Comparison of Dacryocystography and Lacrimal Scintigraphy in the Investigation of Epiphora in Patients With Patent but Nonfunctioning Lacrimal Systems

Clinical characteristics and cytological changes in mucinous obstruction diagnosed by dacryoendoscopy

To analyze the clinical characteristics of mucinous obstruction diagnosed by dacryoendoscopy and compared the cytological changes with membranous obstruction using a modified liquid-based thin prep cytology method. A retrospective chart review was conducted on 53 eyes of 51 patients with mucus obstruction based on dacryoendoscopic findings from January 2022 to October 2022. Liquid-based thin-prep cytology was performed by irrigating the inside of the nasolacrimal drainage system with saline during dacryoendoscopy-guided silicone tube intubation. Pathological findings were analyzed through a comparison of mucinous obstruction with membranous obstruction as determined by dacryoendoscopic findings. The modified liquid-based thin prep cytology technique had a higher cytology detection rate across all cases. Mucinous obstruction exhibited a significantly higher number of successful canalicular irrigation test cases compared to membranous obstruction. In mucinous obstruction, epithelial squamous cells were more frequently detected in pre-sac obstruction, whereas columnar epithelial cells were predominant in post-sac obstruction. Inflammatory cells showed a stronger correlation with primary change and post-sac obstruction. Bacterial colonies were observed exclusively in cases of mucinous obstruction. The use of a modified liquid-based thin prep cytology method enables the examination of histopathological changes in the lacrimal passage in primary acquired nasolacrimal duct obstruction (PANDO), particularly in cases of mucinous obstruction, without the need for invasive biopsies. These findings enhance the understanding of the etiopathogenesis of mucinous obstruction, complementing knowledge of membranous obstruction in PANDO.

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.

Advances in imaging of the lacrimal gland in Sjögren's syndrome: A narrative review

Due to lymphocytic infiltration of the salivary and lacrimal glands, Sjogren's syndrome (SS), a systemic autoimmune illness that mostly affects the exocrine glands, causes dry mouth (xerostomia) and dry eyes (xerophthalmia). Additionally, SS is associated with various comorbidities such as cardiovascular diseases, infections, musculoskeletal diseases, and cancers. Among patients with SS, xerophthalmia frequently arises as a complication, leading to insufficient tear production or rapid tear evaporation, thereby causing discomfort, irritation, and a gritty sensation in the eyes. This article aims to examine recent advancements in the imaging of the lacrimal gland in Sjögren's syndrome and briefly discusses the utilization of various imaging examinations for the lacrimal gland in this particular disease.

Dacryoscintigraphy as a guide for surgery in patients with functional epiphora

OBJECTIVE

To investigate how dacryoscintigraphy (DSG) may benefit surgical planning for functional epiphora.

METHODS

A retrospective multicentred case series was performed on patients with symptomatic tearing despite no identified external cause and normal lacrimal probing and irrigation (i.e., functional epiphora). All patients had preoperative DSG testing. Patients were excluded if DSG testing failed to detect a tear flow abnormality. Those with delayed tear flow prior to entering the lacrimal sac (presac) on DSG underwent surgery aimed at improving flow into the lacrimal sac. Those with delayed tear flow after the lacrimal sac (postsac) on DSG underwent dacryocystorhinostomy. Surgical success was defined as complete resolution of the epiphora, significantly improved, or partially improved. Surgical failure was defined as epiphora being unchanged or worse than at the preoperative timepoint.

RESULTS

A total of 77 cases (53 patients) of DSG-guided surgery were included. A presac delay was observed in 14 cases (18.2%) and post-sac delay in 63 (81.8%). Overall surgical success was 83.1% across the cohort. Success was 100% in the presac group and 79.4% in the postsac group (p = 0.06). Mean follow-up time was 22 months (SD = 21 months).

CONCLUSION

A role was demonstrated for DSG in the planning of surgery for patients with functional epiphora. The DSG-guided approach, when compared with empirical lacrimal intubation or dacryocystorhinostomy, may be especially useful in cases of functional epiphora that are presac in nature.

