Outcome of endoscopic dacryocystorhinostomy in elderly versus younger adults: a comparative analysis.

Endoscopic dacryocystorhinostomy in the pediatric population: a systematic review and meta-analysis.

Craniofacial clefts are rare congenital anomalies with heterogeneous presentations and significant functional and reconstructive challenges. This study evaluates periorbital pathology, surgical burden, and visual outcomes to inform care strategies for affected patients. A retrospective cohort study was conducted of patients with rare craniofacial clefts. Clefts were categorized into superior periorbital (Tessier 9-11), inferior periorbital (3-6, 8), superior medial (12-14), inferior medial (0-2), and lateral (7). Among 102 children, mean age at presentation was 2.0±3.8 years with follow-up 9.6±7.5 years. Thirteen (12.7%) had superior periorbital, 32 (31.4%) had inferior periorbital, 22 (21.6%) had superior medial, 35 (34.3%) had inferior medial, and 44 (43.1%) had lateral clefts. Eighty-two (80.4%) had periorbital abnormalities, including surface pathology (n=41, 40.2%), strabismus (n=26, 25.5%), and nasolacrimal duct obstruction (n=25, 23.5%). Sixty-four (63.3%) subjects underwent 484 periorbital procedures. Poor vision was observed in 39 patients (38.2%) and was associated with a higher number of clefts (2.3 vs 1.6, p=0.002). Inferior periorbital (p=0.004), inferior medial (p=0.023), and globe anomalies (p<0.020), were independent predictors of poor vision. Superior periorbital clefts were associated with ocular surface pathology (p=0.016) but not poor vision after adjusting for confounders. Over one-third of patients with rare craniofacial clefts experience vision loss. Contrary to traditional assumptions that superior clefts pose the greatest threat to vision, inferior clefts carry a disproportionately high risk of visual impairment. These findings underscore the need for early, cleft-specific ophthalmologic evaluation, coordinated multidisciplinary care, and immediate protective measures to prevent irreversible vision loss and guide reconstructive planning.

BackgroundDacryocystorhinostomy (DCR) is a surgery performed for nasolacrimal duct obstruction (NLDO). A high septal deflection may limit surgical access, and if not corrected, contribute to an increase in DCR failure rates due to increased adhesion formation. We hypothesize that a narrower distance between the nasal septum (NS) and lacrimal fossa (LF) is associated with higher rates of DCR failure.ObjectiveTo evaluate whether a reduced nasal septum-lacrimal fossa (NS-LF) distance is associated with higher rates of endoscopic DCR (Endo DCR) failure and to determine a clinically relevant cutoff distance that may guide consideration for concomitant septoplasty.MethodsA single-institution retrospective chart review was performed for patients who received an endoscopic "Endo" DCR between July 2018 and July 2023. Data collected included demographics, septal deviation presence and laterality, NLDO laterality, and failure rates, where failure was defined as the need for a repeat ipsilateral DCR. The NS-LF distance was determined on preoperative computed tomography.ResultsA total of 521 patients were identified, with an average age of 60.3 years (SD = 16.47); 4.4% (n = 23) of patients experienced Endo DCR failure, requiring revision Endo DCR; 8.7% (n = 45) of patients underwent concomitant septoplasty with initial DCR. Patients who failed had a significantly shorter NS-LF distance (8.47 mm vs 9.25 mm, P = .028). Receiver operating characteristic curve analysis cutoff distance of 8.85 mm demonstrated a NS-LF distance ≥8.85 mm had a significantly lower failure rate compared to those with a distance <8.85 mm (2.6% vs 7.3%, P = .016). All revision DCRs were successful regardless of septoplasty status.ConclusionA NS-LF distance of <8.85 mm was significantly associated with Endo DCR failure, suggesting that concomitant septoplasty should be considered in these patients. Prospective studies and standardized preoperative imaging may improve surgical planning and outcomes in Endo DCR.

