Endoscopically assisted balloon dacryoplasty treatment of incomplete nasolacrimal duct obstruction

PURPOSE: To report the success rate of endoscopically assisted balloon dacryoplasty (EADCP) for treatment of acquired incomplete nasolacrimal duct obstructions (NLDOs). DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Records of patients treated for incomplete NLDOs with EADCP by one of the authors (WLW) were reviewed. Diagnosis of incomplete NLDO was based upon subjective complaints of tearing, dye disappearance testing, clinical evidence of epiphora, and nasolacrimal duct irrigation. Endoscopically assisted balloon dacryoplasty was performed for incomplete obstructions identified. METHODS: One hundred forty-two nasolacrimal systems in 103 patients with incomplete NLDOs underwent EADCP for treatment of incomplete obstructions. A 3x15-mm balloon was utilized in all procedures, with silicone lacrimal tubes placed in 131 systems. Patients received postoperative topical antibiotic-steroid drops for 2 weeks and a 1-week tapering dosage of systemic methylprednisolone. MAIN OUTCOME MEASURES: Patients were assessed at their last postoperative visit by nasolacrimal system irrigation, dye disappearance testing, and subjective complaints of epiphora. RESULTS: Eighty systems (56%) experienced complete resolution of symptoms after surgery. Forty-eight additional systems (34%) showed improvement but still experienced periodic epiphora. Fourteen systems (10%) showed no improvement. The average time before follow-up was 7.5 months. CONCLUSION: Endoscopically assisted balloon dacryoplasty as a treatment for incomplete NLDOs provides complete relief or substantial improvement in a significant percentage of patients. Nasal videoendoscopy adds significantly to the understanding of this procedure and its potential for success. Endoscopically assisted balloon dacryoplasty should be considered an appropriate treatment option for selected patients with incomplete NLDOs.     

Nonendoscopic endonasal dacryocystorhinostomy: Outcome in 134 eyes

Aims:To evaluate the outcome of nonendoscopic endonasal dacryocystorhinostomy (NEN-DCR) in patients with nasolacrimal duct obstruction (NLDO) in India.Methods:Retrospective case series of NEN-DCR between July 2012 and October 2014. All patients had follow-up >3 months. Success was defined anatomically as patency on irrigation and functionally as relief from epiphora.Results:A total of 122 patients (134 eyes; 81 female; mean age 37 ± 18 years) were included. Indications were primary acquired NLDO in 92 (68%) eyes of adults (>18 years), NLDO in children (<18 years) in 22 eyes (16%), acute dacryocystitis in 13 eyes, failed prior DCR in six eyes, and secondary acquired NLDO in one eye. Mean duration of surgery was 36 min (range: 16–92). At a median follow-up of 6 months (range: 3–15), 86% eyes had functional success and 85% had anatomical success. Revision NEN-DCR was successful in 13/16 eyes. All patients with acute dacryocystitis were completely symptom-free at final visit. In children, (17/22) 77% achieved functional success after primary NEN-DCR which improved to 100% after one revision. Tube-related epiphora and granuloma in ten eyes resolved after removal.Conclusion:NEN-DCR gives good outcome in primary NLDO and is also effective in those with acute dacryocystitis and in children with NLDO. The technique obviates the need for an endoscope and has an acceptable safety profile and thus may be particularly suited for the developing nations.     

Nasolacrimal duct obstruction secondary to ectopic teeth

OBJECTIVE: To describe two patients with nasolacrimal duct obstruction (NLDO) caused by ectopic eruption of teeth. The literature concerning nasal and other unusual ectopic sites of tooth eruption is reviewed. DESIGN: Two interventional case reports and literature review. PARTICIPANTS: A 3-year-old girl with epiphora and recurrent dacryocystitis of the right eye. Previous medical and surgical management was unsuccessful. A 32-year-old female with a long history of right eye discomfort and epiphora. Previous examinations and workup were negative. INTERVENTION: A computed tomographic (CT) scan of the orbits and sinuses was performed in both patients. The ectopic teeth were surgically removed. MAIN OUTCOME MEASURES: Nasolacrimal system function and response to treatment at the last follow-up were recorded. RESULTS: In the first patient, CT imaging disclosed two teeth within the right inferior meatus compressing the nasolacrimal duct. In the second patient, CT revealed a large dental structure in the maxillary sinus compressing the nasolacrimal duct. Endoscopic tooth extraction and nasolacrimal duct probing in the first patient and surgical removal of the dental structure in the second patient effected complete resolution of symptoms. Both patients were symptom free at last follow-up. CONCLUSIONS: These cases suggest that ectopic eruption of teeth should be added to the differential diagnosis of NLDO. Surgical removal of the ectopic teeth compressing the nasolacrimal duct results in resolution of the lacrimal drainage obstruction.     

