Possibilities and limits of minimal invasive lacrimal surgery

Endoscopy of the lacrimal drainage system with miniaturized endoscopes has been possible since 1990 and permits the direct evaluation of the lacrimal drainage system. Additionally, attached instruments permit recanalization in cases of stenosis of the lacrimal drainage system. Both an Erbium-Yag Laser and a miniaturized drill are available, with which a stenosis of the lacrimal drainage system can be opened under endoscopic control. Favorable findings for endoscopic recanalization are stenoses in the area of the canaliculi or the lacrimal sac, for which the success rate of recanalization is approximately 75%. Unfavorable prognostic factors are submucous scar formations due to a dacryocystitis in the patient's history. Endoscopic findings have also improved the understanding of diseases of the lacrimal drainage system. Punctal stenoses causing epiphora often show intact mucous membranes before and behind the stenosis and it is possible to cure these patients without extensive surgical procedures. Micro-surgical procedures and dacryocystorhinostomy complete the spectrum of the endoscopic surgical possibilities in the lacrimal drainage system.     

Possibilities and limits of minimal invasive lacrimal surgery

Endoscopy of the lacrimal drainage system with miniaturized endoscopes has been possible since 1990 and permits the direct evaluation of the lacrimal drainage system. Additionally, attached instruments permit recanalization in cases of stenosis of the lacrimal drainage system. Both an Erbium-Yag Laser and a miniaturized drill are available, with which a stenosis of the lacrimal drainage system can be opened under endoscopic control. Favorable findings for endoscopic recanalization are stenoses in the area of the canaliculi or the lacrimal sac, for which the success rate of recanalization is approximately 75%. Unfavorable prognostic factors are submucous scar formations due to a dacryocystitis in the patient's history. Endoscopic findings have also improved the understanding of diseases of the lacrimal drainage system. Punctal stenoses causing epiphora often show intact mucous membranes before and behind the stenosis and it is possible to cure these patients without extensive surgical procedures. Micro-surgical procedures and dacryocystorhinostomy complete the spectrum of the endoscopic surgical possibilities in the lacrimal drainage system.     

Tumours of the lacrimal passages

BACKGROUND: Tumours of the lacrimal drainage system are rare. There are several surveys and case reports about tumours in different localisations of the lacrimal drainage system. But we could not find any study which considers all localisations of the lacrimal drainage system. The aim of this study is to give a review of the appearance of tumours of the whole lacrimal drainage system seen during 10 years at the university eye clinic in Münster. MATERIALS AND METHODS: We evaluated retrospectively the files of all patients with tumours in the lacrimal drainage system of the university eye clinic in Münster between 1992 and 2002 considering the dignity and type of tumour, the localisation, the symptoms, operation and the anaesthetic procedure. RESULTS: We could find 75 patients with tumours in the lacrimal drainage system, out of which 40 were benign, 25 semi-malignant and 10 malignant tumours. Among the benign tumours were 15 nevus cell nevi, 7 granulation tissue tumours, 5 papillomas, 4 cysts, 1 fibroma, 1 sebborrhoic keratosis, 1 adenoma of secretory duct, 2 inflamed pseudotumours and 2 benign tumours without histopathologic findings. The semi-malignant tumours were exclusively basal cell carcinomas. Among the malignant tumours were 4 lymphomas, 4 carcinomas and 2 malignant melanomas. With regard to the localisation, almost 85 % of all tumours were situated in the upper part of the lacrimal drainage system (upper and lower lacrimal point, upper and lower canaliculus), that means in a location immediately visible for every ophthalmologist. In that site, most of the tumours were of benign or semi-malignant origin. In 15 % of the patients the tumours were located in the lower lacrimal drainage system (lacrimal sac and nasolacrimal duct). More than the half of these tumours were of malignant origin. CONCLUSION: Tumours of the lacrimal drainage system are rare. Almost 85 % are located in the upper part of the lacrimal drainage system (lower and upper lacrimal point, lower and upper canaliculus) and merely 15 % are located in the lacrimal sac and nasolacrimal duct. These tumours mostly become apparent by symptoms like epiphora. One should be aware of the fact that this symptom can always be masqueraded by a tumour.     

