Complete Nasolacrimal Duct Obstruction Research Articles

A Comparative Study of Endoscopic Endonasal Dacryocystorhinostomy with and without Stenting

Introduction: The definitive management of complete nasolacrimal duct obstruction from chronic dacryocystitis is surgical. The surgery of choice is dacryocystorhinostomy (DCR), which can be done external or endonasal with or without stenting. We aim to compare the anatomical and functional outcomes of endoscopic endonasal DCR with and without stenting. Materials and Methods: This prospective study was carried out involving 30 patients of either sex randomly divided into two groups of 15 patients each. Group A underwent endoscopic DCR with stenting of the canaliculi, whereas Group B underwent endoscopic DCR without stenting. These patients were followed up at week 1, 6, and 12. The success of surgery in each group was determined by the absence of epiphora (Munk scale grades: 0 and 1), patent ostium on irrigation, positive Jones test, and decrease in the marginal tear film volume as seen on dye disappearance test (grade: 0 and 1) at week 12. Final data were analyzed using SPSS 21 version. Results: About 86.6% success rate was noted in the group where stenting was done (Group A) compared to 100% success in the group without stenting (Group B). This difference was, however, not statistically significant (P = 0.143). Failures in the study were attributed to the closure of rhinostomy ostium at week 12 follow-up. The most common complication noted was postoperative pain around the bridge of nose. Stent-related complications such as conjunctivitis and difficulty in removal of the stent were also noted. Conclusion: In our study, the surgical results of endoscopic endonasal DCR without stenting were better than endoscopic dacryocystorhinostomy with stenting both anatomically as well as functionally.

OUTCOME OF DACRYOCYSTECTOMY IN ELDERLY PATIENTS ATTENDING A TERTIARY CARE CENTRE IN KASHMIR

Background: Dacryocystectomy (DCT) is a surgical procedure that involves complete removal of lacrimal sac. It is a less invasive procedure and can be used as an alternative to dacryocystorhinostomy (DCR) in elderly patients. To Aim: determine the surgical outcome of DCT in elderly patients >65 years attending the Department of Ophthalmology, Government Medical College, Srinagar. This was a hospital based prospective study conducted on 35 pat Methods: ients over a period of 2 years from January 2019 to January 2021. Elderly patients >65 years age with presenting complaint of recurrent dacryocystitis, dry eye with no epiphora despite complete nasolacrimal duct obstruction were included in the study. Proper preoperative history was taken with regard to presenting complaints and detailed medical history was recorded. Dry eye was diagnosed using Schirmer-I test and tear lm break-up time. Nasolacrimal duct obstruction was diagnosed by uorescein dye disappearance test and lacrimal irrigation (syringing). Clinical examination was done using slit lamp. Results: In our study, mean age of study population was 75±3 years. Majority of patients were females accounting for 65.7% cases. Main indication of DCT in our study was chronic dacryocystitis accounting for 68.6% cases followed by episodes of acute dacryocystitis in 20% cases and irreducible lacrimal sac swelling accounting for 11.4% cases. Overall surgical outcome was good in our study population with no postoperative complaints at the end of 3 months follow-up in 94.3% cases. Our study indicated that Conclusion: majority of patients who underwent DCT were female with chronic dacryocystitis being the main indication for DCT. DCT is a useful and safe surgical alternative to DCR in elderly patients with recurrent dacryocystitis and in those with underlying systemic comorbidities in whom DCR is associated with a high risk of intraoperative and postoperative complications.

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

Summary Background The aim of this study was to profile patients with simple and complex congenital nasolacrimal duct obstruction (CNLDO) and to determine the success rates of interventions at a third-level referral center. Methods In this retrospective and comparative study, medical records of patients with CNLDO were reviewed. Demographic data, types of CNLDO, surgical approach, type of silicone intubation, as well as outcome were recorded up to 3 months after the intervention. Obstruction location was identified by probing and irrigation following the American Academy of Ophthalmology (AAO) approach. Success rates were calculated for treatment approach and age group. Results Based on the outcome of 130 eyes with CNLDO, the overall success rate was 96%. The mean age of patients was 2.5 ± 2.2 months; 73% of cases were simple and 27% were complex CNLDO. Five children had to undergo reoperation; consequently, there was a lower success rate in the complex CNLDO (91%) than in the simple CNLDO subgroup (97%). There was a male predominance (61.5%), which was also present in the simple and complex CNLDO subgroups. The most frequent type of CNLDO was complete nasolacrimal duct obstruction (NLDO, 55.4%), followed by partial (17.7%) and bony NLDO (11.5%). In 87% of eyes, initial probing was performed followed by dacryocystorhinostomy (10%). Mono- or bi-canalicular lacrimal drainage system intubation was used in 86% of eyes. Conclusion The AAO-based diagnostic approach followed by an individualized treatment regimen yielded excellent success rates of 96% in unselected patients with CNLDO. These success rates were independent of patient age or gender.