Purpose: This study evaluated the long-term clinical outcomes of silicone tube intubation using a Nunchaku&lt;sup&gt;®&lt;/sup&gt; (FCI Ophthalmics Inc., Pembroke, MA, USA) tube in adult patients with epiphora.Methods: A prospective study was conducted on 42 eyes in 32 patients who underwent silicone tube intubation with a Nunchaku&lt;sup&gt;®&lt;/sup&gt; tube between March 2023 and September 2023. Clinical manifestations, Munk scale scores, lacrimal syringing test results, and tear meniscus height were assessed before and after surgery. Surgical success was defined as a Munk score of ≤ 1.Results: The mean age of the participants was 56.2 years. Preoperative lacrimal irrigation testing revealed partial obstruction in 29 eyes (69.0%), patent passage in 11 eyes (26.2%), and punctal stenosis in 2 eyes (4.76%). The mean operative time was 6.4 minutes for monocular procedures and 9.7 minutes for binocular procedures. At three months postoperatively, 33 eyes (78.6%) in 28 patients achieved a Munk scale score of ≤ 1. No significant differences were observed between the surgical success and failure groups in terms of preoperative Munk scale scores, lacrimal syringing test results, or tear meniscus height. One patient who underwent binocular surgery experienced worsening symptoms in both eyes postoperatively with associated punctal inflammation and granuloma formation necessitating early silicone tube removal. Slit punctum was observed in 17 eyes across 11 patients, six of whom underwent a snip procedure during surgery.Conclusions: Silicone tube intubation using the Nunchaku-style tube is a relatively simple and effective treatment for nasolacrimal duct obstruction. However, an increased incidence of lacrimal punctum-related complications was observed compared to previous studies, indicating the need for caution when performing the snip procedure concurrently.

The aim of this study is to evaluate the effect of using local anesthesia at the incision area during external dacryocystorhinostomy (E-DCR) to control intraoperative hemorrhage on hemodynamic and clinical outcomes. All patients aged 18 years and older who underwent external dacryocystorhinostomy at Niğde Training and Research Hospital between January 2024 and March 2025 with a diagnosis of primary acquired nasolacrimal duct obstruction were included in the study. Patients included in the study were randomly divided into 2 groups: those who used local anesthesia (20mg/mL lidocaine hydrochloride and 0.0125mg/mL epinephrine, 3mL) at the incision site during surgery (group 1) and those who did not (group 2). Hemodynamic parameters were measured at three different time points: before osteotomy, during osteotomy, and after osteotomy. Postoperative pain was assessed using the visual analog scale (VAS) score at 0, 2, 6, and 12 hours postoperatively. A total of 39 patients were included in the study. While the average intraoperative hemorrhage was 4.2±1.0mL in group 1, 6.6±1.2mL in group 2. This difference observed between the groups was statistically significant (P<0.001). The average patient satisfaction score was 8.4±0.8 in group 1 and 7.4±0.7 in group 2, and significantly higher in group 1 (P<0.001). In conclusion, when the appropriate anatomical approach is used during E-DCR, local anesthesia improves visibility of the surgical area. It also prevents unnecessary cauterization and may increase postoperative patient satisfaction. This approach is a safe and effective method for patients with acquired nasolacrimal duct obstruction.

ABSTRACT Purpose To report the presentation, management, and outcomes of paediatric frontoethmoidal mucoceles causing epiphora. Methods Retrospective, interventional study involving six paediatric patients with paranasal sinus mucoceles presenting with epiphora over 13 years at a tertiary dacryology centre. Demographics, meticulous history, visual acuity, ophthalmic evaluation, lacrimal irrigation, and endoscopic evaluation of the nostril were documented. Computed tomography scans were performed in all patients. All patients underwent an endoscopic endonasal marsupialization of the mucocele. Functional improvements in epiphora and external signs were analysed. Results Six paediatric patients with a mean age of 12.83 years and equal sex distribution were included. The main presenting complaint was epiphora in all children and proptosis in one over an average period of 2.4 years. One child had history of trauma. External examination showed a telecanthus in all children and proptosis or dystopia in four. One child with prior trauma had a secondary acquired nasolacrimal duct obstruction (SALDO), while the others had freely patent irrigation. Four patients had ethmoidal and two had fronto-ethmoidal mucoceles, compressing the lacrimal drainage passage. After the endoscopic endonasal marsupialization of the mucocele, five children had relief from the epiphora with reduction in the proptosis and telecanthus. The patient with traumatic SALDO underwent additional endoscopic dacryocystorhinostomy and did well Conclusions Paediatric sinus mucoceles are rare cases with very subtle signs, often presenting first to an ophthalmologist. Thus, vigilance and knowledge about the entity is necessary to identify and manage it in early stages.