Paediatric endoscopic endonasal dacryocystorhinostomy in congenital nasolacrimal duct obstruction

Objectives The objectives of this study were to report a series of paediatric patients who underwent endoscopic endonasal dacryocystorhinostomy (DCR) for primary congenital nasolacrimal duct obstruction (NLDO).Methods This is a retrospective, noncomparative review of all consecutive cases in two lacrimal clinics between January 1999 and October 2004. The main outcome measures were patients’ demographics, previous treatments, clinical presentation, operative and postoperative complications, postoperative follow-up and resolution of epiphora.Results Twenty-one patients (15 males) with a mean age of 6±3.5 years (range, 2–14 years) underwent 26 endoscopic DCR operations for congenital NLDO. Sixteen cases were unilateral, and five were bilateral. In 13 cases (50.0%), there was a history of epiphora and chronic dacryocystitis with or without a mucocele. Two cases (7.7%) presented with acute dacryocystitis, and 11 (42.3%) had only a history of epiphora. Previous procedures included probing and irrigation in 25 cases (96.2%) and insertion of Crawford tubes in 19 cases 973.1%). During a mean postoperative follow-up period of 18±8 months, the anatomical success rate (free flow of fluorescein sodium and patency of ostium on nasal endoscopy) was 100%, and the clinical success rate (resolution of epiphora) was 92.3%.Conclusion Endoscopic endonasal DCR is an effective treatment modality for congenital NLDO that compares favourably with the reported success rates of external DCR.     

Endoscopic dacryocystorhinostomy following head and neck radiation therapy

This article determines the efficacy of endoscopic dacryocystorhinostomy (endoDCR) in patients who have undergone adjuvant external beam radiation therapy (XRT) following head and neck cancer resection. A retrospective chart review was performed on all patients who underwent endoDCR between 2006 and 2014 at a tertiary referral center. Cases were reviewed and selected for the following inclusion criteria: history of adjuvant sinonasal XRT following head and neck cancer resection, preoperative probing and irrigation demonstrating nasolacrimal duct obstruction (NLDO), postoperative probing and irrigation following silicone tube extubation. Exclusion criteria included active dacryocystitis, postoperative follow-up of less than 4 months, presence of epiphora prior to XRT, lack of probing/irrigation at preoperative or postoperative visit, and lid malposition including ectropion, facial palsy, and/or poor tear pump. Six patients (7 eyes) met the selection criteria. EndoDCR was performed at a mean time of 30 months following last radiation treatment (range, 3–71 months). Mitomycin C was used in 4/7 cases. Silicone tube removal occurred between 3–8 months postoperatively. Five out of 6 patients had postoperative sinonasal debridement and nasal saline/corticosteroid irrigation. Five out of 6 patients (83%) had both resolution of epiphora and anatomic patency confirmed by probing and irrigation. Our experience suggests that endoDCR procedures can be effective in patients with NLDO following prior sinonasal XRT for head and neck neoplasms. Postoperative management with sinonasal debridement and combined saline/corticosteroid nasal irrigation may help to improve surgical success in patients with increased post-radiotherapy mucosal inflammation.     

Lacrimal sac dacryoliths: predictive factors and clinical characteristics.

