Surgical outcomes of endoscopic dacryocystorhinostomy for eyes with nasolacrimal duct obstruction via tear meniscus height evaluation.

PURPOSE: To evaluate the association of tear meniscus height (TMH) with clinical outcomes of patients who underwent endonasal dacryocystorhinostomy. METHODS: We recruited 304 patients from two institutes. The TMH was measured using anterior segment optical coherence tomography before surgery. All patients underwent endoscopic DCR with lacrimal intubation stent insertion. The lacrimal stent was removed 2 months after surgery. The TMH was measured at 2 months and 12 months after surgery. Improvements in epiphora were assessed using a visual analogue scale (range, 0-2). Recurrence was determined based on lacrimal irrigation and endoscopic evaluation results. RESULTS: All patients experienced improvements in subjective symptoms 2 months after surgery. The mean TMH also decreased significantly compared with that before surgery. During the follow-up period, four patients experienced recurrence. The mean TMH 12 months after surgery was significantly lower than that before surgery. The rate of change in the TMH was significantly associated with the use of a dacryoendoscope during sheath-guided lacrimal stent intubation at all time points. Of the 251 patients who were followed up at 12 months after surgery, three reported recurrences, and 17 reported mild improvement of epiphora. The rate of change in the TMH was significantly associated with epiphora improvement. Height was also associated with epiphora improvement. CONCLUSIONS: Endoscopic DCR is an acceptable surgical procedure for managing nasolacrimal duct obstruction. Sheath-guided lacrimal stent intubation using a dacryoendoscope resulted in a greater reduction in postoperative TMH compared to the blind insertion technique, which may lead to favorable clinical outcomes.

Two cases of nasolacrimal duct obstruction operated by endoscopic dacryocystorhinostomy after orbital fracture reconstruction with an implant.

Purpose: To report two cases of nasolacrimal duct obstruction (NLDO) caused by orbital fracture reconstruction with an implant successfully treated with endoscopic dacryocystorhinostomy (EnDCR). Observations: Two patients presented with NLDO after orbital fracture reconstruction with an implant. Case 1 was a 67-year-old female. She became aware of epiphora in her left eye after undergoing orbital fracture reconstruction with an implant for a left orbital floor fracture 14 years previously. Dacryocystitis was diagnosed based on a lacrimal syringing test because of pus reflux. Computed tomography (CT) showed that the implant was inserted on the left orbital floor, crossing into the lacrimal sac; dacryoendoscopy showed that the implant blocked the nasolacrimal duct. EnDCR was performed without implant removal. The symptoms resolved postoperatively. Case 2 involved a 6-year-old male who had been aware of epiphora in his left eye since undergoing orbital fracture reconstruction with an implant for a left orbital floor fracture one month prior. Dacryocystitis was diagnosed based on a lacrimal syringing test because of pus reflux. CT showed an unclear implant location, but dacryoendoscopy showed that the implant blocked the nasolacrimal duct. The implant was removed. However, EnDCR was performed because there was no improvement in NLDO. The symptoms resolved after EnDCR. Conclusions and importance: One previous report of NLDO after orbital floor fracture reconstruction was performed with external dacryocystorhinostomy with implant removal. Dacryoendoscopy and CT are useful for confirming the location of the implant and obstruction. Depending on the implant's location, it may be possible to perform EnDCR without removing the implant.

DOCK8-expressing T follicular helper cells newly generated beyond self-organized criticality cause systemic lupus erythematosus.

Pathogens including autoantigens all failed to induce systemic lupus erythematosus (SLE). We, instead, studied the integrity of host's immune response that recognized pathogen. By stimulating TCR with an antigen repeatedly to levels that surpass host's steady-state response, self-organized criticality, SLE was induced in mice normally not prone to autoimmunity, wherein T follicular helper (Tfh) cells expressing the guanine nucleotide exchange factor DOCK8 on the cell surface were newly generated. DOCK8+Tfh cells passed through TCR re-revision and induced varieties of autoantibody and lupus lesions. They existed in splenic red pulp and peripheral blood of active lupus patients, which subsequently declined after therapy. Autoantibodies and disease were healed by anti-DOCK8 antibody in the mice including SLE-model (NZBxNZW) F1 mice. Thus, DOCK8+Tfh cells generated after repeated TCR stimulation by immunogenic form of pathogen, either exogenous or endogenous, in combination with HLA to levels that surpass system's self-organized criticality, cause SLE.

Success rates of dacryoendoscopy-guided probing for recalcitrant congenital nasolacrimal duct obstruction.

PURPOSE: Our aim was to review the success rates of dacryoendoscopy-guided probing for recalcitrant congenital nasolacrimal duct obstruction (CNLDO). METHODS: We reviewed the medical records of 498 patients (521 eyes) diagnosed with CNLDO between January 2011 and November 2013. Of these, 54 eyes met the eligibility criteria and underwent probing with a dacryoendoscope. RESULTS: Of the 54 eyes, 21 were classified as failed cases at other hospitals, 13 as cases requiring conversion from blind to dacryoendoscopy-guided probing during surgery at our hospital, and 20 as cases requiring intervention under general anesthesia because of difficulty with topical anesthesia. The overall success rate with dacryoendoscopy was 98.1 % (53/54 eyes) at postoperative week 2 and 97.1 % (33/34 eyes) a year after surgery. Among the cases that failed at other hospitals, one showed the formation of five false passages in the middle area of the nasolacrimal duct. In 11 eyes, slit-like adhesion was confirmed as a blurred linear line at the distal end of the nasolacrimal duct. Patency could be smoothly achieved by releasing the adhesion. CONCLUSIONS: Our study showed a high success rate for dacryoendoscopy-guided probing in CNLDO patients. The use of a dacryoendoscope allows direct visualization of the lacrimal passage and is likely to become necessary for managing CNLDO.

Evaluation of dacryocystorhinostomy using optical coherence tomography and rebamipide ophthalmic suspension.

PURPOSE: To evaluate the surgical outcome of dacryocystorhinostomy (DCR) by measuring the tear meniscus, using optical coherence tomography and rebamipide ophthalmic suspension. METHODS: Patients with nasolacrimal obstruction and chronic dacryocystitis who were scheduled for an endonasal DCR underwent tear meniscus examinations before and 2 months after surgery. Vertical scans of the inferior menisci were performed before and at 1, 3, 5, 7, and 10 minutes after the instillation of rebamipide ophthalmic suspension. The tear menisci areas were measured with imaging software. Ten young adults without epiphora formed the control group. RESULTS: Anatomical success was achieved on 22 sides of 21 patients. The patients' postoperative tear menisci were significantly smaller than the preoperative menisci at all points during the test, and the response to volume loading in the postoperative patients was corrected to nearly that of the young, healthy adults. Nevertheless, the postoperative meniscus area tended to be larger than that of the young adults at all points. CONCLUSION: The reduced tear meniscus area after DCR reflected the success of the surgical procedure. However, incomplete recovery of the meniscus after the test might suggest a residual disorder of the lacrimal drainage system after DCR.