Acute dacryocystitis: changing practice pattern over the last three decades at a tertiary care setup.

AIM: To compare the demographics, clinical features, and changes in the management pattern of acute dacryocystitis at a tertiary care eye institute. METHODS: A retrospective review was performed of electronic medical records of all patients diagnosed with acute dacryocystitis from January 2013 to January 2023. Data retrieved include demographics, history, presenting symptoms, duration of symptoms, surgical interventions, associated systemic conditions, management, complications, and outcomes. A successful anatomical outcome was defined as patency on lacrimal irrigation, and a successful functional outcome was defined as the resolution of infection and epiphora. The data parameters obtained were compared with the historical published data of the earlier two decades from the same Institute. RESULTS: A total of 363 eyes of 349 patients were enrolled in this retrospective study. The median age was 45 years (range: 19-94 years). There were 216 (62%) females and 133 (38%) males. Surgery was performed in 320 (88%) patients. Needle aspiration or incision and drainage were performed in 102(32%) patients with lacrimal abscesses. Of the 320 patients, an endoscopic DCR was performed in 138 (43%) patients and an external DCR in 182 (57%). Of the 320 patients who underwent DCR surgery, 308 (96%) demonstrated anatomical and functional success at 1-year follow-up. CONCLUSION: There is a changing trend towards endoscopic DCR being incorporated as the primary procedure for managing acute dacryocystitis with the advantages of quicker resolution and reduced morbidity. There is a trend for choosing needle aspiration over the traditional incision and drainage in the initial management of lacrimal abscess.

Dacryolithogenesis or Dacryolithiasis-The Story So Far.

The term dacryoliths refers to the concretions found within the lacrimal system. When the term dacryoliths is unspecified, it usually refers to the noninfectious dacryoliths commonly isolated from the lacrimal sac and the nasolacrimal duct. More often, they are diagnosed incidentally during a dacryocystorhinostomy, and the reported incidence among all dacryocystorhinostomy surgeries is 5.7% to as high as 18%. Dacryolithiasis is a complex process occurring within the lacrimal system, and current evidence suggests a multifactorial etiology. The sequence of events can be summarized broadly into 4 stages: stage of susceptibility, stage of initiation/trigger, stage of development, and stage of maintenance. The triggering event is the breach of the lacrimal sac or nasolacrimal duct epithelium, resulting in microtrauma with blood leakage. The blood clots act as a nidus for subsequent sequential laying of mucopeptides, cellular debris present locally, debris washed from the ocular surface, and extraneous agents in tears. This process is aided by altered rheology and composition of the tear film. After the formation of dacryoliths, extracellular neutrophil traps usually form on the surface, which help to maintain the dacryoliths (which do not dissolve). This review highlights and discusses the possible sequence of events during dacryolithiasis.

Lacrimal Sac Characteristics in Patients With Punctal and Canalicular Agenesis: Punctum Update (PUP) Study-Paper 3.

PURPOSE: To explore the endoscopic and histopathologic characteristics of the lacrimal sac (LS) and the nasolacrimal duct in cases with punctal agenesis presenting with LS swellings. METHODS: This is a prospective, interventional study of 13 LSs of 8 patients presenting with punctal agenesis and LS swellings over a 5-year study period (June 2018-July 2023). Complete ophthalmic examination was performed along with CT scans of the orbits. The LS was exposed with an anterior lacrimal crest incision and explored. The exterior and interior of the sac swelling were examined and LS flaps were sent for histopathological analysis. RESULTS: The mean age of the patients was 23 years with a male:female ratio of 5:3. All patients presented with swelling in the LS region. Occasional epiphora was the presenting feature in 6 patients. All patients had both upper and lower punctal agenesis on the affected side with associated LS swelling. CT scans showed a hypodense cystic swelling with expansion of the LS fossa and bony nasolacrimal duct ending abruptly short of the inferior meatus. Intraoperatively, the LS had thin, translucent walls with mucoid secretion and an absence of common canalicular opening. Histopathological analysis showed epithelium consistent with LS with less robust development of the sac walls and poorly structured lacrimal drainage-associated lymphoid tissue with scanty stromal inflammation. CONCLUSIONS: The development of LS and the nasolacrimal duct is structurally affected in patients with punctal agenesis. Retrograde approaches for epiphora resolution are not logical in such cases but conjunctivodacryocystorhinostomy with Jones tube can be a feasible option.