OBJECTIVE: Lacrimal sac dacryoliths are often diagnosed during dacryocystorhinostomy (DCR), although their cause is unclear. Several factors have been suggested to predispose to dacryolith formation. The clinical presentation of nasolacrimal duct obstruction (NLDO) may differ if associated with a dacryolith. Our study evaluated specific risk factors related to dacryolith formation and how the clinical presentation of patients with dacryoliths differs from patients with primary acquired NLDO who undergo DCR. DESIGN: Retrospective, comparative, interventional case series. PARTICIPANTS/INTERVENTION: One hundred thirty-eight consecutive patients with NLDO who underwent DCR (163 total DCR cases) between 1993 and 1998. MAIN OUTCOME MEASURES: We evaluated the frequency of dacryolith formation for all DCR cases. For 115 patients with primary acquired NLDO, we statistically compared the patients with dacryoliths (n = 12) to those without (n = 103) for several variables related to clinical history and presentation. RESULTS: The overall frequency of dacryoliths was 12 of 163 (7.4%) for all DCR cases and 12 of 138 (8.7%) for all patients. All patients with dacryoliths were in the subgroup of 115 patients with primary acquired NLDO, and the frequency in that subgroup was 12 of 115 (10.4%). There was no statistical difference between the group of patients with dacryoliths and those without dacryoliths for age, duration of epiphora, history of acute dacryocystitis, or previous use of antiglaucomatous topical medications. Male gender was more likely to be associated with dacryoliths (P = 0.004), as was initial presentation with lacrimal sac distension (P < 0.001). Partial nasolacrimal obstruction on lacrimal irrigation approached statistical significance for dacryolith formation (P = 0.08), as did a history of cigarette smoking (P = 0.09). CONCLUSIONS: In patients with primary acquired NLDO who require DCR, male gender and presence of sac distension are more frequently associated with dacryoliths. Partial NLDO and history of cigarette smoking may also be relative risk factors for dacryolith formation. These observations may be helpful in the evaluation and surgical planning for patients with lacrimal obstruction.     

Associated morbidity of nasolacrimal duct obstruction—a large community based case–control study

Background

To evaluate the prevalence and risk factors of various conditions among patients with nasolacrimal duct obstruction (NLDO).

Methods

A retrospective, observational case control study of 2,615 patients diagnosed with NLDO in the Central District of Clalit Health Services HMO in Israel, from 2003 to 2012; 15,650 control patients were randomly selected from the district HMO members. Medical and socio-demographic information were extracted from patients’ electronic medical records. The prevalence of various ocular and systemic conditions as risk factors for NLDO was calculated.

Results

The average age of NLDO patients was 68.3?±?14.9 years, 34.4 % were male. Age (p?<?0.001), ischemic heart disease (OR?=?1.29; CI: 1.15–1.44), glaucoma (OR?=?1.17; CI: 1.01–1.36), allergic conjunctivitis (OR?=?3.59; CI: 3.28–3.94), dry eye (OR?=?1.43; CI: 1.31–1.58), epiphora (OR?=?6.34; CI: 5.09–7.91), and allergic rhinitis (OR?=?1.51; CI: 1.33–1.71) were significantly associated with NLDO. Smoking (OR?=?0.86; CI: 0.77–0.96) was significantly less prevalent among NLDO patients.

Conclusions

The etiology of NLDO is multifactorial. The prevalence of associated demographic, systemic, and periocular conditions varies. A better understanding of the patho-physiological association between these factors and NLDO may help its prevention and treatment.     

Silicone intubation with intraoperative mitomycin C for nasolacrimal duct obstruction in adults: a prospective, randomized, double-masked study

PURPOSE: To assess the efficacy of intraoperative mitomycin C (MMC) during silicone intubation (SI) as a substitute for dacryocystorhinostomy (DCR) in nasolacrimal duct obstruction (NLDO). METHODS: In this prospective, double-masked study, 88 patients with complete NLD obstruction who were candidates for DCR were randomized in 2 groups. All study patients underwent SI with application of MMC or placebo in a randomized, double-masked fashion, with the former receiving 0.2 mg/mL for 2 minutes before SI. RESULTS: After a mean follow-up interval of 8 months, 25 of the 43 eyes in the MMC group and 21 of the 44 eyes in the placebo group had a successful outcome and were free of tearing and discharge. No significant difference was noted between the 2 groups (p = 0.331). In patients with simple epiphora and less than 6 months of duration, SI alone was effective in 83% of patients; however, in the same group, MMC application during SI did not show beneficial effect over SI alone. But in patients with simple epiphora of 6-months duration or longer, the application of MMC during SI resulted in better efficacy compared with SI alone. The success rates in the patients that had chronic dacryocystitis was lower (23%) compared with patients that had only epiphora (63.7%). CONCLUSIONS: SI alone could effectively substitute for a more extensive procedure such as DCR in patients with simple epiphora, particularly those with newly developed symptoms. In cases with longer duration of symptoms of epiphora, application of MMC would increase the success rate significantly.     

