Mohammad Javed Ali (Auth.) - Atlas of Lacrimal Drainage Disorders (2018, Springer Singapore) PDF

Mohammad Javed Ali
Atlas of Lacrimal
Drainage Disorders
123
Atlas of Lacrimal Drainage Disorders
Mohammad Javed Ali
Atlas of Lacrimal Drainage

Disorders
Mohammad Javed Ali
Govindram Seksaria Institute of Dacryology (GSID)
L.V. Prasad Eye Institute
Hyderabad
India
ISBN 978-981-10-5615-4 ISBN 978-981-10-5616-1 (eBook)

https://doi.org/10.1007/978-981-10-5616-1
Library of Congress Control Number: 2017960805
© Springer Nature Singapore Pte Ltd. 2018

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Dedicated to
The Lacrimal Drainage System: The Reason for My Existence!

Foreword 1
It is indeed an honor to have been asked to write a foreword to this text entitled Surgical Atlas
of Lacrimal Drainage Disorders.
The author, Dr. Mohammad Javed Ali, from Hyderabad, India, so early in his career as a
lacrimal surgeon, has established himself as the world’s authority in this area and has become
the international leader in clinical care, education, and research in diseases related to the lacri-
mal system. Indeed, he has become the most prolific author in this field. His textbook,
Principles and Practice of Lacrimal Surgery, is acknowledged as the top work on the lacrimal
system in the twenty-first century. I cannot think of any other ophthalmologist who has dedi-
cated his/her total career exclusively to the lacrimal system.
In recognition of Dr. Ali’s outstanding work in this field, the L. V. Prasad Eye Institute in
Hyderabad, India, established the Institute of Dacryology in 2016 with Dr. Ali chosen as the
head. This is the only such institute internationally totally dedicated to the lacrimal system. I
suspect that there are few, if any, other surgeons who have dedicated their careers exclusively
to the lacrimal system, as Dr. Ali has done in the past 4 years. I cannot think of any other sur-
geon that has as much clinical and surgical experience in the lacrimal system on an annual
basis as does Dr. Ali.
An atlas of lacrimal surgery will be a tremendous addition to the literature and of interest
not only to ophthalmologists (especially to oculoplastic surgeons) but also to ENT surgeons,
head and neck surgeons, and plastic surgeons. There is no better person to be the author of an
atlas of this nature than Dr. Ali.
The lacrimal system is often an overlooked and ignored entity within the field of ophthalmol-
ogy. Yet, so many ophthalmic patients have tearing as part of their presenting symptomatology.
Dr. Ali has transformed the field of lacrimal surgery into a real science. This atlas will go a long
way to help in patient care, in educating clinicians, and in finally giving the lacrimal system the
respect it deserves.
Jeffrey Jay Hurwitz, M.D., F.R.C.S.(C)

Department of Ophthalmology and Vision Sciences (DOVS)
University of Toronto, Toronto, ON, Canada
vii
Foreword 2
In 2014, I was asked by an Indian ophthalmic surgeon, who was so far completely unknown to
me, whether he could come and visit me in Germany with regard to my basic work about the
nasolacrimal system more than 10 years ago. I said “yes” and a couple of weeks later
Mohammad Javed Ali was knocking on the door of our Institute of Anatomy visiting me for
1 week. Now, 2 years later, Mohammad Javed Ali is here again but this time as a senior von
Humboldt fellow, an honor given to exceptionally few of his age by the very renowned
Alexander von Humboldt Foundation. This is a great honor for me to have him here for about
1 year in our department doing research together and getting new insights into the anatomy,
physiology, and pathology of the nasolacrimal system. Now I clearly know who Mohammad
Javed Ali is—the world’s leading person with regard to the nasolacrimal ducts who has dedi-
cated himself totally to the nasolacrimal system and its challenges. Mohammad Javed Ali, to
the best of my knowledge, is the first to treat the nasolacrimal ducts as an entity of its own by
exclusively treating patients with nasolacrimal disorders. In doing so, he does not confine his
view to surgical aspects but comes up with a holistic approach to understand the nasolacrimal
system as a whole. Thus, he became the internationally recognized specialist for lacrimal
drainage disorders and founded the first institute of its kind at his hometown Hyderabad: the
Govindram Seksaria Institute of Dacryology at the L. V. Prasad Eye Institute.
Besides the second edition of his textbook Principles and Practice of Lacrimal Surgery,
Javed now comes up with a Surgical Atlas of Lacrimal Drainage Disorders. It is a great honor
for me having been asked to write its foreword. Javed’s daily workload and output is out-
standing especially with regard to his young age. I am very confident that Javed will help his
patients with advances in this field that never have been thought of and would not have been
possible without him and his personality. This new atlas puts together all the basics and
ix
x Foreword 2
advances from clinical and research perspectives of the rapidly evolving field of dacryology.
Without question, this book will be a further tremendous addition to the nasolacrimal field,
and I am convinced that Javed Ali will have great success with it and we will hear and see
more of him in future years.
Friedrich Paulsen
Vice-President, Friedrich Alexander University of Nürnberg-Erlangen
Erlangen, Germany
Preface
“The future belongs to the unreasonable ones, the ones who look forward not backward, who are certain
only of uncertainty, and who have the ability and the confidence to think completely differently.” –
George Bernard Shaw
I am happy to be writing the preface for my second treatise Surgical Atlas of Lacrimal Drainage
Disorders, after the encouraging response received for the other textbook Principles and
Practice of Lacrimal Surgery by the scientific community across the globe. The last few years
have seen an enormous amount of literature on lacrimal drainage system, and this explosion of
information encompassed not only core clinical topics and surgical advancements but also
basic sciences, and these are encouraging signs of progress.
I am sure we all agree that learning is better by seeing than just reading, and medicine is no
exception. This comprehensive pictorial atlas has over 2400 color illustrations divided over 77
topics in a logical sequence. The legends are detailed and explanatory in nature. The topics
cover most, if not all, lacrimal disorders and their managements. Where available, insights into
the basic sciences and their complementary relationship with clinical disorders have been elu-
cidated. Efforts have been made to give a very brief introduction to every topic with selected
references for further reading.
I thank Professors Jeff Hurwitz (ophthalmic plastic surgery) and Friedrich Paulsen (basic
sciences) for their forewords and encouragement. Lastly, I thank Springer for encouraging me
to come up with a surgical atlas and for all the help with logistics. I am sure that this atlas
would become a companion book with my earlier textbook on lacrimal surgery. Together, I
hope they would equally be very useful to ophthalmology residents, subspecialty fellows, oph-
thalmic plastic surgeons, and rhinologists.
Hyderabad, India Mohammad Javed Ali, M.D., F.R.C.S., F.R.C.G.P.
xi
Prologue
Lacrimal Surgery: Glorious Past, Exciting Present Era, and the Audacity of Hope for a
Brilliant Future
“Do not fear to be eccentric in opinion, for every opinion now accepted was once eccentric.” – Bertrand
Russell (1872–1970)
The evolution of lacrimal disorders and its management amply exemplifies the above-stated
quote of the twentieth-century British philosopher Bertrand Russell. Lacrimal surgeries have
been a subject of discussion in antiquity with the earliest documented reference being a lacri-
mal sac incision in the “Code of Hammurabi” in 2250 BC [1]. The past which appears glorious
today had once traveled through many rough terrains in ancient times nurtured by the Egyptians
(Ebers Papyrus, 1500 BC), the Greeks (Hippocrates and Celsus, 25 BC), and the Romans
(Galen, 200 AD) [1, 2]. The Arabians chipped in between with their contributions from Ibn
Sina and Al-Razi in the medieval times. Modern dacryology was given impetus with the hall-
mark anatomical works of Giovanni Morgagni (1682–1771) and Johann Zinn (1727–1759)
and equally by the influential lacrimal treatises by Percivall Pott (1714–1788) and Johann
Schmidt (1759–1809) [3].
“Men love to wonder and that is the seed of science,” said the famous nineteenth-century
American poet, Ralph Waldo Emerson. Lacrimal surgeries have undergone a sea change in
the last two centuries. The original Woolhouse technique (1724) of dacryocystectomy under-
went numerous changes in techniques and approaches to the present age but with progres-
sively lesser indications. The external dacryocystorhinostomy (DCR) had a steeper evolution
for obvious reasons from the times when Addeo Toti (1904) first described it to the current-
day practice with various incisions and lacrimal sac implants [4, 5]. With the introduction of
rigid endoscopy and better view, endonasal dacryocystorhinostomy showed a steep resur-
gence into the practice (McDonough, 1989) [6], more than a century after its original descrip-
tion (Caldwell, 1893) [7] failed to gain wider acceptance. Endocanalicular laser DCR,
however, till the present date have failed to gain widespread acceptance despite numerous
modifications since its introduction to dacryology by Levin and Stormogipson in 1992 [8, 9].
Likewise was the journey of trans-conjunctival DCR (CDCR), which evolved into endoscopic
and lesser invasive approaches along with numerous Jones tube modifications [10, 11].
Balloon dacryoplasty has evolved mostly in terms of indications rather than instrumentation
or techniques [12, 13].
The present era of lacrimal practice is both exciting and at the same time challenging. The
state-of-the-art equipments including high-definition endoscopic systems, diagnostic and ther-
apeutic dacryoendoscopy, and higher-resolution yet safer imaging are increasingly contribut-
ing toward our understanding of the disorders as well as developing minimally invasive surgical
options. Many debates today are centered on the approaches to a DCR, ostium size, mitomycin
C, and intubation. The most recent meta-analyses have been able to shed much-needed light
into these areas with clinical implications [14, 15]. The PEDIG studies have helped greatly in
the management of congenital nasolacrimal duct obstructions in terms of clinical decision
making and outcomes [16, 17]. There is an increasing focus on canalicular and nasolacrimal
duct recanalizations under dacryoendoscopic guidance in an effort to avoid a DCR [18].
xiii
xiv Prologue
Although this mode appears promising, skepticism is very well justified at this stage. The pres-
ent era is also seeing many attempts to standardize the nomenclatures [19], drug dosage [20],
introduction of newer terminologies [21], and paradigm shifts in the understanding of lacrimal
anatomy [22, 23]. The armamentarium of a lacrimal surgeon today is more well equipped than
any other time, and this very fact brings in more responsibility on us than any other time to take
this forward in every possible way into the future!
The audacity of hope and optimism points toward a brighter future for the patients of tomor-
row with lacrimal disorders. However, despite some of the advances highlighted, we still have
a long way to go in our understanding and treatment of lacrimal disorders. This would require
work on two different fronts with concurrent amalgamation. The first front should be science
related, and let the second be related to the surgeon. On the science frontier, the need of the
hour is to demystify the etiopathogenesis of lacrimal disorders primarily that of primary
acquired nasolacrimal duct obstruction or PANDO. It would be inappropriate to continue man-
aging lacrimal disorders mechanically without simultaneous efforts to unravel the elusive etio-
pathogenesis. The key to this, I believe, lies with the basic sciences. Embryonic studies to look
for regulatory proteins influencing lacrimal primordium and sub-adjacent mesenchyme of sur-
face ectoderm during Carnegie stages of development may hold promising clues to under-
standing of congenital lacrimal disorders. Cytochemical analysis was performed for
inflammatory mediators in tears of patients with PANDO, and if the culprits are zeroed in on,
the search to pharmacologically block them or their receptors in the lacrimal system may have
prophylactic value early on in the disease. Lacrimal immunology work on lacrimal drainage-
associated lymphoid tissue (LDALT), its derangements [24], and how differently it behaves
from the rest of the immune system should be carried forward to its logical conclusions as this
may have great bearing on our understanding of lacrimal physiology. Other avenues of poten-
tial research in the near future include lacrimal system stem cell characterization on similar
lines as that of lacrimal gland [25], drug-coated stents, and electron microscopic inter- and
intracellular changes in lacrimal disorders.
On the second front, the lacrimal surgeon should not only focus on evidence-based practice
but also constantly on the endeavor to explore avenues to generate evidence. The research
potential needs to be unlocked, and academic institutes should strive toward protecting and
rearing the endangered species of “clinician-scientists” rather than pure clinicians. The need of
the hour is also to cross-specialize where it matters! The lacrimal drainage system has a long
course within the nasal cavity, and it is obvious that a good lacrimal work cannot be done
without a good anatomical and surgical knowledge of the nose. Although the resurgence of
EENT (eye, ear, nose, and throat) specialists may not be desirable due to explosion in the
knowledge and vast nature of each subject, the benefits of limited cross-specialization cannot
be overemphasized. Cross-specialization also opens up the surgeon to at least some ideas of
one specialty that when appropriately extrapolated to others may have beneficial results. Basic
sciences are the key to the future; hence a very good understanding of fundamentals of lacrimal
system up to the molecular level would greatly help the lacrimal surgeon in dealing with the
disorders both in the lab and the clinics. There should be efforts on the part of the lacrimal
surgeon to do focused clinical and research work with an emphasis on translational values. The
challenge of the future is to set audacious goals and strive hard to achieve them. “We,” as lac-
rimal surgeons, need to remind ourselves frequently of our equally important responsibility to
advance medicine and hand it over in a better shape to the next generation and probably beyond
them. Are we doing enough on these fronts? If not, let us change that from today!
“There is a single light of science, and to brighten it anywhere is to brighten it everywhere.” – Isaac
Asimov (1920–1992)
Mohammad Javed Ali, M.D., F.R.C.S., F.R.C.G.P.

Govindram Seksaria Institute of Dacryology, L. V. Prasad Eye Institute
Hyderabad, India
Prologue xv
References
1. Hirschberg J (1984) The renaissance of ophthalmology in the 18th century. In: Hirschberg
J (ed) The history of ophthalmology, vol 1. Wagenborg Publications, Amsterdam, p 11
2. Hirschberg J (1984) The renaissance of ophthalmology in the 18th century. In: Hirschberg
J (ed) The history of ophthalmology, vol 3. Wagenborg Publications, Amsterdam,
pp 250–255
3. Albert DM (1996) Ophthalmic plastics surgery. In: Albert DM, Edwards DD (eds) The
history of ophthalmology. Blackwell Science, Cambridge, pp 235–254
4. Ekinci M, Cagatay HH, Oba ME et al (2013) The long term follow-up results of external
dacryocystorhinostomy skin incision scar with “W” incision. Orbit 32:349–355
5. De Castro DK, Santiago YM, Cunningham M et al (2013) A modified lacrimal sac implant
for high risk dacryocystorhinostomy. Ophthal Plast Reconstr Surg 29:367–372
6. McDonogh M, Meiring JH (1989) Endoscopic transnasal dacryocystorhinostomy. J
Laryngol Otol 103:585–587
7. Caldwell GW (1893) Two new operations for the obstruction of the nasal duct with pres-
ervation of the canaliculi. Am J Ophthalmol 10:189
8. Levin PS, Stormogipson DJ (1992) Endocanalicular laser assisted DCR. An anatomic
study. Arch Ophthalmol 110:1488–1490
9. Henson RD, Cruz HL, Henson RG Jr et al (2012) Postoperative application of mitomycin
C in endocanalicular laser DCR. Ophthal Plast Reconstr Surg 28:192–195
10. Jones LT (1965) Conjunctivodacryocystorhinostomy. Am J Ophthalmol 59:773–783
11. Ali MJ, Honavar SG, Naik M (2013) Endoscopically guided minimally invasive bypass
tube intubation without DCR: evaluation of drainage and objective outcomes assessment.
Minim Invasive Ther Allied Technol 22:104–109
12. Becker BB, Berry FD (1989) Balloon catheter dilatation in lacrimal surgery. Ophthalmic
Surg 20:193–198
13. Ali MJ, Naik MN, Honavar SG (2013) Balloon dacryoplasty: ushering the new and rou-
tine era in minimally invasive lacrimal surgeries. Int Ophthalmol 33:203–210
14. Feng YF, Yu JG, Shi JL et al (2012) A meta-analysis of primary external dacryocystorhi-
nostomy with and without mitomycin C. Ophthalmic Epidemiol 19:364–370
15. Feng YF, Cai JQ, Zhang JY et al (2011) A meta-analysis of primary dacryocystorhinos-
tomy with and without silicone intubation. Can J Ophthalmol 46:521–527
16. Repka MX, Chandler DL, Holmes JM et al (2009) Balloon catheter dilatation and naso-
lacrimal duct intubation for treatment of nasolacrimal duct obstruction in after failed prob-
ing. Arch Ophthalmol 127:633–639
17. Repka MX, Chandler DL, Bremer DL et al (2009) Repeat probing for treatment of persis-
tent nasolacrimal duct obstruction. J AAPOS 13:306–307
18. Javate RM, Pamintuan FG, Cruz RT Jr (2010) Efficacy of endoscopic lacrimal duct recan-
alization using microendoscope. Ophthal Plast Reconstr Surg 26:330–333
19. Ali MJ, Mohapatra S, Mulay K et al (2013) Incomplete punctal canalization: the external
and internal punctal membranes. Outcomes of membranotomy and adjunctive procedures.
Br J Ophthalmol 97:92–95
20. Ali MJ, Mariappan I, Maddileti S et al (2013) Mitomycin C in dacryocystorhinostomy: the
search for the right concentration and duration – a fundamental study on human nasal
mucosa fibroblasts. Ophthal Plast Reconstr Surg 29:469–474
21. Ali MJ, Naik MN (2013) Canalicular wall dysgenesis: the clinical profile of canalicular
aplasia and hypoplasia, associated systemic and lacrimal anomalies, and clinical implica-
tions. Ophthal Plast Reconstr Surg 29:464–468
22. Park J, Takahashi Y, Nakano T et al (2012) The orientation of the lacrimal fossa to the
bony nasolacrimal canal: an anatomical study. Ophthal Plast Reconstr Surg 28:463–468
xvi Prologue
23. Kakizaki H, Ichinose A, Takahashi Y et al (2012) Anatomical relationship of Horner’s

muscle origin and posterior lacrimal crest. Ophthal Plast Reconstr Surg 28:66–68
24. Ali MJ, Mulay K, Pujari A et al (2013) Derangements of lacrimal drainage associated
lymphoid tissue (LDALT) in human chronic dacryocystitis. Ocul Immunol Inflamm
21:417–423
25. Tiwari S, Ali MJ, Balla MM et al (2012) Establishing human lacrimal gland cultures with
secretory function. PLoS One 7:e29458
Contents
1 Embryology of the Lacrimal Drainage System . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 The Lacrimal Drainage Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
3 Ultrastructural Anatomy of Normal Lacrimal Drainage System. . . . . . . . . . . . . 39
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
4 Nasal Endoscopic Setup. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
5 Evaluation of Epiphora . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
6 Normal Endoscopic Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
7 Nasal Anatomy Using Realistic Anatomical Models . . . . . . . . . . . . . . . . . . . . . . . 89
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
8 Normal Dacryoendoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
9 Normal Lacrimal Optical Coherence Tomography. . . . . . . . . . . . . . . . . . . . . . . . 105
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
10 Digital Subtraction Dacryocystography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
11 Dacryoscintigraphy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
12 Computed Tomography Dacryocystography (CT-DCG). . . . . . . . . . . . . . . . . . . . 123
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
13 Continuously Variable Endoscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
14 Three-Dimensional (3D) Endoscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
15 Microbiological Techniques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
16 Common Endoscopic Pathologies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
17 Dacryoendoscopy and Lacrimal Pathologies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
xvii
xviii Contents
18 CT Scans in Lacrimal Pathologies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
19 Lacrimal Pathologies and Optical Coherence Tomography. . . . . . . . . . . . . . . . . 187
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
20 Punctal Agenesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
21 Supernumerary Puncta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
22 Incomplete Punctal Canalization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
23 Etiopathogenesis of Punctal Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
24 Punctal Stenosis and Punctoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
25 Punctal Keratinizing Cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
26 Peri-Punctal Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
27 Canalicular Wall Dysgenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
28 Lacrimal Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
29 Simple Congenital Nasolacrimal Duct Obstruction and Its Management . . . . . 257
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
30 Complex CNLDO: Buried Probe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
31 Complex CNLDO: Dacryocele. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
32 Complex CNLDO: Other Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
33 Syndromic and Systemic Associations of Congenital
Lacrimal Drainage Anomalies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
34 Infective Canaliculitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
35 Canaliculops . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
36 Canalicular Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
37 Acute Dacryocystitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
38 Chronic Dacryocystitis and LDALT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
Contents xix
39 Lacrimal Sac Diverticulum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
40 Dacryolithiasis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
41 Nasolacrimal Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351
42 Iatrogenic Bony NLD Dehiscence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361
43 Secondary Acquired Lacrimal Drainage Obstruction (SALDO). . . . . . . . . . . . . 367
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
44 Primary External Dacryocystorhinostomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
45 Subciliary Dacryocystorhinostomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
46 Primary Endoscopic Dacryocystorhinostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
47 Ultrasonic Endoscopic Dacryocystorhinostomy. . . . . . . . . . . . . . . . . . . . . . . . . . . 407
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407
48 Non-endoscopic Endonasal Dacryocystorhinostomy. . . . . . . . . . . . . . . . . . . . . . . 415
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415
49 Endocanalicular Laser Dacryocystorhinostomy . . . . . . . . . . . . . . . . . . . . . . . . . . 421
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
50 Entire Lacrimal Sac in Sinus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
51 Difficult Endoscopic DCR Scenarios. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435
52 Etiology of Failed Dacryocystorhinostomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447
53 The DCR Ostium Cicatrix. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455
54 Revision External Dacryocystorhinostomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461
55 Revision Endoscopic Dacryocystorhinostomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . 467
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467
56 Lacrimal Recanalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 481
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 481
57 Balloon Dacryoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
58 Conjunctivodacryocystorhinostomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499
59 Mitomycin C (Techniques and Tissue Effects). . . . . . . . . . . . . . . . . . . . . . . . . . . . 517
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517
xx Contents
60 Intubation Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529
61 Complications of Lacrimal Stents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535
62 Lacrimal Stents and Biofilms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 543
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 543
63 Evaluation of a Dacryocystorhinostomy Ostium. . . . . . . . . . . . . . . . . . . . . . . . . . 555
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555
64 Dacryocystorhinostomy Ostium Granulomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . 571
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 571
65 Adjunctive Endoscopic Procedures: Endoscopic Septoplasty . . . . . . . . . . . . . . . 583
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583
66 Adjunctive Endoscopic Procedures: Middle Turbinoplasty. . . . . . . . . . . . . . . . . 599
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 599
67 Adjunctive Endoscopic Procedures: Inferior Turbinoplasty . . . . . . . . . . . . . . . . 607
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 607
68 Dacryocystectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611
69 Masquerades of Lacrimal Drainage Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . 619
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 619
70 Arhinia and Lacrimal Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627
71 Lacrimal Interventions and Bacteremia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 639
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 639
72 Instrument Fracture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 643
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 643
73 Tumors of the Lacrimal Drainage System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 647
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 647
74 Stereotactic Lacrimal Surgeries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 671
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 671
75 Lacrimal Gland-Targeted Therapies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 691
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 691
76 Quality of Life and Lacrimal Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 697
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 697
77 Atlas Exercises. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 701
Key to Atlas Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 708
About the Author
Mohammad Javed Ali, M.D., F.R.C.S., F.R.C.G.P.

completed his basic medical education and ophthalmology
training at Dr. NTR University of Health Sciences, Hyderabad.
He obtained his fellowship of the Royal College of General
Practitioners (FRCGP), UK, in 2003 and fellowship of the
Royal College of Physicians and Surgeons of Glasgow
(FRCS) in 2008. He also completed his fellowship in orbital
surgery in 2008, followed by a second fellowship in ophthal-
mic plastic surgery, ocular oncology, and aesthetic facial plas-
tic surgery in 2010. He later trained in rhinology with world
leader Peter-John Wormald from Australia. Javed is one of the
rare recipients of the Experienced Researcher—Senior
Alexander von Humboldt Fellowship Award, a pinnacle award
in the research world. He is also a recipient of the Dr. P. Siva
Reddy Gold Medal in ophthalmology, Dr. Pathak Medal in
ophthalmology, Mazher Foundation Award for outstanding academic performance, Vengal
Rao Medal, Raghavachary Medal, Ranga Reddy Endowment Award, Honavar Award, and
Sunayna Medal. He has described two new diseases of the lacrimal system along with their
classifications and clinicopathologic profiles. He was honored with the “Healthcare Leadership
Award 2012” for his research and innovations in dacryology and also received the 2015
ASOPRS Merrill Reeh Award for his groundbreaking work on the etiopathogenesis of punctal
stenosis. His textbook Principles and Practice of Lacrimal Surgery is considered to be the
most comprehensive treatise on the subject. He is a section editor for 7 journals and reviewer
for over 30 major journals. His areas of research include the molecular pathogenesis of NLDO,
stem cells, and minimally invasive lacrimal surgeries.
Research Output: Publications: Total: 276 (peer reviewed – 201; Non Peer reviewed – 38,
Book chapters – 34, Textbooks – 3. Editorial boards – 7, Instruction courses – 22, Keynote
addresses – 6, Conference presentations – 245, live surgical workshops – 18, Awards: 28.
Email: javed@lvpei.org, drjaved007@gmail.com
PubMed ID: Ali MJ
xxi
Embryology of the Lacrimal
Drainage System 1
The understanding of lacrimal embryology is very crucial to References

the understanding of lacrimal anatomy and its subsequent
1. Duke-Elder S. Development of ocular adnexa. In: Duke-Elder S,
clinical and surgical applications. The lacrimal passages editor. System of ophthalmology, volume 1. St. Louis, MO: CV
develop along the line of cleft between the maxillary process Mosby; 1938. p. 364–5.
and the lateral nasal process [1–5]. The development of the 2. Whitnall SE. The lacrimal apparatus. In: Whitnall SE, editor. The
anatomy of the human orbit and accessory organs of vision. Oxford
lacrimal system begins at Carnegie Stage 16 (CRL, 11 mm),
University Press: Oxford; 1921. p. 223–52.
when an epithelial thickening of the lacrimal groove forms 3. O’Rahilly R. Early human development and the chief sources
the lacrimal lamina [4]. At Carnegie Stage 19 (CRL, 17 mm), of information on staged human embryos. Eur J Obstet Gynecol
the lacrimal lamina separates from the surface ectoderm and Reprod Biol. 1979;9:273–80.
4. De la Cuadra-Blanco C, Peces-Pena MD, Janez-Escalada L, et al.
forms the lacrimal cord. The lateral extreme of the cord clos-
Morphogenesis of the human excretory lacrimal system. J Anat.
est to the surface ectoderm bifurcates, thus giving rise to the 2006;209:127–35.
canaliculi. At Carnegie Stage 20 (CRL, 19–21 mm), the lac- 5. Sevel D. Development and congenital abnormalities of the nasolac-
rimal cord is arranged lateral to the nasal capsule and finally rimal apparatus. J Pediatr Ophthalmol Strabismus. 1981;18:13–9.
lateral and inferior to the inferior meatal lamina. At Carnegie
Stage 22 (CRL, 26 mm), the cells of the lacrimal cord con-
dense at its periphery but are more loosely organized cen-
trally, toward the future lumen [4].
From the tenth week (CRL, 48–55 mm), various signifi-
cant changes occur such as canalization of the lacrimal cord
and development of the surrounding tissues [4, 5]. Canalization
occurs at the same time throughout the nasolacrimal appara-
tus [5]. The canalicular epithelium comes in contact with the
palpebral conjunctival epithelium and both epithelia form a
continuous epithelial lamina [4]. The caudal extreme of the
lacrimal duct and the inferior meatal lamina makes contact
and the latter begins to cavitate [1, 2, 4]. During the 12th
week of development, reabsorption of the inferior meatal
lamina is clearly visible (CRL, 74 mm).
Although the canalicular lumina become patent by the
fourth month after gestation, the lacrimal puncta do not open
onto the eyelid margins until the eyelids separate during the
seventh month. However, the lower end of the duct is often
separated from the inferior meatus at birth by a membrane
constituted by the apposed mucosal linings of the lower duc-
tal end and the nasal fossa. Only in 30% is the lowermost end
patent at birth [1, 2]. An obstruction at this site balloons out
later into the inferior meatus and its opening mostly occur
after birth.
© Springer Nature Singapore Pte Ltd. 2018 1

M.J. Ali, Atlas of Lacrimal Drainage Disorders, https://doi.org/10.1007/978-981-10-5616-1_1
2 1 Embryology of the Lacrimal Drainage System
Fig. 1.3 Schematic diagram of lacrimal drainage development. Note

the out budding of solid canaliculi from the lacrimal placode (Photo
courtesy: Himika Gupta, Mumbai)
Fig. 1.1 Schematic diagram of lacrimal drainage development. The earli-

est stage is the formation of a line of cleft between the fronto-nasal process
and the lateral nasal process (Photo courtesy: Himika Gupta, Mumbai)
Fig. 1.4 Schematic diagram of lacrimal drainage development. Note

the differentiation into canaliculi and the attempt of the distal end to
meet the inferior meatal lamina (Photo courtesy: Himika Gupta,
Mumbai)
Fig. 1.2 Schematic diagram of lacrimal drainage development. The dia-

gram shows a clear differentiation of the embryologic processes and the
lacrimal placode between them (Photo courtesy: Himika Gupta, Mumbai)
1 Embryology of the Lacrimal Drainage System 3
Fig. 1.8 Clinico-embryological correlations: Lacrimal drainage agen-

esis in a craniofacial syndrome
Fig. 1.5 Schematic diagram of lacrimal drainage development. The

process of canalization happens centrally and extends toward the
periphery forming the lumina (Photo courtesy: Himika Gupta, Mumbai)
Fig. 1.9 Clinico-embryological correlations: Left eye showing focal

ankyloblepharon and proximal lacrimal drainage agenesis
Fig. 1.6 A 22-week-old fetus. Note the development of the eyelids and
the nose
Fig. 1.7 A 26-week-old fetus. Note the well-developed eyelids and the Fig. 1.10 Clinico-embryological correlations: Right eye showing
nose focal ankyloblepharon and proximal lacrimal drainage agenesis
Fig. 1.11 Clinico-embryological correlations: An ectopic punctum in

the left medial canthus
Fig. 1.14 Clinico-embryological correlations: A left congenital lacri-

mal fistula being demonstrated by a 3-probe test
Fig. 1.12 Clinico-embryological correlations: A right upper punctal

agenesis
Fig. 1.13 Clinico-embryological correlations: A right lower eyelid

showing supernumerary puncta
Fig. 1.15 Clinico-embryological correlations: Lacrimal sac dysgene-
sis in a case of punctal and canalicular agenesis. Note the thinned-out
cystic walls of the lacrimal sac
1 Embryology of the Lacrimal Drainage System 5
Fig. 1.18 Clinico-embryological correlations: Ectopic lacrimal gland

within the lacrimal sac. Clinical photograph of an infant with a large
lacrimal sac mass
Fig. 1.16 Clinico-embryological correlations: Endoscopic view of the

left lacrimal sac with an anterior inferior lacrimal diverticulum

within the lacrimal sac. Clinical photograph of the right eye of the
patient in Fig. 1.18 showing punctal and canalicular agenesis
Fig. 1.17 Clinico-embryological correlations: The lower most non-

canalized segment of the nasolacrimal duct

within the lacrimal sac. Intraoperative photograph of the intra-sac mass
removal
Fig. 1.21 Clinico-embryological correlations: Microphotograph con-

firming the ectopic lacrimal gland within the lacrimal sac
The Lacrimal Drainage Anatomy
2
The lacrimal sac and upper part of the NLD is housed in the References
bony lacrimal fossa or the sulcus lacrimalis which is bounded
anteriorly and posteriorly by the respective lacrimal crests 1. Whitnall SE. Anatomy of the human orbit and accessory organs
of vision. 2nd ed. New York: Krieger Publishing Company; 1979.
[1–5]. Anterior lacrimal crest is a bony projection of the p. 164–5.
frontal process of maxilla and continues inferiorly as the 2. Linberg JV. Surgical anatomy of the lacrimal system. In: Linberg
inferior orbital margin, whereas posterior lacrimal crest is a JV, editor. Lacrimal surgery. New York: Churchill-Livingstone;
projection of the lacrimal bone and ends inferiorly by curv- 1988. p. 1–18.
3. Kurihashi K, Imada M, Yamashita A. Anatomical analysis of the
ing as a small hook. The bony lacrimal fossa continues human lacrimal drainage pathway under an operating microscope.
downward as the nasolacrimal canal, which is formed by the Int Ophthalmol. 1991;15:411–6.
maxilla, lacrimal bone, and the inferior nasal concha and 4. Takahashi Y, Nakamura Y, Nakano T, et al. Horizontal orientation
transmits the nasolacrimal duct, which opens into the infe- of the bony lacrimal passage: an anatomic study. Ophthal Plast
Reconstr Surg. 2013;29:128–30.
rior meatus. 5. Ali MJ, Nayak JV, Vaezeafshar R, et al. Anatomic relationship of
The lacrimal punctum lies on a small fibrous mound, the nasolacrimal duct and major lateral wall landmarks: cadav-
called the “lacrimal papilla.” Diameter of its opening is 0.2– eric study with surgical implications. Int Forum Allergy Rhinol.
0.3 mm and directs somewhat posteriorly toward the lacri- 2014;4:684–8.
mal lake. The lacrimal canaliculus is divided into the vertical
and horizontal portions. Its transitional part occasionally
dilates to form an irregular dilated cavity or ampulla. The
length of the vertical portion is 2 mm, and that of the hori-
zontal part is 10 mm. More than 95% of the upper and lower
canaliculi join to become the common canaliculus to reach
the common internal ostium [1–5]. The canaliculi empty into
the sinus of Maier. The lacrimal sac and the nasolacrimal
duct are contiguous structures. The part within the lacrimal
sac fossa is called as the “sac,” and the part inferior to the
superior opening of the nasolacrimal canal is the “nasolacri-
mal duct.” The part of the sac superior to the medial canthal
tendon (MCT) is called the fundus, with its vertical length
being 3–5 mm [1–5]. The body of the sac, inferior to the
MCT, is about 10 mm in length. The nasolacrimal duct is
approximately 12 mm in length and empties into the superior
part of the inferior meatus. The lacrimal drainage system has
numerous important positional relationships with the lateral
wall and the orbit, and this recognition is important in lacri-
mal surgeries.

8 2 The Lacrimal Drainage Anatomy
Fig. 2.3 Frontal view of a skull demonstrating the nasal bony anatomy.
Note the bony septum being deviated to the right (arrow) and the left
bony middle turbinate (star)
Fig. 2.1 Profile view of a human skull showing details of the left orbit.
Note the two bones that form the lacrimal fossa are the frontal process
of maxilla (purple color) and the lacrimal bone (dark orange color)
Fig. 2.4 Left profile view of a human skull, showing the nasal bones
(N), frontal process of maxilla (M), lacrimal bone (L), and the lacrimal
fossa (F)
Fig. 2.2 Profile view of a skull model showing the details of the lacri-
mal fossa. Note the fossa being contributed by the frontal process of
maxilla (3) and the lacrimal bone (4). The relationship of the lacrimal
bone with the ethmoid bone (2) that forms the medial orbital wall can
be appreciated Fig. 2.5 Right profile view of a human skull showing the fronto-
lacrimal suture (black arrow), lacrimo-maxillary suture (red arrow),
and the sutura notha (black star)
2 The Lacrimal Drainage Anatomy 9
Fig. 2.6 Right profile view of a human lacrimal sac fossa. Note that
the bony lacrimal fossa (F) is bounded anteriorly by the anterior lacri-
mal crest (black arrow) and posteriorly by the posterior lacrimal crest
Fig. 2.9 Cadaveric right mid-sagittal section showing the septum cov-
(red arrow). Note the sutura notha (black star) anterior to the anterior
ering the lateral wall structures
lacrimal crest and the lacrimo-maxillary suture running right in the
middle of the lacrimal fossa (F)
Fig. 2.7 Frontal view of an illuminated human skull showing the bony
nasal anatomical details. Note the bony septum (black arrow) and the
bony inferior turbinate (black star)
Fig. 2.10 Cadaveric photograph of the same individual as in Fig. 2.9.
Note the exposed lateral wall with numerous prominences (turbinates),
following removal of the septum
Fig. 2.8 Left profile view of an illuminated human skull showing the
bony nasal anatomical details. Note the bony middle turbinate (black
star) and the relationship of the lacrimal fossa (black arrow) to the Fig. 2.11 Cadaveric left mid-sagittal section, with the pointer showing
middle turbinate the inferior turbinate
Fig. 2.12 Cadaveric left mid-sagittal section, with the pointer showing
the middle turbinate
Fig. 2.15 Cadaveric right mid-sagittal section, demonstrating the mid-
dle meatus
Fig. 2.13 Cadaveric left mid-sagittal section, with the pointer showing Fig. 2.16 Cadaveric right mid-sagittal section, demonstrating the infe-
the superior turbinate rior meatus
Fig. 2.17 Cadaveric right mid-sagittal section. Upon eversion of the

Fig. 2.14 Cadaveric right mid-sagittal section, demonstrating the middle turbinate, note the bulla ethmoidalis and other middle meatal
superior meatus structures
Fig. 2.18 Cadaveric right mid-sagittal section. Upon removing the

inferior turbinate, note the lacrimal probe in the inferior meatus
Fig. 2.20 Radiological anatomy of the lacrimal drainage system: CT

scan, axial cut, showing the upper bony nasolacrimal ducts
Fig. 2.19 Radiological anatomy of the lacrimal drainage system: CT Fig. 2.21 Radiological anatomy of the lacrimal drainage system: CT
scan, axial cut, showing the lower bony nasolacrimal ducts (red arrows). scan, axial cut, showing the lower bony lacrimal fossa. Note that the
Note the intricate relationship of the bony NLD with the maxillary fossa is not bony all around as with the bony NLD. Compare it with
sinuses (red stars) Figs. 2.19 and 2.20
Fig. 2.24 Cadaveric image of the left eye with the pointer demonstrat-
Fig. 2.22 Radiological anatomy of the lacrimal drainage system: CT ing the lower punctum situated on a punctal papilla
scan, axial cut at the level of mid bony lacrimal fossa. Note the sequen-
tial widening of the fossa. Compare it with Fig. 2.21
Fig. 2.23 Radiological anatomy of the lacrimal drainage system: CT

scan, axial cut at the level of upper bony lacrimal fossa. Note the rela-
tionships with surrounding structures
Fig. 2.25 Cadaveric image of the right eye showing the cut ends of the
canaliculus (black arrow)
Fig. 2.26 Cadaveric image showing the lateral reflection of the lacrimal sac (spatula) from the lacrimal fossa
Fig. 2.27 Cadaveric image showing the completely reflected lacrimal sac (under the spatula) and the entrance of the bony NLD
Fig. 2.28 Cadaveric image demonstrating the boundaries of the lacrimal fossa. The pointer is at the anterior lacrimal crest
Fig. 2.29 Cadaveric image demonstrating the boundaries of the lacrimal fossa. The pointer is at the posterior lacrimal crest
Fig. 2.30 Cadaveric image showing the illuminated bony lacrimal fossa
Fig. 2.31 Cadaveric image showing the bony lacrimal fossa boundaries (blue)
Fig. 2.32 Cadaveric image demonstrating the entrance to the bony nasolacrimal duct
Fig. 2.33 Cadaveric image, showing the exposed bony nasolacrimal duct and its entrance (red arrow)
Fig. 2.34 A below upward view of a cadaveric lateral nasal wall showing the entrance of the nasolacrimal duct into the inferior meatus
Fig. 2.35 Cadaveric image of the lateral nasal wall with the pointer demonstrating the medial wall of the bony nasolacrimal duct
Fig. 2.36 Lacrimal drainage system standing proudly on the lateral nasal wall. Note the lacrimal sac (small red arrow) and the nasolacrimal duct
(large red arrow)
Fig. 2.37 Cadaveric image of the lateral nasal wall. The nasolacrimal duct is reflected to demonstrate the bony nasolacrimal duct (pointer)
Fig. 2.38 Another example of a partly removed bony NLD (black star) and the underlying soft tissue nasolacrimal duct (black arrow)
Fig. 2.39 Cadaveric image showing reflected lacrimal sac to demonstrate the underlying bony lacrimal fossa and its relationship on the lateral
wall of the nose
Fig. 2.40 Opening of the nasolacrimal duct: A fissure type opening of the NLD in the inferior meatus (black arrow)
Fig. 2.41 Opening of the nasolacrimal duct: An exaggerated fissure type opening of the NLD in the inferior meatus (black arrow)
Fig. 2.42 Opening of the nasolacrimal duct: A sulcus type of NLD opening in the inferior meatus (black arrow)
Fig. 2.43 Opening of the nasolacrimal duct: An exaggerated sulcus type of the NLD opening in the inferior meatus (black arrow)
Fig. 2.44 Opening of the nasolacrimal duct: A vertical fissure type of NLD (black arrow) with an anterior edge fold
Fig. 2.45 A completely dissected lacrimal drainage system from the punctum to the nasolacrimal opening
Fig. 2.46 Relationships of the lacrimal drainage system

on the lateral wall: The bony lacrimal fossa is partly in
front and lateral to the head of the middle turbinate. Note
the illuminated lacrimal fossa (spatula) and its relation-
ship to the head of middle turbinate
Fig. 2.47 Relationships of the lacrimal drainage system on the lateral nasal wall: Note the clear relationship between the bony lacrimal fossa and
the head of the middle turbinate
Fig. 2.48 Relationships of the lacrimal drainage system on the lateral nasal wall: Eversion of the middle turbinate exposes the middle meatal
structures, which are closely related to the lacrimal drainage system
Fig. 2.49 Relationships of the lacrimal drainage system on the lateral nasal wall: The bulla ethmoidalis, the largest ethmoidal air cell, is being
grasped by the forceps
Fig. 2.50 Relationships of the lacrimal drainage system on the lateral nasal wall: The uncinate process being grasped by the forceps
Fig. 2.51 Relationships of the lacrimal drainage system on the lateral nasal wall: The probe demonstrates the aditus to the maxillary sinus
opening
Fig. 2.52 Relationships of the lacrimal drainage system on the lateral nasal wall: The image demonstrates the relationship of the fundus of the
lacrimal sac (black arrow) with the agger nasi air cell (black star)
Fig. 2.53 Relationships of the lacrimal drainage system on the lateral nasal wall: The image demonstrates the relationship of the sac-duct junction
(pointer) and the nasolacrimal duct below with the maxillary sinus (white star)
Fig. 2.54 Relationships of the lacrimal drainage system on the lateral nasal wall: The image demonstrates an illuminated maxillary sinus and the
probe traversing through the bony lacrimal passages
Fig. 2.55 Relationships of the lacrimal drainage system on the lateral nasal wall: The image demonstrates the relationship of the bony nasolacri-
mal duct (arrow) on the lateral wall. Note the reflected soft tissue nasolacrimal duct grasped by the forceps
Fig. 2.56 Relationships of the lacrimal drainage system on the lateral nasal wall: The image demonstrates the relationship of the lacrimal sac
(black star) with the frontal sinus pathway (pointer in the pathway) and the ethmoidal air cells
Fig. 2.57 Relationships of the lacrimal drainage system on the lateral nasal wall: The image demonstrates the relationship of the lacrimal sac
(black star) with the lamina papyracea and the medial orbital wall (pointer)
Fig. 2.58 Relationships of the lacrimal drainage system on the lateral nasal wall: The image demonstrates removal of the lamina papyracea. Note
the close relationship of the lacrimal sac (black star) with the orbital fat (pointer)
Fig. 2.60 Histology of a normal lacrimal drainage system:

Fig. 2.59 Histology of a normal lacrimal drainage system: Microphotograph, higher magnification of the transverse section of the
Microphotograph of a transverse section of the superior canaliculus. superior canaliculus. Note the lining of the canaliculus with a stratified
Note the numerous muscle bundles around it (H & E ×40) squamous epithelium and the central lumen (H & E ×100)

Microphotograph, high magnification, longitudinal section, showing
Fig. 2.61 Histology of a normal lacrimal drainage system: the entrance of the common canaliculus into the lacrimal sac (H & E
Microphotograph of a transverse section of the inferior canaliculus. ×100)
Note the lining and the lumen (H & E ×40)
Fig. 2.62 Histology of a normal lacrimal drainage system: Fig. 2.64 Histology of a normal lacrimal drainage system:
Microphotograph of a longitudinal section showing the entrance of the Microphotograph of a longitudinal section of the fundus of the lacrimal
common canaliculus into the sinus of Maier of the lacrimal sac (H & E sac. Note the columnar epithelial lining with few goblet cells, seromu-
×40) cinous glands, and few venules in the substantia propria (H & E ×40)
Microphotograph of a transverse section of the body of lacrimal sac. Microphotograph of the lacrimal sac showing the dense cavernous sys-
Note the columnar epithelial lining, goblet cells, seromucinous glands, tem in the substantia propria. Note the capacitance vessels and throttle
and more number of venules in the substantia propria (H & E ×40) veins (H & E ×100)
Microphotograph of the lacrimal sac showing the dense subepithelial Microphotograph of the lacrimal sac wall showing a large throttle vein
venous plexus that forms the cavernous system (H & E ×40) and an arteriole. This vascular system is proposed to play an important
role in tear physiology (H & E ×100)

Microphotograph of the lacrimal sac wall showing dense arrangement
of collagenous connective tissue between the vascular plexus (H & E
×100).

Microphotograph, high magnification, showing the lining of the lacri-
mal sac. Note the opening of the mucinous gland into the lumen (black
arrow) (H & E ×200)

Microphotograph showing the lining of the lacrimal sac with columnar
epithelium and the lumen (H & E ×100)

Microphotograph showing the lining of the lacrimal sac. Note the open-
ing of a large mucinous gland into the lumen (black arrow) (H & E
×100)
Microphotograph, high magnification, showing the subepithelial sero- Microphotograph, longitudinal section, high magnification, showing
mucinous gland of the lacrimal sac (H & E ×200) the transition of the lacrimal sac into the nasolacrimal duct. Note the
narrow lumen of the nasolacrimal duct as compared to the wide one of
the lacrimal sac (H & E ×100)

Microphotograph, longitudinal section, showing the transition of the
large lacrimal sac lumen into a narrow nasolacrimal duct (H & E ×40)
Ultrastructural Anatomy of Normal
Lacrimal Drainage System 3
Ultrastructural studies help in understanding the tissue func- References

tions and aberrations at a cellular and subcellular level [1–3].
1. Ali MJ, Baig F, Lakshman M, et al. Scanning electron micro-
It is carried out using scanning and transmission electron scopic features of the external and internal surfaces of normal
microscopy. Scanning electron microscopy (SEM) of healthy adult lacrimal drainage system. Ophthal Plast Reconstr Surg.
lacrimal systems has shown demonstrable anatomical junc- 2015;31:414–7.
2. Adenis JP, Loubet A, Leboutet MJ, et al. Ultrastructural morphol-
tions between the distal portion of the punctum and the prox-
ogy at the different levels of the lacrimal passage mucosa. Arch
imal most portion of the vertical canaliculus. Such anatomical Anat Cytol Pathol. 1980;28:371–5.
junction was also noted between the lacrimal sac and naso- 3. Thale A, Paulsen F, Rochels R, et al. Functional anatomy of the
lacrimal ducts. The mucosa of the canaliculus was occasion- human efferent tear ducts: a new theory of tear outflow mechanism.
Graefes Arch Clin Exp Ophthalmol. 1998;236:674–8.
ally thrown into folds with the surface showing rugae as
compared to the normal smooth architecture. These are likely
to represent the valvular structures of the lacrimal system. In
the vicinity of the canaliculi, the orbicularis fibers were
found to be very well organized in bundles. The fundus of the
lacrimal sac showed very peculiar glands not found else-
where and whose function is not yet known. The walls of the
lacrimal sac and nasolacrimal ducts showed dense vascular
plexus which included wide luminal arteries, throttle veins,
and large capacitance vessels. The mucosa of the lacrimal
sacs showed well-defined elevations of submucosal lym-
phoid follicles. These topographic studies have a potential to
enhance our anatomico-physiological understanding which
may then be translated for better clinical understanding and
patient managements.
Figures are from Ali et al., Ophthal Plast Reconstr Surg
2015;31:414–417, and Ophthal Plast Reconstr Surg.
2015;31:103–107.