Transcutaneous (External) Dacryocystorhinostomy with Reconstruction of the Ductus nasolacrimalis. / Transkutane (externe) Dakryozystorhinostomie mit Rekonstruktion des Ductus nasolacrimalis.

BACKGROUND: Dacryocystorhinostomy (DCR) is regarded as the gold standard for the treatment of chronic dacryocystitis (CDC). Different modifications of the surgical procedure have been developed over the years. METHODS: Patients with CDC due to postsaccal lacrimal stenosis and under treatment with DCR have been included in this retrospective study. Two groups of different surgical procedures were analysed: firstly DCR without reconstruction of the ductus nasolacrimalis (DNL, group 1) and secondly patients with reopening the DNL (group 2). Criteria for success were absence of permanent epiphora, absence of inflammation of the lacrimal sac (functional success), and no recurrent surgery with free patency of the lacrimal duct (anatomical success). This was obtained by questionnaire after a follow-up of at least 12 months. The impact of gender, ectasia of the lacrimal sac, dacryoliths, and prior lacrimal surgeries was analysed. RESULTS: Overall, 248 surgeries were enrolled in this trial. Mean age in group 1 was 68 years (range: 22 to 92 years) and gender ratio was 3.2 to 1 (female : male). In that group, 68 operations could be followed up. In group 2, 62 operations on patients of a mean age of 63 years (range: 24 to 89 years) and a gender ratio of 2.9 to 1 (female : male) were observed. Complete success occurred in 75.0% in group 1 and 75.8% in group 2. Recurrent operations were necessary in one case of group 2 (1.6%) and 4 cases of group 1 (5.9%). Gender (group 1 p = 1; group 2 p = 0.115; between groups p = 0.511), ectasia of the lacrimal sac (group 1 p = 0.877; group 2 p = 0.674; between groups p = 0.878), dacryolith (group 1 p = 1; group 2 p = 0.465; between groups p = 1), and prior lacrimal surgery (group 1 p = 0.092; group 2 p = 0.051; between groups p = 0.520) did not influence the success rates in each group or between groups. Significantly more dacryoliths were found during operations of group 2 (p = 0.010). CONCLUSION: Reconstruction of the DNL during DCR is a possible and easy modification, with a slightly better success rate in curing CDC. Intraoperatively, dacryoliths might not be apparent remain in the deeper parts of the lacrimal ducts. Therefore, these segments should be inspected during surgery.

Dilemmas in the management of lacrimal drainage anomalies in BOSMA (congenital arhinia-microphthalmia) syndrome.

Congenital arhinia-microphthalmos syndrome or BOSMA syndrome is an exceptionally rare clinical syndrome characterized by unilateral or bilateral complete absence of the nasal cavity associated with several craniofacial, ocular, and systemic anomalies. Lacrimal drainage anomalies are secondary to absent nasolacrimal duct and usually present as dilated lacrimal sac or mucoceles. While navigation-guided dacryocystorhinostomies into the contralateral nasal cavity are described for unilateral arhinia, the way forward for the complete absence of the nose and nasal cavity is still unclear. A multidisciplinary team from the specialties of genetics, plastic surgery, ophthalmic plastics and reconstructive surgery, otorhinolaryngology, and endocrinology should get involved very early on for better continuity of care.

Lacrimal gland targeted therapies for refractory epiphora: quantitative changes in the gland activity.