Cellular and molecular mechanisms of nasolacrimal duct obstruction: New insights into CD4+ T cell-MIF-fibroblast pathways.

Mitomycin C in Non-endoscopic Endonasal Dacryocystorhinostomy: A Randomized Clinical Trial Involving 442 Cases.

To report a rare case of systemic sarcoidosis initially presenting solely with bilateral nasolacrimal duct obstruction and lacrimal gland hypertrophy, without intraocular involvement. A 48-year-old male presented with bilateral epiphora, palpable orbital masses, and blepharoptosis. Clinical examination, imaging, and biopsy confirmed bilateral nasolacrimal duct obstruction and lacrimal gland enlargement with non-necrotizing granulomatous inflammation. Systemic work-up revealed elevated ACE levels and hilar lymphadenopathy, leading to the diagnosis of systemic sarcoidosis. Despite systemic immunosuppressive treatment, the patient required bilateral dacryocystorhinostomy and subsequent bilateral orbitotomy for mass excision. One year later, ptosis correction with Müller's muscle-conjunctival resection was performed. No recurrence was observed in follow-up. This is the first reported case of systemic sarcoidosis initially presenting solely with adnexal findings, specifically bilateral nasolacrimal duct obstruction and lacrimal gland hypertrophy, without intraocular manifestations.

ObjectiveTo characterize children with congenital nasolacrimal duct obstruction (NLDO) seen by a pediatric ophthalmologist in terms of initiation of tear duct massage and need for lacrimal duct probing.DesignRetrospective chart review.ParticipantsAll children with a diagnosis of congenital NLDO managed by one pediatric ophthalmologist (SH) at a tertiary pediatric center (McMaster Children's Hospital, Hamilton, Ontario, Canada).MethodsCharts were reviewed to determine the percentage of patients requiring nasolacrimal duct probing. Secondary outcomes were percentage of patients who had tear duct massage, accurate or inaccurate, initiated by the referring provider.ResultsOverall, 113 patients with a mean age of 1.8 ± 1.5 years at presentation were included, and 55 (48.7%) were male. Most patients (83.2%) were referred by a primary care provider (family physician or pediatrician) and the remainder by optometrists (13.3%) or ophthalmologists (3.5%). Accurate tear duct massage was initiated by referring providers in 23% of cases. Ultimately, 44.2% of cases required probing, and 4.4% were still pending follow-up at time of data collection. Of children who learned accurate massage technique, 56% avoided surgical intervention, even when proper massage is introduced after 12 months of age.ConclusionMost patients referred to pediatric ophthalmology for congenital NLDO did not have an appropriate trial of tear duct massage before referral, and less than half of patients required probing after appropriate massage was initiated. Educating primary care providers and optometrists on proper initiation of tear duct massage may reduce the volume of congenital NLDO referrals to pediatric ophthalmology, a subspecialty with limited physicians and long wait times.

