Nasolacrimal Duct Obstruction Research Articles

Correction: Retrospective analysis of bicanalicular lacrimal silicone tube intubation in patients with congenital nasolacrimal duct obstruction: a long-term follow-up study.

Correction: Retrospective analysis of bicanalicular lacrimal silicone tube intubation in patients with congenital nasolacrimal duct obstruction: a long-term follow-up study.

Comparative Analysis of Silicone Tube Intubation Versus Probing and Balloon Dilation for Congenital Nasolacrimal Duct Obstruction: A Systematic Review and Meta-Analysis.

Congenital nasolacrimal duct obstruction (CNLDO) is a pediatric disorder with a wide range of pathology. If untreated, the condition may end up with serious complications. Multiple treatment options for CNLDO exist throughout the literature, and there is an ongoing debate on the best intervention for each disease subgroup and the best timing of such interventions. This study compares the success and failure rates of silicone tube intubation (STI) against probing and balloon dilation (BD). The authors searched the literature for relevant articles using PubMed, Scopus, web of Science, and Cochrane Library until January 2024. Using RevMan 5.4, the authors compared STI's success and failure rates to probing and BD using risk ratios (RRs) and a random-effect model. In addition, the complication rate of monocanalicular intubation (MCI) versus bicanalicular intubation (BCI) was investigated. The authors used the leave-one-out method to check for influential studies and to resolve heterogeneity. The screening process resulted in 23 eligible articles for inclusion in the authors' review. Silicone tube intubation had a higher chance of resolving the symptoms of CNLDO than probing (RR = 1.11; 95% CI: 1.04, 1.20; P = 0.004) while having less risk of surgical failure (RR = 0.48; 95% CI: 0.30, 0.76; P = 0.002]. Monocanalicular intubation showed no statistically significant difference when compared with BCI in terms of surgical success and failure; however, MCI had a lower risk of complications (RR = 0.68; 95% CI: 0.48, 0.97; P = 0.04). In addition, STI did not demonstrate any significant difference from BD. There was no significant difference in success/failure between MCI and BCI; monocanalicular had fewer complications. Silicone tube intubation did better in terms of surgical success than probing, especially in children over 12 months, suggesting that it is the preferred intervention for older patients with CNLDO.

Lacrimal Obstruction in Craniosynostosis: Anatomical and Genetic Risk Factors

Purpose: To investigate whether patients with craniosynostosis exhibit higher rates of nasolacrimal duct obstruction (NLDO) and to explore potential risk factors. Methods: Retrospective review including all craniosynostosis patients treated at both the Divisions of Ophthalmology and Plastic, Reconstructive, and Oral Surgery at The Children’s Hospital of Philadelphia between 2009 and 2020 was conducted. Synostosis characteristics, lacrimal disorders, and genetic data were collected. Main outcome measures were the rate of NLDO and associations with anatomical and syndromic/genetic risk factors. Results: The total of 767 participants had a mean age of 2.8 ± 3.8 years, 465 (60.6%) were males, 485 (63.2%) had no syndromic association; 631 (82.3%) had one major suture involved, 128 (17%) had involvement of 2 to 4 major sutures, and 429 (55.9%) underwent craniofacial surgery. Forty-eight (6.2%) patients had NLDO, which more prevalent in the genetic/syndromic group (11.0% vs. 3.5%, respectively, p < 0.001), with the highest prevalence observed in patients with Apert syndrome (n = 4, 30.8%). The genetic variants most associated with NLDO were EFNB1 (n = 1, 100%) and FGFR2 (n = 6, 19.4%). There was no association between NLDO and the number or types of sutures involved or a history of craniofacial surgery. Conclusions: Nasolacrimal duct obstruction is more common in patients with craniosynostosis compared to the general population. Having a putative syndrome or a putative genetic variant and female sex were risk factors for NLDO. Ophthalmic evaluations for all craniosynostosis patients and careful assessments of any symptoms of tearing are recommended.

Unlocking the secrets of success in probing for congenital nasolacrimal duct obstruction: investigating the factors that matter.

