Bilateral Nasolacrimal Duct Obstruction Research Articles

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.].

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.

Comparison of conjunctival microbiota of clinically normal Persian cats with and without nasolacrimal duct obstruction

This study was performed to determine the conjunctival microbiota of Persian cats with and without nasolacrimal duct obstruction (NLDO). Twenty-five Persian cats: 15 with bilateral NLDO (Group A) and 10 with no NLDO (Group B). All fifty eyes were assessed. Sterile swab applicators were used for the collection of specimens, which were cultured. PCR was performed on conjunctival swab and blood samples for the detection of Mycoplasma spp. and feline herpesvirus 1(FHV-1), respectively. FHV-1 was detected in two cats in Group A. Twelve eyes from Group A and four from Group B were Mycoplasma spp. positive based on the PCR results. Moreover, fungal culture was positive in six eyes from Group A and three eyes from Group B. The dominant fungus isolated was Aspergillus spp. (6 out of 11 fungal isolates). Other isolated fungi were Alternaria spp. and Cladosporidium spp. Twenty-three eyes had positive bacterial culture in Group A, while twelve eyes were positive in Group B. The most commonly isolated bacteria were Staphylococcus epidermidis (15 out of 38 bacterial isolates). β-hemolytic Streptococcus spp., Corynebacterium spp., and Staphylococcus aureus were isolated in similar proportions in both groups. Escherichia coli was also present in both groups. Results of this study revealed same isolated fungal and bacterial spp. and in similar proportions in Persian cats with and without NLDO.

Simultaneous bilateral or sequential DCR? What to choose?

Dacryocystorhinostomy is used to treat nasolacrimal duct obstruction when conservative measures fail. It may be performed via an external or endoscopic-endonasal approach. The aim of this study was to compare the outcomes of patients with nasolacrimal duct obstruction treated with simultaneous bilateral or unilateral dacryocystorhinostomy. The database of a tertiary medical center was retrospectively reviewed for all patients treated for nasolacrimal duct obstruction in 2012-2017. The study sample was divided into six groups by surgery type and approach: adults (>18 years) - external or endoscopic-endonasal sequential unilateral or simultaneous bilateral dacryocystorhinostomy (four subgroups); children (18 years) - endoscopic-endonasal unilateral or simultaneous bilateral dacryocystorhinostomy (two subgroups). Data were collected on patient age and sex, surgery and anesthesia type and duration, and complications. The cohort included 95 adults and 27 children who underwent 111 and 41 surgical procedures, respectively. Among the adults, the durations of anesthesia and surgery were significantly longer in the external bilateral dacryocystorhinostomy group than the others, but no such differences were found between simultaneous bilateral endonasal dacryocystorhinostomy and unilateral dacryocystorhinostomy by either approach. Among the children, there was no significant between-group difference in surgery duration.In neither age population was bilateral endoscopic surgery associated with an excess of intraoperative or postoperative complications of hemorrhage, infection, and epiphora. The lack of intergroup differences in clinical, surgical, and outcome parameters suggests that in cases of bilateral nasolacrimal duct obstruction in adults and children, simultaneous bilateral endoscopic-endonasal dacryocystorhinostomy may yield excellent therapeutic results.

Prevalence of Amblyogenic Risk Factors in Congenital Nasolacrimal Duct Obstruction in a Developing Country

PURPOSE: Conventionally, congenital nasolacrimal duct obstruction (NLDO) has been treated as an entity with no bearing on development of visual acuity and routine refraction is not done considering the volume of patients in a in a developing Asian country like India. This research was designed to study the prevalence of amblyogenic refractive error in patients with congenital NLDO, as compared to an age-matched control group, in a developing country. METHODS: In this study, 89 patients with congenital NLDO and 78 patients as age matched controls, less than 4 years of age were included at a tertiary care centre in India. All underwent a complete ocular examination and risk factors for amblyogenic refractive error were noted based on the AAPOS guidelines. RESULTS: There was no gender predisposition and no significant difference between the two groups in terms of mode of delivery, orthoptic check-up, keratometry, axial length, fundus or anterior segment examination. Amblyogenic refractive error, as defined by the AAPOS guidelines, was found in 18 (20.5%) patients in the case group compared to 3 (3.8%) in the control group, and this was as follows: astigmatism in 10, anisometropia in 5, hyperopia in 3 subjects, and myopia in 1. These risk factors were not greater in children with unilateral NLDO compared to bilateral NLDO, but both were greater than their control group. There was also no significant difference found between the two groups in terms of distribution of anisometropia. CONCLUSIONS: The prevalence of amblyogenic refractive error in congenital NLDO was significantly higher than in the control group. Hence, a thorough evaluation is warranted in cases of congenital NLDO for early detection amblyogenic refractive error.

