Opening a dacryocystorhinostomy into the opposite nasal cavity in a case of hemiarhinia

Heminasal agenesis is an exceedingly rare congenital anomaly which is frequently associated with disorders of eye, lacrimal drainage system and face. At times, a proboscis may also be noted with this condition. Herein, we present a case of a 13-year-old boy who presented to us with heminasal agenesis with concomitant microphthalmos, leucomatous corneal opacity, blepharoptosis, dacryocystocoele and maxillary hypoplasia. The child underwent a modified transeptal external dacryocystorhinostomy with placement of a lacrimal stent. There was significant improvement of epiphora and discharged following surgery. Heminasal aplasia with dacryocystocoele is surgical challenge; however, a well thought out surgical approach can yield satisfactory outcomes.

Analysis of the etiological factors of relapse after endonasal endoscopic dacryocystorhinostomy

The aim of this work is to study the etiological factors of failures after endonasal endoscopic dacryocystorhinostomy (EEDCR). We retrospectively studied the case reports of 485 patients (521 cases) with a relapse after EEDCR performed for primary dacryocystitis. The obtained data allowed us to reveal that the largest number of cases of relapse after EEDCR was a consequence of partial or complete obliteration of dacryocystorhinostomy (DCR) ostium (278 cases), which amounted to 53.3% of all analyzed cases. In 127 cases, the reason of recurrence after EEDCR was stenosis or obliteration of the common canaliculus ostium (24.4%). In 116 cases (22.3%), relapse after EEDCR was caused by a combination of several etiological factors. Of these, in 86 cases, synechiae and granulation in the area of dacryostomy were revealed. The retrospective analysis carried out within the framework of this work, based on the study of the results of the applied diagnostic methods, including multislice computed tomography with contrast enhancement of lacrimal drainage system, made it possible to determine and systematize the etiological factors of the development of repeated obstruction of the lacrimal drainage system after EEDCR. Key words: relapse, dacryocystitis, DCR, common canaliculus ostium, DCR ostium, synechiae.

Epiphora; Successful Response to Systemic Steroids vs Topical Steroids

Purpose: Topical steroids are considered to be the first line of treatment for some forms of idiopathic punctal stenosis causing epiphora. We present a case of epiphora, which was unresponsive to traditional management, but responded to one week of systemic steroids. Observations: A 48-year-old male with no significant medical history, was referred to us for excessive tearing. He was seen earlier by an ophthalmologist for redness in one of his eyes. He was prescribed Pataday (Olopatadine) eye drops and Zylet (Tobramycin, Lotepriol) eye drops for both eyes. The patient was seen again after a week of treatment without much improvement. His treatment was changed to Alrex (Loteprednol) and Azasite (Azithromycin) eye drops. The redness of the eye disappeared in a week but patient noticed excessive tearing of his eyes. He was referred to reconstructive ophthalmologist for treatment of possible punctal stenosis. On examination the height of tear meniscus was increased and diagnostic lacrimal probing and syringing of the lacrimal drainage system demonstrated both lacrimal drainage system patent. Punctal stenosis was diagnosed. Over the next couple of weeks, patient underwent multiple syringing of the lacrimal duct system with temporary relief of symptoms. He was also prescribed Tobradex (Tobramycin+Dexamethasone) eye drops to be used for a month. Eye drops helped for the duration of treatment but symptoms returned after a couple of days of discontinuing eye drops. Patient also received ductal probing and punctal dilation in the office without much relief. Mini perforated plugs were placed in both puncta resulting in temporary relief. At the same time the intra ocular pressure started to rise and Tobradex eye drops were discontinued immediately. After almost three months of treatment and continuation of debilitating symptoms of epiphora, patient decided to consider surgical intervention and consulted an ENT surgeon for second opinion. Since he was responding to topical steroids, which was causing an increase in his intra ocular pressure, the ENT surgeon suggested Medrol Pack (Prednisolone for a week). Patient was symptom free after 4 days of treatment and by 7th day, his eyes were back to normal with complete disappearance of epiphora symptoms. Conclusions and importance: Systemic steroids can be beneficial in patients suffering from Idiopathic/Iatrogenic punctal stenosis unresponsive to topical steroids and conventional treatments.