40 3 Ultrastructural Anatomy of Normal Lacrimal Drainage System
Fig. 3.3 The TEM viewing system
Fig. 3.1 A transmission electron microscope (TEM)
Fig. 3.4 The TEM software console
Fig. 3.2 The sample loading chamber which communicates with the
electron chamber
3 Ultrastructural Anatomy of Normal Lacrimal Drainage System 41
Fig. 3.7 Harvesting of the entire lacrimal drainage system
Fig. 3.5 The ultrathin samples mounted on copper grids
Fig. 3.8 The proximal system with the punctum is being demonstrated
Fig. 3.6 The copper grids are then placed securely on the carrier,
which is inserted into the sample loading chamber, as shown in Fig. 3.2 Fig. 3.9 The sac-duct junction and the thin nasolacrimal duct
Fig. 3.12 Numerous lacrimal stents (monoka and bicanalicular)

mounted on multiple stubs for SEM
Fig. 3.10 A scanning electron microscope (SEM)
Fig. 3.13 A higher magnification of sample stub with mounted lacri-

mal stents. Note the gold-coating of the stents
Fig. 3.11 Lacrimal tissues mounted on the sample stubs. Compare

these with those of TEM in Fig. 3.5
Fig. 3.14 SEM image of the punctum: End-on view of the punctum Fig. 3.17 SEM image of the punctum: Higher magnifications of
with central lumen and surrounding punctal rim (SEM ×70) another lacrimal system showing well-defined junctional area (arrow).
Note the smooth inner punctal surface (P). (SEM ×1500)
Fig. 3.15 SEM image of the punctum: Higher magnification clearly Fig. 3.18 SEM image of the punctum: Regular surface of the canalicu-
showing the luminal details (SEM ×150) lar epithelium with occasional large goblet cells (SEM ×20,000)
Fig. 3.16 SEM image of the punctum: Electron microphotograph showing Fig. 3.19 SEM image of the punctum: Ultrastructural appearance of the
smooth inner punctal surface with a junctional area (arrow) (SEM ×350) punctal rims. Note the presence of throttle veins (arrows) (SEM ×450)
Fig. 3.20 SEM image of the canaliculus: Low-magnification image Fig. 3.23 SEM image of the canaliculus: High magnification of the
showing end-on view of the canalicular lumen (SEM ×200) valvular area showing the broad rugae-like mucosal folds on the surface
(SEM ×1500)
Fig. 3.21 SEM image of the canaliculus: External surface of the canalicu- Fig. 3.24 SEM image of the canaliculus: Canalicular epithelial areas
lus showing rough surface with visible large collagen bundles (SEM ×200) showing smooth epithelium with occasional goblet cells (SEM ×25,000)
Fig. 3.22 SEM image of the canaliculus: Lumen of the canaliculus Fig. 3.25 SEM image of the canaliculus: Electron microphotograph show-
showing smooth surface on one end and valvular elevations on the other ing a well-defined arrangement of orbicular muscle with collagen fibers in
(SEM ×400) the vicinity, possibly representing the Horner’s muscle (SEM ×1000)
Fig. 3.26 SEM image of the lacrimal sac: Note the rough external sur- Fig. 3.29 SEM image of the lacrimal sac: End-on view of the wide
faces of the lacrimal sac (SEM ×70) lacrimal sac lumen (SEM ×300)
Fig. 3.27 SEM image of the lacrimal sac: Electron microphotograph Fig. 3.30 SEM image of the lacrimal sac: Luminal surface of the lac-
of the lacrimal sac wall showing the dense vascular plexus (SEM ×700) rimal sac showing numerous rugae-like irregular projections and occa-
sional large villus-like structures (SEM ×1500)
Fig. 3.28 SEM image of the lacrimal sac: High magnification of the Fig. 3.31 SEM image of the lacrimal sac: Electron microphotograph
sac wall showing relationship of muscle bundles and collagen fibers showing the mucosal and sub mucosal well-defined elevations possibly
(SEM ×10,000) lymphoid follicles (SEM ×1600)
Fig. 3.32 SEM image of the lacrimal sac: Glandular structure with Fig. 3.35 SEM image of the nasolacrimal duct: End-on view of the
surrounding epithelium and opening of ducts on the epithelial surface lumen of nasolacrimal duct (SEM ×170)
(SEM ×25,000)
Fig. 3.33 SEM image of the nasolacrimal duct: Low-magnification Fig. 3.36 SEM image of the nasolacrimal duct: High magnification
external surface image showing the junction (arrow) between the lacri- showing vascular plexus openings embedded in the dense matrix of
mal sac and nasolacrimal duct (NLD) (SEM ×150) large collagen bundles (SEM ×500)
Fig. 3.34 SEM image of the nasolacrimal duct: Longitudinal cut sec- Fig. 3.37 SEM image of the nasolacrimal duct: Rugae-like internal
tion of the distal portion of the sac and NLD showing the lumen of the surface of the NLD (SEM ×500)
NLD and the sac-duct junction (arrow) (SEM ×110)
Fig. 3.41 TEM image of a normal nasal mucosa: Electron micro-

graph showing glandular cells with tight intercellular junctions (T),
Fig. 3.38 SEM image of the nasolacrimal duct: Electron microphoto- plenty of Golgi bodies (G), and numerous secretory granules (S) and
graph showing large goblet cells with villus-like structures on the inter- dense endoplasmic reticulum (ER) (OM ×3474)
nal surface of NLD (SEM ×3500)
Fig. 3.39 TEM image of a normal nasal mucosa: Electron micrograph Fig. 3.42 TEM image of a normal nasal mucosa: Electron micrograph
showing the normal nasal mucosa epithelium. Normal epithelial cells showing fibroblast (F) with surrounding collagen fibers (C) (OM
(E) are seen with tight junctions and normal nucleus (N) and nucleolus ×5790)
(NL). Intervening goblet cells (G) and microvilli (M) can be noted
(original magnification (OM) ×2895)
Fig. 3.40 TEM image of a normal nasal mucosa: Electron micrograph

showing large goblet cell with nucleus to one side (OM ×3860)
Nasal Endoscopic Setup
4
References
Endoscopic lacrimal surgery is increasing gaining foothold
in the routine of a lacrimal surgeon. A well-designed oper- 1. Olver J. Adult lacrimal surgery. In: Olver J, editor. Colour atlas of
ating room with well-trained assistants is as important as lacrimal surgery. 1st ed. Oxford: Butterworth-Heinemann; 2002.
p. 91–145.
the instruments for an overall great setup. The major 2. Tsirbas A, Wormald PJ. Mechanical endonasal dacryocystorhinos-
requirement is obviously a good endoscopic system, prefer- tomy with mucosal flaps. Br J Ophthalmol. 2002;87:43–47.
ably a high-definition one for desirable surgical experi- 3. Costello R, Whittet HB. Rigid endoscopy in the outpatient clinic.
ences [1–5]. For a transnasal endoscopic lacrimal surgery, a J Laryngol Otol. 2015;129:502–503.
4. Tschabitscher M, Di Leva A. Practical guidelines for setting up
limited functional endoscopic sinus surgery set as well as an endoscopic/skull base cadaver laboratory. World Neurosurg.
ophthalmic set is required for all the necessary instruments. 2013;79:e1–7.
These should include a set of 4 and 2.7 mm telescopes with 5. Ali MJ, Singh S, Naik MN. The utility of continuously variable
variable angles; fiber-optic light probe to guide to the posi- view rigid endoscope in lacrimal surgeries: first intraoperative
experience. Ophthal Plast Reconstr Surg. 2016;32:477–80.
tion of the lacrimal sac; a 15 blade on a long, slim handle to
provide adequate length for access within the nose; a Freer
elevator for elevating the mucosal flap; a straight and 45°
upturned Blakesley forceps for grasping bony and mucosal
fragments; a microdebrider with a 4 mm Trucut blade for
mucosal trimming and 2.5 mm diamond burr for bone
removal; a standard sinus suction; a keratome for opening
the lacrimal sac; and silicon lacrimal tubes if intubation is
planned.

50 4 Nasal Endoscopic Setup
Fig. 4.1 A modern lacrimal operating suite
Fig. 4.2 A compact OPD endoscopic system (Telepack X®, Karl Storz)
with viewing and recording facilities
Fig. 4.3 The Telepack® OPD endoscopic system with multiple input
and output options
4 Nasal Endoscopic Setup 51
Fig. 4.4 A high-definition operating endoscopic system Fig. 4.7 A three-chip camera head. This provides high-definition
images which are more desirable during surgeries
Fig. 4.5 The halogen and the xenon illuminating systems. Xenon pro- Fig. 4.8 A set of various telescopes
vides a near natural light
Fig. 4.6 An OPD two-chip camera head Fig. 4.9 A set of telescopes with variable angles of view
Fig. 4.10 A 4 mm 0° telescope. It is the one most commonly used for Fig. 4.12 The tip of a 4 mm 0° telescope. The shape of the tips gives a
adults clue to the viewing angulation
Fig. 4.13 A 2.7 mm 0° telescope. Note the shaft is much thinner as

compared to that in Fig. 4.10. This telescope is most commonly used
for OPD examination and for pediatric lacrimal surgeries
Fig. 4.11 The base of the 4 mm 0° telescope, which engages with the Fig. 4.14 The tip of a 4 mm 30° telescope. Compare this with that in
camera head Fig. 4.12
Fig. 4.15 A modern telescope assembly with a three-chip high-

definition camera. Note the self-irrigating telescope sheath that cleans
the tip of the scopes when desired, intraoperatively, without the need to
withdraw and clean
Fig. 4.18 The Medtronic Integrated Power Console® with inbuilt

Fig. 4.16 The Storz endoscopic drill system with inbuilt irrigation irrigation
Fig. 4.17 The routinely used Storz endoscopic burr set Fig. 4.19 The second-generation (M2) drill handpiece
Fig. 4.20 The fourth-generation (M4) drill handpiece
Fig. 4.21 The recent fifth-generation (M5) drill handpiece Fig. 4.23 The straight DCR burr for superior osteotomy. Note the irri-
gation sleeve adjacent to the burr also protects the tissues in the
vicinity
Fig. 4.22 The special curved DCR diamond burr for superior osteot- Fig. 4.24 A 45-degree curved burr for occasional difficult superior
omy. Note the irrigation sleeve adjacent to the burr also protects the osteotomy in a post-trauma setting
tissues in the vicinity
Fig. 4.25 The straight and curved tissue microdebriders
Fig. 4.26 A straight microdebrider set Fig. 4.28 The surgeon is usually placed to the right of the patient dur-
ing an endoscopy. Please check Fig. 4.1
Fig. 4.27 A canalicular light pipe which can be used by the beginners
to assess the location of lacrimal sac
Fig. 4.31 The endonasal monopolar Ellman® cautery. Note the bayo-
net design
Fig. 4.29 The bipolar endonasal Ellman® cautery. Note the bayonet Fig. 4.32 A 3 mm up biting endoscopic DCR bone punch
design
Fig. 4.30 The Wormald bipolar cautery with inbuilt simultaneous aspi- Fig. 4.33 A 2 mm up biting endoscopic DCR bone punch
ration system
Fig. 4.34 A straight endoscopic DCR bone punch Fig. 4.35 A sickle knife
Fig. 4.36 A set of Blakesley forceps
Fig. 4.37 A straight Blakesley forceps Fig. 4.38 The tip of the straight Blakesley forceps self-introduces its
various potential functions
Fig. 4.39 The ethmoid or the alligator forceps Fig. 4.43 Close-up image of the Wormald suction elevator. The edges
of the cup can also act as a cutting device
Fig. 4.40 The tip of the ethmoid forceps. Compare it with that of Fig. 4.37 Fig. 4.44 A fine suction probe
Fig. 4.41 A suction elevator Fig. 4.45 A dual-ended ball probe seeker
Fig. 4.42 Wormald suction and cutting elevator Fig. 4.46 A back-biting punch
Fig. 4.47 The tip of the back-biting punch. Note the reverse placement Fig. 4.50 Sisler’s trephine
of the cutting edge
Fig. 4.48 A rapid taper Nettleship’s punctum dilator Fig. 4.51 Huco trephine
Fig. 4.52 A Crawford bicanalicular intubation set
Fig. 4.49 A fine Bowman’s probe
Fig. 4.53 A routine Merocel® nasal pack

Fig. 4.54 A Merocel® nasal pack with a guide thread at one end Fig. 4.55 A Merocel® nasal pack that enables simultaneous breathing
Evaluation of Epiphora
5
Epiphora or watering is one of the most common symptoms References

of any ocular pathology. Though most cases of watering are
due to non-patency in the lacrimal outflow pathway, others 1. Hurwitz JJ. The lacrimal system. Philadelphia, PA: Lippincott-
Raven Publishers; 1996. p. 23–9.
like eyelid and adnexal disorders and corneal and ocular 2. Kominek P, Della Rocca RC, Rosebaum S. Diagnostics. In: Weber
surface pathology can also manifest as watering. In this con- RK, Keerl R, Schaefer SC, Della Rocca RC, editors. Atlas of lacri-
text, it is important to distinguish between the terms epiph- mal surgery. New York, NY: Springer; 2007. p. 29–51.
ora and pseudoepiphora or hyperlacrimation [1–3]. True 3. Lavrich JB, Nelson LB. Disorders of the lacrimal system apparatus.
Pediatr Clin North Am. 1993;40:767–76.
epiphora refers to watering due to obstruction in the lacri-
mal outflow pathway, while hyperlacrimation refers to
excessive watering due to reflex irritation of the corneal and
conjunctival surface as in cases of dry eye, corneal abrasion,
corneal foreign body, etc. It is also important to differentiate
between anatomical and functional lacrimal pathway
obstruction. Anatomical obstruction refers to any structural
pathology in the lacrimal outflow pathway which hinders
tear drainage. Conditions like punctal and canalicular steno-
sis and block, nasolacrimal duct obstruction (NLDO), etc.
are the causes of anatomical obstruction. In functional dys-
functions, the lacrimal outflow pathway is anatomically pat-
ent, but there is a failure of lacrimal pump mechanisms. This
could also be due to pathologies outside the lacrimal path-
way like facial palsy, eyelid laxity, and ectropion. Hence, a
detailed and comprehensive evaluation is needed to identify
the cause of watering and initiate appropriate management.
The goal of the evaluation is to differentiate true epiphora
from hyperlacrimation, differentiate obstructive cause of
epiphora from non-obstructive cause and to localize the site
of pathology in cases of obstructive epiphora. The evalua-
tion can be divided into history taking, local examination,
lacrimal system irrigation and probing, ancillary investiga-
tions, and nasal evaluation. The lacrimal system irrigation
and probing can be schematically represented as has been
shown in this chapter.
Figures 5.37–5.50 were illustrated by Dr Swati Singh,
LJEI, Ambala, with active inputs from the author.

62 5 Evaluation of Epiphora
Fig. 5.1 Fluorescein dye disappearance test or FDDT: Clinical photo- Fig. 5.4 Fluorescein dye disappearance test or FDDT: Clinical photo-
graph of a child showing asymmetric dye clearance at 5 min. Note the graph of the right eye of patient in Fig. 5.3
retention in the right eye and complete clearance on the left side
Fig. 5.2 Fluorescein dye disappearance test or FDDT: Clinical photo- Fig. 5.5 Fluorescein dye disappearance test or FDDT: Clinical photo-
graph of the right eye of patient in Fig. 5.1. Note the dye retention in graph of the left eye of the patient in Fig. 5.3. Compare this dye reten-
high magnification tion to that of the right eye in Fig. 5.4
Fig. 5.3 Fluorescein dye disappearance test or FDDT: Clinical photo-

graph of a child showing bilateral asymmetric dye retention at 5 min.
Note the retention is more on the left side as compared to the right
5 Evaluation of Epiphora 63

graph showing bilateral delayed and mild asymmetric dye clearance
between the eyes at 5 min

graph of a child post-probing for congenital nasolacrimal duct obstruc-
tion. Note the dramatic clearance of the dye bilaterally. Occasionally,
the dye may flow out of the nostril rather than going toward the naso-
pharynx, as noted in this child

graph of the right eye of the patient in Fig. 5.8. Note the dye retention
at 5 min

graph of the patient in Fig. 5.6. Note the dye coming out of the right
nostril

graph of the left eye of the patient in Fig. 5.8. Compare it with the right
eye in Fig. 5.9
Fig. 5.11 Fluorescein dye disappearance test (FDDT): Clinical photo-

graph showing bilateral gross retention of the dye at 5 min. Compare it
to those in Figs. 5.3 and 5.8
Fig. 5.14 Schematic diagram of the right eye showing the ROPLAS
test (regurgitation on pressure over the lacrimal sac). Positive ROPLAS
would mostly imply a nasolacrimal duct obstruction (Photo courtesy:
Himika Gupta, Mumbai)
Fig. 5.12 Clinical photograph showing Schirmer’s test to assess

hypersecretive epiphora
Fig. 5.15 Clinical photograph of the left eye showing the ROPLAS
test. Note the bud compressing the lacrimal sac swelling
Fig. 5.13 Clinical photograph of the left eye, profile view of the patient
in Fig. 5.12. Note the markings on the strip shows wetting of 15 mm at
the time of photo click
Fig. 5.16 Schematic diagram showing dilatation of the right lower

punctum with punctal dilator. Note the vertical position of the dilator
(Photo courtesy: Himika Gupta, Mumbai)
Fig. 5.18 Clinical photograph showing dilatation of the right upper

punctum with a Nettleship’s punctum dilator
Fig. 5.17 Schematic diagram showing dilatation of the right lower

punctum and proximal canaliculus. Note the horizontal position of the
dilator now and the lateral stretch of the lower lid (Photo courtesy:
Himika Gupta, Mumbai)
Fig. 5.19 Clinical photograph showing dilatation of the right upper

punctum and proximal canaliculus with a Nettleship’s punctum dilator
Fig. 5.20 Interpretation of lacrimal probing: Hard stop is felt when the positive soft stop can be felt if adequate lateral traction is not given on
probe hits the medial wall of the sac and underlying bone (Panel a). the eyelid to straighten the canaliculi while passing the probe through it
Soft stop is felt when the probe drags the lateral wall of the sac toward and the probe drags the roof or floor of the canaliculi against the sac
the medial wall in cases of canalicular obstructions (Panel b). False- (Panel c) (Photo courtesy: Sima Das, SCEH, Delhi)
Fig. 5.21 Choosing a right canula for irrigation: A set of sharp angu- Fig. 5.24 Choosing a right canula for irrigation: 23 and 25 gauge
lated canulas, which should be avoided for irrigation straight canulas are preferred for irrigation
Fig. 5.22 Choosing a right canula for irrigation: High magnification Fig. 5.25 Choosing a right canula for irrigation: The tips of the 23 and
showing various sharp angulation tips, which should be avoided 25 gauge straight canulas
Fig. 5.23 Choosing a right canula for irrigation: A set of curved or Fig. 5.26 Choosing a right canula for irrigation: End-on view of the
smooth angulated canulas, which should preferably be avoided tips of the 23 and 25 gauge straight canulas. Note the smooth contours.
23 gauge is preferred for adults and 25 for pediatric age groups
Fig. 5.30 Lacrimal irrigation: Clinical photograph showing irrigation

from the left upper punctum. Note the canula is horizontal and lies par-
allel to the upper lid margin. Note the lateral stretch of the upper lid to
counteract the accordion effect of the canaliculus.
Fig. 5.27 Lacrimal irrigation: Schematic diagram showing irrigation

from the right lower punctum. Note the vertical position of the canula
Fig. 5.28 Lacrimal irrigation: Schematic diagram showing irrigation

from the right lower punctum. Note the canula is horizontal and in the
lacrimal sac for intra-sac irrigation (Photo courtesy: Himika Gupta,
Mumbai)
Fig. 5.31 Lacrimal irrigation: Endoscopic view of the left inferior

meatus showing flow of dye during irrigation reflecting a patent naso-
lacrimal system
Fig. 5.29 Lacrimal irrigation: Clinical photograph showing irrigation

from the left upper punctum. Note the end-on engagement of the canula
with the punctal opening and the superolateral stretch of the upper lid to
counteract the accordion effect of the canaliculus
Fig. 5.35 Assessing the atonic sac: Clinical photograph of the left eye
of patient in Fig. 5.34. Note the dilated sac after irrigation
Fig. 5.32 Lacrimal irrigation: Endoscopic view of the right inferior

meatus showing overwhelming of the inferior meatus with the dye flow
(Photo courtesy: Nishi Gupta, SCEH, Delhi)
of the patient in Figs. 5.34 and 5.35. Note upon lacrimal sac compres-
sion, the fluid passes into the nasal cavity and the sac decompresses.
However, there is no regurgitation from either of the puncta
Fig. 5.33 Clinical photograph showing a dilated lacrimal sac on the

right side and a mucocele on the left side
during irrigation from lower punctum. Note that upon slow irrigation,
the lacrimal sac dilates and retains the fluid
Fig. 5.37 Representation and interpretation of irrigation and probing: Fig. 5.39 Representation and interpretation of irrigation and probing:
Patent right pathways. Irrigation from the lower punctum with patent Right-sided partial nasolacrimal duct obstruction. Irrigation from the
nasolacrimal duct lower punctum with partial regurgitation from the upper punctum (dot-
ted lines) and partial patency (dotted lines) of the nasolacrimal duct
Fig. 5.38 Representation and Interpretation of Irrigation and Probing:

Patent right pathways. Irrigation from the upper punctum with patent
nasolacrimal duct
Right-sided complete nasolacrimal duct obstruction. Irrigation from the Right-sided complete common canalicular obstruction. Irrigation from
lower punctum shows a complete regurgitation from the upper punctum the lower punctum shows a complete regurgitation from the upper
with no passage of fluid from the nasolacrimal ducts (complete line punctum with a complete obstruction at the level of common canalicu-
across the duct) lus (complete line across)
Right-sided partial common canalicular obstruction. Irrigation from the Right-sided mucocele. Note the complete obstruction being depicted at
lower punctum shows a partial regurgitation from the upper punctum the common canaliculus and at the nasolacrimal duct level with dilated
and partial recovery of the fluid in the nasal cavity. Note the partial soft lacrimal sac and obvious irrigation findings
stop at the level of common canaliculus (dotted lines)
A representation of right-sided upper mid canalicular obstruction and A representation of a lacrimal fistula. Note the irrigation from the lower
lower distal canalicular obstruction with obvious irrigation findings of punctum and fluid partially coming out of the fistula and the remaining
regurgitation from the same punctum passing down the nasolacrimal duct
Fig. 5.47 Representation and interpretation of irrigation and probing:

A representation of a lacrimal fistula. Note the irrigation from the lower
A representation of right-sided proximal bicanalicular obstruction
punctum and all the fluid coming out of the fistula without any flow
from the nasolacrimal duct

Representation of a complete punctal and canalicular agenesis

Representation of a right lower punctal stenosis
Fig. 5.51 Other causes of epiphora: Clinical photograph showing a

right-sided lower lid entropion. Note the rubbing of lashes on the ocular
surface
Fig. 5.52 Other causes of epiphora: Clinical photograph showing a

left-sided lower lid ectropion

Representation of a right lower punctoplasty and irrigation from the
lower system is patent
Fig. 5.53 Other causes of epiphora: Clinical photograph of the left eye Fig. 5.56 Other causes of epiphora: Slit lamp photograph of the left
showing a snap-back test. The lower lid is pulled away from the globe eye in a case of centurion syndrome. Note the punctal-globe incongru-
and released. Normal individuals show an immediate snapping back of ity and the gross punctal ectropion
the lid against the globe. Delay in this process or the need for patient to
blink to get his lower lid back in position reflects a gross lid laxity,
which can contribute to functional epiphora
Fig. 5.57 Other causes of epiphora: Clinical photograph of the left

lower lid showing a case of punctal ectropion
Fig. 5.54 Other causes of epiphora: Clinical photograph of the left eye
showing a lateral distraction test. The lower lid is pulled laterally and
normally; the punctum is not displaced by more than 2 mm. If gross
punctal displacement is possible, it reflects a medial canthal tendon lax-
ity, which can contribute to functional epiphora
Fig. 5.58 Other causes of epiphora: Clinical photograph of a right

lower lid showing a gross lower punctal ectropion associated with lower
lid laxity (Photo courtesy: Nishi Gupta, SCEH, Delhi)
(surgeon’s view) in a case of centurion syndrome. Note the punctal-
globe incongruity and mild punctal ectropion
Fig. 5.59 Other causes of epiphora: Clinical photograph of the left Fig. 5.62 Other causes of epiphora: Clinical photograph of the left
lower lid showing a subtle lid-globe incongruity secondary to conjunc- lower lid showing canalicular edema, and this inflammation can be
tivochalasis in caruncular area subtle and should not be missed while evaluating an epiphora
Fig. 5.63 Other causes of epiphora: Clinical photograph of Stevens-

Johnson patient. Any ocular surface disorder may cause reflex
Fig. 5.60 Other causes of epiphora: Clinical photograph of the left eye epiphora
showing complete apposition of the medial eyelids resulting in obstruc-
tion of the puncta and subsequent epiphora (Photo courtesy: Abhishek
Chandra, Varanasi)
showing enophthalmos, which can contribute to the punctal-globe
incongruity and subsequent epiphora
Fig. 5.64 Other causes of epiphora: Clinical photograph of a right Fig. 5.66 Other causes of epiphora: Clinical photograph of the left
lower lid in a case of Stevens-Johnson patient. Note the keratinization upper lid of the patient in Fig. 5.65. Note the horizontal kink in the
of the punctal and canalicular area tarsus (Photo courtesy: Milind N Naik, LVPEI, Hyderabad)
Fig. 5.65 Other causes of epiphora: Clinical photograph of a neonate Fig. 5.67 Other causes of epiphora: Postoperative photograph of the
with a tarsal kink syndrome. Neonatal epiphora is a common presenting patient in Figs. 5.65 and 5.66. Note the normal lids and compare them
symptom (Photo courtesy: Milind N Naik, LVPEI, Hyderabad) with those in Fig. 5.65 (Photo courtesy: Milind N Naik, LVPEI,
Hyderabad)
EPIPHORA EVALUATION FORM - First Visit Patient Label
Date:
Chief complaint:
HISTORY
Side Right Left Both Past Ocular History
Duration of Month(s) cicatricial disease

Symptoms
eyelid trauma
Associated
dacryocystitis
Symptoms discharge
stickiness or crusting Past Medical History
blurred vision
skin irritation/excoriation
facial/nasal trauma
Symptoms of Chronic Rhinosinusitis: chronic sinus/nasal disease
sinus/nasal surgery
facial pain/pressure/fullness
nasal obstruction/blockage Medications
nasal or postnasal discharge
hyposmia/anosmia
drops
chemotherapy
Precipitating time of dy (AM/PM)
Factors anticoagulants
reading/computer/tv
antiplatelets
cold or wind Allergies
other
Symptoms Score Severity Score

RIGHT LEFT
(Never Rarely Sometimes Frequently Always) (Circle One)
1. Does yours watery eye bother you? 0 1 2 3 4 Never 0 0

2. Does it interfere with:
a. Sight 0 1 2 3 4 Occasional tearing 1 1
b. Driving 0 1 2 3 4
c. Reading 0 1 2 3 4 Dabbing 2–4 times a
2 2
d. Mood 0 1 2 3 4 day
e. Work 0 1 2 3 4
3. Does your watery eye become 0 1 2 3 4 Dabbing 5–10 times a
3 3
embarrassing? day
Total Dabbing more than 10
4 4
times a day
Constant tear flow 5 5
EXAMINATION
Parameter Right Eye Left Eye
Tear Mensicus Height ≤ 1 mm > 1 mm ≤ 1 mm > 1 mm
Schirmer’s Test I*
< 10 mm 10 – 30 mm > 30 mm < 10 mm 10 – 30 mm > 30 mm
*(complete if necessary)
Schirmer’s Test II**
**(complete if Schirmer’s 1< 10 mm)) < 10 mm 10 – 30 mm > 30 mm < 10 mm 10 – 30 mm > 30 mm
Tear Film Break Up Time ≤ 10 seconds > 10 seconds ≤ 10 seconds > 10 seconds
Lid Margin Disease (ant/post blepharitis) present present
Trichiasis/Distichiasis present present
ConjunctivalChalasis medial Occluding punctum medial Occluding punctum
Cornea:
Punctate Erosions present present
Ulcer
Other: present present
Mucocele refluxable non-refluxable refluxable non-refluxable
Fig. 5.68 A detailed evaluation of epiphora sheet in Peter Wormald’s practice. (Photo courtesy: Peter Wormald, Adelaide)
EXAMINATION (cont’d)
Parameter Right Eye Left Eye

Snap Back Test 0 1 2 3 4 0 1 2 3 4
1 – 2-3 sec 3 - >5 sec
2 – 4-5 sec 4 – remains ectropic
DistractionTest mm mm
MCT Laxity
0 1 2 3 4 0 1 2 3 4
1 – 2 mm 3 - >3 mm
2 – 3 mm 4 – remains despite blink
LCT Laxity
0 1 2 3 4 0 1 2 3 4
1 – 2-4 mm 3 - >6 mm
2 – 4-6 mm 4 – remains despite blink
Punctal Position apposed upward everted apposed upward everted
OTHER FINDINGS
LACRIMAL SYRINGING
hard stop hard stop
soft stop soft stop
at: mm at: mm
Partial Partial
complete complete
thick reflux thick reflux
NASAl ENDOSCOPY
narrow narrow
septal deviation septal deviation
polyps polyps
rhinosinusitis (purulence) rhinosinusitis (purulence)
other: other:
IMPRESSION:
INVESTIGATIONS: PLAN:
dacryocystogram
lacrimal scintigraphy
CT
Other:
Name and Signature Date
Fig. 5.68 (continued)
Normal Endoscopic Anatomy
6
A thorough knowledge of a normal endoscopic anatomy is References

essential for lacrimal interventions. It not only helps the sur-
geon identify any deviations from the normal and patholo- 1. Witterick IJ, Hurwitz JJ. Anatomy of the nose and sinuses.
In: Hurwits JJ, editor. The lacrimal system. Philadelphia, PA:
gies but prepares the ground for transnasal surgical Lippincott-Raven; 1996. p. 31–7.
interventions. The nares or nostrils are the two openings into 2. Cottle MH. The structure and function of the nasal vestibule. In:
the nasal cavity [1]. The nasal septum divides the nasal cav- Maurice H, Cottle MD, Barelli PA, editors. Rhinology. Philadelphia,
ity into two sides. The nasal septum comprises cartilage PA: American Rhinologic Society; 1987. p. 74–86.
3. Woo KI, Maeng HS, Kim YD. Characteristics of intranasal struc-
anteriorly (quadrilateral/septal cartilage) and bone posteri- tures for endonasal dacryocystorhinostomy in Asians. Am J
orly (vertical plate of the ethmoid bone posterosuperiorly Ophthalmol. 2011;152:491–8.
and vomer bone posteroinferiorly). The lateral wall of the 4. Yung MW, Logan BM. The anatomy of the lacrimal bone at the
nose is a complex structure [1–5]. There are three or four lateral wall of the nose: its significance to the lacrimal surgeon. Clin
Otolaryngol Allied Sci. 1999;24:262–5.
paired nasal turbinates with a corresponding meatus under 5. Ohnogi J. Endoscopic observation of inferior aperture of the naso-
each turbinate. The middle turbinate is the most prominent lacrimal duct. Jpn J Clin Ophthalmol. 2001;55:650–4.
landmark and is a part of ethmoid bone and is attached to the
lateral wall by its axilla. Lacrimal sac usually lies anterior to
the axilla of the middle turbinate. The inferior turbinate is the
largest turbinate and occupies the lower third of the lateral
nasal wall. It arises from the medial wall of the maxillary
sinus. Its anterior tip is located 1.5–2.0 cm inside the nasal
space in adults, and the nasolacrimal duct empties into the
inferior meatus [1–5].
Examination technique of endoscopy involves three
passes of which the first two are important for a lacrimal
surgeon. During the first pass, the endoscope is introduced
along the floor of the nasal cavity, between the inferior turbi-
nate and the septum, toward the choana. This first pass allows
examination of the inferior part of the nasal cavity including
the inferior meatus where the nasolacrimal duct drains and
the nasal septum, as well as the nasopharynx and Eustachian
tube openings. The endoscope is then withdrawn and gently
reinserted for the second pass between the middle and infe-
rior turbinate, to examine the middle meatus. It is during the
second pass that the lateral nasal wall is inspected including
the maxillary line and attachment of the middle turbinate.

80 6 Normal Endoscopic Anatomy
Fig. 6.1 A set of endoscopic telescopes with variable diameters and

viewing angles
Fig. 6.3 Endoscopic view from the entrance of the left nasal cavity.
Note the two major surfaces, the medial surface on the left is formed by
the nasal septum and opposite to that is the lateral wall of the nose with
turbinates
Fig. 6.2 The telescope tips demonstrating multiple viewing angles
Fig. 6.4 Endoscopic view of the left nasal cavity showing the nasal
floor
6 Normal Endoscopic Anatomy 81
Fig. 6.5 Endoscopic view of the right nasal cavity showing the inferior Fig. 6.7 Endoscopic view of the left nasal cavity showing the lateral
turbinate and the nasal floor wall of the inferior meatus
Fig. 6.6 Endoscopic view of the left nasal cavity showing the inferior Fig. 6.8 Endoscopic view of the left inferior meatus
turbinate and a probe from the nasolacrimal duct in the inferior meatus
Fig. 6.9 Endoscopic view of the right inferior meatus showing the nor- Fig. 6.11 Endoscopic view of the left inferior meatus showing a nor-
mal opening of the nasolacrimal duct on the lateral wall. Note the round mal but slit opening of the nasolacrimal duct on the lateral wall (Photo
shape of the opening courtesy: Nishi Gupta, SCEH, Delhi)
Fig. 6.10 Endoscopic view of the left inferior meatus showing the nor- Fig. 6.12 Endoscopic view of the left inferior meatus showing a verti-
mal opening of the nasolacrimal duct on the lateral wall. Note the little cal slit opening of the nasolacrimal duct with positive fluorescein endo-
less define shape as compared to Fig. 6.9 scopic dye test (Photo courtesy: Nishi Gupta, SCEH, Delhi)
Fig. 6.13 Endoscopic view of the right inferior meatus demonstrating Fig. 6.15 Endoscopic view of the left inferior meatus showing a hori-
a normal nasolacrimal opening (Photo courtesy: Nishi Gupta, SCEH, zontally oval opening of the nasolacrimal duct (Photo courtesy: Nishi
Delhi) Gupta, SCEH, Delhi)
Fig. 6.14 Endoscopic close-up view of the opening of the right naso- Fig. 6.16 Endoscopic view of the left inferior meatus showing the
lacrimal duct on an elevated papilla (Photo courtesy: Nishi Gupta, nasolacrimal duct opening with the remnant of the Hasner’s valve.
SCEH, Delhi) (Photo courtesy: Nishi Gupta, SCEH, Delhi)
Fig. 6.17 Endoscopic view of the left nasal cavity showing the most Fig. 6.19 Endoscopic view of the left nasal cavity. Note the middle
prominent landmark of middle turbinate on the lateral wall meatus lateral to the middle turbinate
Fig. 6.18 Endoscopic view of the left nasal cavity showing a close-up Fig. 6.20 Endoscopic view of the right normal middle meatus
image of a normal middle turbinate
Fig. 6.21 Endoscopic view of the left nasal cavity showing a close-up Fig. 6.23 Endoscopic view of the left nasal cavity showing a broad
image of the body of a normal middle turbinate axilla of the middle turbinate attached to the lateral wall
Fig. 6.22 Endoscopic view of the left nasal cavity showing the axilla Fig. 6.24 Endoscopic view of the left nasal cavity, where the probe is
of the middle turbinate. This is an important landmark for the dacryo- demonstrating a normal uncinate process
cystorhinostomy surgery
Fig. 6.25 Endoscopic view of the left middle meatus showing a close- Fig. 6.27 Endoscopic view of the right middle meatus in a post FESS
up view of the normal uncinate process case showing the widely opened maxillary sinus ostium (arrow)
Fig. 6.26 Endoscopic view of the left middle meatus showing an Fig. 6.28 Endoscopic view of the left nasal cavity showing the supe-
accessory maxillary ostium. Note the normal maxillary sinus ostium is rior turbinate and superior meatus enclosed by it
usually not visible unless an uncinectomy is performed
Fig. 6.29 Endoscopic view of the right nasal cavity demonstrating the Fig. 6.31 Endoscopic view of the right sphenoid sinus, close-up image
frontal sinus opening at the top end showing the optic nerve and the carotid mounds
Fig. 6.30 Endoscopic view of the right sphenoid sinus opening Fig. 6.32 Endoscopic view of the nasopharynx. Note the Eustachian
tube on the lateral wall
Nasal Anatomy Using Realistic
Anatomical Models 7
Endoscopic lacrimal surgeries are rapidly gaining foothold References

with increasing indications and newer technologies.
Training is an essential part of learning any surgical proce- 1. Kamal S, Ali MJ, Nair AG. Outcomes of endoscopic dacryocys-
torhinostomy: experience of a fellowship trainee at a tertiary care
dures; however, the maneuvering of instruments by inexpe- center. Indian J Ophthalmol. 2016;64:648–53.
rienced surgeons can be dangerous in the nasal cavity 2. Rivron RP, Maran AG. The Edinburgh FESS Trainer: a cadaver
owing to its complex structure and relationship to crucial based bench top practice system for endoscopic ethmoidal surger-
anatomical landmarks [1–3]. The most common mode of ies. Clin Otolaryngol Allied Sci. 1991;16:426–9.
3. Kirkman MA, Ahmed M, Albert AF, et al. The use of simulation
training is in the operating room where the inexperienced in neurosurgical education and training. A systematic review. J
surgeon assists or is assisted by an experienced surgeon. Neurosurg. 2014;121:228–46.
Cadavers have also been used but have multiple legal and
ethical issues. Virtual reality-based training with the help
of computer software is an upcoming modality where mul-
tiple algorithms interact with the users. However, lack of
real surgical instrument use and expenses curtails its use
for routine training.
Realistic anatomical models are designed with the help of
normal radiological and endoscopic anatomy. It has numer-
ous advantages and includes the use of real instruments and
materials as in routine surgeries. Simultaneous working with
other colleagues on the anatomical model helps in building
collaborative skills during the surgery. Numerous realistic
anatomical models are available, and the common ones
include the functional endoscopic sinus surgery (FESS)
trainer (Karl Storz, Tuttlingen, Germany) and the sinus model
otorhino-neuro trainer (SIMONT) (Karl Storz, Tuttlingen,
Germany). The FESS trainer is mostly for learning endo-
scopic handling and getting acquainted with the normal ana-
tomical structures, while the SIMONT is used for surgical
procedures. The anatomical plates that constitute the FESS
trainer can be disassociated for detailed anatomical learning.

90 7 Nasal Anatomy Using Realistic Anatomical Models
Fig. 7.1 The functional

endoscopic sinus surgery
(FESS) trainer. Note the
realistic size of the model
Fig. 7.2 The FESS trainer realistic anatomical model
Fig. 7.4 Endoscopic view of right nasal vestibule
Fig. 7.3 Worm’s eye view of the FESS trainer realistic anatomical
model
7 Nasal Anatomy Using Realistic Anatomical Models 91
Fig. 7.5 Endoscopic view of the right nasal cavity showing the lateral Fig. 7.7 Endoscopic view of the right nasal cavity showing inferior
wall turbinates (black stars) and the septum (black arrow) turbinate and floor of the nasal cavity
Fig. 7.6 Endoscopic view of the right nasal cavity showing the middle Fig. 7.8 Endoscopic view of the right nasal cavity showing the inferior
turbinate with its axilla turbinate and its meatus
Fig. 7.9 Endoscopic view of the left nasal cavity showing the middle Fig. 7.11 Endoscopic view of the right nasal cavity showing the supe-
meatus with bulla ethmoidalis (black arrow) and uncinate process rior turbinate (black arrow) and opening of the sphenoid sinus (above
(black star) the black star)
Fig. 7.12 Endoscopic view of the right nasal cavity showing the naso-
pharynx view
Fig. 7.10 Endoscopic view of the left nasal cavity showing the aditus
to the maxillary sinus
Fig. 7.13 Endoscopic view of the anatomical plate in the FESS trainer. Fig. 7.15 Endoscopic view of the anatomical plate in the FESS trainer.
Note the deviated nasal septum (black star) with a septal spur and the Note the agger nasi cell (spatula) which is an important landmark for
right hypertrophied inferior turbinate (black arrow) the fundus of the lacrimal sac
Note the middle meatus (spatula) and the maxillary sinuses (black Note the details of the middle meatus and the frontal sinuses
stars)
Note the maxillary sinus (spatula) and the orbits (black star) Note the skull base and its relationship to the bilateral orbits and the
axilla of the middle turbinate
Fig. 7.20 The Phacon TrainerR. The assembled trainer set fixed on a
plate and can be adjusted in any direction and angles of convenience
Fig. 7.18 Endoscopic view of the anatomical plate in the FESS trainer.
Note the intricate frontal sinus drainage pathway (probe)
Fig. 7.21 The Phacon TrainerR. The assembled trainer set fixed on a
plate and can be adjusted in any direction and angles of convenience
Fig. 7.23 The Phacon TrainerR. The central Function endoscopic sinus
model (red) is fixed centrally to the skull, before placing the soft tissue
cover
Fig. 7.22 The Phacon TrainerR. The bare skull with electric circuits
that can convert it into a navigation-enabled trainer for complex
procedures Fig. 7.24 The Phacon TrainerR. A training exercise in action
Normal Dacryoendoscopy
8
Dacryoendoscopy is a procedure utilizing microendoscopic References

techniques to visualize the entire lacrimal system from the
puncta to the inferior meatus [1–5]. It is gaining firm ground 1. Sasaki T, Nagata Y, Sugiyama K. Nasolacrimal duct obstruction
classified by dacryoendoscopy and treated with inferior meatal
and increasing popularity for expanding indications in lacri- dacryorhinotomy. Part I: Positional diagnosis of primary nasolac-
mal disorders, thus having many diagnostic and potential rimal duct obstruction with dacryoendoscope. Am J Ophthalmol.
therapeutic implications [1–5]. The dacryoendoscope has a 2005;140:1065–9.
thin, rigid fiber endoscope and a side port on the handpiece. 2. Sasaki T, Nagata Y, Sugiyama K. Nasolacrimal duct obstruction
classified by dacryoendoscopy and treated with inferior meatal
The rigid fiber endoscope is attached to the eyepiece through dacryorhinotomy: Part II. Inferior meatal dacryorhinotomy. Am J
a fiber-optic cable. The eyepiece of the dacryoendoscope is Ophthalmol. 2005;140:1070–4.
connected to the camera head and secured. The camera head 3. Emmerich KH, Steinhauer J, Meyer-Rüsenberg HW, et al.
is then connected to the endoscopic viewing system. Dacryoendoscopy—current status. Ophthalmologe. 1998;95:820–2.
4. Küstner M, Clemens S, Tost F. Minimally invasive endoscopic
The normal canaliculus has a narrow lumen which pro- surgery of the lacrimal drainage system—two case reports. Klin
gressively constricts toward the distal segment. The mucosa Monatsbl Augenheilkd. 2005;222:928–32.
classically appears white to whitish pink unless there is an 5. Emmerich KH, Meyer-Rüsenberg HW, Simko P. [Endoscopy of the
inflammation. The walls of the canaliculus are homogenous lacrimal ducts]. Ophthalmologe. 1997;94:732–5. Klin Monatsbl
Augenheilkd. 1997;94:732–5.
and smooth. The canaliculus can be arbitrarily divided into
four walls: anterior, posterior, roof, and floor. As the dacryo-
endoscope enters the lacrimal sac, the lumen is noted to
become very wide. The illumination usually appears to
become dull and may need to be increased for clearer images.
The mucosa of lacrimal sac is pinkish to pinkish-red. The
mucosal folds are sparse and less elevated on the walls as
against the elevated mucosal folds noted in the common can-
aliculus or at canalicular-sac junction. As the scope descends
down, the lumen is found to narrow down significantly at one
point, the sac-duct junction, and may be guarded by mucosal
valves. The nasolacrimal duct begins soon after the sac-duct
junction as described earlier. The lumen is narrow and the
mucosa is reddish in color. The walls usually are flat with no
elevated mucosal folds. Occasionally, a peripheral rim of
residual Hasner’s valve may be noticed. The end of nasolac-
rimal duct can be assessed by the change to intense red
appearance of nasal mucosa and the enormously wide
cavity.