The objective of this study was to analyze the impact of different factors on the success rate of probing for congenital nasolacrimal duct obstruction (CNLDO). A retrospective analysis was conducted on 239 eyes of 202 patients who underwent probing for CNLDO between 2014 and 2019. Patients were divided into three age groups (12-24months, 25-36months, and over 36months) and two groups based on the type of membranous obstruction (MO) and incomplete complex obstruction (ICO), with complete complex obstruction (CCO) cases being excluded. The study involved administering general anesthesia (GA) to all participants during the probing procedure. The patients were then monitored at scheduled intervals for up to 6 months after the surgery. Success was defined as an improvement in symptoms and signs, and logistic regression and Fisher's exact test were used for statistical analysis. The mean age of the patients was 25.48 ± 13.38months, and the total success rate was 86.61%. The success rate for MO was 92.8%, 95.87%, and 97% in age groups 1, 2, and 3, respectively. The success rate for ICO was 91.17%, 80%, and 23.52% in age groups 1, 2, and 3, respectively. The success rate for MO was significantly higher than ICO in all age groups. The success rate for ICO was significantly lower in age group 3 (p = 0.009). The study found that probing performed within the first 36months had high success rates regardless of age and type of obstruction. However, the success rate significantly decreased in patients undergoing probing for ICO at 36months or later.

Lacrimal sac dacryolith treated with endoscopic dacryocystorhinostomy: A case report and literature review

Dacryolith is a concretion within the nasolacrimal systemthat may calcify and cause further obstruction of the nasolacrimal pathway. It may cause intermittent epiphora without inflammation or recurrent dacryocystitis and is often diagnosed during dacryocystorhinostomy (DCR). We report the case of a lacrimal sac dacryolith in a 37-year-old man who was referred to our hospital from the eye clinic with complaints of epiphora that were not relieved by medication. He had no history of epiphora. During endoscopic DCR, the presence of dacryolith in the lacrimal sac was detected and completely removed while the pus was drained. The patient was discharged on the second postoperative day with systemic and topical antibiotics. During routine follow-up, the patient was in good condition and had no complaints. We aim to raise awareness among clinicians of this unusual cause of nasolacrimal duct obstruction, which can be successfully managed with endoscopic DCR rather than an open external approach.

Flap Fixation in Endoscopic Dacryocystorhinostomy: A Comparative Study

ABSTRACT Background: The usual procedure for nasolacrimal duct obstruction is dacryocystorhinostomy (DCR). Flap-based DCR techniques lead to better surgical outcome provided flaps do not dislocate in the post-operative period. Objectives: This study was conducted to compare gelfoam with merocel tamponade for fixation of mucosal flaps in endoscopic DCR. Materials and Method: Merocel tamponade was used for fixation of flaps in 26 patients. Gelfoam was used in 26 patients, and surgical results were compared. Results: The surgical success rate was greater in merocel tamponade fixation with less complications. Conclusion: Merocel tamponade can be used successfully for mucosal flap fixation in endoscopic DCR for better surgical outcome.

The incidence of pediatric dacryocystitis among a population-based cohort of infants with congenital nasolacrimal duct obstruction

PurposeTo report the incidence, clinical characteristics, and outcomes of acute dacryocystitis among a large, population-based cohort of children born with congenital nasolacrimal duct obstruction (CNLDO) over a 10-year period. MethodsThis multicenter retrospective, population-based cohort study included all patients diagnosed with acute dacryocystitis in a cohort of patients diagnosed with CNLDO before age 5 years in Olmsted County, Minnesota, United States of America from January 1, 1995, through December 31, 2004. ResultsOf 1,998 patients with CNLDO, there were 70 cases (36 female [(51%)]) of acute dacryocystitis during the study, yielding an incidence rate of 243 per 100,000 children (95% CI, 170-316). Mean age at diagnosis was 9.0 months. Patients who developed dacryocystitis were significantly less likely to be born via C-section (OR = 0.29, P = 0.009). Less than half of patients with dacryocystitis were treated with oral/intravenous antibiotics (46%), but whose who were had a significantly higher odds of requiring probing (OR = 8.50, P = 0.004). Spontaneous CNLDO resolution was significantly less likely to occur in patients diagnosed with acute dacryocystitis compared with those without (OR = 2.46, P = 0.001). The median age of spontaneous resolution in the dacryocystitis group (6.0 months) was significantly older than the uncomplicated CNLDO group (P = 0.012). ConclusionsPediatric acute dacryocystitis is an uncommon complication of CNLDO and is associated with both a lower likelihood of and older age at spontaneous resolution of CNLDO symptoms.

