Persistent Epiphora Research Articles

External dacryocystorhinostomy in paediatric age group: indications and outcome results

Introduction Management of epiphora in children is a stepwise process, starting with probing after age of 1 year and it provides a high cure rate. Nasolacrimal intubation is recommended when symptoms persist after two probings. For persistent epiphora following probing and intubation, more invasive procedure is required like balloon dacryocystoplasty, or external and endonasal dacryocystorhinostomy. Objective This study was designed to evaluate the indications and surgical outcome of external dacryocystorhinostomy in the paediatric age group. Design A retrospective case series study that was carried out in the oculoplastic unit in Minia University Hospital including children undergoing external dacryocystorhinostomy (DCR) in a 5-year period (from June 2008 to June 2013). Patients and methods Data of all patients who underwent external DCR with silicone intubation in a 5-year period were retrospectively reviewed. Patients aged 15 years or less were chosen for the study and data collected were age and sex of the patients, side of the obstruction, indication for surgery, follow-up period and postoperative results and complications. Criteria of success were disappearance of epiphora, discharge and/or the mucocele in addition to negative fluorescein dye disappearance test and patent lacrimal passages on syringing and probing. The follow-up period was at least 6 months. Data of 29 patients were retrieved and the patients were categorized into two subgroups according to the cause of obstruction: congenital group (17 patients) and acquired group (12 patients) and the collected data were statistically analysed. Results Seventeen (58.6%) out of the 29 patients had congenital causes of epiphora, whereas 12 (41.4%) patients had acquired causes. Age of the patients ranged from 6 to 180 months with a mean of 78 months. Males were slightly more (53%) in the congenital subgroup, whereas 58% of the patients in the acquired subgroup were females and the overall male to female ratio in all patients was nearly 1 : 1. The overall success rate in all patients was 89%, which was higher in the congenital subgroup (94%) than in the acquired subgroup (83%). Conclusion External DCR yielded good results with minimal complications regarding epiphora in children. The results were better in patients with congenital causes than acquired causes.

Management of functional epiphora in patients with an anatomically patent dacryocystorhinostomy.

Approximately 5% to 10% of patients continue to experience persistent epiphora following an anatomically successful dacryocystorhinostomy (DCR) for nasolacrimal duct obstruction or stenosis. To investigate the management and success rate of so-called "functional failure" of DCR for nasolacrimal duct obstruction by experienced lacrimal surgeons. Multicenter retrospective case series including 5 Australian and New Zealand centers. Participants included 61 patients (71% women [n = 46]; mean age, 66 years) with functional epiphora after 65 DCRs (69% transnasal) who were recruited over a mean of 7.6 years. Inclusion criteria included confirmed preoperative diagnosis of nasolacrimal duct obstruction or stenosis, age greater than 18 years, recurrent or persistent epiphora after DCR, an anatomically successful DCR, and follow-up longer than 6 months. Exclusion criteria included evidence of lacrimal hypersecretion, eyelid malposition, and punctal or canalicular abnormalities. The number, type, timing, and success of all clinical interventions performed for the management of functional epiphora after DCR. Epiphora recurred a mean of 8.9 months after primary DCR; 89% of the cases (n = 58) had evidence of a patent ostium and 100% were patent on lacrimal irrigation. Intubation with a lacrimal stent was performed in 82% of the cases at the time of surgery, and all stents were removed a mean of 8 weeks postoperatively. Epiphora was reported immediately following DCR in 32% (n = 21) of the cases and within 6 weeks after removal of the stent in 31% (n = 20); late recurrence (>12 months after DCR) developed in 37% (n = 24) of the cases. In a total of 15% of the cases, participants declined any treatment following DCR. The remainder underwent a mean of 1.3 interventions (range, 1-3) during a mean of 23 to 41 months after primary DCR, following which 72% (n = 47) of the cases had a successful outcome; 12% (n = 8) failed to achieve improvement, and the patients declined further intervention. Thirty-nine interventions (60%) were intubation with a silicone stent with a 54% success rate. Almost half of those undergoing intubation elected to keep the stent permanently; 34% (n = 22) had an eyelid-tightening procedure with 50% success, and 15% (n = 10) required a Lester-Jones tube despite patent canaliculi, with a success rate of 90%. Functional epiphora after DCR among patients with preoperative nasolacrimal duct obstruction or stenosis appears to be uncommon. Benefits can be achieved in most patients with intubation (transient or permanent) or eyelid tightening. More than one procedure is often required.