98 8 Normal Dacryoendoscopy
Fig. 8.1 The 0.6 mm dacryoendoscope Fig. 8.4 The distal end which could attach to the existing camera heads
Fig. 8.2 The working channel with the fiber-optic cable and the side Fig. 8.5 The high-definition dacryoendoscope (HD-DEN) illumina-
port for irrigation tion system
Fig. 8.3 Close-up view of the dacryoendoscope camera tip Fig. 8.6 The high-definition dacryoendoscope (HD-DEN) imaging
system
8 Normal Dacryoendoscopy 99
Fig. 8.7 The HD-DEN control foot switches Fig. 8.10 The smooth curved Ruido FiberscopeR
Fig. 8.8 A HD-DEN probe set Fig. 8.11 The angulated Ruido FiberscopeR
Fig. 8.9 The straight Ruido FiberscopeR Fig. 8.12 Distal ends of the Ruido FiberscopesR
Fig. 8.13 The protective DEN sleeves Fig. 8.16 Respective distal ends of the probe are inserted into their
slots on the illumination and the imaging system
Fig. 8.14 Sleeve preparation for mounting it on the fiberscope Fig. 8.17 The assembled HD-DEN unit
Fig. 8.15 Sleeve mounting on the fiberscope

Fig. 8.20 The vertical lacrimal pass of the dacryoendoscope probe to

evaluate the lacrimal sac and nasolacrimal ducts
Fig. 8.18 The complete HD-DEN unit expanded on the existing endo-
scopic system
Fig. 8.21 Dacryoendoscopic view of a normal canaliculus. It can be

arbitrarily divided into four walls: anterior (A), posterior (P), roof (R),
and floor (F)
Fig. 8.19 The canalicular pass of the dacryoendoscope probe

Fig. 8.22 A normal view of the proximal canaliculus. Note the whitish Fig. 8.24 HD-DEN photo at the junction of common canalicular entry
appearance of the mucosa and the wide lumen end on into the lacrimal sac. Note the incoming appearance of a wide lumen
Fig. 8.23 A normal view of the distal canaliculus. Note the whitish Fig. 8.25 Dacryoendoscopy with standard imaging modality showing
appearance of the mucosa and the lumen getting narrower as distal end a normal lacrimal sac. Note the wide lumen, pinkish mucosa, and the
approaches need to increase illumination
Fig. 8.28 HD-DEN image showing the slit-shaped opening of the

nasolacrimal duct
Fig. 8.26 Dacryoendoscopy with standard imaging modality showing

the sac-duct junction. Note the incoming narrowing as against the wide
sac lumen
Fig. 8.27 HD-DEN image showing the sac-duct junction Fig. 8.29 Dacryoendoscopy with standard imaging showing the nar-
row nasolacrimal duct with a reddish mucosa
Fig. 8.30 HD-DEN image showing nasolacrimal duct with a mucosal

fold in the distance
Fig. 8.31 Dacryoendoscopy with a standard imaging showing the

NLD mucosal folds at a higher magnification
Normal Lacrimal Optical Coherence
Tomography 9
Optical coherence tomography is rapidly gaining foothold as References

an important imaging modality for the punctum and vertical
canaliculus [1–5]. It works on the principle of low coherence 1. Wawrzynski JR, Smith J, Sharma A, et al. Optical coherence
tomography imaging of the proximal lacrimal system. Orbit.
interferometry. The technique involves positioning the 2014;33:428–32.
patient with their chin on the OCT chin rest and their fore- 2. Kamal S, Ali MJ, Ali MH, et al. Fourier domain optical coherence
head against the upper support. With the eyes open, the lower tomography with 3D and En Face imaging of the punctum and ver-
eyelid margin is gently everted using a cotton bud placed tical canaliculus. A step toward establishing a normative database.
Ophthal Plast Reconstr Surg. 2016;32:170–3.
below the punctum just enough to get the punctum into a 3. Allam RS, Ahmed RA. Evaluation of the lower punctum param-
plane perpendicular to the light source. The long axis of scan eters and morphology using spectral domain anterior segment opti-
is aligned approximately parallel to the lid margin, and line cal coherence tomography. J Ophthalmol. 2015;2015:591845.
scan is captured. A corneal adaptor module, 6 mm, line scan 4. Timlin HM, Keane PA, Day AC, et al. Characterization of the
lacrimal punctum using spectral domain anterior segment optical
is used. The various parameters measured include the exter- coherence tomography: an exploratory study. Acta Ophthalmol.
nal lacrimal punctum (ELP) diameter, which is measured as 2016;94:154–9.
a line connecting the points where medial and lateral punctal 5. Kamal S, Ali MJ, Naik MN. Incomplete punctal canalization:
walls meet with the surface of the lid margin, and the internal report of Fourier domain optical coherence tomography features.
lacrimal punctum (ILP) diameter, where the width is mea-
sured at 500 μm from the surface corresponding to the lower
border of the lower most reflective layer. The vertical cana-
licular length or height (VCL/VCH) is measured as a perpen-
dicular from the line across the external lacrimal punctum up
to the visible depth of canaliculus. The mid canalicular diam-
eter (MCD) was measured midway between the punctum
and its visible lower end. In normal humans, the mean ELP,
ILP, VCL, and MCD, recorded in various studies, are
646 μm, 50 ± 104 μm, 890.41 ± 154.76 μm, and
125.04 ± 60.69 μm, respectively.
Figures 9.6–9.12 are from Kamal et al., Ophthal Plast
Reconstr Surg 2016;32:170–173.

106 9 Normal Lacrimal Optical Coherence Tomography
Fig. 9.1 A Fourier domain ocular coherence tomography system (Optovue®)
Fig. 9.2 A corneal adaptor module with the 6 mm lens is required for Fig. 9.3 Clinical photograph showing a gentle eversion of the eyelid,
imaging the proximal lacrimal system so as not to distort the lacrimal anatomy
9 Normal Lacrimal Optical Coherence Tomography 107
Fig. 9.4 Acquisition of the

lacrimal OCT images
Fig. 9.5 A normal Fourier domain OCT (FD-OCT) of the punctum and the vertical canaliculus. Note the various reflectivities of different layers
in the peri-punctal area
Fig. 9.6 A normal FD-OCT of the punctum and vertical canaliculus. Note the three parameters measured include the maximum punctal diameter,
the mid canalicular diameter, and the vertical canalicular height
108 9 Normal Lacrimal Optical Coherence Tomography
Fig. 9.7 A normal FD-OCT showing a wide punctum and vertical

canaliculus. Note the hyper-reflective surface of the tear film, just
within the punctal boundaries
Fig. 9.8 A normal FD-OCT. Note the presence of hyper-reflective and Fig. 9.10 Three-dimensional FD-OCT image showing the morpho-
irregular tear debris in the proximal vertical canaliculus logical features of normal punctum and vertical canaliculus
Fig. 9.9 FD-OCT of an asymptomatic adult. Note the narrowing of the

punctum and vertical canaliculus, and compare them to those of
Figs. 9.7 and 9.8. Note the range of normalcy
Fig. 9.11 En face imaging of the punctum showing slightly raised

punctal edges and a wide beginning of the proximal vertical
canaliculus
9 Normal Lacrimal Optical Coherence Tomography 109
Fig. 9.12 En face imaging of the punctum and vertical canaliculus.

Note the distinct demarcation of the punctal surface topography, rem-
nant fold at one of the edges, and an end-on view of a well-defined
vertical canaliculus
Digital Subtraction Dacryocystography
10
Dacryocystography (DCG) is a modality where the lacrimal References

drainage system is injected with a radiopaque dye and roent-
genograms are obtained to study obstructions or filling defects. 1. Galloway JE, Kavie TA, Raflo GT. Digital subtraction macro-
dacryocystography: a new method of lacrimal system imaging.
However, the plain X-ray DCG has a poor resolution and lac- Ophthalmology. 1984;91:956–62.
rimal system is not highlighted for a detailed study. Digital 2. Kousoubris PD. Radiological evaluation of lacrimal and orbital dis-
subtraction DCG or DS-DCG was first described by Galloway ease. In: Woog JJ, editor. Endoscopic lacrimal and orbital surgery.
et al. in 1984 [1]. Digital subtraction dacryocystography is 1st ed. Oxford: Butterworth-Hienemann; 2004. p. 79–104.
3. Priebe M, Mohr A, Brossman J, et al. Gadobutrol: an alterna-
currently the most favored among conventional X-ray tech- tive contrast agent for digital subtraction dacryocystography. Eur
niques. As the name reflects, this technique can subtract back- Radiol. 2002;12:2083–6.
ground images and noises to give clear contrast-filled lacrimal 4. Walther EK, Herberhold C, Lippel R. Digital subtraction dacryo-
images for study. Its other advantages include reduced radia- cystography (DS-DCG) and evaluation of results of endonasal lac-
rimal duct surgery. Laryngorhinootologie. 1994;73:609–13.
tion exposure as compared to conventional techniques, ability 5. Lefebvre DR, Freitag SR. Update on imaging of the lacrimal drain-
to digitally manipulate the image contrast and brightness, and age system. Surv Ophthalmol. 2012;27:175–86.
cinematic view helping with understanding the flow dynam-
ics. DCG is a useful modality to study the anatomical abnor-
malities of the lacrimal system like stenosis, obstructions, and
diverticula and to detect dacryolithiasis [1–5].
The technique is performed after cannulating the cana-
licular system and gently injecting 1 ml of contrast material
(Lipiodol, Omnipaque, or gadobutrol) [3]. As the dye is
injected, the frames are obtained at a rate of 1 s each. Since
the entire lacrimal system would typically fill up in 10 s,
frames are obtained for similar duration. During the injection
stage, apart from the anteroposterior images, both oblique
frontal projections and off-lateral views are captured to yield
a better delineation. DS-DCG has been reported to not only
be useful in differentiating pre-saccal from post-saccal ste-
nosis but also in evaluating results of a dacryocystorhinos-
tomy [4].

112 10 Digital Subtraction Dacryocystography
Fig. 10.1 A plain X-ray DCG. Note the numerous disadvantages of this technique. The high amount of background structures fails to delineate
the lacrimal system well
10 Digital Subtraction Dacryocystography 113
Fig. 10.2 Digital subtraction DCG. Note the loss of background

noise and the good imaging of the radiopaque dye (black). The image
shows a block at common canaliculus and reflux of the dye in the
conjunctival cul-de-sac
Fig. 10.3 DS-DCG of both the lacrimal systems. Note the complete delineation of the normal right lacrimal system and a common canalicular
obstruction on the left side
114 10 Digital Subtraction Dacryocystography
Fig. 10.4 Digitally subtracted image with a canula in the left lower
lacrimal system
Fig. 10.6 Image contrast and brightness manipulation of the same

patient as in Fig. 10.5 for better lacrimal delineation (Photo courtesy:
Alkis Psaltis, TQEH, Adelaide)
Fig. 10.5 Digitally subtracted image with a canula in the left lacrimal Fig. 10.7 Lateral view of DS-DCG showing canalicular filling with dye
system (Photo courtesy: Alkis Psaltis, TQEH, Adelaide) (Photo courtesy: Alkis Psaltis, TQEH, Adelaide)
10 Digital Subtraction Dacryocystography 115
Fig. 10.8 Sequential DCG of same patient as in Fig. 10.7, showing Fig. 10.9 Sequential DCG of same patient as in Figs. 10.7 and 10.8,
early sac filling (Photo courtesy: Alkis Psaltis, TQEH, Adelaide) showing complete filling of the sac but obstruction at the sac-duct junc-
tion (Photo courtesy: Alkis Psaltis, TQEH, Adelaide)
Dacryoscintigraphy
11
The advances in nuclear medicine have made dacryoscin- References

tigraphy a fairly safe and easy method for assessing the
flow dynamics and other physiological aspects of lacrimal 1. Kousoubris PD. Radiological evaluation of lacrimal and orbital dis-
ease. In: Woog JJ, editor. Endoscopic lacrimal and orbital surgery.
system [1–5]. It has a complementary role to anatomic 1st ed. Oxford: Butterworth-Hienemann; 2004. p. 79–104.
studies and can be useful in evaluating pediatric epiphora, 2. Lefebvre DR, Freitag SR. Update on imaging of the lacrimal drain-
partial obstructions, and functional nasolacrimal duct age system. Surv Ophthalmol. 2012;27:175–86.
obstructions. The test is performed by instilling 10 μl of 3. Rossomondo RM, Carlton WH, Trueblood JH, et al. A new method
of evaluating lacrimal drainage. Arch Ophthalmol. 1972;88:523–5.
technetium 99 pertechnetate into the conjunctival cul-de- 4. Hurwitz JJ, Maisey MN, Welham RAN. Quantitative lacrimal scin-
sac and tracing the dye through the lacrimal system using tillography. Br J Ophthalmol. 1975;59:313–22.
a pinhole-collimated gamma camera. Patients are 5. Sagili S, Selva D, Malhotra R. Lacrimal scintigraphy: interpretation
instructed to blink normally, and images are acquired in more art than science. Orbit. 2012;31:77–85.
real time for up to 30 min. The study end point is the detec-
tion of radionuclide dye in the nasal cavity. In a typical
normal DSG, visualization of canaliculi and sac occurs
before 30 s and with passage into the nasal cavity in
10–20 min. Areas of interest can be marked on the DSG
images, and quantity of tracer and times taken can be plot-
ted on the time-activity scales. For example, if the system
is obstructed at a point, the time-activity slope there would
be flat. Disadvantages of DSG include poor anatomical
details, poor resolution, and variable transit times through-
out the lacrimal system [1–5].

118 11 Dacryoscintigraphy
Fig. 11.1 Dacryoscintigraphy image

showing lack of dye transit bilaterally
beyond the common canaliculus
suggestive of a proximal obstruction
Fig. 11.2 Dacryoscintigraphy image

showing radiotracer retention in the
right lacrimal sac suggestive of a
post-saccal obstruction, whereas the left
lacrimal system appears normal with
dye traced in the nasal cavity
11 Dacryoscintigraphy 119
Fig. 11.3 Dacryoscintigraphy image showing a normal transit of radiotracer in the right lacrimal system. Note the radiotracer retention at the
pre-saccal level on the left side
Fig. 11.4 Dacryoscintigraphy image in a case of bilateral traumatic secondary acquired nasolacrimal duct obstruction. Note the slow dye travers-
ing into the lacrimal sac and filling it in 30 min
Fig. 11.5 Dacryoscintigraphy image of the same patient as in Fig. 11.4. Note the radiotracer retention in the lacrimal sac without transit into the
nasal cavity at 60 and 120 min suggestive of a nasolacrimal duct obstruction
Fig. 11.6 Dacryoscintigraphy showing a normal right lacrimal system and a left distal canalicular obstruction
11 Dacryoscintigraphy 121
Fig. 11.7 Dacryoscintigraphy showing a right pre-saccal and a left post-saccal obstruction (Photo courtesy: Alkis Psaltis, TQEH, Adelaide)
Fig. 11.8 Dacryoscintigraphy showing bilateral pre-saccal obstructions (Photo courtesy: Alkis Psaltis, TQEH, Adelaide)
Computed Tomography
Dacryocystography (CT-DCG) 12
CT-DCG is an excellent tool for delineating the bony struc- References

tures around the lacrimal system and to some extent soft tis-
1. Ashenhurst M, Jaffer N, Hurwitz JJ, et al. Combined computed
sue study of lacrimal system [1–5]. Technique employed can tomography and dacryocystography for complex lacrimal prob-
be either by dye instillation (drop method) or cannulation lems. Can J Ophthalmol. 1991;26:27–31.
technique. The drop method is particularly useful in children 2. Udhay P, Noronha OV, Mohan RE. Helical computed tomographic
dacryosystography and its role in the diagnosis and management of
and in patients unable to cooperate for irrigation. Serial coro-
lacrimal drainage system blocks and medial canthal masses. Indian
nal and axial images (2 mm slices) of the lacrimal area J Ophthalmol. 2008;56:31–7.
should be requested. By using modern spiral CT techniques 3. Hurwitz JJ, Edward Kassel EE, Jaffer N. Computed tomography
with contrast material, high-resolution thin sections of the and combined CT-dacryocystography (CT-DCG). In: Hurwitz
JJ, editor. The lacrimal system. New York: Raven Press; 1996.
system are obtained, and shorter acquisition time and three-
p. 83–5.
dimensional (3D) reconstruction offer very good imaging 4. Ali MJ, Singh S, Naik MN, et al. Interactive navigation-guided
and patient compliance [4, 5]. ophthalmic plastic surgery: navigation enabling of endoscopes
Cross sections of the system are seen in coronal refor- and their use in endoscopic lacrimal surgeries. Clin Ophthalmol.
2016;10:2319–24.
matted images because the line of section is oriented down-
5. Ali MJ, Singh S, Naik MN, et al. Interactive navigation-guided
ward and obliquely backward. Parasagittal reformatted ophthalmic plastic surgery: the utility of 3D-CT DCG guided dac-
images will reveal the entire length of the system in longitu- ryolocalization in secondary acquired lacrimal duct obstructions.
dinal section. This view is indispensable in picking up the Clin Ophthalmol. 2017;11:127–33.
exact level of the obstruction. In trauma cases, it offers addi-
tional benefits of more exact localization of the lacrimal
drainage system fractures, bone displacements, location of
previously placed miniplates, and wires or sheets used in
fracture repair [4, 5].
CT-DCG is very helpful to note the involvement of the sac
in tumors initially and also for noting the features posttreat-
ment such as irradiation where further reconstruction along
with epiphora management is contemplated. Unusual fea-
tures such as diverticulum of sac and canalicular pouch along
with foreign bodies could be picked up. Hence CT-DCG is
an invaluable tool in the diagnosis and management of com-
plex lacrimal duct obstructions.

124 12 Computed Tomography Dacryocystography (CT-DCG)
Fig. 12.1 The radiopaque dye

used for CT-DCG. It needs dilu-
tions of up to 50:50 before inject-
ing into the lacrimal system
Fig. 12.2 The CT-DCG

procedure. The lacrimal
surgeon is injecting the dye
into the lacrimal system, and
the images are captured
immediately following
injection (Photo courtesy: Dr
Swati Singh, LJEI, Ambala)
12 Computed Tomography Dacryocystography (CT-DCG) 125
Fig. 12.3 A pediatric patient with right epiphora following trauma
Fig. 12.5 CT-DCG, axial cut, of the patient in Figs. 12.3 and 12.4.
Note the nasolacrimal duct on the normal left side is filled with dye,
whereas the dye is absent in the right nasolacrimal duct
Fig. 12.6 Clinical photo of a patient following a facial trauma. Note

the epiphora and dye retention on the left side
Fig. 12.4 CT-DCG, coronal cut, of the patient in Fig. 12.3, showing no

transit of dye beyond the right common canaliculus suggestive of a
common canalicular obstruction. Note the dye has traversed the entire
left lacrimal system with good anatomical delineation
Fig. 12.7 CT-DCG, coronal cut, of the patient in Fig. 12.6, showing

dye pooling and enlargement of the left lacrimal sac, suggestive of a
post-saccal obstruction
Fig. 12.9 3D CT-DCG of the same patient as in Fig. 12.8. Note the dye
traversing through the nasal cavity into the pharynx on the left side
Fig. 12.8 Three-dimensional (3D) CT-DCG with volume rendering Fig. 12.10 3D CT-DCG, volume rendered, showing bilateral dye
showing a right post-saccal obstruction reflux into conjunctival sac with irregular filling defects of the left lac-
rimal sac
12 Computed Tomography Dacryocystography (CT-DCG) 127
Fig. 12.11 3D CT-DCG, volume rendered, showing a normal right Fig. 12.13 3D CT-DCG, volume rendered, of a case of bilateral
lacrimal system and a left post-saccal obstruction. This patient had trauma. Note the high post-saccal obstruction on the right side and pat-
undergone a maxillary sinus osteoma excision resulting in an iatrogenic ent but multiple filling defects on the left side
cut of the nasolacrimal duct
Fig. 12.12 3D CT-DCG, volume rendered, of the same patient as in Fig. 12.14 3D CT-DCG, volume rendered, of a case of right maxil-
Fig. 12.11. Note the clean cut of the post-saccal area during the lectomy and iatrogenic NLD excision. Note the remnant lacrimal sac on
surgery the right side and a normal lacrimal system on the left
Fig. 12.15 3D CT-DCG, volume rendered, of the same patient as in

Fig. 12.14. The lateral view demonstrates the remnant lacrimal sac is
displaced posteriorly on the lateral wall of the nose Fig. 12.17 3D CT-DCG, volume rendered, of a patient of facial
trauma. Note the right-sided nasolacrimal duct obstruction with dye
reflux in the conjunctival cul-de-sac. The left system is normal
Fig. 12.16 3D CT-DCG, volume rendered, of the same patient as in Fig. 12.18 3D CT-DCG, volume rendered, of the same patient as in
Figs. 12.14 and 12.15. The below upward view shows a clean cut during Fig. 12.17. The lateral view gives more details. The right lacrimal sys-
the surgery and at a level of lower lacrimal sac tem has a stricture or narrowing at the sac-duct junction as well as a
complete obstruction at the level of distal nasolacrimal duct
Continuously Variable Endoscopy
13
Continuously variable endoscopes have rotatable camera tips There is a limited experience with the use of ECAMR in
which enable visualization over a wide range of angles with- lacrimal surgeries [5]. It was noted that accurate assessment
out actually moving the endoscope [1–5]. This is achieved with enhanced visualization was achieved with regard to
using a specialized Hopkin’s telescope aptly named extent of cicatrization, synechiae, ostium evaluations, and
EndoCAMeleonR or simply ECAMR (Karl Storz, Tuttlingen, monitoring of the internal common opening during Sisler’s
Germany). It looks like a regular standard 4 mm rigid tele- canalicular trephination [5]. Detailed endoscopic inspec-
scope but has a wider proximal body that fits into the camera tions were possible in shorter times. Certain limitations
head. This body has a rotatable black knob that is coupled reported were the need for shaft directions to change for
with the optomechanics at the shaft tip. The knob can be obtaining simultaneous multi-planar views and the need to
rotated for varying the angles from 15° to 90°. The angula- refocus images when sudden shifts to extreme angles is
tions are depicted on the body of the telescope with arrows, desired. Overall, the intra-operative benefits in lacrimal sur-
the vertical arrow at one end represents 15°, the horizontal at geries were perceptible with quicker and detailed assess-
the other end represents 90°, and multiple arrow points in ment and optimization of visualization in a continuous
between represent 30°, 45°, and 70°, respectively. The tip of mode.
the shaft has a swiveling V-block, which has rotatable optics Endoscopic figures are from Ali et al., Ophthal Plast
that respond to the rotation of the knob. Reconstr Surg 2016;32:477–480.
The direction of the open face of the shaft tip reflects the
direction of the plane and can be changed to any plane, one
at a time to cover the entire 360° [1–5]. The commonly used References
directions are superior, inferior, medial, and lateral but may
vary based on the orientation of the area of interest. Keeping 1. Ebner FH, Marquardt JS, Hirt B, et al. Broadening horizons of neu-
roendoscopy with a variable view rigid endoscope: an anatomical
the ECAM rotatable knob at 15°, the endoscope is advanced study. Eur J Surg Oncol. 2010;36:195–200.
to a target point. The direction of shaft is shifted by a simple 2. Ebner FH, Marquardt JS, Hirt B, et al. Visualization of the ante-
rotation as per the desired object of interest without the need rior cerebral artery complex with a continuously variable rigid
to move the telescope. Once the focus is adjusted, the second endoscope: new options in aneurysm surgery. Neurosurgery.
2010;67:321–4.
hand of the surgeon or the assistant can gently rotate the 3. Eskef K, Oehmke F, Tchartchian G, et al. A new variable-view rigid
knob, one step at a time to achieve the desired angulations endoscope evaluated in advanced gynecologic laparoscopy: a pilot
from a range of 15°–90°. Views can be assessed as the angu- study. Surg Endosc. 2011;25:3260–5.
lations change. Images and videos can be captured at each 4. Hackethal A, Ionesi-Pasacica J, Eskef K, et al. Transvaginal NOTES
with semi-rigid and rigid endoscopes that allow adjustable viewing
step. After assessing the full range of angulations in one angles. Arch Gynecol Obstet. 2011;283:131–2.
plane, multiple planes were then assessed after changing the 5. Ali MJ, Singh S, Naik MN. The usefulness of continuously vari-
direction of the endoscopic shaft. able view rigid endoscope in lacrimal surgery: first intraoperative
experience. Ophthal Plast Reconstr Surg. 2016;32:477–80.

130 13 Continuously Variable Endoscopy
Fig. 13.1 The variable view rigid endoscope Fig. 13.4 The tip of the variable view endoscope
Fig. 13.2 The base of the variable view rigid endoscope that gets Fig. 13.5 The swivel “V”-block of the tip that house the rotatable
attached to the camera head optics
Fig. 13.3 The rotatable knob with markings showing range of

angulations
13 Continuously Variable Endoscopy 131
Fig. 13.6 Endoscopic view of the left nasal cavity with the variable Fig. 13.8 Endoscopic view of the left nasal cavity with the variable
view endoscope tip in front and at the axilla of the middle turbinate. view endoscope tip in front and at the axilla of the middle turbinate.
Note the variations in angulation from the central plane to the lateral Note the variations in angulation from the central plane to the lateral
wall of the nose wall of the nose
Note the variations in angulation from the central plane to the lateral Note the variations in angulation from the central plane to the lateral
wall of the nose wall of the nose
Note the variations in angulation from the central plane to the lateral Note the variation in angulation from the central plane toward the
wall of the nose medial wall (septum) of the nose
Note the variation in angulation from the central plane toward the Note the variation in angulation from the central plane toward the
medial wall (septum) of the nose medial wall (septum) of the nose
view endoscope tip in front and at the axilla of the middle turbinate. view endoscope in front and above the axilla of the middle turbinate.
Note the variation in angulation from the central plane toward the Note the variation in angulation from above downward toward the floor
medial wall (septum) of the nose of the nose
view endoscope tip in front and at the axilla of the middle turbinate. view endoscope in front and above the axilla of the middle turbinate.
Note the variation in angulation from the central plane toward the Note the variation in angulation from above downward toward the floor
medial wall (septum) of the nose of the nose
view endoscope in front and above the axilla of the middle turbinate. view endoscope in front and above the axilla of the middle turbinate.
Note the variation in angulation from above downward toward the floor Note the variation in angulation from above downward toward the floor
of the nose of the nose
view endoscope in front and above the axilla of the middle turbinate. view endoscope in front and in line with the floor of the nose. Note the
Note the variation in angulation from above downward toward the floor variation in angulation from below upward toward the roof of the nose
of the nose
view endoscope in front and in line with the floor of the nose. Note the view endoscope in front and in line with the floor of the nose. Note the
variation in angulation from below upward toward the roof of the nose variation in angulation from below upward toward the roof of the nose
view endoscope in front and in line with the floor of the nose. Note the view endoscope in front and in line with the floor of the nose. Note the
variation in angulation from below upward toward the roof of the nose variation in angulation from below upward toward the roof of the nose
Fig. 13.26 Etiology of a failed dacryocystorhinostomy. Endoscopic Fig. 13.28 Etiology of a failed dacryocystorhinostomy. Endoscopic
view of the left nasal cavity with variable view endoscope showing pos- view of the left nasal cavity with variable view endoscope showing pos-
terior location of the lacrimal sac and synechial closure of the anasto- terior location of the lacrimal sac and synechial closure of the anasto-
moses between the lacrimal sac and nasal mucosa (black arrow, moses between the lacrimal sac and nasal mucosa (black arrow,
Figs. 13.28 and 13.29). Note the evaluation happened in one go without Figs. 13.28 and 13.29). Note the evaluation happened in one go without
even moving the telescope from the first position even moving the telescope from the first position
Fig. 13.27 Etiology of a failed dacryocystorhinostomy. Endoscopic Fig. 13.29 Etiology of a failed dacryocystorhinostomy. Endoscopic
view of the left nasal cavity with variable view endoscope showing pos- view of the left nasal cavity with variable view endoscope showing pos-
terior location of the lacrimal sac and synechial closure of the anasto- terior location of the lacrimal sac and synechial closure of the anasto-
moses between the lacrimal sac and nasal mucosa (black arrow, moses between the lacrimal sac and nasal mucosa (black arrow,
Figs. 13.28 and 13.29). Note the evaluation happened in one go without Figs. 13.28 and 13.29). Note the evaluation happened in one go without
even moving the telescope from the first position even moving the telescope from the first position
Fig. 13.30 Etiology of a failed dacryocystorhinostomy. Endoscopic Fig. 13.32 Monitoring of the common canaliculus during Sisler’s
view of the left nasal cavity with variable view endoscope showing pos- trephination. Endoscopic view of the left nasal cavity with variable
terior location of the lacrimal sac and synechial closure of the anasto- view endoscope showing the marsupialized lacrimal sac with opening
moses between the lacrimal sac and nasal mucosa (black arrow, of the flaps and Sisler’s trephine with its guide wire at the internal com-
Figs. 13.28 and 13.29). Note the evaluation happened in one go without mon opening. Note the evaluation happened in one go without even
even moving the telescope from the first position moving the telescope from the first position
Fig. 13.31 Monitoring of the common canaliculus during Sisler’s Fig. 13.33 Monitoring of the common canaliculus during Sisler’s
trephination. Endoscopic view of the left nasal cavity with variable trephination. Endoscopic view of the left nasal cavity with variable
view endoscope showing the marsupialized lacrimal sac with opening view endoscope showing the marsupialized lacrimal sac with opening
of the flaps and Sisler’s trephine with its guide wire at the internal com- of the flaps and Sisler’s trephine with its guide wire at the internal com-
mon opening. Note the evaluation happened in one go without even mon opening. Note the evaluation happened in one go without even
moving the telescope from the first position moving the telescope from the first position
Fig. 13.34 Monitoring of the common canaliculus during Sisler’s Fig. 13.36 Evaluation of a post-operative dacryocystorhinostomy
trephination. Endoscopic view of the left nasal cavity with variable ostium. Endoscopic view of the left nasal cavity with variable view
view endoscope showing the marsupialized lacrimal sac with opening endoscope showing a post-operative DCR ostium with a large superior
of the flaps and Sisler’s trephine with its guide wire at the internal com- edge granuloma and the stent in close relation to the granuloma. Note
mon opening. Note the evaluation happened in one go without even the evaluation happened in one go without even moving the telescope
moving the telescope from the first position from the first position
Fig. 13.35 Monitoring of the common canaliculus during Sisler’s Fig. 13.37 Evaluation of a post-operative dacryocystorhinostomy
trephination. Endoscopic view of the left nasal cavity with variable ostium. Endoscopic view of the left nasal cavity with variable view
view endoscope showing the marsupialized lacrimal sac with opening endoscope showing a post-operative DCR ostium with a large superior
of the flaps and Sisler’s trephine with its guide wire at the internal com- edge granuloma and the stent in close relation to the granuloma. Note
mon opening. Note the evaluation happened in one go without even the evaluation happened in one go without even moving the telescope
moving the telescope from the first position from the first position
Fig. 13.38 Evaluation of a post-operative dacryocystorhinostomy Fig. 13.40 Evaluation of a post-operative dacryocystorhinostomy
ostium. Endoscopic view of the left nasal cavity with variable view ostium. Endoscopic view of the left nasal cavity with variable view
endoscope showing a post-operative DCR ostium with a large superior endoscope showing a post-operative DCR ostium with a large superior
edge granuloma and the stent in close relation to the granuloma. Note edge granuloma and the stent in close relation to the granuloma. Note
the evaluation happened in one go without even moving the telescope the evaluation happened in one go without even moving the telescope
from the first position from the first position
Fig. 13.39 Evaluation of a post-operative dacryocystorhinostomy

ostium. Endoscopic view of the left nasal cavity with variable view
endoscope showing a post-operative DCR ostium with a large superior
edge granuloma and the stent in close relation to the granuloma. Note
the evaluation happened in one go without even moving the telescope
from the first position
Three-Dimensional (3D) Endoscopy
14
The current standard telescopes provide a two-dimensional References

view, and the major disadvantage with this is the lack of
depth perception. The significance of depth perceptions in 1. Altieri R, Tardivo V, Pacca P, et al. 3D HD endoscopy in skull base
surgeries: from darkness to light. Surg Technol Int. XXIX:359–65.
areas with critical anatomical proximities like the head and 2. Cheng J, Gao J, Shuai X, et al. Two dimensional versus three-
neck is obvious. dimensional laparoscopy in surgical efficacy: a systematic review
The TIPCAMR 1S 3D ORL(Karl Storz, Tuttlingen, and meta-analysis. Oncotarget. 2016;7:70979.
Germany) is a specialized Hopkins telescope, rigid with 3. Fergo C, Burchart J, Pommergaard HC, et al. Three dimensional
laparoscopy vs. 2-dimensional laparoscopy with high-definition
4 mm shaft diameter, 18 cm length, and available with 0° and technology for abdominal surgery: a systematic review. Am J Surg.
30° angulations. The endoscopic system consists of the 2016;213:159–70.
Image 1S modular platform (Karl Storz, Tuttlingen, 4. Sakata S, Watson MO, Grove PM, et al. The conflicting evidence of
Germany), on which the existing endoscopic systems can be three-dimensional displays in laparoscopy. A review of systems old
and new. Ann Surg. 2016;263:234–9.
expanded. For the viewing, either a fogless, passive 3D 5. Ali MJ, Naik MN. First intraoperative experience with three-
polarization glass or a circularly polarized 3D clip on glasses dimensional (3D) high-definition (HD) nasal endoscopy for lacri-
can be used. The 3D monitor is ideally placed straight in mal system. Eur Arch Otorhinolaryngol. 2017;274(5):2161–4.
front of the observer at a distance of 2 m.
Systematic reviews and meta-analysis from the laparos-
copy literature have revealed numerous benefits of 3D over
2D in terms of surgical time, blood loss, surgical errors,
perioperative complications, and hospital stay. However
the major limitation in most of these studies was the
unknown stereoacuity of the surgeons or participants
[1–4].
Experiences with HD 3D endoscopy for a wide variety of
lacrimal surgeries found that the intra-operative tissue han-
dling and surgical maneuverability were more precise with-
out depending on the spatial cues [5]. Greater anatomical
delineation facilitated improved hand-eye coordination. The
surgical observers felt enhanced tissue differentiation and
surgical learning experience [5]. The setup was easy on
endoscopic platforms and did not consume additional time.
Overall operating in 3D enhances depth perception, dexter-
ity, and precision.
Figures 14.3–14.6 and 14.8–14.12 are from Ali MJ et al. Eur
Arch Otorhinolaryngol. 2017;274(5):2161–4.

142 14 Three-Dimensional (3D) Endoscopy
Fig. 14.3 The TIPCAM-ORLR camera head. Note the freely program-
mable buttons
Fig. 14.1 The complete 3D endoscopy setup with all its components Fig. 14.4 The Image 1R console which can be expanded on existing
endoscopic systems
Fig. 14.2 The TIPCAM-ORLR 3D endoscope Fig. 14.5 The specialized 3D high-definition monitor
14 Three-Dimensional (3D) Endoscopy 143
Fig. 14.6 The 3D surgical

glasses. Note the individual as
well as the clip on variants
Fig. 14.7 The 3D surgical

endoscopy in action
Fig. 14.8 Image separation gives clues to the depth perception that can Fig. 14.9 Image separation of the external nasal cavity
be achieved
144 14 Three-Dimensional (3D) Endoscopy
Fig. 14.10 Image separation during the preoperative endoscopy
Fig. 14.12 Image separation during the intubation stage. Note the dis-
tance of separation of the two bodkins images
Fig. 14.11 Image separation during the mitomycin c application

Microbiological Techniques
15
Infections affecting lacrimal drainage system are not uncom- References

mon and occur in both pediatric and adult populations [1–5].
The most common among them being infective canaliculitis 1. Kaliki S, Ali MJ, Honavar SG, et al. Primary canaliculitis: clini-
cal features, microbiological profile, and management outcome.
and acute dacryocystitis. Common organisms implicated in Ophthal Plast Reconstr Surg. 2012;28:355–60.
canaliculitis include Staphylococcus aureus, Streptococcus, 2. Ali MJ, Motukupally SR, Joshi SD, et al. The microbiological pro-
Actinomycetales, and Nocardia [1]. Other uncommon organ- file of lacrimal abscess: two decades of experience from a tertiary
isms implicated include Mycobacterium chelonae, eye care center. J Ophthalmic Inflamm Infect. 2013;3:57–61.
3. Ali MJ, Manderwad G, Naik MN. The microbiological spectrum
Lactococcus lactis, Eikenella corrodens, Enterobacter cloa- and antibiotic sensitivity profile of extubated silicone stents follow-
cae, Fusobacterium, Kocuria rosea, viruses like Herpes sim- ing dacryocystorhinostomy. Orbit. 2013;32:298–303.
plex, and fungal organisms like Pityrosporum pachydermatis 4. Ali MJ. Pediatric acute dacryocystitis. Ophthal Plast Reconstr Surg.
and Candida albicans. The microbiological profile of acute 2015;31:341–7.
5. Ganguly A, Ali MJ, Padmaja K, et al. Bacteremia following naso-
dacryocystitis includes Staphylococcus aureus, Streptococcus lacrimal duct probing: is there a role of pre-operative antibiotic pro-
pneumoniae and Streptococcus pyogenes, Haemophilus influ- phylaxis? Ophthal Plast Reconstr Surg. 2016;32:90–2.
enzae, Escherichia coli, and Pseudomonas aeruginosa [2].
Microbiological investigations play a crucial role in the
identification of the organisms and their antibiotic
sensitivity profiles. This helps the surgeon in specifically
targeting the causative organisms and also for monitoring
purposes. A smear from the infected tissues or discharge is
collected using special swabs to avoid contamination.
These swabs are also useful for endoscopic retrieval of the
samples. Other than routine smears, inoculation is carried
out in numerous solid and liquid culture media. Subcultures
can then be performed, and identification of the organism
is carried out using the VITEK2® system. Bacteremia dur-
ing lacrimal surgeries or acute infections especially in the
pediatric populations has been a matter of concern, and
advance culture media are now available for an automatic
detection [5].
Figures 15.9–15.13 and 15.18–15.21 are from Ali et al.,
Orbit 2013;32:298–303, and Ganguly et al., Ophthal Plast

146 15 Microbiological Techniques
Fig. 15.4 Technique of swab collection: The swab is advanced beyond

the sleeve in the area of interest. The material is collected, and the swab
is immediately retracted within the protective sleeve, and then the entire
Fig. 15.1 Technique of swab collection: A sterile swab with a protec- unit is withdrawn. This is to avoid contamination from surrounding
tive sleeve structures
Fig. 15.2 Technique of swab collection: The sterile swab within the Fig. 15.5 Canalicular concretions inoculated onto a chocolate agar
protected sleeve plate
Fig. 15.3 Technique of swab collection: Close-up image showing Fig. 15.6 Lacrimal stent with discharge inoculated onto a chocolate
advancement of the sterile swab toward the tip of the protective sleeve agar plate
15 Microbiological Techniques 147
Fig. 15.7 Lacrimal stents inoculated onto the plates of blood agar and
chocolate agar
Fig. 15.9 Lacrimal stent inoculation into a brain-heart infusion broth
Fig. 15.8 Evolving colonies on the smeared blood and chocolate agar
plates
Fig. 15.10 Positive culture on brain-heart infusion broth. Note the tur-
bidity of the medium and compare it with that of Fig. 15.9
Fig. 15.11 Lacrimal stent inoculation onto Saboraud’s dextrose Fig. 15.13 Positive culture from a lacrimal stent with extensive
medium colonies
Fig. 15.14 The Kirby-Bauer disc diffusion technique of antibiotic sen-

sitivity assessment
Fig. 15.12 Positive fungal culture in Saboraud’s dextrose medium

Fig. 15.15 The Columbia broth culture bottle Fig. 15.16 The dual culture media bottle
Fig. 15.17 Subcultures being taken from the inoculated specimens

Fig. 15.19 BacT® culture bottles. Note the difference in the colors of

the gas permeable sensors at the base
Fig. 15.18 A BacT® culture bottle. Note the gas permeable sensor at
the base
Fig. 15.20 The BacT®

microbial detection system.
Note that multiple bottles can
be housed at any given time
Fig. 15.24 Gram stain of a smear depicting gram-negative bacilli

Fig. 15.21 Console of the BacT® microbial detection system, flagging
a positive result
Fig. 15.22 Gram stain of a smear depicting gram-positive cocci Fig. 15.25 Gram stain of a smear depicting mixed population of gram-
positive cocci and gram-negative bacilli
Fig. 15.23 Gram stain of a smear depicting Micrococcus
Fig. 15.26 Gram stain of a smear depicting Actinomycetales

Fig. 15.29 The VITEK2® organism identification system

Fig. 15.27 Gram stain of smear depicting Nocardia
Biochemical Details
2 APPA + 3 ADO - 4 PyrA + 5 IARL - 7 dCEL - 9 BGAL -
10 H2S - 11 BNAG - 12 AGLTp + 13 dGLU - 14 GGT + 15 OFF -
17 BGLU - 18 dMAL - 19 dMAN - 20 dMNE - 21 BXYL - 22 BAlap -
23 ProA - 26 LIP - 27 PLE - 29 TyrA + 31 URE - 32 dSOR -
33 SAC - 34 dTAG - 35 dTRE - 36 CIT - 37 MNT - 39 5KG -
40 ILATk - 41 AGLU + 42 SUCT - 43 NAGA - 44 AGAL - 45 PHOS +
46 GlyA - 47 ODC - 48 LDC - 53 IHISa - 56 CMT - 57 BGUR -
58 O129R - 59 GGAA + 61 IMLTa - 62 ELLM - 64 ILATa -
Fig. 15.30 A typical VITEK printout depicting multiple biochemical tests performed and their results
Common Endoscopic Pathologies
16
References
Considering the wide breadth of nasal disorders commonly
encountered in the general population, it is not surprising to 1. Tanweer F, Mahkamova K, Harkness P. Nasolacrimal duct tumours
find overlap with patients presenting with lacrimal ailments in the era of endoscopic dacryocystorhinostomy: literature review.
J Laryngol Otol. 2013;127:670–5.
[1–5]. In fact, within the subset of patients in whom surgical 2. Ali MJ, Psaltis AJ, Wormald PJ. The frequency of concomitant
intervention is deemed prudent, it is occasionally necessary adjunctive nasal procedures in powered endoscopic dacryocysto-
to perform simultaneous endonasal procedures at the time of rhinostomy. Orbit. 2015;34:142–5.
dacryocystorhinostomy. In addition to septal deviation 3. Stallman JS, Lobo JN, Som PM. The incidence of concha bullosa
and its relationship to nasal septal deviation and paranasal sinus
requiring septoplasty for access to the lacrimal system, one disease. AJNR Am J Neuroradiol. 2004;25:1613–8.
must also assess for various other nasal diseases including 4. Ali MJ, Psaltis AJ, Murphy J, et al. Powered endoscopic dacryocys-
turbinate hypertrophy, nasal polyposis, rhinosinusitis, and torhinostomy: a decade of experience. Ophthal Plast Reconstr Surg.
multiple other neighboring disease processes [1–5]. 2015;31:219–21.
5. Figueira E, Al Abbadi Z, Malhotra R, et al. Frequency of simul-
Emphasis must be placed on proper pre-operative evaluation taneous nasal procedures in endoscopic dacryocystorhinostomy.
of concurrent disease to ensure the surgical candidate is Ophthal Plast Reconstr Surg. 2014;30:40–3.
properly consented prior to the day of surgery.
In addition to the common disease processes found in the
nasal passages, it is important to first rule out some of the
more threatening disorders that could necessitate further
evaluation or treatment. Office endoscopy may show signs of
a nasal mass, which may warrant a biopsy prior to surgical
planning. Reports can be found citing lymphoma, carcinoma,
or other malignant or benign tumors contributing to nasolac-
rimal duct obstruction [1]. In males, especially adolescents,
it is important to also consider juvenile nasopharyngeal
angiofibromas, as these are not to be biopsied in the office
setting due to risk of hemorrhage. Once the more aggressive
diseases have been ruled out, the more common nasal disor-
ders should be considered.
Of the inflammatory sino-nasal disease processes that
commonly affect patients, the most common includes ana-
tomical nasal airway obstruction, some form of rhinitis or
rhinosinusitis, or a combination of the above. These entities
are further broken down into various categories each with
their own etiopathogenesis. Chronic rhinitis is further cate-
gorized as allergic and non-allergic, although the initial treat-
ment of both is comparable. Acute rhinitis is frequently
infectious in nature and is generally self-limiting.

154 16 Common Endoscopic Pathologies
Fig. 16.1 Endoscopic view of the right nasal cavity showing an ante- Fig. 16.3 Endoscopic view of the right nasal cavity showing a high
rior deviated nasal septum and moderate deviation of the nasal septum
Fig. 16.2 Endoscopic view of the right nasal cavity showing a poste- Fig. 16.4 Endoscopic view of the right nasal cavity showing a high
rior deviation of the nasal septum and severe deviation of the nasal septum, and this will restrict the lacri-
mal access
16 Common Endoscopic Pathologies 155
Fig. 16.5 Endoscopic view of the left nasal cavity showing a severe Fig. 16.7 Endoscopic view of a left nasal cavity showing a normal
deviated nasal septum (Photo courtesy: Nishi Gupta, SCEH, Delhi) middle turbinate
Fig. 16.6 CT scan, coronal cut, showing a right-sided deviation with Fig. 16.8 Endoscopic view of a right nasal cavity showing a gross con-
hypertrophied turbinates cha bullosa that would impede lacrimal access
Fig. 16.9 CT scans, coronal

cuts, demonstrating a concha
bullosa. Note the large air cell
within the left middle
turbinate
Fig. 16.10 Endoscopic view of the right nasal cavity showing a normal Fig. 16.11 Endoscopic view of the left nasal cavity showing the ante-
inferior turbinate rior end of a hypertrophied inferior turbinate
Fig. 16.12 Endoscopic view of the left nasal cavity showing gross Fig. 16.14 Endoscopic view of the right nasal cavity in a case of acute
hypertrophy of the inferior turbinate rhinitis. Note the discharge and the nasal crusting
Fig. 16.13 Endoscopic view of the right nasal cavity showing gross Fig. 16.15 Endoscopic view of the right nasal cavity showing signs of
lateral wall dysgenesis. Note the atrophic turbinates and absence of the sinusitis
inferior meatus
Fig. 16.16 Endoscopic view of the left nasal cavity showing signs of Fig. 16.18 Endoscopic view of the left nasal cavity showing a hyper-
acute rhinosinusitis trophied bulla ethmoidalis (Photo courtesy: Nishi Gupta, SCEH, Delhi)
Fig. 16.17 Endoscopic view of the right nasal cavity in a case of Fig. 16.19 Endoscopic view of the left nasal cavity showing a hyper-
Wegner’s granulomatosis. Note the widespread destruction and necrotic trophied bulla ethmoidalis. This can interfere with the lacrimal bypass
patches (Photo courtesy: Nishi Gupta, SCEH, Delhi)
Fig. 16.20 Endoscopic view of the right nasal cavity showing hyper- Fig. 16.22 Post FESS scenario: The middle meatal area with quite
trophied uncinate process. This can interfere with the lacrimal bypass mucosa
(Photo courtesy: Nishi Gupta, SCEH, Delhi)
Fig. 16.21 Endoscopic view of the left nasal cavity showing a promi- Fig. 16.23 Post FESS scenario: The opened up ethmoids functioning
nent bulla ethmoidalis with medialization of the middle turbinate well
Fig. 16.24 Post FESS scenario: The widely opened maxillary sinus Fig. 16.26 Endoscopic view of the right nasal cavity demonstrating a
opening large antrochoanal polyp
Fig. 16.25 Endoscopic view of the right middle meatus showing a Fig. 16.27 Endoscopic view of the right inferior meatus showing a
large polyp large mass in the area of nasolacrimal duct. Biopsy later proved it to be
a primary transitional cell carcinoma of the lacrimal drainage system
Fig. 16.28 Endoscopic view of the right nasal cavity showing an infe- Fig. 16.30 Endoscopic view of the right nasal cavity showing a turb-
rior meatus foreign body accidentally detected during a probing for inoseptal synechiae involving the inferior turbinate
congenital nasolacrimal duct obstruction
Fig. 16.29 Endoscopic view of the left nasal cavity showing an ante- Fig. 16.31 Endoscopic view of the right nasal cavity showing a turb-
rior foreign body, accidentally noted in a case of pediatric DCR inoseptal synechiae involving the middle turbinate
Fig. 16.32 Endoscopic view of the right nasal cavity showing a broad- Fig. 16.34 Endoscopic view of the right nasal cavity showing a broad-
based synechiae involving the septum and the lateral wall based ostio-septal synechiae, a cause of DCR failure
Fig. 16.33 Endoscopic view of the right nasal cavity showing a broad-
based ostio-septal synechiae, a cause of DCR failure
Dacryoendoscopy and Lacrimal
Pathologies 17
Dacryoendoscopy is a procedure utilizing microendoscopic References

techniques to visualize the entire lacrimal system from the
puncta to the inferior meatus [1–5]. It is gaining firm ground 1. Sasaki T, Miyashita H, Miyanaga T, et al. Dacryoendoscopic
observation and incidence of canalicular obstruction or stenosis
and increasing popularity for expanding indications in lacri- associated with S-1, an oral anticancer drug. Jpn J Ophthalmol.
mal disorders thus having many diagnostic and potential 2012;56:214–8.
therapeutic implications [1–5]. The list of potential indica- 2. Kakizaki H, Takahashi Y, Sa HS, et al. Congenital dacryocystocele:
tions for dacryoendoscopy includes few common patholo- comparative findings of dacryoendoscopy and histopathology in a
patient. Ophthal Plast Reconstr Surg. 2012;28:e85–6.
gies like acquired internal punctal stenosis, canalicular 3. Maier M, Schmidt T, Schmidt M. Endoscopically controlled sur-
stenosis, partial and complete canalicular obstructions, gery with the micro-drill and intubation of the lacrimal ducts.
assessing mucosal inflammations and synechiae in chronic Ophthalmologe. 2000;97:870–3.
dacryocystitis, dacryocele, canalicular concretions, and 4. Ali MJ, Singh S, Naik MN. High-definition dacryoendoscopic fea-
tures of a canalicular squamous papilloma. Int Ophthalmol 2017
dacryolithiasis. Uncommon pathologies can also be diag- (Epub).
nosed and include lacrimal diverticula, foreign bodies, cana- 5. Ali MJ, Alam SM, Naik MN. High-definition dacryoendoscopic
licular wall dysgenesis, and lacrimal drainage tumors. features of a case of canaliculitis. Ophthal Plast Reconstr Surg
Potential therapeutic indications could include punch biop- 2017;33:228–9.
sies of suspected lesions, microdrill dacryoplasty, balloon
canaliculoplasty, laser dacryoplasty, and dacryoendoscopy-
guided intralesional injections (e.g., interferon alpha 2b for
squamous papillomas) [3–5].
Figures 17.26–17.33 are from Ali et al., Int Ophthalmol
2017 (Epub) and Ophthal Plast Reconstr Surg 2017;
33:228–9.

