Lacrimal scintigraphy: "interpretation more art than science"

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 multicenter 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 epiphora being completely resolved, 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.

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 We compared measurements to asymptomatic fellow eyes and to historical reference values from asymptomatic eyes.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

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.

Functional Versus Anatomical Nasolacrimal Obstruction: Are There Differences in Epiphora Severity, Symptoms, or Effects on Quality of Life?

PURPOSE

To elucidate whether the specific cause of nasolacrimal duct drainage impairment impacts the severity, symptoms, and implications on visual tasks and quality of life (QOL) in epiphora.

METHODS

A retrospective review of consecutive adult patients with epiphora attending a tertiary lacrimal clinic from June 2011 to March 2021 was conducted. Cases with evidence of canalicular stenosis, a mucocele, or other identifiable causes of epiphora were excluded. A structured interview assessed the epiphora severity (Munk), symptomatology, precipitating factors, and effects on visual tasks and QOL. Following lacrimal syringing, all eyes were investigated with dacryocystography and dacryoscintigraphy. The domains of the interview were compared between nasolacrimal duct obstruction (NLDO), stenosis (NLDS), and nonanatomical functional delay (FNLDO).

RESULTS

One hundred twenty-two symptomatic eyes (63 patients; mean age 63.3 ± 17.2 years; 59% females) were included. There was no difference in Munk score between the groups (NLDO = 3.71 ± 0.18, NLDS = 3.79 ± 2.0, FNLDO = 3.85 ± 0.15; p = 0.82). In all 3 groups, most cases had a Munk >2 (86.8%, 75.9%, and 89.1%, respectively; p = 0.25). Discharge was more common in NLDO (65.7%) compared with NLDS (30.0%) and FNLDO (36.4%, p = 0.006). Worsening in the cold/wind was more frequent in FNLDO (77.1%) compared with NLDO (48.5%, p = 0.029). Effects on visual tasks and QOL were not significantly different.

CONCLUSIONS

FNLDO patients experience a high severity of epiphora, comparable to patients with NLDS and those with complete NLDO. The distinction between FNLDO and NLDS had little consequence on reported symptoms, precipitating factors, visual tasks, and QOL. Discharge may be more specific to NLDO, whereas precipitating cold or wind is more specific to FNLDO.

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.

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.

Time-resolved three-dimensional technique for dynamic magnetic resonance dacryocystography

IMPORTANCE

This study introduces a new technique in the assessment of nasolacrimal drainage with magnetic resonance imaging.

BACKGROUND

To describe a new dynamic magnetic resonance dacryocystography (MRDCG) protocol and report normative findings on asymptomatic lacrimal drainage systems.

DESIGN

A prospective observational study at the Royal Adelaide Hospital.

PARTICIPANTS

Seventeen patients with unilateral epiphora were prospectively recruited.

METHODS

Patients underwent dynamic MRDCG. The time-resolved angiography with interleaved stochastic trajectories (TWIST) sequence was used to visualise contrast flow through the lacrimal drainage system.

MAIN OUTCOME MEASURES

Tear transit times and anatomical dimensions were measured.

RESULTS

Dynamic MRDCG with TWIST sequence reliably demonstrated contrast flow. Tear transit times and anatomical dimensions were comparable to previously reported values in other imaging modalities.

CONCLUSIONS AND RELEVANCE

Dynamic MRDCG provides good structural and temporal resolution to the assessment of lacrimal outflow obstructions. The physiological nature of this modality allows potential assessment for functional obstruction and future research on tear flow assessment.

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.

Development of Predictive Models in Patients with Epiphora Using Lacrimal Scintigraphy and Machine Learning

PURPOSE

We developed predictive models using different programming languages and different computing platforms for machine learning (ML) and deep learning (DL) that classify clinical diagnoses in patients with epiphora. We evaluated the diagnostic performance of these models.

METHODS

Between January 2016 and September 2017, 250 patients with epiphora who underwent dacryocystography (DCG) and lacrimal scintigraphy (LS) were included in the study. We developed five different predictive models using ML tools, Python-based TensorFlow, R, and Microsoft Azure Machine Learning Studio (MAMLS). A total of 27 clinical characteristics and parameters including variables related to epiphora (VE) and variables related to dacryocystography (VDCG) were used as input data. Apart from this, we developed two predictive convolutional neural network (CNN) models for diagnosing LS images. We conducted this study using supervised learning.