Nasolacrimal duct obstruction secondary to dermatofibrosarcoma protuberans

OBJECTIVE: To describe a patient wtih dermatofibrosarcoma protuberans causing a nasolacrimal duct obstruction (NLDO). DESIGN: Case report. PARTICIPANT: A 33-year-old female with an NLDO. RESULTS: We report a patient with NLDO as the presenting sign of a rare tumor of the skin, dermatofibrosarcoma protuberans. The patient presented with epiphora, and after dacryocystorhinostomy was done, histopathology revealed dermatofibrosarcoma protuberans. The clinical course, magnetic resonance imaging, and histopathology are discussed. CONCLUSION: Obstruction of the lacrimal drainage system can be seen with dermatofibrosarcoma protuberans.     

Trephination and silicone stent intubation for the treatment of canalicular obstruction: effect of the level of obstruction

PURPOSE: To investigate the efficacy of canalicular trephination and silicone stent intubation procedure for relief of epiphora according to the level of obstruction within the canaliculus. METHODS: The medical records of 32 patients (41 eyes) who underwent canalicular trephination followed by silicone stent intubation of the nasolacrimal system for the treatment of canalicular obstruction were retrospectively reviewed. Canalicular obstruction was diagnosed on preoperative irrigation and probing. Level of obstruction was confirmed by intraoperative probing. Proximal obstruction was classified as those within 4 mm of the punctum, distal obstruction as those 5 mm or greater from the punctum, and common canalicular obstruction as those 10 mm or greater from the punctum. Silicone stents were kept in for a minimum of 5 months, and outcome was based on symptomatic relief of epiphora at the end of follow-up (minimum of 6 months). Partial relief of epiphora was defined as improved symptoms and at least a fair clearance on fluorescein dye disappearance testing. RESULTS: On average, 49% of eyes had complete relief of epiphora, 38% had partial relief, and 13% had no relief. Eighty percent of eyes with distal lower canalicular obstructions had complete relief of epiphora and 20% had partial relief of epiphora. Eyes with distal bicanalicular obstructions had 66% complete and 33% partial relief. Patients with common canalicular obstructions had 59% complete, 29% partial, and 12% no relief. Proximal bicanalicular obstructions were the least successful, with 55% partial relief and 45% no relief. CONCLUSIONS: Success of canalicular trephination and silicone stent intubation for treatment of canalicular obstruction is based on the site of obstruction. Distal monocanalicular obstructions have the highest degree of symptomatic epiphora relief, followed by distal bicanalicular, common, and proximal obstructions.     

Lacrimal intubation during dacryocystorhinostomy utilizing the STENTube

The traditional use of the Crawford tube for lacrimal intubation during dacryocystorhinostomy (DCR) carries several drawbacks. We describe the use of the STENTube for DCR intubation and detail its advantages. Retrospective, noncomparative, interventional case series; 313 patients with nasolacrimal duct obstruction (NLDO) underwent 339 DCRs (216 external, 123 endonasal) with the STENTube from January 2007 – June 2013 by 5 surgeons (RS, QN, TS, SB, TN) across 3 institutions (SUNY Downstate Medical Center, Texas Oculoplastics Consultants, and Moorfields Eye Hospital). Study outcome measures included patient demographics, surgical complications, and epiphora improvement/resolution. 206 (66%) females and 107 (34%) males had a mean age of 63 years (range 2–94 years). Distribution of diagnoses included: 314 complete idiopathic acquired NLDO, 20 partial idiopathic acquired NLDO, and 5 congenital complete NLDO. 316 (93%) were primary DCRs and 23 (7%) were revisions. Epiphora improved in 312 (92%) cases with 294 (86%) experiencing resolution with patent lacrimal irrigation at a mean last follow-up of 9.4 months. Twenty-eight (8%) patients experienced surgical complications with 16 (5%) experiencing tube prolapse, and 20 (6%) requiring re-operation. The STENTube represents a simple method for lacrimal intubation during external or endonasal DCR at a comparable cost to the Crawford tube. It allows for low prolapse rates without the need for additional endonasal fixation procedures, resulting in a simple and comfortable post-operative extraction without risk of lacrimal trauma. The STENTube is our preferred intubation technique during DCR, and should be considered by oculofacial surgeons performing DCR with intubation.     