泪液引流系统的研究进展

泪液引流是将泪液自眼表引流至鼻腔的过程,它的机制是复杂的,不仅需要眼睑的腺体及肌肉系统的协同,也需要泪液分泌系统及引流系统的共同参与才能发挥。数百年来,泪液引流系统的功能及机制一直受到眼科界的关注,提出了许多代表性的观点,取得了较大的进展,对提高泪道系统疾病的诊疗水平具有重要的临床意义。本文综述了泪液引流系统的解剖背景、机制及目前尚待解决的问题及前景。     

Endoscopic diagnosis of the lacrimal drainage system

Endoscopic study of the lacrimal drainage system is the only way to directly observe the lacrimal sector of the lacrimal drainage system. The first experiments on this subject date from 1979. Recent technological progress has allowed us to test the latest instruments. These experiments have demonstrated the unquestionable progress of endoscopes and their potential contribution to diagnosing lacrimal pathology. However, certain factors still limit their everyday use. Image improvements and low cost will no doubt facilitate its integration in the diagnosis and therapy of the lacrimal drainage system.     

Augen-assoziiertes lymphatisches Gewebe (EALT) durchzieht die Augenoberfläche kontinuierlich von der Tränendrüse bis in die ableitenden Tränenwege

INTRODUCTION: Components of the mucosal immune system (MALT) have been identified in the conjunctiva (as CALT) and the lacrimal drainage system (as LDALT). Their structural and functional relation with the established immune protection by the lacrimal gland is unclear. MATERIAL AND METHODS: Macroscopically normal and complete tissues of the conjunctiva, lacrimal drainage system and lacrimal gland from human body donors were investigated by analysis of translucent whole mounts, and using histology, immunohistology as well as scanning and transmission electron microscopy. RESULTS: A typical diffuse lymphoid tissue, composed of effector cells of the immune system (T-lymphocytes and IgA producing plasma cells) under an epithelium that contains the IgA transporter SC, is not isolated in the conjunctiva and lacrimal drainage system. It is anatomically continuous from the lacrimal gland along its excretory ducts into the conjunctiva and from there via the lacrimal canaliculi into the lacrimal drainage system. Lymphoid follicles occur in a majority (about 60%) and with bilateral symmetry. The topography of CALT corresponds to the position of the cornea in the closed eye. CONCLUSION: These results show that the MALT of the lacrimal gland, conjunctiva and lacrimal drainage system constitute an anatomical and functional unit for immune protection of the ocular surface. Therefore it should be integrated as an "eye-associated lymphoid tissue" (EALT) into the MALT system of the body. EALT can detect ocular surface antigens by the lymphoid follicles and can supply other organs and the ocular surface including the lacrimal gland with specific effector cells via the regulated recirculation of lymphoid cells.     

Lacrimal disease and surgery

The lacrimal drainage system includes the nasolacrimal duct, lacrimal sac, and canaliculi. Stenosis or obstruction at any portion of the lacrimal drainage system or an impaired lacrimal pump may cause bothersome epiphora. Tear stasis may also be associated with ocular or adnexal infections. This article reviews the recent literature pertaining to anatomy and physiology, pathology, and clinical evaluation and treatment, as well as complications of lacrimal drainage-system disorders.     

SURGICAL MANAGEMENT OF THE LACRIMAL DRAINAGE SYSTEM

The physiology of normal tear drainage has been better defined in recent years. Some of the refined techniques developed in the fields of anaesthesia and surgery have been applied to the lacrimal drainage system. The combination of these advances has resumed in more rational and successful treatment of lacrimal drainage abnormalities. A review of these advances is presented with a discussion on the treatment of lacrimal drainage abnormalities.     

Surgical management of the lacrimal drainage system

The physiology of normal tear drainage has been better defined in recent years. Some of the refined techniques developed in the fields of anaesthesia and surgery have been applied to the lacrimal drainage system. The combination of these advances has resulted in more rational and successful treatment of lacrimal drainage abnormalities. A review of these advances is presented with a discussion on the treatment of lacrimal drainage abnormalities.     