To evaluate the relationship between primary acquired nasolacrimal duct obstruction (PANDO), internal nasal valve angle (INVA), and peak nasal inspiratory flow (PNIF) values. This retrospective clinical study was conducted in a tertiary otorhinolaryngology and ophthalmology clinic. It included 94 eyes of 47 PANDO patients (47 affected and 47 unaffected eyes) and the right eyes of 47 healthy individuals as controls. Individuals with a history of nasal or sinus surgery, pediatric patients, and cases with epiphora but patent nasolacrimal ducts on irrigation were not included in the study. The internal nasal valve angle (INVA) was measured using computed tomography (CT), and peak nasal inspiratory flow (PNIF) testing was performed. CT cross-sectional images were used to assess the diameters and directions (inner/outer) of the lacrimal canals in both sides of PANDO patients and the right side of control participants. The PNIF value was 76.50 ± 39.08 (20-170) in the PANDO group and 64.47 ± 23.50 (30-110) in the control group, with a significant difference (p = 0.045). INVA was 12.71 ± 3.94 on the affected side and 12.06 ± 3.19 on the unaffected side in PANDO patients, and 11.36 ± 5.63 in controls (p = 0.419). The mean minimum transverse diameter of the bony lacrimal canal was significantly wider on the affected side than the unaffected side and controls (p = 0.005). These findings suggest that intranasal airflow dynamics may contribute to the pathogenesis of PANDO, potentially leading to better understanding and management of nasolacrimal duct obstructions.

IntroductionCongenital nasolacrimal duct obstruction (CNLDO) is one of the most common causes of persistent epiphora and discharge in infants. While lacrimal sac massage is frequently advised as an initial therapy, the role of early probing in infants older than six months remains a subject of discussion. This study aimed to compare the outcomes of primary probing and lacrimal sac massage in infants aged 6-12 months with CNLDO. MethodsA prospective interventional study (non-randomized controlled trial) was conducted over a one-year period involving infants aged 6 to 12 months diagnosed with CNLDO. Participants were assigned to two groups: Group 1 underwent primary probing, while Group 2 was instructed to perform lacrimal sac massage for three months. Treatment success was defined as the absence of clinical signs of CNLDO, namely watering, increased tear lake, and mucoid discharge. Analysis of data was performed using IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 23. Armonk, NY: IBM Corp.ResultsA total of 128 infants were included; 48 children with CNLDO underwent primary probing, and 80 were treated with lacrimal sac massage. Probing achieved a significantly higher success rate (83.33%) compared to massage (25%). A chi-square test comparing the difference in success rates was highly statistically significant (p < 0.0001). Identified contributors to massage failure included poor compliance, improper technique, and recurrent upper respiratory infections. ConclusionBased on the significantly superior success rates and favorable compliance observed in our patient cohort, our findings suggest that early referral to an ophthalmologist and a decision for primary probing may represent a more efficacious initial treatment strategy than prolonged massage in this specific age group. Further larger-scale, multi-center trials are warranted to confirm these findings and provide a comprehensive assessment of long-term complication rates for both modalities.

Monocanalicular intubation systems such as Mini-Monoka and Monoka are well established in the treatment of adult patients with nasolacrimal duct obstruction (NLDO). This retrospective study aimed to analyse the occurrence and subjective burden of postoperative foreign body sensation (FBS) following DCR using either intubation method. A total of 130 adult patients who underwent DCR with monocanalicular nasolacrimal duct intubation for 3 months via the upper punctum were included. Group 1 (n = 68) received Mini-Monoka, while Group 2 (n = 62) received Monoka (4 mm) intubation. FBS was assessed via a standardised patient questionnaire. Mean age was 63.7 years (range 22 - 91) in group 1 and 61.2 years (range 25 - 79) in group 2. The male-to-female ratio was 3.25 : 1 and 4.64 : 1, respectively. Postoperative FBS was reported by 22.1% in group 1 and 40.3% in group 2. Moderate to severe discomfort was reported by 40% and 56% of affected patients, respectively. Logistic regression revealed a significant influence of the stent system (p = 0.024), but not gender (p = 0.617). Both stenting systems are associated with postoperative FBS in a considerable proportion of patients. Due to the higher rate of perceived discomfort under Monoka, Mini-Monoka should be preferred whenever anatomically feasible.

