Exorbital Lacrimal Gland Ablation and Regrafting Induce Inflammation but Not Regeneration or Dry Eye.

The study evaluated the regenerative responses of the lacrimal functional unit (LFU) after lacrimal gland (LG) ablation. The LG of Wistar rats was submitted to G1) partial LG ablation, G2) partial ablation and transplantation of an allogeneic LG, or G3) total LG ablation, (n = 7-10/group). The eye wipe test, slit lamp image, tear flow, and histology were evaluated. RT-PCR analyzed inflammatory and proliferation mediators. The findings were compared to naïve controls after 1 and 2 months (M1 and M2). G3 presented increased corneal sensitivity, and the 3 groups showed corneal neovascularization. Histology revealed changes in the LG and corneal inflammation. In the LG, there was an increase in MMP-9 mRNA of G1 and G2 at M1 and M2, in RUNX-1 at M1 and M2 in G1, in RUNX-3 mRNA at M1 in G1, and at M2 in G2. TNF-α mRNA rose in the corneas of G1 and G2 at M2. There was an increase in the IL-1ß mRNA in the trigeminal ganglion of G1 at M1. Without changes in tear flow or evidence of LG regeneration, LG ablation and grafting are unreliable models for dry eye or LG repair in rats. The surgical manipulation extended inflammation to the LFU.

[A case of eyelid fistula after cosmetic lateral canthoplasty].

A 35-year-old female presented with a chief complaint of exudates from the outer corner of the left eye for more than half a year after cosmetic lateral canthoplasty. A fistula was seen in the skin of the left eye 5 mm from the lateral canthus, with clear fluid inside it. Left eyelid fistula was diagnosed and surgically removed. The histopathological examination confirmed that the tissue connected with the fistula was lacrimal gland tissue. No recurrence was found during the 2-month follow-up.

Bilateral Lacrimal Gland Lymphoma - Case Presentation.

Lacrimal gland lymphomas are rare orbital tumors, constituting a minor fraction of all orbital and ocular adnexal malignancies. This case study presents an 83-year-old male with bilateral lacrimal gland tumors, more prominent in the left orbit, causing decreased visual acuity, red eye, excessive tearing, and diplopia. Initial ophthalmological evaluations and imaging suggested bilateral lacrimal gland lymphoma, confirmed by histopathology as diffuse large B-cell non-Hodgkin lymphoma of the MALT type. Due to the significant tumor size and risk of visual function loss, surgical intervention was performed, followed by corticosteroid therapy. Postoperatively, a marked improvement in symptoms and a reduction in tumor size were observed. This case underscores the importance of comprehensive diagnostic approaches, including clinical, imaging, and histopathological evaluations, highlighting the need for a multidisciplinary approach in managing rare orbital tumors like lacrimal gland lymphoma. The patient's postoperative and follow-up care included oncological management to monitor and ensure long-term disease control and patient well-being. Abbreviations: RE = right eye, LE = left eye, CT = Computer tomography, MRI = Magnetic Resonance Imaging, TOD = intraocular pressure of right eye, TOS = intraocular pressure of left eye, US = ultrasound.

Pigtail with self-retaining bicanalicular intubation combined with Mitomycin C for the treatment of acquired lower punctal stenosis.

BACKGROUND: The pigtail was used to create an opening at the lower punctal site in grade 0 stenosis with insertion of self-retaining tube and Mitomycin C (MMC). METHODS: The patients with acquired lower punctal stenosis (grade 0) were divided randomly into equal groups, Group A: were treated with pigtail and MMC 0.02% and Group B: were treated with pigtail alone. The pigtail was inserted through the upper punctum until its tip reached the occluded punctum, this site was incised with a scalpel (No. 11). A self-retaining bicanalicular tube was then placed. RESULTS: Results of 36 eyes from 26 patients were included. No differences were observed between both groups regarding epiphora score, FDD test and punctal size preoperatively. The postoperative epiphora score, there were significant differences at 1 month (P = 0.035), 3 months (P = 0.005), and 6 months after removal (P < 0.001). The FDD test, there were significant differences at 6 months (P = 0.045), 1 month (P = 0.021), 3 months (P = 0.012), and 6 months post tube removal (P = 0.005). The punctal size, both groups differed at 1 month (P = 0.045), 3 months (P = 0.03), and 6 months post tube removal (P = 0.005). Only one case (5.5%) at each group showed extrusion of the tube. CONCLUSION: The pigtail probe, bicanalicular stent and MMC can be an effective method in treatment of severe punctal stenosis.

