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.     

Minimally invasive endoscopic surgery of the lacrimal drainage system--two case reports

BACKGROUND: Dacryoendoscopy is a standard procedure to directly evaluate the lacrimal system. The existence and localisation of dacryostenosis and mucosal changes as well as rare diseases in the drainage system, such as intracanalicular foreign bodies or dacryoliths, can be reliably detected and treated by minimally invasive endoscopic surgery. HISTORY AND SIGNS: A patient treated by canaliclulodacryozystorhinostomy with silicone tube intubation 5 years ago had a long symptom-free period but now shows tearing (epiphora) and occasional mucous secretion. During endoscopy residues of a silicone tube coated with a biofilm could be removed over the lacrimal canaliculus and then tested for microbiological contamination. A second patient with tearing, light mucous secretion and positive nasolacrimal duct irrigation was initially diagnosed with a tear-film disorder. Dacryoendoscopy showed a dacryolith in the saccus lacrimalis. This was consequently fragmented using a microdrill system and fully removed through the nasolacrimal duct as well as the lacrimal canaliculus. CONCLUSIONS: Endoscopy of the proximal and distal lacrimal system allows the assessment of intracanalicular structures and a reliable detection or exclusion of disorders in the draining system. This method is of great diagnostic importance as symptoms are frequently non-specific and the causes are multiple. Through endoscopy in combination with the use of a microdrill system the lacrimal system can be reopened and adequately reconstructed.     

上下泪点进针探通治疗新生儿泪囊炎的对比观察

目的:比较上泪小点进针和下泪小点进针行泪道探通术治疗新生儿泪囊炎的治疗效果。方法:选取2006-01/2013-01在我院门诊就诊的262例286眼经保守治疗2wk无效的新生儿泪囊炎患儿作为本次的观察对象;按数字表法随机分为A,B两组,其中A组133例149眼从上泪小点进针行泪道探通,B组129例137眼从下泪小点进针行泪道探通,比较两种方法的治疗效果及并发症,并随访1mo。结果:A组治愈率98.7%;B组治愈率93.4%;A组并发症发生率少于B组;两组比较差异具有统计学意义(P<0.05)。结论:从上泪小点进针行泪道探通术对新生儿泪囊炎的治疗效果优于从下泪小点进针行泪道探通术,且减少泪小管撕裂、假道及泪道继发性粘连等并发症的发生率。     

Lacrimal drainage function after cheese wiring of lacrimal passage intubation

Graefe's Archive for Clinical and Experimental Ophthalmology - To investigate how cheese wiring affects lacrimal drainage function by quantitative assessment of tear function and punctal...     

Lacrimal drainage obstruction from lacrimal sac infiltration by lymphocytic neoplasia

In two patients, a 52-year-old woman with chronic lymphocytic leukemia and a 71-year-old woman with malignant lymphoma, lymphocytic neoplasia infiltrated the lacrimal sac, obstructed the lacrimal drainage system, and resulted in acute or chronic dacryocystitis. The prognosis of lymphocytic neoplasia is sufficiently good that definitive treatment is usually warranted. Both patients benefitted from dacryocystorhinostomy with placement of silicone tubing in concert with management of the neoplasia and hemoglobin level.     

Lacrimal drainage surgery in Wegener's granulomatosis

AIM: To examine the results of open lacrimal surgery in patients with Wegener's granulomatosis. METHODS: A retrospective review of patients with Wegener's granulomatosis who underwent lacrimal surgery over a 17 year period. RESULTS: 11 patients were identified and a total of 14 primary dacryocystorhinostomies (DCR) and one revisional DCR were performed; symptomatic relief was achieved in 13/14 operations and one patient required revisional surgery for persistent symptoms. There were no intraoperative and few postoperative complications. CONCLUSIONS: In contrast with some previous reports, open DCR appears to be a safe procedure and it is recommended as a treatment for lacrimal obstruction in patients with Wegener's granulomatosis, but an increase of perioperative immunosuppression is recommended in certain cases.     

Stenoses and functional disorders of the lacrimal drainage apparatus. Radiological examination

The diagnosis of epiphora can be greatly aided by a special radiologic technique, performed during bilateral injection of contrast medium into the lacrimal passages and utilizing seriography, magnification and image subtraction. The authors describe the technique, discuss the interpretation of the various radiologic patterns, and stress the importance of this method for evaluating inflammation, stenoses and functional alterations of the lacrimal passages.     

