Frequency of the common canaliculus: a radiological study.

ObjectivesMany factors influence the outcome of endoscopic dacryocystorhinostomy (DCR). One of the most important prognostic factors is the level of obstruction in the lacrimal drainage system. The main objective of this report is to evaluate both the frequency of obstruction by anatomical region of the lacrimal drainage system on dacryocystography (DCG) and the surgical outcome of endoscopic DCR according to the obstruction level.MethodsA retrospective series of 48 patients (60 eyes) who had undergone endoscopic DCR from January 2005 to November 2007 were enrolled. Preoperative evaluation consisted of a standard examination which included lacrimal irrigation, probing, DCG and osteomeatal unit (OMU) computed tomography. Patients were classified into four groups according to the obstruction level on DCG. Surgical outcome was evaluated postoperatively by subjective improvement of epiphora and patent rhinostomy opening on nasal endoscopic exam.ResultsOf 60 eyes, the levels of obstruction were the common canaliculus in 14 eyes (23.3%), the lacrimal sac in 13 eyes (21.7%), the duct-sac junction in 13 eyes (21.7%) and the nasolacrimal duct (NLD) in 20 eyes (33.3%). The ductsac junction obstruction was treated most successfully (100%), followed by NLD obstruction (90%), common canaliculus obstruction (78.6%) and saccal obstruction (69.2%).ConclusionIn patients with lacrimal drainage system obstruction, preoperative evaluation of obstruction level using DCG may be helpful for predicting the surgical outcome of endoscopic DCR. The saccal obstruction may have a worse prognosis than the other obstruction levels.

The lacrimal drainage system consists of the lacrimal puncta, inferior and superior canaliculi, common canaliculus, lacrimal sac, and nasolacrimal duct. It is classically divided into upper and lower portions. Obstruction of the drainage system can be congenital or acquired, and may result in persistent epiphora and mucopurulent discharge. This paper discusses the etiology, clinical picture, diagnosis, and surgical treatment of lacrimal drainage system obstruction.

BackgroundThe middle turbinate axilla (MTA) has always been used as a stable anatomic landmark for endoscopic surgeons to locate the lacrimal sac on the lateral nasal wall. Yet, little is known about whether the lacrimal sac size will affect the positioning effect of MTA on lacrimal sac. The aim of this study was to investigate the regularity of lacrimal sac size and lacrimal sac localization through the reference position of the MTA on computed tomographic dacryocystography (CT-DCG) images.MethodsA series of 192 endoscopic dacryocystorhinostomy (DCR) surgeries were performed. All the patients had been diagnosed as unilateral nasolacrimal duct obstruction and received CT-DCG examinations. According to the maximum transverse diameter of the lacrimal sac on CT-DCG, the patients were classified into three groups. Measurements were taken on CT-DCG parasagittal images.ResultsThe average distance from the sac superior fundus (SSF) to the MTA was 7.52 mm ± 3.23 mm, and it increased with the increase of the maximum transverse diameter of the sac among groups (p < 0.01). The average distance from the common canaliculus (CC) to the MTA was 3.95 mm ± 2.49 mm. No significant difference was observed among the groups (p = 0.11). The average distance from the CC to the SSF was 3.41 mm ± 1.31 mm, and it increased with the increase of the sac transverse diameter among groups (p < 0.01).ConclusionsThe lacrimal sac can be accurately located on the lateral nasal wall by the reference position of the MTA on CT-DCG images. The distance of the SSF to the MTA and the SSF to the CC is related to the lacrimal sac size. The relative position of the CC to the MTA is relatively stable on CT-DCG images, which make it possible to locate the lacrimal sac of different sizes and the corresponding nasal mucosa incision design in endoscopic DCR.

Treatment of nasolacrimal duct obstruction in adults with polyurethane stent

The purpose of this study was to investigate the prevalence of a common canalicular entrance in the lacrimal sac and to investigate the anatomy of the canalicular/lacrimal sac junction with direct visualization using a novel cadaveric dissection technique. Preserved cadavers were dissected to allow direct visualization of the canalicular entrance(s) to the lumen of the lacrimal sac. The prevalence of a common canaliculus and the anatomical variations of the canalicular/lacrimal sac mucosal fold of tissue were recorded. One hundred twenty-four lacrimal systems (95 cadavers; 43 female, 52 male) were included in the study analysis. Overall, 123 lacrimal systems demonstrated a common canaliculus entering the lacrimal sac. Only one demonstrated 2 separate orifices (right orbit; male) in the sac (0.08%; 95% confidence interval, 0.1%-4.4%). Seventy-four lacrimal systems had some variation of a canalicular/lacrimal sac mucosal fold (59.7%). The remaining 50 (40.3%) had no visible canalicular/lacrimal sac mucosal fold. This study provides direct anatomical evidence that the prevalence of separate canalicular orifices in the lacrimal sac is lower than previously reported (<1%). Additionally, the presence of a valve-like structure at the canalicular/lacrimal sac junction is common. These observations can potentially play a role in evaluating and treating lacrimal system pathology.