Exclusive or combined endoscopic approach to tumours of the lower lacrimal pathway: review of the literature.

A literature review was conducted to assess the role of minimally-invasive endoscopic treatments for lacrimal pathway neoplasms. The study involved the analysis of 316 patients with benign or malignant tumours affecting the lacrimal drainage system. Histologically, the analysis revealed a prevalence of squamous cell carcinoma, followed by lymphatic neoplasms and melanomas. In terms of treatment, minimally-invasive endoscopic approaches, such as endoscopic dacryocystorhinostomy, play a predominant role in managing early-stage tumours, rather than merely obtaining samples for histological analysis. For more extensive tumours, which constitute the majority of cases, more aggressive external approaches are required, along with the use of adjuvant radiotherapy and chemotherapy. The lack of universally shared staging systems poses a limitation in standardisation and comparison of results. Treatment of these tumours remains complex due to their rarity and histological heterogeneity. A multidisciplinary approach is mandatory to optimise outcomes.

Diagnosis and Treatment of Lacrimal Gland Prolapse: A Narrative Review.

BACKGROUND: Lacrimal gland prolapse (LGP) is considered to be one of the causes for upper eyelid contour abnormality that should be recognized and treated properly to yield satisfactory outcomes in blepharoplasty. To describe current findings about the prevalence, pre- and intraoperative diagnosis of LGP and its treatment options. METHODS: PubMed and Google Scholar were thoroughly searched for articles published describing the diagnosis and treatment of LGP. RESULTS: The reported prevalence of LGP by various authors varies between 10 and 60% based on their preoperative or intraoperative reports. Techniques such as dacryoadenopexy, modified dacryoadenopexy, and dacryoplasty have been described to secure the prolapsed lacrimal gland back into its original position. Additionally, creating a Whitnall's barrier has also been suggested as a method to reposition the gland. While all these surgical procedures have shown promising immediate results, there is a lack of published data on their long-term outcomes. CONCLUSION: Diagnosis and proper treatment of LGP could enhance the cosmetic results of upper eyelid blepharoplasty. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Long-term outcome of minor salivary gland transplantation for pediatric congenital alacrimia.

A 3-year-old boy presented with repeated episodes of corneal erosions and ulceration and absence of tear secretion since birth. Examination under anesthesia revealed a dry ocular surface, with corneal scarring and vascularization. Computed tomography of the orbit showed complete absence of lacrimal glands bilaterally. Minor salivary gland transplantation was performed in the right eye, which was more severely affected. This procedure has been used to manage severe dry eyes but not previously for congenital alacrimia. On long-term follow-up, 5 years after surgery, we observed considerable improvement in the photophobia, corneal transparency, and neovascularization.

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.

Canalicular laceration repair using a novel bicanalicular silicone stent versus traditional bicanalicular stent with nasal fixation.

