Punctal Agenesis Research Articles

Buried Probe in Complex Congenital Nasolacrimal Duct Obstructions: Clinical Profiles and Outcomes.

To report the clinical profiles and outcomes of buried probe variant of complex congenital nasolacrimal duct obstruction (CNLDO). Retrospective chart review of all patients endoscopically diagnosed as a buried probe variant of complex CNLDO, over a 3.5 year period from a single surgeon's (MJA) database were included in the study. A detailed lacrimal system evaluation was performed and intraoperative findings including nasal endoscopy were documented. A minimum follow up of 3 months following the final intervention was considered for analysis. Anatomical and functional success of the interventions was assessed at the final follow up. Twenty-two eyes of 21 patients with buried probes were studied. The mean age at presentations was 41.2 months. Epiphora and discharge were the commonest presenting symptoms noted in 77.2% (17/22). Associated lacrimal anomalies include punctal agenesis, incomplete punctal canalization and atonic lacrimal sac. All patients underwent irrigation and probing under nasal endoscopic guidance. Further, 3 patients underwent endoscopic dacryocystorhinostomy for persistent CNLDO. At a mean follow up of 4.9 months, the final anatomical and functional successes were noted in 90.9% and 81.8%, respectively. Buried probe is a variant of complex CNLDO, noted more commonly in older children. Endoscopic guidance is crucial for its diagnosis and satisfactory outcomes.

Lacrimal and nasal masquerades of congenital nasolacrimal duct obstructions: etiology, management, and outcomes.

The purpose of this study was to report various conditions masquerading as congenital nasolacrimal duct obstruction (CNLDO). Retrospective review was designed in a tertiary hospital setting. 92 eyes of 65 consecutive patients were included in this study. All patients presenting with CNLDO symptomatology but where the diagnosis of CNLDO was subsequently ruled out were included in the study. The study patients were recruited from a single surgeon's (MJA) tertiary eye care practice over a 3-year period from 2011 to 2013. A detailed clinical evaluation and a further lacrimal system evaluation were performed under general anesthesia. The main outcome measure was other lacrimal and nasal conditions masquerading as CNLDO. Average age at presentation was 43.49 ± 31.78 months. All cases had symptoms of either watering or discharge with an increase tear meniscus or abnormal fluorescein dye disappearance test. The commonest masquerades of congenital nasolacrimal duct obstruction include incomplete punctal canalisation (27.2 %), functional epiphora (14.1 %), punctal agenesis (14.1 %), monocanalicular obstructions (10.8 %), and presaccal stenosis (8.7 %). Each masquerade was managed specifically and at the last follow-up of 5.85 ± 10.85 months, 63 % eyes (58/92) had no epiphora and 2.2 % (2/92) eyes had occasional epiphora. Parents of patients with punctal agenesis were counseled for option of conjunctivodacryocystorhinostomy in future. Incomplete punctal canalisation is the commonest masquerade among many conditions that may mimic CNLDO and mandates a careful evaluation. Specific management of each masquerade results in satisfactory outcomes.

Congenital Optic Nerve Pit in Trisomy 18

The authors report the first case of trisomy 18 associated with a clinically detectable optic nerve pit. A female infant with a birth weight of 2,150 g was born by cesarean section to a healthy 40-year-old woman at 38 weeks of gestation. Trisomy 18 had been diagnosed by prenatal genetic testing. Ophthalmologic examination was remarkable for bilateral narrowed palpebral fissures with punctal agenesis, corectopic pupils without reaction to light, bilateral inferior peripapillary retinochoroidal hypopigmentation, and significant optic nerve cupping in the left eye with associated temporal optic nerve pit. It has generally been accepted that optic nerve pits are a congenital anomaly. However, the pathophysiological background of optic nerve pits remains unclear and controversial. This is the first clinical and photographic documentation of an optic nerve pit in a neonate and in Edwards syndrome. [J Pediatr Ophthalmol Strabismus 2013;50:e24–e26.]