164 17 Dacryoendoscopy and Lacrimal Pathologies
Fig. 17.1 Dacryoendoscopy with standard imaging showing an Fig. 17.3 Dacryoendoscopy with standard imaging showing a partial
acquired internal punctal stenosis canalicular obstruction by a fibrous tissue
Fig. 17.2 Dacryoendoscopy with standard imaging showing a cana- Fig. 17.4 Dacryoendoscopy with standard imaging showing a com-
licular stenosis plete canalicular obstruction by a chunk of fibrous tissue
17 Dacryoendoscopy and Lacrimal Pathologies 165
Fig. 17.5 Dacryoendoscopy with standard imaging showing diffuse Fig. 17.7 HD-DEN image showing sequential mid canalicular steno-
mucosal inflammation and edema of the nasolacrimal ducts sis. Note the narrowing as compared to Fig. 17.6
Fig. 17.6 HD-DEN image showing sequential mid canalicular steno- Fig. 17.8 HD-DEN image showing sequential mid canalicular steno-
sis. Note the incoming stenosis sis. Note the gross narrowing secondary to a partial obstruction
Fig. 17.9 HD-DEN image showing sequential distal canalicular steno- Fig. 17.11 HD-DEN image showing sequential distal canalicular ste-
sis. Note the incoming narrowness of the lumen nosis. Note the gross narrowing of the lumen without any obstructive
tissues
Fig. 17.10 HD-DEN image showing sequential distal canalicular ste- Fig. 17.12 HD-DEN image of a canalicular stenosis with associated
nosis. Compare the luminal narrowing with that of Fig. 17.9 mucosal edema, reflecting an active inflammatory process
Fig. 17.13 HD-DEN image of a canalicular stenosis with associated Fig. 17.15 HD-DEN image of a partial canalicular obstruction. Note
mucosal edema the inferior fibrous tissue and superior dark lumen
Fig. 17.14 HD-DEN image of an organizing discharge on the roof of Fig. 17.16 HD-DEN image, a close-up view of the same partial cana-
the canaliculus licular obstruction as in Fig. 17.15
Fig. 17.17 HD-DEN image of a circumferential scarring of the cana- Fig. 17.19 HD-DEN image showing a scarred lateral wall of the cana-
licular lumen liculus with a near total obstruction in the distance
Fig. 17.18 HD-DEN image of a circumferential scarring of the cana- Fig. 17.20 HD-DEN image showing an end-on view of the near total
licular lumen obstruction. Note the tiny dark lumen straight in the distance
Fig. 17.21 HD-DEN image demonstrating a complete obstruction of the Fig. 17.23 HD-DEN image in a case of active canaliculitis. Note the
canaliculus with a fibrovascular tissue. Note the color difference in this mucosal inflammation at the internal punctum
case between the obstructed tissue and the whitish scarred canaliculus
Fig. 17.22 HD-DEN close-up image demonstrating a complete Fig. 17.24 HD-DEN image in a case of active canaliculitis: Note the
obstruction of the canaliculus with a fibrovascular tissue grossly inflamed mucosa of the canaliculus. Note that there is no more
classical whitish appearance
F
BC
C1
C2
HC
Fig. 17.25 HD-DEN image in a case of active canaliculitis: Note the Fig. 17.27 Schematic diagram representing the HD-DEN photo in
discharge and walls showing specks of hemorrhages Fig. 17.26. Note the horizontal canaliculus (Hc), well-defined luminal
concretion (C1), ill-defined concretion (C2), fibrous tissue (F), and
blood clot (Bc)
Fig. 17.26 High-definition dacryoendoscopic photograph showing an Fig. 17.28 High-definition dacryoendoscopic photograph of the hori-
end-on view into the horizontal canaliculus. Note the edematous zontal canaliculus showing edematous mucosa with both types of
mucosa of the canaliculus with an ill-defined, yellowish, and fluffy con- concretions
cretion toward the canalicular wall. Note the overlying blood clot over
this concretion. Also appreciate the well-defined central luminal con-
cretion in the distance with an overlying small fibrous tissue
BC
Skin
C1
Vc
C2
Amp
Vc
HC
Fig. 17.29 Schematic diagram representing the HD-DEN photo in Fig. 17.31 Schematic diagram representing the HD-DEN photo in
Fig. 17.28. Note the edematous lining of the horizontal canaliculus Fig. 17.30. Note the vertical canaliculus (Vc), the ampulla (Amp), and
(Hc), well-defined concretion (C2), ill-defined concretion (C1), and the mass lesion (M)
blood clot (Bc)
Fig. 17.30 High-definition dacryoendoscopic photograph showing an Fig. 17.32 High-definition dacryoendoscopic photograph of the hori-
end-on view into the vertical canaliculus. Note the brownish red lesion zontal canaliculus showing the mass to extend into the distal canalicu-
near the medial wall of the vertical canaliculus extending deep down. lus. Note the progressive occupation of the lumen by the lesion as it
Also note the grossly dilated ampulla extends to the distal end
Hc
Hc
Hc
M V
P
P
Hc
Fig. 17.33 Schematic diagram representing the HD-DEN photo in

Fig. 17.32. Note the lining of the horizontal canaliculus (Hc) and the Fig. 17.35 Schematic diagram of Fig. 17.34. Note the horizontal cana-
mass lesion (M) licular walls (Hc), multilobed papillomas (P), and the vascular fronds
(V)
Fig. 17.34 High-definition dacryoendoscopic photograph showing an Fig. 17.36 Dacryoendoscopy-guided transcanalicular injection of
end-on view into the proximal horizontal canaliculus. Note the multi- interferon alpha 2b. Note the tip of the 30 gauge needle entering the
lobed, papillomatous, pinkish white lesion filling the entire lumen of lumen from the roof
the canaliculus. Also note the intervening reddish spots of vascular
fronds on the surface
N Hc
P
P V
Hc
Hc
Fig. 17.39 Schematic diagram of Fig. 17.38. Note the consolidated

Fig. 17.37 Schematic diagram of Fig. 17.36, showing the engaged
lesion (P), its rounded nature, the walls of the horizontal canaliculus
needle (N) entering from the roof, papillomas (P), and vascular fronds
(Hc), and the loss of the typical vascular fronds
(V) within the horizontal canaliculus (Hc)
Fig. 17.38 High-definition dacryoendoscopic photograph of the hori-

zontal canaliculus at the end of 1 month showing the mass to consoli-
date. Note that the lesion has now become round with decreased
vascular fronds
CT Scans in Lacrimal Pathologies
18
Computed tomography is one of the most useful imaging References

tools in the armamentarium of a lacrimal surgeon.
Improvements in techniques like the helical and the spiral 1. Kousoubris PD. Radiological evaluation of lacrimal and orbital dis-
ease. In: Woog JJ, editor. Endoscopic lacrimal and orbital surgery.
CT scans have remarkably reduced the acquisition times. In 1st ed. Oxford: Butterworth-Hienemann; 2004. p. 79–104.
addition better control with radiopaque dyes and three- 2. Udhay P, Noronha OV, Mohan RE. Helical computed tomographic
dimensional reconstructions has facilitated diagnosis and dacryocystography and its role in the diagnosis and management of
planning of complicated lacrimal pathologies. lacrimal drainage system blocks and medial canthal masses. Indian
J Ophthalmol. 2008;56:31–7.
The most common indication of CT imaging in lacrimal 3. Estes JL, Tsiouris AJ, Christos PJ, et al. 3-D volumetric assessment
disorders is trauma [1–5]. CT scan plays a useful role in the of the nasolacrimal duct in patients with obstructions. Ophthal Plast
evaluation of the patient with tearing when an anatomic Reconstr Surg. 2015;31:211–4.
abnormality is suspected and is particularly helpful for surgi- 4. At’Kova EL, Yartsev VD, Tomashevsky IO, et al. Treatment choice
in dacryostenosis based on single-photon emission computed
cal planning. In axial scans through the lower orbit, the lac- tomography and X-ray computed tomography findings. Vestn oftal-
rimal sac fossa appears as a depression in the anteromedial mol. 2016;132:15–20.
wall. In successively lower sections, the duct appears as a 5. Lefebvre DR, Freitag SR. Update on imaging of the lacrimal drain-
round to oval defect in the frontal process of the maxillary age system. Surv Ophthalmol. 2012;27:175–86.
bone at the anteromedial corner of the antrum. In the absence
of contrast, the duct may be filled with air or fluid. As the
duct is traced inferiorly, it can be seen to open beneath the
inferior turbinate. Cross sections of the system are seen in
coronal reformatted images because the line of section is ori-
ented downward and obliquely backward. Parasagittal refor-
matted images will reveal the entire length of the system in
longitudinal section. This view is indispensable in picking
up the exact level of the obstruction. In trauma cases, it offers
additional benefits of more exact localization of the lacrimal
drainage system fractures, bone displacements, location of
previously placed miniplates, wires or sheets used in fracture
repair, etc. [1–5].
CT scans are also useful in assessment of primary or sec-
ondary tumors of the lacrimal drainage system. Useful clues
can be gathered in terms of extent of the lesions, infiltration
into surrounding tissues, and rate of growth. These help in
surgical planning, monitoring of response to therapies, and
prognostication. Other lacrimal pathologies which can be
assessed and monitored include acute dacryocystitis with
orbital cellulitis, fungal granulomas, extension of mucoceles,
and dacryoceles.

176 18 CT Scans in Lacrimal Pathologies
Fig. 18.1 A normal CT scan, axial cut, showing bilaterally the normal Fig. 18.3 A normal CT scan, axial cut, higher level than Fig. 18.2,
bony nasolacrimal duct (arrow) showing the bony lacrimal sac fossa (arrow) which house the lacrimal
sac
Fig. 18.2 A normal CT scan, axial cut, higher level than in Fig. 18.1,
showing the sac-duct junction
Fig. 18.4 A normal CT scan, coronal cut, showing the lacrimal sac
fossa and its contiguity as a bony nasolacrimal duct (arrow) in the
medial wall of maxilla
18 CT Scans in Lacrimal Pathologies 177
Fig. 18.5 Clinical photograph showing a patient with mild fullness of

the left medial canthus and discharge
Fig. 18.7 CT scan, axial cut, of the patient in Fig. 18.5. Note the
dilated bony nasolacrimal duct on the left side. Compare it with the
normal right side
Fig. 18.6 CT scan, coronal cut, of the patient in Fig. 18.5. Note the left
dilated lacrimal sac, expanded lacrimal sac fossa, and proximal bony
nasolacrimal duct. Compare that with the normal right side Fig. 18.8 CT scan, coronal cut, showing a grossly dilated right lacri-
mal sac fossa and bony NLD secondary to a large mucocele. Compare
this with the patient in Fig. 18.6
Fig. 18.11 Clinical photo of a patient with left acute dacryocystitis

with orbital cellulitis
Fig. 18.9 CT scan, axial cut, of the patient in Fig. 18.8. Note the large
right-sided lacrimal sac mucocele
Fig. 18.10 CT scan, axial cut, of the patient in Figs. 18.8 and 18.9. The Fig. 18.12 CT scan, coronal cut, of the patient in Fig. 18.11. Note the
slice is at the level of bony NLD. Note the expansion of the right bony enlarged lacrimal sac and the surrounding inflamed orbital tissues with
NLD secondary to a dilated nasolacrimal duct. Compare it with the globe dystopia
normal side
Fig. 18.13 CT scan, coronal cut, showing a left lacrimal fossa

fracture
Fig. 18.15 CT scan, axial cut, showing bilateral bony reactive sclero-
sis following a facial trauma
Fig. 18.14 CT scan, axial cut, showing comminuted fracture of the Fig. 18.16 CT scan, 3D reconstruction of a gross naso-orbito-ethmoid
right lacrimal fossa. Note the large right lacrimal sac mucocele fracture involving the bony lacrimal drainage system
Fig. 18.17 CT scan, 3D reconstruction, volume rendered, showing a

gross naso-orbito-ethmoid fracture involving the bony lacrimal drain-
age system
Fig. 18.19 Same patient as in Fig. 18.18. CT scan, plain coronal cut,
showing a mass lesion around the lower part of lacrimal sac and naso-
lacrimal duct
Fig. 18.18 A patient with right-sided epiphora. CT-DCG, coronal cut, Fig. 18.20 Same patient as in Figs. 18.18 and 18.19. CT scan, plain
shows filling of the lacrimal sac but not the nasolacrimal duct axial cut, showing a massive breach of the posterior and posteromedial
bony NLD and a mass lesion in the vicinity
Fig. 18.23 Another example of a lacrimal sac granuloma. CT scan,

coronal cut, showing the dilated lacrimal sac and expanded bony lacri-
mal fossa
Fig. 18.21 Same patient as in Figs. 18.18, 18.19, and 18.20. CT-DCG

scan, axial cut, showing the filling of the lacrimal sac without any filling
defects
Fig. 18.24 CT scan, coronal cut, of a patient following trauma. Note

the bilateral lacrimal sac fossa fracture (right more than left)
Fig. 18.22 Same patient as in Figs. 18.18, 18.19, 18.20, and 18.21.

CT-DCG scan, coronal cut at lower lacrimal sac level, showing filling
of the sac and a surrounding mass lesion extending into the inferior
nasal cavity. An endoscopic biopsy proved it to be an inflammatory
granuloma, mimicking a malignancy
Fig. 18.27 CT scan, coronal cut, showing a massive fungal granuloma

involving the right-sided maxillary and ethmoid and secondary involve-
ment of the right lacrimal drainage system
Fig. 18.25 CT scan, coronal cut, of a patient following a conjunctivo-

dacryocystorhinostomy with a Jones tube. Note the position of the
migrated tube
Fig. 18.26 CT scan, coronal cut, showing a massive pan-fungal sinus- Fig. 18.28 Post-operative CT scan, coronal cut, of the patient in
itis with destructive involvement of the lacrimal drainage system Fig. 18.27. Note the clearance of the sinuses and the lacrimal drainage
system
Fig. 18.29 CT scan, coronal cut, showing a massive ethmoidal muco- Fig. 18.31 CT scan, axial cut, of the patient in Fig. 18.30. Note the
cele with orbital extension and secondary compressive lacrimal drain- mass lesion circumferentially surrounding the bony nasolacrimal duct
age obstruction (center of the mass lesion)
Fig. 18.30 CT scan, coronal cut, showing a left-sided pansinus mass Fig. 18.32 CT scan, coronal cut, of a case of left sino-nasal squamous
lesion with secondary involvement of the orbit and lacrimal drainage cell carcinoma infiltrating the lacrimal drainage system and the orbit
system. The biopsy proved it to be a non-Hodgkin’s lymphoma
Fig. 18.33 Implications in a dacryocystorhinostomy (DCR): CT scan Fig. 18.35 Implications in a DCR: CT scan, coronal cut, showing a
coronal cuts showing a narrow left nasal cavity low skull base and lower level of cribriform plate
Fig. 18.34 Implications in a DCR: CT scan, coronal cuts, showing a Fig. 18.36 Implications in a DCR: CT scan, coronal cut, showing a
narrow left nasal cavity left evolving maxillary sinus polyp and a small right turbinoseptal
synechiae
Fig. 18.39 Implications in a DCR: CT scan, coronal cut, demonstrat-

ing a failed DCR secondary to inadequate osteotomy and improper
marsupialization. Note the bone in front of the upper half of the reason-
ably well-defined lacrimal sac
Fig. 18.37 Implications in a DCR: CT scan, coronal cut, showing a

right-sided deviated nasal septum with hypertrophied turbinates
Fig. 18.38 Implications in a DCR: CT scan, coronal cut, showing a Fig. 18.40 Implications in a DCR: CT scan, coronal cut, showing an
broad-based synechiae between the left lateral wall and the septum orbital breach during the osteotomy in a DCR
impeding the lacrimal access
Fig. 18.41 Implications in a DCR: CT scan, coronal cut, showing an

orbital breach with inflammation of the tissues in the vicinity following
a DCR
Lacrimal Pathologies and Optical
Coherence Tomography 19
Optical coherence tomography is being increasingly utilized References

to study disorders of the proximal lacrimal drainage system
1. Kamal S, Ali MJ, Ali MH, et al. Fourier domain optical coherence
[1–5]. OCT can be useful for diagnosis and monitoring treat- tomography with 3D and en face imaging of the punctum and verti-
ments for numerous conditions like the punctal stenosis, cal canaliculus: a step toward establishing a normative database.
punctal agenesis, incomplete punctal canalization, punctal Ophthal Plast Reconstr Surg. 2016;32:170–3.
2. Kamal S, Ali MJ, Naik MN. Incomplete punctal canalization:
keratinizing cyst, and canaliculus. Typical FD-OCT features
report of Fourier domain optical coherence tomography features.
described for IPC include a hyper-reflective membrane cov- Ophthal Plast Reconstr Surg. 2015;31:251–2.
ering the punctal surface with distinctly identifiable and nor- 3. Singh S, Ali MJ, Naik MN. Familial incomplete punctal canali-
mal lumen of the vertical canaliculus beneath. Membranotomy zation: clinical and fourier domain optical coherence tomography
features. Ophthal Plast Reconstr Surg. 2016;33(3):e66–9.
is the preferred modality of managing IPC with very high
4. Singh S, Ali MJ, Naik MN. Imaging the canaliculops with ultra-
success rates where normal appearing wide punctum can be sound biomicroscopy and anterior segment ocular coherence
seen on OCT. Punctal stenosis is characterized by near total tomography. Ophthal Plast Reconstr Surg. 2017. (Epub).
or complete closure at the level of internal punctum with 5. Kamal S, Ali MJ, Naik MN. Punctal keratinizing cyst: report in a
pediatric patient with fourier domain optical coherence tomography
very narrow vertical canaliculus or no visualization of under-
features. Ophthal Plast Reconstr Surg. 2015;31:161–3.
lying canaliculus. Typical FD-OCT features in a case of
punctal keratinizing cysts include an obliterated punctal
opening with a hyper-reflective lesion extending into the ver-
tical canaliculus. Hyper-reflectivity is attributed to the pres-
ence of keratin. FD-OCT in a case of canaliculus demonstrates
a dilated canaliculus with empty lumen surrounded by a
well-defined cyst wall.
Figures 19.9, 19.11, 19.13, and 19.15 are from Kamal
et al., Ophthal Plast Reconstr Surg. 2015;31:161–163, and
Singh et al., Ophthal Plast Reconstr Surg 2016 (Epub).

188 19 Lacrimal Pathologies and Optical Coherence Tomography
Fig. 19.1 Photograph of the

left eye in a clinical case of
punctal agenesis,
demonstrating the site of line
scans obtained to confirm the
diagnosis
Fig. 19.2 FD-OCT image of the

patient in Fig. 19.1. Note the
absence of punctum and vertical
canaliculus and the replacement
of it by thick eyelid tissues
19 Lacrimal Pathologies and Optical Coherence Tomography 189

right eye in a clinical case of
punctal agenesis,
scans obtained to confirm the
diagnosis
Fig. 19.4 FD-OCT image of

the patient in Fig. 19.3. Note
the absence of punctum and

right lower lid in a case of
clinical punctal stenosis

the gross narrowing of the
punctum and vertical
canaliculus

right lower eyelid in a case of
punctal stenosis,
scans

the extreme narrowing of the
punctum and the near total
occlusion of the vertical
canaliculus
Fig. 19.9 A case of familial incomplete punctal canalization (IPC). that of vertical canaliculus. The right lower panel shows a hyper-
Note the normal right upper lacrimal punctum whereas the left one has reflective membrane over the narrowed punctum, but the vertical cana-
an external membrane variant of the IPC. The lower left panel shows a liculus within is normal
normal optical coherence tomography with normal punctal opening and
Fig. 19.11 Ocular coherence tomography features of IPC. Note the

hyper-reflective uniform membrane over the punctum and the visible
proximal edges of the vertical canaliculus
Fig. 19.10 En face image in a case of an IPC. Note the raised edges of

the punctum
Fig. 19.12 Ocular coherence tomography features of another patient

after membranotomy. There is a normal punctal opening with a normal
vertical canaliculus. Compare this with OCT image of Fig. 19.10 and
note the differences
Fig. 19.14 Three-dimensional FD-OCT image in a case of punctal

keratinizing cyst. The raised dense white area represents the elevated
punctal cyst
Fig. 19.13 FD-OCT image in a case of punctal keratinizing cyst. Note

the obliterated punctal opening with a hyper-reflective lesion extending
into the proximal vertical canaliculus, which is the keratin
Fig. 19.15 Post-operative FD-OCT image of the patient in Fig. 19.13 following marsupialization of the cyst and evacuating the keratin contents.
Note the patent punctum with a patent vertical canaliculus
Fig. 19.16 FD-OCT image showing evolving mucosal inflammation of the right upper punctum. Note the hyper-reflective and demarcated
mucosa of the vertical canaliculus that is normally not visible
Fig. 19.17 FD-OCT image showing progressive obliteration of the punctum and vertical canaliculus of the left upper punctum secondary to
idiopathic inflammation. Note the hyper-reflective mucosa of the vertical canaliculus and narrowing of its lumen
Fig. 19.18 FD-OCT image showing a well-dilated punctum and vertical canaliculus immediately after monoka stent removal
Fig. 19.19 FD-OCT image of the right lower punctum of the patient in Fig. 19.18 after 4 weeks. Although patent, note the restenosis of the once
dilated punctum and vertical canaliculus
Punctal Agenesis
20
Punctal agenesis refers to absence of punctum. The basic References

etiopathogenesis is likely to be failure of canaliculi out bud-
ding from the upper end of the solid lacrimal cord in an 1. Ahn Yuen SJ, Oley C, Sullivan TJ. Lacrimal outflow dysgenesis.
Ophthalmology. 2004;111:1782–190.
embryo of 18–24 mm [1–5]. It is very rare to have intact 2. Cahill KV, Burns JA. Management of epiphora in the presence of
canaliculi with a punctal agenesis. The diagnosis of punctal congenital punctal and canalicular atresia. Ophthal Plast Reconstr
agenesis should include a careful history and examination. Surg. 1991;7:167–72.
History of epiphora and other symptoms may be variable 3. Lyons CJ, Rosser PM, Welham RAN. The management of punctal
agenesis. Ophthalmology. 1993;100:1851–5.
depending upon the agenesis of single or both puncta of the 4. Buerger DG, Schaefer AJ, Campbell CB, et al. Congenital lacrimal
eye. Patients with single punctum missing may have mild disorders. In: Nesi F, Levine MR, editors. Smith’s ophthalmic plas-
epiphora, but a severe epiphora usually indicates an associ- tics and reconstructive surgery. Maryland Heights: Mosby; 1998.
ated nasolacrimal duct obstruction. In contrast, patients with p. 649–60.
5. Kirk RC. Developmental anomalies of the lacrimal passages. A
both puncta missing have universal epiphora but are usually review of the literature and presentation of three unusual cases. Am
not very symptomatic. Clinical examination by slit lamp J Ophthalmol. 1956;42:227–32.
would show absence of the punctal papilla, absence of any
transilluminant membrane, absence of any dimple in the area
of punctum, and occasionally the presence of eyelashes
medial to the punctum in the pars lacrimalis area of eyelids
[1–5]. Punctal agenesis has important associated ocular and
systemic associations. Ocular abnormalities reported include
lacrimal fistula, blepharitis, distichiasis, eyelid tags, absence
of caruncle, and divergent strabismus. Syndromes associated
include ectrodactyly ectodermal clefting, and Hay-Wells and
Levy-Hollister syndromes [1–5].
Management of punctal agenesis is challenging. Patients
who have a single punctum missing and are asymptomatic
may be observed without any intervention. However, prob-
ing is warranted in those who have associated nasolacrimal
duct and most would do well. Failure of probing is an indica-
tion for a dacryocystorhinostomy with a mini-monoka stent.
Patients with both puncta missing but with minimal symp-
toms can be observed. For those with severe symptoms, we
prefer to manage using an endoscopic conjunctivodacryo-
cystorhinostomy with placement of Lester Jones tube or
Gladstone-Putterman tube.

198 20 Punctal Agenesis
Fig. 20.1 Clinical photograph of a right lower lid showing punctal

agenesis. Note the absence of punctal papilla
Fig. 20.3 Clinical photograph of the left upper lid of the patient in
Fig. 20.2. Note the normal punctum and compare this area with that of
Fig. 20.2
Fig. 20.2 Clinical photograph of the right upper lid showing punctal
agenesis. Note the flat lid margin in the area of punctum and absent Fig. 20.4 Clinical photograph of left upper and lower punctal agenesis
punctal papilla with a lacrimal sac mucocele
20 Punctal Agenesis 199
Fig. 20.5 Clinical photograph of a patient with gross right-sided Fig. 20.8 Clinical photograph of the right upper lid of the patient in
epiphora Figs. 20.5, 20.6, and 20.7. Note the absent upper punctum
Fig. 20.6 Clinical photograph of the patient in Fig. 20.5, close-up Fig. 20.9 Clinical photograph of the right upper lid of another patient
image of the right eye. Note the gross welling of the tears showing punctal agenesis
Fig. 20.7 Clinical photograph of the right lower lid of patient in Fig. 20.10 Clinical photograph of the right lower lid in a case of punc-
Figs. 20.5 and 20.6. Note the absent lower punctum tal agenesis, showing the area of the lid scanned by ocular coherence
tomography (OCT) for confirming the diagnosis
200 20 Punctal Agenesis
Fig. 20.11 Fourier domain OCT image of the patient in Fig. 20.10.

Note the complete absence of the punctum and vertical canaliculus
Fig. 20.13 Endoscopic view of the left nasal cavity of patient in

Fig. 20.12. Note the sac is marsupialized and the lacrimal sac flaps are
very thin and membranous. This could reflect associated maldevelop-
ment of lacrimal sac in cases of punctal and canalicular agenesis
Fig. 20.12 Endoscopic view of the left nasal cavity in a patient with
both upper and lower punctal and canalicular agenesis. The patient was
undergoing an endoscopic conjunctivodacryocystorhinostomy. Note
the thinned and ballooned out lacrimal sac following osteotomy
Fig. 20.14 Microphotograph of the patient in Figs. 20.12 and 20.13.

The sac wall here shows thinned out epithelium and poor organization
of subepithelial tissues and lamina propria (H&E × 100)
Supernumerary Puncta
21
Supernumerary puncta are uncommon lacrimal anomalies. References

They possibly result from multiple epithelial buds develop-
ing from the upper end of the lacrimal cord in an 18–24 mm 1. Kirk RC. Developmental anomalies of the lacrimal passages. A
review of the literature and presentation of three unusual cases. Am
embryo [1–3]. The incidence of supernumerary puncta and J Ophthalmol. 1956;42:227–32.
canaliculi is estimated to be 1 in 60,000. Their location can 2. Wicherkiewicz W. Proceeding of XI International Congress of
be along the line of canaliculus or caruncle or medial con- Medicine, vol. 6. Rome, 1895; p. 49.
junctival cul-de-sac. Epiphora is the common complaint and 3. Satchi K, McNab AA. Double lacrimal puncta: clinical presen-
tation and potential mechanisms of epiphora. Ophthalmology.
is usually due to associated lacrimal anomalies or secondary 2010;117:180–3.
to reflux of tears through the accessory punctum. These are
known to be associated with lacrimal anomalies like nasolac-
rimal duct obstruction, lacrimal fistula, lacrimal sac diver-
ticulum, and monocanalicular agenesis. Systemic
associations known are Down’s syndrome and preauricular
sinus [1–3].

202 21 Supernumerary Puncta
Fig. 21.1 Clinical external photograph of right lower lid supernumer-

ary puncta
Fig. 21.4 Slit lamp photograph of the left upper lid supernumerary
puncta
Fig. 21.2 Clinical external photograph of left lower lid supernumerary Fig. 21.5 Clinical external photograph of right lower lid supernumer-
puncta ary puncta
Fig. 21.3 Slit lamp photograph of right lower lid supernumerary Fig. 21.6 Clinical external photograph of left lower lid supernumerary
puncta puncta
21 Supernumerary Puncta 203
Fig. 21.7 Clinical external photograph of right lower lid supernumer-

ary puncta (photo courtesy: Nishi Gupta, SCEH, Delhi)
Incomplete Punctal Canalization
22
Incomplete punctal canalization is a term that refers to a form of References

punctal dysgenesis with membranes [1–5]. The term was first
described by Ali et al. [1], who studied 55 such dysgenetic 1. Ali MJ, Mohapatra S, Mulay K, et al. Incomplete punctal canali-
zation: the external and internal punctal membranes. Outcomes
puncta. The pathogenesis of punctal membranes is unknown but of membranotomy and adjunctive procedures. Br J Ophthalmol.
is believed to either represent failed dehiscence of epithelium 2013;97:92–5.
overlying the normally formed canaliculi or failure of canaliza- 2. Ali MJ, Naik MN. Incomplete punctal canalization—a balloon
tion of the most proximal part of lacrimal apparatus. Patients variant of the external membrane: a case report. J Med Case Rep.
2014;8:120–2.
typically present in the first decade with symptoms of epiphora 3. Kamal S, Ali MJ, Gupta A, et al. Lacrimal and nasal masquerades
since birth or infancy. Clinical examination reveals punctal of congenital nasolacrimal duct obstruction: etiology, management
membranes which could be external or internal. The external and outcomes. Int Ophthalmol. 2015;35:807–10.
membrane (EM) variety, which is also called IPC-EM, typically 4. Kamal S, Ali MJ, Naik MN. Incomplete punctal canalization:
report of Fourier domain ocular coherence tomography features.
covers the external surface of the puncta and hides it beneath, Ophthal Plast Reconstr Surg. 2015;31:251–2.
giving a false impression of punctal agenesis. The internal mem- 5. Singh S, Ali MJ, Naik MN. Familial incomplete punctal canali-
brane (IM) variety, which is also called IPC-IM, typically dem- zation: clinical and fourier domain ocular coherence tomography
onstrates blurred punctal margins but, just at the entry into the features. Ophthal Plast Reconstr Surg. 2017;33:e66–9.
puncta, covers it entirely with a membrane. The membranes
usually appear translucent. Clinical diagnosis is based on high
degree of suspicion and slight avascular dimple at the site of
puncta, and the membrane tends to stand out as a translucent
structure from the surroundings if indirect illumination is used
with the help of slit lamp and a thin slit beam is placed perpen-
dicular and adjacent to the punctum. The punctal membranes on
histopathological examination uniformly are fibrovascular
membranes without any signs of inflammation.
Management of IPC is usually simple. A membranotomy
using a slow taper punctum dilator is almost always helpful.
Once the membrane is overcome, the surgeon would find a nor-
mal punctum beneath, and usually the canaliculus and the rest of
the lacrimal outflow are found to be normal. Intubation is help-
ful for the rarely associated canalicular stenosis; however the
authors do not advocate the use of routine intubation following
membranotomy, since the diameter of the punctum is fairly large
following the procedure and does not tend toward restenosis
later on. With a simple membranotomy and occasional adjunc-
tive procedures, the reported outcomes are excellent [1–5].
Figures 22.12, 22.13, 22.17, 22.18, 22.19, 22.20, 22.21,
22.22, and 22.23 are from Ali et al. Br J Ophthalmol.
2013;97:92–5 and Singh et al. Ophthal Plast Reconstr Surg.
2017;33:e66–9.

206 22 Incomplete Punctal Canalization
Fig. 22.1 Clinical photograph of the right lower lid showing the exter- Fig. 22.4 Clinical photograph of the left lower lid of the patient in
nal membrane variant of the incomplete punctal canalization (IPC). Fig. 22.3 showing the ballooned external membrane (arrow). Note the
Note the translucent whitish membrane over the punctum without dis- fine vascularity over the membrane
tinct punctal margins
Fig. 22.2 Clinical photograph of the right lower lid showing an exter- Fig. 22.5 Clinical photograph of a classical external membrane type
nal membrane variant of IPC (arrow). Compare this with Fig. 22.1 and of IPC
note the significance of high magnification and illumination in the
diagnosis
Fig. 22.3 Clinical photograph of the right lower lid showing the bal- Fig. 22.6 Clinical photograph of a classical ballooned external mem-
looned external membrane (arrow). Note the translucent bulge in the brane variant of IPC
area of punctum
22 Incomplete Punctal Canalization 207
Fig. 22.7 Clinical photograph of the right lower lid showing a translu- Fig. 22.10 Clinical photograph of the left eye demonstrating a muco-
cent membrane over the punctum cele in a case of a congenital nasolacrimal duct obstruction. IPC can
occasionally be associated with a CNLDO
Fig. 22.8 Clinical photograph and close-up image of the patient in Fig. 22.11 Clinical photograph of the left lower lid of the patient in
Fig. 22.5. Note the punctal margins are clearly discernable, and there is Fig. 22.10. Note the classical external membrane variant of IPC
a translucent membrane just within the edges. This is the internal mem-
brane variant of IPC
Fig. 22.9 Clinical photograph of a classical case of an internal mem-

brane variant of IPC
Fig. 22.12 A case of a familial IPC: clinical photographs of the opening and that of vertical canaliculus. The right lower panel shows a
mother. Note the normal right upper lacrimal punctum, whereas the left hyper-reflective membrane over the narrowed punctum but the vertical
one has an external membrane variant of the IPC. The lower left panel canaliculus within is normal.
shows a normal ocular coherence tomography with normal punctal
Fig. 22.13 A case of a familial IPC: clinical photographs of the son. row vertical canaliculus. The right lower panel shows a hyper-reflective
Note the internal membrane variant of right upper lacrimal punctum, membrane over the punctum but the vertical canaliculus within is
whereas the left one has an external membrane variant of the IPC. The normal
lower left panel shows a near total occlusion of the punctum with nar-
Fig. 22.14 Clinical photograph demonstrating the membranotomy Fig. 22.17 Clinical photograph of a right lower lid external membrane
procedure using the slow taper punctum dilators variant of IPC
Fig. 22.15 Clinical photograph demonstrating the membranotomy Fig. 22.18 Clinical photograph of the patient in Fig. 22.17, demon-
procedure using the slow taper punctum dilators strating a membranotomy
Fig. 22.16 Clinical photograph demonstrating the membranotomy Fig. 22.19 Clinical photograph of the patient in Figs. 22.17 and 22.18,
procedure using the slow taper punctum dilators. The punctum should showing post-membranotomy punctum. Note the well-dilated and
be well dilated to completely get rid of the membrane without leaving delineated punctum
remnant edges
Fig. 22.21 Microphotograph of the IPC membrane at higher magnifi-

cation showing fibrocollagenous tissue, few blood vessels, and no evi-
dence of any inflammation, suggestive of its embryonic origins
Fig. 22.20 Microphotograph of the IPC membrane showing a fibro-

vascular structure (H&E ×40)
Fig. 22.22 Clinical
photograph in panel a
showing a right lower lid with
external membrane variant of
incomplete punctal
canalization. Panel b shows
the corresponding ocular
coherence tomography
features of IPC. Note the
hyper-reflective uniform
membrane over the punctum
and the visible proximal
edges of the vertical
canaliculus
Fig. 22.23 Clinical
photograph of the patient in
Fig. 22.22 after
membranotomy. Panel a
shows a normal well-formed
punctum without any evidence
of membranous remnants.
Panel b shows the
corresponding ocular
coherence tomography
features after membranotomy.
There is a normal punctal
opening with a normal vertical
canaliculus. Compare this
OCT figure with that of
Fig. 22.22 and note the
differences
Etiopathogenesis of Punctal Stenosis
23
Inflammation and fibrosis have long been implicated as a References

common pathogenic mechanism in punctal stenosis [1–3].
Direct histopathological studies of the punctal tissues in ste- 1. Ali MJ, Mishra DK, Baig F, et al. Punctal stenosis: histopathology,
immunology and electron microscopic features—a step towards
nosis have shown marked subepithelial fibrosis with pre- unraveling the mysterious etiopathogenesis. Ophthal Plast Reconstr
dominant lymphocytic infiltration by CD45 and CD3 cells Surg. 2015;31:98–102.
[1]. Electron microscopy has shown blunted microvilli, 2. Port AD, Chen YT, Lelli GJ. Histopathological changes in punctal
inter- and intracellular edema, irregular deposition of colla- stenosis. Ophthal Plast Reconstr Surg. 2013;29:201–4.
3. Kashkouli MB, Beigi B, Murthy R, et al. Acquired external punc-
gen, and activated fibroblasts with typical lymphocytes in tal stenosis: etiology and associated findings. Am J Ophthalmol.
their vicinity [1]. The ultrastructural effects to noxious stim- 2003;136:1079–84.
uli are likely to be variable and would corroborate with the
degree of inflammation. The close proximities of lympho-
cytes and fibroblasts could possibly signal some intercellular
communications and influences. These studies open up more
avenues for better understanding of the etiopathogenesis of
punctal stenosis and possible preventive strategies.
Figures are from Ali et al. Ophthal Plast Reconstr Surg.
2015;31:98–102.

214 23 Etiopathogenesis of Punctal Stenosis
Fig. 23.1 Facets of fibrosis in punctal stenosis: microphotograph Fig. 23.4 Facets of fibrosis in punctal stenosis: microphotograph
showing dense fibrosis with fibroblasts beneath the canalicular epithe- showing subepithelial canalicular tissues showing areas of dense fibro-
lium (Hematoxylin-Eosin × 400) sis (Masson trichrome × 400)
showing widespread fibrosis beneath the focally metaplastic canalicular showing areas of dense fibrosis with inflammation beneath the conjunc-
epithelium (Masson trichrome × 100) tival epithelium (Hematoxylin-Eosin × 100)
showing high magnification of subepithelial canalicular tissues show- showing widespread subconjunctival fibrosis with sparse cellular infil-
ing areas of less dense fibrosis (Masson trichrome × 400) tration (Masson trichrome × 100)
23 Etiopathogenesis of Punctal Stenosis 215
Fig. 23.7 Facets of inflammation in punctal stenosis: microphoto- Fig. 23.10 Facets of inflammation in punctal stenosis: microphoto-
graph showing inflammatory infiltrate in vicinity of canalicular epithe- graph showing inflammatory changes in subconjunctival tissues with
lium (Hematoxylin-Eosin × 400) less dense fibrosis (Masson trichrome × 100)
Fig. 23.8 Facets of inflammation in punctal stenosis: microphoto- Fig. 23.11 Immunophenotyping in punctal stenosis: microphotograph
graph showing inflammatory infiltrate along with fibrosis below the showing immunohistochemical patterns of positive staining of fibro-
canalicular epithelium (Masson trichrome × 400) blasts and blood vessel walls with smooth muscle actin (SMA × 400)
Fig. 23.9 Facets of inflammation in punctal stenosis: microphoto- Fig. 23.12 Immunophenotyping in punctal stenosis: microphotograph
graph showing marked inflammatory infiltrate below the conjunctival showing strong immunoreactivity with CD3 (×400)
epithelium (Hematoxylin-Eosin × 400)
216 23 Etiopathogenesis of Punctal Stenosis
Fig. 23.13 Immunophenotyping in punctal stenosis: microphotograph Fig. 23.16 Immunophenotyping in punctal stenosis: microphotograph
showing strong immunoreactivity with CD45 (×400) showing negative immunoreactivity with CD5 (×100)
Fig. 23.17 Electron microscopy of punctal stenosis: transmission

electron microphotograph showing epithelial cells (E), their nuclei (N),
Fig. 23.14 Immunophenotyping in punctal stenosis: microphotograph goblet cell (G), and microvilli (M) (Original magnification
showing focal areas of immunoreactivity with CD138 (×400) (OM) × 6755)
Fig. 23.18 Electron microscopy of punctal stenosis: transmission

electron microphotograph showing less dense fibrotic areas with the
Fig. 23.15 Immunophenotyping in punctal stenosis: microphotograph fibroblast (F) surrounded with increased but neat collagen bundles.
showing focal areas of immunoreactivity with CD20 (×400) There is evidence of nuclear halo (NH), pleomorphic mitochondria
(M), and dilated endoplasmic reticulum (ER) (OM × 15,440)
23 Etiopathogenesis of Punctal Stenosis 217
Fig. 23.19 Electron microscopy of punctal stenosis: transmission Fig. 23.21 Electron microscopy of punctal stenosis: transmission
electron microphotograph showing dense fibrotic areas showed both the electron microphotograph showing mononuclear inflammatory infil-
longitudinal (Co) and cross-sectional bundles to be extensive and irreg- trate (L) within the collagen bundles (Co) with intervening edematous
ular with edematous areas (E) and one artifact (A) (OM × 7720×) spaces (E) (OM × 3860)
Fig. 23.20 Electron microscopy of punctal stenosis: transmission Fig. 23.22 Electron microscopy of punctal stenosis: transmission
electron microphotograph and higher magnification showing a com- electron microphotograph showing mononuclear infiltration (L) in
pressed fibroblast (F) with dense and irregular collagen bundles (Co) vicinity of fibroblasts (F) (OM × 11,580×)
(OM × 9650)
Punctal Stenosis and Punctoplasty
24
Punctal stenosis is a common disorder of the punctum. It is an References

important cause of epiphora and accounted for 8% of all
patients presenting with epiphora in a tertiary care oculoplastic 1. Kashkouli MB, Beigi B, Murthy R, et al. Acquired external punc-
tal stenosis. Etiology and associated findings. Am J Ophthalmol.
practice [1–5]. Although numerous factors have been impli- 2003;136:1079–84.
cated as causative agents, the exact pathogenesis is still elusive. 2. Ali MJ, Mishra DK, Baig F, et al. Punctal stenosis: histopathology,
The widely believed hypothesis that has been supported by his- immunology and electron microscopic features—a step towards
tological studies is a common mechanism involving inflamma- unraveling the mysterious etiopathogenesis. Ophthal Plast Reconstr
Surg. 2015;31:98–102.
tion leading to fibrosis and subsequent stenosis [2]. 3. Ali MJ, Ayyar A, Naik MN. Outcomes of rectangular 3-snip punc-
There are no uniform acceptable guidelines for the man- toplasty in acquired punctal stenosis: is there a need to be mini-
agement of punctal stenosis. Several modalities described in mally invasive? Eye (Lond). 2015;29:515–8.
the literature include punctal dilatation, one-snip puncto- 4. Caesar RH, McNab AA. A brief history of punctoplasty: the three
snip revisited. Eye. 2005;19:16–8.
plasty, two-snip punctoplasty, three-snip punctoplasty, 5. Mathew RG, Olver JM. Mini-monoka made easy: a simple tech-
rectangular three-snip punctoplasty, four-snip punctoplasty, nique for mini-monoka insertion in acquired punctal stenosis.
punctal punching with Kelly or Riess punch, and puncto- Ophthal Plast Reconstr Surg. 2011;27:293–4.
plasty with mitomycin C and inserting perforated punctal
plugs, self-retaining bicanalicular stents, or mini-monoka
[1–5]. It is important to note that there is increasing evi-
dence in the literature about the benefits of mini-monoka as
a noninvasive modality of managing punctal stenosis, and
the author anticipates this to be one of the most acceptable
modality in the near future. Cicatrization following puncto-
plasty due to wound healing is a major cause of restenosis,
which is much more difficult to manage than the primary
stenosis.

220 24 Punctal Stenosis and Punctoplasty
Fig. 24.1 Clinical photograph of a right eye lower lid showing a nor- Fig. 24.3 Clinical photograph of a left eye lower lid showing a ste-
mal punctum nosed punctum. Compare it with that of Fig. 24.2
Fig. 24.2 Clinical photograph of a left eye lower lid showing a normal
punctum
Fig. 24.4 External
photograph of the right lower
lid, taken from anterior
segment ocular coherence
tomography (AS-OCT)
machine, in a case of punctal
stenosis, showing the area
(green box) scanned for
assessing the punctum and
24 Punctal Stenosis and Punctoplasty 221
Fig. 24.5 Fourier domain

OCT image of the patient in
Fig. 24.4. Note the gross
stenosis of the punctum and
the vertical canaliculus
Fig. 24.6 Punctal stenosis and mini-monoka case study: clinical pho- Fig. 24.8 Punctal stenosis and mini-monoka case study: clinical pho-
tograph of the right lower lid demonstrating punctal stenosis tograph of the left lower lid demonstrating punctal stenosis
tograph of the right upper lid demonstrating punctal stenosis tograph of the left upper lid demonstrating punctal stenosis
tograph of the right lower lid of the patient in Fig. 24.6, demonstrating tograph of the left upper lid of the patient in Fig. 24.9, demonstrating
retrieval of the monoka stents after 6 weeks of intubation retrieval of the monoka stents after 6 weeks of intubation
tograph of the right upper lid of the patient in Fig. 24.7, demonstrating tograph of the right lower lid of the patients in Figs. 24.6 and 24.10,
retrieval of the monoka stents after 6 weeks of intubation demonstrating the post-monoka dilatation of the punctum
tograph of the left lower lid of the patient in Fig. 24.8, demonstrating tograph of the left lower lid of the patient in Figs. 24.8 and 24.12, dem-
retrieval of the monoka stents after 6 weeks of intubation onstrating the post-monoka dilatation of the punctum
Fig. 24.16 Clinical photograph of the right upper lid showing a

monoka in place Fig. 24.20 Clinical photograph of the right lower lid, demonstrating
the post-monoka dilatation of the punctum
Fig. 24.17 Clinical photograph taken immediately after stent removal

showing a grossly dilated punctum
Fig. 24.21 Clinical photograph of the left lower lid of the patient in
Fig. 24.20. This punctum was treated only with dilatation without any
stents. Note the progressive restenosis of the punctum and compare it
with that of Fig. 24.20
Fig. 24.18 Clinical photograph of the right upper lid showing well-
maintained punctal dilatation, 6 weeks after monoka retrieval
Fig. 24.22 Endoscopic view of the right nasal cavity demonstrating

Fig. 24.19 Clinical photograph of the left lower lid showing well- the monoka stent exit from the nasolacrimal duct in a case of punctal
maintained punctal dilatation, 6 weeks after monoka retrieval stenosis with associated nasolacrimal duct stenosis
Fig. 24.26 The three-snip punctoplasty procedure: intra-operative

photograph of the left lower lid showing the first vertical snip with the
help of Vannas scissors
Fig. 24.23 Endoscopic view of the left nasal cavity demonstrating the
monoka stent exit from the nasolacrimal duct in a case of punctal steno-
sis with associated nasolacrimal duct stenosis

photograph of the left lower lid, immediately after the first snip
Fig. 24.24 Slit lamp view of the right upper lid, 1 week after monoka
retrieval. Note the punctal inflammation with a fine transparent mem-
brane over it. The margins of the punctum behind the membrane can be
well appreciated. Hence this is not a punctal restenosis but an inflam-
mation possibly induced by the stent itself

photograph of the left lower lid, showing the second horizontal snip.
Fig. 24.25 Slit lamp view of the left upper lid, 1 week after monoka Note that one end of the Vannas scissor is within the canalicular lumen
retrieval. Note the punctal inflammation with a fine transparent mem-
brane over it
Fig. 24.29 The three-snip punctoplasty procedure: intra-operative Fig. 24.32 The three-snip punctoplasty procedure: intra-operative
photograph of the left lower lid soon after the second snip. Note the photograph of the right lower lid soon after the three-snip triangular
clear and wide-opened lumen punctoplasty
Fig. 24.30 The three-snip punctoplasty procedure: intra-operative Fig. 24.33 Clinical photograph of the right lower lid, 6 weeks after a
photograph of the left lower lid demonstrating the third snip of the tri- three-snip punctoplasty. Note the widely dilated lumen with fluorescein
angular punctoplasty dye flow into the lumen
Fig. 24.31 The three-snip punctoplasty procedure: intra-operative Fig. 24.34 Clinical photograph of the left lower lid, 6 weeks after a
photograph of the left lower lid after the third snip. Note the triangular- three-snip punctoplasty. Note the widely dilated lumen with fluorescein
segmented grasp by the forceps dye flow into the lumen
Fig. 24.35 Clinical photographs at 6 weeks of post-operative period of left lower lid, left upper lid, and right upper lid. The right panel demon-
a patient who underwent a three-snip punctoplasty for all the puncta. strates high-magnification views of the post-punctoplasty puncta
The left panel demonstrates from above downward the right lower lid,
Fig. 24.36 Clinical photograph of a left lower lid, post-punctoplasty Fig. 24.37 Clinical photograph of the left lower punctum after punc-
punctum, demonstrating a grossly dilated puncta toplasty. Note the gross extension of the incision up to the distal cana-
liculus. This complication itself can induce functional compromise of
tear flow
Fig. 24.38 Clinical photograph of the left lower punctum after punc- Fig. 24.39 Clinical photograph of the right lower lid, post-punctoplasty,
toplasty. Note the mild extension of the punctoplasty into the horizontal demonstrating a complete cicatricial closure of the punctum
canaliculus with a symblepharon near the distal extent of the puncto-
plasty. This could have possibly resulted from undue trauma to the
structures in the vicinity while operating
Fig. 24.40 Clinical photograph of the right upper lid, post-

punctoplasty, demonstrating a complete cicatricial closure of the
punctum
Punctal Keratinizing Cyst
25
Punctal keratinizing cyst is an extremely rare keratin-piling References

ectasia [1–3]. This usually presents with an obliterated punc-
tum with a dome-shaped translucent covering with under- 1. Yonekawa Y, Jakobiec FA, Zakka FR, et al. Keratinizing cyst of the
lacrimal punctum. Cornea. 2013;32:883–5.
lying whitish discoloration representing the keratin [1–3]. 2. Ali MJ, Naik MN, Kaliki S, et al. Punctal keratinizing cyst: a clini-
Fourier domain ocular coherence tomography shows a cystic copathological correlation of an exceptionally rare lacrimal disor-
globular obliteration of the punctal orifice with dense multi- der. Ophthal Plast Reconstr Surg. 2015;31:e66–8.
layered hyper-reflectivity in the area of vertical canaliculus. 3. Kamal S, Ali MJ, Naik MN. Punctal keratinizing cyst: report in a
pediatric patient with Fourier domain ocular coherence tomography
Excision of the m embrane with evacuation of the keratin is features. Ophthal Plast Reconstr Surg. 2015;21:161–3.
usually curative. Histopathological analysis has shown the
cyst wall to be crenated and lined by stratified squamous
epithelium with numerous elongated needlelike keratin
arranged in multilayered wavy patterns.
2015;31:e66–68 and Kamal et al. Ophthal Plast Reconstr
Surg. 2015;21:161–3.

