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

Clinical utility of digital radiography dacryocystography for preoperative assessment in nasolacrimal duct obstruction prior to endoscopic dacryocystorhinostomy

Purpose

To evaluate the clinical usefulness of digital radiography dacryocystography in patients with primary acquired nasolacrimal duct obstruction prior to endoscopic dacryocystorhinostomy.

Methods

All dacryocystography images from 129 patients with primary acquired nasolacrimal duct obstruction were analyzed. Each group was assessed for postoperative epiphora severity using Munk's score via telephone follow-up three years post-surgery. Receiver operating characteristic (ROC) curve was plotted to obtain a suitable cutoff value of the transverse diameter of the lacrimal sac (LS), used to categorize LS size into small (≤4.350 mm) and large (>4.350 mm).

Results

Analysis of the transverse diameter of the LS among 129 patients showed a negative correlation between it and Munk's score (r = -0.282, p = 0.001). There was a statistical difference between the surgical outcomes and the sizes of the LS (p = 0.041). The ROC curve analysis showed that the transverse diameter of the LS at 4.350 mm was the ideal cutoff value for the outcome of endoscopic dacryocystorhinostomy, with a sensitivity of 42.2 %, and specificity of 92.3 %. After adjusting for the age and sex, the small LS was associated with an increased risk of postoperative failed outcome (adjusted odds ratio [95 % CI]: 8.628 [1.074, 69.335]).

Conclusion

The small LS was independently associated with the failed surgical outcome. Furthermore, the preoperative measurement of the LS transverse diameter serves as one of the reliable predictors for postoperative epiphora severity.

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 We compared measurements to asymptomatic fellow eyes and to historical reference values from asymptomatic eyes.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.

Functional epiphora: an under-reported entity

PURPOSE

To determine the etiology of epiphora in a tertiary Australian lacrimal clinic and highlight the high proportion of 'functional' cases.

METHODS

Single-center retrospective review: Records of adult patients presenting to a tertiary lacrimal clinic from January 2011 to February 2021 with epiphora were reviewed. Patients underwent testing with syringing/probing and lacrimal imaging to reach a diagnosis of functional epiphora. Functional epiphora was diagnosed based on the exclusion of alternate causes of epiphora on clinical examination, patent lacrimal syringing, normal dacryocystography, and delay on dacryoscintigraphy.

RESULTS

Five hundred and seventy-six symptomatic eyes of 372 adult patients (mean 66.2 ± 15.5 years, 63.4% females) with epiphora were evaluated for causes. Post-sac obstruction (stenosis/complete obstruction) and functional epiphora (non-anatomical delay) were the most common causes of presentations to the lacrimal clinic (26% each). Functional epiphora with post-sac delay was substantially more common than functional epiphora with pre-sac delay (89% vs. 11% of functional epiphora cases). In 16% of the cases, no cause for the epiphora was found while more than one cause (multifactorial) was present 11% of the time.

CONCLUSION

Functional epiphora was found to be as common as a nasolacrimal anatomical obstruction when lacrimal imaging is utilized.

Outcomes of intubation and endoscopic DCR in functional nasolacrimal duct obstruction

BACKGROUND

To ascertain the success of lacrimal intubation and DCR in alleviating epiphora due to functional nasolacrimal duct obstruction (FNLDO).

METHODS

Consecutive adult patients with epiphora attending a tertiary lacrimal clinic from May 2010 to February 2021 were reviewed to identify cases with FNLDO. FNLDO was defined as epiphora with the exclusion of alternate causes of watering on clinical examination, patent lacrimal syringing, normal DCG, and post-sac delay on DSG. Epiphora resolution and improvement rates in FNLDO were compared between lacrimal intubation and endo-DCR.

RESULTS

23 endo-DCRs (20 patients, 65% females, mean age 68.9±12.2) and 41 intubations (29 patients, 61.2% females, mean age 65.0±14.1) performed in FNLDO were included. Resolution of epiphora was achieved in 15 of the DCR procedures (median follow-up 9 months) compared to 14 of intubations (median follow-up 10 months). Significant epiphora improvement (i.e., either improvement or resolution) was noted in 21 DCRs and 24 intubations. Seven patients undergoing intubation as the primary procedure had endo-DCR performed following the intubation. Among respondents to a phone questionnaire, 53.8% who had endo-DCR (median 69 months) and 50% that had intubation (median 28 months) reported significant improvement in epiphora.

CONCLUSIONS

Improvement in epiphora due to FNLDO was approximately 59% in intubations, while the success of endo-DCR was higher (91%). The long-term results of these interventions warrant further investigation.

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.