Endoscopically guided minimally invasive bypass tube intubation without DCR : Evaluation of drainage and objective outcomes assessment

Aim: To report a series of 15 consecutive patients with complete proximal bicanalicular obstructions managed with endoscopically guided minimally invasive placement of bypass tubes without a dacryocystorhinostomy (DCR), their indications, interventions, complications and objective and uniform assessment of outcomes. Material and methods: Fifteen consecutive patients presenting with complete proximal bicanalicular obstructions were included in a retrospective, non-comparative case series. Medical records were reviewed for demographic data, etiology, symptoms at presentation, type of bypass tube used, length of the tubes, duration of follow-up, class of lacrimal drainage, patency of the tube, resolution of symptoms, complications and their outcomes. Results: The mean age at presentation was 18.7 years (range: 10-32 years). The most common indication was punctal agenesis (46.6%) followed by complete proximal bicanalicular block secondary to trauma (26.6%). All patients presented with epiphora. The most common bypass tube was a straight Jones variety (60%). The mean length of the bypass tubes was 21 mm (range 19-24 mm). All patients were followed up for a mean duration of 9.6 months following surgery (range 7-13 months). The majority of the patients were post-operatively objectively classified into type I lacrimal drainage (66.6%). At the last follow-up, the success rate was 86.6%. None of the tubes extruded but were removed in two patients due to peritubal soft tissue infection and conjunctival pressure necrosis. Conclusion: Endoscopically guided minimally invasive placement of a bypass tube without DCR is an easier and effective alternative to the traditional conjunctivodacryocystorhinostomy and is likely to help in avoiding major complications of tube extrusion and malpositions seen with the latter procedure. Objective evaluation of lacrimal drainage helps in typifying and uniformly assessing the outcomes.

Punctal and canalicular agenesis presented with congenital nasolacrimal duct obstruction

Punctal and canalicular agenesis presented with congenital nasolacrimal duct obstruction

Retrograde intubation dacryocystorhinostomy for proximal and midcanalicular obstruction

Objective Retrograde intubation of canaliculi during dacryocystorhinostomy can restore canalicular patency in cases otherwise managed with bypass tubes. The surgical technique and success for this procedure are discussed. Design A retrospective, noncomparative case series with clinic or telephone interview for long-term follow-up of patients’ symptoms. Participants One hundred two patients who had undergone this particular lacrimal drainage surgery at Moorfields Eye Hospital between 1992 and 1997. Intervention All patients underwent a dacryocystorhinostomy and retrograde canaliculostomy while under general anesthetic. Main outcome measures Relief or reduction of epiphora and discharge. Results One hundred twenty-three lacrimal systems of 102 patients were included. There were 53 females and 49 males, with ages at surgery ranging from 6 to 83 years (mean, 49 years). The etiology was idiopathic (30%), herpetic canaliculitis (24%), punctal agenesis (18%), and trauma (11%); less-common causes included dacryocystitis, Stevens-Johnson syndrome, eczema, and prior radiation therapy. Both upper and lower canalicular systems were involved in the majority (73%) of patients, and in 13 (11%) systems a dacryocystorhinostomy had previously been performed. The silicone tube was placed for a mean of 2 months (range, 1 week–9 months), and the mean postoperative follow-up was 8 months (range, 2–24 months). Epiphora subjectively improved in 90 (73%) of 123 systems, of which 27 (22%) of 123 were asymptomatic. In 33 systems (27%) in which epiphora persisted, 14 (11%) have undergone closed placement of a Jones canalicular bypass tube with control of symptoms. Conclusions Retrograde canaliculostomy and intubation can spare a significant number of patients the long-term inconvenience of Jones tubes. Failure of this technique does not, however, compromise or complicate the future placement of a bypass tube.

Orbital cyst of nasolacrimal duct derivation: a late complication of dacryocystectomy

Dacryocystectomy was a commonly used operation for dacryocystitis before dacryocystorhinostomy became more popular. At present, the major use of this procedure is for tumors of the lacrimal sac and less frequently for correction of chronic dacryocystitis in the elderly. Although the operation has a relatively low rate of complications, scarring in the medial canthal area, recurrent infections in the lacrimal sac fossa, regeneration of the lacrimal sac and recurrence of the malignancies may occur postoperatively.A 29-year-old woman who had undergone removal of her right lacrimal sac for dacryocystitis eleven years ago presented with a mass in the right lacrimal sac region. She had had bilateral epiphora since childhood. Ocular examination showed a non-tender, cystic mass in the right medial canthal region. She had upper and lower punctal agenesis bilaterally. Computed tomography demonstrated a soft tissue mass located medial to the globe that extended to the proximal nasolacrimal duct. The lesion was excised completely via anterior orbitotomy and submitted for histopathologic examination.Hematoxylin-eosin stains revealed a cystic cavity lined by pseudostra-tified columnar epithelium with cilia, consistent with a cyst derived from the nasolacrimal duct epithelium.The development of an orbital cyst as a potential complication after dacryocystectomy is presented. The proliferation of the remaining nasolacrimal duct epithelium played a role in the etiopathogenesis.