Epiphora as the Presenting Sign of Relapsed Non-Hodgkin Lymphoma in a Child with Bruton Agammaglobulinemia

Primary or secondary infiltration of the lacrimal drainage system by a lymphoid neoplasm is rare in children. Primary immunodeficiencies are characterized by occurrence of unusual malignancies at unexpected locations in the pediatric age group. Case report. A 12-year-old boy with a history of Bruton agammaglobulinemia and non-Hodgkin lymphoma (NHL) that primarily originated in the perianal region was referred to our oculoplastics department for persistent epiphora. Computed tomography scan and nasal endoscopy revealed relapse of NHL in the inferior portion of the nasolacrimal duct. Complete remission was achieved with chemotherapy. Epiphora could be the initial manifestation of a relapse or a recurrence of an underlying malignancy in the pediatric population with predisposing immunodeficiency.

Associated factors of functional failure of external dacryocystorhinostomy

ObjectiveTo evaluate the incidence and associated factors of functional failure of anatomically patent external dacryocystorhinostomy (DCR). DesignProspective, nonrandomized case series. ParticipantsThirty-four consecutive patients who underwent external DCR at the oculoplasty clinic in the Department of Ophthalmology, Seoul National University Hospital between December 2008 and July 2009. MethodsAll patients underwent external DCR for primary acquired nasolacrimal duct obstruction. The silicone tubes were removed around 6 months after the DCRs, and patients were examined 1 month after tube removal. Anatomical patency was evaluated by a nasal endoscopic dye test and lacrimal syringing test. Tearing symptoms were evaluated using Munk’s scoring system. Patients were divided into 2 groups according to the presence of epiphora symptom; a functional success and functional failure group, and the incidence of functional failure were calculated. Potential associated factors were also compared between 2 groups. ResultsThis study involved 50 eyes of 34 patients, and 8 eyes of 6 patients showed significant epiphora in spite of anatomical patency (16% functional failure). We compared associated factors between 42 functionally successful and 8 functionally failed DCRs. Among variables studied, demographic factors and intraoperative surgical findings were not statistically different between the 2 groups. With respect to intranasal endoscopic findings, the shape of the rhinostomy showed significant differences between the 2 groups (p = 0.03, Fisher’s exact test). In the functional failure group, there were no flat shape rhinostomies. Three showed alcove shape rhinostomies, and the other 5 showed cavern shape rhinostomies. ConclusionsAmong anatomically patent DCRs, the incidence of persistent epiphora was 16%. The shape of rhinostomy is a possible associated factor for functional failure after external DCR.

Transcanalicular Diode Laser Assisted Dacryocystorhinostomy in Primary Acquired Nasolacrimal Duct Obstruction

To evaluate the success rate of 980 nm transcanalicular diode laser-assisted dacryocystorhinostomy (TDL-DCR) in patients with primary acquired nasolacrimal duct obstruction (PANDO) and to consider the time and the reasons of failure. Hundred and thirty eyes of 125 patients who underwent of TDL-DCR for the treatment of PANDO are included in this retrospective, noncomparative, nonrandomized, interventional study. The mean follow-up time was 24.29 months (range 8-34 months). Functional success was described as disappearance of epiphora and presence of a patent ostium on lacrimal irrigation. Anatomical success was described as a patent ostium to irrigation but continuing epiphora. Patients with persistent epiphora and a closed ostium were classified as a surgical failure. At third month follow up, 85.4% of cases had complete resolution of their symptoms. The functional success rate decreased to 67.7% at 6 months, to 63.3% at first year, and to 60.3% at second year, while the patency of the lacrimal drainage system was restored in 93.1%, 74.6%, 69.5%, and 68.2% of the cases, respectively. The average total amount of delivered laser energy was 1322.7 J. No correlation could be found between the age of the patient, delivered laser energy, and the surgical success (p = 0.38, p = 0.62). Transcanalicular diode laser-assisted DCR is a fast and relatively easy alternative surgical method, which avoids a facial skin scar, to treat PANDO. The functional success rate is higher in the first months but decreases to low 60 %'s at the end of first year and remains the same at the second-year follow up.