Retrospective Analysis of Bicanalicular Lacrimal Silicone Tube Intubation in Patients with Congenital Nasolacrimal Duct Obstruction: A Long-term Follow-up Study.

Congenital nasolacrimal duct obstruction (CNLDO) is the most common cause of epiphora in the first year of life. In addition to conservative therapy, there are several invasive methods available. The aim of this retrospective study was to conduct a long-term follow-up of bicanalicular lacrimal duct intubation as the primary intervention in a large cohort of patients with CNLDO. The electronic medical records of 487 patients with CNLDO who underwent bicanalicular tube intubation were reviewed. To determine the long-term outcomes, a telephone interview was conducted. A total of 328 eyes of 235 patients were included in the study. The median average follow-up period was 6.67 (5.58 - 8.67) years. At the time of the survey, 218 patients (92.8%) were symptom free. Mean patient satisfaction with surgical outcome was 10/10. To our knowledge, this study provides the longest follow-up of the largest patient cohort in the literature consisting of patients who underwent probing with bicanalicular lacrimal silicone tube intubation as a primary intervention for CNLDO. This study showed a high long-term postoperative success rate, with high postoperative satisfaction, few complications, and a low need for reintervention.

Endoscopic Dacryocystorhinostomy Following Nasolacrimal Drainage System Trauma and Medial Orbital Wall Reconstruction

Study Design Case series. Objective To describe the assessment and surgical approach to dacryocystorhinostomy (DCR) for patients with nasolacrimal duct obstruction (NLDO) in the presence of orbital wall hardware. Methods The pre-operative assessment, management and outcomes of two patients with secondary acquired NLDO following medial orbital wall fracture repair treated by nasal endoscopic DCR. Results Anatomical and functional success was achieved in both cases at 6 weeks post operatively without disruption of the orbital plate. There was persistent success at 1 and 3 years’ post-operatively. Conclusions Endoscopic DCR is a good option for the treatment of NLDO in patients with previous medial orbital wall fracture repair where the location of the plate may complicate the external approach.

Nasolacrimal duct Probing versus Silicone Intubation in the Treatment of Complex Congenital Nasolacrimal Duct Obstruction

Nasolacrimal duct Probing versus Silicone Intubation in the Treatment of Complex Congenital Nasolacrimal Duct Obstruction

Nasolacrimal duct obstruction prevalence is 0.3% among alpacas evaluated with ophthalmic disease at a veterinary teaching hospital between 2000 and 2023.

To examine the prevalence of nasolacrimal duct (NLD) obstruction in hospital populations and assess signalment, diagnostics, and clinical approaches for alpacas and llamas diagnosed with NLD atresia or obstruction. 29 alpacas and 2 llamas. Medical records were reviewed to identify camelids with NLD evaluated between 2000 and 2023. Signalment, history, physical examination data, diagnosis, and treatments were recorded. Follow-up information was gathered via phone and email questionnaire. Data were evaluated to determine prevalence and describe signalment and treatments for NLD disease. 31 camelids met the inclusion criteria. A total of 8,027 alpacas and 1,998 llamas were seen within the study period at 1 teaching institution. The prevalence of NLD obstruction for this population of alpacas was 0.3% (26/8,027). Nineteen of 31 (61%) camelids presented at 1 year of age or younger. The most common physical exam finding was ocular discharge (68%). The most common diagnosis was NLD atresia (16/31 [51%]). Patency was established by surgical opening or lavage of the NLD. Long-term follow-up was available for 13 alpacas and 2 llamas, of which 11 (73%) had successful outcomes. Results indicate that NLD obstruction is a condition that most commonly affects alpacas < 1 year of age and is associated with a good prognosis for treatment success.

