[Pharmacological prevention of fibrosis in dacryosurgery]. / Medikamentoznaya profilaktika fibrotizatsii v dakriokhirurgii.

Chronic inflammatory process in the lacrimal drainage system is the main etiological factor leading to dacryostenosis and consequent obliteration - partial and total nasolacrimal duct obstruction. Prevention of this process is an urgent problem in dacryology. Currently, there is very little research on the development and use of conservative methods for treating dacryostenosis using anti-inflammatory, as well as anti-fibrotic drugs. In this regard, the main method of treating lacrimal drainage obstruction is dacryocystorhinostomy. However, the problem of recurrence after this operation has not been resolved. The causes of recurrence can be cicatricial healing of dacryocystorhinostomy ostium, canalicular obstruction, formation of granulations and synechiae in its area. Surgical methods of recurrence prevention are associated with possible complications, and there is conflicting data on the feasibility of their use. Based on this, the development of pharmacological methods for the prevention of fibrosis in dacryology is promising, among which the antitumor antibiotic Mitomycin C is the most studied. However, there are no specific scientifically substantiated recommendations for the use of this drug, and the data on its effectiveness vary. This has prompted researchers to look for and study alternative anti-fibrotic agents, such as antitumor drugs, glucocorticoids, hyaluronic acid, small molecule, biological, immunological and genetically engineered drugs, as well as nanoparticles. This review presents the current data on the efficacy and prospects of the use of these drugs in dacryology.

Rebamipide promotes lacrimal duct epithelial cell survival via protecting barrier function.

Nasolacrimal duct obstruction (NLDO) is thought to be due to inflammation and fibrosis of lacrimal duct epithelial cells (LDECs). Here we investigated the effect of rebamipide, a drug that is used for the protection of the mucosa and the treatment of gastritis and gastroduodenal ulcers, on LDECs, both in vitro and in vivo. In this study, LDECs were cultured from rabbit lacrimal duct tissues, and the barrier function of LEDCs was examined in vitro via transepithelial electrical resistance (TER) measurement, with or without interleukin (IL)-6 and/or rebamipide. For the in vivo examination, benzalkonium chloride (BAC) was injected into the rabbit lacrimal ducts, followed by the application of rebamipide or a placebo vehicle alone. The results of the in vitro examination revealed a significant decrease in TER in the group treated with IL-6 alone compared with the placebo-vehicle group (p < 0.05) and the group treated with IL-6 and rebamipide (p < 0.01). The results of the in vivo examination revealed that the infiltration of neutrophils under the basement membrane and the disruption of tight junction proteins with BAC injection and rebamipide attenuates the disturbance of tissue construction. These results suggest that rebamipide protects LDECs via an anti-inflammatory effect and preserves the barrier function of those cells.

Comparative study of stenting and ostium packing in Endoscopic Dacryocystorhinostomy for Primary Acquired Nasolacrimal Duct Obstruction.

In this retrospective study, we compared the efficacy and safety of mechanical adjuvants in mucosal-sparing, mechanical endoscopic dacryocystorhinostomy (MMED) for primary acquired nasolacrimal duct obstruction (PANDO). 116 adult patients (90 female) aged 61 ± 11 received one of the following after MMED without topical mitomycin: no stenting or packing (group 1, n = 25), 1-week ostium packing by ribbon gauze (group 2, n = 29) or non-medicated absorbable gelatin sponge (group 3, n = 25), 8-week bicanalicular stenting (group 4, n = 28). 104 patients(92%) provided 12-month outcomes. Number of patients, age, gender, surgeon, and osteotomy size were comparable among groups (p = 0.4-0.9). Marginal significance was found in anatomical (group 1:80%, group 2:96.6%, group 3:96%, group 4:96.4%, p = 0.05) but not functional success (group 1:85%, group 2:85.7%, group 3:83.3%, group 4:88.9%, p = 0.75) at postoperative 12-month. Patients receiving any packing or stenting achieved better anatomical (96% versus 80%, p = 0.015) but not functional success (85% versus 86%, p = 0.90) compared to those receiving none. More patients receiving stenting developed postoperative granuloma than those who did not (87% versus 63%, p = 0.04). 1-week ostium packing was found to be as effective as 8-week bicanalicular intubation in improving anatomical outcome after MMED for PANDO. Functional outcome, however, did not differ among patients receiving mechanical adjuvant or not.

