Depending on the severity of the symptoms, surgical rehabilitation can be performed, and endoscopic procedures and modern lacrimal drainage intubation systems may be employed.

Co-existing lacrimal drainage anomalies in eyes with congenital Glaucoma

AIM

To evaluate the occurrence of co-existing congenital nasolacrimal duct obstruction (CNLDO) and other lacrimal anomalies in eyes with congenital glaucoma (CG).

METHODS

Retrospective analysis of children aged ≤1-year with co-existing CG and CNLDO seen between 1998 and 2019, treatment interventions and outcomes.

RESULTS

During the study period, 1993 children had CG and 6203 children had CNLDO, among the children aged 1-year or less. Of these, 51 children (73 eyes) had co-existing CG and CNLDO. The prevalence of CNLDO in CG was 2.5% (51/1993) and the prevalence of CG among CNLDO was 0.8% (51/6203). Median age (Interquartile range, IQR) was 53 days (IQR: 8, 155), when they were diagnosed with CG. Among the children with CNLDO, 68 eyes (93.1%) had simple CNLDO, and 5 eyes (6.9%) had complex CNLDO. Associated lacrimal anomalies were present in 7/73 eyes, including congenital lacrimal fistula in two eyes, upper punctal agenesis and upper mid-canalicular obstruction in two eyes each, and upper single canalicular-wall hypoplasia in one eye. Lacrimal syringing and probing were successful in 69/72 eyes (95.8%), and failed in 3 eyes (4.2%). These 3 eyes had complex CNLDO and underwent Dacryocystorhinostomy (DCR) with Mitomycin-C and intubation. Sixty-two eyes underwent combined trabeculotomy and trabeculectomy, and two eyes underwent trabeculectomy. Median age at glaucoma surgery was 87 days (IQR: 54, 193). Median time delay for glaucoma surgery after probing was 18 days (IQR: 12, 35).

CONCLUSION

Among children aged ≤1-year presenting with congenital glaucoma coexisting lacrimal drainage anomalies was noted in 2.5% and simple CNLDO was the commonest. Early intervention is of paramount importance to prevent sight-threatening intraocular infection with CNLDO, and to minimize the delay of glaucoma surgery. The outcomes of lacrimal probing were excellent, however complex CNLDO required DCR.

The effect of lacrimal drainage abnormality on the surgical outcomes of congenital lacrimal fistula and vice versa

PURPOSE

To evaluate the various surgical modalities of congenital lacrimal fistula and assess the mutual effect of lacrimal fistula and lacrimal drainage abnormality on the individual surgical outcomes.

METHODS

In this retrospective cohort and case-control study, 74 eyes from 63 patients with lacrimal fistula who underwent surgical management between 2000 and 2015 at three medical centers were enrolled. The data collected included sex, age, preoperative symptoms, presence of concurrent lacrimal drainage abnormality, surgical methods, and surgical outcomes. The main outcome measures were treatment outcomes based on lacrimal drainage patency and symptom improvement, surgical outcome of fistulectomy according to the presence of lacrimal drainage abnormality, and surgical outcome of lacrimal drainage abnormality according to the presence of fistula.

RESULTS

The mean age at the time of surgery was 9.2 (SD, ±8.8) years and the mean follow-up duration was 14.4 (SD, ±19.5) months. All eyes (37/37) with fistula without lacrimal drainage abnormality demonstrated surgical success after simple fistulectomy. Patients with concurrent lacrimal drainage abnormalities showed more frequent surgical failure than those with fistula alone (p = 0.009). However, the presence of fistula did not affect the outcomes of surgery for lacrimal drainage abnormality (p = 0.179).

CONCLUSION

Simple fistulectomy is sufficient for sole asymptomatic or pauci-symptomatic lacrimal fistula. Symptomatic fistula as well as those accompanied with lacrimal drainage abnormality underwent fistulectomy and lacrimal drainage system surgery. Patients with accompanying lacrimal drainage system abnormalities showed less favorable outcomes. Meticulous preoperative examination of the lacrimal drainage system is critical for surgical planning and prognosis prediction.