English

PURPOSE: To compare the results of intra-operative Mitomycin C application in DCR surgery compared to external DCR in terms of patency at the end of 6 months. METHODS: The study was conducted in the Department of Ophthalmology, KR Hospital, Mysore between January 2011 to July 2013. 60 patients who were diagnosed as chronic dacryocystitis with the obstruction at the level of the NLD were divided into two groups on the basis of simple random sampling. Thirty cases underwent DCR without Mitomycin C and thirty cases underwent DCR with intraoperative MMC application. RESULTS: The study results were tabulated in terms of symptoms (tearing), tear meniscus height and lacrimal syringing patency at the end of 6 months post-operatively. CONCLUSION: Distinctly higher success rates were achieved in patients undergoing DCR with intra- INTRODUCTION: Blockage of nasolacrimal duct (NLD) commonly presents with persistent bothersome epiphora and many a times discharge from the affected eyes. It may be congenital or acquired. The acquired variety presents more commonly in fifth to seventh decade of life, affecting women three times more than men 1,2,3,4. Chronic tear stasis and secondary infection occurring in this condition can lead to acute exacerbations of dacryocystitis, mucocele, chronic conjunctivitis, corneal ulcer, orbital cellulitis in untreated cases and panophthalmitis in cases having undergone intraocular surgeries 2,5. Medical treatment consists of topical antibiotic administration and massage over lacrimal sac area which is helpful for most cases of congenital NLD obstruction only in first six months of life. But definitive treatment for chronic NLD obstruction in adults is Dacryocystorhinostomy.

Pediatric endonasal endoscopic dacryocystorhinostomy

ObjectiveNasolacrimal duct obstruction is a relatively common problem among children. Although spontaneous resolution is possible and various conservative treatment options are available, dacryocystorhinostomy is recommended for persistent epiphora. The aim of this study was to report our experience of performing 83 procedures of pediatric endoscopic dacryocystorhinostomy. MethodsThis retrospective study included 71 children who underwent endonasal endoscopic dacryocystorhinostomy between 2000 and 2011. Thirteen of these children had bilateral procedures. The diagnosis of nasolacrimal duct obstruction was based on the presence of eye discharge, the patient's history obtained from his or her parents and the results of testing the patency of the nasolacrimal canal by irrigating the lacrimal sac. The procedure was considered to be successful if the patient's eye discharge was completely resolved and the dacryocystorhinostomy ostium was patent at end of the postoperative first year. ResultsEighty-three dacrycystorhinostomy procedures were performed in 71 children. There were 35 (49.3%) male and 36 (50.7%) female patients. The age of the patients ranged between 11 months and 14 years, with a mean of 8.9 years. The mean follow-up period was 27.1 months (range of 14–84 months). The overall success rate for primary endoscopic dacryocystorhinostomy was 92.7%. No major complications were encountered in any of the surgical procedures. ConclusionPediatric endonasal endoscopic dacryocystorhinostomy is a safe and effective procedure to correct nasolacrimal system obstruction in cases that are unresponsive to conservative treatments. It has a high success rate and a low incidence of complications.

Effect of lacrimal silicone intubation in persistant epiphora after an anatomically successful but functionally failed dacryocystorhinostomy (Mansoura technique)

Purpose To investigate the effectiveness of lacrimal silicone intubation for management of epiphora in patients who had undergone a dacryocystorhinostomy (DCR) (the Mansoura technique) with anatomical success but with functional failure. Patients and methods The study included 20 patients (six men and 14 women, one of them bilateral) who experienced persistent epiphora after an anatomically successful primary external DCR (Mansoura technique) and who underwent lacrimal silicone intubation through the previous DCR site. Results The mean patient age was 40 years (range 20–60 years) and mean follow-up duration was 10 months (range 6–14 years). Epiphora was resolved in 18 patients following silicone intubation. Conclusion Lacrimal silicone intubation is an easy and effective procedure for patients with epiphora after an anatomically successful external DCR Mansoura T-tube technique.

Chronic Rhinosinusitis and Lacrimal Obstructive Disease

Objective: To investigate if chronic inflammatory sinus disease has a pathogenic role in the obstructive pathology of the neighboring lacrimal system, including obstruction alone and chronic or recurring dacryocystitis. Method: One hundred patients were selected for endoscopic DCR because of persistent epiphora and/or chronic or recurrent dacryocystitis. Their sinus CT scans were evaluated using the Lund-Mackay score.The nonoperated side and a further group of 30 head trauma patients were the control groups. Results: No statistically significant differences were found in either presence or absence, or even disease extension or location, of image defined inflammation of the sinuses and obstructive pathology of the lacrimal system, including chronic or recurring dacryocystitis. DCR sides and patients do not have higher scores of sinonasal disease than nonsurgical sides or normal subjects. Conclusion: These results lead to the conclusion that chronic inflammatory sinus disease is a comorbidity that very likely does not play a pathogenic role in any form of obstructive disease of the lacrimal system.