PURPOSE: To investigate the effect of botulinum toxin (BTX) and partial orbital lobe dacryoadenectomy (POLD) on the main lacrimal gland functions using the direct assessment of its secretory activity. METHODS: A pilot study involving 14 subjects (mean age, 42.16 years) with proximal bicanalicular block (n = 9) or complete punctal effacement (n = 5) received either intraglandular 2.5 units of BTX (n = 7) or underwent the POLD procedure (n = 7). Dynamic assessment of tear secretion from the palpebral lobes was performed as per standard protocols. The parameters studied included Schirmer I, changes in the glandular outflow, and the neurosensory secretory lag. RESULTS: Schirmer I values showed a mean reduction of 5.25 mm (range, 2-8 mm) following BTX injection, and mean tear flow decreased from 1.46 µl/min to 1.11 µl/min (P = 0.15). The POLD group showed a significant mean reduction of 0.45 µl/min in mean tear flow at 1 month (P = 0.03) and 0.32 µl/min at 3 months of follow-up (P = 0.20). However, there was no statistically significant change of the Schirmer values in the POLD group at 3 months. CONCLUSION: Direct assessment of lacrimal gland function can be used to monitor changes following the gland therapies. Although POLD shows a significant reduction in short term, significant surgical improvisation would be needed for it to be effective in long term. A larger study is ongoing to further our understanding.

Caruncle and plica hypertrophy causing mechanical secondary acquired lacrimal duct obstruction: - SALDO update study (SUP) - paper I.

PURPOSE: To exclusively report the clinical category of mechanical secondary acquired lacrimal duct obstruction (SALDO) secondary to the caruncle and plica hypertrophy. METHODS: Prospective interventional case series involving 10 consecutive eyes with megalocaruncle and plica hypertrophy were enrolled in the study. All patients presented with epiphora secondary to a demonstratable mechanical obstruction of the puncta. All patients underwent high magnification slit-lamp photography and Fourier-domain ocular coherence tomography scans (FD-OCT) of the tear meniscus height (TMH) pre- and post-operatively at 1-month and 3-months. Caruncle and plica size, position, and their relationship to the puncta were noted. All patients underwent partial carunculectomy. Primary outcome measures were demonstrable resolution of the mechanical obstruction of the puncta and the reduction in the tear meniscus height. The secondary outcome measure was the subjective improvement of the epiphora. RESULTS: The mean age of the patients was 67 years (range: 63-72 years). The average TMH was 843.1 (range: 345-2049) microns pre-operatively and 195.1(91-379) microns at 1-month follow-up. All patients reported significant subjective improvement in epiphora at 6-months follow-up. One patient had bilateral granuloma at the surgical site at two weeks and was managed by simple excision and topical tapering steroids. Histopathology revealed hyperplastic epithelium with goblet cells with chronic inflammatory cells in the sub-epithelial region and the stroma. CONCLUSION: The role of the caruncle in the causation of mechanical SALDO needs to be carefully assessed in patients beyond the sixth decade. Excellent objective and subjective outcomes can be achieved by a partial carunculectomy and plica semilunaris excision.

Post-traumatic canalicular fistula: description and review of literature - SALDO update study (SUP) - paper II.

PURPOSE: To discuss the clinical spectrum and management strategies in patients with post-traumatic canalicular fistula (PTCF). METHODS: Retrospective, interventional case series of consecutive patients diagnosed with PTCF over a 6-year study period between June 2016 and June 2022. The demographics, mode of injury, location, and communication of the canalicular fistula were noted. The outcomes of several management modalities including dacryocystorhinostomy, lacrimal gland therapies, and conservative approaches were assessed. RESULTS: Eleven cases with PTCF over the study period were included. The mean age at presentation was 23.5 years (range: 6-71 years), with male: female ratio of 8:3. The median time interval between trauma to presentation at the Dacryology clinic was 3 years (range: 1 week to 12 years). Seven had iatrogenic trauma and four had the canalicular fistula following primary trauma. Management modalities pursued include conservative approach for minimal symptoms, and dacryocystorhinostomy, dacryocystectomy, and lacrimal gland botulinum toxin injection. The mean follow-up period was 30 months (range: 3-months-6 years). CONCLUSION: PTCF is a complex lacrimal condition and the management of the PTCF needs a tailored approach guided by its nature and location and patient symptomatology.

Practice patterns in revision dacryocystorhinostomy.