Dear Editor, Recently, we experienced two cases of lacrimal sac tumors discovered in patients who presented with persistent epiphora after receiving dacryocystorhynostomy (DCR). A 75-year-old female visited the clinic complaining persistent epiphora in the right eye for 5 years. The patient was diagnosed with nasolacrimal duct obstruction in the right eye and received a DCR twice 2 years ago at a local hospital, but epiphora persisted post operation. Lacrimal irrigation test revealed a reflux through contralateral puncta in the right eye. There was a protrusion superior to medial canthus and a mass was palpable at the medial side of the right orbit. Computed tomography (CT) scan confirmed a 3-cm-sized mass involving the right lacrimal sac and surrounding soft tissue of inferomedial orbit (Fig. 1A and 1B). An excisional biopsy was performed and diagnosed as invasive squamous cell carcinoma from lacrimal sac. Wide resection of lacrimal sac and nasolacrimal duct via anterior orbitotomy and medial maxillectomy via lateral rhinotomy was performed (Fig. 1C). The patient received adjuvant radiotherapy and is under observation. Fig. 1 Computed tomography (CT) scan and operation images of epiphora patients diagnosed with tumor in lacrimal duct (A,B). Preoperative orbital CT images of the 75-year-old female patient show a 3-cm mass at the right lacrimal sac. (C) An excisional biopsy ... The second case presents a 51-year-old female whose history included a DCR received at a local hospital for epiphora in the left eye. She was complaining of persistent epiphora and swelling of upper and lower eyelids. The slit lamp examination and lacrimal irrigation test was normal. Sinus endoscopy showed intact bony opening from the previous DCR. A CT scan was done and a mass occluding the lacrimal sac and invading the inferomedial orbit was observed (Fig. 1D and 1E). An excisional biopsy was performed and the pathology report diagnosed a papilloma with mild nuclear dysplasia, which has a risk of advancing into a squamous carcinoma. Wide resection of inferomedial orbit including lacrimal sac and endoscopic medial maxillectomy was performed (Fig. 1F). Pathology report diagnosed a carcinoma arose from papilloma, and the patient received adjuvant radiotherapy. This is the first case series of lacrimal sac tumors discovered in patients with persistent epiphora after receiving DCR in Korea. A tumor originating from the lacrimal sac is a rare cause of epiphora [1], but a half of the cases turn out to show malignancy with a high mortality rate, which raises a need for precaution. Tumors of lacrimal sac can be categorized into three types. The first type is a primary tumor in the lacrimal sac, in which 72% of the cases are malignant. The second type is a tumor invading from the nearby tissue such as eyelids, paranasal sinuses or orbits. The third type is an inflammatory tumor such as sarcoidosis or Wegener's granulomatosis, which may require an internal medical approach to evaluate systemic symptoms. Epithelial tumor is the most common type of primary tumor in the lacrimal sac. Benign epithelial tumors include papilloma and oncocytoma, and can be treated with surgical resection [2,3]. Malignant epithelial tumors include squamous cell carcinoma and transitional cell carcinoma, and a wide resection including lacrimal canaliculi, sac and nasolacrimal duct with lateral rhinotomy is needed with preoperative and/or postoperative radiotherapy. If the tumor is invasive, an orbital exenteration including wide resection, lymphadenectomy and paranasal sinus resection is required. The local recurrence rate is 50% and the mortality rate is 50% for invasive squamous cell carcinoma and 100% for transitional cell carcinoma. Non-epithelial tumor includes mesenchymal tumor and lymphoproliferative tumor [2,3]. Because recent DCRs are performed using sinus endoscopes to avoid scar formation, it is more difficult to find tumors than in conventional DCRs. The possibility of a tumor in the lacrimal sac must be ruled out in the patients with a palpable mass superior to the medial canthus, a bloody reflux and/or a simultaneous exophthalmos [3,4]. Palpation around the medial canthal area and pathologic confirmation of tissue whenever discovering any sign of abnormality is important, especially when eyelid swelling or epiphora persist after DCR. Imaging study of the lacrimal drainage system using CT scan is also a good screening process.