泪道阻塞性疾病的ECT观察

应用发射型计算机断层（ECT）影象技术检测56例（98眼）泪道阻塞患者，其中泪小管阻塞10例（18眼），泪囊都阻塞25例（40眼），鼻泪管阻塞21例（40眼），结果表明：ECT诊断泪道阻塞性疾病是一种简便、快速的方法。     

经泪小点泪道内窥镜治疗难治性泪道阻塞性疾病

目的:探讨经泪小点泪道内窥镜治疗难治性泪道阻塞性疾病的疗效,评价其临床应用价值。方法:难治性泪道阻塞患者29例(32眼)于局麻下使用经泪小点泪道内窥镜系统进行泪道检查,并针对阻塞部位进行激光或电钻处理,泪道冲洗通畅后,注入3g/L妥布霉素+1mg/g地塞米松眼膏,术后随访6mo观察疗效。结果:全部患眼泪道均能被有效观察,术中再通率100%,术后随访治愈20眼(62%),好转5眼(16%),无效7眼(22%)。结论:经泪小点泪道内窥镜能对难治性泪道阻塞性疾病进行有效观察,并能进行有效的针对性治疗。     

Lacrimal scintigraphy. III. Physiological aspects of lacrimal drainage.

Lacrimal scintigraphy (LS) was performed on asymptomatic lacrimal drainage systems and the results were evaluated to understand the physiology of lacrimal drainage. It was found that a physiological obstruction can exist at the level of the nasolacrimal duct in normal asymptomatic individuals, and it is suggested that this obstruction is due to the resistance offered by the valve of Hasner, which in turn is dependent on (a) the volume of fluid in the lacrimal sac and the nasolacrimal duct, and (b) the anatomical integrity of the valve. The LS observations are taken into account to postulate a mechanism of drainage from the lacrimal sac into the nose, which hitherto has not been very clear. It is also suggested that reflux can occur between the various compartments of the lacrimal drainage system and that the various valves in the membranous passageway can become incompetent in an obstructed system.     

Congenital lacrimal system anomalies mimicking recurrent acute dacryocystitis

We describe 2 cases of congenital lacrimal system anomalies that mimicked recurrent acute dacryocystitis. Two patients with painful swelling below the medial canthal tendon who were referred for acute dacryocystitis were evaluated clinically with findings suggestive of lacrimal system anomalies. Both patients presented in adulthood and both had a history of recurrent presumed acute dacryocystitis without epiphora. Both patients had complete absence of the lower puncta on the involved side. Irrigation via the upper system showed lacrimal drainage system patency in both cases. Surgical exploration confirmed the diagnosis of lacrimal system anomalies. The first patient had a lacrimal sac diverticulum; the second patient had a fistula connected to the common canaliculus with an adjacent cyst. Both patients were successfully treated with excision of the outpouchings. Congenital lacrimal drainage system anomalies should be considered in the diagnosis of recurrent dacryocystitis in cases where the lacrimal system appears patent. The infection can involve a fistula or diverticulum.     

泪道孤立性纤维瘤特征及治疗

孤立性纤维瘤是一种罕见的起源于成纤维细胞间充质的肿瘤。最早报道于胸膜，近年来对胸膜外部位的孤立性纤维瘤病例报道越来越多，有报道该肿瘤几乎可发生于所有部位。泪道系统的结构功能有其特殊性，且目前关于泪道系统的孤立性纤维瘤报道仍然较少，故本文总结现有泪道孤立性纤维瘤的报道，以分析泪道这一疾病的临床特征和治疗方法。     

Medial canthal anatomy and the lacrimal drainage system

The Lacrimal drainage system has a close relationship with the orbicularis oculi muscle. The lacrimal sac and the lacrimal canaliculus are divided into 2 compartments by Horner's muscle. Namely, the lacrimal sac has one part attached to Horner's muscle and one part unattached, and the lacrimal canaliculus has one part in Horner's muscle and a part out side. The upper part of the sac dilates during contraction of Horner's muscle and is compressed during muscle relaxation. On the other hand, the lower part of the sac, affected by the orbital pressure, is compressed during contraction of the orbicularis oculi muscle, but dilates during relaxation. The lacrimal canaliculus in Horner's muscle is compressed during contraction of Horner' s muscle, and dilates during muscle relaxation. However, the contraction of the Horner's muscle dilates the part of the canaliculus not covered by the muscle, but the muscle relaxation compresses the part between Horner's muscle and the medial canthal tendon. The movement of this part functions as a valve. In addition to this dynamic drainage, the architecture of the lacrimal sac and nasolacrimal duct aids the lacrimal drainage as a static drainage system.     

