Nasolacrimal duct obstruction associated with radioactive iodine therapy for thyroid carcinoma

A 50-year-old woman presented with a 5-year history of unilateral epiphora that began shortly after 131I therapy for thyroid carcinoma. A recent recombinant human thyroid-stimulating hormone (Thyrogen) scan had shown a focus of uptake adjacent to the right eye that was initially thought to be a possible metastasis. Probing and irrigation revealed complete blockage of the right nasolacrimal duct. The patient underwent a right dacryocystorhinostomy (DCR) and biopsy of the lacrimal sac. Histopathologic examination of the lacrimal sac and nasal mucosa revealed foreign-body reaction and fibrosis with no malignant cells. A repeat Thyrogen scan after DCR showed no residual focus of activity in the nose or near the lacrimal sac and confirmed reestablishment of lacrimal drainage on the right side. This case demonstrates that 131I therapy for thyroid carcinoma can be associated with nasolacrimal duct obstruction. The appearance of a focus of uptake near the lacrimal sac on Thyrogen scanning in a patient with a history of thyroid carcinoma may not be due to a new focus of metastasis and may indeed be due to pooling of 131I in the lacrimal sac due to nasolacrimal duct blockage.     

Anatomie und Physiologie der ableitenden Tränenwege

The human nasolacrimal ducts consist of the upper and lower lacrimal canaliculi, the lacrimal sac and the nasolacrimal duct and drain tear fluid from the ocular surface into the nose. The lining epithelium of the lacrimal sac and the nasolacrimal duct is lined by microvilli supporting the hypothesis that tear fluid components are absorbed. Based on its composition epithelial secretions fulfill functions in tear transport and antimicrobial defense. Further defense mechanisms are displayed by IgA and defense cells which show a special intraepithelial and subepithelial distribution. Moreover, tear duct-associated lymphoid tissue (TALT) is present, displaying the cytomorphological and immunophenotypic features of mucosa-associated lymphoid tissue (MALT). The mechanisms of tear outflow are not yet resolved and several hypotheses exist. Significance is attributed to the lacrimal part of the orbicularis eye muscle surrounding the canaliculi, the helically arranged system of connective tissue fibres and the cavernous body that surrounds the lacrimal sac and the nasolacrimal duct. Moreover, the cavernous body has a function in protecting the lacrimal passage and is active during emotions.     

Treatment of nasolacrimal duct obstruction in adults with polyurethane stent

PURPOSE: To evaluate the efficacy of polyurethane nasolacrimal duct stents in the treatment of epiphora resulting from primary acquired nasolacrimal duct obstruction in adults. MATERIALS AND METHODS: In 25 patients (21 women and four men with mean age of 44 years, range 20 to 74 years) with nasolacrimal duct obstruction, 28 hollow polyurethane stents designed by Song and associates were placed under fluoroscopic guidance. The obstruction was complete in 20 lacrimal drainage systems and partial in eight. The lacrimal sac size was normal or large on dacryocystogram in all lacrimal drainage systems. A Ritleng probe was introduced through the upper punctum and advanced past the obstruction. A guide wire with a flexible tip was then introduced through the probe, over which the stent was advanced in retrograde fashion and placed into the lacrimal sac and nasolacrimal duct. Clinical success was defined by the demonstration of a completely patent lacrimal drainage pathway through saline irrigation and no or minimal complaint of epiphora. RESULTS: Stent placement was technically successful in 26 of 28 lacrimal drainage systems (93%). The mean time of fluoroscopy screening was 3.2 minutes (range, 1.4 to 5.8 minutes). The overall success rate was 82% (23 of 28 lacrimal drainage systems). Two stents were completely occluded. In one lacrimal drainage system with minimal epiphora, the stented drainage pathway was partially occluded. The patients were followed up from 4 to 22 months (mean, 7.2 months). CONCLUSIONS: Retrograde placement of a hollow polyurethane nasolacrimal duct stent is a technique that is simple and well tolerated by patients. This method achieves a high success rate and may be suggested as a nonsurgical procedure for adults with primary nasolacrimal duct obstruction and proper lacrimal sac size. The Ritleng probe facilitates the procedure.     