230 25 Punctal Keratinizing Cyst
Fig. 25.1 Clinical photograph of the punctal keratinizing cyst. Note Fig. 25.4 Slit lamp photograph of the patient in Figs. 25.1 and 25.2,
the medial aspect of the left lower eyelid showing a tense, elevated, following cyst excision, showing the punctum with a narrow orifice,
dome-shaped cystic lesion in the region of lower punctum, away from and the inner walls of the vertical canaliculus were noted to have muco-
the cilia sal folds and mild mucosal edema. Compare it with image in Fig. 25.2
Fig. 25.2 Slit lamp photograph of the patient in Fig. 25.1 showing the
cyst wall as transparent all around except in the central area, which
showed a creamy white discoloration and focal areas of vascularization Fig. 25.5 Microphotograph showing a cyst wall lined by multi-lami-
on the slopes of the dome. Note that the punctum could not be nar keratinizing stratified squamous epithelium with keratin on the
visualized other side (H&E ×100)
Fig. 25.3 Clinical photograph of the patient in Fig. 25.1, showing the

excision of the cyst in line with the lid surface. Compare it with image
in Fig. 25.1 Fig. 25.6 Microphotograph showing the adluminal cells shedding
elongated and needle-like keratin into the lumen (H&E ×100)
25 Punctal Keratinizing Cyst 231
Fig. 25.7 The epithelium was multilayered and showed a regular basa- Fig. 25.9 Clinical photograph of the left lower punctum showing a
loid germinal layer without any goblet cells or any granular layer cystic globular swelling with underlying visible whitish discoloration
(H&E ×400)
Fig. 25.8 The desquamated keratin showed laminar and wavy patterns
and was typically thin, elongated, and needle-like (H&E ×400)
Fig. 25.10 Intra-operative
photograph showing
evacuation of the keratin
following excision of the cyst
232 25 Punctal Keratinizing Cyst
Fig. 25.11 FD-OCT image in a case of punctal keratinizing cyst. Note the obliterated punctal opening with a hyper-reflective lesion extending
into the proximal vertical canaliculus, which is the keratin
Fig. 25.12 Three-dimensional FD-OCT image in a case of punctal

keratinizing cyst. The raised dense white area represents the elevated
punctal cyst
Fig. 25.13 Post-operative FD-OCT image of the patient in Fig. 25.13 following marsupialization of the cyst and evacuating the keratin contents.
Note the patent punctum with a patent vertical canaliculus
Peri-Punctal Disorders
26
Peri-punctal disorders refer to those which involve the References

periphery of punctal rim and vicinity or encircle it all around
[1–3]. Numerous lesions can have a peri-punctal location 1. Rumelt S, Pe’er J, Rubin PA. The clinicopathological spectrum of
benign peri-punctal tumors. Graefes Arch Clin Exp Ophthalmol.
like a peri-punctal granuloma secondary to a foreign body 2005;243:113–9.
or stent, nevus, papilloma, hemangioma, basal cell car- 2. Scott KR, Jakobiec FA, Font RL. Peripunctal melanocytic
cinoma, neurofibroma, and a peri-punctal abscess [1–3]. nevi. Distinctive clinical findings and differential diagnosis.
The management of these lesions can be very challenging Ophthalmology. 1989;96:994–8.
3. Ali MJ, Paulsen F. Circumpunctal nevus. Saudi J Ophthalmol. 2017.
since a regular excision may result in a loss of the puncta (Epub).
and proximal canaliculus. Lesions that are benign and not
showing a growth may be observed or excised if there is
cosmetic concern. Nevi may have to be followed up closely
in elderly patients. A simple clinical tip would be to assess
the patency of the punctum with a probe. Obstruction in a
previously patent punctum should be viewed with a high
suspicion. Occasionally hemangiomas may have a similar
lesion, and careful use of steroids or propranolol (if associ-
ated with extensive hemangioma) may be helpful in preserv-
ing the punctal integrity. In all benign lesions where excision
becomes mandatory, all attempts must be made for preserv-
ing the canaliculus and stenting the passages for lacrimal
reconstruction.

234 26 Peri-Punctal Disorders
Fig. 26.1 Clinical photograph of the right eye showing a right upper Fig. 26.4 Clinical photograph of the patient in Fig. 26.3, close-up
lid peri-punctal nevus image, showing the peri-punctal extent of the lesion
Fig. 26.2 Clinical photograph of the right upper lid of patient in Fig. 26.5 Clinical photograph of right upper lid showing a deep peri-
Fig. 26.1. Note the elevated circumpunctal nevus with a slit punctal punctal nevus without an elevated surface lesion
opening at its top surface
Fig. 26.3 Clinical photograph of a large left peri-punctal nevus Fig. 26.6 Clinical photograph of the left eye showing a raised pig-
mented lesion in the region of the lower punctum
26 Peri-Punctal Disorders 235
Fig. 26.7 Clinical photograph of the left lower lid of patient in Fig. 26.10 Microphotograph of an excised peri-punctal nevus. Note
Fig. 26.6. Note the grossly raised circumpunctal lesion with a slit punc- the numerous subepithelial pigment-laden cells (H&E ×100)
tal opening on its top surface
Fig. 26.8 Clinical photograph showing the vertical pass of a probe

through the punctal opening in the nevus. It is important to document
patent punctal opening as most benign tumors, especially nevi, do not Fig. 26.11 Microphotograph of an excised peri-punctal nevus. Note
occlude the punctum the numerous pigment-laden cells (H&E ×100)
Fig. 26.9 Clinical photograph showing the horizontal pass of the Fig. 26.12 Clinical photograph of the right eye in a case of a right
probe. Obstruction of a previously patent punctum in a case of peri- lower lid peri-punctal chalazion
punctal nevus should raise suspicion with regard to its neoplastic
potential
Fig. 26.13 Clinical photograph of the right lower lid of patient in

Fig. 26.10. The location of the chalazion mandates a careful incision
and curettage, if planned, to avoid lacrimal injury Fig. 26.16 Microphotograph demonstrating features of a squamous
papilloma with epithelial downgrowth and fibrosis (H&E ×100)
Fig. 26.14 Clinical photograph of the left lower lid showing a peri-
punctal granuloma following a cautery
Fig. 26.17 Microphotograph demonstrating features of a squamous
papilloma with epithelial downgrowth and fibrosis (H&E ×400)
Fig. 26.15 Clinical photograph of the left eye showing extensive, mul- Fig. 26.18 Clinical photograph of a left upper lid squamous
tifocal eyelid squamous papilloma, completely engulfing the punctal papilloma
and canalicular areas
Fig. 26.19 Clinical photograph of a left upper lid pigmented Fig. 26.22 Post-operative clinical photograph of the patient in
papilloma Figs. 26.20 and 26.21. Note the well-rescued punctum and the dilatory
effect of the stent placed following surgery
Fig. 26.20 Clinical photograph showing another example of a right Fig. 26.23 Clinical photograph of the right lower lid, showing peri-
lower lid peri-punctal pigmented papilloma punctal pigmentation in a case of nevus of Ota
Fig. 26.21 Clinical photograph of the patient in Fig. 26.20. Note the Fig. 26.24 Clinical photograph of the left lower lid of the patient in
patency of punctum on probing Fig. 26.23, showing the peri-punctal pigmentation. Note also the char-
acteristic episcleral pigmentation
Fig. 26.25 Clinical photograph of left lower lid demonstrating peri- Fig. 26.28 Clinical photograph of the left upper lid of patient in
punctal keratinization in a case of Stevens-Johnson syndrome Fig. 26.27, close-up image, showing a well-defined peri-punctal lesion
Fig. 26.26 Clinical photograph of the left eye demonstrating a sym-

blepharon involving the upper and lower peri-punctal areas
Fig. 26.29 Intra-operative photograph of the patient in Figs. 26.27 and

26.28. Note the lesion’s vicinity with the punctum, which is probed to
avoid any inadvertent injury
Fig. 26.27 Clinical photograph of the left upper lid peri-punctal

lesion, proved later to be a choristoma
Fig. 26.32 Clinical photograph of the patient in Figs. 26.27, 26.28,

26.29, and 26.30. Note the complete excision of the lesion with punctal
salvage
Fig. 26.30 Intra-operative photograph of the patient in Figs. 26.27,

26.28, and 26.29. Note the features of the lesion
Fig. 26.33 Clinical photograph of a left lower lid basal cell carcinoma
engulfing the entire peri-punctal area
Fig. 26.31 The excised peri-punctal lesion in toto Fig. 26.34 Clinical photograph of a right lower lid peri-punctal
hemangioma
Fig. 26.35 Clinical photograph of a left lower lid isolated neurofi- Fig. 26.37 Clinical photograph of the left upper lid, showing a peri-
broma. Note the demarcated punctal papilloma standing proudly on the punctal lesion which later proved to be a sebaceous gland carcinoma
superior surface of the lesion
Fig. 26.36 Clinical photograph, close-up image of the left lower lid of
patient in Fig. 26.35
Fig. 26.38 Microphotograph of the excised lesion of the patient in
Fig. 26.37. Note the comedo pattern of sebaceous gland carcinoma
(H&E ×40)
Canalicular Wall Dysgenesis
27
Proximal lacrimal outflow dysgenesis involving the punctum References

and canaliculus is sparsely documented entity in the litera-
ture [1–5]. Ali and Naik [3] introduced the term canalicular 1. Ahn Yuen SJ, Oley C, Sullivan TJ. Lacrimal outflow dysgenesis.
Ophthalmology. 2004;111:1782–190.
wall dysgenesis and its eight subtypes of aplasia and hypo- 2. Cahill KV, Burns JA. Management of epiphora in the presence of
plasia. The same group also introduced an arbitrary division congenital punctal and canalicular atresia. Ophthal Plast Reconstr
of a canaliculus into four walls, namely, roof, floor, anterior Surg. 1991;7:167–72.
wall, and a posterior wall toward the conjunctiva. 3. Ali MJ, Naik MN. Canalicular wall dysgenesis: the clinical profile
of canalicular hypoplasia and aplasia, associated systemic and lac-
The diagnosis of single canalicular wall dysgenesis rimal anomalies and clinical implications. Ophthal Plast Reconstr
(SCWD) is made on slit lamp biomicroscopy. The typical Surg. 2013;29:464–8.
finding in cases of aplasia, which is called single canalicular 4. Ali MJ, Mohapatra S, Mulay K, et al. Incomplete punctal canali-
wall aplasia (SCWA), includes an obvious defect in the cana- zation: the external and internal punctal membranes. Outcomes
of membranotomy and adjunctive procedures. Br J Ophthalmol.
licular wall, which is a complete dehiscence. This defect can 2013;97:92–5.
be further classified as focal if it involves a part of the cana- 5. Kirk RC. Developmental anomalies of the lacrimal passages.
liculi or diffuse if the defect extends along the entire length A review of the literature and presentation of three unusual cases.
of the canaliculi. The other variant of SCWD is hypoplasia, Am J Ophthalmol. 1956;42:227–32.
which is called single canalicular wall hypoplasia (SCWH)
and requires a high degree of suspicion for the clinical diag-
nosis. The most obvious finding in SCWH is thinning of the
wall, most noticeable if a probe is placed in the canaliculus.
The surface of the probe becomes more obvious and is easily
visualized in the areas of hypoplasia. As for SCWA, the
hypoplastic component can be focal or diffuse.
When more than one wall of the canaliculus is affected,
the term multiple canalicular wall dysgenesis (MCWD) is
used and is further classified into aplastic and hypoplastic
components. The diagnosis of multiple canalicular wall apla-
sia (MCWA) and hypoplasia (MCWH) would follow similar
principles with subtle differences.
In a large series, SCWD involving only the roof was the
most common feature noted in 71.4%, and about 28.5%
patients had three wall involvements [3]. Associated lacrimal
anomalies were seen in all patients and included supernu-
merary puncta, incomplete punctal canalization (IPC), punc-
tal agenesis, punctal stenosis, and congenital nasolacrimal
duct obstruction (CNLDO). Systemic anomalies were noted
in 28.5% (n = 7) of the patients and included right hemipare-
sis with left cerebral hypoplasia and delayed milestones [3].
Figures 27.5, 27.6, 27.9, 27.17, and 27.19 are from Ali
et al. Ophthal Plast Reconstr Surg. 2013;29:464–8.

242 27 Canalicular Wall Dysgenesis
a Single Canalicular Wall Dysgenesis (SCWD)
1. Single Canalicular Wall Hypoplasia (SCWH)
a) Focal
b) Diffuse
2. Single Canalicular Wall Aplasia (SCWA)
a) Focal
b) Diffuse
b Multiple Canalicular Wall Dysgenesis (MCWD)
1. Multiple Canalicular Wall Hypoplasia (MCWH)
a) Focal
b) Diffuse Fig. 27.2 Dacryoendoscopy image of a normal canaliculus. Note the

walls as anterior (A), posterior (P), roof (R), and floor (F)
2. Multiple Canalicular Wall Aplasia (MCWA)
a) Focal
b) Diffuse
Fig. 27.1 Classification of canalicular wall dysgenesis
Fig. 27.3 Clinical photograph of a probe tilt test in a case of single canalicular wall hypoplasia. Note the focal thinning of the canalicular
roof and the corresponding visualization of the canalicular portion of lacrimal probe
27 Canalicular Wall Dysgenesis 243
Fig. 27.4 Clinical
photograph of a probe tilt test
of the patient in Fig. 27.3.
Note the change in
illumination better delineates
the canalicular wall
hypoplasia
Fig. 27.5 Clinical photograph of a single canalicular wall hypoplasia. Fig. 27.6 Clinical photograph of a normal canaliculus with a probe in
The close-up image shows the thinned out segment of the canalicular it. Note the difference between this figure and those of Figs. 27.3, 27.4,
roof and 27.5
Fig. 27.7 Clinical photograph of the right lower lid showing another Fig. 27.8 Clinical photograph of the left lower lid. Note an isolated
example of a single canalicular wall hypoplasia. Note, that if one is not area (black arrow) of single canalicular wall hypoplasia
careful, how easy it would be to slit open the dysgenetic canaliculi
Fig. 27.9 Clinical
canaliculus showing focal
single canalicular wall
aplasia. Note the absence of
the canalicular roof
Fig. 27.10 Clinical
canaliculus showing diffuse
single canalicular wall
aplasia. Note the absence of
the canalicular roof
Fig. 27.11 Clinical
photograph showing another
case of a single canalicular
wall aplasia
27 Canalicular Wall Dysgenesis 245
Fig. 27.12 Clinical photograph of the left lower eyelid showing a case Fig. 27.15 Clinical photograph of the left lower eyelid showing a
of multifocal canalicular wall aplasia gross canalicular wall aplasia. This needs to be differentiated from a
post-traumatic canalicular fistula
Fig. 27.13 Clinical photograph of the left lower eyelid of the patient in Fig. 27.16 Clinical photograph of the left lower eyelid, close-up
Fig. 27.12. Note one of the focal aplasia segments being better delin- image, showing a gross canalicular wall aplasia. This needs to be dif-
eated with a probe ferentiated from a post-traumatic canalicular fistula
Fig. 27.14 Clinical photograph of the left lower eyelid of the patient in
Figs. 27.12 and 27.13. Note the medial most aplastic segments
Fig. 27.17 Clinical
photograph of the left lower
eyelid showing a multiple
canalicular wall aplasia
(arrow). Note the loss of all
the canalicular walls except
the floor
Fig. 27.18 Clinical photograph of the left lower eyelid showing a Fig. 27.19 Clinical photograph of the left lower eyelid showing a case
case of multiple canalicular wall hypoplasia. Note the increased visu- of multiple canalicular wall hypoplasia with a probe tilt test. Note the
alization of the probe circumference. Compare that with those of increased visualization of the probe circumference
Figs. 27.8 and 27.13
Lacrimal Fistula
28
Lacrimal fistula is an accessory or an anlage duct communi- determining the origin [1, 3]. The management of lacrimal
cating with the skin on one side and the canaliculus, lacrimal fistulae is case dependent. All patients should undergo lacri-
sac, or nasolacrimal duct on the other [1–5]. These result mal system irrigation to assess the patency of the lacrimal
from abnormal embryological development at the optic end system. In cases of associated congenital nasolacrimal duct
of the naso-optic fissure, whereby there is additional out bud- obstruction, the patient should undergo a probing along with
ding from the embryonic lacrimal epithelial cord in an a simple excision of the fistulous tract (fistulectomy). In
embryo of 18–24 mm. The external opening can be on the patients with failed probing or in adults, fistulectomy can be
skin below the punctum, lid margin, or medial end of lower performed along with a dacryocystorhinostomy with or
lid crease. without intubation (based on canalicular manipulation) for
Lacrimal fistulas can be congenital or acquired following associated nasolacrimal duct obstructions.
trauma or surgical interventions. There might be associated Figures 28.24, 28.25, 28.26, 28.27, 28.28, 28.29, 28.30,
epiphora or discharge from the fistula. Occasionally the sur- 28.31, 28.32, and 28.33 are from Ali et al. Ophthal Plast
rounding skin may get excoriated. Congenital fistula is usually Reconstr Surg. 2016;32:17–19.
small with a well-defined opening, classically present 1–2 mm
inferomedial to medial canthus [1–5]. In contrast, the acquired
fistulas may be irregular, large with surrounding scarring and References
without any probable location. A lacrimal probe can be passed
through the fistula to assess its depth and possible internal com- 1. Chaung JQ, Sundar G, Ali MJ. Congenital lacrimal fistula: a major
review. Orbit. 2016;35:212–20.
municating structure. A few decades earlier, a radiological test 2. Al-Salem K, Gibson A, Dolman PJ. Management of congenital lac-
called the three-point test was popular to differentiate congeni- rimal (anlage) fistula. Br J Ophthalmol. 2014;98:1435–6.
tal and acquired varieties, whereby three lacrimal probes are 3. Ali MJ, Mishra DK, Naik MN. Histopathology and immunophe-
passed (one from the upper and lower punctum each and one notyping of congenital lacrimal (anlage) fistulae. Ophthal Plast
from the fistula) and assessed. All the three probes would meet 4. Francois J, Bacskulin J. External congenital fistulae of the lacrimal
in a congenital but not in acquired fistulae. sac. Ophthalmologica. 1969;159:249–61.
Most of the congenital fistulae originate from the com- 5. Sullivan TJ, Clarke MP, Morin JD, et al. The surgical manage-
mon canaliculus. Histopathological examination can help in ment of congenital lacrimal fistulae. Aust N Z J Opthalmol.
1992;20:109–14.

248 28 Lacrimal Fistula
Fig. 28.1 Clinical photograph demonstrating a congenital lacrimal fis-

tula (arrow) communicating with the common canaliculus. Note the
typical location of the fistula
Fig. 28.3 Clinical photograph demonstrating a three-probe test in a

congenital lacrimal fistula
Fig. 28.2 Clinical photograph showing a congenital lacrimal fistula

communicating with the lacrimal sac
Fig. 28.4 Clinical photograph of the right eye showing an acquired

fistula. Note the scarring of the skin in the vicinity
28 Lacrimal Fistula 249
Fig. 28.5 Clinical photograph showing a right medial canthus acquired Fig. 28.8 Close-up image of the left eye of patient in Fig. 28.7. Note
fistula following trauma. Note the medial symblepharon the associated medial canthal dystopia
Fig. 28.6 Close-up image of the patient in Fig. 28.5. Note the peri- Fig. 28.9 Clinical photograph showing a left acquired lacrimal fistula
fistula skin changes immediately inferomedial to the punctum. Note the scarring in the
vicinity
Fig. 28.7 Clinical photograph of an acquired fistula at left medial can- Fig. 28.10 Clinical photograph of the patient in Fig. 28.9, where the
thus, following a dog bite fistula is being probed
Fig. 28.11 Clinical photograph of the left eye showing upper post-
traumatic canalicular fistula
Fig. 28.12 Clinical photograph of the patient in Fig. 28.11, close-up

image of the post-traumatic canalicular fistula
Fig. 28.13 Clinical photograph of a left lower lid gross post-traumatic

canalicular fistula. Note the disruption of the medial canthal anatomy
Fig. 28.16 Clinical photograph of the patient in Fig. 28.15. Note the

irregular edges of the canalicular wall

image of the post-traumatic canalicular fistula and the malalignment of
the distal canaliculus with disrupted medial canthal structures
Fig. 28.15 Clinical photograph of a right lower lid post-traumatic

canalicular fistula. The closest differential diagnosis here would be a
canalicular wall dysgenesis. The canalicular edge scarring gives a clue
to the diagnosis
Fig. 28.17 Operative steps

of a fistulectomy: clinical
photograph demonstrating a
three-probe test. Note the oval
ellipse marked around the
congenital fistula. It is useful
to keep the probes in the
upper and lower canaliculus
to avoid injury to them during
excision of fistulae
communicating with the
common canaliculus

of a fistulectomy: incision on
the oval mark, elevation of
one of the edges and
beginning of excision of the
fistula all around

of a fistulectomy: excision of
the superficial half of the
fistula. Note the small
opening in the depths

of a fistulectomy: gentle mild
cautery of the exposed
epithelium of the remnant
fistula. Note that this should
be very superficial, just touch
and of low power, to avoid
damaging the normal
underlying lacrimal ducts

of a fistulectomy: purse string
suture all along to close the
fistula. Note the central dark
mark of the surface cautery
Fig. 28.22 Operative steps of a fistulectomy: complete closure of Fig. 28.23 Operative steps of a fistulectomy: histopathological speci-
the fistula and skin with 8-0 re-absorbable sutures men of the excised fistulous tract
Fig. 28.24 Histopathology of congenital lacrimal fistula: microphoto- Fig. 28.25 Histopathology of congenital lacrimal fistula: microphoto-
graph showing the superficial portion of the lacrimal fistula lined by a graph of a fistula showing its lining by the stratified squamous epithe-
keratinized squamous epithelium. Note the horn cysts and the basal pig- lium, the same as that of a canaliculus, reflecting a canalicular origin
mentation (H&E ×400) (H&E ×100)
Fig. 28.26 Histopathology of congenital lacrimal fistula: microphoto- Fig. 28.29 Histopathology of congenital lacrimal fistula: microphoto-
graph of a fistula showing lining by columnar epithelium with goblet graph showing subepithelial edema with dense inflammatory infiltrate,
cells, the same as that of a lacrimal sac, reflecting a sac origin (H&E ×400) possibly was reflecting an ongoing inflammation at the time of excision
(H&E ×400)
Fig. 28.27 Histopathology of congenital lacrimal fistula: microphoto-

graph of a fistula showing areas of squamous metaplasia (H&E ×400) Fig. 28.30 Immunophenotyping of congenital lacrimal fistula: micro-
photograph showing subepithelial infiltration by CD3+ lymphocytes
(anti CD3 ×400)
Fig. 28.28 Histopathology of congenital lacrimal fistula: microphoto-

graph of a fistula showing hyperplastic squamous epithelium with sub- Fig. 28.31 Immunophenotyping of congenital lacrimal fistula: micro-
epithelial fibrosis and inflammatory infiltrate, possibly reflecting past photograph showing subepithelial infiltration by CD5+ lymphocytes
attacks of fistulitis (H&E ×100) (anti CD5 ×400)
Fig. 28.32 Immunophenotyping of congenital lacrimal fistula: micro- Fig. 28.33 Immunophenotyping of congenital lacrimal fistula: micro-
photograph showing subepithelial infiltration by CD20+ lymphocytes photograph showing negative results for CD10+ lymphocytes (anti
(anti CD20 ×400) CD10 ×400)
Simple Congenital Nasolacrimal Duct
Obstruction and Its Management 29
Congenital nasolacrimal duct obstruction (CNLDO) is a References

common cause of epiphora in children with incidence of
symptoms ranging from 1.2 to 30% [1–5]. In a simple 1. Kushner BJ. The management of nasolacrimal duct obstruc-
tion in children aged between 18 months and 4 years. JAAPOS.
CNLDO, there is a lack of resistance in passing probe 1998;2:57–60.
through the NLD until a point of membranous obstruction 2. Paediatric Eye Disease Investigator Group. Resolution of congeni-
which can be perforated [5]. The characteristic triad includes tal nasolacrimal duct obstruction with nonsurgical management.
watering, discharge, and matting of eyelashes. The onset of Arch Ophthalmol. 2012;130:730–4.
3. Paediatric Eye Disease Investigator Group. Primary treatment of
epiphora is usually within first month of age. Condition can nasolacrimal duct obstruction with probing in children less than
be unilateral or bilateral. Symptoms may worsen with occur- four years. Ophthalmology. 2008;115:577–84.
rence of upper respiratory tract infection. Other signs include 4. Paediatric Eye Disease Investigator Group. Primary treatment of
increased tear meniscus height, positive fluorescein dye dis- nasolacrimal duct obstruction with nasolacrimal duct intubation in
children less than four years old. JAAPOS. 2008;12:445–50.
appearance test (FDDT), and regurgitation on pressure over 5. Ali MJ, Kamal S, Gupta A, et al. Simple vs complex congenital
lacrimal sac (ROPLAS). Spectrum of presentation can rarely nasolacrimal duct obstruction: etiology, management and out-
include acute dacryocystitis, dacryocele, mucopyocele, pre- comes. Int Forum Allergy Rhinol. 2015;5:174–7.
septal, and orbital cellulitis. Management of CNLDO is prin-
cipally guided by natural history of disease and high
spontaneous remission rate by 1 year of age [1–5]. Hence
conservative measures like lacrimal sac compression are
usually employed initially. The standard of care for non-
resolving cases is endoscopic-assisted probing with or with-
out intubation. There is an increasing role of dacryoendoscopy
and simultaneous correction of associated intranasal abnor-
malities. Balloon dacryoplasty and dacryocystorhinostomy
also have their specific indications in refractory CNLDO.

258 29 Simple Congenital Nasolacrimal Duct Obstruction and Its Management
Fig. 29.1 Clinical photograph of an infant with right-sided congenital Fig. 29.4 Clinical photograph of left eye of the patient in Fig. 29.3.
nasolacrimal duct obstruction (CNLDO) Note the epiphora, discharge, and matting of eyelashes
Fig. 29.2 Clinical photograph of right eye of the patient in Fig. 29.1.

Note the epiphora, matting of eyelashes and discharge Fig. 29.5 Clinical photograph of an older child with a left-sided
CNLDO. Note the severe left-sided epiphora
Fig. 29.3 Clinical photograph of an infant with a left-sided

CNLDO. Compare the left eye with the right eye
29 Simple Congenital Nasolacrimal Duct Obstruction and Its Management 259
Fig. 29.6 Clinical photograph of the patient in Fig. 29.5, close-up Fig. 29.8 Clinical photograph of an infant with bilateral CNLDO and
image, showing severe epiphora without any discharge. Note the very right-sided dilatation of the lacrimal sac
high tear meniscus
Fig. 29.9 Clinical photograph of right eye of the patient in Fig. 29.8.

Note the dilated lacrimal sac and lower lid position. Dilated lacrimal
sacs are an indication for an early probing to avoid atonicity and prevent
infantile acute dacryocystitis
Fig. 29.7 Clinical photograph of an infant with left-sided

CNLDO. Note the severe epiphora
Fig. 29.10 Clinical photograph of the right eye of the patient in

Figs. 29.8 and 29.9. The eye which was managed with conservative
lacrimal sac compression now shows an impending acute dacryocysti-
tis. Note the diffuse erythema over the dilated lacrimal sac
Fig. 29.12 Clinical photograph showing the technique of lacrimal sac

compression. Note that only the lacrimal sac needs to be compressed
near the medial canthus and not the lateral wall of the nose
Fig. 29.11 Clinical photograph of a left-sided neonatal acute dacryo-

cystitis with a spontaneous fistula
Fig. 29.13 Clinical photograph showing the technique of lacrimal sac

compression
Fig. 29.14 The rapid taper Nettleship’s punctum dilator is well suited
for pediatric punctal dilatation Fig. 29.17 The tips of various Bowman’s probes. The tips and sizes
distinguish Bowman’s probes from Clarke’s probes
Fig. 29.15 The tip of the rapid taper Nettleship’s punctum dilator
Fig. 29.18 The size 000 I-probe® with a Luer lock at one end and
markings at the other
Fig. 29.16 A set of various Bowman’s probes from size 0000 to 2
Fig. 29.19 The size 000 I-probe®. Note the black markings that depict
various levels of the probe in the lacrimal system as well as the distal
opening on the surface of the canula for simultaneous irrigation
Fig. 29.20 The 27 gauge pediatric bicanalicular Crawford intubation
Fig. 29.22 The monocanalicular Monoka-Crawford stent
Fig. 29.21 The tips of the pediatric Crawford intubation. Note the
olive-tipped bodkins
Fig. 29.23 The mono- and bicanalicular Crawford nasal retrieval

device
Fig. 29.24 Close-up view of the Crawford nasal retrieval device. Note
the hook at the tip that engages the olive tips of the stent
Fig. 29.25 A typical

Irrigation and probing
instrument set
Fig. 29.26 Irrigation and probing procedure: nasal decongestion can Fig. 29.27 Irrigation and probing procedure: note the cotton tip appli-
be achieved by either sprays or preferably a focal placement of medi- cator should be introduced initially directed toward the floor and then
cated cotton tip applicator laterally toward the inferior turbinate
Fig. 29.28 Irrigation and probing procedure: right upper punctal dila- Fig. 29.31 Irrigation and probing procedure: another example demon-
tation with a rapid taper dilator. Note the vertical end-on engagement of strating left upper punctal dilatation
the dilator with the punctum
Fig. 29.29 Irrigation and probing procedure: the dilator is then Fig. 29.32 Irrigation and probing procedure: another example demon-
brought to a horizontal plane. During this movement, there should not strating left upper punctal and proximal canalicular dilatation. Note the
be any force on the dilator to avoid injury to the ampulla superolateral stretch on the upper lid
Fig. 29.30 Irrigation and probing procedure: dilatation of the punctum Fig. 29.33 Irrigation and probing procedure: irrigation using straight
and proximal canaliculus. Note the dilator lies parallel to and on the canulas. Note the end-on engagement of the canula with the dilated
surface of the lid margin upper punctum
Fig. 29.34 Irrigation and probing procedure: horizontal engagement Fig. 29.37 Irrigation and probing procedure: irrigation showing regur-
of the canula with the proximal upper canaliculus gitation of clear fluid from the opposite punctum
Fig. 29.35 Irrigation and probing procedure: the canula is preferably Fig. 29.38 Irrigation and probing procedure: vertical end-on engage-
rotated once it is in the lacrimal sac. The irrigation can be performed at ment of a Bowman’s probe with the dilated left upper punctum
this stage or the next stage (Fig. 29.34)
Fig. 29.36 Irrigation and probing procedure: the canula in the lacrimal Fig. 29.39 Irrigation and probing procedure: horizontal engagement
sac with a direction toward the nasolacrimal duct. Irrigation can now be of the Bowman’s probe with the canaliculus. Note that the probe is
performed at this stage lying parallel and on the surface (lid margin) of the stretched upper lid
Fig. 29.40 Irrigation and probing procedure: once the probe crosses
the common canaliculus and one feels the hard stop, a gentle minimal
retraction and rotation by 90° is achieved to engage the nasolacrimal
duct
Fig. 29.43 Irrigation and probing procedure: endoscopic view of the
left nasal cavity. Note the minimally medialized inferior turbinate and
the nasolacrimal duct with a probe in it (white circle)
Fig. 29.41 Irrigation and probing procedure: the probe is gently

advanced into the nasolacrimal duct under protection of a finger to
avoid undue probe movements
left inferior meatus, clearly demonstrating the nasolacrimal duct with a
probe in it (arrow)

left inferior meatus. Under endoscopic guidance, the probe is now gen-
Fig. 29.42 Irrigation and probing procedure: once a resistance to tly pushed to overcome the membrane and the probe can then be clearly
advancing of probe is felt, endoscopic guidance is resorted to. Note the visualized
left inferior turbinate being gently and minimally medialized (not
infractured!) to view the inferior meatus and the probe
Fig. 29.46 Irrigation and probing procedure: post-probing irrigation is

performed to assess the patency and clear off any membranous debris
Fig. 29.49 Irrigation and probing procedure: alternatively, the irri-

gated fluid in the nasopharynx can be evacuated with suction canulas
under endoscopic guidance

left nasal cavity showing the free flow of the fluorescein dye
Fig. 29.48 Irrigation and probing procedure: the irrigated fluid can Fig. 29.50 Endoscopic view of the right nasal cavity showing the
then be aspirated with a silicone suction tube probe within the nasolacrimal duct just before breaking the membrane
at inferior end of NLD (photo courtesy: Nishi Gupta, SCEH, Delhi)
Fig. 29.51 Endoscopic view of the left nasal cavity showing the probe
within the nasolacrimal duct just before breaking the membrane at infe-
rior end of NLD (photo courtesy: Nishi Gupta, SCEH, Delhi) Fig. 29.53 Endoscopic monitoring of probing: endoscopic view of the
left inferior meatus showing an impending rupture of the NLD mem-
brane by the probe
Fig. 29.54 Endoscopic monitoring of probing: endoscopic view of the

left inferior meatus showing the ruptured membrane. Note the probe
left inferior meatus showing the probe advancing into the lower end of
can be clearly visualized
nasolacrimal duct

left inferior meatus showing patent nasolacrimal duct after probing and Fig. 29.57 Endoscopic view of the right nasal cavity demonstrating a
free flow of dye into the nasal cavity dilated nasolacrimal duct. Occasionally, dilated lacrimal sac is accom-
panied by a dilated nasolacrimal duct (photo courtesy: Nishi Gupta,
SCEH, Delhi)

right inferior meatus showing the probe following rupture of the distal Fig. 29.58 Endoscopic view of the left inferior meatus demonstrating
nasolacrimal membrane a dilated nasolacrimal duct (photo courtesy: Nishi Gupta, SCEH, Delhi)
Fig. 29.59 Endoscopic view of the left inferior meatus demonstrating

a sacculated and dilated nasolacrimal duct (photo courtesy: Nishi
Gupta, SCEH, Delhi)
Complex CNLDO: Buried Probe
30
Buried probe is a variant of complex congenital nasolacrimal References

duct obstruction and is more commonly noted in older chil-
dren [1–5]. This is an endoscopic diagnosis and is defined 1. Ali MJ, Kamal S, Gupta A, et al. Simple vs complex congenital
nasolacrimal duct obstruction: etiology, management and out-
“as a condition when the entire nasolacrimal duct remains comes. Int Forum Allergy Rhinol. 2015;5:174–7.
submucosally in the lateral wall of the nose up to the floor 2. Gupta A, Kamal S, Ali MJ, et al. Buried probe in complex congeni-
without any opening into the inferior meatus” [2]. It tal nasolacrimal duct obstruction: clinical profiles and outcomes.
accounted for 10% of complex CNLDO’s [1]. The probe in Ophthal Plast Reconstr Surg. 2015;31:318–20.
3. Mirecki R. Causes of failures in probing the nasolacrimal duct
these patients passes smoothly up to the floor without com- in infants and children and ways of avoiding them. J Pediatr
ing out in the inferior meatus. In such a case, the entire length Ophthalmol. 1968;5:171–5.
of the probe movement in the lateral wall of the inferior 4. Olver JM. Pediatric lacrimal surgery. In: Olver JM, editor. Colour
meatus should be assessed to find out the thinnest mucosal Atlas of lacrimal surgery. Oxford: Butterworth-Heinemann; 2002.
p. 79–80.
point. This can be noted by the maximum light reflectance 5. Al-Faky YH. Nasal endoscopy in the management of congenital
from the probe at the thinnest point. The probe is then gently nasolacrimal duct obstruction. Saudi J Ophthalmol. 2014;28:6–11.
tilted to come out from this point into the inferior meatus [2].
Routine intubation following buried probe exteriorization is
not needed. Rarely, the probe may be covered by a thick
nasal mucosa, and a 2–3 mm incision is given along the long
axis of the NLD to exteriorize the probe followed by intuba-
tion. The outcomes are good with an anatomical success rate
of around 90% [2]. This again emphasizes the fact that endo-
scopic guidance is mandatory for a good evaluation and
management of CNLDO.

272 30 Complex CNLDO: Buried Probe
Fig. 30.1 Endoscopic view of the left inferior meatus showing a buried Fig. 30.3 Endoscopic view of the right inferior meatus showing a
probe. Note the mound of the thin probe (black arrow) buried within the complete buried probe with a thin overlying nasolacrimal mucosa
lateral wall allowing a good reflection of light from the probe (photo courtesy:
Nishi Gupta, SCEH, Delhi)
Fig. 30.2 Endoscopic view of the left inferior meatus. Note the direc- Fig. 30.4 Endoscopic view of the left inferior meatus showing a com-
tion of the probe is along the curve of the lateral wall toward the floor plete buried probe. Compare the thickness of the overlying nasolacri-
mal mucosa with that of Fig. 30.3 (photo courtesy: Nishi Gupta, SCEH,
Delhi)
30 Complex CNLDO: Buried Probe 273
Fig. 30.5 Endoscopic view of the left inferior meatus showing a buried Fig. 30.7 Endoscopic view of the same patient after a partial incision.
probe with thick overlying nasolacrimal mucosa. Compare this thick- Note the increase reflectance of the probe now
ness to that of Figs. 30.3 and 30.4 (photo courtesy: Nishi Gupta, SCEH,
Delhi)
Fig. 30.6 Endoscopic view of the right inferior meatus demonstrating Fig. 30.8 Endoscopic view showing deeper incision of 2–3 mm with a
a complete buried probe with a thick overlying nasolacrimal mucosa sickle knife
274 30 Complex CNLDO: Buried Probe
Fig. 30.9 Endoscopic view showing good exteriorization of the probe
Fig. 30.11 A bicanalicular Crawford intubation
Fig. 30.10 Endoscopic view showing a freely patent nasolacrimal duct

following the incision
Complex CNLDO: Dacryocele
31
Dacryocystocele or simply dacryoceles are bluish cystic lac- References

rimal sac swelling, typically present in neonates, below the
medial canthal tendon, filled with secretions from epithelial 1. Ali MJ, Psaltis AJ, Brunworth J, et al. Congenital dacryocele
with large intranasal cysts. Efficacy of cruciate marsupialization,
lining and tears. It is an uncommon manifestation of congeni- adjunctive procedures and outcomes. Ophthal Plast Reconstr Surg.
tal nasolacrimal duct obstruction. CNLDO when combined 2014;30:346–51.
with either functional obstruction of proximal lacrimal sys- 2. Perry LJ, Jakobiec FA, Zakka FR, et al. Giant dacryocystomucopy-
tem or common canaliculus leads to accumulation of secre- ocele in an adult: a review of lacrimal sac enlargements with clini-
cal and histopathologic differential diagnoses. Surv Ophthalmol.
tions in the lacrimal sac. This leads to distortion of common 2012;57:474–85.
canaliculus and creates a ball-valve mechanism at the valve of 3. Paysee EA, Coats DK, Bernstein JM, et al. Management and com-
Rosenmuller which allows ingress of tears into the sac but plications of congenital dacryocele with concurrent intranasal
interferes with egress [1–5]. Dacryocystocele can be bilateral mucocele. J AAPOS. 2000;4:46–53.
4. Ali MJ, Kamal S, Gupta A, et al. Simple vs complex congenital
in 25% cases and can complicate into superadded infection nasolacrimal duct obstruction: etiology, management and out-
and respiratory distress [1–5]. Associated intranasal cyst can comes. Int Forum Allergy Rhinol. 2015;5:174–7.
be small or large (if >50 of nasal cavity) and if large, can 5. Ali MJ, Singh S, Naik MN. Long-term outcomes of cruciate mar-
cause respiratory insufficiency because neonates are nasal supialization of intra-nasal cysts in patients with congenital dacryo-
celes. Int J Pediatr Otorhinolaryngol. 2016;86:34–6.
breathers, which can potentially be life threatening in cases of
bilateral pathology [1]. Infection can lead to preseptal celluli-
tis, orbital cellulitis, and sepsis and therefore indicating early
management of this condition. In the absence of intranasal
cysts, dacryocele can be managed conservatively, and the suc-
cess rate achieved with sac compression alone was 76% in
one of the series. In non-resolving cases and with associated
intranasal cyst, it is preferable to marsupialize the intranasal
cyst early [1]. Intranasal cysts are classified as small and large
based on endoscopic features, and a technique of cruciate
marsupialization has been found to be effective for large
intranasal cysts with good long-term outcomes [1, 5].
Figures 31.20, 31.21, 31.22, 31.23, 31.24, 31.25, 31.26,
31.27, 31.28, 31.29, 31.30, and 31.31 are from Ali et al.

276 31 Complex CNLDO: Dacryocele
Fig. 31.4 Close-up view of the patient in Fig. 31.3. Note the elevation
involving the lacrimal sac area and inferomedial eyelid
Fig. 31.1 A right-sided classical dacryocele. Note the typical bluish

swelling in the lacrimal sac region
Fig. 31.5 External photo of a bilateral CNLDO without any external

manifestations of a dacryocele
Fig. 31.2 A left-sided classical dacryocele
Fig. 31.6 CT scan, coronal cut of the same patient as in Fig. 31.5. Note
bilateral dacryoceles, left more than right secondary to dilatation of the
Fig. 31.3 A subtle and evolving left-sided dacryocele in a neonate
nasolacrimal ducts
31 Complex CNLDO: Dacryocele 277
Fig. 31.10 CT scan, sagittal reconstruction, of the same patient as in

Figs. 31.7 and 31.8. Note the presence of an intranasal cyst below the
inferior turbinate
Fig. 31.7 CT scan, axial cut of the inferior meatus of the same patient
as in Figs. 31.5 and 31.6. Note the bilateral cysts, left much more than
the right
Fig. 31.11 Clinical photograph of an infant with left-sided dacryocele

Fig. 31.8 Clinical photograph of a neonate with bilateral evolving
dacryoceles
Fig. 31.9 CT scan, axial cut, inferior meatus, of the patient in Fig. 31.8. Fig. 31.12 Clinical photograph of the patient in Fig. 31.8. Note the
Note the presence of bilateral intranasal cysts progression on conservative management
Fig. 31.13 Clinical photograph of the patient in Figs. 31.8 and 31.9.