Normative Quantitative Values for Dacryoscintigraphy and the Effect of Lid Massage

Our objectives were to establish normative quantitative values for dacryoscintigraphy in an older population and to evaluate the effect of lid massage. Methods: We conducted a prospective study of 44 eyes of 22 participants aged between 54-90 y that had no symptoms of epiphora and no clinical tear film instability, lid abnormality, lacrimal system impairment, or patent lacrimal duct on syringing. Dacryoscintigraphy was performed and interpreted by a single nuclear medicine physician. The scan protocol involved instillation of ^99mTc-pertechnetate in each eye, with a 45-min scan performed with 1-min frames. Lid massage and a sinus clearing maneuver were then performed, followed by a further 45 min of scanning. Results: The mean age of the 22 participants was 71.9 y. Quantitative analysis by half-clearance time (HCT) demonstrated a median presac HCT of 25.5 ± 15.0 min and a whole-eye HCT of 40.0 ± 19.5 min. There was no association between age or sex and HCT. Qualitatively, 29 of 44 eyes (66%) appeared to have at least 1 region of delayed clearance, with improvement noted in 23 after lid massage (79%). Conclusion: We report the quantitative values for dacryoscintigraphy in an asymptomatic older population who had normal findings on lacrimal examination. A high rate of delay in radiotracer transit on qualitative examination suggesting a low specificity. The false-positive rate was significantly improved with the novel approach of adding lid massage, and the significance of this finding merits further research.

Lacrimal imaging findings in fellow asymptomatic eyes of unilateral epiphora

AIMS

To investigate the prevalence of subclinical anatomical and functional abnormalities of lacrimal drainage in fellow asymptomatic eyes of unilateral epiphora using dacryocystography and dacryoscintigraphy.

METHODS

Retrospective case note review of lacrimal imaging of adult patients presenting to a hospital Oculoplastic clinic with unilateral epiphora over 10 years.

RESULTS

A total of 172 patients with unilateral epiphora were included. The median age was 67 (range 18-96 years). A dacryoscintigraphy (DSG) abnormality was present in 54 (42%) asymptomatic eyes, and dacryocystography (DCG) abnormality in 10 (10%). The most common finding on DSG was no delay in 76 eyes (58%), and most common DSG abnormality was post sac delay in 51 (39%) eyes. The most common finding on DCG was no obstruction in 88 (90%) eyes, and the most common DCG abnormality was post sac stenosis (7.1%). Of the 92 asymptomatic eyes with both DCG and DSG, 53 (57%) showed neither an obstruction on DCG or delay on DSG, and 28 (30%) showed a post sac delay on DSG and no abnormality on DCG.

CONCLUSION

Greater than a third of asymptomatic eyes displayed post sac delay on DSG, frequently without accompanying anatomical obstruction on DCG. Subclinical DSG delay in asymptomatic eyes may represent physiological variation in tear transit time, subclinical lacrimal drainage dysfunction or anatomical stenosis undetected by DCG. Furthermore, the DSG results of fellow asymptomatic eyes in unilateral epiphora may not represent a normal standard that can be utilised for comparison. Further investigation with dacroyendoscopy, the use of control eyes, and long term follow up is required.

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 Efficacy of Lacrimal Syringing under General Anesthesia