PURPOSE: This study aimed to report the practice patterns while performing revision dacryocystorhinostomy (RevDCR) amongst oculoplastic surgeons from several regions across the globe. METHODS: The survey consisted of 41 specific questions sent via email that contained a link to the Google forms. The questions covered several aspects of the respondents' practice profiles, evaluation methods, pre-operative choices, surgical techniques, and follow-up preferences while dealing with patients of prior failed DCRs. Questions were answerable either as multiple choice or free text typing. The survey respondents were anonymized. The responses were collected and analyzed, and data were tabulated to understand the preferred practice trends. RESULTS: A total of 137 surgeons completed the survey. Most respondents identified themselves as experienced surgeons managing failed DCRs (76.6%, total respondents (n) = 137). The commonly preferred modalities for evaluation of a failed DCR were lacrimal irrigation (91.2%) and nasal endoscopy (66.9%). About 64% (87/137) of the respondents performed a combination of nasal endoscopy, lacrimal irrigation, and probing to localize the area of the failed DCR. A majority of the respondents used anti-metabolites (73.3%, n = 131) and stents (96.4%, 132/137) during the revision surgery. Most surgeons preferred endoscopic approach (44.5%), (61/137) for revising a failed DCR and most preferred general anaesthesia with local infiltration (70.1%, 96/137). Aggressive fibrosis with cicatricial closure was identified as the most frequently encountered cause of failure (84.6%, 115/137). The osteotomy was performed on an as-needed basis by 59.1% (81/137) of the surgeons. Only 10.9% of the respondents used navigation guidance while performing a revision DCR, mainly for post-trauma scenarios. Most of the surgeons completed the revision procedure within 30-60 minutes (77.4%, 106/137). The self-reported outcomes of revision DCRs were good (80-95%, median-90%, n = 137). CONCLUSION: A significantly high percentage of oculoplastic surgeons who responded to this survey from across the globe performed nasal endoscopy in their pre-operative evaluations, preferred endoscopic surgical approach, and used antimetabolites and stents while performing revision DCRs.

Nasolacrimal Duct Coronary Stent Recanalization (NCR): First Cadaver Experience and Its Potential as an Alternative to DCR.

PURPOSE: To investigate the feasibility of implanting a drug-eluting cobalt-chromium alloy coronary stent in the nasolacrimal ducts (NLDs) of human cadavers. METHODS: The pilot study was carried out in 5 NLDs of 4 adult human cadavers. Sirolimus-eluting coronary stents of 2 mm in width and lengths of 8 and 12 mm, which were mounted on balloon catheters, were used. Following dilatation of the NLDs, the balloon catheters were introduced into the NLDs under direct endoscopy guidance. The stents were delivered following dilatation of the balloon to 12 ATMs and secured in a locked (spring out) position. The balloon is then deflated and securely extubated. The dacryoendoscopy confirmed the stent position. The lacrimal system was then dissected to assess several key parameters like the uniformity of the NLD expansion, anatomical interactions of the NLD mucosa with the stent rings and struts, integrity of the soft and bony NLD, stent movement on mechanical push and pull, and ease of manual removal. RESULTS: The cobalt-chromium alloy coronary stents could be delivered with ease and secured in the cadaveric NLDs. Its position was confirmed by a dacryoendoscopy and later by the direct NLD dissection. The NLD was uniformly dilated 360° with a wide and uniform lumen. NLD mucosa was noted to be uniformly distributed in spaces between the stent rings without influencing the expanded lumen. Following the lacrimal sac's dissection, the NLD stent showed significant resistance to downward movement but could be easily retrieved with forceps. The 12-mm stents could reach the near total length of the NLD with good luminal expansion. The integrity of the bony and soft-tissue NLD was maintained. The learning curve is shallow if the surgeon is adept with the techniques of balloon dacryoplasty. CONCLUSION: Drug-eluting cobalt-chromium alloy coronary stents can be precisely deployed and secured within the human NLDs. The study is the first of its kind to demonstrate the technique of NLD coronary stent recanalization in human cadavers. It is a step forward in the journey to evaluate their use in patients with primary acquired NLD obstructions and other NLD disorders.

ChatGPT and Lacrimal Drainage Disorders: Performance and Scope of Improvement.