Congenital nasolacrimal duct obstruction update study (CUP study): Paper II - Profile and outcomes of complex CNLDO and masquerades

OBJECTIVE

To assess the profiles and outcomes of complex congenital nasolacrimal duct obstruction (C-CNLDO).

METHODS

Retrospective interventional case-series was performed on patients diagnosed with C-CNLDO and managed at a tertiary care Dacryology Institute from Jan 2016 to June 2019. Complex CNLDO was diagnosed based on intraoperative findings during probing and are defined as entities where CNLDO is secondary to, or associated with complex embryonic entities like buried probe, mal-development or non-development of bony NLD, additional proximal lacrimal dysgenesis, atonic sac, or associated craniofacial syndromes and craniofacial dysostosis. The parameters studied include patient demographics, clinical presentation, types of C-CNLDO, management modalities, and outcomes. Success was defined as the subjective resolution of epiphora and discharge with objective measures of normal tear meniscus height and dye clearance on fluorescein dye disappearance test. For patients who underwent a dacryocystorhinostomy (DCR), a minimum follow-up of 1-year post-DCR was considered for outcome analysis.

RESULTS

Of the 2714 cases of CNLDO managed during this period, 482 (17.75%) were diagnosed as complex CNLDO. C-CNLDO showed predilection to the male gender (60.3%, 291/482). A significant number of patients (40.2%, 194/482) presented beyond 36 months of age. The common subtypes of C-CNLDO were atonic sacs (33.8%, 163/482), buried probes (19.7%, 95/482), and associated proximal lacrimal drainage anomalies (11.2%, 54/482). Since C-CNLDO is usually confirmed during the initial endoscopy-guided probing, the managements varied based on the type of C-CNLDO. Silicone intubation and/or balloon dacryoplasty (BDCP), and/or additional minimally invasive procedures were added to the initial endoscopy-guided irrigation and probing based on the nature of C-CNLDO. The overall resolution rate with these non-bypass modalities was 72.6% (350/482). Although the success rates start dropping in C-CNLDO patients beyond 3-years of age, significant success rates with multi-modal (non-bypass) management were noted in age-groups 3-5 years (71.8%, 79/110) and encouraging results (38.5%, 27/70) in 5-10 years age group. The anatomical and functional outcomes in those who underwent endoscopic or external dacryocystorhinostomy with a follow-up beyond 1-year was 96.4% (55/57).

CONCLUSION

The age at presentation is delayed in patients with C-CNLDO. Multi-modal endoscopy-guided management facilitates the identification of several sub-types of C-CNLDO, and achieves significantly high favourable outcomes in older children. C-CNLDO refractory to probing, intubation and BDCP demonstrates high success with external or endoscopic dacryocystorhinostomy.

Novel Findings in Floating-Harbor Syndrome and a Mini-Review of the Literature

Floating-Harbor syndrome (FHS) is a rare autosomal dominant genetic disorder characterized by proportionate short stature with delayed bone maturation, lack of expressive language, and distinctive facial features including a large nose, long eyelashes, deeply set eyes, and triangular face. Mutations in the SRCAP gene cause truncated SNF2-related CREBBP activator protein (SRCAP) and lead to FHS. SRCAP is one of several proteins that act as coactivator for the CREB-binding protein which is associated with Rubinstein-Taybi syndrome (RSTS). This condition likely explains the phenotypic overlap between FHS and RSTS. Herein, we report on a patient with FHS who also had dystrophic toenails, preauricular skin tag, and nasolacrimal duct obstruction which is also defined in patients with RSTS. In summary, the fact that especially nasolacrimal duct obstruction has also been observed in RSTS reinforces the idea that this finding is one of the features of FHS. Assessment of the lacrimal system and examination of skin and nails should be suggested in patients with FHS.