Transcanalicular laser dacryocystorhinostomy for acquired nasolacrimal duct obstruction: an audit of 104 patients.

PURPOSE: External dacryocystorhinostomy (DCR) is considered as the gold standard in the treatment of acquired nasolacrimal duct obstruction. However, many advances have been made towards the development of modern minimally invasive therapies. These new techniques were proven less harmful to the patients' skin and medial palpebral structures with their palpebral-canalicular pump mechanism. Options include endonasal and transcanalicular procedures. Here, we report on our 2-year experience with the surgical technique, results and complications of transcanalicular laser-assisted DCR. METHODS: This is a retrospective study. A total of 104 patients with acquired nasolacrimal duct obstruction underwent transcanalicular laser-assisted DCR combined with bicanalicular silicon intubation. We then analyzed intra-/post-operative complications and subjective and objective success rates. The institutional ethics committee ruled that approval was not necessary. The trial was registered with the German Clinical Trials Register (DRKS00012879). RESULTS: Transcanalicular laser-assisted DCR in combination with bicanalicular silicon intubation could be performed surgically successfully in 101 patients (97%). In three cases (3%) using the superior canalicular approach, positioning of the laser instrument at the anteroinferior rim of the middle turbinate failed. Complications included thermal injury to the canaliculus (one), canalicular infection (two) and silicon tube prolapse (ten). Functional success (resolution of preoperative symptoms) was achieved in 80 cases (77%), functional failure occured in 24 cases with all patients reporting persisting epiphora, 15 reporting failure to irrigate the nasolacrimal duct and 15 requiring secondary external DCR. CONCLUSIONS: Laser-assisted DCR shows promising results with few complications. It seems well suited as a second-step procedure after failed recanalization and before external DCR.

Lateral tarsal strip versus lateral tarsal strip with three-snip punctoplasty for managing epiphora in involutional ectropion.

PURPOSE: To compare the efficacy of two surgical techniques-lateral tarsal strip (canthoplasty) alone, and lateral tarsal strip with three-snip punctoplasty-in reducing epiphora arising from involutional ectropion with partial punctal stenosis. METHODS: Fourty patients with involutional ectropion and partial stenosis of the lacrimal punctum were randomly allocated to two treatment groups. Group 1 patients received lateral tarsal strip alone with only non-invasive stenting of the punctum, and group 2 patients received tarsal strip plus three-snip punctoplasty. Subjective assessment of epiphora was achieved via completion of a quality of life (QoL) questionnaire preoperatively and at postoperative month 3. Eyelid position, adverse outcomes and corneal dryness (via Oxford grading scheme) were also assessed postoperatively. Only patients with unilateral problems were included in the study. RESULTS: Forty eyes of 40 patients were included: 20 in each group. The mean ages of group 1 and group 2 patients were 79±11 and 80±9 years, respectively. All patients reported significantly reduced eye watering after surgery, with no significant intergroup difference in subjective outcomes, except that computer usage and night driving (P<0.05), improved in a more significant way in group 2. Eyelid malposition was corrected in all cases, there were no cases of postoperative punctal eversion, and no significant adverse events or complications occurred. Finally, the mean improvements in the dryness/keratitis score (using the Oxford scheme) were comparable between the 2 groups (P=0.34). CONCLUSION: The study findings indicate that treatment of involutional ectropion with partial punctal stenosis by lateral tarsal strip with three snip punctoplasty does not provide greater reduction in discomfort secondary to epiphora than conventional lateral tarsal strip alone, except for specific situations such as night driving or computer use.