Endonasal Dacryocystorhinostomy for Nasolacrimal Duct Obstruction in Patients with Sarcoidosis

Abstract

Purpose: To evaluate the outcomes of endonasal dacryocystorhinostomy (EN-DCR) surgery in patients with sarcoidosis.

Methods: Retrospective chart review of all patients with sarcoidosis undergoing EN-DCR in 6 practices from 1999–2011.

Results: We included 18 procedures in 14 patients (8 female, 6 male) who underwent EN-DCR for acquired NLDO secondary to sarcoidosis. The mean age was 53.7 (range 38–82). The presenting symptom in all cases was epiphora. Eight patients (57%) complained of having additional nasal congestion. Surgery was performed using endoscopic powered-type DCR with flaps in 12/18 (67%) and non-endoscopic mechanical EN-DCR in 6/18 (33%). In 15 (83%) cases the lacrimal sac and nasal mucosa appeared abnormally yellowish, crusty, oedematous and friable. Five patients were treated with pre-operative oral steroid and overall 8 patients had oral prednisolone post operatively, 30–60?mg tapered within 10 days–8 weeks. One patient had difficulties in tapering down the oral steroids at 6 months of follow-up. All patients were free of epiphora and patent to syringing, with nasal endoscopy revealing free flow of fluorescein through the ostium at a mean follow-up of 11.3 months (median follow-up 9 months).

Conclusions: All 18 cases of acquired nasolacrimal duct obstruction secondary to sarcoidosis were treated successfully with EN-DCR. An abnormal appearance of the nasal mucosa is an important sign. Nasal congestion is a frequent sign. A successful outcome may not depend on intensive long-term therapy with local or systemic steroids. Mechanical or powered EN-DCR for nasolacrimal duct obstruction secondary to sarcoidosis achieves encouraging medium-term outcomes.     

应用小梁咬切器行泪点咬切成形术治疗泪点膜

目的探讨手术显微镜下应用小梁咬切器行泪点咬切成形和联合双泪小管置管术治疗泪点膜覆盖及泪点膜闭的效果。方法36例（48眼）泪点膜覆盖和泪点膜闭,按照泪点膜的基底部占泪点口径圆周的范围由小到大分为4组,第1组8例（9眼）,采用小梁咬切器在显微镜下行单纯泪点咬切成形术;第2组16例（23眼）;第3组7例（9眼）;第4组5例（7眼）。第2、3、4组采用小梁咬切器咬切成形联合双泪小管人工泪管置管术。3个月后拔除人工泪管,拔管后随访6～12个月。结果4组均取得了较为良好的效果,溢泪症状完全消失者30例（42眼）,占87．5％;好转4例（4眼）,占8．3％;无效2例（2眼）,占4．2％。其中第1组治愈7例（8只眼）,占88．8％,好转1例（1眼）,无无效病例。第2、3、4组共治愈24例（34眼）占87．1％,好转各组1例（1眼）共3例（3眼）,第3组、第4组无效各1例（1眼）。结论手术显微镜下应用小梁咬切器行泪点咬切成形术和必要时联合双泪小管人工泪管置管术是治疗泪点膜覆盖及泪点膜闭的一种损伤小、疗效好、成功率高的方法。     

Endoscopic dacryocystorhinostomy in children.