外伤性泪道阻塞的CT检查

目的　探讨外伤性泪道阻塞的CT检查方法并分析其检查结果。方法　采用CT轴位扫描、冠状扫描及三维重建的方法 ,分析 12例泪道外伤的CT检查和结果。结果　CT轴位扫描良好显示泪囊和鼻泪管断面 ,冠状CT显示周围组织合并损伤 ,三维重建则直观显示泪囊窝和上颌骨额突骨折情况。CT显示外伤性泪道病变包括 :泪囊区软组织增厚、密度增高、泪囊扩张 ,泪囊区异常骨碎片影 ;泪囊窝和鼻泪管凹陷性、粉碎性和线性骨折 ;鼻泪管密度增高。结论　泪道CT轴位扫描、冠状扫描及三维重建可良好显示泪道及其周围组织的外伤情况 ,可用于诊断和进行手术设计。     

正常泪道和泪道阻塞的CT检查

目的观察正常泪囊和鼻泪管以及泪道阻塞的CT表现。方法对32例正常泪道CT片及19例泪道阻塞患者CT表现进行观察分析。结果对正常泪道轴位软组织窗CT扫描图像进行分析:泪囊78.1%显影、21.9%不显影,鼻泪管均可显示;显影的泪囊和鼻泪管可分为双侧含气影、双侧黏膜影、一侧含气一侧黏膜影。4例泪道占位病变CT显示:泪囊区高密度影,鼻泪管扩张增粗,管内组织高密度。9例外伤后泪道阻塞CT显示:泪囊区软组织增厚,泪囊扩张或密度增高,泪囊区异常骨碎片影,鼻泪管骨折和阻塞。6例泪囊和鼻泪管炎症CT表现:泪囊区软组织增厚、密度增高,鼻泪管阻塞和密度增高。结论对正常泪道软组织窗轴位进行CT扫描:泪囊可显影或不显影;鼻泪管均可显影;显影的泪囊和鼻泪管表现为含气影或黏膜密度影。泪道占位、外伤和炎症均可在CT片上明确显示,利于诊断。     

Anatomic position of the common canaliculus in patients with a large lacrimal sac

PURPOSE: To study the canalicular anatomy in patients with an enlarged sac secondary to nasolacrimal duct obstruction. METHODS: This study included 76 lacrimal drainage systems (LDS) of 41 adult patients with a palpable sac, which were visualized using posteroanterior digital subtraction macrodacryocystography. In 42 LDS, there was a palpable enlarged sac secondary to nasolacrimal duct obstruction. In 20 LDS, the sac enlargement was associated with a valve-type canalicular obstruction preventing retrograde reflux of the sac content, and in 22 LDS, there was no associated canalicular obstruction. Thirty-four LDS were either normal or had a nasolacrimal duct obstruction without a palpable sac. RESULTS: Dacryocystography showed a common canaliculus in all LDS. In 35 (83%) of 42 LDS with a palpable sac (17 LDS with and 18 LDS without canalicular obstruction), the anatomic orientation of the common canaliculus in the superior-inferior direction showed a consistent change. The common canaliculus was bending inferiorly with a sharp angle as it was coursing to the sac. In all LDS with a nonpalpable sac, the common canaliculus had an approximately direct, horizontal, or slightly upward course to the sac. CONCLUSIONS: Lacrimal sac enlargement secondary to nasolacrimal duct obstruction changes the anatomic orientation of the common canaliculus. The canaliculus shows an acute, inferior angulation from the superior-to-inferior direction while coursing to the sac in most instances. This anatomic variation should be considered during lacrimal interventions.     