PURPOSE: To compare the clinical effects of two types of lacrimal stents in the repair of canalicular lacerations. METHODS: A retrospective analysis was conducted on patients with canalicular lacerations between January 2017 and December 2022. The canalicular reconstruction was performed using either the Runshi-RS bicanalicular silicone stent or the traditional bicanalicular silicone stent with nasal fixation, under a surgical microscope. The stent was placed for 3 months, and patients were followed up for more than 3 months after extubation. The anatomical and functional success rates were compared between the two groups. Anatomical success was assessed through diagnostic probing and irrigation of lacrimal passage, while functional success was determined by the patient's subjective symptoms of epiphora. RESULTS: The study included 315 patients (315 eyes) undergoing canalicular laceration repair. The Runshi-RS stent was utilized in 147 patients (46.7%), while the traditional stent with nasal fixation was employed in 168 patients (53.3%). The anatomical success rates (99.3% vs 98.8%, P = 0.642) and functional success rates (87.2% vs 88.1%, P = 0.926) were similar between the RS group and the traditional stent group. Postoperative complications were fewer (4.1% vs 10.1%, P = 0.04) and the operation time was shorter (67.1 ± 35.3 min vs 86.1 ± 43.4 min, P < 0.001) in the RS group. CONCLUSION: The Runshi-RS tube demonstrates favorable surgical outcomes for the repair of canalicular lacerations. Compared to the traditional stent with nasal fixation, the RS stent allows for shorter operation times and fewer postoperative complications in the repair of canalicular lacerations.

An effective approach for the treatment of severe punctal stenosis: Bicanalicular silicone tube intubation with pigtail probe.

PURPOSE: To evaluate the results of using a pigtail probe to open the inferior punctum followed by bicanalicular silicone tube intubation in patients with severe acquired punctal stenosis. METHODS: Forty-one eyes of 25 patients with severe inferior punctal stenosis admitted to our tertiary care center were included in the study. The degree of epiphora was determined using the Munk score and the fluorescein disappearance test. The inferior punctum was located and opened by entering the superior punctum with a pigtail probe. Then, bicanalicular silicone tube intubation was performed. The silicone tube was removed after six months. A Munk score of 0 or 1 and a fluorescein disappearance test score of 1 and 2 were considered a complete success. RESULTS: Ten (40%) patients were male, and 15 (60%) were female. The mean age was 60.4±15.5years. One year after the surgery, epiphora was absent in 18 eyes (43.9%) (Munk score grade 0) and rarely seen in 9 eyes (22%) (Munk score grade 1). At the one-year follow-up, the fluorescein disappearance test score was stage 1 (<3min) in 21 eyes (51.2%) and stage 2 (3-5min) in 13 eyes (31.7%). There was a statistically significant difference between the preoperative and one-year postoperative test results (P<0.001). CONCLUSION: In cases with severe punctal stenosis, a pigtail probe is an effective method for locating and opening the punctum, and punctal opening and prevention of restenosis were achieved by a bicanalicular stent.

[Lacrimal system trauma]. / Traumatologie lacrymale.

Among lacrimal system injuries, canalicular lacerations are at the top of the list. Men are more affected than women, but children are most likely to experience such trauma. The cause depends on the patient's age: in young children, there is a higher prevalence of animal bites (dogs and cats); in young adults, fights predominate, since motor vehicle accidents have become less common; in the elderly, falls are among the most frequent causes. Tetanus vaccination is required in all cases, but assessment for rabies exposure is necessary in the case of dog or cat bites. Diagnosis is very simple: it is based on examination or wound probing. Other head, facial, or ocular injuries must be excluded; for example, an injury to the globe must take precedence over a canalicular laceration. In the absence of an ocular injury, the canalicular wound should be managed surgically within 48hours under an operating microscope: identification of both severed ends of the injured canaliculus, suture of the severed canaliculus with monofilament suture, and appropriate lacrimal intubation if indicated. Other trauma to the lacrimal system, such as sharp or blunt trauma to the lacrimal sac or nasolacrimal duct, are much rarer.

Soft Tissue Robotic Assisted Orbital Surgery Using da Vinci SP: A Cadaveric Experience.