[Recognition and prevention of problems in lacrimal duct surgery]. / Erkennung und Vermeidung von Schwierigkeiten bei der Tränenwegschirurgie.

Surgical management of lacrimal duct obstruction beyond the canaliculi proves to be a promising endeavor in most cases. To realize the full potential of endonasal dacryocystorhinostomy, some aspects of diagnosis and differential indication setting should be considered in order to avoid errors and problems during patient selection, execution of the technical procedure, and communication with ophthalmologists. These issues are described according to the clinical management of patients; current literature is cited.

The use of prophylactic Nunchaku stents to reduce the risk of nasolacrimal duct obstruction in patients with midfacial tumours undergoing radiotherapy.

The treatment of midfacial tumours with radiotherapy, chemotherapy and radio-iodine can cause nasolacrimal duct fibrosis resulting in epiphora. Nasolacrimal patency can be maintained by stenting. We report our experience of prophylatic Nunchaku stent insertion in 5 patients prior to midfacial radiotherapy. Four out of 5 patients (80%) had patent nasolacrimal ducts without any symptoms of epiphora following removal of the stents. One patient was initially asymptomatic with patent nasolacrimal duct, but subsequently developed epiphora. Nunchaku stents may provide a simple and effective way of preventing epiphora, obviate the need for nasal retrieval that is required for other nasolacrimal stents, and reduce the risk of requiring further lacrimal surgery.

[Tumors of the lacrimal drainage system]. / Tumoren der ableitenden Tränenwege.

BACKGROUND: The prevalence of tumors affecting the lacrimal drainage system is low, thus generating a risk of late diagnosis and treatment in clinical routine. However, these tumors can be potentially life-threatening, which emphasizes the relevance of early diagnosis and treatment. OBJECTIVE: This review focuses on the symptoms, incidence, management, and prognosis of the different tumor entities affecting the lacrimal drainage system. METHODS: The study provides a PubMed-based literature review and presents own clinical results. RESULTS: Alongside detailed medical history taking and comprehensive clinical examination, precise inspection during external dacryocystography is important for diagnosis of tumors affecting the lacrimal drainage system. There is a wide spectrum of tumor entities located in the lacrimal drainage system. The tumors are classified into three groups: primary epithelial, primary nonepithelial, and inflammatory lesions. The most common primary epithelial tumors include papilloma, squamous cell carcinoma, and transitional cell carcinoma. The most common nonepithelial tumors include fibrous histiocytoma, malignant lymphoma, and malignant melanoma; while the most common inflammatory lesions comprise sarcoidosis, Wegener granulomatosis, and pyogenic granuloma. Treatment depends on the entity and stage of the tumor. In the case of malignancy, a multimodal and interdisciplinary approach is usually indicated. CONCLUSION: Differential diagnostic signs in favor of a malignancy include a long medical history, predisposing conditions in the patient's history, a mass above the medial canthal ligament, teleangiectasis above the mass, and serosanguinous secretion.

A Multi-tool to Reduce Nasolacrimal Stent Complications With the Home-Removable Farson Crawford Tube.

PURPOSE: Tear duct obstruction can be treated with probing and stenting, providing a reduced reoperation rate. A new instrument combining punctual dilation with the graduated diameter probe and bony-rasp was developed to assist the procedure. METHODS: Laterality, type of nasolacrimal disorder, type of procedure, patient age, and postoperative outcome were monitored for one surgeon for two decades. RESULTS: From 617 cases of pediatric tear duct obstruction, 494 used the bilateral, monocanalicular Farson method, yielding a 1.7% reoperation rate and 0.6% wire-strip rate. The nasolacrimal duct dilator rasp multi-tool, used since 1996, had a similarly low rate of complications. CONCLUSIONS: The Farson technique with the multi-tool provides an affordable, effective procedure for childhood nasolacrimal obstruction, allowing home removal of the stent.