Nasolacrimal duct obstruction caused by a cylindroma. Report of an atypical tumor manifestation and review of the literature

BACKGROUND: The purpose of this report is to describe the clinical characteristics, management and histological findings in a patient with obstruction of the nasolacrimal duct caused by a cylindroma. About 618 lacrimal sac tumours have been reported previously in reviews and case reports, which were reviewed after searching in medline database. CASE REPORT: A 79-year old man suffered from multiple cylindromas (Spiegler tumour) on his head for about 40 years. He presented with a 6 months' history of left-sided epiphora and a painless medial canthal mass of various size. A tumour which caused nasolacrimal duct obstruction was found during dacryocystorhinostomy. After complete excision histological examination revealed a cylindroma, which had shown expansive growth from dermis to the lacrimal sac area. The patient felt well; there was no longer any epiphora or dacryocystitis after the operation. CONCLUSION: Although very rare, lacrimal sac tumours must be considered in the differential diagnosis of nasolacrimal duct obstruction. To our knowledge this case represents the first report on an atypical manifestation on a Spiegler tumour in the lacrimal sac region.     

Nasolacrimal outflow drainage anomalies in Down's syndrome

PURPOSE: To describe structural abnormalities of the lacrimal drainage system and outcomes after treatment for lacrimal outflow obstruction in children with Down's syndrome. DESIGN: Retrospective comparative interventional case series. PARTICIPANTS: Thirty-eight eyes of 22 consecutive Down's syndrome patients who underwent surgical treatment for nasolacrimal drainage obstruction (mean age, 32 months) and 59 eyes of 44 non-Down's syndrome patients who underwent surgical treatment after 2 years of age. MAIN OUTCOME MEASURES: Resolution of symptoms after surgery and presence of anatomic abnormalities of the lacrimal drainage system other than persistent Hasner's membrane. RESULTS: Among the Down's syndrome eyes, complete or partial resolution was noted in 34 (89%) of 38 eyes; 7 (18%) eyes underwent more than 1 procedure. Twenty-eight (74%) of 38 eyes had anatomic anomalies other than persistent Hasner's membrane; anomalies proximal to the nasolacrimal sac predominated. In comparison, 50 (85%) non-Down's syndrome eyes experienced complete or partial resolution, and 19 (32%) had anatomic abnormalities other than persistent Hasner's membrane; anomalies distal to the nasolacrimal sac predominated. CONCLUSIONS: Compared with older non-Down's syndrome patients, nasolacrimal outflow obstruction in Down's syndrome patients is more often complicated by anomalies of the lacrimal drainage system proximal to the lacrimal sac. Despite this, surgery can be similarly successful. Awareness of the possible peculiarities of lacrimal outflow obstruction in Down's syndrome patients may allow better selection and use of available treatment options.     

Nasolacrimal obstruction secondary to I(131) therapy

PURPOSE: To report the finding of nasolacrimal drainage system obstruction associated with I(131) therapy for thyroid carcinoma from an updated and expanded cohort. METHODS: Patients with a history of epithelial derived thyroid carcinoma who had tearing were offered referral for evaluation by an oculoplastic surgeon. Patients underwent nasolacrimal probing and irrigation procedures with localization of their nasolacrimal obstruction. Therapy for the site of obstruction was instituted. RESULTS: Clinically significant tearing was identified in 26 patients, all of whom had previously undergone I(131) therapy (n = 563). Nineteen patients were evaluated and confirmed to have nasolacrimal drainage system obstruction; 7 have yet to be formally evaluated. Areas of obstruction included nasolacrimal duct, common canaliculus, and, rarely, distal upper and lower canaliculi. Patients were treated with a variety of modalities including silicone intubation, balloon dacryoplasty, dacryocystorhinostomy, and conjunctival dacryocystorhinostomy. CONCLUSIONS: The use of I(131) for thyroid carcinoma is associated with a 3.4% incidence of documented nasolacrimal drainage obstruction and an overall 4.6% incidence of documented or suspected obstruction. The true incidence may be higher, since - I(131) treated individuals were neither systematically evaluated nor questioned about tearing. It has yet to be established if the obstructions result from local toxicity caused by the passive flow of radioactive iodine containing tears through these tissues or the active uptake and concentration of I(131) in lacrimal drainage system tissues through the sodium/iodide supporter.     