PURPOSE: This study aimed to report the performance of the large language model ChatGPT (OpenAI, San Francisco, CA, U.S.A.) in the context of lacrimal drainage disorders. METHODS: A set of prompts was constructed through questions and statements spanning common and uncommon aspects of lacrimal drainage disorders. Care was taken to avoid constructing prompts that had significant or new knowledge beyond the year 2020. Each of the prompts was presented thrice to ChatGPT. The questions covered common disorders such as primary acquired nasolacrimal duct obstruction and congenital nasolacrimal duct obstruction and their cause and management. The prompts also tested ChatGPT on certain specifics, such as the history of dacryocystorhinostomy (DCR) surgery, lacrimal pump anatomy, and human canalicular surfactants. ChatGPT was also quizzed on controversial topics such as silicone intubation and the use of mitomycin C in DCR surgery. The responses of ChatGPT were carefully analyzed for evidence-based content, specificity of the response, presence of generic text, disclaimers, factual inaccuracies, and its abilities to admit mistakes and challenge incorrect premises. Three lacrimal surgeons graded the responses into three categories: correct, partially correct, and factually incorrect. RESULTS: A total of 21 prompts were presented to the ChatGPT. The responses were detailed and were based according to the prompt structure. In response to most questions, ChatGPT provided a generic disclaimer that it could not give medical advice or professional opinion but then provided an answer to the question in detail. Specific prompts such as "how can I perform an external DCR?" were responded by a sequential listing of all the surgical steps. However, several factual inaccuracies were noted across many ChatGPT replies. Several responses on controversial topics such as silicone intubation and mitomycin C were generic and not precisely evidence-based. ChatGPT's response to specific questions such as canalicular surfactants and idiopathic canalicular inflammatory disease was poor. The presentation of variable prompts on a single topic led to responses with either repetition or recycling of the phrases. Citations were uniformly missing across all responses. Agreement among the three observers was high (95%) in grading the responses. The responses of ChatGPT were graded as correct for only 40% of the prompts, partially correct in 35%, and outright factually incorrect in 25%. Hence, some degree of factual inaccuracy was present in 60% of the responses, if we consider the partially correct responses. The exciting aspect was that ChatGPT was able to admit mistakes and correct them when presented with counterarguments. It was also capable of challenging incorrect prompts and premises. CONCLUSION: The performance of ChatGPT in the context of lacrimal drainage disorders, at best, can be termed average. However, the potential of this AI chatbot to influence medicine is enormous. There is a need for it to be specifically trained and retrained for individual medical subspecialties.

The Evolving Story of CNLDO: Serial Photographic Documentation and Parental Perspectives.

PURPOSE: The purpose of this study is to report the temporal sequence of symptomatology of bilateral congenital nasolacrimal duct obstruction and parental perspectives of 2 established lacrimal surgeons studying the natural history of their newborn child. METHODS: Prospective observational report. Once epiphora was noted, a daily assessment and documentation of several symptoms and signs were initiated using iPhone 11 pro camera. These include epiphora, associated discharge, tear meniscus level, matting of lashes, day-night variation in symptomatology, difficulty in eye-opening upon waking up, conjunctival congestion, periocular changes, especially in the tear trough area and lateral canthus, changes in symptom severity with time, regurgitation on pressure over lacrimal sac area, the fullness of the lacrimal sac area or palpable lacrimal sac swelling, and other associated clinical findings. RESULTS: The weekly course of congenital nasolacrimal duct obstruction showed similar patterns in OU, although the phase of severe symptoms was spaced by a 6-week interval between the eyes. The epiphora appeared first, followed by rapidly increasing discharge, the severity of which was alarming to the parents. Periocular skin developed excoriation due to persistent epiphora and cleaning attempts. Focused and regular lacrimal sac compressions resulted in abrupt resolution of epiphora at different time points in each eye. The baby was comfortable when compressions were performed during breastfeeding. Cleaning the discharge regularly can be a daunting task for the new parents. The use of wet 'eye wipes' was more effective and comfortable than a cotton bud or cloth piece. Both the parents were lacrimal surgeons, and they did not overtly feel socially embarrassed due to the congenital nasolacrimal duct obstruction, but questions from family and friends were discomforting. CONCLUSION: Parental perspectives of the temporal sequence of congenital nasolacrimal duct obstruction provide better insights into disease management and counseling.