Clinical characteristics and cytological changes in mucinous obstruction diagnosed by dacryoendoscopy

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

A New Patient-reported Outcomes Measure for Surgically Treated Epiphora: Tearing Assessment and Rating Scale-12 (TEARS-12).

No widely accepted, validated instrument currently exists to measure clinical outcomes in patients who undergo dacryocystorhinostomy (DCR) for treatment of epiphora. To develop a patient-reported outcome measure applicable to this population. Psychometric evaluations, consultation with experts, and review of the literature informed item generation of a 12-question questionnaire to incorporate the most relevant symptoms experienced by patients with nasolacrimal duct obstruction. This questionnaire, known as the Tearing Assessment and Rating Scale-12 (TEARS-12), was administered to 32 patients before and after intervention, in the form of endoscopic DCR. Statistical analysis was performed to measure internal consistency, responsiveness, and test-retest reliability. Pre-operative and post-operative TEARS-12 scores (28.2 [standard error (SE) 3.19] vs 11.8 [SE 3.25], respectively, P = 0.001) demonstrated improved patient outcome within 6 weeks following endoscopic DCR. Cronbach's alpha for the questionnaire was 0.90, indicating high overall reliability. Additionally, each question demonstrated internal reliability, with a corrected item-total correlation greater than 0.30. The intraclass correlation between the two pre-operative scores was 0.858 (P < 0.001), indicating high test-retest reliability. TEARS-12 is a statistically valid, easy-to-administer instrument to measure clinical outcomes in patients who undergo endoscopic DCR.

Ocular manifestations of CHARGE syndrome in a pediatric cohort with genotype/phenotype analysis.

CHARGE syndrome is a rare multi-system condition associated with CHD7 variants. However, ocular manifestations and particularly ophthalmic genotype-phenotype associations, are not well-studied. This study evaluated ocular manifestations and genotype-phenotype associations in pediatric patients with CHARGE syndrome. A retrospective chart review included pediatric patients under 20 years-old with clinical diagnosis of CHARGE syndrome and documented ophthalmic examination. Demographics, genetic testing, and ocular findings were collected. Comprehensive literature review enhanced the genotype-phenotype analysis. Forty-two patients (20 male) underwent eye examination at an average age of 9.45 ± 6.52 years-old. Thirty-nine (93%) had ophthalmic manifestations in at least one eye. Optic nerve/chorioretinal colobomas were most common (38 patients), followed by microphthalmia (13), cataract (6), and iris colobomas (4). Extraocular findings included strabismus (32 patients), nasolacrimal duct obstructions (11, 5 with punctal agenesis), and cranial nerve VII palsy (10). Genotype-phenotype analyses (27 patients) showed variability in ocular phenotypes without association to location or variant types. Splicing (10 patients) and frameshift (10) variants were most prevalent. Patients with CHARGE syndrome may present with a myriad of ophthalmic manifestations. There is limited data regarding genotype-phenotype correlations and additional studies are needed.

Dynamic viscosity of the wall of the lacrimal sac in disorders of the patency of the lacrimal ducts.

To assess the dynamic viscosity of the lacrimal sac wall in patients with various origins of lacrimal duct obstruction. The study was performed in 35 cases: 21 cases with primary nasolacrimal duct obstruction (PANDO) and 14 cases with secondary nasolacrimal duct obstruction after radioiodine therapy (SALDO). The study of biomechanical properties of the lacrimal sac was carried out using a test bench. The principle of the study was to indent the sample at a given speed and record the data obtained from the sensor of the force transmitted to the sample. The area under the curve (AUC) and the peak viscosity were calculated. A qualitative characteristic of the obtained curve was given. Median AUC in patients with PANDO was 17 × 106 [6 × 106; 19 × 106] N/m2 × s, in patients with SALDO 21 × 106 [13 × 106; 25 × 106] N/m2 × s. Intergroup differences were statistically significant (p = 0,048). The median peak viscosity in PANDO patients was 29 × 106 [25 × 106; 35 × 106] N/m2, in patients with SALDO 32 × 106 [21 × 106; 41 × 106] N/m2. The qualitative characteristics of the obtained curves differed. Biomechanical properties of the lacrimal sac may vary depending on the cause of obliteration of the lacrimal ducts. The integrated dynamic viscosity is significantly higher in SALDO patients due to exposure to radioiodine compared to that in PANDO patients.