Purpose: To compare the results of lacrimal syringing performed in clinical practice and under general anesthesia, and the clinical efficacy of lacrimal syringing under general anesthesia before endoscopic dacryocystorhinostomy and dacryoscintigraphy.Methods: The study included 148 eyes of 82 patients who underwent endoscopic dacryocystorhinostomy and silicone tube intubation from August 2018 to April 2019. The patients were examined with lacrimal syringing in clinical practice and re‐examined under general anesthesia. Based on the change in lacrimal syringing, the patients were assigned to inconsistent and consistent groups. The inconsistent group was subclassified into complete (‘regurgitation’ of lacrimal syringing changes to a ‘passage’ pattern) and partial improvement groups (the degree of regurgitation improves under general anesthesia).Results: Twenty (13.5%) eyes showed inconsistent results of lacrimal syringing performed in clinical practice and under general anesthesia; all showed improved passage under general anesthesia. The surgical results did not differ significantly (p = 0.336) between the consistent and inconsistent groups, but did between the complete and partial improvement groups (p < 0.01). Conclusions: Lacrimal syringing under general anesthesia may enable an accurate preoperative diagnosis of the degree of obstruction. The combined results of dacryoscintigraphy and lacrimal syringing performed in clinical practice and under general anesthesia allow surgeons to evaluate the lacrimal drainage anatomy precisely and may be useful for predicting the functional success of endoscopic dacryocystorhinostomy.

Syringing has limited reliability in differentiating nasolacrimal duct stenosis from functional delay

PURPOSE

To elucidate the role of syringing in assessing nasolacrimal duct (NLD) stenosis and non-anatomical functional NLD delay.

METHODS

Consecutive adult patients with epiphora attending a tertiary lacrimal clinic from June 2011 to March 2021 were reviewed. Cases with evidence of canalicular stenosis or other identifiable causes of epiphora were excluded. Following syringing, patients were investigated with dacryocystography (DCG) and dacryoscintigraphy (DSG). The sensitivity and specificity of syringing were evaluated using the combined findings on DCG and DSG.

RESULTS

A total of 289 symptomatic lacrimal systems (197 patients; mean age 65.5 ± 14.9 years, 66% females) were included. More than one-third of cases with both normal DCG and DSG were noted to have some degree of reflux on syringing (specificity = 65.1%, 95% CI 50.2-77.6%). The sensitivities were considerably low for NLD stenosis (i.e., stenosis on DCG and delay on DSG) and for functional NLD delay (i.e., normal DCG and delay on DSG), of which 43.7% (95% CI 32.2-55.9%) and 54.3% (95% CI 45.7-62.7%) had full patency on syringing, respectively (p = 0.17).

CONCLUSIONS

Full patency on syringing was unreliable for ruling out NLD stenosis and functional delay. Furthermore, a positive syringing may be associated with functional NLD delay and cannot reliably differentiate it from stenosis.

[Modern methods in diagnostics of lacrimal system vertical part obliteration]

A review of the literature is devoted to the description of modern diagnostic methods that are directed at detecting lacrimal pathway obstruction. The presented analysis is based on the study of data from Russian and foreign literary sources on both routine and high-tech lacrimal system examination methods, as well as on authors' experience in studying the diagnostic efficiency of imaging methods such as lacrimal scintigraphy, computed tomography with lacrimal pathway contrasting, and also single photon emission computed tomography. The article gives information about the advantages and disadvantages of the presented methods, highlights the questions of the prospects of their usage in practical dacryology.

Comparison of a manometric tear duct irrigation test with dacryoscintigraphy in the investigation of epiphora

PURPOSE

Assessment of lacrimal resistance in patients with patent lacrimal systems is important in determining whether dacryocystorhinostomy (DCR) surgery is appropriate. Current techniques, including lacrimal syringing and dacryoscintigraphy (DSG), can be unreliable. We compare the results of a manometric tear duct test (mTDT) irrigation technique with DSG in these patients.

METHODS

All symptomatic patients in a specialist lacrimal clinic had full work-up apart from syringing. Lacrimal resistance was assessed using mTDT which applies a fixed head of fluid pressure via a cannula sealed to punctum. Conventional syringing was also performed in cases with abnormal mTDT. Symptomatic patients with delayed tear clearance, no external cause for watering and patent lacrimal systems had DSG. MTDT and DSG results were compared, including in asymptomatic fellow eyes.