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

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. 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). 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. 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.

DCR for nasolacrimal duct stenosis may be less effective than for complete obstruction

ObjectivesTo ascertain the success of endo-DCR in nasolacrimal duct stenosis (NLDS) versus nasolacrimal duct obstruction (NLDO).MethodsConsecutive adult patients with epiphora attending a tertiary lacrimal clinic from February 2012 to February 2021 were reviewed. NLDS was diagnosed by patent lacrimal syringing and combined dacryocystography (NLD stenosis) and dacryoscintigraphy (post-sac delay) findings in all eyes. Cases with evidence of canalicular stenosis or other identifiable causes of epiphora were excluded. The epiphora resolution and improvement rates following endo-DCR were compared between NLDS and complete NLDO cases.ResultsDCRs in 24 NLDS (23 patients, 69.6% females, mean age 61.0 ± 17.07) and 58 NLDO (56 patients, 69.6% females, mean age 61.9 ± 17.4) were included. Resolution of epiphora was achieved in 10 (41.7% [95% CI 0.24–0.61]) of the NLDS cases compared to 40 (69.0% [95% CI 0.56–0.79]) in NLDO (p = 0.021). Improvement of epiphora (i.e., either improvement or resolution) was noted in 17 (70.8% [95% CI 0.51–0.85]) of NLDS and 53 (91.4% [95% CI 0.81–0.96]) of NLDO cases (p = 0.034). Three patients (12.5%) with NLDS had subsequent lacrimal procedures (one DCR revision, two Jones tube) at a median of 14 (range 11–21) months. 71.4% of the NLDS patients responded to a phone questionnaire at a median of 93 months postoperatively. Of these, 46.7% reported resolution or significant improvement, and 33.3% reported slight improvement. 64.3% said they would recommend DCR to others suffering from epiphora.ConclusionEndo-DCR may benefit approximately 70% of patients with NLDS. The success of endo-DCR in complete NLDO may be higher.

Long-term outcome of lacrimal stent intubation for complete acquired lacrimal drainage obstructions.

To investigate long-term outcome and report reoperation rate of non-infected, complete acquired lacrimal drainage obstruction (ALDO) treated with canaliculodacryocystoplasty (CDCP) depending on site of stenosis. Consecutive adult patients with non-infected, complete ALDO treated with CDCP were followed for 76months. Location of stenosis at preoperative visit and intraoperative probing was recorded, and during follow-up, recurrence of stenosis prompting additional surgery and complications were noted. Survival analysis was applied to compare reoperation rate depending on site of stenosis. A follow-up questionnaire was sent to patients not requiring reoperation asking to grade current epiphora problems. Among 85 included cases (71 patients), 57 were classified as canalicular stenosis and 28 as nasolacrimal duct obstruction (NLDO) preoperatively. At the end of follow-up, 39% (33/85) of cases had required additional surgery due to persistent/recurrent symptoms. No statistical difference was found between these groups. During CDCP, 25 of the 57 preoperatively classified canalicular stenosis were found to have an additional obstruction below the sac. The group with only canalicular stenosis had a statistically significant higher survival compared with cases with NLDO or multiple obstructions (p=0.03). Of patients responding to the follow-up questionnaire, 11/37 cases experienced epiphora often or constant. Treating complete NLDO with CDCP results in a high reoperation rate and seems an insufficient alternative. Canaliculodacryocystoplasty (CDCP) may be discussed if preoperative examination indicates canalicular stenosis and dacryocystorhinostomy is not desirable. However, the patient needs to be aware of the higher risk for additional surgery, especially if a second stenosis is found during probing.