RESULTS

Among 500 eyes of 250 patients, 59 eyes had anatomical obstruction, 338 eyes had functional obstruction, and the remaining 103 eyes were normal. For the data set that excluded VE and VDCG, the test accuracies in Python-based TensorFlow, R, multiclass logistic regression in MAMLS, multiclass neural network in MAMLS, and nuclear medicine physician were 81.70%, 80.60%, 81.70%, 73.10%, and 80.60%, respectively. The test accuracies of CNN models in three-class classification diagnosis and binary classification diagnosis were 72.00% and 77.42%, respectively.

CONCLUSIONS

ML-based predictive models using different programming languages and different computing platforms were useful for classifying clinical diagnoses in patients with epiphora and were similar to a clinician's diagnostic ability.

How reliable is the lacrimal scintigraphy report? An inter-observer agreement and reliability study

AIM

To assess the inter-observer agreement and reliability as well as intra-observer repeatability for lacrimal scintigraphy (LS) reports with and without considering the irrigation test results.

METHODS

A prospective, observational, cross sectional study. Two masked clinicians (lacrimal surgeon and nuclear medicine specialist) independently reported 100 LS images (50 patients of >6 years of age with unilateral anophthalmic socket) in a university hospital. The lacrimal surgeon performed a diagnostic irrigation test and repeated the report of the same LS images 2y after the first report (intra-observer agreement). A weighted Kappa analysis was performed to determine inter-observer agreement and reliability as well as intra-observer repeatability for the type (normal, partial and complete obstruction) and location (presac, preduct, and intraduct) of the obstruction. Subgroup analysis was also performed with consideration of irrigation test results.

RESULTS

A significantly moderate agreement was found between lacrimal surgeon and nuclear medicine specialist for both the type (Kappa=0.55) and location (Kappa=0.48) of obstruction. Agreement values were higher for the type (Kappa=0.61 vs 0.41) and location (Kappa=0.56 vs 0.31) of obstruction in cases with normal than abnormal irrigation test. Strong and significant intra-observer (lacrimal surgeon) repeatability was found for both the type (Kappa=0.66) and location (Kappa=0.69) of obstruction. LS showed no to slight reliability based on irrigation test.

CONCLUSION

A moderate agreement is found between lacrimal surgeon and nuclear medicine specialist regarding the interpretation of LS suggesting the importance of consensus groups among nuclear medicine specialists and lacrimal surgeons to create a common language for interpretation of LS. Intra-observer repeatability is strong for the lacrimal surgeon.

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.

Value of ultrasound biomicroscopy in assessment of small masses at medial canthal region

PURPOSE

Conventional imaging techniques are not sensitive enough to reveal detailed structures of lacrimal drainage system (LDS) and its surrounding tissue (ST). Our study aimed to explore utility of ultrasound biomicroscopy (UBM) in assessment of small masses at the medial canthal region and compare performance of UBM with conventional imaging techniques.

METHODS

We prospectively recruited cases with small mass (long axis < 1 cm) at the medial canthal region (upper LDS-located area) from June 2017 to October 2018. UBM ± color Doppler flow imaging (CDFI) and conventional imaging techniques (computed tomography, magnetic resonance imaging, and dacryocystography) were conducted by four independent practitioners. Results were analyzed against gold standards with Cohen's kappa test in three aspects including LDS patency, mass location, and presumptive diagnosis. Corresponding gold standards were syringe and dacryocystography, intraoperative findings, and pathological/empirical diagnosis.

RESULTS

Seventy-two cases were recruited, including 20 cases of LDS lesions and 52 cases of ST lesions. Female (odds ratio 7.14) and age ≥ 37 (odds ratio 9.80) were risk factors for LDS lesion, and age range of 15-25 (odds ratio 9.17) was a risk factor for inflammatory ST lesion. In terms of LDS patency, UBM results were reliable for the detection of pre-saccal obstruction (kappa = 0.920), but were not reliable for intra-saccal and post-saccal obstruction (kappa = 0.106). In terms of mass location, the UBM (kappa = 0.766) performed better than conventional techniques (except for dacryocystography) to sort out ST lesions, with sensitivity of 93.8% and specificity of 83.3%. In terms of diagnosis, the UBM (kappa = 0.882) outweighed conventional techniques (except for magnetic resonance imaging) to distinguish cysts from nodules, with sensitivity of 93.8% and specificity of 94.4%. Notably, the UBM + CDFI achieved better performance than the UBM when screen out inflammatory lesions (kappa = 0.926 vs kappa = 0.689) and LDS-adjacent lesions (kappa = 0.815 vs kappa = 0.673), resulting in sensitivity of 91.7% and specificity of 100% for both testing items. If deep lesions (at the lacrimal sac-harbored area) were excluded, UBM reliability to detect inflammatory lesions (kappa = 0.915) and LDS-adjacent lesions (kappa = 0.770) improved, achieving sensitivity of 90.0% and 88.9%, and specificity of 100.0% and 92.7%, respectively.