Age-Related Changes in the Lacrimal Punctum Morphology in a Normal Population: Punctum Update (PUP) Study-Paper 1.

PURPOSE: To define the clinical and optical coherence tomography (OCT) morphology of the lacrimal punctum and assess the age-related changes across 8 decades of life in a normal population. METHODS: A total of 1310 high-magnification slit-lamp, Fourier-domain OCT (FD-OCT), and optical coherence tomography angiography (OCTA) images were obtained from 320 puncta of normal asymptomatic individuals representing the Indian population. The punctum and peri-punctal area were defined with the help of 2 rims (inner punctal rim and outer punctal rim ) and 3 zones (white zone [Wz], separation zone [Sz], and peri-punctal vascularity). FD-OCT images were used to measure the external punctal diameters and internal lacrimal punctal diameters and the reflectivity patterns of the 3 punctal layers. OCTA was used to assess the branching and extent of vascular networks. RESULTS: The upper puncta were narrower and more circular than the lower puncta across the decades. The elevation of the punctal papilla began in the upper puncta in the fifth decade, involved the lower puncta in the sixth decade, and gradually became exaggerated by the eighth decade. A typical punctal narrowing in previously wide puncta began to appear in the sixth decade of life, peaks in the seventh decade, and reverses gradually and spontaneously by the end of the eighth decade of life. The third and fourth decades saw a narrowing of the Sz with prominent vascularity crossing the Sz to reach the Wz. The Sz became indistinct in the fifth and sixth decades of life. The FD-OCT showed gradual thickening and dominance of the fibrous layer from the fifth to eighth decade of life. The clinical vascularity in the peri-punctal region increases from the third decade onwards, with vascular networks becoming increasingly dense, intricate, and branched as the age progresses. CONCLUSION: The present study defined and characterized the involutional changes in a normal population's first-eighth decades of life. Significant morphological changes were noticed across the different age groups with several clinical implications.

Effect of Topical 5-Fluorouracil on Lacrimal Drainage System: Histopathological Evidence From Animal Experiments and Potential Clinical Implications.

PURPOSE: The purpose of this study is to investigate the histopathological changes in the lacrimal drainage system of rabbits following the application of 1% topical 5-fluorouracil (5-FU) for 4 weeks. METHODS: Ten eyes of 10 healthy New Zealand white rabbits were subjected to topical instillation of 1% (10 mg/mL) 5-FU, 1 drop 4 times a day for 4 weeks. Rabbits underwent a detailed ocular examination including eyelids, ocular surface, punctal, peri-punctal changes, and nasolacrimal duct patency at baseline and after 4 weeks of 5-FU. The rabbits were then sacrificed, and the eyelid, conjunctiva, lacrimal gland, and the entire lacrimal drainage system were retrieved for histopathological analysis as per standard protocols. RESULTS: Clinically demonstrable peripunctal changes and canalicular stenosis were noted in 6 (60%, 6/10) rabbits. Two of these (20%, 2/10) had additional complete regurgitation of clear fluid, indicating a nasolacrimal duct obstruction. The remaining 4 (40%, 4/10) clinically did not demonstrate lacrimal drainage changes and were patent on irrigation. The conjunctiva showed focal loss of goblet cells in several areas. Significant changes were noted in the canalicular, lacrimal sac, and the nasolacrimal duct tissues in the form of epithelial hyperplasia, subepithelial inflammation, edema, dilated and congested vessels, and fibrosis. The lacrimal gland, eyelid tissue (excluding tarsal conjunctiva), and cornea showed no significant histopathological changes. CONCLUSIONS: Clinical and histopathological changes were noted in the lacrimal drainage system of rabbits subjected to topical 5-FU application. These findings can have potential clinical implications for patients receiving 5-FU therapy.

Cadaveric Evaluation of the Canalicular-Lacrimal Sac-Mucosal Folds and Clinical Implications.