Clinical study of efficacy of probing as a treatment for epiphora in adults

Background/Context: Probing is a simple operative procedure, can be performed easily in adults under local anesthesia, and is associated with minimal postoperative morbidity. The study aimed to determine the efficacy of probing in adults with epiphora due to common canalicular block (CCB) and nasolacrimal duct obstruction (NLDO). Materials and Methods: A prospective, interventional study was conducted on 44 patients with epiphora. Probing was done through upper and lower canaliculus under local anesthesia in all patients with epiphora due to CCB and NLDO. Probing was considered successful if the epiphora had been resolved or reduced to an acceptable level and if the lacrimal system was patent on lacrimal syringing for 6 months. Results: Patients comprised 36 women and eight men with the age group between 25 and 80 years who had epiphora for 3–24 months. Twenty-six patients had common CCB and 18 had complete NLDO. Complete patency was achieved in 12 and 5 and partial patency in 9 and 6 patients with CCB and NLDO, respectively. Treatment was successful in 72.72% of the patients. Ten patients underwent uneventful cataract surgery and 12 failed cases needed dacryocystectomy. Conclusion: Since probing is a simple, quick, cost-effective, and daycare procedure with low morbidity and obviates the need for further nasolacrimal surgery, probing can be recommended as an initial treatment in adults with epiphora.

Learning Curve in External DCR - A Trainee's Perspective.

The aim of this study is to determine the success rate over time in patients undergoing External Dacryocystorhinostomy (DCR) with acquired naso-lacrimal duct obstruction (NLDO), when done by a trainee ophthalmologist. The study was Prospective Observational study and was conducted in Tertiary Eye Hospital, Uttar Pradesh, India. One hundred and fourteen consecutive adult patients underwent external DCR for acquired complete NLDO by a trainee with less than 3 years of experience in ophthalmology between November 2011 and March 2013. Postoperative anatomic success rate was determined at 6 months on the basis of the patency of lacrimal sac syringing and patients were asked to subjectively evaluate improvement of their epiphora using a questionnaire. Anatomical success rate across the entire study period was 93.7% and this improved from 87% in the first tertile of 38 patients to 94% in the second tertile and 100% in the final tertile of cases (p<0.05). Overall complication rate was 16.67% and reduced from 29% in the first tertile to 8% in the final tertile (p<0.05). Loss of anterior nasal flap was the commonest complication (10 cases) during the training period. External DCR, as a primary procedure for acquired NLDO, even when operated by trainee ophthalmologists, has a relatively high success rate that improves over time. As the learning curve improves, complication rates reduce significantly. No author has any financial or proprietary interest in the material or method mentioned.

Lacrimal intubation during dacryocystorhinostomy utilizing the STENTube

ABSTRACTThe traditional use of the Crawford tube for lacrimal intubation during dacryocystorhinostomy (DCR) carries several drawbacks. We describe the use of the STENTube for DCR intubation and detail its advantages. Retrospective, noncomparative, interventional case series; 313 patients with nasolacrimal duct obstruction (NLDO) underwent 339 DCRs (216 external, 123 endonasal) with the STENTube from January 2007 – June 2013 by 5 surgeons (RS, QN, TS, SB, TN) across 3 institutions (SUNY Downstate Medical Center, Texas Oculoplastics Consultants, and Moorfields Eye Hospital). Study outcome measures included patient demographics, surgical complications, and epiphora improvement/resolution. 206 (66%) females and 107 (34%) males had a mean age of 63 years (range 2–94 years). Distribution of diagnoses included: 314 complete idiopathic acquired NLDO, 20 partial idiopathic acquired NLDO, and 5 congenital complete NLDO. 316 (93%) were primary DCRs and 23 (7%) were revisions. Epiphora improved in 312 (92%) cases with 294 (86%) experiencing resolution with patent lacrimal irrigation at a mean last follow-up of 9.4 months. Twenty-eight (8%) patients experienced surgical complications with 16 (5%) experiencing tube prolapse, and 20 (6%) requiring re-operation. The STENTube represents a simple method for lacrimal intubation during external or endonasal DCR at a comparable cost to the Crawford tube. It allows for low prolapse rates without the need for additional endonasal fixation procedures, resulting in a simple and comfortable post-operative extraction without risk of lacrimal trauma. The STENTube is our preferred intubation technique during DCR, and should be considered by oculofacial surgeons performing DCR with intubation.

