Severe Epiphora Research Articles

Clinical value of dacryoscintigraphy using a simplified analysis

To study the discriminatory ability of dacryoscintigraphy in differentiating between patients with epiphora and volunteers using a simple method. Twenty eyes in ten volunteers and 66 eyes in 55 patients with severe epiphora were studied. Dacryoscintigraphy (15 frames of 1 min) was performed after administration of 4 MBq (99m)Tc-pertechnetate (10 mul) in both eyes. By mapping a single region of interest (ROI) over the conjunctival sac we determined T1 (%dose in first minute) and linear clearance rate (LCR, defined as [see text] from the tracer disappearance curve. Reproducibility was determined in volunteers. Conjunctival resorption was determined from completely obstructed systems. Sensitivity and specificity were calculated and receiver operating characteristics (ROC) analysis was conducted. In volunteers mean T1 was 52.8+/-11.9% (95% CI 47.1-58.4%), and LCR was 74.2+/-11.1% (95% CI 69.0-79.4%). Reproducibility was good (mean difference 4.1+/-13.3% for T1 and 0.7+/-17% for LCR). Epiphora patients had clearly higher T1 (82.1+/-15.2%, P<0.0001) and lower LCR (38.9+/-22.5%, P<0.0001) values. Tracer resorption was 24%. Based on ROC analysis 70% for T1 and 50% for LCR were considered optimal cut-off levels to separate patients from volunteers. Sensitivity/specificity were 77/95% for T1 and 71/100% for LCR. T1 and LCR values did not correlate with symptom scores or Anel test results. Dacryoscintigraphy, using LCR and T1 as parameters, is a reliable and objective method to detect tear-flow abnormalities.

Three-Dimensional Rotational Dacryocystography for Imaging of the Lacrimal Draining System and Adjacent Anatomical Structures

Purpose: A three-dimensional (3D) rotational angiography system was used to perform 3D dacryocystography (3DRD) as an adjunct to the conventional dacryocystography assisted by digital subtraction angiography (DSA). Methods:In 15 patients with severe epiphora, 3DRD was performed after inconclusive results from DSA-assisted dacryocystography. Results:3DRD was technically feasible and well tolerated in all 15 cases. In 5 out of 15 patients, 3DRD, in contrast to DSA-assisted dacryocystography, distinguished clearly between stenotic lesions of the canaliculi, lacrimal sac or nasolacrimal duct. In 10 cases, the simultaneous display of tear ducts and adjacent structures of the nasal cavity provided critical anatomical information for decision making between endoscopic and open dacryocystorhinostomy. Conclusions: 3DRD is technically feasible and adds important information to conventional DSA-assisted dacryocystography.

Severe Blepharoconjunctivitis Induced by a Peeling Mask Containing Trichloroacetic Acid

Purpose: To report a case of severe blepharoconjunctivitis induced by a peeling mask. Methods: A 32-year-old healthy female was examined one day after undergoing a face-peeling procedure with a mask containing trichloroacetic acid. She complained of severe burning, redness, and epiphora in her left eye that started several hours after the procedure. Results: Her vision was LE 0.2, RE 0.8. Mild upper eyelid edema of the right eye and severe edema of the left eyelids, LE inferior ectropion, and LE blepharoconjunctivitis were noted. The conjunctiva was severely hyperemic with papillary reaction and chemosis. The corneas, anterior chambers, irides, lenses, and posterior segments were normal. The patient was treated with Dexamethasone 0.1% q2h and ocular lubrication. The reaction subsided after 3–4 days. Conclusion: Face-peeling masks containing trichloroacetic acid can sometimes severely irritate the eyelids and the ocular surface.