The Use of Hand-Held Digital Otoscope as a Basic Nasal Endoscopy Tool for Lacrimal Evaluation and Pedagogy Instrument

Purpose To investigate the utility of a hand-held digital otoscope for nasal endoscopy and as a pedagogy tool for residents and fellows in patients undergoing external dacryocystorhinostomy (DCR) surgery Methods A digital otoscope (MS450-NTE, Teslong Inc., USA) comprising a digital screen device and a connectible camera probe was used for performing nasal endoscopy. Inspection of nasal cavities was performed pre-, intra-, and post-operatively in sequential patients with nasolacrimal duct obstruction, who underwent DCR or lacrimal probing. Images (1920 × 1080 pixels) and videos (1280 × 720 pixels) were captured. The device was also used for training residents and fellows in performing nasal endoscopy, and to teach basic concepts. Results The digital otoscope could be used for routine outpatient nasal examination and for performing minor procedures. 53.8% (n = 13) of ophthalmology trainees had never observed nasal endoscopy and 84.6% could not identify more than one major structure correctly prior to the current training. Post-training, all trainees could independently perform nasal endoscopy with the device and 76.9% identified all structures correctly. Conclusion A digital otoscope with a camera probe is a handy tool for nasal endoscopy and pedagogy. Low-cost gadgets such as this device can effectively be used for performing outpatient nasal endoscopy when expensive endoscopes are unavailable and in peripheral healthcare centers.

Mono-canalicular Lacrimal Stent Intubation for Congenital Nasolacrimal Duct Obstruction Treatment

Background Epiphora, marked by tear overflow at the eyelid margin, is a prevalent condition in ophthalmology, affecting over 20% of infants. The causes involve hypersecretion due to anterior segment diseases or compromised lacrimal drainage systems. While congenital nasolacrimal duct obstruction (CNLDO) in children often resolves spontaneously, persistent cases may necessitate surgical intervention. The management, which includes probing, stent insertion, and dacryocystorhinostomy, remains challenging due to the miniaturized and variable anatomy of the lacrimal pathways. Objective and Aims This study aims to investigate the efficacy of mono-canalicular Lacrijet stent insertion in managing congenital nasolacrimal duct obstruction (CNLDO) in pediatric patients, particularly those aged over 24 months. It focuses on assessing success rates in cases with prior probing or no previous probing. The study aims to contribute valuable insights to the existing literature on the effectiveness of Lacrijet intubation as a management option for CNLDO. Patients and Methods A prospective observational study following 25 pediatric patients diagnosed with epiphora in an ophthalmology hospital. The procedure included using mono-canalicular Lacrijet intubation. Patients were followed for 180 days post-operatively via subjective and objective measures. Independent and paired t-tests were used for numerical variables. Chi-square was applied to check the significant association of variables with outcome. A p-value less than or equal to 5% is considered significant. Results More than half of the sample was 3-6 years of age (56%), males (52%), and had previous probing attempts (56%). Seven (28%) patients were relieved from symptoms within less than 5 days, 12 (48%) recovered within 5-9 days, and 2 (8%) patients were symptom-free after 10 days. The success rate was 84%. Only 4 patients (16%) had unsuccessful outcomes. There was no significant difference in outcome regarding patients’ age, gender, affected eye, previous probing, and site of intubation. Conclusions and Recommendations Mono-canalicular Lacrijet stent insertion appears as a simple, safe, and reliable outpatient procedure for treating CNLDO in children. Age and prior failed probing did not significantly impact success rates. Early and detailed assessments are recommended for children with epiphora, with consideration for mono-canalicular stenting. Future research could compare outcomes between probing and intubation as initial treatments for pediatric epiphora.