Recent developments in ophthalmology such as balloon dilatation, stent implantation, laser therapy and endoscopy of the lacrimal drainage system raise the need for a detailed anatomical knowledge of this system. In this study morphometric measurements of the lacrimal drainage system were performed with thin-section axial computed tomography (CT) examinations in 147 patients with no signs of pathology related to the lacrimal drainage system. The mean length of the nasolacrimal duct measured 11.2 +/- 2.6 mm (range: 6-21 mm), the narrowest diameter was 3.7 +/- 0.7 mm (range: 2-7 mm). The mean length of the nasolacrimal sac was 11.8 +/- 2.5 mm (range: 6-18 mm). The width of the nasolacrimal sac did not exceed 4 mm unless filled with air. In 43 (29.3%) of the subjects air was visible within the nasolacrimal sac or duct. The knowledge of the morphometry of the lacrimal drainage system enables the ophthalmologist to plan intervention on the lacrimal drainage system precisely and avoid unnecessary manipulations.

This chapter describes the diseases of the orbit, lacrimal gland, and the lacrimal drainage system. The embryology and anatomy of these structures is described shortly. All disease processes are discussed subsequently: congenital abnormalities, inflammation and infection, degenerations, and neoplasms. In order to prevent doublures, certain disease processes and diseases are described in detail as orbital diseases which may be subsequently referred to in the paragraphs of the lacrimal gland and drainage system.

To investigate the distribution of elastic fibers in lacrimal sac and nasolacrimal duct of Japanese cadavers. We examined 8 lacrimal sacs and nasolacrimal ducts of 7 Japanese cadavers (4 right sides, 4 left sides; 3 males, 4 females; average age of 89 years at death) that were preserved with 10% buffered formalin. The harvested specimens were transversely sectioned. All specimens were stained with Elastica van Gieson. Micrographs were taken, and then converted to white and black images, and the elastic fiber density of 4 locations (middle and upper levels of lacrimal sac, and middle and lower levels of nasolacrimal duct) was compared. Elastic fibers showed greater distribution in the lamina propria, compared with the submucosal tissue, at all locations (p < 0.001). Elastic fiber density within the lamina propria at the middle lacrimal sac level (13.5% ± 4.3%) was similar to the density observed at the upper lacrimal sac level (13.2% ± 2.3%, p = 0.87) and the lower nasolacrimal duct level (17.8% ± 6.0%, p = 0.088), but was significantly greater than the density observed at the middle nasolacrimal duct level (9.5% ± 3.8%, p = 0.0001). Elastic fibers in the lacrimal sac and nasolacrimal duct are primarily distributed in the lamina propria, with a greater density at the upper and middle lacrimal sac levels, and at the lower nasolacrimal duct level, compared with the middle nasolacrimal duct level. This distribution of elastic fibers likely reflects the magnitude of mechanical stress within the lacrimal drainage system.

The purpose of this study was to investigate the proximal part of the lacrimal tract. The dissection was performed on 20 specimens of adult cadavers under an operating microscope. The upper lacrimal canaliculus (ULC) and the lower lacrimal canaliculus (LLC) were opened to the lacrimal sac (LS) in three types. In Type A, the ULC and the LLC unite before opening to the LS and form the a common canaliculus (CC). In Type B, the ULC and the LLC unite at the wall of the LS and open to the LS via common hole. In Type C, however, the ULC and the LLC open to the LS separately. Type A, Type B and Type C were observed in 85%, 5% and 10% cases, respectively. Type A and Type B opened to the LS from back to front at an acute angle in 72% of the specimens, and at a right angle in 22%. The opening angles of the CC with lacrimal canaliculus; the ULC with the LS, and the LLC with the LS were realized at an acute angle. Crucial parameters, which have not been previously mentioned such as the opening angles of the ULC and the LLC, were investigated as they might be used during the procedure.

Affections of the lacrimal drainage system are often seen by ophthalmologists. Inspection, palpation, diagnostic rinsing and sounding can distinguish anatomical stops before or after tear sac. For final diagnostics however more apparative examinations are necessary. The ultrasonic examination with contrast media is a simple method for diagnostics of affections of the lacrimal drainage system besides the dacryocystography, the scintigraphy and other ones. On 12 patients with a dysfunctional lacrimal drainage system and 12 normal controls the ultrasonic examination with instillation of contrast media: silicon oil, glycerine, dispersions of almond oil and viscoelastic substances was performed. All examinations were performed with the 13 B-scan. The lacrimal drainage way was detectable from the canaliculus to the middle nasolacrimal duc An additional advantage of the ultrasonic examination with contrast-media is the neglect of radiation, the simple and often repeatable examination method, especially the enhancement of the contrast of different valves and stenoses and mucinous deposits in stationary anatomical variations and dynamic defects.