Potential of dosage reduction of cone-beam CT dacryocystography in healthy volunteers by decreasing tube current

PURPOSE

Cone-beam CT dacryocystography (CBCT-DCG) is a newly developed lacrimal passage imaging technique. This pilot study aimed to determine the effect of reducing tube current on image quality and radiation dose of CBCT-DCG in healthy volunteers.

MATERIALS AND METHODS

Thirty volunteers were randomly divided into three groups of ten. Each group of subjects underwent CBCT-DCG using a tube current of 13 mA, 10 mA, and 7 mA respectively. The image quality of CBCT-DCG was assessed independently by two observers using three different scoring methods and compared among the groups. The effective dose was estimated and compared among the three different tube current groups.

RESULTS

The CBCT-DCG images provided a high spatial and contrast resolution of the bony structures and the contrast medium. No significant differences were found in the image quality between different tube current groups. Compared with the 13 mA group (49.44 μSv), the effective dose for 10 mA group (38.40 μSv) and 7 mA group (27.12 μSv) decreased by 22.33% and 45.15%, respectively.

CONCLUSION

By decreasing the tube current, CBCT-DCG can be performed with a significant reduction of effective dose without loss of image quality in healthy volunteers.

Updates on congenital lacrimal drainage anomalies and their association with syndromes and systemic disorders: A major review

BACKGROUND

To review and update the syndromic and non-syndromic systemic associations of congenital lacrimal drainage anomalies.

METHODS

The authors performed a PubMed search of all articles published in English on congenital lacrimal drainage anomalies (CLDA). The current review provides an update from January 2017 to August 2020 on all CLDA associated with clinical syndromes or non-syndromic systemic disorders. The update intends to appraise the readers on all papers that were published in the interim 3-year period since the publication of the previous major review by authors (1933-2016). Patients with specific syndromes or systemic disorders were then reviewed. Pertinent cross-references from each of the short-listed articles were also included. Data reviewed include syndromic descriptions, systemic details, demographics, lacrimal presentations, management, and outcomes.

RESULTS

There have been significant new updates. Eleven new syndromes have been added to the list of syndromic associations, of which three were suspects. Among the new syndromic associations, three (PHACE, Williams-Beuren, and Peter's plus syndromes) described CLDA details in depth. Several new non-syndromic systemic conditions with associated CLDA also came to light, the foremost amongst them being proboscis lateralis, diprosopus dirrhinus, cerebral palsy, and NGLY-1 related disorders. Although familial presentations have been reported, the inheritance patterns are unclear for most anomalies. Surgical challenges in these patients are distinct, and a thorough pre-operative assessment, including detailed imaging when indicated, may facilitate good outcomes. Two updated tables reflecting the summary of syndromic and non-syndromic systemic associations are provided to capture the details at a glance.

CONCLUSION

It is not very uncommon to find CLDA in syndromic or non-syndromic systemic disorders. Diagnosis of a craniofacial syndrome should prompt the physician to look out for CLDA. Similarly, a diagnosis of multiple CLDA should alert the examiner for the possible presence of associated systemic anomalies.

Lacrimal drainage system involvement in Peters anomaly: clinical features and outcomes

PURPOSE

To present first of its kind series on the clinical features and outcomes of lacrimal drainage disorders in Peters anomaly and Peters plus syndrome.

METHODS

A retrospective chart review was performed of all consecutive patients who were known cases of Peters anomaly or Peters plus anomaly and were diagnosed with associated congenital lacrimal drainage disorders. The study period was from June 2016 to Dec 2020. All these patients underwent examination under anaesthesia for a detailed assessment of lacrimal drainage anomalies. Where indicated, they were treated with probing, intubation, or in refractory patients with a dacryocystorhinostomy. The anatomical and functional outcomes were assessed.