Effects of Capsaicin and Carbachol on Secretion From Transplanted Submandibular Glands and Prevention of Duct Obstruction.

PURPOSE: To investigate whether capsaicin and carbachol promote secretion from and prevent duct obstruction in transplanted submandibular glands (SMGs). METHODS: This retrospective cohort study included consecutive patients with severe keratoconjunctivitis sicca and successful SMG transplantation. Patients were divided into 2 groups: an exposed group receiving both capsaicin and carbachol after surgery and an unexposed group receiving neither. Secretion changes in response to capsaicin and carbachol administration were recorded in the exposed group. The main outcome measures were the secretory flow rate and duct obstruction rate in the transplanted SMGs. RESULTS: Forty-four patients (44 eyes) in the unexposed group and 115 patients (128 eyes) in the exposed group were followed up for more than 3 months postoperatively. The baseline characteristics were similar between the groups. The secretory flow rate before and 5, 25, 55 minutes after administration was 1 mm (0-2 mm) (median with interquartile range), 3 mm (1-5 mm), 4 mm (2-5 mm), 1 mm (0-2.5 mm), respectively, for capsaicin and 1 mm (0-3 mm), 1050 mm (450-1500 mm), 375 mm (150-600 mm), 0 mm (0-150 mm), respectively, for carbachol (P < 0.001 for both). In the exposed group, 6.2% of eyes had duct obstruction, whereas 18.2% of eyes in the unexposed group had duct obstruction (P = 0.031) (odds ratio = 0.3, 95% confidence interval, 0.105-0.856). CONCLUSIONS: This study provides evidence that capsaicin and carbachol effectively promote secretion from and prevent duct obstruction in transplanted SMGs during at least 3 months after transplantation.

Selective partial middle turbinectomy to minimize postoperative obstruction following Lester Jones tube placement.

PURPOSE: Conjunctivodacryocystorhinostomy (CDCR) with the insertion of a Jones tube is a surgical procedure used to relieve epiphora caused by upper lacrimal system dysfunction from extensive proximal canalicular obstruction, canalicular stenosis, or canalicular flaccidity. Jones tube obstruction, which is the second most frequent complication of CDCR with tube placement, can result from tube placement against the anterior end of the middle turbinate. In this study, we describe our results in 5 patients who underwent anterosuperior partial middle turbinectomy to prevent obstruction. METHODS: A retrospective analysis was performed on 5 patients who underwent selective anterosuperior partial middle turbinectomy to prevent Jones tube obstruction. Three of these patients developed Jones tube obstruction due to contact between a previously placed Jones tube and the anterosuperior aspect of the adjacent middle turbinate. Two other patients had observed contact between the Jones tube and middle turbinate at initial Jones tube placement and underwent anterosuperior partial middle turbinectomy to prevent development of obstruction. Patency of the Jones tube was assessed symptomatically and by nasal endoscopy at the latest follow-up. RESULTS: All 5 patients displayed a patent Jones tube after a mean follow-up of 29.6 months without complications. Longer-term complications associated with CDCR with Jones tube placement, including continuous epiphora, dacrocystitis, and poor patient satisfaction, were not observed. CONCLUSIONS: Selective anterosuperior partial middle turbinectomy may prevent or relieve Jones tube obstruction, provide increased room along the lateral nasal wall along which to place the Jones tube, and decrease the need for further surgeries arising from tube blockage.

Clinical outcomes of dacryocystorhinostomy with or without intraoperative use of mitomycin C: a systematic review and meta-analysis.