Resolution of Epiphora with Nasolacrimal Stents: Results of Long-term Follow-up in a Multicenter Prospective Study

To evaluate in a prospective, multicenter setting the long-term effectiveness of polyurethane stents in the percutaneous management of epiphora. Patients (n = 426; age range, 19-88 years, mean, 48; 91 men, 335 women) with severe epiphora had stents (470 eyes/496 stents) inserted to treat unilateral or bilateral and complete or partial obstruction of the nasolacrimal system. The etiology of the obstruction was idiopathic in 280 cases (59.5%) and chronic dacryocystitis in 190 (40.4%). The stent set designed by Song was used in all patients, and the original technique was slightly modified by us and conducted on an outpatient basis. The initial technical success rate of stent placement was 95%. The average time of the procedure was 6 minutes (range, 3-70). Resolution of epiphora was complete in 452 eyes and partial in 18. On follow-up (mean, 24 months; range, 1 week to 67 months), 340 of 496 stents remained patent (68.5%). Segregating primary patency by year of follow-up, the rates were 75.6%, 68.4%, 64.8%, 60.1%, and 59.2% in the first, second, third, fourth, and the current (67 months) years, respectively. Minor complications such as moderate pain (21 cases), epistaxis (75 cases), palpebral edema and hematoma (31 cases), and headache (four cases) and two acute dacryocystitis events were recorded. Of the 156 obstructed stents, 114 were withdrawn, and 49 of these patients remained asymptomatic for a mean of 27 months (secondary patency, 31.4%). After stent removal, the sac configuration was unchanged in 93 (81.5%), contracted in 11 (9.6%), and widened in 10 (8.8%) cases. The procedure is simple and safe, both in stent insertion and in withdrawal when occluded. The success rate was >75% in the short term and >55% in the long term. Although not totally without concerns, the technique is attractive for most patients who prefer not to undergo surgery or are unsuitable surgical candidates. Stent failure does not preclude subsequent treatment options and is an excellent first-line treatment of epiphora.

Severe allergic blepharoconjunctivitis induced by a dye for eyelashes and eyebrows

Purpose: To report a case of severe allergic blepharoconjunctivitis induced by a dye for eyebrows and eyelashes. Methods: A 38-year-old healthy female was examined one day after dyeing her eyebrows and eyelashes with a black cream dye intended for this purpose (FDA-approved). The patient complained of severe eye itching, redness, and epiphora. Results: Vision was 20/40 in both eyes; a moderate edema of the eyebrows and eyelid margins was noted. The conjunctiva was severely hyperemic with papillary reaction and chemosis. The corneas, anterior chambers, irides, lenses, and posterior segments were normal. The patient was treated with Dexamethasone 0.1% and ocular lubrication. After five days of treatment, the ocular symptoms improved, her vision returned to 20/20 in both eyes, and the ocular examination was within normal limits. Conclusion: FDA-approved dyes for eyebrows and eyelashes can sometimes irritate the ocular surface.

Treatment of nasolacrimal duct obstruction with polyurethane stent placement: long-term results.

The purpose of this study was to evaluate the long-term efficacy of polyurethane stent placement in adults with nasolacrimal duct obstruction. Polyurethane stents were placed under fluoroscopic guidance in 52 eyes of 49 patients (mean age, 43 years) with severe epiphora due to idiopathic nasolacrimal duct obstruction. The obstruction was complete in 44 eyes and partial in eight. Clinical success was defined as complete resolution of or great improvement in the symptoms of epiphora and the patency of the lacrimal system to irrigation. Mean follow-up was 23 months (range, 14-44 months). Stent placement was technically successful in 50 eyes (96%). The mean fluoroscopy screening time was 2.2 min (range, 0.2-5.8 min). Two patients were lost to follow-up. Clinical success was obtained in 33 (69%) of 48 eyes. Lacrimal symptoms developed in 23 (70%) of these 33 eyes at least once during the follow-up, but these patients responded well to topical drug treatment and lacrimal irrigation. External dacryocystorhinostomy was performed in 13 eyes after failure of the stents. At surgery, lacrimal sacs were shrunken, hyperemic, and fragile in all eyes, making it difficult to anastomose with nasal mucosa. Histologic examination showed granulation tissue and chronic inflammation of the sac epithelium. The success rate of the nasolacrimal stent decreases as follow-up lengthens. After stent treatment, lacrimal symptoms frequently develop, even if the stent remains patent, and require multiple office visits and therapy. The polyurethane stent may induce a chronic inflammatory response in the lacrimal sac, which can interfere with subsequent dacryocystorhinostomy.