To compare the appropriateness and readability of responses generated by four different large language models (LLMs) to frequently asked questions about congenital nasolacrimal duct obstruction (CNLDO). Twenty-five frequently asked questions (FAQs) related to CNLDO were answered by four LLMs: ChatGPT-4o, Gemini, DeepSeek, and Microsoft Copilot. Two experienced oculoplastic surgeons evaluated the responses for appropriateness and comprehensiveness using a Likert scale. In addition, the readability of the responses was assessed using an online readability tool. ChatGPT-4o demonstrated significantly higher accuracy in the treatment and management category (P=0.001). Overall, DeepSeek provided the most appropriate responses across all categories (P=0.001). While DeepSeek achieved the highest total Likert scores, the differences among the models were not statistically significant (P=0.2). In terms of readability, Gemini and Copilot produced more readable texts, whereas DeepSeek's responses were more complex and structured. DeepSeek showed superior performance in appropriateness and comprehensiveness across all questions related to CNLDO. However, its responses were less readable compared to those of the other LLMs, which may limit accessibility for some users.

Goldenhar Syndrome (GS), also known as the Oculo-Auriculo-Vertebral Spectrum (OAVS), is a rare congenital disorder characterised by variable craniofacial and ocular anomalies due to aberrant development of the first and second branchial arches. This case series describes three paediatric patients who exhibited diverse phenotypic features of the syndrome, highlighting its clinical heterogeneity and the importance of individualised management. All three patients presented with epibulbar dermoids since birth, an ocular hallmark of GS. The first patient, a 12-year-old female, had a limbal dermoid, medial canthal swelling suggestive of nasolacrimal duct obstruction, a symblepharon, and microtia with preauricular tags. She was advised dacryocystorhinostomy and excision of the dermoid but was lost to follow-up. The second patient, a 15-year-old had a reddish limbal mass extending to the lateral canthus and preauricular tags, and a cosmetic symblepharon release was advised. The third patient, a 15-year-old had a non-progressive limbal dermoid with no significant adnexal involvement and was managed conservatively. None of the patients had associated spinal, cardiac, or neurological anomalies on systemic evaluation. This case series reinforces the phenotypic variability of GS and underscores the importance of early ophthalmic diagnosis, systemic screening, and a multidisciplinary approach to optimise functional and cosmetic outcomes in affected children.

ABSTRACT Purpose To evaluate the diagnostic performance of the endoscopic Jones (eJones) I and II tests in patients presenting with epiphora. Methods A retrospective review was conducted of patients assessed for epiphora in a tertiary oculoplastic unit. All patients underwent rigid nasal endoscopy, dacryocystography (DCG), and dacryoscintigraphy (DSG). Lacrimal drainage status was categorized as nasolacrimal duct obstruction (NLDO), nasolacrimal duct stenosis (NLDS), or functional epiphora based on imaging findings. eJones I and II test outcomes were compared across diagnostic groups. Results Thirty-five symptomatic eyes were included. Functional epiphora was identified in 17 eyes, NLDO in 13 eyes, NLDS in one eye, and four eyes demonstrated normal lacrimal systems. All eyes with NLDO or NLDS had negative eJones I results, while all symptomatic eyes with normal imaging findings had positive eJones I results. Eyes with functional epiphora showed mixed eJones I outcomes. Conclusions The eJones I test reliably confirmed anatomical obstruction but yielded variable results in cases of functional epiphora, highlighting the multifactorial mechanisms underlying this condition. Further studies are warranted to validate and refine the diagnostic utility of eJones testing.