CONCLUSIONS

The UBM is a valuable tool to assess superficial masses at the medial canthal region regarding pre-saccal obstruction, mass location, and presumptive diagnosis.

TRIAL REGISTRATION

This work was registered on Chinese Clinical Trial Registry website with registration number ChiCTR1800018956 .

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.

[Treatment choice in dacryostenosis based on single-photon emission computed tomography and X-ray computed tomography findings]

AIM

To develop surgical indications in dacryostenosis within the vertical portion of lacrimal pathways that would consider findings of single-photon emission computed tomography (SPECT) combined with X-ray computed tomography (CT).

MATERIAL AND METHODS

A total of 96 patients with isolated vertical-portion dacryostenosis (127 cases) were enrolled. The examination included collecting Munk's scores for epiphora, optical coherence tomography of the lower tear meniscus, lacrimal scintigraphy, and SPECT/CT. Group 1 (40 cases) was composed of patients with lacrimal obstruction on CT, group 2 (87 cases) - of those whose lacrimal pathways proved passable. There were also 3 patients (4 cases) from group 1, whose lacrimal pathways, despite being blocked on CT, were still passable on SPECT. Surgeries performed in group 1 were endoscopic endonasal dacryocystorhinostomy (DCR) (36 cases) and pathways recanalization with bicanalicular intubation and balloon dacryoplasty (DCP) (4 cases). In group 2, all patients (87 cases) underwent recanalization with bicanalicular intubation (supplemented with balloon DCP in 32 cases). Surgical results were evaluated 8-12 months after the treatment. In group 2, particular attention was paid to the concordance in locations of dacryostenosis provided by CT and SPECT scans.

RESULTS

Favorable outcomes of endoscopic endonasal DCR were obtained in as many as 32 cases from group 1 (88.9%), while in 4 cases (12.1%) the condition relapsed. Of those patients whose stenosis was not complete on SPECT, 3 cases (75.0%) improved, 1 (25.0%) - relapsed. In group 2, favorable outcomes were obtained in 65 cases (74.7%), relapses were 22 (25.3%). A high concordance in stenosis locations by CT and SPECT was noted in 60 cases of those who improved (92.3%) and 3 cases of those who relapsed (13.6%).

CONCLUSION

The value of information provided by SPECT/CT has proved high in patients with nasolacrimal duct stenosis or obstruction. A combined scan allows to establish causal relationships between anatomical changes and functional failure of lacrimal pathways and to make an optimal treatment choice.

The effectiveness of simultaneous lateral tarsal strip with endonasal dacryocystorhinostomy for the treatment of nasolacrimal duct obstruction and lower lid laxity

PURPOSE

The aim of this study was to evaluate the effectiveness of simultaneous lateral tarsal strip procedure (LTS) and endonasal dacryocystorhinostomy (DCR) for the treatment of nasolacrimal duct obstruction and lower lid laxity.

METHODS

We conducted a retrospective, interventional study of concurrent DCR with LTS for patients with nasolacrimal duct obstruction and lower lid laxity performed between March 2009 and July 2011 by a single surgeon (S.H.B.). Patient age, sex, the results of dacryoscintigraphy, time of tube removal, follow-up duration, and cause of failed surgery were recorded. Lower eyelid laxity was evaluated by a medial distraction test.

RESULTS

A total of 29 eyes in 17 patients were included in the study. The mean age was 61.1 ± 11.8 years (range 41 to 81 years). The mean degree of lower lid laxity was 2.4 ± 0.5. Dacryoscintigraphy showed presac delay in 22 eyes (75.9%). The tube was removed after 11.3 ± 1.9 weeks. The primary anatomical success rate was 89.5% (27 eyes) and the functional success rate was 86.2% (25 eyes). Membranous obstructions were the cause of failed surgery in 2 patients, but both patients remained symptom free after revision surgery with a diode laser.

CONCLUSIONS

Concurrently performed DCR with LTS can be an effective tool for the treatment of nasolacrimal duct obstruction and lower lid laxity. It is recommended for examining lid laxity carefully using lid distraction test in patients with epiphora.