Nasolacrimal Stents in the Management of Epiphora: Medium-term Results of a Multicenter Prospective Study

To evaluate in a prospective multicenter setting the clinical utility of polyurethane stents in the percutaneous management of epiphora. Patients (N = 163; age range = 22-85 y, mean = 52 y; 29 men, 134 women) with severe epiphora had stents (n = 183) inserted under fluoroscopic guidance in 180 lacrimal systems (unilateral = 146; bilateral = 17) to treat complete (n = 172) or partial (n = 8) obstruction of the nasolacrimal duct or sac. The junction between sac and duct was the most frequent location (n = 102), followed by the sac alone (n = 48), and the duct alone (n = 30). The etiology of the obstruction was idiopathic in 113 cases (63%) and chronic dacryocystitis in 67 (37%). The set designed by Song was used in all patients and the original technique was slightly modified by the authors. All patients were treated on an outpatient basis. Average time of the procedure was 14 minutes (range = 3-70 min). Initial technical success rate of stent placement was 97%. Resolution of epiphora was complete in 175 eyes and partial in five. On follow-up (mean = 450 d; range = 8-730 d), 157 of 183 stents remained patent (85.8%). Of the 24 obstructed, 19 were easily withdrawn and 17 of these patients remained asymptomatic for a mean of 15 months (secondary patency rate = 89.5%). The procedure is simple and safe. It can be performed on an outpatient basis and the original technique could be improved with some technical modifications. It is well tolerated by patients and may be considered as a valid alternative technique for the resolution of epiphora.

Nonsurgical fluoroscopically guided dacryocystoplasty of common canalicular obstructions.

To assess dacryocystoplasty in the treatment of epiphora due to obstructions of the common canaliculus. Twenty patients with severe epiphora due to partial (n = 16) or complete (n = 4) obstruction of the common canaliculus underwent fluoroscopically guided dacryocystoplasty. In all cases of incomplete obstruction balloon dilation was performed. Stent implantation was attempted in cases with complete obstruction. Dacryocystography and clinical follow-up was performed at intervals of 1 week, and 3, 6, 12, and 18 months after the procedure. The mean follow-up was 6 months (range 3-18 months). Balloon dilation was technically successfully performed in all patients with incomplete obstructions (n = 16). In three of four patients with complete obstruction stent implantation was performed successfully. Subsequent to failure of stent implantation in one of these patients balloon dilation was performed instead. The long-term primary patency rate in patients with incomplete obstructions was 88% (n = 14/16). In three of four cases with complete obstruction long-term patency was achieved during follow-up. Severe complications, infections, or punctal splitting were not observed. Fluoroscopically guided balloon dacryocystoplasty is a feasible nonsurgical therapy in canalicular obstructions with good clinical results that may be used as an alternative to surgical procedures. In patients with complete obstructions stent placement is possible but further investigations are needed to assess the procedural and long-term results.

Dacryoliths: nonsurgical fluoroscopically guided treatment during dacryocystoplasty.

To evaluate dacryocystoplasty with fluoroscopically guided nonsurgical removal of dacryoliths in the treatment of dacryolithiasis. Ten patients with severe epiphora due to partial (n = 8) or complete (n = 2) obstruction of the nasolacrimal duct system associated with dacryolithiasis underwent fluoroscopically guided removal of dacryoliths during dacryocystoplasty. Balloon dilation was performed initially to widen the nasolacrimal duct obstructions and to fragment dacryoliths. This was followed by forced irrigation with saline solution through the canaliculi. In patients with incomplete dacryolith washout, a 6.3-F sheath was advanced in a retrograde fashion into the nasolacrimal sac, and forced irrigation was repeated with aspiration of the fragments through the sheath. In two patients with therapy-resistant dacryoliths, additional fragmentation of the concrements was performed with a gooseneck snare. Removal of dacryoliths was technically successful in all patients (complete removal, n = 6; partial removal, n = 4). During a follow-up period of up to 18 months, complete resolution of epiphora was achieved in five patients, and five patients showed partial resolution of their symptoms. Fluoroscopically guided removal of dacryoliths during dacryocystoplasty is a feasible nonsurgical therapy with good clinical results and may be used as an alternative to dacryocystorhinostomy.