PURPOSE: The purpose is to study the anatomical variations of the characteristic mucosal folds at the canalicular-lacrimal sac junction and their potential clinical implications. METHODS: Twelve lacrimal drainage systems of six fresh frozen Caucasian cadavers were studied to assess the openings of the common canaliculus into the lacrimal sac. A standard endoscopic dacryocystorhinostomy was performed until complete lacrimal sac marsupialization and reflection of the flaps. All specimens were subjected to clinical assessment of lacrimal patency via irrigation. A high-definition nasal endoscopy assessed the internal common opening and the mucosal folds in its close vicinity. Probing at the internal common opening was performed to aid in the assessment of the folds. Videography and photo documentation was performed. RESULTS: All 12 specimens had a single common canalicular opening. Ten of the 12 specimens (83.3%) were noted to have canalicular/lacrimal sac-mucosal folds (CLS-MF). Anatomical variations were noted across these 10 specimens and included inferior 180° (n = 6), anterior 270° (n = 2), posterior 180° (n = 1), and 360° CLS-MF (n = 1). Cases were randomly chosen to demonstrate the clinical implications of misinterpreting them as canalicular obstructions or the potential to cause an inadvertent false passage. CONCLUSION: The inferior 180° was the most common CLS-MF noted in the cadaveric study. It is helpful for clinicians to recognize the prominent CLS-MF and their clinical implications intraoperatively. Further fundamental work is needed to characterize the anatomy and the possible physiological role of CLS-MFs.

Impact of Microplastics on the Ocular Surface.

Plastics are synthetic materials made from organic polymers that are ubiquitous in daily living and are especially important in the healthcare setting. However, recent advances have revealed the pervasive nature of microplastics, which are formed by degradation of existing plastic products. Although the impact on human health has yet to be fully characterised, there is increasing evidence that microplastics can trigger inflammatory damage, microbial dysbiosis, and oxidative stress in humans. Although there are limited studies investigating their effect on the ocular surface, studies of microplastics on other organs provide some insights. The prevalence of plastic waste has also triggered public outcry, culminating in the development of legislation aimed at reducing microplastics in commercial products. We present a review outlining the possible sources of microplastics leading to ocular exposure, and analyse the possible mechanisms of ocular surface damage. Finally, we examine the utility and consequences of current legislation surrounding microplastic regulation.

Atypical presentation of punctal keratin cyst: an underdiagnosed entity.

Punctal keratin cyst (PKC) is a rare disorder believed to be due to ectasia of the vertical canaliculus. The etiopathogenesis of this disorder is very poorly understood due to the paucity of literature. To the best of authors' knowledge, only two cases of punctal keratin cyst have been described earlier, which presented as cystic lesions. The authors report four cases of punctal keratin cyst which differ in clinical presentation and also describe the anterior segment ocular tomography features, which aids in recognition and diagnosis of this rare disorder. The key message of the article is that lack of a defined cyst on clinical examination and optical coherence tomography (OCT) cannot rule out the presence of a PKC. A combination of clinical, radiology, and histopathology are confirmative of the diagnosis. Once diagnosed, the subsequent outcomes with membranotomy and keratin curettage are excellent.

Endoscopic and radiological evidence refuting intra-abscess septae.

PURPOSE: To investigate the presence of septae within the lacrimal abscess and to explore simple aspiration as an alternative to the traditional management by incision and drainage. METHODS: Prospective, interventional pilot study involved eight lacrimal sac abscesses of eight patients over a period of three months. All patients underwent a pre-operative MRI with surface coils followed by aspiration of the abscess (n = 4) or incision and drainage of the abscess (n = 4). An intra-sac endoscopic evaluation was performed during the abscess drainage. Primary outcome measures - presence or absence of septae on MRI scan images and endoscopic evaluation of the abscess cavity. Secondary outcome measures - relief from pain and symptoms following aspiration and anatomical patency following definitive management. RESULTS: Eight patients underwent either aspiration (n = 4) or incision and drainage of the abscess (n = 4). Mean age of the patients 43.3 years and male to female ratio was 1:1. Left eye involvement was more common (Right: left = 1:3). Average duration of acute symptoms - 3.75 days. High resolution MRI showed a well- defined abscess cavity with few undulations which on endoscopic evaluation correlated with oedematous mucosal folds. There was absence of a loculi or septae within the abscess cavity. Definitive surgery in the form of endoscopic DCR was performed for all the patients with post-operative FICI grading was +5. CONCLUSION: The present study refutes the presence of septae within the abscess cavity and proposes aspiration of the lacrimal sac abscess as a minimally invasive procedure with minimal logistics and a shallow learning curve.