Lacrimal drainage capacity and symptomatic improvement after dacryocystorhinostomy in adults presenting with patent lacrimal drainage systems

AIM. To determine the rate of symptomatic improvement after dacryocystorhinostomy (DCR) in patients with epiphora and insignificant obstruction to preoperative lacrimal syringing, and to measure the conductance of the postoperative lacrimal drainage anastomosis. METHODS. Retrospective cohort study of patients with symptomatic epiphora and patent tear ducts, with at least two-year follow-up after DCR. Patients underwent structured telephone interview together with clinical examination for lacrimal drainage capacity using the saline drop test.(1) RESULTS. Thirty-seven of 383 adult patients having had DCR were noted to have patent tear ducts at preoperative examination. Ten patients with previous surgery were excluded and two other patients were excluded because of other factors contributory to epiphora. Of the remaining 25 patients, 22 (aged 35-75 years at surgery; median 56 years) underwent a structured telephone interview: Of the 13 (60%) who felt that symptoms had improved, 9 (41%) were relieved of indoor epiphora and 11 (50%) thought the procedure was an overall success. Seventeen patients underwent clinical examination. The lacrimal drainage anastomosis was patent in all patients and the saline drop test result was well within the normal range in 3/4 patients who had persistent indoor epiphora. CONCLUSION. Of patients with epiphora due to minor nasolacrimal duct stenosis, open DCR produces a marked improvement or cure of symptoms in 50%. The lacrimal drainage capacity was well within the normal range in 3/4 patients with persistent postoperative lacrimal symptoms, suggesting that other factors (such as hypersecretion) may be significant in this group of patients with 'functional block'.     

Obstruction of the lacrimal drainage system

This review covers evolving concepts in lacrimal outflow obstruction. Recent studies have increased our understanding of the surgical anatomy and pathophysiology of the lacrimal drainage system through radiologic, clinical, and microbiologic techniques. While external dacryocystorhinostomy remains an important treatment for nasolacrimal duct obstruction, there have been a number of therapeutic developments worthy of review, including advances in endoscopic and transcanalicular dacryocystorhinostomy, conjunctivodacryocystorhinostomy, and the use of mitomycin C in these procedures. In addition, we summarize recent advances in minimally invasive techniques for lacrimal outflow obstruction, including balloon dacryocystoplasty, lacrimal stents, and conjunctivoplasty. Finally, the roles of probing versus irrigation, nasal endoscopy, and endoscopic dacryocystorhinostomy in children are discussed.     

Tumors of the lacrimal drainage system

Tumors of the lacrimal drainage system are rare, but potentially life-threatening. They comprise a large and variable spectrum of entities grouped into three major categories of primary epithelial, primary nonepithelial and inflammatory lesions. The most common primary epithelial tumors include papilloma, squamous cell carcinoma and transitional cell carcinoma, the most frequent primary nonepithelial tumors fibrous histiocytoma, malignant lymphoma and malignant melanoma, and the most common inflammatory lesions sarcoidosis, Wegener granulomatosis and pyogenic granuloma. This review outlines the incidence, types, management and prognosis of tumors affecting the lacrimal drainage system.     

Diseases of the lacrimal drainage system

We will refer to lacrimal system pathologies involving the outflow pathways, as well as to the recent advances in the management of canalicular and lacrimonasal duct anomalies, including modifications to dacrycystorhinostomy technique, treatment for congenital obstructions, and lacrimal intubations. Special emphasis will be placed on the usefulness of nasal and canalicular endoscopy for the examination and treatment of congenital obstructions and endonasal pathologies, as an aid for intubations and lacrimal surgery, as well as on reasons for failed procedures.     

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.      

A review of lacrimal drainage surgery

The advent of improved silicone intubation sets, increased understanding of lacrimal and nasal anatomy and physiology, and refinements in surgical instrumentation and technique have led to higher success rates in lacrimal surgery. Recent clinical studies, combined with new techniques in canalicular reconstruction, have helped identify which patients will benefit from surgical intervention and which techniques are indicated. Fortunately, this has greatly reduced the number of CDCRs necessary.     

Current concepts in lacrimal drainage surgery

Dacryocystorhinostomy remains the mainstay of treatment of acquired primary and secondary obstructions of the lacrimal drainage system. The advent of the endoscope has prompted renewed interest in the intranasal or endonasal approach to fistulae formation. As results of the intranasal approach are reported, they are compared with the time-tested and effective external approach, bringing controversy to the once staid subject of lacrimal drainage surgery. Debate continues regarding the optimal timing of intervention in the treatment of congenital nasolacrimal duct obstruction. Clinical outcome analysis suggests that early office-based lacrimal probing is more cost-effective than a hospital-based procedure. Others warn that when other factors are included in the decision process, the recommended course of intervention may be different. If dacryocystorhinostomy is required in a child with congenital nasolacrimal duct obstruction, the results by an experienced surgeon are comparable with those in an adult operated on for primary acquired lacrimal obstruction.     

Size variation of the lacrimal punctum in adults

This is the first reported study on accurate computerized measurements of lacrimal punctal size in normal adults. There was a wide variation found between patients. The lower lid puncta were consistently noted to be larger than those of the upper lids. This is clinically significant in dry-eye patients who may need to be treated with punctal plugs of various sizes.     

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。