Congenital Absence of the Lacrimal Puncta.

Boerner, M.; Seiff, S. R.; Arroyo, J.Editor(s): Arterberry, Joe F. M.D., F.A.C.S., Editor Author Information

Congenital Absence of the Lacrimal Puncta

We report seven cases of congenital absence of the lacrimal puncta, a condition that may be either an isolated finding or associated with other developmental anomalies. General pediatric evaluation of two patients with punctal agenesis revealed no additional abnormalities; these cases were managed by probing and silicone intubation. The other five cases were associated with other significant, clinically obvious abnormalities; several of these patients required more aggressive management of their lacrimal disorders, including dacryocystorhinostomy and conjunctivo-dacryocystorhinostomy. Previous reports support the impression generated by this series that otherwise normal appearing children with congenital absence of the lacrimal puncta do not require an extensive work-up. Probably many children with absent puncta are asymptomatic and remain undiagnosed.

Paediatric dacryocystorhinostomy

Of 258 cases of dacryocystorhinostomy performed on children in the period September 1981 to September 1991, 130 were for simple, unresolved congenital nasolacrimal duct obstruction. Other indications for surgery included punctal agenesis, lacrimal fistula, post-traumatic and post-inflammatory canalicular obstruction. Of 177 children without canalicular pathology, 171 (96%) were relieved of symptoms with one operation, without canalicular intubation. Of 81 cases with canalicular disease, 55 of 70 (79%) who underwent DCR plus canalicular intubation, and 10 of 11 who underwent DCR plus Lester-Jones tube, were substantially improved with one operation. No child required peroperative or postoperative blood transfusion. Dacryocystorhinostomy in childhood, in experienced surgical hands, is a safe procedure, achieving relief of symptoms in most cases, particularly in the absence of canalicular disease.

The Management of Punctal Agenesis

Agenesis of one or more lacrimal puncta is a rare cause of presentation to ophthalmologists. Where normal canalicular tissue lies within the lid, it may occasionally be successfully exteriorized to the conjunctival surface with relief of symptoms. The pattern of punctal agenesis, its relationship to the presence of underlying canalicular tissue, and its management have not been defined previously in a large cohort. The authors reviewed the pattern of agenesis, underlying anatomic abnormalities and patient symptomatology in 57 patients seen over a 10-year period. A management plan was devised for eyes with no puncta and those with a single missing punctum. Both puncta were absent in 53 eyes, and a single punctum was missing in 41 eyes. In 86% of eyes with absence of both puncta, no canalicular tissue was identified when the lacrimal sac was opened at surgery. The underlying canaliculus also was absent in patients with one absent punctum. Nasolacrimal duct obstruction frequently accounted for the onset of symptoms in patients with a single punctum. Fifty-three (93%) of the 57 operated eyes were functionally cured at the completion of this report. Punctal agenesis usually is associated with the absence of underlying canalicular tissue. Where both puncta are absent, the authors recommend inspection of the internal opening of the common canaliculus at surgery and, if no canalicular tissue can be identified (86% in this series), insertion of a Lester-Jones tube. Symptomatic patients with a single punctum frequently require surgery to relieve nasolacrimal rather than canalicular obstruction.

Lacrimal Surgery in Children

Of 142 children who underwent major lacrimal surgery (160 dacryocystorhinostomies, one congenital fistula excision, one dacryocystectomy, and one canaliculostomy), 49 had congenital nasolacrimal duct obstruction (34%). Lacrimal obstruction was also associated with canaliculitis, punctal agenesis, trauma, congenital fistula, dacryocystitis, craniofacial defects, and functional eyelid abnormalities. Although the timing and technique of the surgery varied according to the abnormalities, an overall functional success rate of 90% (144 of 160 procedures) was achieved.