Clinicopathologic study of lacrimal sac and nasal mucosa in 44 patients with complete acquired nasolacrimal duct obstruction.

We studied 44 patients who had dacryocystorhinostomy for primary acquired complete nasolacrimal duct obstruction. The lacrimal sac and nasal mucosa adjacent to the osteotomy were examined histologically. The lacrimal sac had chronic inflammatory changes in 33 of 37 patients with varying degrees of fibrosis in 34 of 37. Focal ulceration of the lacrimal sac epithelium was present in 15 cases. Goblet cells, present in 11 specimens, were not identified in 26 specimens. Moderate or severe chronic inflammation was found in 14 of 44 nasal mucosal specimens and marked fibrosis in 22. The pathology of the lacrimal sac and nasal mucosa is similar to that of the nasolacrimal duct in complete nasolacrimal duct obstruction. The nasal inflammation may have resulted from dacryocystitis or alternatively contributed to the dacryocystitis.     

Occult oncocytoma of the lacrimal sac

Oncocytoma of the lacrimal sac is a rarely encountered clinical entity. We report the case of a 72-year-old female patient who was diagnosed to have bilateral nasolacrimal duct obstruction during a pre-cataract surgery screening. Subsequently, she underwent bilateral dacryocystectomy. Histopathological examination of the left lacrimal sac revealed a tumour composed of acini lined by oncocytic cells; features consistent with those of a lacrimal sac oncocytoma. Although rare, oncocytomas arising from the lacrimal sac may co-exist with a nasolacrimal duct obstruction. This report describes the histological and immunochemistry characteristics of oncocytomas and underscores the need to subject all excised lacrimal sacs to histopathological examination.     

Inverted papilloma of the nasolacrimal system invading the orbit

A 73-year-old man with a history of epiphora, discharge from the left eye, and left-sided nasal congestion underwent external dacryocystorhinostomy for nasolacrimal duct obstruction. The procedure revealed bony erosion of the majority of the lacrimal sac fossa and a large papillomatous mass filling the lacrimal sac and nasolacrimal duct. Inverted papilloma was diagnosed via biopsy. A subsequent orbitotomy with combined endoscopic medial maxillectomy was performed to remove the mass. This case illustrates the importance of including inverted papilloma, a benign but invasive neoplasm, in the differential diagnosis of nasolacrimal duct obstruction.     

激光指示光引导鼻内镜下手术治疗外伤性鼻泪管阻塞伴泪囊移位

目的 观察通过激光指示光引导定位泪囊，行鼻内镜下泪囊鼻腔吻合手术治疗泪囊移位的方法。方法 对12例（12眼）经CT、MRI或泪囊造影后证实泪骨、鼻骨、或上颌骨鼻突骨折造成鼻泪管阻塞和泪囊移位，在局麻下激光指示光针于上或下泪小管进入泪囊，鼻内镜光源反复打开和关闭以观察指示光最靠近骨窗的最佳位置，切开相应鼻黏膜，做骨窗，然后顺势扩大鼻黏膜和骨窗口，准确找到泪囊后放入泪囊鼻腔引流支架。结果 12眼外伤性鼻泪管阻塞伴泪囊移位采用上述方法均顺利完成泪囊鼻腔吻合手术，术中大大减少了手术探查寻找泪囊带来的鼻黏膜和骨组织过多的损伤，术中患者痛苦少，术后恢复快，鼻腔换药次数减少。结论 激光指示光引导行鼻内镜下泪囊鼻腔吻合手术其定位准确，操作简单，组织损伤少，手术时间短。     