Management and outcomes of patients with epiphora referred to a specialist ophthalmic plastic unit

To describe the aetiology and management of the symptom epiphora presenting to a specialist ophthalmic service. A retrospective case series and patient postal questionnaire of all new referrals seen in a specialist unit with primary symptoms of epiphora between January 2007 and December 2008. The study was begun in 2010 to allow a 2-year follow-up for this cohort. Two hundred thirty-seven patients were identified, of which 192 met the inclusion criteria. Fifty-seven were male, 135 were female, with a mean age of 60.7 (range 0-95) years. Patients were identified using a key word search of clinic letters and a search of primary care coding. Duration of symptoms, referral source, aetiology and subjective improvement of symptoms post treatment. At consultation, patients had experienced epiphora for a mean of 41.1 (range 0.066-360) months. A diagnosis of partial or complete nasolacrimal duct obstruction (31.8%), dry eye with secondary reflex tearing (29.2%), eyelid malposition (10.4%) and multi-factorial epiphora (28.7%) was made after follow-up and treatment. A postal questionnaire follow-up showed that 25% of patients no longer had any epiphora, with 67% reporting an improvement in their symptoms. Final follow-up was 30-54 months. This study highlights the protean aetiology of the symptom and sign, epiphora. Sparse data exist on the audited success in managing this common symptom and sign. This study helps introduce an example of a benchmark for evaluating the effectiveness of epiphora. The majority of patients were referred, usually by ophthalmologists for lacrimal surgery.

Nasolacrimal duct obstruction as a complication of iodine-131 therapy in patients with thyroid cancer

There are few studies evaluating the effect of radioioine therapy on the lacrimal drainage system. This study reports on symptomatic and asymptomatic nasolacrimal duct obstruction (NLDO) as complications of high-dose radioiodine therapy in these patients. Eighty-one cases were randomly selected from a population of radioiodine-treated differentiated thyroid carcinoma patients and were enrolled in a historical cohort study. The patients were categorized into four subgroups on the basis of the received cumulative dose of iodine-131 (I-131). In addition, 17 age-matched and sex-matched individuals were selected as the control group. Using dacryoscintigraphy and a clinical datasheet, the patients and controls were evaluated for partial or complete and symptomatic or asymptomatic NLDO. The data on different subgroups of patients were compared with the data of the control group. Twenty-nine out of 162 exposed eyes (18%) and three out of 34 control eyes (9%) had evidence of NLDO on scintigraphic images. Among patients treated with less than 11.1 GBq of I-131 (subgroup A), six out of 78 eyes (7.7%) had partial or complete NLDO. This was evident in 23 out of 84 eyes (27.4%) among patients treated with 11.1 GBq or more (subgroup B). The frequency of complete NLDO increases significantly when the cumulative dose of radioiodine exceeds 11.1 GBq (2.9% in the control group, 3.8% in subgroup A, and 23.8% in subgroup B; P=0.006). NLDO may be considered as a side effect of I-131 therapy, especially with a cumulative dose of 11.1 GBq or more.

Can Lacrimal Sac Washout Predict Outcomes of Endoscopic DCR?

Objective: High success rates for endoscopic dacryocystorhinostomy (END-DCR) in partial nasolacrimal duct obstruction (NLDO) have been reported, but comparisons with complete NLDO are lacking. This study compares the success of primary END-DCR with respect to the preoperative nasolacrimal duct patency and reviews factors associated with failure. Method: Retrospective review of END-DCRs performed at a tertiary referral center. Partial and complete NLDO were defined by the presence or absence of flow into the nose with lacrimal sac washout (SWO), respectively. Intraoperative findings including thickness of bone, level and state of the common canaliculus, state of inflammation, and contents of the lacrimal sac during END-DCR were recorded. For patients with at least 3 months follow-up, the outcome of resolution of epiphora (none/partial/complete), postop Jones 1 (J1; positive/ negative) and endoscopy of the neo-ostium (closed/partially or fully-open) were defined. Results: A total of 245 primary END-DCRs were reviewed (mean age, 63.6 ± 5.3 years, 70% women). Based on SWO, the groups were defined as 39.6% and 60.4% complete NLDO. Overall improvement in epiphora was 95.5%. In cases where symptoms improved, absence of flow into nose on SWO was associated with a higher rate of complete resolution (93.6% vs 84.9%, RR 1.102 [1.001, 1.213]). The ostia were fully open in 93.9% and postop J1 was positive in 97.1% of patients and were not different between groups. Conclusion: END-DCR is highly successful for both types of NLDO. Preoperative absence of flow into nose on SWO was associated with slightly higher chance of complete resolution.

Localized Nasopharyngeal Amyloidosis Causing Bilateral Nasolacrimal Duct Obstruction

A 62-year-old woman with a history of localized nasopharyngeal amyloidosis presented with bilateral complete nasolacrimal duct obstruction and 2 previous episodes of right dacryocystitis. Workup for systemic involvement was negative. Pathology was confirmed at the time of previous endonasal sinus surgery, showing submucosal amorphous deposition of Congo Red-positive material with apple-green birefringence. Computed tomography revealed extensive submucosal calcifications in the head and neck region, including bilateral nasolacrimal ducts. Localized amyloidosis is rare and most commonly involves the head and neck region. There is a previously reported case of nasolacrimal obstruction secondary to amyloidosis focal only to the nasolacrimal system, but we believe this to be the first report of localized nasopharyngeal amyloidosis to involve the nasolacrimal system.