Extranodal Rosai-Dorfman disease involving the orbit and sinuses is well documented in the literature. However, those involving the lacrimal drainage system alone are rare. A woman presenting with Rosai-Dorfman disease involving the lacrimal drainage system, masquerading as a lacrimal sac malignancy, and its treatment is highlighted in the report described. Minimally invasive treatment for lacrimal drainage system involving Rosai-Dorfman disease in the form of intralesional steroids can be a safe and effective option.

Next to medical therapy, blockage of the lacrimal drainage system is the commonest form of treating dry eye. Rather than applying an artificial tear, the latter helps to preserve any remaining natural tear fluid, which by far has the best wetting and nutrient capacity for the ocular surface. A temporary block is usually induced by implants to tamponade on the level of the lacrimal puncta or canaliculi. A Medline search was performed with the keywords 'lacrimal drainage system, punctum, canaliculus, temporary occlusion, plug, dry eye, keratoconjunctivitis sicca' for the years 1986-2006. Plugs are a suitable treatment in patients with moderate or more severe disease. The characteristics of the devices used and procedures as well as the complications described were analyzed. Criteria such as a lack of Schirmer strip wetting, ocular surface staining and the frequency of artificial tears instillation should be assessed prior to making the decision to occlude the lacrimal drainage. Lacrimal plugs made of silicone or a thermodynamic acrylic polymer, such as hydrogel, appear to be safe and effective, although each patient should be followed on a long-term basis to exclude alterations of the lacrimal system such as chronic inflammatory reactions, extrusion or migration, which may all lead to discomfort. High-frequency ultrasound as a non-invasive, simple diagnostic technique can be used to identify the type or position of plug or inflammatory reaction present. Tamponade of the lacrimal drainage system is a simple procedure that is underused. Preserving natural tears by blocking the lacrimal drainage system can successfully maintain the integrity of the ocular surface and corneal transparency and visual acuity. In patients with moderate or severe dry eye, it is capable of improving quality of life and preventing loss of vision.

Malignant melanoma of the conjunctiva is a rare tumor of the ocular surface with potential fatal consequences and a high likelihood of recurrence. Although routes for extending the tumor, including local, hematogenous, and lymphatogenous, are pretty straightforward, the indirect extension through free-floating tumoral cells to the nasolacrimal duct is not described thoroughly. We report a case of malignant melanoma of the conjunctiva which presented with local recurrence in the intranasal cavity and lacrimal sac two years after the primary surgery (without involvement of the ocular surface and punctum on the second occasion). However, there was no evidence of distant metastasis on either occasion. This case demonstrates the possible noncontiguous spreading route of melanoma tumoral cells and highlights the need for attention to the surgical technique, and careful follow-up to detect further disease activity.

To report long-term outcomes after surgery for primary benign papillomas of the lacrimal drainage system. Retrospective review of patients with primary lacrimal drainage system papillomas, first seen between 1984 and 2021, but excluding lesions with sino-nasal origin or malignant histology. Patients were categorized by tumor histology (squamous, transitional, and mixed cell) and growth pattern (exophytic, endophytic, or mixed). Thirty patients (18 female; 60%) presented at a mean age of 46.1 years (12-79 years). Over an average follow-up of 10.4 years, 30% of patients experienced recurrence, with rates differing slightly by growth pattern: 25% for exophytic tumors and 40% for endophytic and mixed-pattern tumors ( p = 0.431). The overall 5-year recurrence-free survival was 67% (± 9% standard error), this being slightly higher for exophytic lesions (75% ± 10%) as compared to 48% (± 19%) for tumors with an endophytic component ( p = 0.370). No cases of malignant transformation were observed, and the tumor type at recurrence matched the initial diagnosis. Primary benign papillomas of the lacrimal drainage system have a long-term recurrence rate of about one-third, with a higher frequency in those exhibiting an endophytic growth pattern. The study highlights the importance of prolonged surveillance for recurrence, especially for endophytic and mixed growth pattern tumors, and for the potential to undergo malignant transformation. The results support the effectiveness of endoscopic surgical excision or laser thermos-ablation in managing recurrent lacrimal drainage system papillomas after dacryocystorhinostomy.