RESULTS

105 tear ducts were examined, 85 symptomatic. Symptomatic eyes had a significantly higher mean mTDT resistance (p = .0003) and more had abnormal mTDT (52%) compared to asymptomatic eyes (10%). Although mean tear duct resistance was higher in those with nasolacrimal duct stenosis (NLDS) than freely patent (FP) on syringing (8.5 vs 10.8 dpm), this was not significant (p = .6). High proportions of both FP and NLDS groups had no flow at all on mTDT (60% and 53%, respectively). DSG showed no significant difference in the symptomatic versus asymptomatic eyes (p = .36), nor between those with a normal or abnormal mTDT (p = .25), nor between FP and NLDS groups (p = .25).

CONCLUSIONS

In contrast to DSG, the mTDT provides valuable, objective information on lacrimal resistance that can guide a decision to DCR surgery.

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.

Usefulness of the dacryoscintigraphy in patients with nasolacrimal duct obstruction prior to endoscopic dacryocystorhinostomy

PURPOSE

To evaluate the clinical usefulness of the dacryoscintigraphy in patients with nasolacrimal duct obstruction prior to endoscopic dacryocystorhinostomy.

METHODS

One hundred thirty-five lacrimal views of endoscopic dacryocystorhinostomy (DCR) with a single surgeon for primary nasolacrimal duct obstruction (PANDO) were included. These were assigned into three groups according to the type of dacryoscintigraphy. Group 1 was a pre-sac obstruction pattern. Group 2 was an intra-sac obstruction pattern. Group 3 was post-sac obstruction pattern. Each group was evaluated for an anatomical and functional surgical success, presence of complications including granuloma, synechiae, and tube-induced inflammation at least 12 months after the surgery.

RESULTS

Both anatomical and functional success rate showed no significant difference among the three groups (P = .297 and .472 linear by linear association). Functional failure rate (functional failure/total failure) also showed no clinically significant differences between groups. Logistic regression analysis was performed to determine the factors associated with functional success. There were no statistically significant factors in age, sex, scintigraphy type, pre-operative endoscopic grade, post-operative granuloma, and synechiae.

CONCLUSION

In patients with nasolacrimal duct obstruction, preoperative evaluation of obstruction level using dacryoscintigraphy may be not useful for predicting the functional success of the endoscopic dacryocystorhinostomy.

Interobserver agreement on interpretation of conventional dacryocystography and dacryoscintigraphy findings: A retrospective single-centre study

IMPORTANCE

This study assesses the interobserver agreement on dacryocystography (DCG) and dacryoscintigraphy (DSG) findings.

BACKGROUND

There are no standard grading criteria to guide the interpretation of conventional DCG and DSG findings and therefore there may be a degree of subjectivity. This study evaluates the level of interobserver agreement in the interpretation of DCG and DSG findings.

DESIGN

A retrospective observational study at the Royal Adelaide Hospital.

PARTICIPANTS

A total of 165 patients who presented with epiphora with 276 DCGs and 290 DSGs performed were included in this study.

METHODS

DCG and DSG images were obtained, anonymized, randomized and interpreted by three independent oculoplastic surgeons. Standard grading criteria were set for both DCG and DSG images. Data from all observers were analysed for interobserver agreement using Kappa (κ) statistics, generated using a variation of Cohen's kappa for multiple observers.

MAIN OUTCOME MEASURES

Level of interobserver agreement (κ values) in the grading of DCG and DSG findings.

RESULTS

There was an overall moderate interobserver agreement for DCG findings (κ = 0.55), with the highest agreement on interpreting canalicular obstruction (κ = 0.80), followed by proximal nasolacrimal duct obstruction (κ = 0.67) and normal patency (κ = 0.63). There was an overall fair interobserver agreement for DSG findings (κ = 0.36), with the best being moderate agreement (κ = 0.42-0.50) for interpreting pre-sac delay and post-sac proximal delay.

CONCLUSIONS AND RELEVANCE

DCG offers good reliability in interpreting patent and obstructed systems. On the other hand, DSG has poor agreement and highlights some of the limitations in the ability to guide epiphora management.