Clinical efficacy of the polyurethane stent without fluoroscopic guidance in the treatment of nasolacrimal duct obstruction

PURPOSE: To evaluate the clinical efficacy of the polyurethane (Song) stent in the treatment of nasolacrimal duct obstruction without fluoroscopic guidance, especially at the junction between the lacrimal sac and nasolacrimal duct or at the nasolacrimal duct. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: This study evaluated 59 cases of nasolacrimal duct obstruction in 53 patients, with mean epiphora of 36 months (range, 2 months-17 years). METHODS: Without the assistance of a radiologist, a polyurethane nasolacrimal stent was placed by introducing a guidewire through the superior or inferior punctum into the canaliculus and advancing it across the obstruction into the opening of the inferior meatus of the nasal cavity. The mean follow-up period was 22 months (range, 12 months-48 months). MAIN OUTCOME MEASURES: Patency of the lacrimal passage to irrigation and the duration of this procedure. RESULTS: Complete resolution of epiphora was accomplished in 55 (93.2%) of the 59 eyes. There was recurrence of epiphora in four cases because of obstruction of the stent in three cases and obstruction of the common canaliculus by recurrent dacryocystitis in one case. CONCLUSIONS: Polyurethane stenting without fluoroscopic guidance seems to be a valuable technique for primary management of nasolacrimal duct obstruction before dacryocystorhinostomy.     

鼻内镜下泪囊鼻腔吻合术联合丝裂霉素C治疗鼻泪道阻塞

目的:探讨鼻内镜下泪囊鼻腔吻合术联合丝裂霉素C(MMC)治疗鼻泪道阻塞的疗效和安全性。方法:选择32例38眼鼻泪道阻塞(或伴泪囊炎、泪囊脓肿)患者,鼻内镜下鼻丘处制成骨孔,切开泪囊并充分翻转泪囊前后瓣,0.1g/L MMC棉球于泪囊吻合口保留48h后取出。结果:术后7d;3,6mo行鼻内镜检查并冲洗泪道。术后7d,治愈34眼,好转3眼,无效1眼,治疗好转率97.4%;术后3mo,治愈32眼,好转4眼,无效2眼,治愈好转率94.7%;术后6mo,治愈32眼,好转4眼,无效2眼,治疗好转率94.7%。所有病例,均未发生鼻出血和眼眶内并发症等术后并发症。结论:鼻内镜下泪囊鼻腔吻合术联合MMC治疗鼻泪道阻塞(或伴泪囊炎、泪囊脓肿)是一种安全有效的治疗方法。     

Comparison of dacryocystography and lacrimal scintigraphy in the diagnosis of functional nasolacrimal duct obstruction

AIM: It appears from the literature that no standardised examination exists for patients with functional nasolacrimal duct obstruction. The role of dacryocystography and lacrimal scintigraphy was compared in the diagnosis and management of these patients. METHOD: Patients who were clinically diagnosed as having unilateral or bilateral functional nasolacrimal duct obstruction were prospectively entered into the study and data collected over 12 months in Moorfields Eye Hospital and Whipps Cross Hospital, London. All cases had, on separate occasions, a standardised dacryocystogram with delayed erect films and a lacrimal drainage scintigram. RESULTS: 45 lacrimal systems of 32 patients (mean age 62 years; 59% male) fulfilled the inclusion criteria. Abnormalities were detected with dacryocystography in 93% of systems and with lacrimal drainage scintigraphy in 95% of systems. Based on the results of previous quantitative studies, the positive scintigrams were subdivided into those demonstrating prelacrimal sac delay (13%), delay at the lacrimal sac/duct junction (35%), or delay within the duct (47%). Combining the two imaging techniques increased the sensitivity to 98%. CONCLUSIONS: Both investigations are very sensitive at detecting abnormalities in patients with a clinical diagnosis of functional nasolacrimal duct obstruction. Lacrimal drainage scintigraphy is a slightly more sensitive test, but missed an abnormality detected by dacryocystography in two (4%) systems. A combination of the two techniques gives the highest sensitivity with maximum anatomical and physiological information but, in clinical practice, it is reasonable to perform a dacryocystogram initially and proceed to scintigraphy only if contrast radiography is normal.     