RESULTS

Of the 282 patients with Peters anomaly, 4 (1.4%) patients had associated lacrimal drainage system anomalies while of the 16 Peters plus anomaly children, 3 (18.75%) had associated lacrimal drainage system anomalies. A total of 12 lacrimal drainage systems of 12 eyes of 7 patients of Peters anomaly were found to be involved. Upper or lower punctal agenesis were noted in 3 eyes. Three eyes had complex congenital nasolacrimal duct obstruction (CNLDO), two of which had a bony NLD block and one had a misdirected nasolacrimal duct through the inferior turbinate. One eye had a diffuse NLD stenosis without a CNLDO. Following appropriate management, at a mean follow-up of 25.7 months (range: 3-48 months), all the eyes except one (91%, 10/11) demonstrated anatomical and functional success.

CONCLUSION

Lacrimal drainage involvement was more common in Peters plus syndrome. Multiple proximal and distal lacrimal drainage segment anomalies were noted in all the variants of Peters anomaly; however, Peters plus syndrome was noted to usually involve both the segments.

Congenital nasolacrimal duct obstruction update study (CUP study): paper I-role and outcomes of Crigler's lacrimal sac compression

PURPOSE

To assess the exclusive role and outcomes of Crigler's lacrimal sac compression in the management of congenital nasolacrimal duct obstruction (CNLDO).

METHODS

Retrospective interventional case-series was performed on patients diagnosed with CNLDO and who were advised Crigler's lacrimal sac compression (CLSC) at a tertiary care Dacryology Institute from Jan 2016 to June 2019. CNLDO patients who were practicing incorrect techniques of lacrimal sac compression at presentation were separately assessed. All the patients were assigned to four groups (Gr 1: 0-3 months, Gr 2: >3 & <6 months, Gr 3: >6 & <9 months and Gr 4: >9 and <12 months) based on the age at which the CLSC was initiated and followed up quarterly or as needed till at least 1 year of age. The parameters studied include patient demographics, clinical presentation, age of initiation of CLSC, success rate with CLSC, and need for additional interventions. Success was defined as the subjective resolution of epiphora and discharge with objective measures of normal tear meniscus height and dye clearance on fluorescein dye disappearance test.

RESULTS

A total number of 1240 patients with CNLDO were assessed. Of these, 1037 patients were advised correct techniques of CLSC from the beginning, and the remaining 203 patients were referred but performing it incorrectly at presentation. Of the 1037 patients, 236 were lost to follow-up; hence, a total of 1004 patients (801 + 203) were included for final analysis. CLSC was found to be an effective conservative strategy in the management of CNLDO. The rate of resolution of CNLDO in Gr 1 to Gr 4 was 87.3%, 78.9%, 77.9%, and 76.8%, respectively. There were no statistically significant differences in the outcomes based on the age of CLSC initiation. The referred patients whose techniques were rectified following the initial incorrect techniques showed a resolution of 61.2% (79/129). The correct techniques of CLSC appeared to influence the outcomes. However, the age of its initiation did not substantially impact the outcomes. Significantly high resolution was noted even beyond nine months of age and encouraging results beyond 12 months of age.

CONCLUSIONS

It is crucial to initiate the correct techniques of Crigler's lacrimal sac compression to achieve favourable outcomes. Age of initiation of CLSC in infancy does not appear to influence the outcomes. The resolution rate continued to be significantly high up to 1 year of age. There is a need to assess the role of CLSC beyond 12 months of age.

Hypohidrotic ectodermal dysplasia: a case report

Hypohidrotic ectodermal dysplasia is a common variation of ectodermal dysplasia, characterized by hypohidrosis (or anhidrosis), hypotrichosis, hypodontia, and other distinct facial features. Furthermore, ocular tissues of ectodermal origin may also be affected in this disease. The most common ocular manifestations of hypohidrotic ectodermal dysplasia are dry eye, madarosis, alterations in the meibomian glands, abnormalities in the nasolacrimal duct, and infantile glaucoma. Herein, author reports a case of hypohidrotic ectodermal dysplasia in a 12-year-old Indian boy with dry eye and lacrimal sac mucocele.