Pulled versus Pushed Monocanalicular Silicone Intubation in Adults with Lacrimal Drainage System Stenosis: A Comparative Case Series

Purpose. To compare the success rate and complications of pulled versus pushed monocanalicular intubation in adults with incomplete lacrimal drainage system obstruction (lacrimal drainage system stenosis). Methods. Patients with lacrimal drainage system stenosis (Munk grade ≥3), including both nasolacrimal duct (NLD) stenosis and common canalicular stenosis, were recruited in this prospective comparative case series. Patients underwent probing and either Monoka (51 eyes) or Masterka (48 eyes) intubation under general or local anesthesia. Tubes were removed 4–14 weeks after the procedure. Six months after tube removal, Munk grades 0 and 1 were defined as a complete success, Munk grade 2 was defined as a partial success, and Munk grade ≥3 was defined as failure. All complications were recorded. Results. Ninety-nine eyes from 89 patients with lacrimal drainage system stenosis who underwent either Monoka (51 eyes) or Masterka (48 eyes) intubation were included. The mean (SD) age of the patients was 55.4 (12) years in the Monoka group and 53.5 (12.9) in the Masterka group. Groups were matched on demographics. Masterka intubation could not be performed in one eye. Complete and partial successes were observed in 52.9% (27/51) and 17.6% (9/51) of eyes in the Monoka group and 42.6% (20/47) and 12.8% (6/47) of eyes in the Masterka group, respectively ( p = 0.29 ). There was a trend toward a higher total success rate in patients with NLD stenosis treated with Monoka 66.7% (26/39) than Masterka 45.5% (15/33) intubation ( p = 0.07 ). This trend also existed in patients with common canalicular stenosis (83.3% (10/12) vs. 76.6% (11/14), p = 0.75 ). Age, sex, bilateral involvement, and duration of intubation did not have a significant impact on the success rate. Early tube loss, slit puncta, and temporary superficial punctate keratopathy were observed complications. Conclusion. Intubation with the pulled monocanalicular silicone tube was associated with a slightly but not significantly higher success rate in adults with lacrimal drainage system stenosis. Patients with NLD stenosis may achieve better results with pulled silicone tubes.

Human Papillomavirus Related Neoplasia of the Ocular Adnexa

Human papillomaviruses (HPV) are a large group of DNA viruses that infect the basal cells of the stratified epithelium at different anatomic locations. In the ocular adnexal region, the mucosa of the conjunctiva and the lacrimal drainage system, as well as the eyelid skin, are potential locations for HPV-related neoplasia. The role of HPV in squamous cell neoplasia of the ocular adnexa has been debated for several decades. Due to the rarity of all these tumors, large studies are not available in the scientific literature, thereby hampering the precision of the HPV prevalence estimates and the ability to conclude. Nevertheless, increasing evidence supports that defined subsets of conjunctival papillomas, intraepithelial neoplasia, and carcinomas develop in an HPV-dependent pathway. The role of HPV in squamous cell tumors arising in the lacrimal drainage system and the eyelid is still uncertain. Further, the potential of HPV status as a diagnostic, prognostic, or predictive biomarker in these diseases is a topic for future research.

Usefulness of high definition sialoendoscope for evaluation of lacrimal drainage system in congenital nasolacrimal duct obstruction

Purpose: Sialoendoscope was used as a dacryoendoscope, high- definition images of the lacrimal drainage system (LDS) were captured and its performance in congenital nasolacrimal duct obstruction (CNLDO) is reported. Methods: Nasal endoscopy was done as the first in all the cases using a 0°, 2.7 mm nasal endoscope (Karl Stroz Tutlingan Germany). This was followed by Dacryoendoscopy (DEN) of the lacrimal drainage system from puncta till the valve of Hasner. DEN was performed under general anaesthesia in 26 children (including 17 primary and 9 failed probing cases). All cases were examined using 0.8 mm sialoendoscope (Karl Storz, Tuttlingen, Germany) with fibreoptic light transmission with a side port for irrigation. Results: We were able to obtain high-definition images of canaliculi, lacrimal sac, sac duct junction, proximal, mid and distal segments of nasolacrimal duct in all the children with CNLDO. In 17 primary cases 16 had distal membranous obstruction and I case had proximal canalicular obstruction. In nine children with history of failed probing, five had membranous obstruction, two had dacryoliths, two had NLD malformation at different levels. An overall success rate of 88.4% was achieved. Conclusion: Sialoendoscope can be used as high-definition dacryoendoscope for diagnostic and therapeutic use in CNLDO. Useful information can be obtained on dacryoendoscopy in complex CNLDO cases.