Note the resolution on cruciate marsupialization
Fig. 31.16 A neonate with a dacryocele and spontaneous fistula
Fig. 31.14 A neonate with a right-sided dacryocele and left-sided lac-

rimal sac fullness. Patient was placed on a conservative management
Fig. 31.17 Clinical photograph of a right-sided dacryocele with a

spontaneous fistula
Fig. 31.15 Photograph of the patient in Fig. 31.11. Note the progression Fig. 31.18 Close-up image of the patient in Fig. 31.17. Note the par-
into bilateral full-blown dacryoceles with right-sided dacryopyocele tially and spontaneously discharged secretions and blood
Fig. 31.19 A CT scan, axial cut, of a different patient showing bilat-

Fig. 31.21 Cruciate marsupialization case study 1: endoscopic view
eral dacryoceles. Note the massive one on the left side
of the right nasal cavity of the patient in Fig. 31.20, showing a large
intranasal cyst
Fig. 31.20 Cruciate marsupialization case study 1: clinical photo- Fig. 31.22 Cruciate marsupialization case study 1: endoscopic view
graph of a neonate with a large right-sided dacryocele showing cruciate marsupialization with a sickle knife
Fig. 31.23 Cruciate marsupialization case study 1: endoscopic view

immediately after marsupialization showing the decompressed swelling
and mucopus being evacuated Fig. 31.25 Cruciate marsupialization case study 1: endoscopic view
of the right nasal cavity at 4 weeks post-operative. Note the disappear-
ance of the entire cyst
Fig. 31.24 Cruciate marsupialization case study 1: 45° probe tilt test Fig. 31.26 Cruciate marsupialization case study 1: endoscopic view at
being performed to assess the adequacy of the marsupialization 12 weeks post-operative. Note the normal inferior meatus
MT
S
IT
Fig. 31.27 Cruciate marsupialization case study 1: endoscopic view at Fig. 31.29 Endoscopic schematic diagram of cruciate marsupializa-
12 weeks post-operative showing patency of the nasolacrimal duct to tion technique: the horizontal arm of the cruciate incision
irrigation
MT
MT
IT
IT
Fig. 31.28 Endoscopic schematic diagram of cruciate marsupializa-

tion technique: note the large cyst (C) below the inferior turbinate (IT) Fig. 31.30 Endoscopic schematic diagram of cruciate marsupializa-
with cruciate markings on its medial wall. The sickle knife shows the tion technique: note the directional healing of the four flaps resulting in
vertical arm of the incision a large nasolacrimal opening
MT
IT
Fig. 31.31 Endoscopic schematic diagram of cruciate marsupializa- Fig. 31.33 Cruciate marsupialization case study 2: endoscopic view
tion technique: note the 45° probe test to assess the adequacy of the of the patient in Fig. 31.32. Note the massive intranasal cyst occupying
marsupialization the entire breadth of the nasal cavity
Fig. 31.32 Cruciate marsupialization case study 2: a neonate with a Fig. 31.34 Cruciate marsupialization case study 2: endoscopic view
large right-sided dacryocele showing the marsupialization with the help of a spear knife
Fig. 31.35 Cruciate marsupialization case study 2: alternatively, a Fig. 31.37 Cruciate marsupialization case study 2: endoscopic view,
cataract crescent knife can also be employed for a cruciate incision immediately post-marsupialization. Note the decompression of the cyst
and the freeing up of the nasal cavity at that level
Fig. 31.36 Cruciate marsupialization case study 2: the vertical arm of Fig. 31.38 Cruciate marsupialization case study 2: endoscopic view
the marsupialization demonstrates the 45° probe test. Note the probe is nearly vertical
Fig. 31.39 Cruciate marsupialization case study 2: endoscopic view Fig. 31.41 Endoscopic view of the right nasal cavity showing a large
demonstrates the 45° probe test. Note the probe is at approximately 30° intranasal cyst
from the original position in Fig. 31.38
Fig. 31.40 Cruciate marsupialization case study 2: endoscopic view Fig. 31.42 Endoscopic view of the right nasal cavity of the patient in
demonstrating the 45° probe test. Note the probe was able to freely Fig. 31.41, immediately after marsupialization
move from the vertical position to this one reflecting adequacy of the
marsupialization
Fig. 31.43 Endoscopic view of the right nasal cavity showing a mas-
sive intranasal cyst
Fig. 31.45 Endoscopic view of the right nasal cavity showing a mas-
sive intranasal cyst completely obliterating the nasal cavity at that
location
Fig. 31.44 Endoscopic view of the right nasal cavity of the patient in
Fig. 31.43, immediately after marsupialization. Note the dramatic
decompression effect
Fig. 31.48 Endoscopic view of the left nasal cavity of the patient in
Fig. 31.47, showing an intranasal cyst
Fig. 31.45, immediately after marsupialization. Note the dramatic
decompression effect
Figs. 31.47 and 31.48, immediately on marsupialization. Note the puru-
lent material draining into the nasal cavity
Fig. 31.47 Clinical photograph of a neonate with a massive left-sided

dacryopyocele
Fig. 31.50 Clinical photograph of a neonate with a large left-sided Fig. 31.53 Clinical photograph 4 weeks after cruciate marsupializa-
dacryocele tion of the patient in Figs. 31.50 and 31.51. Compare it with Fig. 31.51
Fig. 31.51 Close-up image of the patient in Fig. 31.50 Fig. 31.54 Clinical photograph of a neonate with a right-sided
dacryocele
Fig. 31.52 Clinical photograph 4 weeks after cruciate marsupializa- Fig. 31.55 Clinical photograph at 4 weeks post-operatively showing a
tion of the patient in Figs. 31.50 and 31.51. Compare it with Fig. 31.50 complete resolution of dacryocele
Complex CNLDO: Other Causes
32
References
Congenital nasolacrimal duct obstructions can be of either
simple or complex variants based on associated lacrimal 1. Jones LT, Wobig JL. Surgery of the eyelids and lacrimal system.
anomalies and intra-operative findings during probing [1–5]. Birmingham: Aesculapius; 1976. p. 162–4.
In cases of simple obstruction, there is lack of resistance in 2. Kushner BJ. The management of nasolacrimal duct obstruc-
passing the probe through the NLD up to a point of membra- tion in children aged between 18 months and 4 years. J AAPOS.
1998;2:57–60.
nous obstruction which can be perforated. Simple obstruc- 3. Lueder GT. Endoscopic treatment of intranasal abnormali-
tion also includes cases of canalicular valves, where ties associated with nasolacrimal duct obstruction. J AAPOS.
resistance is encountered while bypassing them, although 2004;8:128–32.
there may not be true obstruction. Complicated obstruction 4. Honavar SG, Prakash VE, Rao GN. Outcome of probing for con-
genital nasolacrimal duct obstruction in older children. Am J
can be those associated with any of the variations described Ophthalmol. 2000;130:42–8.
earlier like a buried probe, a bony obstruction, diffuse 5. Ali MJ, Kamal S, Gupta A, et al. Simple vs complex congenital
nasolacrimal stenosis, nondevelopment of nasolacrimal duct, nasolacrimal duct obstruction: etiology, management and out-
NLD opening into inferior turbinate, and anlages. comes. Int Forum Allergy Rhinol. 2015;5:174–7.
A number of variations of CNLDO were described way
back in1976 by Jones and Wobig [1]. These variations are
seen in the lower end of NLD, and the most common one
described is the duct that fails to open through the nasal
mucosa and stops at the vault of the anterior end of the infe-
rior nasal meatus. The other variations include NLD extend-
ing lateral to the nasal mucosa, extending up to the floor,
complete absence of duct, or impacted anterior end of the
inferior turbinate.

290 32 Complex CNLDO: Other Causes
Fig. 32.1 Schematic diagram

showing various CNDLO
variations: Nasolacrimal duct
(NLD) entering at the vault of
the inferior meatus (Panel A).
NLD extending up to the floor
lying lateral to the nasal
mucosa or a buried probe
(Panel B). NLD obstruction
caused by impacted anterior
end of the inferior turbinate
(Panel C). NLD ending in the
anterior end of the inferior
turbinate (Panel D). NLD
ending blindly into the
maxillary wall (Panel E).
Complete absence of NLD
(Panel F) (blue: lacrimal sac
and NLD, yellow: lateral wall
of nose, orange: inferior
turbinate) (Photo courtesy:
Saurabh Kamal, EyeHub,
Faridabad)
32 Complex CNLDO: Other Causes 291
Fig. 32.2 Endoscopic view of the left nasal cavity showing gross lat- Fig. 32.4 Endoscopic view of the right nasal cavity showing poor
eral wall dysgenesis development of the inferior meatus and a subsequent bony block (photo
courtesy: Nishi Gupta, SCEH, Delhi)
Fig. 32.3 Endoscopic view of the left nasal cavity showing the poorly Fig. 32.5 Endoscopic view of the right nasal cavity with the NLD
developed inferior turbinate and absent inferior meatus being misdirected into the inferior meatus and hence the subsequent
probe also entering the inferior meatus. This can also give a feeling of
bony block from the IT bone
292 32 Complex CNLDO: Other Causes
Fig. 32.6 Endoscopic view of the left inferior meatus showing the Fig. 32.7 Endoscopic view of the left inferior meatus showing the
monoka stent that was used for nasolacrimal duct stenosis with associ- dilatation of the nasolacrimal opening by the arm of the monoka stent
ated lower canalicular stenosis
Syndromic and Systemic Associations
of Congenital Lacrimal Drainage 33
Anomalies
Numerous syndromes are known to have associated congeni- References

tal lacrimal anomalies [1–5]. The most common among them
being Down’s syndrome and the ectrodactyly-ectodermal 1. Ali MJ, Paulsen F. Syndromic, non-syndromic and systemic asso-
ciation of congenital lacrimal drainage anomalies: a major review.
dysplasia-cleft or EEC syndrome [1–5]. The prevalence of Ophthal Plast Reconstr Surg. 2017. (Epub).
nasolacrimal anomalies in Down syndrome has been reported 2. Coats DK, McKreery KM, Plager DA, et al. Nasolacrimal
to be as high as 22% [1]. Lacrimal anomalies associated with outflow anomalies in Down’s syndrome. Ophthalmology.
it include punctal agenesis, canalicular stenosis, canalicular 2003;110:1437–41.
3. Elmann S, Hanson SA, Bunce CN, et al. Ectrodactyly-ectodermal
atresia, supernumerary punctum, nasolacrimal duct stenosis, dysplasia clefting (EEC) Syndrome. A rare cause of congenital lac-
and frank distal or multilevel nasolacrimal duct obstructions. rimal anomalies. Ophthal Plast Reconstr Surg. 2015;31:e35–7.
Among these, the proximal anomalies are known to predom- 4. Yuen SJ, Oley C, Sullivan TJ. Lacrimal outflow dysgenesis.
inate as compared to the distal ones. The EEC syndrome has Ophthalmology. 2004;111:1782–90.
5. Ali MJ, Kamal S, Gupta A, et al. Simple versus complex congeni-
been reported to be associated with punctal agenesis, cana- tal nasolacrimal duct obstructions: etiology, management and out-
licular atresia, lacrimal fistula, and congenital nasolacrimal comes. Int Forum Allergy Rhinol. 2015;5:174–7.
duct obstruction with dacryocystitis [1, 3]. Other than the
syndromes’ numerous non-syndromic systemic associations
like facial clefting and craniometaphyseal dysplasia, a wide
range of anomalies spread across the central nervous, renal,
and gastrointestinal systems. Most of these associated anom-
alies have complex congenital nasolacrimal duct obstruction
which may occasionally by refractory to the routine manage-
ments [5].
Figures 33.1, 33.2, and 33.28 are from Ali et al. Ophthal
Plast Reconstr Surg. 2017. (Epub) and Ali, Ophthal Plast
Reconstr Surg. 2014;30:e167.

294 33 Syndromic and Systemic Associations of Congenital Lacrimal Drainage Anomalies
Fig. 33.1 Syndromes 1. Down’s syndrome

associated with congenital 2. Ectrodactyly-ectodermal dysplasia clefting (EEC) syndrome
lacrimal anomalies 3. Treacher Collins syndrome
4. Rubinstein-Taybi syndrome
5. Lacrimo-auriculo-dento-digital (LADD)or Levy-Hollister syndrome
6. Hay-Wells syndrome
7. ADULT syndrome
8. Limb-Mammary syndrome
9. Rapp-Hodgkin syndrome
10. Split-Hand/Split-Foot syndrome
11. Aplasia of the lacrimal and salivary glands (ALSG) Syndrome
12. APERT syndrome
13. Seathre-Chotzen syndrome
14. CHARGE syndrome
15. Branchio-oculo-facial (BOF) syndrome
16. Goldenhar Syndrome
17. Cornelia de Lange syndrome
18. Congenital arhinia-microphthalmia syndrome
19. Johanson Blizzard syndrome
20. Pashayan syndrome
21. Millers syndrome
22. Kallman syndrome
23. Nager’s syndrome
24. Blepharophimosis syndrome
25. VACTERL Association
26. Branchio-oto-renal syndrome
27. Crouzon syndrome
28. Klinefelter’s syndrome
29. Fraser syndrome
30. Goltz-Gorlin Syndrome
31. Wolf-Hirschhorn or 4p- syndrome
32. Congential rubella syndrome
33. Turner syndrome
34. Foetal-alcohol syndrome
35. Hallermann-Streiff syndrome
36. Foetal Valproate syndrome
37. HPPD syndrome (Hypertelorism, preauricular sinus, punctal pits, deafness)
38. Velocardiofacial (VCFS) syndrome
39. Poland-Möbius syndrome
40. Robinow’s syndrome
41. Angelman syndrome
42. Waardenburg-Klein syndrome
33 Syndromic and Systemic Associations of Congenital Lacrimal Drainage Anomalies 295
1. Facial clefting
2. Amniotic bands
3. Craniometaphyseal dysplasia
4. Craniodiaphyseal dysplasia
5. Frontonasal dysplasia
6. Pre-auricular sinus
7. Bifid uvula
8. Accessory auricle
9. Colobama auris
10. Isolated choanal atresia
11. Laryngeal stenosis
12. Non-syndromic dysmorphisms
13. Holoprosencephaly
14. Meningocele
15. Hydroencephalocele
16. Corpus Callosum agenesis
17. Sever midline anomalies
18. Maxillary and Mandibular hypoplasia
19. Hypertelorism
20. Hemifacial microsomia
21. Anophthalmia
22. Microphthalmia
23. Hypotonia and motor delays
24. Phacomelia and club foot
25. Pyloric stenosis
26. Esophageal atresia
27. Uretheral stenosis
28. Cystic fibrosis
29. Uterine didelphys
30. Renal agenesis
Fig. 33.2 Non-syndromic and systemic associations of congenital lac-

rimal anomalies
Fig. 33.3 Clinical photograph of a case of an epiphora in a patient of

ectrodactyly-ectodermal dysplasia-cleft (EEC) syndrome
Fig. 33.4 Clinical photograph of a facial dysmorphism in a patient with Fig. 33.5 Clinical photograph of the patient in Figs. 33.3 and 33.4.
EEC syndrome. Note the repaired cleft lip and gross bilateral epiphora Note the abnormal dentition
Fig. 33.6 Clinical photograph of

the patient in Figs. 33.3, 33.4, and
33.5. Note the partly repaired
cleft palate
Fig. 33.7 Clinical
photograph of the patient in
Figs. 33.3, 33.4, 33.5, and
33.6 showing upper limb
ectrodactyly
Fig. 33.8 Clinical photograph of the patient in Figs. 33.3, 33.4, 33.5, Fig. 33.9 Clinical photograph of the right eye of patient in Figs. 33.3, 33.4,
33.6, and 33.7 showing lower limb ectrodactyly 33.5, 33.6, 33.7, and 33.8. Note the colobomatous defect of the pars lacrima-
lis portion of the lower eyelid with absence of punctum and canaliculus
Fig. 33.10 Clinical photograph of the left eye of the patient in

Figs. 33.3, 33.4, 33.5, 33.6, 33.7, 33.8, and 33.9. Note the coloboma-
tous defect of the pars lacrimalis portion of the lower eyelid
Fig. 33.12 Clinical photograph of a repaired facial clefting syndrome.

Note the clefting line characteristically traversing through the lacrimal
drainage system bilaterally
Fig. 33.11 Clinical photograph of a craniofacial clefting syndrome

with left lacrimal sac fullness and maldeveloped left punctum and
canaliculus
Fig. 33.13 Clinical photograph of a repaired cleft lip and palate with
associated left complex congenital nasolacrimal duct obstruction
Fig. 33.14 Clinical photograph of milder variants of facial clefts with

bilateral complex CNLDO
Fig. 33.17 Clinical photograph of a patient with a craniofacial syn-

drome with a right complex CNLDO. Note the right telecanthus, full-
ness of the lacrimal sac area, and ocular discharge

image. Note the bilateral epiphora
Fig. 33.18 Clinical photograph of the patient in Fig. 33.17, showing

abnormal dentition and high arched palate
Fig. 33.16 Clinical photograph of a gross facial clefting. Note the

involvement of the lacrimal drainage system
Fig. 33.19 Clinical photograph of the patient in Figs. 33.17 and 33.18. Fig. 33.22 Clinical photograph of a bilateral CNLDO patient with
Note the gross anterior deviation of the nasal septum associated craniofacial syndromic features and absent radius
Fig. 33.23 Clinical photograph of the patient in Fig. 33.22. Note the

limb with absence of radius
Fig. 33.20 CT scan, coronal cut, of the patient in Figs. 33.17, 33.18,
and 33.19. Note the gross anterior deviation of the nasal septum
Fig. 33.21 CT scan, coronal cut, of the patient in Figs. 33.17, 33.18,

33.19, and 33.20. Note the expanded bony nasolacrimal duct on the
right side
Fig. 33.24 Plain X-ray of the patient in Fig. 33.22 showing the cranio- Fig. 33.26 Clinical photograph of a patient of Cornelia de Lange syn-
facial bony anomalies drome with bilateral CNLDO

image. Note the gross epiphora and dye retention
Fig. 33.25 Clinical photograph of another case of a craniofacial syn-

drome with bilateral CNLDO
Fig. 33.29 Clinical photograph of another patient with congenital par-

tial arhinia-microphthalmia syndrome. Note the left-sided partial
arhinia and ipsilateral dilated lacrimal sac secondary to absent nasolac-
rimal duct
Fig. 33.28 Clinical photograph of a patient with congenital arhinia-

microphthalmia syndrome. Note the large bilateral mucoceles second-
ary to absence of the nasolacrimal duct
Infective Canaliculitis
34
Infective canaliculitis accounts for 2% of all patients with References

lacrimal diseases [1]. Canaliculitis affects the lower eyelid
more than the upper eyelid and women more than men [1]. 1. Kaliki S, Ali MJ, Honavar SG, et al. Primary canaliculitis: clini-
cal features, microbiological profile, and management outcome.
The common causative factors include Staphylococcus, Ophthal Plast Reconstr Surg. 2012;28:355–60.
Streptococcus, Actinomycetes, and Nocardia species. 2. Ali MJ, Pujari A, Motukupally S, et al. Kocuria rosea canaliculitis:
Common presenting symptoms include epiphora, swelling a clinicomicrobiological correlation. Ophthal Plast Reconstr Surg.
of the eyelid, pain, and redness. On clinical examination, 2014;30:e139–40.
3. Ali MJ, Alam SM, Naik MN. Dacryoendoscopic features in a case
typical signs of canaliculitis include thickening of the cana- of canaliculitis with concretions. Ophthal Plast Reconstr Surg.
licular portion of the eyelid margin, expressible punctal dis- 2017;33(3):228–9.
charge, and pouting erythematous punctum [1–5]. A 4. Ali MJ, Joseph J, Sharma S, et al. Canaliculitis with isolation of
thorough clinical examination is sufficient for the diagnosis Myroides species. Ophthal Plast Reconstr Surg. 2017;33(3S Suppl
1):S24–5.
in most cases. Dacryoendoscopy may have a potential role in 5. Watve A, Ali MJ. Infections of the lacrimal drainage system. In: Ali
diagnosis and monitoring of the disease. Various modalities MJ, editor. Principles and practice of lacrimal surgery. New Delhi:
of treatment have been described for canaliculitis [1–5]. Springer; 2015. p. 149–58.
Conservative measures include oral and topical antibiotics,
punctal dilatation, and canalicular expression or canalicular
irrigation with antibiotics. Surgical measures include punc-
toplasty and canalicular curettage, canaliculotomy with can-
alicular curettage, or canaliculotomy. However, with any of
the modality of treatment, it is important to send the material
for a meticulous microbiological examination and culture
sensitivity profile.

304 34 Infective Canaliculitis
Fig. 34.1 Classical canaliculitis: clinical photograph of a patient with Fig. 34.4 Clinical photograph of the right lower lid showing only the
a left upper medial lid lesion mucosal edema of the punctum. This could be the earliest sign of an
evolving canaliculitis
Fig. 34.2 Classical canaliculitis: clinical photograph of the left eye of Fig. 34.5 Clinical photograph of the left lower lid showing gross
the patient in Fig. 34.1. Note the erythematous swelling in the region of mucosal edema of the punctum. This could be the earliest sign of an
the upper canaliculus evolving canaliculitis
Fig. 34.3 Classical canaliculitis: clinical photograph of the left upper Fig. 34.6 Clinical photograph of the left upper lid showing punctal
lid of the patient in Figs. 34.1 and 34.2. Note the characteristic pouting mucosal pouting with severe congestion over the canalicular area
of punctal opening and purulent discharge
34 Infective Canaliculitis 305
Fig. 34.10 Clinical photograph showing the expressed canalicular

concretions
Fig. 34.7 Clinical photograph of the right eye showing matting of
lashes with congestion and swelling of the upper and lower canalicular
portions of the eyelid
Fig. 34.8 Clinical photograph of the right eye of the patient in Fig. 34.11 Clinical photograph showing another example of milking
Fig. 34.7. Upon lower lid eversion, note the bicanalicular stent, severe the canaliculus to express out its contents
congestion, and matting of lashes. This was a stent induced infective
canaliculitis
Fig. 34.9 Clinical photograph showing a technique of expression of Fig. 34.12 Clinical photograph demonstrating the use of a chalazion
canalicular contents. Note the canalicular segment is milked from distal clamp to milk out the canalicular contents. Note the clamp is at the
to proximal with the help of two cotton-tipped applicators distal end
306 34 Infective Canaliculitis
Fig. 34.13 Clinical photograph demonstrating the use of a loose cha- Fig. 34.16 Intra-operative photograph of the right upper canaliculitis,
lazion clamp to milk out the canalicular contents. Note the clamp is demonstrating the use of blunt chalazion scoop for gentle canalicular
near the punctum. It is important to note that this maneuver should be curettage, following punctal dilatation. This non-incisional way of can-
gentle with the clamp ends being loose enough for an easy slide alicular curettage gives good results in the author’s experience without
the fear of functional compromise with canaliculotomy
Fig. 34.14 Clinical photograph demonstrating the expressed canalicu-

lar contents Fig. 34.17 Intra-operative photograph demonstrating the scooped out
canalicular contents
Fig. 34.15 Clinical photograph of the right lower lid showing good Fig. 34.18 Clinical photograph of a left lower canaliculitis on medica-
results following a manual expression and conservative therapy tion. Note the grossly thickened canalicular segment with a narrowed
punctum secondary to the concretions
34 Infective Canaliculitis 307
Fig. 34.22 Intra-operative photograph demonstrating the numerous

concretions expressed out from a case of canaliculitis
Fig. 34.19 Clinical photograph of the left lower lid of the patient in
Fig. 34.18, following the punctal dilatation and non-incisional curet-
tage. Note the normal canalicular segment
Fig. 34.23 Multiple canalicular concretions plated on the chocolate

agar for microbiological evaluation
Fig. 34.20 Intra-operative photograph demonstrating a right upper
canaliculotomy with the help of Vannas scissors
Fig. 34.21 Intra-operative photograph demonstrating the numerous

concretions within the canaliculus following the canaliculotomy
Canaliculops
35
Canaliculops or canaliculocele is a term used for a noninfec- References

tious and noninflammatory distention of a localized segment
1. Yoon MK, Jakobiec FA, Mendoza PR. Canaliculops: clinico-
of the canaliculus with accumulation of serous fluid within
pathologic features and treatment with marsupialization. Am J
the lumen [1–3]. It is an uncommon disorder and equally Ophthalmol. 2013;156:1062–8.
involves the upper and lower lids without a clear-cut gender 2. Ali MJ, Saha D, Mishra DK, et al. Canaliculops associated with
predilection. Predisposing factors include trauma, surgeries, punctal agenesis: a clinicopathological correlation and review of
literature. Ophthal Plast Reconstr Surg. 2015;31:e108–11.
or past infections. The lesion usually presents as a painless,
3. Singh S, Ali MJ, Peguda HK, et al. Imaging the canaliculops with
translucent, and slow-growing medial eyelid swelling. ultrasound biomicroscopy and anterior segment ocular coherence
Rarely it may be associated with a punctal agenesis. tomography. Ophthal Plast Reconstr Surg. 2017. (Epub).
Ultrasound biomicroscopy and OCT have been reported to
be useful adjuncts in the diagnosis [3]. Careful excision of
the lesion with maintenance of the canalicular pathway with
temporary intubation is usually curative. Histopathological
analysis is crucial for the definite diagnosis. The cyst wall is
lined by the canalicular epithelium; however, the characteris-
tic feature is superficial epithelial layer staining by cytokera-
tin 7 or CK7 [1–3].
2015;31:e108–111, and Singh et al. Ophthal Plast Reconstr
Surg. 2017. (Epub).

310 35 Canaliculops
Fig. 35.1 Canaliculops case study 1: clinical photograph of the right

eye showing a swelling in the medial aspect of the right upper eyelid Fig. 35.4 Canaliculops case study 1: microphotograph of the cut sec-
extending to just short of the medial canthus tion of the cyst showing an entire cyst wall with the lumen (H&E ×40)
Fig. 35.2 Canaliculops case study 1: clinical photograph with lid ever-
sion showing an elevated, bluish cystic lesion in the region of the right
upper canaliculus. Note the absence of the punctal papilla Fig. 35.5 Canaliculops case study 1: microphotograph showing the
multilayered nonkeratinizing stratified squamous epithelium similar to
that of a canalicular lining (H&E ×100)
Fig. 35.3 Canaliculops case study 1: gross specimen photograph of Fig. 35.6 Canaliculops case study 1: microphotograph, high magnifi-
the excised lesion showing the cyst with the central lumen cation, demonstrating the orderly arrangement of cells, and the charac-
teristic regimented basal layer arranged in a palisading fashion, similar
to a canalicular lining (H&E ×400)
35 Canaliculops 311
Fig. 35.7 Canaliculops case study 1: microphotograph with a special Fig. 35.10 Canaliculops case study 1: immunohistochemistry micro-
stain demonstrating the muscle fibers to be in close relation to the epi- photograph showing negative staining for cytokeratin 20 (CK 20 ×400)
thelium (Masson trichrome ×100)
Fig. 35.8 Canaliculops case study 1: immunohistochemistry micro- Fig. 35.11 Canaliculops case study 1: immunohistochemistry micro-
photograph demonstrating the diagnostic patchy superficial staining of photograph showing suprabasilar staining with cytokeratin 14 (CK
the epithelial layer with cytokeratin 7 (CK 7 ×100) 14 ×400)
Fig. 35.9 Canaliculops case study 1: immunohistochemistry micro- Fig. 35.12 Canaliculops case study 1: immunohistochemistry micro-
photograph, higher magnification, demonstrating the diagnostic CK7 photograph demonstrating strong but patchy suprabasilar staining with
staining pattern (CK 7 ×400) cytokeratin 17 (CK 17 ×400)
312 35 Canaliculops
Fig. 35.13 Canaliculops case study 2: clinical photograph showing a

lesion on the medial aspect of the right upper lid
Fig. 35.16 Canaliculops case study 2: ultrasound biomicroscopy

showing a dilated canaliculus with a well-defined cystic lesion within
its lumen
Fig. 35.14 Canaliculops case study 2: clinical photograph, high mag-

nification, showing the lesion to extend up to the medial canthus
Fig. 35.17 Canaliculops case study 2: external photograph taken from
the anterior segment ocular coherence tomography (AS-OCT) system.
Note the area scanned by the green box
Fig. 35.18 Canaliculops case study 2: Fourier domain OCT image

Fig. 35.15 Canaliculops case study 2: clinical photograph of the right showing the thick hyper-reflective cyst wall with an internal nonreflec-
upper lid following eversion, demonstrating a large cystic lesion involv- tive cavity
ing the right upper canalicular area
35 Canaliculops 313
Fig. 35.19 Canaliculops case study 2: microphotograph of the cyst

wall excised, showing histopathological features consistent with that of
a canalicular wall (H&E ×400)
Fig. 35.20 Canaliculops case study 2: immunohistochemistry micro-

photograph demonstrating a strong positive reaction of the superficial
epithelial layer with cytokeratin 7, which is a diagnostic feature of a
canaliculops (CK 7 ×400)
Canalicular Trauma
36
References
Canalicular trauma is the most common among the lacrimal
system trauma. The overall incidence of lacrimal system 1. Almousa R, Amrith S, Mani AH, et al. Radiological signs of perior-
injuries vary from 7 to 20% depending upon the mechanism bital trauma—the Singapore experience. Orbit. 2010;29:307–12.
2. Kennedy RH, May J, Daily J, et al. Canalicular laceration: an
of the injury and reporting [1–3]. Failure to recognize and 11-year epidemiologic and clinical study. Ophthal Plast Reconstr
manage lacrimal injuries is one of the common complica- Surg. 1990;6:46–53.
tions of eyelid/midfacial injuries. Canalicular lacerations 3. Murchison AP, Bilyk JR. Pediatric canalicular lacerations: epidemi-
may result from road-traffic accidents, blouse hooks in chil- ology and variables affecting repair success. J Pediatr Ophthalmol
Strabismus. 2014;51:242–8.
dren (developing nations), or from animal bites (dogs) and
broken spectacles. The general principle of eyelid lacera-
tions is that all eyelid lacerations medial to the puncta involve
the canaliculus until proven otherwise. Once the patient’s
general condition is stabilized, it is important to assess the
trauma meticulously. Canalicular trauma associated with
injuries in the vicinity or suspected bony injuries may require
a CT scan prior to surgery. All canalicular traumas should be
repaired with the help of stents. The most commonly used is
the mini-monoka stent. Untreated canalicular lacerations or
poorly repaired canalicular trauma can later be very symp-
tomatic and challenging to deal with.

316
… 36 Canalicular Trauma
Fig. 36.1 Clinical photograph of a classical right lower lid canalicular Fig. 36.4 Clinical photograph of a classical right lower lid canalicular
laceration. The etiological factor was a blouse hook, which is common laceration in an adult
cause in the developing nations
Fig. 36.2 Clinical photograph of the right lower lid demonstrating the
canalicular laceration. Note that the injury usually occurs at the weakest
point, just medial to the punctum
Fig. 36.5 Clinical photograph of a left lower lid. What appeared to be

a subtle injury on external examination turned out to be a canalicular
laceration. Hence it is important to meticulously examine all cases of
trauma
Fig. 36.3 Clinical photograph of a left lower lid canalicular laceration

secondary to blouse hook injury
36 Canalicular Trauma 317
Fig. 36.6 Clinical photograph of the left lower lid of patient in Fig. 36.9 Clinical photograph of the patient in Fig. 36.7 at 4 weeks
Fig. 36.5. Note the oblique canalicular laceration following repair. Note the normal lower lid contour and normal peri-
ocular area
Fig. 36.7 Clinical photograph of a child with right lower lid canalicu- Fig. 36.10 Clinical photograph of the right lower lid of the patient in
lar laceration with associated large lid hematoma Fig. 36.7. Note the in situ mini-monoka stent
Fig. 36.8 Clinical photograph of the patient in Fig. 36.7 at day 10 fol- Fig. 36.11 Clinical photograph of the right eye with extensive trauma
lowing repair. Note the hematoma has mostly resolved, and the self- and canalicular laceration. This is an indication for CT scan imaging
reabsorbing lid laceration sutures
318 36 Canalicular Trauma

Fig. 36.13. Note the grossly infected wound
Fig. 36.12 Clinical photograph of a complex right-sided trauma. This

is an indication for CT scan imaging
Fig. 36.15 Intra-operative photograph demonstrating the Calamari

sign. Note the whitish cut end of the canaliculus
Fig. 36.13 Clinical photograph of a delayed presentation of a right

canalicular laceration with infected wounds
Fig. 36.16 Technique of canalicular laceration repair: intra-operative

photograph of a right lower canalicular laceration with additional peri-
ocular lacerations
Fig. 36.17 Technique of canalicular laceration repair: intra-operative Fig. 36.20 Technique of canalicular laceration repair: intra-operative
photograph demonstrating assessment of the proximal cut end of the photograph demonstrates the passage of mini-monoka from the punctal
canaliculus end
photograph demonstrating the distal cut end of the canaliculus. Note the photograph demonstrates securing of the mini-monoka at the punctum
classical Calamari sign
photograph demonstrating gentle dilatation of the punctum with a photograph demonstrates passage of the monoka stent from the distal
Nettleship’s rapid-taper punctum dilator cut end
Fig. 36.26 The Nunchaku® pushed stents are also a good option for a
bicanalicular laceration repair

photograph demonstrates completion of the monoka passage through
both the ends
Fig. 36.27 Clinical photograph of the right lower lid showing mini-
monoka extubation

photograph demonstrating approximation of the lacerated ends of the
lid margin
Fig. 36.28 Clinical photograph of the right lower lid showing mini-
monoka extubation

photograph demonstrates a primary repair with re-absorbable sutures.
Fig. 36.29 Clinical photograph of the right lower lid following a cana- Fig. 36.32 Clinical photograph of a left lower lid demonstrating a poor
licular laceration repair. Note the intact monoka stents canalicular repair with a lid standoff, which would require a revision
Fig. 36.30 Clinical photograph of the right lower lid of patient in Fig. 36.33 Clinical photograph of a right lower lid demonstrating a
Fig. 36.29, after extubation. Note the restoration of normal anatomy poor eyelid repair with a lid standoff
Fig. 36.31 Clinical photograph of the left upper lid, demonstrating an Fig. 36.34 Clinical photograph of a left lower lid following a cana-
unrepaired canalicular laceration. Note the exposed canalicular lumen licular repair. Note a coloboma in the region of lower canaliculus
Fig. 36.35 Clinical photograph of the left lower lid of the patient in Fig. 36.38 Clinical photograph demonstrating the left lower lid colo-
Fig. 36.34. Note the in situ monoka is exposed in the canalicular portion boma following an unrepaired eyelid trauma
secondary to a poor canalicular repair
Fig. 36.36 Clinical photograph of a left upper lid demonstrating a Fig. 36.39 Clinical photograph of the left lower lid of the patient in
post-traumatic canalicular fistula Fig. 36.38. Note the coloboma involving the canalicular region
Fig. 36.37 Clinical photograph of the right lower lid demonstrating a Fig. 36.40 Clinical photograph of a right lower lid, post-trauma, dem-
post-traumatic canalicular fistula onstrating a symblepharon involving the canalicular region
Fig. 36.41 Clinical photograph of a poorly repaired right lower lid. Fig. 36.43 Clinical photograph of the right lower lid of patient in
Note the maligned canalicular segments Fig. 36.42. Note the malaligned canaliculus. The distal segment has
healed in an abnormal position
Fig. 36.42 Clinical photograph of a right lower lid showing a shallow

coloboma involving the canalicular area. Note the scarring just medial
to the punctum
Acute Dacryocystitis
37
Acute dacryocystitis can be defined as “a medical urgency References

which is clinically characterized by rapid onset of pain, ery-
thema, and swelling, classically below the medial canthal ten- 1. Ali MJ, Joshi DS, Naik MN, et al. Clinical profile and management
outcome of acute dacryocystitis: two decades of experience in a ter-
don with or without preexisting epiphora mainly resulting tiary eye care center. Semin Ophthalmol. 2015;30:118–23.
from the acute infection of the lacrimal sac and perisac tis- 2. Ali MJ, Motukupally SR, Joshi SD, et al. The microbiological pro-
sues” [1, 2]. It constitutes 2.4% of all lacrimal disorders with file of lacrimal abscess: two decades of experience from a tertiary
a female preponderance (2:1). It can affect any age and is eye care center. J Ophthalmic Inflamm Infect. 2013;3:57–61.
3. Ali MJ. Pediatric acute dacryocystitis. Ophthal Plast Reconstr Surg.
predominantly unilateral. The common causative organisms 2015;31:341–7.
include Staphylococcus aureus, Streptococcus pneumoniae, 4. Kamal S, Ali MJ, Pujari A, et al. Primary powered endoscopic dac-
Haemophilus influenzae, Escherichia coli, and Pseudomonas ryocystorhinostomy in the setting of acute dacryocystitis and lacri-
aeruginosa [2]. There is a varied spectrum of its clinical pre- mal abscess. Ophthal Plast Reconstr Surg. 2015;31:293–5.
5. Chisty N, Singh M, Ali MJ, et al. Long-term outcomes of pow-
sentations ranging from tenderness and erythema of the over- ered endoscopic dacryocystorhinostomy in acute dacryocystitis.
lying tissues, lacrimal sac swelling with regurgitation of Laryngoscope. 2016;126:551–3.
purulent material, and frank lacrimal abscess. If left untreated,
it can progress to preseptal cellulitis, orbital cellulitis, orbital
abscess, and cavernous sinus thrombosis. Conservative man-
agement includes warm compresses, systemic antibiotics,
and anti-inflammatory drugs. Definitive surgical management
is dacryocystorhinostomy. External DCR can be performed
with good outcomes following resolution of the infection and
inflammation by conservative therapy. Alternatively endo-
scopic dacryocystorhinostomy can also be performed with
good outcomes even in an acute stage and can hence hasten
recovery and reduce the morbidity [3–5].

326 37 Acute Dacryocystitis
Fig. 37.1 Evolution of acute dacryocystitis—case study: clinical pho- Fig. 37.4 Evolution of acute dacryocystitis—case study: clinical pho-
tograph of a patient with left-sided acute dacryocystitis with evolving tograph of left eye of the patient in Fig. 37.3. Note the resolution of
lacrimal abscess acute dacryocystitis and compare it with Fig. 37.2. An endoscopic DCR
was planned, but the patient refused any further surgical intervention
tograph of left eye, of the patient in Fig. 37.1, showing the evolving tograph of the patient in Fig. 37.1 at 6 weeks post first attack. Note the
lacrimal abscess recurrence of lacrimal sac swelling
tograph of the patient in Fig. 37.1 at 1-week post-conservative treat- tograph of the left eye of the patient in Fig. 37.5. Note the recurrent
ment. Compare it with Fig. 37.1 lacrimal sac swelling. Patient refused any surgical intervention again
and was lost to follow up
37 Acute Dacryocystitis 327
Fig. 37.7 Evolution of acute dacryocystitis—case study: clinical pho- Fig 37.10 Evolution of acute dacryocystitis—case study: clinical pho-
tograph of the patient in Fig. 37.1 at more than 1 year after the first tograph of left eye of the patient in Fig. 37.9. Note the worsening of the
attack. Note the left-sided acute dacryocystitis with orbital cellulitis orbital cellulitis with evolving orbital abscess. Compare it with Fig. 37.8
Fig. 37.8 Evolution of acute dacryocystitis—case study: clinical pho-

tograph of left eye of the patient in Fig. 37.7. Note the acute dacryocys-
titis complicated by an orbital cellulitis. The patient was admitted and Fig. 37.11 Evolution of acute dacryocystitis—case study: CT scan
started on intravenous medications, and a CT scan was requested orbits and coronal cut of the patient in Fig. 37.9 demonstrating an
orbital abscess
Fig. 37.9 Evolution of acute dacryocystitis—case study: clinical pho-

tograph of the patient in Fig. 37.7 after 24 h on intravenous antibiotics.
Fig. 37.12 Evolution of acute dacryocystitis—case study: CT scan
Note the worsening of orbital cellulitis with evolving orbital abscess.
orbits, axial cut, of the patient in Fig. 37.9 demonstrating features of an
Compare it with Fig. 37.7
orbital abscess with diffuse cellulitis
Fig. 37.16 Evolution of acute dacryocystitis—case study: clinical

Fig. 37.13 Evolution of acute dacryocystitis—case study: CT scan photograph of the patient in Fig. 37.9 at 4 weeks following endoscopic
orbits, axial cut, of the patient in Fig. 37.9 showing the extent of the DCR. The stent was removed at this visit
abscess. The patient underwent drainage of the abscess along with an
endoscopic DCR
Fig. 37.14 Evolution of acute dacryocystitis—case study: clinical Fig. 37.17 Evolution of acute dacryocystitis—case study: clinical
photograph of the patient in Fig. 37.9 at 1 week after endoscopic photograph of the patient in Fig. 37.9 at 4 weeks following endoscopic
DCR. Note the complete resolution of the orbital cellulitis DCR. Note that the stent is extubated
Fig. 37.15 Evolution of acute dacryocystitis—case study: clinical Fig. 37.18 Clinical photograph of the left eye of a patient with evolv-
photograph of left eye of the patient in Fig. 37.14. Note the complete ing acute dacryocystitis. The patient underwent an endoscopic DCR in
resolution of orbital cellulitis. Also note the bicanalicular lacrimal stent the acute stage
near the caruncle
Fig 37.19 Clinical photograph of left eye of the patient in Fig. 37.18, Fig. 37.22 Clinical photograph of a right eye demonstrating a pediat-
3 days following an endoscopic DCR. Note the resolution of the acute ric acute dacryocystitis with a spontaneous fistula
dacryocystitis and the bicanalicular lacrimal stent
Fig. 37.20 Clinical photograph of left eye of the patient in Figs. 37.18

and 37.19 at 4 weeks following an endoscopic DCR. Note the extuba-
tion of stent and the normal periocular area Fig. 37.23 Clinical photograph of a neonate showing a right-sided
massive dacryopyocele and a left-sided dacryocele
Fig. 37.21 Clinical photograph of a right eye demonstrating a pediat-

ric acute dacryocystitis with a spontaneous fistula
Fig. 37.26 Clinical photograph of a patient with right-sided acute dac-

ryocystitis complicated by a severe preseptal cellulitis and evolving
orbital cellulitis
Fig. 37.24 Clinical photograph of a neonate with a left-sided massive

dacryopyocele
Fig. 37.27 Clinical photograph of the patient in Fig. 37.26 demon-

strating early restriction of ocular motility
Fig. 37.25 Endoscopic view of the left nasal cavity in a case of dac-
ryopyocele, showing a dilated nasolacrimal duct with purulent whitish
material

Fig. 37.31 CT scan orbits, axial cut, of the patient in Figs. 37.26,

37.27, 37.28, and 37.29. Note the lacrimal sac dilatation with peripheral
rim enhancement and limited spillover in the orbit

Fig. 37.32 CT scan orbits, coronal cut, of another case of left acute
dacryocystitis. Note the clear peripheral rim enhancement of the dilated
lacrimal sac
Fig. 37.30 CT scan orbits, coronal cut, of the patient in Figs. 37.26,

37.27, 37.28, and 37.29. Note the lacrimal sac dilatation with peripheral
rim enhancement and limited spillover in the orbit
Fig. 37.33 CT scan orbits, coronal cut of the patient in Fig. 37.32. Fig. 37.36 CT scan, coronal cut, of the patient in Fig. 37.34 demon-
Note the dilated bony nasolacrimal duct filled with diffusely enhancing strating features of orbital cellulitis
tissues
Fig. 37.34 Clinical photograph of a left side acute dacryocystitis with Fig. 37.37 Clinical photograph of a patient with right-sided lacrimal
orbital cellulitis. Note the left proptosis and ptosis with right compensa- abscess with gross facial cellulitis following a facial trauma
tory upper lid retraction
Fig. 37.35 Clinical photograph of left eye of the patient in Fig. 37.34. Fig. 37.38 Aspiration of lacrimal abscess—case study 1: clinical pho-
Note the massive chemosis and discharge at the medial canthus tograph of a patient with a massive right-sided lacrimal abscess
Fig. 37.39 Aspiration of lacrimal abscess—case study 1: clinical pho-

tograph of right eye of the patient in Fig. 37.38 showing the large and
tense lacrimal abscess
Fig. 37.41 Aspiration of lacrimal abscess—case study 1: the aspirated

pus from the patient in Fig. 37.38

tograph of the patient in Fig. 37.38 demonstrating aspiration of the lac-
rimal abscess with a wide bore needle. This can be an alternative to a
frank incision and drainage. Care should be taken not to go very deep

tograph of the patient in Fig. 37.38 immediately after aspiration
Fig 37.43 Aspiration of lacrimal abscess—case study 1: clinical pho-

tograph of right eye of the patient in Fig. 37.38 immediately after the
aspiration. Note the grossly decompressed abscess. Conservative man-
agement and DCR usually follow this technique
Fig. 37.44 Aspiration of lacrimal abscess—case study 2: clinical pho- Fig. 37.46 Aspiration of lacrimal abscess—case study 2: the aspirated
tograph, surgeon’s view, showing a right-sided lacrimal abscess. Note pus from the patient in Fig. 37.44
the wide bore needle in the vicinity
Fig. 37.45 Aspiration of lacrimal abscess—case study 2: clinical pho- Fig. 37.47 Aspiration of lacrimal abscess—case study 2: clinical pho-
tograph, surgeon’s view, of the patient in Fig. 37.44 demonstrating tograph of right eye of patient in Fig. 37.44. Note the grossly decom-
abscess aspiration pressed abscess cavity
Fig. 37.48 Endoscopic view of the left nasal cavity demonstrating the Fig. 37.49 Endoscopic view of the left nasal cavity of the patient in
marsupialization of the lacrimal sac in acute dacryocystitis. Note the Fig. 37.48. Note the purulent lacrimal sac material being evacuated fol-
unusual congestion of the tissues lowing the marsupialization
Chronic Dacryocystitis and LDALT
38
The term chronic dacryocystitis is usually referred to the References

inflammatory process that occurs in the lacrimal sac follow-
ing a nasolacrimal duct obstruction of more than 6 months of 1. Knop E, Knop N. Lacrimal drainage associated lymphoid tis-
sue (LDALT): a part of human mucosal immune system. Invest
duration. The histopathological changes include epithelial Ophthalmol Vis Sci. 2001;42:566–74.
thickening, denuded epithelium, metaplastic epithelium, 2. Knop E, Knop N. MALT tissue of the conjunctiva and nasolacrimal
stromal fibrosis, stromal hyalinization, luminal stagnation of system in rabbit and human. Vision Res. 1996;36:60.
secretions and denuded cellular debris, loss of distinct acinar 3. Paulsen FP, Paulsen JI, Thale AB, et al. Mucosa associated lym-
phoid tissues in the human efferent tear ducts. Virchows Arch.
patterns, increased goblet cell density, mostly atrophic and 2000;437:185–9.
occasional hypertrophic mucosal glands, proliferative blood 4. Mauriello JA, Palydowycz S, Deluca J. Clinicopathologic study
vessels, and dilated lymphatics [1–5]. of the lacrimal sac and nasal mucosa in 44 patients with complete
The lacrimal drainage system is exposed to numerous acquired nasolacrimal duct obstruction. Ophthal Plast Reconstr
Surg. 1992;8:13–21.
organisms and antigens from the environment and ocular sur- 5. Ali MJ, Mulay K, Pujari A, et al. Derangements of lacrimal drainage
face via the tears, and hence the immune defenses of this sys- associated lymphoid tissue (LDALT) in human chronic dacryocysti-
tem are well developed. Lacrimal drainage-associated tis. Ocul Immunol Inflamm. 2013;21:417–23.
lymphoid tissue (LDALT) or tear duct-associated lymphoid
tissue (TALT) is a part of a generalized mucosa-associated
lymphoid tissues and is believed to be functionally contigu-
ous with the conjunctiva-associated lymphoid tissue (CALT).
In LDALT, the diffuse type is more predominant as compared
to the follicular type. The T cells were more confined to the
diffuse variety and B cells to the follicular type. Primary fol-
licles are more common than the occasional secondary folli-
cles. High-end venules seen in the diffuse type could possibly
reflect lymphocytic homing mechanisms [1–3].
Derangement of LDALT in chronic dacryocystitis can
significantly influence the local immunity, ocular surface
interactions, and lymphocyte recirculation. The lymphoid
infiltration pattern in chronic dacryocystitis was noted to be
diffuse and mostly confined to epithelial and subepithelial
locations [5]. Distinct lymphoid follicles are noted in nearly
one-third of such patients. Plasma cell infiltrations and IgA-
rich secretions in the lumen and on the lining epithelium are
common findings. Proliferative blood vessels and dilated
lymphatics are nearly universal findings [5]. These derange-
ments could have a significant bearing on the ocular surface
immunity and tear film characteristics.
Figures are from Ali et al. Ocul Immunol Inflamm.
2013;21:417–23.