To review and analyze lymphoid tumors involving the lacrimal drainage apparatus (LDA) through retrospective review of an orbital surgeon's (T.J.S.) practice across multiple centers, including incidence, clinical presentation, signs, radiological features, management, and mortality. Retrospective cohort analysis of ocular and adnexal lymphoproliferative disease (OALD) seen through Queensland orbital services between 1992 and 2024. Inclusion criteria were patients with histologically proven OALD. Twenty-two patients with OALD demonstrating involvement of the LDA were identified. Fifty percent of patients presented with dacryocystitis, 32% with a palpable mass in the medial canthus and 27% with symptomatic epiphora. However, 7 (30%) patients had disease detected incidentally at the time of elective dacryocystorhinostomy surgery. CT findings included variable patterns of bony remodeling, erosion, or destruction depending on histology and nasolacrimal duct obstruction. MRI, when utilized, better defined the extent of lesions; commonly isointense on T1 and T2-weighted imaging and moderately gadolinium enhancing, with positron emission tomography-CT effective at screening for undiagnosed systemic disease. Histological review highlighted 8 cases (38%) of diffuse large B-cell lymphoma, 4 (18%) T-cell lymphoma, 3 (14%) chronic lymphocytic or small lymphocytic lymphoma, and 7 (30%) other variants. Ann Arbor lymphoma classification highlighted 30% (6) of patients with stage 1, with 60% (13) identified at stage 3 or 4. Ten patients have achieved disease-free survival, with 1 patient requiring ongoing treatment. Three patients died due to OALD. OALD affecting the LDA, while rare, represents a potentially life-threatening differential for patients with LDA symptoms. Presentations are variable; early detection, timely imaging, and histological identification can meaningfully affect associated mortality.

To compare surgical outcomes of 2 lacrimal sac approaches (medial wall excision and marsupialization) in endonasal dacryocystorhinostomy (DCR) for nasolacrimal duct obstruction (NLDO). This retrospective study included 78 eyes of 73 patients who underwent endoscopic DCR between June 2017 and January 2024. Group 1 underwent medial wall excision; Group 2 had marsupialization. All surgeries were performed by a single surgeon. Demographic data, preoperative Munk score, symptom duration, operative time, complications, and success rates were evaluated. Functional success was defined as the complete resolution of epiphora as reported by the patient; anatomical success as a patent ostium regardless of symptoms. Group 1 included 41 eyes (52.6%), and Group 2, 37 eyes (47.4%). Mean operative time was shorter in Group 1 (38.17 ± 8.60min) than Group 2 (44.97 ± 11.70min; p = 0.004). Functional and anatomical success rates were 87.2% and 89.7%, with no significant difference (p = 0.999). Minor complications occurred in both groups and resolved conservatively. Both techniques offer similarly high success in endonasal DCR. Medial wall excision may provide technical ease with shorter operative time.

Congenital nasolacrimal duct obstruction (CNLDO) represents the most prevalent cause of epiphora in infancy, with a reported incidence of approximately 6-20% of newborns. In the majority of cases, a membranous occlusion at the valve of Hasner is responsible, with spontaneous resolution occurring in up to 96% within the first year of life.Clinical signs comprise persistent tearing, an elevated tear meniscus and recurrent mucopurulent discharge; digital pressure on the lacrimal sac may induce retrograde reflux. Ophthalmic examination is indispensable to exclude differential diagnoses such as congenital glaucoma, keratoconjunctivitis or eyelid malposition.Given the high probability of spontaneous resolution, conservative management is the treatment of choice during the first 6-12 months of life, including parental instructions, consistent lid hygiene, and lacrimal sac massage. Topical antibiotics should be restricted to short-term application in the presence of bacterial superinfection.In cases of persistent obstruction or complicated disease lacrimal probing is indicated, usually after 12 months of age in general anaesthesia. Silicone intubation is recommended for complex or recurrent obstructions, failed probing, or in older children, and associated with substantially improved success rates. Endoscopic techniques including transcanalicular dacryoendoscopy, ballon dacryoplasty, and endonasal endoscopy can be helpful in refractory and anatomically complex cases. Dacryocystorhinostomy serves as ultima ratio surgery in treatment-refractory or bony stenosis and should not be performed before the age of one year.A staged, evidence-based therapeutic management beginning with conservative measures and escalating to age- and anatomy-adapted interventions, is recommended to achieve favourable outcomes.