Long-term outcomes of StopLoss™ Jones tube (SLJT) and minimally invasive conjunctivodacryocystorhinostomy.

PURPOSE: To assess the long-term outcomes of minimally invasive conjunctivodacryocystorhinostomy (MICDCR) with StopLoss™ Jones tubes. METHODS: A retrospective interventional case series was performed on all patients who underwent a MICDCR with StopLoss™ Jones tubes (SLJT) over a period of 5 years. Patients were followed for a minimum of 1 year after surgery. The parameters studied include patient demographics, clinical presentation, indication for MICDCR, duration of surgery, SLJT length, standard Jones tube drainage classification, complications, and anatomical and functional successes. The variables influencing the outcomes were assessed. Anatomical success was defined as patent SLJT on irrigation, and functional success was defined as resolution of epiphora. Statistical analysis was performed using the R 4.0.4 (R Project, R Foundation). RESULTS: A total number of 44 eyes of 42 patients were studied. The mean age of patients was 61.81 years. Approximately 87% and 64% of the patients completed 2 years and 3 years of follow-up, respectively. The Jones tube drainage class dipped significantly from class I to others at the 3-month follow-up. Classes III and IV dominated the follow-up period between 3 and 18 months, and class II dominated at 24 months and beyond. The anatomical and functional successes at the end of 1-year follow-up were 77.2%. The success was not affected by age, gender, length of SLJT tube, or duration of the surgery. However, the middle turbinate reduction influenced the success (P < 0.03). The common complications noted were tube occlusions (40.9%, 18/44) and inferior tube migration (38.6%, 17/44). CONCLUSION: The long-term outcomes with SLJT were good, but the inferior migration was a significant complication. The results of this study reflect the need for continuity of care as long as the tube is in situ.

Microbial Metagenomics of the Extubated Lacrimal Stents Following Dacryocystorhinostomy: The Lacriome Paper 4.

PURPOSE: To study the metagenome of the microbes present on the extubated lacrimal stents following a dacryocystorhinostomy. METHODS: A prospective study was performed on 10 consecutive extubated lacrimal stents obtained for the metagenomic analysis from the patients following an endoscopic dacryocystorhinostomy. The stents were extubated at 4 weeks postoperatively under endoscopic guidance and immediately transported on ice to the laboratory. Following DNA extraction and library preparation, a whole shotgun metagenome sequencing was performed on the Illumina platform. The downstream processing and bioinformatics of the samples were performed using multiple software packaged in SqueezeMeta pipeline or MG-RAST pipeline. RESULTS: The taxonomic hit distribution across the stent samples showed that bacteria were the most common isolates (mean, 69.70%), followed by viruses (mean, 0.02%) and archaea (0.003%). The 3 major phyla identified were Firmicutes, Actinobacteria, and Proteobacteria. The prevalent organisms include Pseudomonas aeruginosa, Staphylococcus aureus, Corynebacterium accolens, Dolosigranulum pigrum, Citrobacter koserii, Staphylococcus epidermidis, E. coli, and Hemophilus influenza . The functional subsystem profiling demonstrated microbial genes associated with metabolism, cellular, and information processing. The functional subsystem categories were metabolism involving carbohydrates, amino acids, DNA and RNA, cell wall or cell capsule biogenesis, membrane transport, virulence, and defense mechanisms. CONCLUSIONS: The present study is the first whole metagenome sequencing of the microbes isolated from the extubated lacrimal stents. The stents harbor diverse microbial communities with distinct ecosystem dynamics. Further studies on microbes-host interactions in the early postoperative period would provide valuable insights.