Endoscopy of the lacrimal drainage system

Summary The available picturing methods in the diagnosis of functional and mechanical stenosis of the lacrimal drainage system do not allow direct optical evaluation of the mucosa. With the help of dacryoendoscopy, for the first time there is the possibility of receiving a direct morphological picture of the tissue of the lacrimal drainage system. Patients and methods: In a clinical study in the period January to June 1996, 76 dacryoendoscopies were done before an operative intervention in the lacrimal drainage system to find out what information can be obtained with dacryoendoscopy and what use this extra information is. Results: In all of the dacryoendoscopies performed, direct evaluation of the mucosa was possible. Normal findings could be clearly differentiated from mucosa of acute or chronical inflammatory processes. The choice of the operative strategy changed in part of the planned operations, although in 37 cases where the preoperative diagnosis was stenosis of the lacrimal sac, only in 26 cases was dacryocystorhinostomy performed. Dacryoendoscopy provides an additional means of guaranteeing the quality of operative procedures, e. g., after intubation. Conclusions: Dacryoendoscopy provides an important additional diagnostic possibility in the diagnosis of diseases of the lacrimal drainage system. Dacryoendoscopy offers the possibility of direct evaluation of the mucosa, the choice of operative strategy is checked and, if necessary, changed, and with the connection of an erbium YAG Laser there is minimal invasive surgery with the aim of rechannelization of the lacrimal drainage system.      

Acquired lacrimal drainage obstruction: an etiologic classification system, case reports, and a review of the literature. Part 1.

The cause of acquired lacrimal drainage obstruction may be primary or secondary. Primary acquired nasolacrimal duct obstruction results from inflammation of unknown cause that eventually leads to occlusive fibrosis. Secondary acquired lacrimal drainage obstruction, the theme of this report, may result from a wide variety of infectious, inflammatory, neoplastic, traumatic, or mechanical causes. An etiologic classification system for acquired lacrimal drainage obstruction is proposed, and it is illustrated by representative patients from the author's practice and discussed with reference to published reports.     

Dilation and diagnostic irrigation of the lacrimal drainage system

The anatomy of the lacrimal excretory system provides a logical basis for evaluation of the physiological drainage of tears. A review of the methods for examining the lacrimal drainage passages with emphasis on the techniques of punctal dilation and diagnostic irrigation is presented.     

Radionuclide dacryocystography

Radionuclide dacryocystography (RNDCG) is a safe, physiologic method of evaluating lacrimal drainage. The technique is performed by placing a radioactive "tear" in the eye(s) and following the passage of radioactivity through the lacrimal drainage apparatus with a scintillation (gamma) camera. RNDCG is indicated in any patient with tearing who has a lacrimal drainage system which is open to irrigation. It is also useful in children, when clinical signs are equivocal. Interpretation is made by comparing a patient's scan to "normal" scans, or in unilateral cases, by comparing the symptomatic side to the asymptomatic side. Many causes of functional or partial lacrimal drainage obstruction can be detected and differentiated from various tear hypersecretion abnormalities. RNDCG also has many research applications.     

新型泪道探通引流装置治疗泪小管断裂及泪囊炎的临床研究

目的 设计，临床应用新型泪道探通引流装置治疗小不止管断裂及鼻泪管阻塞所致泪囊炎。方法 新型泪道探通引流装置由两端金属探子及中间软性硅胶管组成。共42例患者（27例泪囊炎，15例泪小管断裂，女23例，男19例），首先收敛鼻粘膜，在表面麻醉下，探通泪道，自上下泪小点插入泪道探通引流装置，末端引至鼻腔鼻泪管开口处，内窥镜下取出探子，硅胶管留置在鼻腔内，术后第1周冲洗2次，术后1月每周冲洗1次，术后3个月取出引流管。结果 21例泪囊炎患者均在植管后1周内症状消失，6例泪囊炎患者明显好转，15例泪小管断裂者术后流泪症状立即消失，拔管后观察3个月，6例泪囊炎患者复发，冲洗泪道不通，其余患者痊愈。结论 应用新型泪道探通引流装置治疗由泪小管断裂所致溢泪，泪道狭窄，鼻泪管阻塞所致长期溢泪，流脓具有良好的临床效果。组织创伤小，疗效显著。具有广泛的临床应用价值。