Office- or Facility-Based Probing for Congenital Nasolacrimal Duct Obstruction: A Report by the American Academy of Ophthalmology

To review the published literature assessing the efficacy and safety of in-office probing compared with facility-based probing to treat congenital nasolacrimal duct obstruction (NLDO). Literature searches were conducted in March 2020 in the PubMed database with no date restrictions and limited to studies published in English and in the Cochrane Library database with no restrictions. The combined searches yielded 281 citations. Of these, 21 articles were deemed appropriate for inclusion in this assessment and assigned a level of evidence rating by the panel methodologist. Four articles were rated level I, 2 articles were rated level II, and 15 articles were rated level III. Treatments consisted of observation, in-office nasolacrimal probing, or facility-based nasolacrimal probing. Success rates and complications or recurrences were recorded from 1 week to 6 months after surgery. Complete resolution of symptoms after surgery ranged from 66% to 95.6% for office-based procedures versus 50% to 97.7% for facility-based procedures. Level I evidence indicated that 66% of cases spontaneously resolved after 6 months of observation in infants between 6 and 10 months of age. Success rates for in-office probing were lower for bilateral than for unilateral NLDO (67% vs. 82%), whereas success rates were high in both unilateral (83%) and bilateral (82%) patients who underwent facility-based probing after 6 months of observation. Cost data did not indicate a definitive cost savings of either treatment method ($562 for in-office vs. $701 for facility-based, depending on cost models predicting spontaneous resolution rates at different ages). No serious adverse events with treatment or anesthesia were reported for either treatment method. Evidence supports the efficacy and safety of both in-office and facility-based surgery for congenital NLDO. However, treating bilateral NLDO in a facility setting may be better. Because a significant percentage of children achieved resolution spontaneously before 12 months of age, deferring treatment until 12 to 18 months of age is a reasonable option. Additional research may address symptom burden on families and the impact of anesthesia and emotional trauma of nonsedated office probings on patients and may explore further the cost of treatment for each treatment method.

A Case of Primary Tuberculosis of the Lacrimal Sac Presenting as Epiphora

Extra-pulmonary tuberculosis usually progresses as a secondary infection from pulmonary tuberculosis, and tuberculosis of the head and neck region. Tuberculosis of ocular and periocular areas, however, is a rare disease. Among ocular tuberculosis involving the adnexal structures, a few lacrimal sac tuberculosis has been reported. We recently experienced a case of lacrimal sac tuberculosis presenting as epiphora. Examination revealed bilateral nasolacrimal duct obstruction and the patient underwent endoscopic endonasal dacryocystorhinostomy. During the operation, a biopsy taken from the unhealthy looking lacrimal sac filled with caseous necrotic tissue was suggestive of tuberculosis. Histopathological features and further systemic evaluation confirmed tuberculosis. She was treated medically with anti-tubercular agents. The new opening of the lacrimal sac was patent and epiphora was resolved successfully at a year follow up. This report highlights the requirement of high suspicion of tuberculosis, even in the nasolacrimal drainage system.

Bilateral Simultaneous Endoscopic Dacryocystorhinostomy: Outcome and Impact on the Quality of Life of the Patients.