338 38 Chronic Dacryocystitis and LDALT
Fig. 38.1 Microphotograph showing diffuse stromal fibrosis in Fig. 38.4 Microphotograph showing focal areas of dystrophic calcifi-
chronic dacryocystitis (H&E ×100) cation (H&E ×100)
Fig. 38.2 Microphotograph showing grossly increased goblet cell Fig. 38.5 Microphotograph showing areas of thickened and multilay-
density and mucinous gland hyperproliferation (H&E ×40) ered epithelium in chronic dacryocystitis (H&E ×40)
Fig. 38.3 Microphotograph showing proliferative blood vessels in Fig. 38.6 Microphotograph demonstrating areas of squamous meta-
chronic dacryocystitis (H&E ×100) plasia in chronic dacryocystitis (H&E ×40)
38 Chronic Dacryocystitis and LDALT 339
Fig. 38.7 Microphotograph demonstrating strong IgA expressions of Fig. 38.10 LDALT in chronic dacryocystitis—follicular pattern of
the lining epithelium of the lacrimal sac (anti-IgA ×40) LDALT (H&E ×40)
Fig. 38.8 High-magnification microphotograph showing IgA expressions Fig. 38.11 LDALT in chronic dacryocystitis—diffuse inflammatory
of the lining epithelium and subepithelial plasma cells (anti-IgA ×400) infiltrate with proliferative blood vessels (H&E ×100)
Fig. 38.9 LDALT in chronic dacryocystitis—diffuse and mixed type Fig. 38.12 LDALT in chronic dacryocystitis—diffuse intraepithelial
of LDALT (H&E ×400) and subepithelial infiltrates of lymphocytes and plasma cells (H&E ×400)
340 38 Chronic Dacryocystitis and LDALT
Fig. 38.13 Immunotyping in chronic dacryocystitis—a distinct sec- Fig. 38.15 Immunotyping in chronic dacryocystitis—areas of
ondary lymphoid follicle with light staining of the germinal centers and T lymphocytes (anti-CD3 ×100)
B lymphocytes in the periphery (anti-CD20 ×40)
Fig. 38.14 Immunotyping in chronic dacryocystitis—areas of dense B Fig. 38.16 Immunotyping in chronic dacryocystitis—areas of plasma
lymphocytes (anti-CD20 ×400) cell infiltration (anti-CD138 ×400)
Lacrimal Sac Diverticulum
39
Lacrimal diverticula are cystic outpouchings, mostly com- References

municating with the lacrimal sac [1–5]. An abnormal cellular
cord stem from the lacrimal sac region during embryogene- 1. Zonis S, Gdal-On M. A congenital diverticulum of the lacrimal sac
successfully operated. Ear Nose Throat Mon. 1972;51:62–4.
sis could contribute to diverticula. Diverticula of the lacrimal 2. Ackay EK, Cagil N, Yulek F, et al. Congenital lacrimal sac diver-
sac can be congenital, inflammatory, or post-traumatic [1]. ticulum as a cause of recurrent orbital cellulitis. Can J Ophthalmol.
Congenital lacrimal sac diverticula are rare anomalies that 2009;44:e29–30.
may present with epiphora, recurrent acute dacryocystitis, 3. Kavanagh MC, Cahill KV. Congenital lacrimal system anomalies
mimicking recurrent acute dacryocystitis. Ophthal Plast Reconstr
and medial orbital mass [1–5]. A high suspicion, careful Surg. 2008;24:53–4.
examination, and imaging would help in diagnosis. The 4. Kim JH, Chang HR, Woo KI. Multilobular lacrimal sac diver-
infero-lateral wall of the sac is a common area for the diverticulum presenting as a lower eyelid mass. Korean J Ophthalmol.
ticula, since resistance to any expansion is least in this region 2012;26:297–300.
5. Ali MJ. Endoscopic approach to management of a lacrimal sac
as compared to other walls which have support of the perios- diverticulum. Ophthal Plast Reconstr Surg. 2016;32:e49.
teum and orbicularis. Diagnosis is usually by a plain dacryo-
cystography (DCG) or by a CT or MR-DCG. Management
usually consists of excision of the outpouching with or with-
out a surgical bypass [1–5].
Figures 39.15, 39.16 and 39.17 are from Ali et al., Ophthal
Plast Reconstr Surg 2016;32:e49.

342 39 Lacrimal Sac Diverticulum
Fig. 39.3 Lacrimal sac diverticulum case study 1: CT scan orbits, axial
cut, of the patient in Figs. 39.1 and 39.2 showing the orbital extension.
Note the irregularity of the posterior wall of the lacrimal sac
Fig. 39.1 Lacrimal sac diverticulum case study 1: clinical photograph

showing a child presenting with a left inferomedial lower eyelid
fullness
Fig. 39.2 Lacrimal sac diverticulum case study 1: CT scan orbits, cor-
onal cut, of the patient in Fig. 39.1 showing a large lacrimal sac dilata-
tion with infero-lateral orbital extension Fig. 39.4 Lacrimal sac diverticulum case study 1: CT scan orbits, sag-
ittal cut, of the patient in Figs. 39.1, 39.2 and 39.3 showing the irregular
diverticular wall of the lacrimal sac
39 Lacrimal Sac Diverticulum 343
Fig. 39.5 Lacrimal sac diverticulum case study 2: clinical photograph

of a patient with right lacrimal sac dilatation and patent irrigation.
There were no features of atonic sac clinically
Fig. 39.8 Lacrimal sac diverticulum case study 2: CT scan orbits, axial
cuts, of the patient in Figs. 39.5, 39.6 and 39.7 showing the dilated right
lacrimal sac
Fig. 39.6 Lacrimal sac diverticulum case study 2: clinical photograph Fig. 39.9 Lacrimal sac diverticulum case study 3: clinical photograph
of the patient in Fig. 39.5, closeup image of the right lacrimal sac region of an infant showing right-sided fullness over the lacrimal sac area with
upward displacement of the medial canthus
Fig. 39.10 Lacrimal sac diverticulum case study 3: CT scan, coronal

cut, showing the dilated bony lacrimal fossa with a well-defined lacri-
Fig. 39.7 Lacrimal sac diverticulum case study 2: CT scan orbits, sag-
mal sac lesion extending into the orbit. Note the peripheral rim enhance-
ittal cut, of the patient in Figs. 39.5 and 39.6 showing a right lacrimal
ment and displacement of air toward the orbital portion of the lesion
sac enlargement with an infero-lateral extension
Fig. 39.11 Lacrimal sac diverticulum case study 3: intraoperative pho- Fig. 39.13 Lacrimal sac diverticulum case study 3: anatomical restora-
tograph taken through an endoscope, showing the lacrimal sac tion of the lacrimal sac. Note the sutures on the lateral side of the sac
diverticula and the sharp anterior lacrimal crest on the other side
Fig. 39.14 Lacrimal sac diverticulum case study 3: microphotograph

showing the lining of the wall by flattened columnar epithelium with
stromal lymphoplasmacytic infiltration and fibrosis
Fig. 39.12 Lacrimal sac diverticulum case study 3: end on view of the
lumen of lacrimal sac following excision of the diverticula
39 Lacrimal Sac Diverticulum 345
Fig. 39.15 Endoscopic approach to lacrimal sac diverticulum: endo- Fig. 39.17 Endoscopic approach to lacrimal sac diverticulum: endo-
scopic view of the left nasal cavity. Note the marsupialized lacrimal sac scopic view of the left nasal cavity. Note the mucosa to mucosa approx-
with its flaps and an anterolateral diverticular recess imation of the lacrimal flaps with the mucosa of the recess following
excision of the diverticula
Fig. 39.16 Endoscopic approach to lacrimal sac diverticulum: endo-

scopic view of the diverticular recess. Note the mucosa is smooth and
whitish, without any features of diverticulitis in the past Fig. 39.18 Endoscopic approach to lacrimal sac diverticulum: 6-month
postoperative endoscopic photograph of the patient in Figs. 39.15, 39.16,
39.17 and 39.18. Note the large ostium with a shallow base
Fig. 39.20 Endoscopic approach to lacrimal sac diverticulum: micro-

photograph of the excised diverticulum of the patient in Figs. 39.15,
39.16 and 39.17. The diverticular lining was made up of flattened
columnar epithelium
Fig. 39.19 Endoscopic approach to lacrimal sac diverticulum: 6-month

postoperative endoscopic photograph of the patient in Figs. 39.15, 39.16,
39.17 and 39.18. Note the positive functional endoscopic dye test
Fig. 39.21 Endoscopic approach to lacrimal sac diverticulum: micro-

photograph of the excised diverticulum in higher magnification show-
ing subepithelial fibrosis with lymphoplasmacytic infiltration
Dacryolithiasis
40
Dacryoliths or mucoliths are concretions formed within References

the lacrimal drainage system. They can be broadly classi-
fied as infectious and non-infectious dacryoliths [1–3]. 1. Mishra A, Hu KY, Kamal S, et al. Dacryolithiasis: a review. Ophthal
Plast Reconstr Surg. 2017;33:83–9.
Etiopathogenesis is unclear, but some form of lacrimal drain- 2. Perry LJ, Jakobiec FA, Zakka FR. Bacterial and mucopeptide con-
age obstruction potentially triggers numerous mechanisms cretions of the lacrimal drainage system. An analysis of 30 cases.
leading to epithelial metaplasia and alteration of the mucin Ophthal Plast Reconstr Surg. 2012;28:126–33.
and trefoil factor peptides [3]. This would further lead to 3. Paulsen FP, Schaudig U, Fabian A, et al. TFF peptides and mucins
are major components of dacryoliths. Graefes Arch Clin Exp
formation of amorphous materials and subsequent deposi- Ophthalmol. 2006;244:1160–70.
tion of mucins, peptides, and debris, finally forming a con-
cretion. They are mostly yellowish white or light brown in
color. Clinically they can present as epiphora, dacryocysti-
tis, or a firm medial canthal mass lesion. The definite diag-
nosis is usually established on visualizing the dacryoliths
during a dacryocystorhinostomy. CT scans can diagnose a
mass lesion but are unlikely to characterize the dacryoliths.
A dacryoendoscopy may be more suitable for direct visu-
alization of the concretions. Since dacryolithiasis is mostly
an incidental finding during a DCR, the surgical procedure
itself is curative. Occasionally spontaneous extrusion of the
dacryolith can relieve the symptoms. In rare instances, dac-
ryocystostomy with reclosure of the lacrimal sac walls and
intubation or dacryoendoscopy-guided removal can be per-
formed to expel the dacryoliths from the lacrimal drainage
system.

348 40 Dacryolithiasis
Fig. 40.1 Clinical photograph of a patient with right-sided epiphora

and lacrimal sac dilatation. Note the fullness of the lacrimal sac fossa
Fig. 40.2 CT scan orbits, coronal cut, of the patient in Fig. 40.1. Note
the large dilated lacrimal sac with multiple areas of variable densities
within the lesion, which were noted intraoperatively to be dacryoliths
Fig. 40.3 CT scan orbits,

axial cuts, showing right
lacrimal sac lesion with
multiple internal densities
40 Dacryolithiasis 349
Fig. 40.6 Endoscopic view of the lacrimal sac dacryoliths in a higher

magnification
Fig. 40.4 A dacryoendoscopic view of the horizontal canaliculus show-
ing the canalicular dacryoliths or concretions. Note the well-defined
concretion in the center and the ill-defined one in the periphery
Fig. 40.7 Infected dacryoliths or concretions obtained from a patient

of infective canaliculitis
Fig. 40.5 Endoscopic view of the right nasal cavity during a dacryo-
cystorhinostomy. Note the accidental detection of a large dacryoliths
following sac marsupialization
350 40 Dacryolithiasis
Fig. 40.8 A well-defined lacrimal sac dacryolith
Fig. 40.9 Lacrimal sac dacryolith
Fig. 40.11 A massive dacryolith of the lacrimal sac and nasolacrimal

duct, which has taken the shape of the lacrimal drainage system
Fig. 40.10 High-magnification image of the lacrimal sac dacryolith in

Fig. 40.9.
Nasolacrimal Trauma
41
Nasolacrimal duct (NLD) injuries may be either bony duct References

fractures alone with intact soft tissue duct or may involve
both bony and soft tisse NLD [1–3]. They are less common 1. Ali MJ, Gupta H, Honavar SG, et al. Acquired nasolacrimal duct
obstructions secondary to naso-orbito-ethmoid fractures: patterns
than the canalicular trauma and mostly occur in facial inju- and outcomes. Ophthal Plast Reconstr Surg. 2012;28:242–5.
ries (Le Fort II and III) and specifically in naso-orbito-eth- 2. Ali MJ, Naik MN. Image guided dacryolocalisation (IGDL) in trau-
moid or NOE fractures. Blunt high-impact injuries matic secondary acquired lacrimal drainage obstructions (SALDO).
(industrial, motor vehicle accident, assaults) commonly Ophthal Plast Reconstr Surg. 2015;31:406–9.
3. Ali MJ, Singh S, Naik MN, et al. Interactive navigation-guided
result in NOE factures. Once the patient’s general condition ophthalmic plastic surgery: the utility of 3D CT-DCG guided dac-
is stabilized, it is important to assess the trauma meticu- ryolocalization in secondary acquired lacrimal duct obstructions.
lously. In all patients with facio-maxillary trauma, an evalu- Clin Ophthalmol. 2016;11:127–33.
ation of the CT scan for evidence of bony nasolacrimal duct
disruption should be carried out. It is preferable to perform a
careful lacrimal irrigation, either immediately before facial
fracture repair or after reduction of the NOE fragments but
before plating of the involved bones. Failure to recognize
and manage lacrimal injuries is one of the common compli-
cations of eyelid/midfacial injuries. Most lacrimal surgeons
initially prefer a wait-and-watch approach for an isolated
NLD injury and later consider a definitive surgery like a dac-
ryocystorhinostomy. The outcomes of external and endo-
scopic DCR are good. The advent of navigation guidance
and preoperative 3D reconstructions has facilitated DCR sur-
geries with greater ease in complex post-traumatic nasolacri-
mal duct obstructions.
Figures 41.4, 41.5, are from Ali et al., Ophthal Plast

352 41 Nasolacrimal Trauma
Fig. 41.1 Mechanism of lacrimal trauma in bony injuries: schematic

diagram showing involvement of the lacrimal drainage system by the Fig. 41.3 Mechanism of lacrimal trauma in bony injuries: endoscopic
growing callus. This can be an additional mechanism other than direct view of the right nasal cavity demonstrating the direct injury of the
disruption of the bony and soft tissues of lacrimal drainage system nasolacrimal duct by a screw from the past surgery
Fig. 41.2 Mechanism of lacrimal trauma in bony injuries:

schematic diagram showing the lacrimal drainage injuries by the
screws and plates (Photo courtesy: Himika Gupta, Mumbai)
41 Nasolacrimal Trauma 353
Fig. 41.4 Nasolacrimal injury in a type III NOE fracture: clinical pho- CT scan orbits and PNS, coronal cut demonstrating a naso-orbito-
tograph of a patient post-fracture reduction. Note the depressed nasal ethmoid (NOE) fracture type III (Panel c). A 3D volumetric CT scan
bridge, telecanthus, and scars from the past surgery (Panel a). X-ray reconstruction demonstrating a type III NOE fracture (Panel d)
skull, PA view demonstrating numerous plates and screws (Panel b).
Fig. 41.5 Nasolacrimal injury in a type IV NOE fracture: clinical pho- cicatricial ectropion (Panel b). Three-dimensional CT reconstruction
tograph of a patient post-fracture reduction. Note the depressed nasal showing repair of only the unstable maxillary component (Panel c). CT
bridge, telecanthus, and scars from the past surgery (Panel a). Clinical scan orbits, axial cut, showing nasal fractures with a left mucocele
photograph of the left eye demonstrating a lacrimal sac mucocele with (Panel d)
acute dacryocystitis, spontaneous discharging fistula, and lower lid
Fig. 41.6 Clinical photograph of a child with right eye dystopia, eso-
tropia, telecanthus, and dilated lacrimal sac, following a facial trauma
Fig. 41.7 CT scan orbits, axial cut, of the patient in Fig. 41.6. Note the right
lacrimal mucocele with involvement of bony lacrimal system in trauma
Fig. 41.8 NOE fracture and nasolacrimal injury: clinical photograph

of a patient, post NOE fracture. Note the right lacrimal mucocele,
depressed nasal bridge, and telecanthus
Fig. 41.11 NOE fracture and nasolacrimal injury: CT scan orbits,

axial cut, of the patient in Fig. 41.8 demonstrating the lacrimal sac
mucocele and the fractured segments of the bony lacrimal sac fossa

of right eye of the patient in Fig. 41.8. Note the lacrimal sac mucocele
with irregular scarring in the vicinity
Fig. 41.12 NOE fracture and nasolacrimal injury: CT scan orbits,
axial cut, of the patient in Fig. 41.8 demonstrating disruption of the
bony NLD in the trauma
Fig. 41.10 NOE fracture and nasolacrimal injury: CT scan orbits, coro- Fig. 41.13 NOE fracture and nasolacrimal injury: clinical photograph
nal cut, of the patient in Fig. 41.8 demonstrating a NOE type IV fracture of another patient showing a left enophthalmos with dilated left lacri-
with gross disruption of the bony lacrimal sac fossa mal sac
Fig. 41.17 Clinical photograph of a patient with right acute dacryo-

cystitis and facial cellulitis post-trauma
Fig. 41.14 NOE fracture and nasolacrimal injury: 3D CT reconstruc-

tion of the patient in Fig. 41.13 demonstrating a NOE fracture with
some plates and screws in the vicinity of the lacrimal drainage system

of a left lacrimal sac mucocele post NOE fracture
Fig. 41.18 CT scan orbits, coronal cut, of the patient in Fig. 41.17

demonstrating facial fractures involving the bony lacrimal fossa

of a left lacrimal sac dilatation, post NOE fracture. Note the medial
canthal dystopia, telecanthus, and epiphora
Fig. 41.19 CT scan orbits, axial cut, of the patient in Fig. 41.17 dem-
onstrating involvement of the bony nasolacrimal duct in the fractures
Fig. 41.21 A 3D CT-dacryocystography image of the patient in

Fig. 41.20. Note the right nasolacrimal duct obstruction and the left
dilated lacrimal sac with patent NLD (atonic sac)
Fig. 41.20 Clinical photograph of a patient following a facial trauma. Fig. 41.22 A 3D CT-DCG image of the patient in Figs. 41.20 and
Note the right exotropia and telecanthus, depressed nasal bridge, and 41.21. Left profile view demonstrates the dilated and sacculated lacri-
the fullness of the left lacrimal fossa mal sac
Fig. 41.23 Clinical photograph of a patient with left lacrimal muco-

cele and phthisical eye post-trauma
Fig. 41.26 CT scan orbits, axial cut, of the patient in Fig. 41.25. Note
the expansion of the right bony NLD and bilateral reactive osteitis fol-
lowing trauma
Fig. 41.24 Clinical photograph of left eye of the patient in Fig. 41.23.

Note the phthisical eye and the inferomedial lacrimal sac mucocele
Fig. 41.27 Iatrogenic nasolacrimal injury: clinical photograph of a

patient with a left lacrimal abscess following a maxillary sinus osteoma
excision
Fig. 41.25 CT scan orbits, axial cut, of another patient, post-trauma,

demonstrating a right-sided mucocele and ipsilateral phthisical eye

the pre-lacrimal approach to maxillary sinus. Note the exposed medial
wall of the maxillary sinus (black star). This approach when needed
preserves the nasolacrimal duct and minimizes the risk of lacrimal
Fig. 41.28 Iatrogenic nasolacrimal injury: CT scan PNS, coronal cut, trauma (Photo courtesy: PJ Wormald, Adelaide)
of the patient in Fig. 41.27. Note the left-sided abrupt ending of the
lacrimal drainage system at the level of nasolacrimal duct
Fig. 41.30. Note the completely exposed maxillary sinus as well as the
preserved nasolacrimal duct (black arrow) (Photo courtesy: PJ
Fig. 41.29 Iatrogenic nasolacrimal injury: endoscopic view of the left Wormald, Adelaide)
nasal cavity of the patient in Figs. 41.27 and 41.28. Note the excision at
the level of upper nasolacrimal duct (black arrow)
Iatrogenic Bony NLD Dehiscence
42
The course of nasolacrimal duct is directed downward, pos- References

terior, and lateral, and this is very important on the lateral
wall topography. Nasolacrimal duct injury has been reported 1. Ali MJ, Murphy J, Wormald PJ, et al. Bony nasolacrimal duct
dehiscence in functional endoscopic sinus surgery: radiological
as a consequence of numerous surgical procedures including study and discussion of surgical implications. J Laryngol Otol.
uncinectomy, endoscopic sinus surgery, frontal sinusotomy, 2015;129:S35–40.
maxillary osteotomy, external or endoscopic medial maxil- 2. Serdahl CL, Berries CE, Chole RA. Nasolacrimal duct obstruction
lectomy, rhinoplasty, inferior turbinectomy, and maxillofa- after endoscopic sinus surgery. Arch Ophthalmol. 1990;108:391–2.
3. Sadeghi N, Joshi A. Management of the nasolacrimal system during
cial trauma repair [1–3]. The NLD passes anterior to hiatus transnasal endoscopic medial maxillectomy. Am J Rhinol Allergy.
semilunaris in the wall of the middle meatus, and in here the 2012;26:e85–8.
distance between NLD and maxillary ostium varies from 3 to
6 mm. This close anatomical relationship predisposes it to
iatrogenic injury during uncinectomy and middle meatal
antrostomy. The incidence of dehiscence reported varies
from 3.6 to 15% [1–3]. It is also important to note that pre-
operative or preexisting dehiscence has also been reported. It
is equally important to distinguish postoperative reactive
osteitis form a frank NLD trauma [1]. Otolaryngologists
themselves should become familiar with the radiological
course of the NLD and variants in its bony anatomy in the
hope of predicting patients at risk of iatrogenic injury. Other
factors that may reduce the incidence of injury during FESS
include clear visualization of the surgical field, appreciation
of regional anatomy, controlled enlargement of maxillary
ostium, posteroinferior direction of back biting punch, and
avoiding bone engagement anterior to uncinate process.
NLD injury following FESS is uncommon but does occur,
and so all patients should be consented appropriately
preoperatively.
Figures are from Ali et al., J Laryngol Otol 2015;129:
S35–40.

362 42 Iatrogenic Bony NLD Dehiscence
Fig. 42.1 CT scan, axial cut, showing bilateral intact bony nasolacri- Fig. 42.3 CT scan, axial cut, depicting another example of a thin-
mal ducts (NLD) but with residual uncinate process on the left side walled but bilaterally intact NLD
Fig. 42.2 CT scan, axial cut, showing a thin-walled but bilaterally Fig. 42.4 CT scan, axial cut, showing preoperative large bilateral bony
intact NLD NLD dehiscence
42 Iatrogenic Bony NLD Dehiscence 363
Fig. 42.7 CT scan, axial cut, preoperative, showing bilaterally thin but
Fig. 42.5 CT scan, axial cut, of the patient in Fig. 42.4, showing the intact NLD
postoperative scan. Note there is no increase in dehiscence and is
stable
Fig. 42.8 CT scan, axial cut, showing postoperative images of the

patient in Fig. 42.7. Note that although the NLD is intact, there is reac-
tive osteitis of the posteromedial and posterolateral walls
Fig. 42.6 CT scan, axial cut, showing another example of a preopera-

tive bilateral NLD dehiscence
364 42 Iatrogenic Bony NLD Dehiscence
Fig. 42.9 CT scan, axial cut, showing another example of a bilateral Fig. 42.11 CT scan, axial cut, of the patient in Fig. 42.10 depicting the
reactive osteitis affecting the posterior wall of the NLD, left side more postoperative scans. Note the gross posterior NLD wall dehiscence
than right, following a FESS bilaterally
Fig. 42.12 Preoperative CT scan, axial cut, showing bilaterally intact

NLD with thin rims posteromedially
Fig. 42.10 CT scan, axial cut, showing thinned but intact bony NLD
42 Iatrogenic Bony NLD Dehiscence 365
Fig. 42.13 Postoperative CT scan, axial cut, of the patient in

Fig. 42.12, showing left posteromedial wall dehiscence with minimal
prolapsed of soft tissue
Secondary Acquired Lacrimal Drainage
Obstruction (SALDO) 43
Secondary acquired lacrimal duct obstructions or SALDO References

is a term used to define all the secondary causes of lacrimal
obstructions [1–4]. It essentially means that the specific 1. Bartley GB. Acquired lacrimal drainage obstruction: an etiologic
classification system, case reports, and a review of the literature.
cause of obstructions could be zeroed in on, and therapies Part 1. Ophthal Plast Reconstr Surg. 1992;8:237–42.
targeting the cause may result in relief from obstructions. 2. Bartley GB. Acquired lacrimal drainage obstruction: an etiologic
Bartley GB et al. [1–4] described five categories of second- classification system, case reports and a review of literature. Part 2.
ary obstructions, namely, infectious, inflammatory, trau- Ophthal Plast Reconstr Surg. 1992;8:243–9.
3. Bartley GB. Acquired lacrimal drainage obstruction: an etiologic
matic, mechanical, and neoplastic with numerous etiologies classification system, case reports and a review of literature. Part 3.
for each category. Most of the traumatic and neoplastic eti- Ophthal Plast Reconstr Surg. 1993;9:11–26.
ologies have been covered under specific chapters in this 4. Sobel KR, Carter KD, Allen RC. Bilateral lacrimal drainage
Atlas. Inflammatory SALDO can include endogenous eti- obstruction and its association with secondary causes. Ophthal
ologies like Stevens-Johnson syndrome, cicatricial pem- 5. Ali MJ. Iodine-131 therapy and nasolacrimal duct obstructions:
phigoid, sarcoidosis, and Wegener’s granulomatosis. what we know and what we need to know. Ophthal Plast Reconstr
Exogenous etiologies include burns, allergies, use of eye Surg. 2016;32:243–8.
drops like antiviral, radiotherapy, and certain chemothera-
peutic agents like 5-fluorouracil, paclitaxel, and radioac-
tive iodine (I-131) [4–5]. The term mechanical refers to a
lacrimal passage physically obstructed anywhere along its
entire course by specific agents. These could be endoge-
nous factors like dacryoliths and migrated punctal plugs or
exogenous factors like conjunctivochalasis, sinus muco-
cele, or caruncular masses. The general principle of treat-
ment for a SALDO is to remove the causative factor or to
minimize its influence.
Figure 43.46, taken from Ali et al, Ophthal Plast Reconstr
Surg 2016;32:243–8.

368 43 Secondary Acquired Lacrimal Drainage Obstruction (SALDO)
Fig. 43.1 Mechanical SALDO: clinical photograph of the right eye Fig. 43.4 Mechanical SALDO: clinical photograph of a left eye show-
with medial orbital fat prolapsed. Note the obstruction of the lower ing a caruncular sebaceous cyst directly obstructing the lower
punctum with the prolapsed fat punctum
Fig. 43.2 Mechanical SALDO: clinical photograph, high magnifica- Fig. 43.5 Mechanical SALDO: clinical photograph of a left eye in a
tion, of the patient in Fig. 43.1. Note the orbital fat and its interaction patient of thyroid eye disease, showing the chemosis to directly obstruct
with the lower punctum the lower punctum
Fig. 43.3 Mechanical SALDO: clinical photograph of a right eye Fig. 43.6 Mechanical SALDO: clinical photograph, higher magnifica-
showing the caruncular hypertrophy mechanically interfering with the tion, of the patient in Fig. 43.5. Note the relationship of the chemosed
functions of the punctum conjunctiva with the lower punctum
43 Secondary Acquired Lacrimal Drainage Obstruction (SALDO) 369
Fig. 43.7 Mechanical SALDO: clinical photograph of a patient with Fig. 43.10 Clinical photograph of a patient with right-sided SALDO
nevus sebaceous syndrome. Note the left lower lid standoff resulting in secondary to chemical trauma
a mechanical SALDO
Fig. 43.8 Mechanical SALDO: Clinical photograph of left eye of the Fig. 43.11 Clinical photograph of a left eye SALDO with phthisical
patient in Fig. 43.7. Note the lower lid position eye secondary to thermal burns
Fig. 43.12 Autoimmune disorders and SALDO: clinical photograph

of a right SALDO in a case of Stevens-Johnson syndrome
Fig. 43.9 Mechanical SALDO: clinical photograph of the left eye

showing an eyelash follicle (foreign body) in the upper punctal orifice
Fig. 43.16 Scleroderma and SALDO: CT scan orbits, coronal cut, of

the patient in Fig. 43.15. Note the gross left-sided enophthalmos
Fig. 43.13 Autoimmune disorders and SALDO: endoscopic view in a

patient of SALDO secondary to Wegener’s granulomatosis. Note the
widespread necrosis of the nasal mucosa
Fig. 43.14 Autoimmune disorders and SALDO: endoscopic view of Fig. 43.17 Scleroderma and SALDO: microphotograph of the subcu-
the right nasal cavity in a patient with SALDO secondary to lichen pla- taneous tissues of the patient in Fig. 43.15. Note the orbicularis fibers
nus. Note the extensive intrasac synechiae are interspersed in and around a dense homogenized and abnormal col-
lagen (Masson trichrome ×100)
Fig. 43.15 Scleroderma and SALDO: external photograph of a patient

with scleroderma. Note the skin on the left side is depressed, retracted
Fig. 43.18 Scleroderma and SALDO: microphotograph of the lacri-
with left eye enophthalmos
mal sac of the patient in Fig. 43.15. Note the dense fibrosis has replaced
most of the stromal components (H & E ×100)
Fig. 43.19 Ethmoidal mucocele and SALDO: CT scan orbits, coronal

cut, showing a large left ethmoidal mucocele. These can mechanically
compress the lacrimal drainage system in the vicinity causing a
mechanical SALDO
Fig. 43.22 Ethmoidal mucocele and SALDO: postoperative CT scan
orbits, coronal cut, of the patient in Fig. 43.19. Note the restoration of
normal anatomy following surgical intervention for the mucocele
Fig. 43.20 Ethmoidal mucocele and SALDO: CT scan orbits, axial

cut, of the patient in Fig. 43.19. Note the close relationship of the muco-
cele to the lacrimal drainage system
Fig. 43.23 Ethmoidal mucocele and SALDO: postoperative CT scan

orbits, axial cut, of the patient in Fig. 43.20. Note the restoration of
normal anatomy following surgical intervention for the mucocele
Fig. 43.21 Ethmoidal mucocele and SALDO: endoscopic view taken

within a partially decompressed ethmoidal mucocele of another patient.
Note the intricate relationship of the lacrimal drainage system (white
arrow) with the mucocele cavity
Fig. 43.24 Encephalocele and SALDO: clinical photograph of a

patient who presented with a right epiphora. Note the right telecanthus
and fullness of the lacrimal sac fossa above the medial canthus. Similar Fig. 43.27 Encephalocele and SALDO: CT scan orbits, axial cut,
to ethmoid mucocele, an encephalocele in the vicinity of the lacrimal showing the encephalocele compressing the lacrimal sac
sac fossa can compress the lacrimal drainage system and present as an
epiphora
Fig. 43.25 Encephalocele and SALDO: clinical photograph of the Fig. 43.28 Fungal granuloma and SALDO: clinical photograph of a
patient in Fig. 43.24. Note the epiphora of the right eye patient who presented with a right-sided proptosis and epiphora. Note
the right telecanthus
Fig. 43.26 Encephalocele and SALDO: CT scan orbits, coronal cut,

showing a breach in the skull base and the descending encephalocele in
the lacrimal sac fossa Fig. 43.29 Fungal granuloma and SALDO: CT scan orbits, coronal
cut, of the patient in Fig. 43.28. Note involvement of the inferior orbit
with a mass lesion which is extending into the lacrimal fossa and bony
nasolacrimal duct
Fig. 43.33 Fungal granuloma and SALDO: CT scan PNS, coronal cut,
showing a massive fungal granuloma involving the entire maxillary and
ethmoid sinuses. Note the lesion involve the lacrimal sac and the naso-
Fig. 43.30 Fungal granuloma and SALDO: CT scan orbits, axial cut, lacrimal duct
of the patient in Fig. 43.28. Note the mass lesion involving the nasolac-
rimal duct
Fig. 43.31 Fungal granuloma and SALDO: microphotograph of the

biopsy taken from patient in Fig. 43.28. Note the characteristic features Fig. 43.34 Fungal granuloma and SALDO: Postoperative CT scan PNS,
of a granuloma (H & E ×100) coronal cut, of the patient in Fig. 43.29, following extensive debridement,
FESS, and medical treatment. Note the good response to the treatment
Fig. 43.32 Fungal granuloma and SALDO: microphotograph of the Fig. 43.35 Traumatic SALDO: clinical photograph of a patient with
biopsy taken from the patient in Fig. 43.28. Note the characteristic fun- left enophthalmos and epiphora following a facial trauma
gal filaments within the granuloma (Gomori methenamine Silver ×400)
Fig. 43.39 Fibrous dysplasia and SALDO: CT scan orbits, axial cut, of
the patient in Fig. 43.37. Note the clear involvement of the bony naso-
lacrimal duct
Fig. 43.36 Traumatic SALDO: CT scan orbits, axial cut, of the patient
in Fig. 43.35. Note the left bony nasolacrimal duct fracture. Compare it
with the normal right side
Fig. 43.37 Fibrous dysplasia and SALDO: clinical photograph of a

child with a right eye dystopia, telecanthus, and gross epiphora
Fig. 43.40 Clinical photograph of a left lower lid demonstrating filling

up of the punctal orifice by a canalicular squamous papilloma
Fig. 43.38 Fibrous dysplasia and SALDO: CT scan orbits, coronal

cut, of the patient in Fig. 43.37 demonstrating a diffuse lesion with
patchy ossification involving the right paranasal sinuses and the lacri-
mal drainage system
Fig. 43.41 Clinical photograph of the left eye, post external beam
radiotherapy. Note the gross peri-punctal inflammation and kertatiniza-
tion involving the lower punctum
Fig. 43.42 Radioactive iodine (RAI) and SALDO: planar I-131 scin-
tigraphy image of a patient following RAI therapy. Note the moderate
update by the nasal tissues. The nasolacrimal uptake of RAI leads to
beta irradiation of the ducts and its subsequent obstruction
Fig. 43.43 Radioactive iodine and SALDO: whole body iodine scintigraphy image following RAI therapy demonstrating high uptake by the nasal
tissues
Fig. 43.44 Radioactive iodine and SALDO: SPECT-CT image following RAI therapy showing moderate uptake by the nasal tissues
Fig. 43.45 Radioactive iodine and SALDO: SPECT-CT image following RAI therapy demonstrating high uptake by the nasal tissues
Fig. 43.46 Radioactive PROPOSED SCREENING FOR I-131 INDUCED SALDO

iodine and SALDO: proposed
screening guidelines to assess WHOM TO SCREEN
SALDO in patients following
RAI therapy 1. High risk patients (Females, Age>45 years, I-131 dose >150 mCi)
2. All patients complaining of epiphora
WHEN TO SCREEN
1. Before Radioiodine therapy - All high risk patients/symptomatic patients
2. After Radioiodine therapy – Symptomatic patients (Symptoms to be elicited actively in all patients)
Abnormal LDS activity on routine WBI/SPECT
HOW TO SCREEN
1. History (What to ask)
a. Presence of teary eye

b. Tears overflowing in outdoor environments
c. Sticky eyes especially in the mornings
d. Swelling over the inner side of the eye
2. Analyzing the routinely performed WBI/SPECT
a. Intense intranasal localization on WBI

b. RAI activity in the lacrimal sac and NLD on SPECT
3. Positive History or WBI/SPECT positivity
a. Fluorescein dye disappearance test (FDDT)

b. Irrigation and probing
c. DCG/CT-DCG/DSG – If clinical examination not conclusive, multiple level stenosis or as an adjunctive
value to clinical examination
(Glossary: mCi – millicurie, LDS-lacrimal drainage system, WBI-whole body imaging, SPECT- single
photon emission computed tomography, NLD-nasolacrimal duct, DCG- dacryocystography)
Fig. 43.47 Iatrogenic SALDO: clinical photograph of the right eye Fig. 43.48 Iatrogenic SALDO: CT scan orbits, coronal cut, demon-
demonstrating a punctal switch flap taken to cover the upper punctal strating a left lacrimal mucocele with an abrupt end at the level of naso-
opening lacrimal duct. This was following an angiofibroma excision
Fig. 43.52 Iatrogenic SALDO: CT scan orbits, coronal cut, of the

patient in Fig. 43.51. Note the scans show the drain to interfere with the
Fig. 43.49 Iatrogenic SALDO: CT scan orbits, axial cut of the patient lacrimal sac area possibly causing an injury
in Fig. 43.48, demonstrating the left-sided lacrimal mucocele. Compare
the sinus anatomy on the right with the left side
Fig. 43.50 Iatrogenic SALDO: a clinical photograph of a child who

presented with right-sided epiphora. Past history was suggestive of hos-
pitalization for surgical treatment of gross infective sinusitis with
orbital cellulitis
Fig. 43.53 Iatrogenic SALDO: clinical photograph of a patient with a

left lacrimal abscess following a maxillary sinus osteoma excision
Fig. 43.51 Iatrogenic SALDO: CT scan orbits, coronal cut, of the

patient in Fig. 43.50. These earlier scans were taken following the sur-
gical intervention demonstrating a foreign body, a sino-orbital drain (as
per records)
Fig. 43.55 Iatrogenic SALDO: endoscopic view of the left nasal cav-
Fig. 43.54 Iatrogenic SALDO: CT scan PNS, coronal cut, of the ity of the patient in Figs. 43.50 and 43.51. Note the excision at the level
patient in Fig. 43.50. Note the left-sided abrupt ending of the lacrimal of upper nasolacrimal duct (black arrow)
drainage system at the level of nasolacrimal duct
Primary External Dacryocystorhinostomy
44
Dacryocystorhinostomy or DCR is among the common ocu- References

loplastic surgeries performed for managing epiphora due to
nasolacrimal duct obstruction [1–3]. It is a bypass procedure 1. Ali MJ, Naik MN, Honavar SG. External dacryocystorhinostomy:
tips and tricks. Oman J Ophthalmol. 2012;5:191–5.
that creates an anastomosis between the lacrimal sac and the 2. Ali MJ, Gupta H, Naik MN, et al. Endoscopic guided self-linking
nasal mucosa via a bony ostium. The indication for the sur- stents in pediatric external dacrycystorhionstomy. Minim Invasive
gery include persistent congenital nasolacrimal duct obstruc- Ther Allied Technol. 2013;22:266–70.
tions unresponsive to previous therapies, primary acquired 3. Ali MJ, Gupta H, Honavar SG, et al. Acquired naso-lacrimal
duct obstructions secondary to naso-orbito-ethmoid frac-
nasolacrimal duct obstructions (PANDO), and secondary tures: patterns and outcomes. Ophthal Plast Reconstr Surg.
acquired nasolacrimal duct obstructions (SALDO). There 2012;28:242–5.
are two clear goals of a DCR procedure: one is to make a
large bony ostium into the nasal cavity and that remains so
and second is to have a mucosa-lined anastomosis. Since
both these purposes are equally well served by an external
route, it can be one of the approaches with a predictable and
a high success rate in primary and secondary nasolacrimal
duct obstructions [1–3].

382 44 Primary External Dacryocystorhinostomy
Fig. 44.1 Technique of an external DCR: intra-operative photograph Fig. 44.4 Technique of an external DCR: intra-operative photograph
demonstrating the infratrochlear anesthesia block demonstrating the location of the anterior lacrimal crest by the spatula
demonstrating the infiltration anesthesia demonstrating a curvilinear incision just in front of the anterior lacrimal
crest
demonstrating the topical anesthetic-decongestant preoperative nasal demonstrating separation of the subcutaneous tissues to reach the
packing periosteum
44 Primary External Dacryocystorhinostomy 383
demonstrating the periosteal incision over the frontal process of max- demonstrating the beginning of osteotomy by gently perforating the
illa, just anterior to anterior lacrimal crest thin lacrimal bone
demonstrating the lateral reflection of the lacrimal sac along with peri- demonstrating the osteotomy of the frontal process of maxilla
osteum. Note the exposed frontal process of maxilla and the deeper
bluish thin lacrimal bone
demonstrating the progressive osteotomy. An adequate osteotomy is demonstrating the filled and dilated lacrimal sac with fluorescein-
one which exposes the entire length of the lacrimal sac including its stained viscoelastic
fundus to the nasal mucosa
demonstrating filling of the lacrimal sac with a fluorescein-stained demonstrating lacrimal sac marsupialization. Note the green viscoelas-
viscoelastic tic within the lumen of the lacrimal sac
demonstrating a completely marsupialized sac with a central internal demonstrating fashioning of the nasal mucosa
common opening
demonstrating the internal common opening with the help of a probe. demonstrating trimming of the nasal mucosa to achieve a taut anasto-
Note the well-defined anterior and posterior lacrimal sac flaps mosis with lacrimal sac flaps
demonstrating anastomosis of the anterior lacrimal and nasal mucosal demonstrating post-operative povidone iodine and Vaseline soaked
flaps nasal packing
Fig. 44.23 Clinical photograph of a left acute dacryocystitis with

orbital cellulitis
Fig. 44.20 Technique of an external DCR: intra-operative photograph
demonstrating securing of anastomosis with reabsorbable sutures
Fig. 44.24 Clinical photograph of the patient in Fig. 44.23, following

conservative therapy and an external DCR
Fig. 44.21 Technique of an external DCR: intra-operative photograph
demonstrating wound closure
Fig. 44.25 Clinical photograph of a left eye showing an ugly scar fol- Fig. 44.28 Wound dehiscence following external DCR: clinical photo-
lowing an external DCR graph of the right eye of patient in Fig. 44.27, on post-operative 1 week
showing necrosis of the wound and gross dehiscence
Fig. 44.26 Clinical photograph of a right eye showing a webbed scar Fig. 44.29 Wound dehiscence following external DCR: clinical photo-
following an external DCR. This usually happens when the incision is graph of the right eye of patient in Fig. 44.28. The wound was debrided
extended above the medial canthus followed by a pedicle skin grafting. Note the in situ stent
Fig. 44.27 Wound dehiscence following external DCR: clinical photo- Fig. 44.30 Clinical photograph showing post-operative right DCR
graph of a right eye on post-operative day 1 following an external wound inflammation. Note that this should not be confused with an
DCR. Note the intact sutures and the bicanalicular stent acute dacryocystitis
Subciliary Dacryocystorhinostomy
45
The surgical success rate of an external approach DCR is References

high; however, the inevitable downside of ex-DCR has been
an external skin scar, which has led to the evolution of endo- 1. Dave TV, Javed Ali M, Shravani P, et al. Subciliary incision for
an external dacryocystorhinostomy. Ophthal Plast Reconstr Surg.
nasal and several other non-incisional techniques. The eyelid 2012;28:341–5.
subciliary incision is an established approach for several 2. Dave TV, Javed Ali M, Shravani P, et al. Reply re “Subciliary
orbital and eyelid procedures and is known to provide excel- incision for an external dacryocystorhinostomy”. Ophthal Plast
lent cosmesis [1–3]. A 10–15 mm subciliary incision is Reconstr Surg. 2013;29:71–2.
3. Waly MA, Shalaby OE, Elbakary MA, et al. The cosmetic outcome
placed along the medial half of lower eyelid, reaching up to of external dacryocystorhinostomy scar and factors affecting it.
the medial canthus. The incision is placed 1–2 mm below the Indian J Ophthalmol. 2016;64:261–5.
lash line (subciliary) and not within the eyelid crease. It
extends from the punctum medially, to mid-pupillary line
laterally. Subcutaneous dissection is then carried out infero-
medially, to reach the anterior lacrimal crest and subsequent
surgery is like that of an external DCR. In a series on subcili-
ary DCR, at a mean post-operative follow-up of 29 weeks
(range 6–72 weeks), the objective grading reported 47% of
the scars to be invisible (grade 0) and 88.2% to have invisible
to minimally visible (grade 0–1) scars [1]. The subjective
grading by the patient reported 88% of the scars to be invis-
ible (grade 0) and 100% scars to be invisible or minimally
visible (grade 0–1) [1]. Hence subciliary approach provided
excellent cosmetic outcomes while retaining both access and
success of an external DCR.
Figure 45.8 is from Dave et al., Ophthal Plast Reconstr
Surg 2012; 28:341–345. Other photos are courtesy Dr.
Milind N Naik, LVPEI, Hyderabad.

390 45 Subciliary Dacryocystorhinostomy
Fig. 45.4 Technique of a subciliary DCR: intra-operative photograph

demonstrating the subcutaneous dissection toward the lateral nasal wall
Fig. 45.1 Clinical photograph showing the conventional incision and (Photo courtesy: Milind Naik, LVPEI, Hyderabad)
the subciliary incision (Photo courtesy: Milind Naik, LVPEI, Hyderabad)
Fig. 45.2 Technique of a subciliary DCR: intra-operative photograph Fig. 45.5 Technique of a subciliary DCR: intra-operative photograph
demonstrating the marking for a subciliary incision (Photo courtesy: demonstrating the osteotomy (Photo courtesy: Milind Naik, LVPEI,
Milind Naik, LVPEI, Hyderabad) Hyderabad)
Fig. 45.3 Technique of a subciliary DCR: intra-operative photograph Fig. 45.6 Technique of a subciliary DCR: intra-operative photograph
demonstrating the subciliary incision (Photo courtesy: Milind Naik, demonstrating the orbicularis closure (Photo courtesy: Milind Naik,
LVPEI, Hyderabad) LVPEI, Hyderabad)
45 Subciliary Dacryocystorhinostomy 391
Fig. 45.7 Technique of a subciliary DCR: intra-operative photograph

demonstrating the skin closure (Photo courtesy: Milind Naik, LVPEI,
Hyderabad)
Fig. 45.8 Technique of a subciliary DCR: intra-operative photographs of the nasal mucosa following the osteotomy (panel e), fashioning of
demonstrating the subciliary incision (panel a), subcutaneous dissec- the lacrimal sac flaps (panel f), fashioning of the nasal mucosal flaps
tion toward the lateral nasal wall (panel b), exposure of the periosteum (panel g), anastomosis of the lacrimal and nasal mucosal flaps (panel
over the anterior lacrimal crest (panel c), osteotomy (panel d), exposure h), and wound closure (panel i).
392 45 Subciliary Dacryocystorhinostomy
Fig. 45.9 Clinical preoperative photograph of a patient (Photo cour- Fig. 45.12 Postoperative 6 weeks photograph of the patient in
tesy: Milind Naik, LVPEI, Hyderabad) Fig. 45.11, following a right subciliary DCR. Note that the scar is
hardly visible (Photo courtesy: Milind Naik, LVPEI, Hyderabad)
Fig. 45.10 Postoperative 6 weeks photograph of the patient in Fig. 45.13 Clinical preoperative photograph of a patient (Photo cour-
Fig. 45.9, following a right subciliary DCR. Note excellent cosmetic tesy: Milind Naik, LVPEI, Hyderabad)
outcome (Photo courtesy: Milind Naik, LVPEI, Hyderabad)
Fig. 45.11 Clinical preoperative photograph of a patient (Photo cour- Fig. 45.14 Postoperative 6 weeks photograph of the patient in
tesy: Milind Naik, LVPEI, Hyderabad) Fig. 45.13, following a right subciliary DCR. Note excellent cosmetic
outcome (Photo courtesy: Milind Naik, LVPEI, Hyderabad)
45 Subciliary Dacryocystorhinostomy 393
Fig. 45.15 Clinical preoperative photograph of the left eye (Photo Fig. 45.17 Postoperative 6 weeks photograph of the patient in
courtesy: Milind Naik, LVPEI, Hyderabad) Figs. 45.15 and 45.16. Note the faint scar (Photo courtesy: Milind Naik,
LVPEI, Hyderabad)
Fig. 45.16 Postoperative 1-day photograph of the patient in Fig. 45.15 Fig. 45.18 Postoperative 3 months photograph of the patient in
following a subciliary DCR. Note the sutures (Photo courtesy: Milind Figs. 45.15, 45.16 and 45.17. Note the excellent cosmetic outcome
Naik, LVPEI, Hyderabad) (Photo courtesy: Milind Naik, LVPEI, Hyderabad)
Primary Endoscopic
Dacryocystorhinostomy 46
Primary endoscopic dacryocystorhinostomy is increasingly References

becoming an equally effective alternative to an external
approach DCR. It avoids a facial incision, disruption of the 1. Ali MJ, Psaltis AJ, Murphy J, et al. Powered endoscopic dacryocys-
torhinostomy: a decade of experience. Ophthal Plast Reconstr Surg.
medial canthal tendon, injury to the terminal branch of facial 2015;31:219–21.
nerve, or a full-thickness (skin to mucosa) ring contracture 2. Ali MJ, Psaltis AJ, Bassiouni A, et al. Long-term outcomes
over the osteotomy site, all of which may lead to secondary in primary powered endoscopic dacryocystorhinostomy. Br J
lacrimal pump failure despite anatomical patency [1–5]. Ophthalmol. 2014;98:1678–80.
3. Ali MJ, Psaltis AJ, Wormald PJ. Long-term outcomes in revision
Endoscopic DCR is not contraindicated during active dac- powered endoscopic dacryocystorhinostomy. Int Forum Allergy
ryocystitis, presumably allowing faster healing process and Rhinol. 2014;4:1016–9.
is perceivably less traumatic compared to external DCR [4, 4. Kamal S, Ali MJ, Pujari A, et al. Primary powered endoscopic dac-
5]. Recent published series have reported higher success ryocystorhinostomy in the setting of acute dacryocystitis and lacri-
mal abscess. Ophthal Plast Reconstr Surg. 2015;31:293–5.
rates up to 95% and beyond [1–3]. This likely reflects an 5. Chisty N, Singh M, Ali MJ, et al. Long-term outcomes of pow-
increased experience with endoscopic instrumentation and ered endoscopic dacryocystorhinostomy in acute dacryocystitis.
anatomy among lacrimal surgeons and an improved under- Laryngoscope. 2016;126:551–3.
standing and control of postoperative mucosal healing. The
key to successful endoscopic DCR relies on the creation of a
large osteotomy with adequate superior bony clearance,
complete marsupialization of the lacrimal sac, maximal pres-
ervation of the nasal and lacrimal sac mucosa with close
approximation of the mucosal edges, as well as regular endo-
scopic monitoring of ostial healing during the early postop-
erative period [1–5].