Indications and contraindications of lacrimal duct balloon dilatation

The aim of the study was to determine the indications and contraindications for balloon dacryocystoplasty. So far 85 patients with severe epiphora because of relative stenosis (n = 47) or occlusion (n = 38) of the nasolacrimal duct have undergone dilation. The success rates were evaluated during the acute phase and the follow-up period of 6-12 months. Treatment failures and recurrence of stenosis were analyzed and compared to the clinical and dacryocystographic indications prior to treatment. A recanalization success rate of 79% was achieved in patients with isolated postsaccal stenoses or short-distance occlusions of the nasolacrimal duct. Patients with additional presaccal and saccal stenoses, filling defects in the duct lumen, or long-distance occlusions had lower initial recanalization rates (66%). Main predictors for recurrent obstructions were active inflammation, filling defects due to calculi, extensive occlusion and post-traumatic lesions. In the absence of these factors 12-month patency rates of 80% were proved. Dacryocystoplasty procedures should preferably be performed in patients with circumscribed functional postsaccal stenosis. In these cases a success rate of about 80% is possible. Otherwise the value of the intervention is limited by high failure and recurrence rates.

Balloon dacryocystoplasty: indications and contraindications.

To define the indications and contraindications for balloon dacryocystoplasty. Eighty-five patients with severe epiphora due to partial (n = 47) or complete (n = 38) obstruction of the nasolacrimal duct (NLD) were treated with balloon dacryocystoplasty (DCP). Steerable micro-guide wires with flexible tips were used. Success rates of DCP were evaluated clinically and dacryocystographically during the acute phase and at 6- and 12-month follow-up. Failures and recurrences were correlated with clinical and dacryocystographic indications for treatment. Recanalization was successful in 35 (92%) of 38 patients with isolated focal stenoses (n = 20) or short-distance occlusions (n = 18) of the NLD. Among all 85 patients, recanalization was successful in 25 patients (66%) with complete and 37 patients (79%) with partial obstructions. In the absence of the main predictors for recurrent obstructions (ie, active inflammation, filling defects due to calculi, long-distance occlusions, and posttraumatic lesions), 12-month patency rates were 89% (17 of 19 focal stenoses) and 94% (15 of 16 focal occlusions). Otherwise, reobstruction rate was 46% (12 of 26 cases). Balloon dacryocystoplasty is successful only in select cases. To achieve results comparable to those of operative treatment, the indication should be limited to patients with circumscribed focal stenoses or occlusions of the NLD. Active dacryocystitis, dacryocystolithiasis, and posttraumatic lesions are the main contraindications.

Balloon dacryocystoplasty: an alternative treatment for obstructed tear ducts.

Twenty-two patients with severe epiphora due to relative (n = 13) or absolute (n = 9) stenoses of the nasolacrimal duct were treated by means of radiologically guided balloon dacryocystoplasty. The recanalization was performed with a steerable microguide wire with flexible tip, which was advanced through the lacrimal draining system and manipulated out of the nasal cavity. A 3-mm PTA balloon was then introduced from the nasal site. In 20 of 22 cases the procedure was technically successful. Dacryocystography proved a normal lumen in 9 of 20 patients and an improvement without impairment of flow in another 8 cases. Two months after dilation a clear regression of epiphora could be demonstrated in 17 of 20 patients. The procedure was complicated by the occurrence of 2 reobstructions within the first 3 months; other serious side effects were not observed.

Complete obstruction of the nasolacrimal system. Part II. Treatment with expandable metallic stents.