Reliability index of DDT in detecting a complete nasolacrimal duct obstruction

Reliability index of DDT in detecting a complete nasolacrimal duct obstruction

Conventional dacryocystorhinostomy versus endonasal dacryocystorhinostomy-a comparative study

The objective of present study was to compare the results of endonasal endoscopic dacryocystorhinostomy and external dacryocystorhinostomy. It was a prospective non-randomized study. Forty consecutive patients having complaints of watering with complete naso lacrimal duct obstruction were selected for the study. Dacryocystography was done in all the cases. Selection of type of operation was left to the patient's choice. All patients had preoperative counseling and both the procedures were explained in detail with their advantages and disadvantages. Twenty patients underwent endonasal dacryocystorhinostomy and twenty had external dacryocystorhinostomy. Silicon intubation was done in all cases of endonasal dacryocystorhinostomy for three months after surgery. The final follow-up was done at 12 months after surgery. The patency of lacrimal passage was confirmed by syringing and patients were questioned about their symptoms. There was no significant difference in the results of both surgeries. The complication rate in both groups was almost equal. Thus we came to the conclusion that these two different dacryocystorhinostomy techniques are acceptable alternatives.

Effect of nasolacrimal duct obstruction on nasal mucociliary transport

Most patients with nasolacrimal duct obstruction have dry, crusty nasal mucosa. Mucociliary clearance is modulated by the amount and biochemical composition of nasal mucus. Nasolacrimal duct obstruction disturbs the drainage of tears into the nasal cavity. We examined the effect of nasolacrimal duct obstruction on the mucociliary transport of nasal mucosa, by comparing saccharine test results for epiphora patients versus healthy volunteers. Prospective, randomised, clinical trial. Eight patients with bilateral epiphora and 10 patients with unilateral epiphora were included in the study group. Complete nasolacrimal duct obstruction was demonstrated by studying irrigation of the nasolacrimal system, and by fluorescein dye study. The control group comprised 20 healthy volunteers. Mucociliary transport was assessed by the saccharine test in both the study and control groups. The saccharine transit times of 26 impaired nasal cavities were compared with those of 20 healthy nasal cavities of controls. Also, the saccharine transit times of the healthy nasal cavities of the 10 patients with unilateral epiphora were compared with those of their diseased sides, and also with those of healthy volunteers. The saccharine transit times of the epiphora patients were statistically significantly greater than those of the control group. Also, there was a statistically significant difference in saccharine transit times, comparing the healthy and impaired nasal cavities of patients with unilateral epiphora. Nasolacrimal duct obstruction has a negative effect on nasal mucociliary clearance. This may be related to changes in the amount and biochemical composition of nasal mucus.

Double Lacrimal Puncta: Clinical Presentation and Potential Mechanisms of Epiphora

Congenital supernumerary lacrimal puncta and canaliculi are rarely reported. Our purpose is to present the largest series of patients with supernumerary puncta and to describe the clinical presentation and associated lacrimal anomalies. Observational retrospective case series. All patients diagnosed with supernumerary puncta by a single surgeon between 1988 and 2008. Retrospective case note review. Patient demographics, clinical presentation, lacrimal and systemic examination findings, management, and surgical outcomes. Twenty-three patients (12 female, 11 male) with a median presenting age of 54 years (range, 1-88 years) had unilateral double lower lid puncta. In 5 patients the presence of a double punctum was an incidental examination finding. Eighteen patients had unilateral tearing on the same side as the double punctum. In 6 children presenting with tearing, associated congenital lacrimal anomalies included nasolacrimal duct obstruction, a lacrimal fistula, a lacrimal sac diverticulum, and absence of the upper canaliculus. Associated systemic findings in 3 children included Down syndrome (1 patient) and preauricular sinuses (2 patients). Of 12 adult patients presenting with ipsilateral tearing, 5 had complete nasolacrimal duct obstruction and 6 had either partial nasolacrimal duct obstruction or functional epiphora. Dacryocystorhinostomy was performed in 12 patients and resulted in improvement or resolution of symptoms in 11 patients (92%). Double lower lacrimal puncta may be associated with epiphora. In younger patients, tearing may be due to associated congenital anomalies of the nasolacrimal system. A proportion of patients presenting with onset of tearing in adulthood have patent lacrimal systems and otherwise normal adnexal examination results, suggesting that the presence of double puncta may be associated with compromised canalicular function. Reflux of tears through the accessory canaliculus is a potential mechanism and would be consistent with a recently proposed 2-compartment model of lacrimal canalicular drainage. The authors have no proprietary or commercial interest in any materials discussed in this article.