A multidisciplinary approach to atypical lacrimal obstruction in childhood.

PURPOSE: This study explores the diagnosis and management of unusual anomalies involving the canaliculi, nasolacrimal duct, nasal cavity, and sinuses in childhood. METHODS: A case series of eight children with lacrimal outflow anomalies ranging from distal nasolacrimal duct cyst formation to persistent dacryocystitis following failed probing or silicone intubation were reviewed retrospectively. Diagnostic studies including intranasal endoscopy and preoperative or intraoperative dacryocystography (DCG) were of value. RESULTS: Treatment modalities included endoscopically guided resection of lacrimal cyst mucosa, endoscopic dacryocystorhinostomy (DCR), and monocanalicular or bicanalicular intubation of the lacrimal outflow system. In our series, endoscopic surgery was well tolerated by all patients with improvement in symptoms. CONCLUSIONS: This initial experience suggests that endoscopic techniques may be useful in the management of atypical lacrimal outflow obstruction in childhood.     

CT-泪道造影术（CT-DCG）在泪道阻塞性疾病中的临床应用

目的　探讨CT-泪道造影术（computed tomography-dacryocystography。CT-DCG）在泪道阻塞性疾病中的临床应用价值，进一步明确CT-DCG术前检查的必要性。方法　收集2016年8月至2018年4月因泪道阻塞性疾病就诊于南昌大学附属眼科医院以泪溢为主诉的患者216例（235眼）。所有患者术前均进行泪道CT-DCG检查，每人均行泪道轴位及冠状薄层CT扫描，层厚1 mm，层间距1 mm。轴位上至眶上缘，下至硬腭下鼻道顶；冠状位行多平面重建；从轴位和冠状位观察泪道及周围情况，明确泪道阻塞情况及CT造影征象。结果　本研究216例235眼泪道造影均成功，发现患者均存在泪道阻塞性疾病，其中10例复发性泪囊炎，178例慢性泪囊炎，23例泪囊囊肿，5例外伤性泪囊炎。泪道狭窄6眼；高位阻塞（泪总管以上）5眼；中位阻塞（泪囊阻塞）28眼；低位阻塞（鼻泪管中上段）189眼；极低位阻塞（鼻泪管膜性段阻塞）7眼。结论　CT-DCG可提供泪道阻塞的具体位置和泪囊大小及与周围组织的关系，其检查结果是个性化手术方式选择的重要影像学依据。     

在鼻泪管阻塞性疾病中应用CT测量鼻泪道相关解剖参数的研究进展

鼻泪管阻塞性疾病(NLDOD)是临床发病率较高的一种眼科常见病,是由于炎症或其他原因引起的鼻泪管部分或全部阻塞不通,主要表现为溢泪,继发泪囊炎可出现溢脓,继发泪囊囊肿导致泪囊扩大、内眦肿胀等,开通阻塞的鼻泪管则是治疗鼻泪管阻塞性疾病的关键,明确鼻泪道相关解剖参数在鼻泪管阻塞性疾病的诊断和治疗中显得极为重要。而泪道CT是泪道影像学检查常用方法之一,便于对鼻泪道相关解剖参数进行测量。本文综述近年来在鼻泪管阻塞性疾病中应用CT测量鼻泪道相关解剖参数的研究进展,主要包括鼻泪道及泪囊的经线、面积、体积、角度等,分析总结相关解剖参数与鼻泪管阻塞性疾病的相关性,以便更好地指导临床。