PURPOSE: Robotic surgical techniques have transformed many surgical specialties however robotic techniques and applications have been much more limited in ophthalmology. This study aims to evaluate the feasibility of robotic assisted orbital surgery using a single-port novel robotic platform, the da Vinci SP. METHODS: A series of orbital procedures were performed in cadaveric specimens utilizing the da Vinci SP robotic system. The procedures performed included lacrimal gland dissection and biopsy, medial and lateral orbital wall dissections, enucleation, and lid-sparing orbital exenteration. Successful completion of each procedure was defined by the operating surgeon and was considered the primary outcome and marker of feasibility. RESULTS: Seven cadaveric procedures were performed in 3 cadaveric specimens. All 7 procedures were completed successfully without complication. Setup optimization occurred throughout the study and setup and operative times were acceptable. Three instrument arms and 1 endoscope were utilized throughout the study allowing 3 arm operating and dynamic retraction. Instrument size was found to limit surgical access and precision particular at the orbital apex. CONCLUSIONS: This preclinical study demonstrates that the da Vinci SP can be utilized within the orbit and is feasible for several applications. Robotic surgical systems offer significant advantages over conventional techniques and should be embraced. However, current commercially available robotic platforms are not optimized for the orbit and have their limitations although they may be suitable for some clinical applications.

Optimisation of reduction for prolapsed silicone tube after lacrimal intubation.

BACKGROUND: A common complication of bicanalicular intubation is dislocation of the silicone tube. METHODS: Eleven patients with prolapsed silicone tubes who had undergone bicanalicular nasal intubation were injected with a 2 per cent lidocaine solution to infiltrate the lacrimal duct mucosa. A memory wire probe was used to pull a 4-0 suture through the lacrimal passage retrogradely, allowing the suture to grab the silicone tube. Paraffin oil was applied to the contact part of the rope and the silicone tube, then the distal end of the silk thread was removed from the nostril until the tube was pulled into place. RESULTS: The prolapsed silicone tubes were restored by surgery in nine patients, with the drainage tube in the correct position in the eye and the lacrimal duct irrigation unobstructed. CONCLUSION: The optimisations made in this study are considered effective adjustments of reduction surgery for a prolapsed silicone tube.

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.

The Whitnall Barrier: A Technique for the Management of Lacrimal Gland Prolapse.

BACKGROUND: The Whitnall barrier procedure, a modified Beer and Kompatscher surgical technique to reposition the lacrimal gland, is presented alongside a case series of patients demonstrating excellent aesthetic and functional outcomes. METHODS: The Whitnall barrier procedure is illustrated procedurally and accompanied by a case series of 20 consecutive patients treated in a single institution by a single surgical team between December of 2016 and February of 2020. Lid contour and function were assessed postoperatively, as was patient satisfaction. RESULTS: Thirty-seven eyes of 20 patients were included. All patients were women, with an average age of 50 years. Fourteen patients underwent surgery for cosmesis, four had inactive thyroid eye disease, and two had lacrimal gland enlargement secondary to dacryoadenitis. The degree of lacrimal gland prolapse was described as mild in two eyes and moderate in 35 eyes. All patients had one or more additional surgical procedures. Mean follow-up duration was 11 months, with complete resolution of lacrimal gland prolapse in 34 eyes. The patient who did not have complete resolution had dacryoadenitis and required ongoing immunosuppressive therapy. Two patients were discharged on topical lubricants: one with thyroid eye disease and one cosmetic patient who underwent upper and lower lid blepharoplasties at the same time. There were no intraoperative complications and no incidences of infection, dehiscence, or damage to the lacrimal gland ductules. CONCLUSIONS: The Whitnall barrier technique is a safe and effective surgical procedure to restore the anatomic location of the lacrimal gland. It provides excellent aesthetic and functional outcomes.

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.