Functional success evaluation of lacrimal drainage system by dacryoscintigraphy after transcanalicular diode laser dacryocystorhinostomy

Purpose:

The purpose of the study was to evaluate the functional success rates using dacryoscintigraphy (DSG) after transcanalicular diode laser dacryocystorhinostomy (TDL-DCR).

Methods:

In this retrospective study, we investigated the records of 56 patients who underwent TDL-DCR for unilateral primary acquired nasolacrimal duct obstruction and anatomic patency was achieved. The lacrimal drainage systems of the other eyes of the patients were normal and were selected as control group. The functional success was evaluated with tear transit time (TT) on DSG and epiphora complaints’ score (ECS) at postoperative 6 months.

Results:

Twenty-two (39%) of the patients were male and 34 (61%) were female, with a mean age of 46.6 (21–64). The dacryoscintigraphic findings of the operated and healthy eyes showed that there was statistically insignificant prolongation in the tear TT at the operated side at postoperative 6^th month (P > 0.05). The mean ECS of operated eyes was 0.89. Functional success was achieved in 43 (76.8%) patients when the ECS of 0 and 1 was accepted as successful. A statistically significant delay in drainage was observed in DSG in all of the cases with epiphora score of 2 and 3 (P < 0.05). The tear TT was prolonged with the age increase (P < 0.05), but there was no significant difference concerning the gender.

Conclusion:

DSG is an effective tool to evaluate the functional success of TDL-DCR.

Estimation of Eyelid Pressure Using a Blepharo-Tensiometer in Patients with Functional Nasolacrimal Duct Obstruction

Purpose

To compare the eyelid pressure between patients with functional nasolacrimal duct obstruction (FNLDO) and normal controls using blepharo-tensiometer, and to evaluate the relationship between eyelid pressure and the outcomes of silicone intubation (SI) in patients with FNLDO.

Study design

Prospective case-control study.

Methods

We enrolled 36 eyes of 36 patients with suspected FNLDO who underwent SI and 36 healthy eyes of age-matched controls. One eye of each patient with FNLDO was randomly selected for analysis. The eyelid pressure was estimated using a blepharo-tensiometer and compared between the control and FNLDO groups. The relationship between eyelid pressure and clinical variables was analyzed. The outcomes of SI were assessed at 6 months after surgery using subjective and objective criteria.

Results

The eyelid pressure was significantly lower in the FNLDO group than in the control group (P=0.008). In the control group, the eyelid pressure was correlated with age (P<0.001) and lower eyelid laxity (P=0.016). In the FNLDO group, the eyelid pressure was only correlated with age (P<0.001). The success rate of SI for FNLDO was 69.4% (25 of 36 eyes). The eyelid pressure was higher in the surgical success subgroup than in the failure subgroup, although the difference was not statistically significant (P=0.08).

Conclusions

Our results suggest that the eyelid pressure measured using a blepharo-tensiometer has a diagnostic value since it is decreased in patients with FNLDO. The role of eyelid pressure as a possible predictor of the outcomes of SI for FNLDO should be investigated in further studies. This trial is registered with KCT0002828.

Lacrimal Canaliculus Imaging Using Optical Coherence Tomography Dacryography

Lacrimal canaliculus (LC) has a key role in tear drainage, but it is difficult to evaluate the LC in detail, using the existing examinations. In this study, our novel LC imaging technique provided the high-resolution images of LC in a non-invasive manner. Three-dimensional images of LC were acquired via the palpebral conjunctiva from 20 healthy volunteers (20 eyes) and 10 patients with various lacrimal disorders (10 eyes), using optical coherence tomography (OCT) dacryography (OCTD). The LC images showed morphological differences between the vertical and horizontal segments. The function of LC could be evaluated by measuring the intralumen signal intensity over time after instillation of a contrast agent (2% rebamipide ophthalmic suspension). OCTD clearly visualised the blind extremity of the LC in four patients with punctal obstruction, which was useful for deciding the punctal incision location. In one patient with canalicular obstruction, contrast agent successfully highlighted the LC that had become narrow toward the site of obstruction. Significant differences were not found in the function and morphology of LC between the patients with NLDO and the healthy subjects. OCTD may be a useful tool for LC imaging, because it facilitates quantitative and simultaneous evaluation of LC morphology and function.