Cerebral palsy and associated complex congenital nasolacrimal duct obstruction and pediatric acute dacryocystitis

Cerebral palsy (CP) is a congenital syndrome with systemic manifestations secondary to a non-progressive lesion of the immature brain. It is associated with numerous cerebral and non-cerebral malformations. The present report describes a 2-year-old baby with spastic CP, diplegic type, associated with congenital cardiac malformations and right eye complex congenital nasolacrimal duct obstruction (CNLDO) (bony nasolacrimal duct stenosis and buried probe) requiring endoscopic dacryocystorhinostomy and left eye simple CNLDO which resolved on probing the system. This report also lays emphasis on the need for examination of the lacrimal drainage system in all patients with CP, so as to treat them appropriately and reduce the morbidity.

Lacrimal drainage system anomalies in microphthalmia anophthalmia coloboma complex

Purpose: To study the prevalence and types of lacrimal drainage system (LDS) anomalies inchildren with congenital microphthalmia anophthalmia coloboma (MAC) complex.Methods: This is a prospective, consecutive, non-comparative, case series of LDS anomalies in 31 children presenting with MAC complex. Previously untreated children with MAC complex, enrolled for socket surface and volume expansion during the study period from January 2017 to April 2018 were included.Results: Thirty-one patients with MAC complex were evaluated for LDS anomalies. Incidence of LDS anomalies in children presenting with MAC complex was 68% (42 of 62 lacrimal systems evaluated). Mean age of the patients at the time of examination under anaesthesia was 27 ± 25 (median 15 months, range 3-108 months). Proximal bicanalicular block (BCB) was the commonest LDS anomaly, noted in 15 (48%) cases. In patients with unilateral ocular disease (n = 20), LDS was affected in 14 (70%) patients and in 9 (45%) patients ipsilateral side LDS was affected. In patients with bilateral ocular disease (n = 11), LDS was affected in 7 (64%) patients. Three patients with unilateral anophthalmos (25%) had an ipsilateral upper canalicular block and contralateral nasolacrimal duct obstruction, of which one patient had a single canalicular wall hypoplasia along with CNLDO. No patient had punctal anomalies.Conclusions: LDS anomalies are seen in nearly two-thirds (68%) of children with MAC complex. The lacrimal drainage system anomaly is not limited to the side of the MAC complex. Commonest LDS anomaly is proximal bicanalicular blocks while punctal anomalies are unusual.

Outcomes of primary powered endoscopic dacryocystorhinostomy in syndromic congenital nasolacrimal duct obstruction

Purpose: To evaluate the outcomes of powered endoscopic dacryocystorhinostomy (DCR) in syndromic individuals with congenital nasolacrimal duct obstruction (CNLDO).Methods: A retrospective multicenter case series of patients who required a primary powered endoscopic DCR for refractory CNLDO associated with syndromes or congenital craniofacial abnormalities was performed. A minimum follow-up of more than 6 months was considered for final analysis. Main outcome measures were anatomical and functional success at the last follow up.Results: Twenty primary powered endoscopic DCR's were performed in 12 patients (7 males, 5 females) with syndromic anomalies. The mean age at the time of surgery was 7.6 years (range: 2-22 years). The associated systemic anomalies were Down syndrome (42%, 5/12), ectrodactyly-ectodermal dysplasia-clefting (EEC) syndrome (17%, 2/12), gross craniofacial dysgenesis (25%, 3/12) Tessier cleft type 3 (8%, 1/12) and velocardiacfacial syndrome (8%, 1/12). Proximal system agenesis of the upper or lower canaliculus was present in 42% of patients (5 patients, 9 eyes). Adjunctive treatment in the form of Mitomycin C and/or intubation was performed in 55% (11/20) eyes. At a mean postoperative follow-up of 20 months, successful outcomes were noted in 95% of the eyes (19/20). The one eye with an anatomical failure was secondary to a complete cicatricial closure of the ostium and was successfully treated subsequently with a revision endoscopic DCR.Conclusion: Primary powered endoscopic DCR has good outcomes in patients with a CNLDO associated with craniofacial syndromes.