PURPOSE: To examine the possible benefit of intraoperative use of mitomycin C (MMC) application in dacryocystorhinostomy (DCR) and to assess its potential risk. METHODS: Systematic review and meta-analysis of randomized-controlled trials (RCTs). A comprehensive literature search was performed according to a protocol set in advance. The participants included 811 patients of which 820 eyes were sampled for 14 RCTs. Only pertinent RCTs were identified and included in this meta-analysis. The primary efficacy measure was "patency of irrigation" at follow-up end point. The subjective outcome of "symptom relief" was also extracted as a secondary efficacy measure. For each study, relative risk was extracted. Heterogeneity, publication bias, subgroup, and meta-regression analyses were performed. RESULTS: RevMan version 5.0 software was used for statistical analysis. In the primary efficacy measure, the use of MMC can significantly increase the rate of "patency of irrigation" [risk ratio (RR), 1.10; 95% confidence interval (CI), 1.04-1.17; P=0.0006]; the outcome of "symptom relief" was also affected by the use of MMC (RR, 1.15; 95% CI, 1.05-1.26; P=0.003). Sensitivity analysis suggested that the result was comparatively reliable. CONCLUSION: Intraoperative use of MMC can bring about a positive effect to the outcomes of "patency of irrigation" and "symptom relief," which increases the success rate of DCR surgery.

[Prevention of ostial obstruction after microendoscopic endonasal dacryocystorhinostomy].

Ostial dilatator was created to prevent recurrence and improve efficacy of microendoscopic endonasal dacryocystorhinostomy. Proposed technique was for the first time used in 52 patients. Postoperative results were analyzed: recovery was achieved in 78% of cases, improvement - in 22%. In a control group (51 patients) we used conventional technique, recovery was achieved in 67% of patients and improvement in 28%, in 5% recurrence occurred. The use of ostial dilatator resulted in microendoscopic endonasal dacryocystorhinostomy efficacy improvement.

[Clinical study on the treatment of relapse canalicular obstruction with trephination under lacrimal endoscopy].

OBJECTIVE: To evaluate the efficacy of trephination under lacrimal endoscopy in the treatment of relapse canalicular obstruction. METHODS: In this retrospective cases series, 67 patients (73 eyes) with relapse canalicular obstruction were examined and treated in the Second Affiliated Hospital of Nanjing Medical University between Feb. 2007 and Feb. 2008. These patients were examined by endoscopy of the lacrimal drainage system under local anesthesia, the obstructions were treated with miniature annular drill and silicone stent intubation. All patients were followed up for 6 months postoperatively. RESULTS: Silicone tubes were successfully removed after 3 to 5 months postoperatively in all eyes. After followed up for 6 months, the complete successful rate, as defined on a total relief of epiphora and patent on nasolacrimal irrigation, was 69.86% (51/73). Nineteen eyes (26.03%) showed improvement, which showed slight epiphora and were unobstructed during irrigation of lacrimal passage. Three eyes (4.11%) were failure, which still had epiphora and showed reflex during nasolacrimal irrigation. The effective rate of treatment was 95.89% (70/73). The effective rate for the treatment of upper and lower canalicular obstruction combined with nasolacrimal duct obstruction was lower than that of simple lower canalicular obstruction or common canalicular obstruction. CONCLUSIONS: Trephination under lacrimal endoscopy is a nontraumatic and effective procedure for the treatment of relapse canalicular obstruction. It significantly improves the effective rate of treatment for canalicular obstruction.

[Lacrimal-nasal canal stenosis after intranasal surgery]. / La stenose du canal lacrymo-nasal après chirurgie intranasale.

The etiology of the nasolacrimal duct obstruction usually reported is: idiopathic, infectious, traumatic, congenital, tumoral and others. The nasolacrimal duct stenosis after intranasal surgery is rarely reported in the literature. We describe 5 cases of iatrogenic nasolacrimal duct stenosis found in our series of 41 patients treated the last 2 years for nasolacrimal duct obstruction and we propose how to avoid this complication of intranasal surgery.

Prophylaxis of nasolacrimal duct obstruction after major sinus surgery using a silicone stent.

Damage to the nasolacrimal duct during major sinus procedures results in troublesome symptoms of epiphora and acute infection. Prophylactic stenting of the lacrimal apparatus using a silicone stent is described as a means of preventing such complications.