To evaluate the clinical usefulness of expandable metallic stents for maintenance of the dilated nasolacrimal sac and duct, double stents were implanted under fluoroscopic guidance in seven patients with severe epiphora after failed balloon dacryocystoplasty. Stents were constructed of 0.25-mm stainless steel wire in a cylindrical zigzag configuration of 10 bends. A single stent was 4 mm in diameter when fully expanded and 10 mm long. The stent was placed accurately in all but one patient, in whom a second stent was placed accurately after removal of the dislodged stent with a hemostat under endoscopic guidance. After stent placement, all patients demonstrated complete resolution of epiphora. During follow-up of 4-20 weeks, complete blockage of the stent occurred in one patient. This was treated with intrastent balloon dacryocystoplasty. No stents migrated. Although the long-term validity of this treatment has not been proved, expandable metallic stents seem to be of value in the treatment of complete obstruction of the lacrimal sac and nasolacrimal duct.

Complete obstruction of the nasolacrimal system. Part I. Treatment with balloon dilation.

Fluoroscopically guided balloon dilation in treatment of complete obstruction of the nasolacrimal system was assessed in 39 eyes of 35 patients. All patients had severe epiphora. With nasal endoscopic guidance, a 0.018-inch guide wire was introduced through the superior punctum into the inferior meatus of the nasal cavity and was pulled out through the nasal aperture with a hemostat. A deflated angioplasty balloon catheter was passed retrograde over the guide wire through the inferior meatus until it straddled the stricture. Balloons were dilated with water-soluble contrast medium. No major complications occurred. At 7 days after balloon dilation, epiphora decreased in 22 of 39 eyes; 17 demonstrated complete resolution of severe epiphora, and five showed incomplete resolution. At 2 months, improvement had not been maintained in 10 of the 22 eyes. This technique for treatment of complete obstruction of the nasolacrimal system is simple and safe, but the high failure and recurrence rates in this study are not encouraging.

Epiphora: treatment by means of dacryocystoplasty with balloon dilation of the nasolacrimal drainage apparatus.

A new interventional radiologic procedure was developed for treatment of epiphora. A small-bore, soft-tipped guide wire was introduced through the superior canaliculus and guided under fluoroscopic control through the nasolacrimal drainage system for retrieval through the nasal aperture. A small-bore angioplasty catheter was then introduced in a retrograde direction into the nasolacrimal drainage apparatus and dilated under fluoroscopic control. The procedure was attempted in 18 eyes of 17 patients with moderate to severe epiphora and was technically completed in 16; 13 of these cases demonstrated improvement, with 11 patients showing complete resolution of symptoms. In the three patients whose epiphora did not improve, no worsening of symptoms occurred. These results are preliminary; follow-up ranged from 7 weeks to 6 months. The authors believe that this technique may hold promise in the treatment of epiphora and may obviate the use of more invasive procedures.

Epiphora After Irradiation of Medial Eyelid Tumors

Thirteen patients had severe epiphora after undergoing radiation therapy for medially located basal cell epitheliomas. All 13 had obstructions of both upper and lower canalicular systems, usually in the lateral one-third. Twelve of the patients became symptom-free after dacryocystorhinostomy with the insertion of a Jones tube. The symptoms of one patient who had a medial obstruction were relieved after a canaliculodacryocystorhinostomy.

KERATITIS DUE TO N-BUTYL ALCOHOL

<h3>To the Editor:</h3> —In a recent report (An Unusual Type of Keratitis Associated with the Exposure to N-Butyl Alcohol [Butanol],Arch. Ophth.<b>33</b>: 106 [Feb.] 1945) describing keratitis in 28 workers exposed to n-butyl alcohol (butanol), we overlooked an article by M. Bücklers (Tröpfchenförmige Niederschläge auf der Hornhautoberfläche bei Möbelarbeitern,<i>Klin. Monatsbl. f. Augenh.</i><b>99</b>: 676, 1937) describing what appears to have been the same condition in 7 furniture lacquerers. The causative agent was unknown to Bücklers, since the composition of the lacquer was an industrial secret ; but the author's description of vacuoles ("not larger than 40 microns") situated symmetrically in the epithelium of otherwise clear corneas, the occurrence of severe epiphora, burning and watering of the eyes, and the complete reversibility of the process when the patients stayed away from their work leave little doubt that the keratitis which we described in connection with the use of n-butyl alcohol