Endoscopic dacryocystorhinostomy to treat congenital nasolacrimal canal dysplasia: a retrospective analysis in 40 children

BACKGROUND

To investigate the therapeutic effectiveness and safety of endoscopic dacryocystorhinostomy (EN-DCR) to treat congenital nasolacrimal canal dysplasia (CNCD).

METHODS

Forty children (50 eyes) with congenital nasolacrimal duct obstruction (CNLDO) and lacrimal bony dysplasia, including 8 children with bony atresia (10 eyes) and 32 with bony stenosis (40 eyes), were recruited in this retrospective study. Standardized EN-DCR was performed in all cases. The postoperative observations included relief of symptoms, fluorescein dye disappearance test (FDDT), syringing of lacrimal passages and anastomotic patency under nasal endoscopy. Patients were followed up for 8-18 months.

RESULTS

Standardized EN-DCR surgery had a success (cure and improvement) rate of 100%, including a cure rate of 82% and an improvement rate of 18%. The cure rate among 40 cases of bony nasolacrimal duct stenosis was 82.5%, while that of 10 cases of bony nasolacrimal duct atresia was 80%. Statistical analysis showed that nether the receipt of other treatments before surgery nor the type of bony nasolacrimal duct dysplasia affected the cure rate. No significant complications were observed during postoperative follow-up except for four cases (4 eyes) that suffered middle turbinate and nasal mucosal adhesion and two cases with sinusitis.

CONCLUSIONS

CNCD is a type of CNLDO that does not respond to conservative and conventional treatment. EN-DCR represents a safe and effective treatment for children with CNCD. In addition, the combination of EN-DCR with lacrimal CT scanning provides advantages over traditional lacrimal surgery in that it has a high success rate with a low incidence of complications.

Lacrimal drainage anomalies in Tessier cleft 3 with unilateral anophthalmos

Bilateral Tessier cleft types 3 and 4 are rare and commonly involve the lacrimal drainage system owing to their anatomical location. Such clefts commonly present with associated ocular anomalies and include colobomatous eyelids, hypertelorism, microphthalmia, punctal or canalicular agenesis, and nasolacrimal duct obstruction or exstrophy. The current report presents an 18-month-old baby with bilateral Tessier cleft 3 with a unilateral anophthalmos, symmetrical eyelid colobomas, and lacrimal drainage anomalies. The lacrimal anomalies noted include small lacrimal sac with inferior canaliculus on the right side and upper and lower punctal and canalicular agenesis on the left side. Computed tomographic dacryocystography demonstrated unilateral lacrimal sac and bilateral maldevelopment of the bony nasolacrimal duct.

A rare association of blepharophimosis-ptosis-epicanthus inversus case with congenital nasolacrimal duct obstruction

PURPOSE

The aim of reporting this case is to describe a rare combination of blepharophimosis-ptosis-epicanthus inversus syndrome with congenital nasolacrimal duct obstruction. A variety of lacrimal anomalies have been seen in blepharophimosis-ptosis-epicanthus inversus syndrome but the occurrence of nasolacrimal duct obstruction is rare.

METHOD

The blepharophimosis-ptosis-epicanthus inversus syndrome is an autosomal dominant rare genetic defect with clinical manifestation of dysplasia of the eyelids, palpebral fissures, flat nasal bridge, and ptosis. A 20-month-old boy was referred with the complaints of watering and discharge from his right eyes since birth. On examination, the child had all the features of blepharophimosis-ptosis-epicanthus inversus syndrome with right congenital nasolacrimal duct obstruction in line with the published reports.