Laceração de canalículo lacrimal em centro de referência do centro-oeste paulista / Lacrimal canaliculus laceration in a reference center in the Center-West of the state of São Paulo

RESUMO Objetivo: Descrever as características clínico-epidemiológicas, técnicas cirúrgicas e resultado do tratamento das lacerações canaliculares operadas em nosso serviço. Métodos: Estudo retrospectivo, realizado de janeiro de 2012 a junho de 2020, considerando-se as lesões de canalículo lacrimal operadas em um serviço de referência. Dados demográficos, características das lesões, detalhes das cirurgias e resultado do tratamento foram obtidos de prontuários eletrônicos e analisados estatisticamente. Resultados: Foram incluídos 26 portadores de lesões canaliculares, com idade entre 2 e 71 anos, sendo 73,1% homens. A lesão acometia o canalículo superior em 53,9%; 80,8% pacientes procuraram pelo serviço nas primeiras 24 horas, e 46,2% tiveram a cirurgia realizada entre 24 e 72 horas após o traumatismo. Todos os pacientes tiveram intubação mono ou bicanalicular, e o tempo transcorrido entre a cirurgia e a retirada do silicone, variou de zero a 183 dias. Após a cirurgia, 21 pacientes (80,8%; p<0,05) não apresentaram complicações, 2 (7,7%) evoluíram com obstrução canalicular, 2 (7,7%) com granuloma e 1 (3,8%) com ectrópio de ponto lacrimal. Conclusão: As lesões de canalículo encontradas em nossa prática são mais comuns em crianças ou homens jovens, acometem mais o canalículo superior e as nossas condutas levam a sucesso no tratamento na maior parte dos casos. As grandes controvérsias no assunto persistem, como o tipo e o tempo de permanência do tubo de silicone na via lacrimal. Somente estudos com grandes amostras podem consolidar esses conceitos.

ABSTRACT Objective: To describe the clinical and epidemiological characteristics, surgical techniques, and results of the canalicular laceration treatment at our service. Methods: A retrospective study was carried out from January 2012 to June 2020, considering canalicular injuries operated at a reference center. Demographic data, lesion characteristics, surgical details, and treatment outcomes were obtained from electronic medical records and were statistically analyzed. Results: Twenty-six cases of people with canalicular lesions aged between 2 to 71 years old were included, of whom 73.1% were men. The superior canaliculus was affected in 53.9%; 80.8% of patients searched for care within the first 24 hours, and 46.2% had the surgery performed between 24-72 hours after trauma. All patients had mono or bicanalicular intubation and the time elapsed between surgery and silicone removal ranged from 0 to 183 days. After surgery, 21 patients (80.8%, p<0.05) did not present any complications, two (7.7%) evolved with canalicular obstruction, two (7.7%) with granuloma, and one (3.8 %) with lacrimal puncta ectropion. Conclusion: In our practice, canalicular injuries are more common in children or young men, affecting mainly the superior canaliculus, and treatment success using our approach can be achieved in most of the cases. However, great controversies remain on the subject, such as type of intubation and when to remove the silicone tube from the lacrimal pathway. Larger series are required to consolidate controversial concepts.

Purple Corn Extract Improves Dry Eye Symptoms in Models Induced by Desiccating Stress and Extraorbital Lacrimal Gland Excision.

Dry eye disease (DED) occurs when there are not enough tears, and the associated symptoms-burns, itching, and a gritty feeling in the eye-can cause great discomfort. The purpose of this study was to evaluate the therapeutic effect of purple corn extract (PCE) on DED. Pretreatment with PCE prevented desiccation-stress-induced cell damage in human retinal pigment epithelial cells and primary human corneal epithelial cells. Furthermore, PCE reduced the mRNA expression of inflammatory mediators in the induction of desiccation stress. The therapeutic effects of PCE on DED were evaluated in an animal model with induced unilateral excision of the exorbital lacrimal gland. The administration of PCE was effective at recovering tear production, corneal surface irregularity, and conjunctival goblet cell density, as well as at reducing apoptotic cell death in the outer layer of the corneal epithelium. Collectively, PCE improved dry eye symptoms, and, therefore, it could be a potential agent to ameliorate and/or treat DED.