Nasolacrimal drainage system obstruction from radioactive iodine therapy for thyroid carcinoma.

Ophthalmic complications of (131)I therapy, including ocular dryness, have been recently investigated and described. However, nasolacrimal drainage system obstruction (NDSO), complicating (131)I therapy, has not been previously well appreciated or characterized. One of our patients developed bilateral complete nasolacrimal duct obstruction after (131)I therapy that prompted awareness of this potential complication. Over 16 months, 423 patients with epithelial-derived thyroid cancer were provided routine clinical care; 390 of these patients had received (131)I ablation or therapy, and 10 patients subsequently reported epiphora. All had evidence of NDSO disease after a mean cumulative (131)I dose of 17,279 +/- 2,923 MBq (467 +/- 79 mCi), with a mean individual (131)I dose of 6,660 +/- 555 MBq (180 +/- 15 mCi). Symptoms appeared 6.5 +/- 1.4 (range, 3-16) months after the last (131)I dose, whereas the mean time from symptom onset to correct diagnosis was 18 +/- 5 months. A causal relationship between (131)I administration and NDSO is strongly suspected. Patients reporting epiphora should be evaluated promptly by an oculoplastic surgeon.

The micro-reflux test: A new test to evaluate nasolacrimal duct obstruction

Objective The authors describe a new and simple procedure, the Micro-Reflux Test (MRT), to screen for primary acquired nasolacrimal duct obstruction (PANDO). This study sought to determine the reliability of this new test in the diagnosis of complete nasolacrimal duct obstruction. Design A nonrandomized, prospective, self-controlled, comparative case series. Participants Two hundred eyes of 100 patients with documented unilateral complete PANDO were examined. Intervention The MRT was performed by a masked examiner on both eyes of each patient. Two drops of 0.25% sodium fluorescein dye were instilled in the inferior cul-de-sac and the patient made to blink five times to activate the lacrimal pump mechanism. Excess fluorescein dye was blotted away using tissue paper. The patient was positioned at the slit lamp, and observation of the inferior punctum with the cobalt blue filter was done using 5× magnification. The tissue overlying the lacrimal sac was massaged in a counterclockwise direction with moderate pressure using the index finger. The test was considered positive if there was continued observed reflux of fluorescein-stained tears from the inferior punctum after the initial counterclockwise massage to empty the inferior canaliculus. The validity of the MRT was measured by sensitivity and specificity as well as positive- and negative-predictive values. Main outcome measure The MRT was considered positive if there was continued reflux of fluorescein-stained tears from the inferior punctum after the initial digital massage to empty the dye from the inferior canaliculus. Results The MRT used for the evaluation of complete PANDO has a sensitivity of 97% and a specificity of 95%. It has a positive-predictive value of 95% and a negative-predictive value of 97%. Conclusion The MRT is a reliable screening test for presence of complete nasolacrimal duct obstruction.

Dacryocystectomy

The main indication for dacryocystectomy (DCT) is excision of lacrimal sac tumors. DCT may be considered less invasive than dacryocystorhinostomy (DCR) because lacrimal bone and nasal mucosa are not violated. To determine other indications for DCT, we performed a retrospective review of all patients who underwent DCT from the Oculoplastics Division, Department of Ophthalmology, UMD-New Jersey Medical School from July 1983 through July 1994. Patients with lacrimal sac tumors were excluded from the study. All 25 patients in the study demonstrated complete nasolacrimal duct obstruction (NLDO) and dry eye with minimal preoperative complaints of tearing. Nine of 25 patients also had systemic medical problems making them at medical risk for local anesthesia with monitored sedation. Four of 25 patients had underlying medical conditions (ocular cicatricial pemphigoid [OCP], Crohn's disease, and systemic lupus erythematosus) that might predispose them to nasal scarring after standard DCR. None of the 25 patients required secondary hospital admission and no patient demonstrated or complained of significant tearing that affected daily function after DCT. Although DCR is the standard for improving lacrimal outflow, we conclude that DCT is a useful alternative to it in selected patients with underlying dry eye and other medical conditions.