Outcomes of Dacryocystorhinostomy in Patients With Head and Neck Cancer Treated With High-Dose Radiation Therapy

To evaluate the outcomes of dacryocystorhinostomy (DCR) in patients with head and neck cancer treated with high-dose radiation therapy. The clinical records of 43 consecutive patients with head and neck cancer who underwent DCR after high-dose external beam radiation therapy plus ablative surgery and/or chemotherapy between December 2001 and April 2011 were retrospectively reviewed. There were 23 men and 20 women. The median age was 56 years (range, 2-92 years). Thirty-one patients were Caucasian, 6 Hispanic, 4 Asian, and 2 African American. Thirty patients (70%) presented with epiphora, 3 (7%) with dacryocystitis, and 10 (23%) with both epiphora and dacryocystitis. Symptoms were unilateral in 34 patients (79%) and bilateral in 9 patients (21%). The most common primary cancer diagnoses were squamous cell carcinoma (n = 14), sarcoma (n = 8), adenoid cystic carcinoma (n = 4), and basal cell carcinoma (n = 4). The most common primary tumor locations were the sinonasal cavity (n = 16), maxillary sinus (n = 9), palate (n = 3), and ethmoid sinus (n = 3). Thirty-seven patients (43 eyes) had DCR with silicone tube placement, and 6 patients (7 eyes) had DCR with Pyrex glass tube placement. Following DCR, 31 patients (72%) had resolution of their symptoms, and 12 patients (28%), 9 with silicone tubes and 3 with Pyrex glass tubes, had persistent or recurrent epiphora (DCR failure). The most common reason for failure was significant residual canalicular and nasal mucosal scar tissue. Eight of these 12 patients underwent additional surgery, most commonly with placement of a Pyrex glass tube. Seven (35%) of the 20 patients who underwent DCR less than 12 months after radiation therapy and 5 (21%) of the 23 patients who underwent DCR at least 12 months after radiation therapy had recurrent symptoms. Dacryocystorhinostomy in patients with head and neck cancer previously treated with high-dose radiation therapy is generally successful, especially when delayed until at least 12 months after the completion of radiation therapy. A common reason for DCR failure after high-dose radiation therapy is severe canalicular and nasal mucosal scarring.

Silicone Intubation for the Treatment of Epiphora in Adults With Presumed Functional Nasolacrimal Duct Obstruction

To evaluate the long-term efficacy of silicone intubation in adults with presumed functional nasolacrimal duct obstruction. This retrospective cohort study reviewed adults with unilateral or bilateral epiphora and presumed functional nasolacrimal duct obstruction treated with silicone intubation and followed for signs of treatment failure (defined as persistent epiphora or need for a secondary procedure). Median time to event (failure) after silicone intubation was calculated using Kaplan-Meier survival analysis. Analysis was conducted at the level of the individual eye, with clustering by person taken in account. Cox proportional hazards models were used and adjusted for within-subject variance using a robust sandwich estimator. Forty-four eyes from 30 patients with isolated functional nasolacrimal duct obstruction underwent silicone intubation for epiphora. Mean time to stent removal in 40 of 44 eyes was 4.0 (±4.1) months. Mean duration from the time of stent placement to last follow-up was 2.6 (±2.0) years. Overall success after silicone intubation for resolution of symptoms was 77%. Kaplan-Meier survival analysis for time to event after silicone intubation yielded a median time of 5.7 years. Extrapolated data demonstrated a 96% success rate at 2 years and 85% success rate at 3 years and predicted approximately 50% of patients to have relief of epiphora between 5 and 6 years after silicone intubation. In this study, silicone intubation has good long-term success for relief of epiphora in patients with presumed functional nasolacrimal duct obstruction. This study provides important clinical information to guide management of epiphora in adults with functional nasolacrimal duct obstruction.

Rezidivierende Canaliculitis bei einem 22-Jährigen

A 22-year-old patient presented with persistent epiphora over a period of about 7 months. The clinical examination revealed a canalicular swelling in both lacrimal ducts, which postoperatively transpired to be an exophytic tumor. The histopathology result of the excised tumor showed an epithelial lesion, a partially inverted papilloma without malignancy. For tumors arising from lachrimal ducts the first-line therapy is complete tumor resection.