Introduction Bilateral simultaneous endoscopic dacryocystorhinostomy (endo-DCR) has received little attention in the literature, thus many surgeons continue to address bilateral nasolacrimal duct obstruction at two stages, rather than in the same setting. Objective To evaluate the feasibility and the outcome of simultaneous bilateral Endo-DCR and its impact on the quality of life of the patients. Methods We have conducted a retrospective analysis of patients who underwent bilateral simultaneous endo-DCR between March 2013 and February 2017 at our tertiary care institution. The reviewed data included clinical presentation; operative details; success rate; pre and postoperative evaluation of the symptoms of the patients, using the Nasolacrimal Duct Obstruction Symptom Score Questionnaire; satisfaction of the patients, and improvement in the quality of life, assessed by the Glasgow Benefit Inventory (GBI) questionnaire. Results Out of 128 cases in which endo-DCRs were performed, 13 were bilateral (26 sides). Postoperative success was documented in 24 of the 26 sides (92.3%), with a mean follow-up duration of 16.2 months. The two failed sides were reported in the same case. The preoperative symptom score ranged between 12 and 80 (mean ± standard deviation [SD]: 38.23 ± 15.7). The postoperative symptom score was significantly lower (mean ± SD: 5.4 ± 12.9). The success rates in unilateral and bilateral cases were comparable, with no statistically significant difference. A notable improvement in the quality of life of the patients was also reported, with a mean GBI score of 81.38 ± 12.37. Conclusion Our results support that a simultaneous bilateral endo-DCR is a safe procedure that offers a high success rate, spares the patient from the stress of a second surgery, provides the patient with a bilateral resolution of the symptoms, and confers an immediate improvement in the quality of life of the patients.

Impact of Flab Technique Versus Non-Flap Techniques on Endoscopic Dacryocystorhinostomy

Objective: to compare the influence of flap versus non-flap technique on endoscopic dacryocystorhinostomy (EDCR). Patients and Method: A prospective randomized trial in patients with bilateral nasolacrimal duct obstruction, comparing the two techniques to avoid inter-patient variability. We included all patients where bilateral epiphora, excluding unilateral, previously operated or recurrent cases. Results: One hundred patients, fifty females and fifty males with bilateral epiphora due to naso-lacrimal duct obstruction were operated upon by EDCR with or without flap technique. Out of 100 EDCR procedures with flap technique, only 3 had recurrent epiphora with stenosis of the ostium on endoscopic examination and failed fluorescein dye test. In contrast, 4 procedures without flap failed as evident by recurrent epiphora, endoscopic and fluorescein dye test criteria. Conclusion: There is no difference between DCR with flap preservation and flap removal in success rate but the preservation of both lacrimal and mucosal flaps aids in reducing the post-operative granuloma development.

Probing for congenital nasolacrimal duct obstruction.

Probing for congenital nasolacrimal duct obstruction.

Canaliculosinostomy as a Long-Term Treatment of Seven Horses for Permanent Obstruction of the Nasolacrimal Duct.

To describe canaliculosinostomy performed to resolve epiphora caused by nasolacrimal duct obstruction and to report the outcome of horses undergoing this procedure. Case series. Seven horses with uni- or bilateral nasolacrimal duct obstruction. The ventral lacrimal punctum and canaliculus were expanded with catheters of increasing diameter until a 14 gauge, Jamshedi needle could be passed into and through the lacrimal sac into the caudal maxillary sinus. One end of a plastic tube was inserted through the needle into the sinus, and the needle was withdrawn over the tubing. Using a hubless needle, the other end of the tube was passed through the lower eyelid leaving a segment of tubing exposed ventral to the eyelid. The end of the tubing within the sinus was exteriorized through a trephine hole in the frontal sinus and then tunneled beneath the skin adjacent to the osteotomy using a hubless needle, leaving a segment of tubing exposed on the forehead. Exposed tubing was sutured to the skin. The tubing was removed at 5-6 weeks. Canaliculosinostomy was easily performed with the horses sedated. Five horses had resolution of epiphora, and 2 had improvement. Canaliculosinostomy to divert lacrimal secretions into the sinuses resolves or improves epiphora caused by nasolacrimal duct obstruction and provides a good functional and cosmetic outcome. Canaliculosinostomy can be performed in the sedated horse.

Outcome comparison between transcanalicular and external dacryocystorhinostomy.

To compare the outcomes achieved with external dacryocystorhinostomy (EX-DCR) and transcanalicular dacryocystorhinostomy (TC-DCR) using a multidiode laser in patients with bilateral nasolacrimal duct obstruction (NLDO). This prospective study was conducted on 38 eyes of 19 patients with bilateral NLDO. Simultaneous bilateral surgery was performed on all patients. TC-DCR (Group 1) with a diode laser was used in the right eye, and EX-DCR (Group 2) was used in the left eye. All patients were placed under general anesthesia. Routine follow-ups were scheduled at 1wk; 1, 3, 6 and 12mo postoperative intervals. Objective (lacrimal system irrigation) and subjective [tearing, irritation, pain, discharge and visual analogue scale (VAS) score] outcomes were evaluated. The overall objective success rate at 12mo was 73.7% (14/19) in Group 1 and 89.5 % (17/19) in Group 2. This difference was statistically significant. There were no significant between-group differences in the subjective results, such as tearing, pain and irritation. Only the discharge scores were found to be significantly higher in Group 1 compared to Group 2 at the 1y follow-up. The average VAS score was 6.8 in Group 1 and 8.7 in Group 2, with no statistically significant differences. Although TC-DCR allows surgeons to perform a minimally invasive and safe procedure, EX-DCR offers better objective and subjective outcomes than TC-DCR.