RESULT

On endoscopic probing and irrigation, the probe could not be visualized into the inferior meatus. On dacryoendoscopy, the membranous part of the nasolacrimal duct was found to be completely obliterated with no light transmission into the nose indicating a malformed nasolacrimal duct. The child was managed by endoscopic dacryocystorhinostomy. We could find only one case report published so far on the combination of congenital nasolacrimal duct obstruction with blepharophimosis-ptosis-epicanthus inversus syndrome. This study adds one more case of blepharophimosis-ptosis-epicanthus inversus syndrome with congenital nasolacrimal duct obstruction and adjuvant use of dacryoendoscopy.

Lacrimal Drainage Anomalies in CHARGE Syndrome: Case Report and Review of Literature

The common ocular manifestations of CHARGE syndrome include colobomatous defects in the eye, strabismus, nystagmus, and micropthalmia. Lacrimal drainage anomalies have been rarely reported and to the best of the authors' knowledge, only 5 such cases have been reported earlier. The present case describes CHARGE syndrome associated with bilateral complex congenital nasolacrimal duct obstruction with multiple prior attacks of acute dacryocystitis and left lower punctal agenesis, successfully managed with a right-sided dacryocystorhinostomy and awaiting a left dacryocystorhinostomy.Lacrimal drainage anomalies in CHARGE syndrome include complex CNLDO, punctal agenesis, and acute dacryocystitis.

Dacryocystography: From theory to current practice

PURPOSE

To provide a review and an update on dacryocystography (DCG) and its relevance in the current era.

METHODS

The authors performed a PubMed search of all articles published in English on DCG, digital subtraction-DCG (DS-DCG), computed tomographic DCG (CT-DCG) and magnetic resonance-DCG (MR-DCG). Data analyzed include the indications, techniques, interpretations, complication and limitations.

RESULTS

Dacryocystography has been used for illustrating the morphological and functional aspects of the lacrimal drainage system (LDS). Subtraction DCG provides the precise location of the alterations and acceptably delineates stenosis or an obstruction. Transit time for contrast into the nose varies widely across the studies. Low osmolality iodinated contrast media are tolerated well for DS-DCG and CT-DCG. However, normal saline either mixed with lidocaine or alone provided similar image quality as obtained with gadolinium for MR-DCG. CT-DCG provides useful information in complex orbitofacial trauma and lacrimal tumors. MR-DCG allows better 3D visualization of the LDS and dynamic functional evaluation. Sensitivity of CT-DCG and MR-DCG are mostly similar in identifying an LDS obstruction.

CONCLUSION

Various forms of DCGs can provide additional information to evaluate patients with maxillo-facial trauma, functional epiphora, suspected lacrimal sac diverticula, partial nasolacrimal duct obstruction, and lacrimal drainage tumors. Canaliculi and the membranous part of the nasolacrimal duct are not yet visualized in detail and further focused studies with advanced techniques are required.

A Case of Velocardiofacial Syndrome With Bilateral Inferior Punctum and Canalicular Agenesis

A 16-year-old girl diagnosed with velocardiofacial syndrome complained of occasional bilateral ocular discharge. Examination revealed an agenesia of the inferior puncti and canaliculi, while the irrigation through the superior puncta was patent on both sides. Dacryocystorhinostomy with insertion of Lester Jones tubes is not considered for the time being because of the absence of epiphora. To the best of the authors' knowledge, this is the second reported case of lacrimal system agenesia in velocardiofacial syndrome.

Lacrimal drainage anomalies in Rubinstein-Taybi syndrome: case report and review of literature

Rubinstein-Taybi syndrome is a rare multisystem disorder characterized by broad thumbs and first toes, short stature, microcephaly, delayed milestones, beak nose, and hypertelorism. Lacrimal drainage anomalies are not uncommon in this syndrome. We present a patient with Rubinstein-Taybi syndrome with bilateral congenital nasolacrimal duct obstruction and left-sided grossly dilated nasolacrimal duct.