Endocanalicular Diode Laser Dacryocystorhinostomy for Nasolacrimal Duct Obstruction

To evaluate the results, complications, effectiveness, and operative results of the endocanalicular laser dacryocystorhinostomy (ECL DCR) in the distal obstructions of the lacrimal drainage system. Sixty eyes of 57 patients who had a diagnosis of distal obstruction of the lacrimal drainage system were evaluated retrospectively in this study. All patients underwent ECL DCR by diode laser between October 2008 and July 2009. Forty-nine patients (86%) were females, 8 patients (14%) were males, and age distribution was between 3 and 84 years old (median, 40 y). The canaliculi were intubated by a silicone tube. The patency of the nasolacrimal system was controlled by lacrimal lavage, loss of epiphora, and endoscopic evaluation of the endonasal rhinostomy site with routine follow-up scheduled at first day and 1-week, 1-month, and 3-month postoperative intervals. After the 60 ECL DCRs, 10 patients underwent revision ECL DCR because of the persistent epiphora. The patency of the nasolacrimal duct or the decrease of the symptoms was assigned as success. There were no symptoms at all in 83.3% of the patients. The ECL DCR in the treatment of the distal obstructions of the lacrimal drainage system was easily tolerated by the patients, cosmetically preferred because there was no incision and scar formation with high success rates, and a minimally invasive alternative technique.

Anatomischer und subjektiver Erfolg einer strukturierten chirurgischen Therapiestrategie zum Management der chronischen Epiphora – eine postoperative Zufriedenheitsanalyse

Epiphora is the result of hypersecretion or reduced tear outflow because of relative or absolute obstruction of the lacrimal system. For the treatment a specific surgical procedure is usually required. Herein we present the subjective and objective findings of 243 consecutive patients with non-irritative induced epiphora, who underwent an operation in a standardised therapy scheme, which is used at the eye departments of the Universities of Lübeck and Würzburg. In a retrospective cohort study 243 patients were included who underwent lateral tarsal strip (n = 72), external dacryocystorhinostomy (DCR) in the case of an absolute nasolacrimal duct obstruction (NLDO) (n = 116) and relative NLDO (n = 25), DCR with canalicular surgery (n = 18) and simple canalicular surgery (n = 12) with a follow-up of at least 6 month. Common patient and cosmetical satisfaction, intensity of symptoms and further symptoms of 168 patients were evaluated by sending a questionnaire with subsequent telephone survey. Objective findings were recorded from hospital charts. 59.5% of the patients were free of complaints, 19.6% had an absolute decrease of symptoms (epiphora outside and in windy weather) and 20.8 % persistent epiphora (symptoms both in- and outside persisted). 81% of patients with absolute NLDO and 57% with relative NLDO were graded as being free of symptoms, 7% (24%) as a relative decrease and 12% (19%) as a persistence of symptoms. There was a significant difference in success between these indications (p = 0.018). Patency of the lacrimal system assessed by irrigation was found in 95% (absolute NLDO). Commonly, 73.8% were satisfied, 7.7% indifferent and 18.4 % not satisfied. 4 patients were cosmetically not satisfied. Use of a standardised therapy scheme reduces the symptoms in 79.1% of the patients. In patients with absolute NLDO external DCR achieves an anatomic success rate of 95% and a subjective improvement in 88% with excellent cosmetic results. In comparison with absolute NLDO the success rate of relative NLDO is lower, but still with a subjective improvement in 81%. Our results show that postoperative success depends on the preoperative cause of the epiphora.

Watery Eye Following Patent External DCR: An MR Dacryocystography Study

Purpose: To examine patients with persistent watery epiphora following patent external dacryocystorhinostomy (DCR) with magnetic resonance imaging dacryocystography (MR-DCG).Methods: Patients with unobstructed nasolacrimal irrigation following external DCR were included. Five patients with watery epiphora constituted the study group (SG). Five patients without epiphora constituted the control group (CG). All patients underwent MR-DCG following the instillation of artificial tears in the conjunctival fornix. The osteotomy site was identified in T1-weighted coronal images. Lacrimal flow was assessed with modified T2-weighted (True Fast Imaging Steady State Pulse, “TrueFISP”) coronal images before and 10 min after repeated blinking. Signal intensities at three regions of interest (ROIs), corresponding to the eyeball (ROI-1), conjunctival sac (ROI-2), and anastomotic site (ROI-3) were measured.Results: Differences in the diameter of both osseous and soft tissue ostia between SG and CG were statistically not significant. A post-blink increase in signal intensity at ROI-3 was noted in both groups, whereas differences in signal intensity for ROI-1 and ROI-2 were statistically not significant. The post-blink signal intensity increase in ROI-3 was significantly more pronounced in the CG, compared with the SG.Conclusions: The fact that signal intensity increase at ROI-3 was less pronounced in the SG, compared with CG, implies a compromised “lacrimal pump” mechanism in the former group. The methodology presented may be used for the evaluation of post-DCR epiphora.