High myopia, V-pattern esotropia and bilateral nasolacrimal duct obstruction in a child with Rubinstein–Taybi syndrome

We report a female child of Indian origin with Rubinstein–Taybi syndrome with ocular features of convergent strabismus (V-pattern esotropia), bilateral high myopia and congenital nasolacrimal duct obstruction. We present the details of the management of this case and the final outcome. This case report not only highlights the variability of the ocular features, but also the importance of an ocular examination in patients with Rubinstein–Taybi syndrome.

Bloody tears and recurrent nasolacrimal duct obstruction due to a retained silicone stent

A 6-year-old girl with a history of bilateral nasolacrimal duct obstruction presented with recurrent tearing, discharge, and bloody tears from the right eye. The patient had a history of multiple prior probing and stenting procedures on the right nasolacrimal system. Endoscopic dacryocystorhinotomy revealed a retained portion of a prior stent and accompanying pyogenic granuloma, removal of which resolved her symptoms.

Bilateral canalicular and nasolacrimal duct obstruction in congenital erosive and vesicular dermatosis: a case report and review of the literature

We report the ocular findings in a 2.5-year-old girl with a history of congenital erosive and vesicular dermatosis at birth. We highlight the complexity of the associated nasolacrimal duct obstruction with canalicular scarring and review the ocular manifestations of this rare disease.

Office probing for treatment of nasolacrimal duct obstruction in infants

To determine whether demographic or clinical factors are associated with the outcome of office-based nasolacrimal duct probing for the treatment of congenital nasolacrimal duct obstruction (NLDO). In two multicenter prospective studies, 384 eyes of 304 children aged 6 to <15 months with NLDO underwent a nasolacrimal duct probing performed in the office using topical anesthesia. Treatment success, defined as no clinical signs of NLDO (epiphora, increased tear lake, or mucous discharge) and no reoperation, was assessed 1 month after probing in one study and 6 months after probing in the other study. Data from both studies were pooled to evaluate associations between baseline characteristics and treatment success. Office probing was successful in 75% of eyes overall (95% CI, 70%-80%). The procedure was less successful in eyes of children with bilateral NLDO compared with unilateral NLDO (63% vs 80%; relative risk = 0.78 [95% CI, 0.66-0.92]) and in eyes that had 2 or 3 clinical signs of NLDO compared with one (71% vs 83%; relative risk = 0.88 [95% CI, 0.81-0.96]). Treatment success did not appear to be related to age, specific clinical signs of NLDO, prior treatment, or research study. Performing nasolacrimal duct probing in the office successfully treats NLDO in the majority of cases in children aged 6 to <15 months. The success rate is lower with bilateral disease or when more than one clinical sign of NLDO is present.

Comparison of the effect of W-shaped and linear skin incisions on scar visibility in bilateral external dacryocystorhinostomy.

BackgroundThe aim of this study was to compare the effect of W-shaped skin (WS) and linear skin (LS) incisions on cutaneous scar tissue formation in patients who have undergone bilateral external dacryocystorhinostomy.MethodsSixteen patients (14 females and two males) with acquired bilateral nasolacrimal duct obstruction were included in this prospective, interventional comparative study. LS incision was applied to one side and WS skin incision to the other side. The skin incisions were assessed 6 months after each procedure by the patients themselves and by two ophthalmologists who were unaware of the skin incision shape and side. Scar tissue that was not recognized under the same light conditions and in the same room from a 100 cm distance was recorded as grade 1. Minimally visible scar tissue was assessed as grade 2, moderately visible scar tissue as grade 3, and easily visible scar tissue as grade 4.ResultsThe mean scar assessment scores recorded by the first ophthalmologist were 2.50±0.82 for the LS group and 1.25±0.45 for the WS group (P<0.001). The second ophthalmologist’s assessment scores were 2.25±0.86 for the LS group and 1.25±0.45 for the WS group (P<0.001). The mean patient self-assessment score for the incision scars was 2.44±1.03 for the LS group and 1.56±0.73 for the WS group (P<0.001).ConclusionCompared with LS incision, WS incision resulted in less cutaneous scar tissue formation in patients who have undergone bilateral external dacryocystorhinostomy.