BACKGROUND: Persistent nasolacrimal duct obstruction (NLDO) often requires treatment by probing, intubation, or balloon dacryoplasty. Refractory cases have been managed by external dacryocystorhinostomy (DCR), which leaves a scar; however, this procedure is generally avoided in young children. Endoscopic DCR has been successfully performed in adults and described in children. We report the success of this procedure in a series of pediatric patients. METHODS: A retrospective review of all endoscopic lacrimal procedures performed in a 3-year period was undertaken. Seventeen children (22 ducts) with persistent NLDO after at least one failed probing, with or without silicone tube placement, underwent endoscopic DCR. Follow-up ranged from 6 to 36 months, and success was defined as resolution of tearing and discharge by follow-up clinical evaluation and by parental history. RESULTS: All but 2 patients (88%) with NLDO showed complete resolution of tearing and discharge. These 2 patients had recurrent symptoms after the Crawford tubes were removed and required revision endoscopic DCR. No complications from this procedure were noted. CONCLUSIONS: Endoscopic DCR is a safe and effective means of treating persistent NLDO in infants and young children when simple probing, intubation, or balloon procedures have failed. The team ophthalmology-otolaryngology endoscopic approach provides a highly successful alternative for patients with a persistent distal obstruction that might otherwise require an external procedure.     

Retrospective safety study of the herrick lacrimal plug: a device used to occlude the lacrimal canaliculus.

PURPOSE: The purpose of this study was to evaluate the safety of the Herrick Lacrimal Plug (HLP) (Lacrimedics, Eastsound, WA) by reviewing medical records obtained from patients in whom the HLP was implanted. METHODS: A total of 228, primarily dry-eye, patients who had received one or more HLP implants at 19 centers during 1994 were included in the review; both centers and patients were randomly selected for inclusion. Medical records were examined for evidence of adverse events, which were characterized by presumed relationship to treatment, time of occurrence, severity, treatment required, and clinical outcome. Patients were contacted by phone whenever possible to verify the accuracy of the information extracted from their medical records. RESULTS: A total of 35 adverse events likely, or definitively related to treatment, were recorded for 25 (11.0%) of 227 evaluable patients who were followed for 0 to 4.6 years (mean, 0.9 years). The most common adverse event was epiphora (21), followed by plug displacement (7), ocular irritation (5), ocular pain (1), and headache (1). Sixteen (7.0%) patients (15 epiphora, 1 headache) had one or more plugs removed using a perfusion technique, with symptoms resolving for 13 patients, reduced for one but persisting for the remaining two. None of the baseline or treatment variables were found to be predictors of the occurrence of an adverse event following plug implantation. DISCUSSION: Approximately 10% of the patients who underwent implantation with the HLP in this series presented with a device-related adverse event, most commonly epiphora, which usually resolved following plug removal with a saline perfusion method. For the two patients (0.9%) whose epiphora did not resolve following plug removal, both had the same symptom before plug implantation, so it is unclear if persistence was the result of plug retention in the lacrimal drainage system or merely continuation of a preexisting condition.     

Transcanalicular dacryocystorhinostomy with diode laser: long-term results

PURPOSE: To evaluate the effectiveness of transcanalicular dacryocystorhinostomy with diode laser in treatment of epiphora in adults. METHODS: A prospective, noncomparative, interventional case series of transcanalicular dacryocystorhinostomy in 25 patients presenting with epiphora due to nasolacrimal obstruction. Patient age ranged from 32 to 72 years. Patients were evaluated postoperatively at 12, 24, and 36 months. Patients were evaluated for symptom improvement through a visual analog scale, and patency of osteotomy by lacrimal system irrigation with fluorescein and direct visualization by nasal endoscopy. Success was defined as resolution of epiphora. RESULTS: Transcanalicular dacryocystorhinostomy was able to re-establish patency of the lacrimal system in 88% of cases after 36 months of surgery. No differences were found between patients older than 65 years and younger patients (chi-square, p > 0.05). Early (12 months) and late (36 months) results were similar (chi-square, p > 0.05). CONCLUSIONS: In this prospective series, transcanalicular dacryocystorhinostomy was effective in treatment of epiphora in adults with little morbidity.     