Lacrimal Drainage System Obstruction

The lacrimal drainage system consists of the lacrimal puncta, inferior and superior canaliculi, common canaliculus, lacrimal sac, and nasolacrimal duct. It is classically divided into upper and lower portions. Obstruction of the drainage system can be congenital or acquired, and may result in persistent epiphora and mucopurulent discharge. This paper discusses the etiology, clinical picture, diagnosis, and surgical treatment of lacrimal drainage system obstruction.

Endoscopic revision of external dacryocystorhinostomy failure

To evaluate the usefulness of endoscopic analysis and surgery of the lacrimal sac in cases of external dacryocystorhinostomy (DCR) failure. In a retrospective study, 17 endoscopic procedures in 17 patients during 11 years with recurrent lacrimal obstruction after external DCR were performed. Endoscopic analysis and procedures were carried out with a routine silicone tube catheterization for 3 to 6 months. In 13 patients, scar tissue was the cause of the obstacle, while in 3 patients an unsuitable location of the ostia and in 1 case an inflammatory polyp were found. After a long-term follow-up (56 months), the epiphora was controlled in 94% of the cases. The mean delay between the first DCR and the recurrence of epiphora was 22 months. A persistent or recurrent epiphora can be explored after an external procedure and treated by endoscopic procedure. The endonasal approach for DCR was considered safe, and effective particularly in patients with unsuccessful external DCR.

Sebaceous Carcinoma of the Eyelid Metastasizing to the Lacrimal Sac after 5 Years

ABSTRACTEyelid sebaceous carcinoma metastasizing to lacrimal sac is rare. A 65 year old female underwent excision with 5 mm margins and Cutler-beard reconstruction for a nodulo-ulcerative mass showing eyelash loss in the middle third of the right upper eyelid. Histopathology confirmed it to be sebaceous carcinoma with uninvolved margins. Five years after primary excision, the patient presented with persistent epiphora and mass in the ipsilateral lacrimal sac region. Repeat excision biopsy and conjunctival map biopsy confirmed recurrent sebaceous carcinoma of the lacrimal sac. Thirteen months after adjuvant radiotherapy to the orbit, the patient is alive and well with no loco-regional recurrence.

Primary Non-Hodgkins Lymphoma of the Lacrimal Sac: Mortality-Related Epiphora

ABSTRACTWe report a case of primary non-Hodgkins lymphoma of the lacrimal sac in a 60-year-old Asian lady, who presented with persistent epiphora and recurrent medial canthal swelling. Primary lymphoma of the lacrimal sac is rare and it can be easily misdiagnosed. Delayed in diagnosis may be related to mortality. To minimize the risk of overlooking specific pathology it is important to assess the appearance of the lacrimal sac and its surrounding structures intraoperatively. Biopsy of the lacrimal sac is required in cases where specific pathology is suspected.

Centurion Syndrome: Clinical Presentation and Surgical Outcome

ABSTRACTPurpose: To describe the clinical signs and outcome of surgery in cases with Centurion syndrome and highlight the clinical presentation of this syndrome. Methods: A retrospective review of records of patients with Centurion syndrome who underwent surgery between January 2002 and July 2007. The position of the punctum, nasal bridge prominence, Hertel exophthalmometry and the presence of inferiorly directed sharp angulation of the medial canthus was noted. The patients underwent anterior canthal tendon release, punctoplasty or medial conjunctivoplasty or a combination of these. Results: Of the 13 cases, 10 had been treated medically elsewhere. The mean age of onset was 20.7 years. Most of the patients were male 10 (76.9%). A prominent nasal bridge was demonstrable in 9 (69.2%) patients and sharp inferior angulation of the medial canthus, the ‘beak’ sign was present in 9 (69.2%) cases. Anterior canthal tendon release alone was performed in 4 patients, in combination with punctoplasty in 5 and with conjunctivoplasty in 4. Watering resolved in 10 patients. 3 patients who had a combination of anterior canthal tendon release and punctoplasty had persistent but asymptomatic epiphora. Discussion: Centurion syndrome is characterised by the abnormal anterior insertion of the medial canthal tendon with displacement of the punctum out of the lacrimal lake. Most cases present with unexplained watering. Surgical management by anterior canthal tendon release with or without conjunctivoplasty or lower lid retractor plication is usually successful.