The value of lacrimal scintillography in the assessment of patients with epiphora

PurposeTo assess the influence of dacryoscintillography (DSG) on the treatment decision for patients with epiphora and clinically patent non-functioning lacrimal systems.MethodsA retrospective 3-year review. Inclusion: patients having DSG for epiphora with delayed tear clearance, lacrimal system patency on syringing, and no visible external cause for watering. On the basis of regurgitation during syringing, tear ducts were divided into freely patent (FP≤20%) or stenosed. The DSG results were examined for correlation with symptoms and clinical examination, the influence on decision to proceed to dacryocystorhinostomy (DCR), and the ability to predict the surgical outcome.ResultsA total of 242 eyes were examined. The clinical diagnosis was FP in 45.5%, nasolacrimal duct stenosis (NLDS) in 26.4%, and other in 3.3%. The DSG was normal in 30.9% of FP and 18.7% of NLDS eyes. Of the asymptomatic eyes, 46.7% had an abnormal DSG. DSG sensitivity was 73.6% and specificity 53.3%. There was no significant difference in DSG results in those with FP or NLDS.DCR was recommended in 39.1% of the symptomatic eyes with abnormal DSG. DCR surgery was considered inappropriate in all 46 eyes with normal DSG. DCR was successful in 76.5%, however, the DSG result did not affect the success of surgery.ConclusionDSG has severe limitations due to lack of correlation with symptoms and clinical examination, inability to separate lacrimal duct narrowing from lacrimal pump function, and inability to predict the results of surgery. DSG can at best provide limited guidance on whether to proceed to DCR surgery.

External Dacryocystorhinostomy for the Treatment of Functional Nasolacrimal Drainage Obstruction

OBJECTIVES

To determine the outcome and long-term efficacy of external dacryocystorhinostomy (ext-DCR) with or without bicanalicular silicon intubation in patients with functional nasolacrimal drainage obstruction (FNLDO).

MATERIALS AND METHODS

Patients with epiphora and patent lacrimal systems on nasolacrimal irrigation were prospectively enrolled in the study. Each patient was assessed with lacrimal scintigraphy to differentiate drainage abnormalities as presac (proximal) or postsac (distal) delays. All patients underwent ext-DCR; bicanalicular silicone intubation was performed only in presac delay cases. On follow-up examinations patients were asked to report their symptoms as none, mild, moderate or unchanged. Success was defined as lacrimal patency to irrigation and no or mild epiphora at the end of the follow-up period.

RESULTS

Twenty-six lacrimal systems of 23 patients were eligible for inclusion. There were 9 presac delay and 17 postsac delay cases. Average follow-up time was 72.85 weeks (47-88 weeks). A successful outcome was achieved in 76.9% of the operated lacrimal systems. Success rate was 55.5% among presac obstructions and 88.2% among postsac obstructions.

CONCLUSION

The long-term efficacy of ext-DCR in FNLDO patients is confirmed with our overall successful outcome of 76.9%. In preoperative assessment, lacrimal scintigraphy is helpful to determine the surgical approach and to predict the surgical outcome.