Occult oncocytoma of the lacrimal sac

Oncocytoma of the lacrimal sac is a rarely encountered clinical entity. We report the case of a 72-year-old female patient who was diagnosed to have bilateral nasolacrimal duct obstruction during a pre-cataract surgery screening. Subsequently, she underwent bilateral dacryocystectomy. Histopathological examination of the left lacrimal sac revealed a tumour composed of acini lined by oncocytic cells; features consistent with those of a lacrimal sac oncocytoma. Although rare, oncocytomas arising from the lacrimal sac may co-exist with a nasolacrimal duct obstruction. This report describes the histological and immunochemistry characteristics of oncocytomas and underscores the need to subject all excised lacrimal sacs to histopathological examination.

A Comparison of Treatment Approaches for Bilateral Congenital Nasolacrimal Duct Obstruction

To compare the clinical outcomes of two treatment approaches for bilateral nasolacrimal duct obstruction (NLDO) in infancy. Multicenter, randomized clinical trial. We studied 57 infants between the ages of 6 and <10 months who had bilateral NLDO. Participants were randomized to receive either (1) immediate office-based probing within two weeks (n = 31) or (2) 6 months of observation and nonsurgical management followed by surgical facility-based probing for unresolved cases (n = 26). Treatment success was defined as the absence of clinical signs of NLDO (epiphora, increased tear lake, mucous discharge) in both eyes on masked examination at 18 months of age. In the observation and deferred facility probing group, resolution without surgery occurred by 6 months after randomization in both eyes for 14 participants (56%), in one eye for 5 (20%), and in neither eye for 6 (24%). Eight participants in the observation and deferred facility probing group underwent facility probing (one of whom later had a second facility probing). Four participants in the immediate office probing group later underwent an additional procedure in a surgical facility. In the immediate office probing group, treatment success at 18 months of age occurred in both eyes for 19 of 29 (66%) participants and in one eye for 3 (10%); in the observation and deferred facility probing group, treatment success occurred in both eyes for 19 of 25 (76%) participants and in one eye for 3 (12%) (difference in success = -10%; 95% CI = -35% to 14%). Both the immediate office probing approach and the observation and deferred facility probing approach are successful and reasonable treatment options for infants with bilateral NLDO.

Anisometropia and amblyopia in nasolacrimal duct obstruction

To investigate an association of childhood nasolacrimal duct obstruction (NLDO) with anisometropia and amblyopia. The medical records of patients from newborn to 6 years of age with a diagnosis of NLDO seen from 2000 to 2010 were retrospectively reviewed. Data collected included age at onset of NLDO, laterality of NLDO, cycloplegic refractive error, determination of clinically significant anisometropia (defined as ≥1 D), and diagnosis of amblyopia with amblyopia subtype (anisometropic vs other). A total of 1,218 patients with NLDO were included. Of these, 887 cases (72.8%) were unilateral; 331 (27.2%), bilateral. Anisometropia was found in 67 (7.6%) unilateral cases and 12 (3.6 %) bilateral cases on initial examination (χ2=5.48, P < 0.01). Same-sided unilateral NLDO was significantly associated with greater hyperopia in the anisometropia patients (χ(2) = 33.01, P < 0.001). Follow-up data were available for 482 NLDO patients and revealed an additional 26 patients with anisometropia for a total of 105 of 1218 (8.6%). Of the 482 patients, 28 (5.8%) developed amblyopia, 16 cases of which were purely attributable to anisometropia. Of 41 patients with anisometropia who were in the follow-up, 9 (22%) developed amblyopia. Anisometropia occurred at a greater rate in unilateral NLDO patients compared with bilateral NLDO patients and occurred at a greater rate in this NLDO cohort than expected in the general pediatric population. Several patients with anisometropia developed clinical amblyopia. Measurement of cycloplegic refraction in all NLDO patients at initial examination should be considered. Periodic follow-up is appropriate for patients with NLDO and anisometropia.