Etiology, diagnosis, management and outcomes of epiphora referrals to an oculoplastic practice

AIM: To investigate the etiology, diagnosis, management and outcome of epiphora referrals to an oculoplastic practice. METHODS: Retrospective chart review of patients referred for epiphora to an oculoplastic clinic between 2005 and 2009. Patient demographics, past history, ophthalmic examination, treatment and outcome were analyzed. RESULTS: There were 237 subjects with a primary complaint of epiphora. They included 130 (55%) females and 107 (45%) males with an average age of 55.9±25.9y. The most common cause of epiphora was lacrimal obstruction (46%); followed by multifactorial epiphora (22%), reflex tearing (22%) and eyelid malposition (11%). Differences in prevalence of etiology were noted in terms of age and gender distribution. Of the 182 (77%) patients who returned for follow up, 41 (23%) reported a complete resolution and 102 (56%) reported a significant improvement in their symptoms. CONCLUSION: Epiphora is a common condition with many causes. A thorough history and examination are required to provide the appropriate treatment tailored to the underlying cause.     

Transconjunctival dacryocystorhinostomy: Long term results

Purpose

To evaluate the outcomes of transconjunctival dacryocystorhinostomy (TRC-DCR) surgery in patients with epiphora due to primary acquired nasolacrimal duct obstruction (PANDO) at second year follow-up.

Methods

In this retrospective, interventional study, 33 eyes of 29 patients, with epiphora due to PANDO, are included. Lower eyelid conjunctiva is incised at vestibulum inferomedially to access the lacrimal sac and nasal mucosa. Bone is perforated with burr and rongeurs and saccal and nasal flaps are anastomosed. Conjunctival wound edges are apposed and left unsutured. Intraoperative difficulties, surgical time and complications are noted. Average follow-up time was 2 years. Anatomical success was defined as patent lacrimal passages upon irrigation and functional success was defined as relief of epiphora.

Results

In nineteen (57.6%) eyes the surgeries were completed with the anterior and the posterior flaps sutured. In eight eyes (24.2%) only anterior flaps could be sutured. In 6 eyes (18.2%), the surgical procedure was converted to external dacryocystorhinostomy since the nasal mucosa could not be exposed adequately via transconjunctival route. The mean surgical time was 65.1 min. One patient had a millimeter long lower eyelid margin laceration in one eye (3.7%) intraoperatively due to traction for visualization of the operative site.Epiphora resolved in 25 of 27 eyes (92.5%) in whom TRC-DCR could be completed. Epiphora and failure to irrigation were noted in two eyes (7.4%) at the postoperative 4th and 8th months, respectively and required reoperation. No complications occurred, except granuloma formation at the conjunctival incision site in three eyes (11.1%).Epiphora resolved in all the six eyes of patients who underwent an external DCR (100%).

Conclusion

Transconjunctival dacryocystorhinostomy is a scarless dacryocystorhinostomy technique which is performed without endoscope and/or laser assistance, with 92.5% success rate comparable to external DCR at the second year follow-up without major complications.     

Palpebral dacryoadenectomy for epiphora

The efficacy of palpebral dacryoadenectomy (PDA) to relieve epiphora was studied in 37 patients. Symptomatic relief and postoperative Schirmer testing was used in the evaluation. The technique is described. All patients had patent lacrimal excretory systems: 62% of patients undergoing lacrimal lobectomy had complete relief of epiphora; 19% had some improvement, but incomplete relief; 76% had postoperative decrease in their Schirmer testing; and 14% had postoperative foreign body sensation and some degree of dry eye.     

Treatment of Frey's syndrome (gustatory sweating) and 'crocodile tears' (gustatory epiphora) with purified botulinum toxin

PURPOSE: To determine whether purified botulinum toxin might be as effective in the treatment of "crocodile tears" (gustatory epiphora) as it has been in the treatment of other hypersecretion syndromes such as Frey's syndrome (gustatory sweating). METHODS: One patient with Frey's syndrome (gustatory sweating) was successfully treated with botulinum toxin. After this, two patients with chronic symptomatic crocodile tears (related to previous facial palsy) were treated with botulinum toxin injections into and around the lacrimal gland. RESULTS: Both patients reported remarkable relief from symptoms and were observed to have no tearing while eating. CONCLUSIONS: Purified botulinum toxin appears to be an effective treatment for crocodile tears.