Update on imaging techniques in oculoplastics

Imaging is a beneficial aid to the oculoplastic surgeon especially in orbital and lacrimal disorders when the pathology is not visible from outside. It is a powerful tool that may be benefited in not only diagnosis but also management and follow-up. The most common imaging modalities required are CT and MRI, with CT being more frequently ordered by oculoplastic surgeons. Improvements in technology enabled the acquisition times to shorten incredibly. Radiologists can now obtain images with superb resolution, and isolate the site and tissue of interest from other structures with special techniques. Better contrast agents and 3D imaging capabilities make complicated cases easier to identify. Color Doppler imaging is becoming more popular both for research and clinical purposes. Magnetic resonance angiography (MRA) added so much to the vascular system imaging recently. Although angiography is still the gold standard, new software and techniques rendered MRA as valuable as angiography in most circumstances. Stereotactic navigation, although in use for a long time, recently became the focus of interest for the oculoplastic surgeon especially in orbital decompressions. Improvements in radiology and nuclear medicine techniques of lacrimal drainage system imaging provided more detailed analysis of the system.

Update on imaging of the lacrimal drainage system

Epiphora is a common problem seen by the ophthalmologist. There are numerous etiologies of a watering eye, and the underlying diagnosis is not always clear. A variety of in-office examination techniques and procedures exist to aid with diagnosis and determination of appropriate therapy, but sometimes the diagnosis remains elusive, or an instituted therapy fails. Lacrimal imaging, particularly in these cases, can be helpful in assessing the function and anatomy of the lacrimal drainage system. This review serves to examine the literature of the last 10 years concerning imaging of the lacrimal drainage system.

Perspective: what does the term functional mean in the context of epiphora?

The term 'functional block' is used to encompass the concept of lacrimal drainage dysfunction in the presence of anatomical patency. There is significant variability in the nomenclature, clinical and investigative criteria used in the literature to define this entity. This has led to confusion and lack of comparability of studies looking at this group. The clinical features, investigative findings and treatment options in this group of patients are described. In addition, the need to differentiate between nasolacrimal stenosis and 'functional block' is emphasized, as evidence suggest patients with nasolacrimal duct stenosis have better outcomes with dacryocystorhinostomy. To better define the disease entity and enable comparability of future studies, it was proposed that this entity be replaced by the term functional epiphora with no delay, pre- or post-sac delay.

Lacrimal scintigraphy: "interpretation more art than science"

Lacrimal scintigraphy (LS) or dacryoscintigraphy can demonstrate abnormalities in 80%-95% of patients with symptoms of epiphora and a patent lacrimal system on syringing and up to 40% asymptomatic individuals. Precise localization of the site of delay may not always be possible due to lack of anatomic detail on LS. LS is considered useful in patients with epiphora with delayed tear clearance and patency to syringing and suspected to have either nasolacrimal duct (NLD) stenosis or lacrimal pump failure. It remains unclear, however, as to whether LS can reliably distinguish between the two. The literature reports considerable variation in the technique, normative data, analysis, and interpretation of LS. Qualitative or visual analysis is simpler to perform and to our knowledge used more frequently in comparison to quantitative analysis. There is little extra information to be gained from LS in cases with complete NLD obstruction or severe NLD stenosis on syringing.

Evaluation of lacrimal tear drainage mechanism using dynamic fluoroscopic dacryocystography

PURPOSE

To evaluate the dynamic change of the canaliculus and the lacrimal sac during blinking using fluoroscopic dacryocystography.

METHODS

Sixteen patients presenting with unilateral epiphora were enrolled in the study. Fluoroscopic dacryocystography was performed in both eyes, and sequential images of the lacrimal drainage system were acquired during blinking. On examination of the contralateral asymptomatic side, the length of the lower canaliculus and the width of the superior and inferior portions of the lacrimal sac were measured and compared between eyelid closure and opening.

RESULTS

The length of the lower canaliculus decreased with eyelid closure in 13 of 16 patients, and the change was statistically significant (p = 0.006, Wilcoxon signed rank test). The width of the superior portion of the lacrimal sac increased with eyelid closure (p = 0.033), but the width of the inferior part did not change significantly (p = 0.679).

CONCLUSIONS

With eyelid closure, the canalicular system contracts, and the superior portion of the lacrimal sac dilates; these may be important parts of the active lacrimal pump mechanism. These findings suggested that the canalicular system and the superior portion of the lacrimal sac play key roles in active tear drainage pump.