A Case of Nasolacrimal Duct Obstruction Caused by a Lacrimal Sac Retention Cyst

Acquired nasolacrimal duct obstruction may result from chronic infection, lacrimal stones, anatomical variations such as aberrant ethmoid cells, facial fractures, or complications following nasal surgery. In Korea, there has been no reported case of secondary nasolacrimal duct obstruction due to a retention cyst in the lacrimal sac. Recently, the authors encountered a 65-year-old female patient who presented with epiphora, was diagnosed with a lacrimal sac retention cyst, and was successfully treated with endoscopic marsupialization.

ScRNA-Seq: First Atlas and Cellular Landscape of Lacrimal Sac: Implications in Primary Acquired Nasolacrimal Duct Obstruction Pathogenesis.

The aim of this study was to describe the transcriptional changes of individual cellular components in the lacrimal sac in patients with primary acquired nasolacrimal duct obstruction (PANDO) and attempt to construct the first lacrimal sac cellular atlas to elucidate the potential mechanisms that may drive the disease pathogenesis. Lacrimal sac samples were obtained intra-operatively during the endoscopic dacryocystorhinostomy (EnDCR) procedure from five patients. Single-cell RNA sequencing was performed to analyze each individual cell population including epithelial and immune cells during the early inflammatory and late inflammatory phases of the disease. Eleven cell types were identified among 25,791 cells. T cells and B cells were the cell populations with the greatest variation in cell numbers between the two phases and were involved in immune response and epithelium migration-related pathways. The present study showed that epithelial cells highly expressed the genes of senescence-associated secretory phenotype (SASP) and were involved in influencing the inflammation, neutrophil chemotaxis, and migration during the late inflammatory stage. Enhanced activity of CXCLs-CXCRs between the epithelial cells and neutrophils was noted by the cell-cell communication analysis and is suspected to play a role in inflammation by recruiting more neutrophils. The study presents a comprehensive single-cell landscape of the lacrimal sac cells in different phases of PANDO. The contribution of T cells, B cells, and epithelial cells to the inflammatory response, and construction of the intercellular signaling networks between the cells within the lacrimal sac has further enhanced the present understanding of the PANDO pathogenesis.

Virtual Reality and Mixed Reality-Assisted Endoscopic DCR in Extremely Complex Lacrimal Obstructions.

To report the techniques and outcomes of virtual reality (VR) and mixed reality (MR)-assisted powered endoscopic dacryocystorhinostomy (DCR) in extremely complex lacrimal drainage obstructions. A prospective, non-randomized clinical study was performed in complex syndromic congenital nasolacrimal duct obstruction (CNLDO) and post-traumatic secondary acquired lacrimal duct obstruction (SALDO) in the setting of Le Fort fractures. All patients underwent preoperative planning in VR and intraoperative planning with a step ahead with MR assistance during the surgery. Surgery was supported by mixed reality intraoperative guidance with the use of the prearranged 3D models and real-time-rendered digital models. Parameters assessed include demographics, clinical presentation, complexities of the nasolacrimal duct obstruction, preoperative and intraoperative utility of VR and MR models, surgical techniques, complications, and outcomes. The technique is described as a proof of concept in challenging situations with Apert syndrome and traumatic SALDOs with gross malposition of the sac, and gross nasal and lacrimal anatomical deformities. The VR models helped the surgeon to assess the details of the altered anatomy preoperatively to plan an appropriate approach. Intraoperatively, MR models were present in the surgeon's view without disturbing the endoscopic procedure. Intermittently, the surgeon could pull any of the models virtually present in the operating room, slice them, rotate them, and intricately study the alterations in a stepwise manner, as the surgery proceeds. Virtual reality and mixed reality-assisted powered endoscopic DCR can be an alternate approach reserved for extremely challenging cases of complex syndromic CNLDOs and post-traumatic SALDOs. Level 4 Laryngoscope, 2024.