396 46 Primary Endoscopic Dacryocystorhinostomy
Fig. 46.1 Technique of a primary endoscopic DCR: endoscopic view Fig. 46.3 Technique of a primary endoscopic DCR: endoscopic view
of the right nasal cavity demonstrating local anesthesia infiltration in demonstrating a decongested nasal cavity outlining the horizontal and
front of the axilla of the middle turbinate in a congested nasal cavity vertical incisions. Compare it with Figs. 46.1 and 46.2
Fig. 46.2 Technique of a primary endoscopic DCR: endoscopic view

demonstrating the nasal packing with decongestants Fig. 46.4 Technique of a primary endoscopic DCR: endoscopic view
demonstrating the horizontal nasal mucosal incision of about 10–15 mm
taken around 8–10 mm above the axilla of the middle turbinate
46 Primary Endoscopic Dacryocystorhinostomy 397
demonstrating the vertical nasal mucosal incision demonstrating good exposure of the frontal process of maxilla
demonstrating reflection of the incised nasal mucosal flap demonstrating the first inferior bony perforation in the posterior thin
lacrimal bone
demonstrating the removal of the inferior portion of the lacrimal bone demonstrating exposure of the nasolacrimal duct (white arrow)
demonstrating the beginning of the bony osteotomy with the help of demonstrating exposure of the inferior half of the lacrimal sac (white
specialized endoscopic bone punches arrow)
demonstrating removal of the superior portion of the posterior lacrimal demonstrating exposure of the agger nasi (white arrow). This also
bone (white arrow) reflects that one has reached the level of lacrimal sac fundus
demonstrating superior osteotomy with a powered drill demonstrating complete length of lacrimal sac following an osteotomy
demonstrating a close-up view of the exposed lacrimal sac. Note the demonstrating full-length lacrimal sac marsupialization. Note the puru-
well demarcated lacrimal venous plexus lent lacrimal sac contents within the lumen
demonstrating lacrimal sac marsupialization with the help of crescent demonstrating the horizontal lacrimal flap incisions to facilitate reflec-
knife tion of the flaps like an open book on the lateral nasal wall
demonstrating reflection of the anterior lacrimal flap. Note the primary demonstrating repositioning of the superior nasal mucosal flap
mucosa to mucosa approximation between the lacrimal flap (white
arrow) and the nasal mucosa (white star)
demonstrating reflection of the posterior lacrimal flap (white star). Note demonstrating retrieval of the first bodkin of a bicanalicular Crawford
the primary mucosa to mucosa approximation between the lacrimal flap stent
(white star) and the agger nasi mucosa (pointed by the crescent knife)
Fig. 46.27 Endoscopic DCR in a lacrimal abscess: clinical photograph

of a 12-year-old child with a large lacrimal abscess

demonstrating retrieval of the second bodkin of bicanalicular Crawford
stent
Fig. 46.28 Endoscopic DCR in a lacrimal abscess: clinical photograph

of the right eye of the patient in Fig. 46.27 demonstrating a large lacrimal
abscess. This patient underwent an endoscopic DCR the next day

demonstrating a complete mucosa to mucosa approximation all around
to facilitate a primary intention healing. Note the bicanalicular
intubation
Fig. 46.29 Endoscopic DCR in a lacrimal abscess: postoperative

1 week clinical photograph of the patient in Fig. 46.27. Note the com-
plete resolution of the abscess
Fig. 46.30 Endoscopic DCR in a lacrimal abscess: postoperative

1 week clinical photograph of the right eye of patient in Fig. 46.27.
Compare the right eye with Fig. 46.28 and also note in situ bicanalicular
stent
Fig. 46.32 Endoscopic DCR in a lacrimal abscess: endoscopic view of

the right nasal cavity of the patient in Fig. 46.31. Note the positive fluo-
rescein endoscopic dye test (FEDT)
Fig. 46.31 Endoscopic DCR in a lacrimal abscess: endoscopic view of Fig. 46.33 Orbital Cellulitis following an endoscopic DCR: clinical
the right nasal cavity at 4 weeks following stent removal, demonstrating photograph of a diabetic patient who presented 1 week after a left endo-
a large ostium with a deep base and well-healed edges scopic DCR. Note the left proptosis, ptosis, and chemosis
Fig. 46.34 Orbital cellulitis following an endoscopic DCR: clinical

photograph demonstrating restriction of left ocular movements
Fig. 46.37 Orbital cellulitis following an endoscopic DCR: CT scan

orbits, coronal cut demonstrates the orbital breach with diffuse
ethmoiditis

photograph demonstrating restriction of left ocular movements
Fig. 46.38 Orbital cellulitis following an endoscopic DCR: endo-

scopic view of the left nasal cavity demonstrating severe discharge-
covered wounds
Fig. 46.36 Orbital cellulitis following an endoscopic DCR: CT scan

orbits, coronal cut demonstrated a large inferomedial orbital breach.
This is a very bad complication of an endoscopic DCR and happens
when the anatomical boundaries are not respected

photograph of the patient 2 weeks following debridement and intrave-
nous antibiotics. Note the near total resolution of proptosis, ptosis, and
chemosis. Compare it with Fig. 46.33
Fig. 46.39 Orbital cellulitis following an endoscopic DCR: endo-

scopic debridement was performed. Note the orbital tissues lateral to
the middle meatus

photograph of the patient at 2 weeks, demonstrating full regaining of
ocular movements. Compare it with Fig. 46.34
Fig. 46.40 Orbital cellulitis following an endoscopic DCR: post-

debridement the orbital fat prolapse in the wound with infection and
hemorrhages. Microbiology proved it to be a bacterial infection. In
addition to debridement, the patient was treated with intensive antibiot-
ics and good blood sugar control was achieved

photograph of the patient at 2 weeks, demonstrating full regaining of
ocular movements. Compare it with Fig. 46.35
Ultrasonic Endoscopic
Ultrasonic surgeries use piezoelectric or ultrasonic waves in References

the range of 20–30 KHz to cut mineralized tissues only, thus
sparing the soft tissues. The advantage of safety in crucial 1. Murchinson AP, Pribitkin EA, Rosen MR, et al. The ultrasonic
bone aspirator in transnasal endoscopic dacryocystorhinostomy.
areas made its adaptation for orbital and lacrimal surgeries Ophthal Plast Reconstr Surg. 2013;29:25–9.
natural [1–3]. The instrumentation consists of a piezoelectric 2. Ali MJ, Singh M, Chisty N, et al. Endoscopic ultrasonic dac-
handpiece, peristaltic pump house, console, various cutting ryocystorhinostomy: clinical profile and outcomes. Eur Arch
tips, and food pedal. It is used for the osteotomy step of Otorhinolaryngol. 2016;273:1789–93.
3. Ali MJ, Ganguly A, Ali MH, et al. Time taken for superior oste-
endoscopic DCR and has numerous advantages that include otomy in primary powered endoscopic dacryocystorhinostomy: is
easy osteotomy, easy superior osteoplasty, minimal heat/no there a difference between an ultrasonic aspirator and mechanical
necrosis, minimizes bleeding, safe for sac and soft tissues, drill? Int Forum Allergy Rhinol. 2015;5:764–7.
enhanced visualization (LED), quicker surgery, low surgeon
fatigue, superior histological healing, and hence good for
training of inexperienced surgeons. The diamond cutting tip
is placed perpendicular to the target bone and bone emulsifi-
cation is achieved by brush-stroke movements. A trench is
initially created and subsequently deepened all around to
achieve a good osteotomy. The reported outcomes of lacri-
mal surgeries with ultrasonic techniques are good and simi-
lar to those with powered drills [1–3].

408 47 Ultrasonic Endoscopic Dacryocystorhinostomy
Fig. 47.1 The piezoelectric system

Fig. 47.4 The touch-sensitive console with numerous function
controls
Fig. 47.2 The piezoelectric handpiece set Fig. 47.5 The food pedal which can control all the console functions
Fig. 47.3 The peristaltic pump housing Fig. 47.6 The piezoelectric handpiece
47 Ultrasonic Endoscopic Dacryocystorhinostomy 409
Fig. 47.7 The various piezoelectric tips Fig. 47.10 The flat wrench
Fig. 47.8 The diamond tip, which is commonly used in endoscopic Fig. 47.11 The cutting tip is mounted on the hand piece and secured
dacryocystorhinostomy with the help of wrench
Fig. 47.9 The semicircular flat tip useful in certain cases for superior Fig. 47.12 The assembled piezoelectric handpiece
osteotomy in DCR
Fig. 47.13 The LED-illuminated handpiece which provides with addi-

tional light when needed, deep inside the nose
horizontal nasal mucosal incision above and in front of the axilla of the
middle turbinate
Fig. 47.14 Endoscopic view of the left nasal cavity, decongested and
ready for the ultrasonic endoscopic dacryocystorhinostomy
vertical nasal mucosal incision
Fig. 47.17 Endoscopic view of the left nasal cavity demonstrating Fig. 47.19 Endoscopic view of the left nasal cavity demonstrating the
reflection of the nasal mucosal flap exposing the frontal process of beginning of bone emulsification
maxilla
Fig. 47.18 Endoscopic view of the left nasal cavity demonstrating the Fig. 47.20 Endoscopic view of the left nasal cavity demonstrating cre-
placement of diamond tip on the frontal process of maxilla ation of the first trench
Fig. 47.21 Endoscopic view of the left nasal cavity demonstrating Fig. 47.23 Endoscopic view of the left nasal cavity demonstrating a
expansion and deepening of the trench circumferential enlargement of the osteotomy
Fig. 47.22 Endoscopic view of the left nasal cavity demonstrating the Fig. 47.24 Endoscopic view of the left nasal cavity demonstrating the
focal bone removal exposing the underlying lacrimal sac superior osteotomy
Fig. 47.27 Clinical photograph demonstrating a small epithelial burn.

This rarely happens, if there is a sudden loss of irrigation during
osteotomy
progressive superior osteotomy
Fig. 47.28 Clinical photograph demonstrating a small epithelia burn
Fig. 47.26 Endoscopic view of the left nasal cavity demonstrating a

complete osteotomy and the well-exposed lacrimal sac
Fig. 47.29 Endoscopic photograph of the right nasal cavity showing

an epithelial mucosal burn secondary to loss of irrigation
Non-endoscopic Endonasal
Endonasal approach DCR has several advantages which References

include the absence of a visible scar, minimal post-operative
morbidity, faster recovery, and comparable success rates to 1. Ganguly A, Videkar C, Goyal R, Rath S. Nonendoscopic endonasal
dacryocystorhinostomy: outcome in 134 eyes. Indian J Ophthalmol.
that of external DCR. Non-endoscopic endonasal dacryocys- 2016;2:215–1.
torhinostomy (NEN DCR), first described in 2003, relies on 2. Jain S, Ganguly A, Singh S, et al. Primary nonendoscopic endona-
direct visualization rather than video endoscopy to perform sal versus delayed external dacryocystorhinostomy in acute dacryo-
endonasal dacryocystorhinostomy. The surgical technique cystitis. Ophthal Plast Reconstr Surg. 2017;33:285–8.
3. Ganguly A, Kaza H, Kapoor A, et al. Comparative evaluation of
obviates the need for expensive lasers, ultrasound, or the ostium after external and non-endoscopic endonasal dacryocys-
mechanical drills. Good surgical outcomes of NEN DCR torhinostomy using Image processing (Matlabs and Image J) soft-
have been reported extensively [1–3]. The outcomes of NEN wares. Ophthal Plast Reconstr Surg. 2017;33:345–9.
DCR are comparable to that of endoscopic DCR with regard
to routine cases, revision cases, and those with acute dacryo-
cystitis. The final sizes of the post-operative ostium in NEN
DCR are comparable to those of external DCR.

416 48 Non-endoscopic Endonasal Dacryocystorhinostomy
Fig. 48.1 Clinical
photograph showing the
position of the operating
surgeon (Panel a) and the set
of instruments used in
non-endoscopic endonasal
dacryocystorhinostomy (Panel
b). (Photo Courtesy:
Suryasnata Rath, LVPEI,
Bhubaneshwar)
48 Non-endoscopic Endonasal Dacryocystorhinostomy 417
Fig. 48.2 Endoscopic image of the left nasal cavity showing the bright Fig. 48.4 Endoscopic image of the left nasal cavity showing the trans-
transillumination (black star) owing to vitrectomy endoilluminator illumination through the bone (black star) and reflected nasal mucosa
placed on medial wall of the lacrimal sac. (Photo Courtesy: Suryasnata (black diamond). (Photo Courtesy: Suryasnata Rath, LVPEI,
Rath, LVPEI, Bhubaneshwar) Bhubaneshwar)
Fig. 48.3 Endoscopic image of the left nasal cavity showing a Fig. 48.5 Endoscopic image of the left nasal cavity showing the edges
“C”-shaped incision of the nasal mucosa is made with myringotomy of the bony ostium (black arrowhead), and the lacrimal sac is seen
sickle knife around the transillumination (black star) target. The long through the bony ostium (black stars). (Photo Courtesy: Suryasnata
blades of the nasal speculum are seen above and below the surgical site. Rath, LVPEI, Bhubaneshwar)
(Photo Courtesy: Suryasnata Rath, LVPEI, Bhubaneshwar)
418 48 Non-endoscopic Endonasal Dacryocystorhinostomy
Fig. 48.6 Endoscopic image of the left nasal cavity showing the large Fig. 48.8 Endoscopic image of the left nasal cavity showing a large
bony ostium and the exposed body of the lacrimal sac. The removal of bony ostium with an exposed lacrimal sac with transillumination target
the superior bone (black arrowhead) is critical to the success of the (black star). Also seen are the reflected nasal mucosa (black diamond)
procedure. A fine angled up-biting Kerrison rongeurs or microdrill may and ethmoid air cells (black triangle). (Photo Courtesy: Suryasnata
be used to remove the superior bone. (Photo Courtesy: Suryasnata Rath, Rath, LVPEI, Bhubaneshwar)
LVPEI, Bhubaneshwar)
Fig. 48.7 Endoscopic image of the left nasal cavity showing the large Fig. 48.9 Endoscopic image of the left nasal cavity showing the vitrec-
bony ostium and the exposed body of the lacrimal sac. The removal of tomy endoilluminator tenting the lacrimal sac to facilitate a full-
the superior bone (black arrowhead) is critical to the success of the thickness marsupialization. (Photo Courtesy: Suryasnata Rath, LVPEI,
procedure. (Photo Courtesy: Suryasnata Rath, LVPEI, Bhubaneshwar) Bhubaneshwar)
48 Non-endoscopic Endonasal Dacryocystorhinostomy 419
Fig. 48.10 Endoscopic image of the left nasal cavity showing the vit-
Fig. 48.12 Endoscopic image of the left nasal cavity showing free
rectomy endoilluminator tenting the lacrimal sac and full-thickness
patency upon irrigation with fluorescein-stained saline (black arrow-
incision (black arrowhead) along the length of the lacrimal sac. Inferior
head). (Photo Courtesy: Suryasnata Rath, LVPEI, Bhubaneshwar)
extension of this incision coupled with horizontal relaxing incisions
help to fashion a large posteriorly hinged lacrimal sac flap. (Photo
Courtesy: Suryasnata Rath, LVPEI, Bhubaneshwar)
Fig. 48.11 Endoscopic image of the left nasal cavity showing com- Fig. 48.13 Endoscopic image of the left nasal cavity showing adjunc-
plete marsupialization of the lacrimal sac. Also highlighted are the edge tive Mitomycin C application at the end of the procedure. (Photo
of the sac (row of dots) and common internal punctum (black arrow- Courtesy: Suryasnata Rath, LVPEI, Bhubaneshwar)
head). (Photo Courtesy: Suryasnata Rath, LVPEI, Bhubaneshwar)
Endocanalicular Laser
Advances in endoscopy and laser technology led to the con- References

cepts of endocanalicular laser dacryocystorhinostomy (ECL-
DCR). The principle of ECL-DCR remains the same as that 1. Henson RD, Henson RG Jr, Cruz HL Jr, et al. Use of the diode laser
with intra-operative mitomycin C in endocanalicular laser dacryo-
of any DCR [1-3]. In ECL-DCR, a fiber-optic laser is inserted cystorhinosotmy. Ophthal Plast Reconstr Surg. 2007;23:134–7.
in the punctum, passed through the canaliculus, and finally 2. Henson RD, Cruz HL Jr, Henson RG Jr, et al. Postoperative appli-
into the lacrimal sac. A standard-diameter nasal endoscope is cation of Mitomycin-C in Endocanalicular laser dacryocystorhinos-
used to visualize the laser glow from the nasal side (Fig. 49.1). tomy. Ophthal Plast Reconstr Surg. 2012;28:192–5.
3. Kaynak P, Ozturker C, Yazgan S, et al. Transcanalicular diode laser
Then the fiber-optic laser is utilized to puncture into the nasal assisted dacryocystorhinostomy in primary acquired nasolacrimal
cavity thereby creating an osteotomy. Since there is no full- duct obstruction: 2-year follow up. Ophthal Plast Reconstr Surg.
length marsupialization of the lacrimal sac and anastomosis 2014;30:28–33.
of its flaps with nasal mucosa, the patency of the ostium is of
utmost importance in ECL-DCR. The surgical success of a
primary ECL-DCR will depend on proper patient selection,
thorough pre-operative nasal endoscopy, appropriate laser
machine, good technique, and appropriate timing of adjuvant
therapy (Mitomycin-C). However, the concerns include the
abilities of the laser to create large osteotomies, charring of
the mucosal tissues due to laser, and the long-term outcomes,
which have not been very encouraging. Hence, careful
patient selection and appropriate informed consent is
essential.

422 49 Endocanalicular Laser Dacryocystorhinostomy
Fig. 49.4 Various configuration laser probes
Fig. 49.1 A recently launched diode laser machine used in endocana-

licular laser (ECL) DCR. (Photo courtesy: Raoul Henson, SLMC,
Philippines)
Fig. 49.5 The tip of the laser probe
Fig. 49.2 The console of the laser machine demonstrating various

function controls (Photo courtesy: Raoul Henson, Philippines)
Fig. 49.6 An active laser probe. Note the laser emanating from the
fiber-optic cable
Fig. 49.3 A laser probe

49 Endocanalicular Laser Dacryocystorhinostomy 423
Fig. 49.7 The other commonly used instruments during an ECL-DCR (Photo courtesy: Raoul Henson, SLMC, Philippines)
Fig. 49.8 When using it, the author prefers to use the Sisler’s canalicu- Fig. 49.10 The laser probe incorporated Sisler’s trephine in action
lar trephine as the vehicle for the laser probe tip rather than directly
using a naked probe
Fig. 49.9 The tip goes a little beyond the edge of the trephine
Fig. 49.13 Technique of ECL-DCR: intra-operative image demon-

strating the transcanalicular placement of the laser probe (Photo cour-
tesy: Raoul Henson, SLMC, Philippines).
Fig. 49.11 Schematic diagram showing the principle of an endocana-

licular laser DCR (Photo courtesy: Josie Henson, Angeles City,
Philippines)
Fig. 49.14 Endoscopic view of a right nasal cavity demonstrating the

illuminated light window of the laser probe
Fig. 49.12 Technique of ECL-DCR: intra-operative image demon-

strating the transcanalicular placement of the laser probe (Photo cour-
tesy: Raoul Henson, SLMC, Philippines)
Fig. 49.15 Technique of

ECL-DCR: the operating
room setup and an ECL-DCR
in action (Photo courtesy:
Raoul Henson, SLMC,
Philippines)
Fig. 49.16 Technique of ECL-DCR: endoscopic view of a right nasal Fig. 49.17 Technique of ECL-DCR: endoscopic view of a right nasal
cavity (another patient) demonstrating the first puncture osteotomy cavity demonstrating the second puncture osteotomy. The ostium is
with the help of laser probe (Photo courtesy: Raoul Henson, SLMC, then sequentially enlarged (Photo courtesy: Raoul Henson, SLMC,
Philippines) Philippines)
cavity at the end of laser osteotomy. Note the reasonably large ostium cavity demonstrating the inferior ostial edge circumostial mitomycin C
created (Photo courtesy: Raoul Henson, SLMC, Philippines) injection (Photo courtesy: Raoul Henson, SLMC, Philippines)
cavity demonstrating the anterior ostial edge circumostial mitomycin C cavity at the end of surgery. Note the bicanalicular intubation in situ
injection (Photo courtesy: Raoul Henson, SLMC, Philippines) (Photo courtesy: Raoul Henson, SLMC, Philippines)
Fig. 49.23 Clinical photograph of a patient post ECL-DCR demon-

strating a positive regurgitation due to sump syndrome. Note the stent
Fig. 49.22 Clinical photograph of another patient demonstrating the in place
securing of stents in the nasal cavity by silk sutures (Photo courtesy:
Raoul Henson, SLMC, Philippines)
Entire Lacrimal Sac in Sinus
50
The bony lacrimal fossa has an intricate relationship with the References
ethmoid sinuses, and it is not uncommon to encounter ante-
rior ethmoid air cells during a DCR [1–3]. However, occa- 1. Ali MJ, Singh S, Naik MN. Entire lacrimal sac within the ethmoid
sinus: outcomes of powered endoscopic dacryocystorhinostomy.
sionally, the lacrimal sac may be malpositioned entirely Clin Ophthalmol. 2016;10:1199–203.
within the boundaries of ethmoid sinuses and can pose a sur- 2. Dave TV, Mohammed FA, Ali MJ, et al. Etiological analysis of 100
gical challenge [1]. The bony ethmoid lateral to the sac in anatomically failed dacryocystorhinostomies. Clin Ophthalmol.
such cases should be carefully preserved to avoid orbital 2016;10:1419–22.
3. Ali MJ, Psaltis AJ, Wormald PJ. Dacryocystorhinostomy ostium:
injury. The lateral ethmoidal wall mucosa should be utilized parameters to evaluate the DCR ostium scoring. Clin Ophthalmol.
for a mucosa to mucosa approximation. The anatomical vari- 2014;8:2491–9.
ations of ethmoidal vessels must be kept in mind to avoid
injury. Post-operative evaluation of the ostia can be confus-
ing as most heal as a pseudo-cicatricial ostia [3]. Good sinus
surgery training, through endoscopic anatomy, careful
maneuvering, and occasional use of image guidance tech-
niques, is helpful in achieving good outcomes.

430 50 Entire Lacrimal Sac in Sinus
Fig. 50.1 Endoscopic view of the right nasal cavity demonstrating the Fig. 50.3 Endoscopic view demonstrating the entire lacrimal sac
illuminated lacrimal sac behind the ethmoid mucosa behind the bulla ethmoidalis (white star). Note the middle turbinate
(white arrow) and its location in relationship to the lacrimal sac
(illuminated)
Fig. 50.2 Endoscopic view of the right nasal cavity of patient in

Fig. 50.1. The ethmoid mucosa is being incised Fig. 50.4 Three-dimensional CT dacryocystography (DCG), volume
rendered, demonstrating an obstructed right nasolacrimal duct obstruc-
tion and a patent left system. Note the posterior location of the right
lacrimal sac in relation to the left. This case most likely would show a
lacrimal sac in sinus during the endoscopic surgery
50 Entire Lacrimal Sac in Sinus 431
Fig. 50.7 3D reconstruction by stereotactic software, from a

CT-DCG. Note the superior displacement of the lacrimal sac
Fig. 50.5 Three-dimensional CT-DCG, volume rendered, right lateral

view demonstrating the posterior location of the right lacrimal sac. Note
its clear relationship with the more anterior and patent left lacrimal
system
Fig. 50.6 3D reconstruction by stereotactic software, from a

CT-DCG. Note the right-sided nasolacrimal duct obstruction and the Fig. 50.8 Endoscopic view of a right nasal cavity demonstrating a lac-
posterosuperior displacement in a case of a trauma. This case would rimal sac within the ethmoid sinus. Note the additional superior malpo-
most likely show a lacrimal sac in sinus during the endoscopic surgery sition of the lacrimal sac. Compare the malpositions with relation to the
middle turbinate (white arrow)
432 50 Entire Lacrimal Sac in Sinus
Fig. 50.9 Endoscopic view of the right nasal cavity of patient in Fig. 50.11 Endoscopic view of the right pseudocicatrical ostium of
Fig. 50.8. Note the rather thin superior bone near the fundus of the lac- patient in Fig. 50.10. Note the positive fluorescein endoscopic dye test
rimal sac (white arrow) (FEDT) deep inside
Fig. 50.10 Endoscopic view of a right nasal cavity demonstrating a

pseudocicatrical ostium. It is very common to see this kind of post- Fig. 50.12 Endoscopic view of a left post-operative, posterosuperior
operative ostium in cases of lacrimal sac within ethmoid sinuses. The ostium with a positive FEDT
anterior nasal mucosa heals with a cicatrix while the actual ostium with
the internal common opening is way behind owing to its anatomical
location. The anterior cicatrix may be misdiagnosed as evolving cicatri-
cial closure of the ostium
50 Entire Lacrimal Sac in Sinus 433
Fig. 50.14 Endoscopic view of a left post-operative ostium of patient

in Fig. 50.13. Note the positive FEDT
Fig. 50.13 Endoscopic view of a left post-operative ostium. Note the
posterior and superior location of the ostium (white arrow)
Difficult Endoscopic DCR Scenarios
51
Endoscopic DCR is fast becoming the first choice in the References

management of nasolacrimal duct obstructions owing to its
multiple advantages over other approaches, better instru- 1. Ali MJ. Endoscopic approach to management of lacrimal sac diver-
ticula. Ophthal Plast Reconstr Surg. 2016;32:e49.
mentation, and better training opportunities. With increasing 2. Ali MJ, Singh S, Naik MN. Entire lacrimal sac within the ethmoid
use, there are numerous circumstances which can be classi- sinus: outcomes of powered endoscopic dacryocystorhinostomy.
fied under difficult scenarios [1–5], and these include thick Clin Ophthalmol. 2016;10:1199–203.
frontal process of maxilla which may be very difficult to 3. Ali MJ, Naik MN. Image-guided dacryolocalization in traumatic
secondary acquired lacrimal drainage obstructions (SALDO).
manage without powered drills. Endoscopic DCR becomes a Ophthal Plast Reconstr Surg. 2015;31:406–9.
challenge in post-trauma setting since endoscopic anatomy 4. Ali MJ, Singh S, Naik MN. Interactive navigation-guided ophthal-
may be distorted like loss of positional relationship of mid- mic plastic surgery: the utility of 3D CT-DCG-guided dacryolo-
dle turbinate (MT) with the lacrimal sac, loss of spatial rela- calization in secondary acquired lacrimal duct obstructions. Clin
Ophthalmol. 2016;11:127–33.
tionship between the MT and bulla ethmoidalis, roof at a 5. Ali MJ, Psaltis AJ, Wormald PJ, et al. Bony nasolacrimal duct
lower level, MT fractures, septal perforations, and breach in dehiscence in functional endoscopic sinus surgery: radiological
the periorbita with fat prolapse in the vicinity of lacrimal sac. study and discussion of surgical implications. J Layngol Otol.
Other challenges include post-sinus surgery scenarios, lacri- 2015;129:S35–40.
mal sac diverticula, intra-sac granulomas, and nasolacrimal
duct obstructions in the setting of autoimmune disorders.
Some extremely difficult but special scenarios like DCR’s in
unilateral arhinia have been demonstrated separately in this
Atlas.
Figures 51.17, 51.18, 51.27, 51.28, 51.29 and 51.30 are
from Ali et al. Ophthal Plast Reconstr Surg 2015;31:406–
409; and Clin Ophthalmol 2016;11:127–133.

436 51 Difficult Endoscopic DCR Scenarios
Fig. 51.2 Necessary armamentarium in difficult endoscopic DCRs:

the straight DCR-cutting burr

the integrated drills and irrigation system
Fig. 51.3 Necessary armamentarium in difficult endoscopic DCRs: Fig. 51.4 Necessary armamentarium in difficult endoscopic DCRs:
the curved DCR diamond burr the sharp upward-angulated diamond burr
51 Difficult Endoscopic DCR Scenarios 437
Fig. 51.5 Necessary armamentarium in difficult endoscopic DCRs: Fig. 51.7 Necessary armamentarium in difficult endoscopic DCRs:
the radiofrequency endoscopic monopolar probe the Wormald integrated suction cautery®

the telescope lens-clearing system

the radiofrequency endoscopic bipolar probe

the assembled simultaneous telescope lens-clearing system

the Merocel® sponges
Fig. 51.12 Endoscopic view of the left nasal cavity of patient in

Fig. 51.11. Note the osteotomy being performed in the depths
Fig. 51.11 Endoscopic view of a left nasal cavity demonstrating a very Fig. 51.13 Endoscopic view of the left nasal cavity of patient in
thick superior portion of the frontal process of maxilla. This is not ame- Figs. 51.11 and 51.12. Note the exposure of the fundus (black arrow)
nable to punches easily and would require a powered drill as being
shown
Fig. 51.16 Endoscopic view of a left nasal cavity demonstrating large

Fig. 51.14 Endoscopic view of the left nasal cavity of patient in anteroinferior lacrimal sac diverticula (black star). Note the marsupial-
Figs. 51.11, 51.12 and 51.13. Note the image at the end of surgery ized lacrimal sac flaps (black arrow)
shows the extent of superior osteotomy that was needed.

lacrimal sac entirely within the ethmoid sinuses
Fig. 51.17 Endoscopic view of a left nasal cavity demonstrating a

large intra-sac granuloma arising below the internal common opening
(probe), from the anterior wall
Fig. 51.18 Endoscopic view of the left nasal cavity of patient in Fig. 51.21 Endoscopic view of a right nasal cavity demonstrating the
Fig. 51.17, following excision of the granuloma ethmoidal mucocele projection in a case of compressive lacrimal
obstruction secondary to the sinus mucocele. Note the location of the
mucocele overlaps with that of lacrimal drainage topography
Fig. 51.19 Endoscopic view of a right nasal cavity in a case of lichen

planus. Note the thick lacrimal sac walls noted upon marsupialization
and numerous intra-sac elevations and synechiae
Fig. 51.22 Post-traumatic endoscopic DCR—case study 1: intra-

operative endoscopic view of the right nasal cavity demonstrating a
fractured middle turbinate and its synechiae to the lateral wall. One
should expect lacrimal sac malpositions in the newer acquired
anatomy
Fig. 51.20 Microphotograph of the lacrimal sac biopsy of patient in

Fig.51.19, demonstrating chronic inflammatory infiltrate with extensive
submucosal fibrosis
Fig. 51.23 Post-traumatic endoscopic DCR—case study 1: intra- Fig. 51.25 Post-traumatic endoscopic DCR—case study 1: intra-
operative endoscopic view of the right nasal cavity demonstrating a operative endoscopic view of the right nasal cavity demonstrating the
gentle synechiolysis of the turbinate from the lateral wall superior osteotomy
Fig. 51.26 Post-traumatic endoscopic DCR—case study 1: intra-

Fig. 51.24 Post-traumatic endoscopic DCR—case study 1: intra- operative endoscopic view of the right nasal cavity demonstrating the
operative endoscopic view of the right nasal cavity demonstrating the careful superior osteotomy of the thick bone. Note how close the roof of
end of middle turbinoplasty to gain access to lacrimal sac the nasal cavity is from the point of superior osteotomy
Fig. 51.27 Post-traumatic
endoscopic DCR—case study
1: intra-operative navigation
and endoscopic integrated
view demonstrating the
lacrimal sac. Note the probe
in the common canaliculus
and note how high the
lacrimal sac is in this
post-trauma setting
Fig. 51.28 Post-traumatic
endoscopic DCR—case study
1: intra-operative navigation
and endoscopic integrated
view demonstrating the
frontal sinus opening. Note
the silicone stents and their
anatomical relation with the
frontal sinus opening in this
post-trauma setting
Fig. 51.31 Post-maxillectomy endoscopic DCR—case study 2: 3D

stereotactic reconstruction of the DCG of patient in Figs. 51.29 and
Fig. 51.29 Post-maxillectomy endoscopic DCR—case study 2: intra- 51.30. Note the posterosuperior location of the lacrimal sac as com-
operative endoscopic view of the right nasal cavity demonstrating pared to the normal side
absence of lateral wall landmarks and a large palatal perforation through
which the endotracheal tube can be seen
Fig. 51.30 Post-maxillectomy endoscopic DCR—case study 2: 3D

CT-DCG view of the patient in Fig. 51.29. Note the abrupt iatrogenic
injury to the lower part of lacrimal sac. Also note the absence of the
maxilla on the right side and a normal patent lacrimal system on the left
side
Fig. 51.32 Post-
maxillectomy endoscopic
DCR—case study 2:
intra-operative navigation—
endoscopy integrated view
demonstrating the
dacryolocalization using
stereotactic measures. The
image uses the look ahead
protocol that suggests that the
lacrimal sac is 5 mms ahead
from the current location of
the surgeon’s probe
Fig. 51.33 Post-maxillectomy endoscopic DCR—case study 2: intra- Fig. 51.34 Post-maxillectomy endoscopic DCR—case study 2: intra-
operative endoscopic view of the right nasal cavity demonstrating infe- operative endoscopic view of the right nasal cavity demonstrating the
rior incision in the area of localized lower part of lacrimal sac. The probe from the inferior aspect of the lacrimal sac
lower part is devoid of an overlying bone as noted in the CT-DCG
Fig. 51.36 Post-maxillectomy endoscopic DCR—case study 2: intra-

Fig. 51.35 Post-maxillectomy endoscopic DCR—case study 2: intra- operative endoscopic view of the right nasal cavity demonstrating the
operative endoscopic view of the right nasal cavity demonstrating the exposure of the fundus of the lacrimal sac (black arrow) following dac-
superior osteotomy ryolocalization and osteotomy. The rest of the steps would be as that of
a routine endoscopic DCR
Etiology of Failed
The common causes of a DCR failure are cicatricial closure References

of the ostium, inadequately sized osteotomy, inadequate lac-
rimal sac marsupialization, common canalicular obstruction, 1. Dave TV, Mohammad FA, Ali MJ, et al. Etiologic analysis of 100
anatomically failed dacryocystorhinostomies. Clin Ophthalmol.
intervening ethmoids, inappropriately placed osteotomy 2016;10:1419–22.
with respect to the lacrimal sac leading to sump syndrome, 2. Ali MJ, Psaltis AJ, Murphy J, et al. Outcomes in primary pow-
turbinoseptal synechiae in and around the ostium, inappro- ered endoscopic dacryocystorhinostomy: comparison between
priate granulation tissue, and internal ostium stenosis [1–3]. experienced and less experienced surgeons. Am J Rhinol Allergy.
2014;28:514–6.
Not uncommonly, multiple causes for failure may be noted. 3. Ali MJ, Mishra DK, Baig F, Naik MN. Histopathology, immu-
Other less common causes of failure include a deviated nasal nohistochemistry, and electron microscopic features of a dacryo-
septum and inadequately excised middle turbinate where cystorhinostomy ostium cicatrix. Ophthal Plast Reconstr Surg.
needed. Rare causes may be occult carcinoma, bony obstruc- 2016;32:333–6.
tion caused by Paget’s disease, ethmoidal sinus osteoma, and
soft tissue obstruction caused by inflammatory diseases like
sarcoidosis and Wegener granulomatosis. Factors that have
reported to be associated with higher risk of failure include
small lacrimal sac opening, prolong surgery, active inflam-
mation, inadequate or inappropriate flaps, and intra-operative
prolapse of orbital fat.

448 52 Etiology of Failed Dacryocystorhinostomy
Fig. 52.1 Endoscopic view of the right nasal cavity demonstrating a Fig. 52.3 Endoscopic view of the right nasal cavity demonstrating a
complete cicatricial closure of the ostium. Note the linear whitish scars complete ostio-septal synechiae
Fig. 52.2 Endoscopic view of the right nasal cavity demonstrating a

complete cicatricial closure of the ostium. Note the linear whitish scars
gross anterior synechiae which can make access in revision surgeries
difficult
52 Etiology of Failed Dacryocystorhinostomy 449
Fig. 52.7 Endoscopic view of the right nasal cavity demonstrating an

example of a non-interfering ostial synechiae. Note the ostium (white
arrow) and the synechiae (white star)
gross synechiae directly interfering with the ostium
Fig. 52.5. Note the high magnification shows synechiae (white star)
obliterating the ostium (white arrow)

another example of a non-interfering synechiae. Note the synechiae
across (black arrow) the ostium, but below the internal common open-
ing, and hence non-interfering with its functions. Note the normal fluo-
rescein endoscopic dye test
Fig. 52.9 Endoscopic view of a left nasal cavity demonstrating a syn-

echial closure of the ostium secondary to turbino-ostial synechiae
(black arrow) Fig. 52.11 Endoscopic view of a left nasal cavity demonstrating a
complete ostio-septal synechial closure (synechiae) of the ostium
bridging the septum (S) and the lateral wall (LW). Also note the addi-
tional synechiae between the septum (S) and middle turbinate (MT)
Fig. 52.12 Endoscopic view of a right nasal cavity demonstrating

extensive ostio-septal synechial closure
Fig. 52.10 Schematic diagram of a right nasal cavity demonstrating a
complete turbino-ostial synechial closure (black arrow) involving the
middle turbinate (M)
Fig. 52.15 CT scan orbits, coronal cut, in a left side post-DCR patient
who presented with a mucocele. Note the large lacrimal sac mucocele
and an inferior inadequate osteotomy. Note the frontal process of max-
illa (red arrow) covering the superior half of the sac has not been
removed
Fig. 52.13 Endoscopic view of the right nasal cavity in a post-DCR
patient, demonstrating a large but non-interfering antrochoanal polyp
Fig. 52.16 CT scan orbits, axial cut of the patient in Fig. 52.15. Note
the large left-sided lacrimal sac mucocele and an intact overlying bone
Fig. 52.14 Endoscopic view of a left nasal cavity in a post-DCR

patient, demonstrating the entire ostium being occupied by polypoidal
mucosa
Fig. 52.17 Endoscopic view of a right nasal cavity 3 weeks post-DCR

surgery. Note the early and exuberant fibrovascular tissue obliterating
the entire ostium Fig. 52.19 Endoscopic view of a right nasal cavity (2 weeks post-
DCR) showing a bang on ostium granuloma most likely secondary to
tube-induced reaction. Note the tube is being pushed to one side by the
organizing granuloma. This would need excision of the granuloma as
well as extubation of the stent and topical steroids
Fig. 52.20 Endoscopic view of a right nasal cavity showing impaction

of the tube into the ostial cicatrix
Fig. 52.18 Endoscopic view of a left nasal cavity (3 weeks post-DCR)
showing a bang on ostium granuloma that is engulfing the entire ostium.
If not treated with urgency, this would consolidate and obliterate the
ostium resulting in a failure

Fig. 52.20. Note the stent is being carefully extubated Fig. 52.23 Endoscopic view of a left nasal cavity demonstrating
another example of a tube impaction. Note the strangulation of the stent
by the ostium cicatrix

Figs. 52.20 and 52.21, following stent extubation. Note the near total
cicatricial closure of the ostium
The DCR Ostium Cicatrix
53
Complete cicatricial closure of the ostium is one of the References

common causes of a failed DCR [1–3]. The precise nasal
mucosal wound healing is unclear; human models of 1. Dave TV, Mohammed FA, Ali MJ, et al. Etiologic analysis of 100
failed anatomical dacryocystorhinostomies. Clin Ophthalmol.
wound healing has shown four distinct phases: first phase 2016;10:1419–22.
(7–12 days) of wound enveloping by blood crusts, second 2. Ali MJ, Psaltis AJ, Wormald PJ. Long-term outcomes in revision
phase (2–4 weeks) of granulation tissue formation, third powered endosocopic dacryocystorhinostomies. Int Forum Allergy
phase (4–8 weeks) of tissue edema, and fourth phase (12– Rhinol. 2014;4:1016–9.
3. Ali MJ, Mishra DK, Baig F, et al. Histopathology, immuno-
14 weeks) of macroscopic normalization. Tissues from histochemistry, and electron microscopic features of a dacryo-
complete cicatrical closures, analyzed by electron micros- cystorhinostomy ostium cicatrix. Ophthal Plast Reconstr Surg.
copy, showed irregular laying of collagen in bundles with 2016;32:333–6.
numerous intervening fibroblasts and mononuclear lym-
phocytic infiltrates (immunophenotyping showed them to
be CD3+, CD5+, and CD20+ essentially reflecting mixed T
and B lymphocytes) [3]. Amorphous bony osteoid was
noted in the fibrillary background with numerous metaboli-
cally active osteoblasts. These osteoblasts showed hyper-
proliferative mitochondria, large Golgi apparatus, and
dense endoplasmic reticulum [3]. There is hence ample
evidence of new bone formation within the scarred DCR
tissues, and these may open up newer avenues in under-
standing the wound healing patterns and possible adjunc-
tive pharmacotherapies.
Figures are from Ali et al., Ophthal Plast Reconstr Surg
2016;32:333–336.

456 53 The DCR Ostium Cicatrix
Fig. 53.3 Histopathology of a dacryocystorhinostomy cicatrix: micro-

photograph showing a complete respiratory epithelial covering with
few submucosal glands (H&E ×40)
Fig. 53.1 Endoscopic view of the right nasal cavity showing a com-
plete cicatricial closure of the ostium
Fig. 53.4 Histopathology of a dacryocystorhinostomy cicatrix: micro-

photograph showing deeply eosinophilic hyalinised collagen with inter-
vening fibroblasts (H&E×100)
Fig. 53.2 Endoscopic view of the right nasal cavity showing a near
total cicatricial closure of the ostium
53 The DCR Ostium Cicatrix 457
Fig. 53.5 Histopathology of a dacryocystorhinostomy cicatrix: micro- Fig. 53.7 Histopathology of a dacryocystorhinostomy cicatrix: micro-
photograph showing occasional areas of loose edematous connective photograph showing osteoid with osteocytes (H&E ×100)
tissue (H&E ×100)
Fig. 53.6 Histopathology of a dacryocystorhinostomy cicatrix: micro- Fig. 53.8 Histopathology of a dacryocystorhinostomy cicatrix: micro-
photograph showing new bone formation within the dense connective photograph showing osteoid laying and osteoblastic rimming (H&E
tissue (H&E ×100) ×400)
Fig. 53.9 Special staining of a dacryocystorhinostomy cicatrix: micro- Fig. 53.11 Immunohistochemistry of a DCR cicatrix: microphoto-
photograph showing dense and irregular collagen laying within sub- graph showing strong and diffuse immunostaining with vimentin
stantia propria (Masson’s trichrome ×100) (vimentin ×100)
Fig. 53.10 Special staining of a dacryocystorhinostomy cicatrix: Fig. 53.12 Immunohistochemistry of a DCR cicatrix: microphoto-
microphotograph showing hydroxyapatite or osteoid staining within the graph showing strong and diffuse immunostaining with smooth muscle
scar tissue (alizarin red ×100) actin (SMA ×100)
53 The DCR Ostium Cicatrix 459
Fig. 53.13 Immunohistochemistry of a DCR cicatrix: microphoto- Fig. 53.15 Immunohistochemistry of a DCR cicatrix: microphoto-
graph showing subepithelial areas infiltrated by CD3+ lymphocytes graph showing subepithelial areas with CD20+ lymphocytes (anti-
(anti-CD3 ×100) CD20 ×100)
Fig. 53.14 Immunohistochemistry of a DCR cicatrix: microphoto-

graph showing subepithelial areas with CD5+ lymphocytes (anti-CD5
×100)
a b
500nm 1.7µm
c d
CZ
CZ
VL
RER GO
HA RER
O
HA VL
O
1.7µm 1.0µm
e RER f O
VM
G O
RER
400nm 2.9µm
Fig. 53.16 Electron microscopic features of a DCR cicatrix: transmis- magnification TEMG of another osteoblast showing greater details of
sion electron micrograph (TEMG) showing irregularly arranged colla- CZ, RER, VL, enlarged Golgi apparatus (GO), and osteoid (O) (OM
gen fibrils (original magnification (OM) ×38,600) (Panel a). TEMG ×19,300) (Panel d). A very high magnification TEMG showing the
showing a fibroblast with peripheral dense areas of collagen (OM vesicular cytoplasm with well demarcated and abundant RER, vesicular
×11,580) (Panel b). TEMG of an osteoblast with a clear zone (CZ) mitochondria (VM), and glycogen pockets (G) (OM ×48,250) (Panel
between it and the matrix. Note the peripheral villous-like (VL) struc- e). TEMG showing dense osteoid and bony lamellae (O) within the
tures, abundant rough endoplasmic reticulum (RER), and hydroxyapa- cicatricial tissue (OM ×6755) (Panel f)
tite (HA) on collagen fibers (OM ×11,580) (Panel c). Higher
Revision External Dacryocystorhinostomy
54
The common causes of a DCR failure are cicatricial closure of References

the ostium, inadequately-sized osteotomy, inadequate sac
opening, common canalicular obstruction, intervening eth- 1. Welham RA, Wulc AE. Management of unsuccessful lacrimal sur-
gery. Br J Ophthalmol. 1987;71:152–7.
moids, inappropriately placed osteotomy with respect to the 2. Dave TV, Mohammad FA, Ali MJ, et al. Etiologic analysis of 100
lacrimal sac leading to sump syndrome, turbinoseptal syn- anatomically failed dacryocystorhinostomies. Clin Ophthalmol.
echiae in and around the ostium, inappropriate granulation tis- 2016;10:1419–22.
sue, and internal ostium stenosis [1–5]. Not uncommonly, 3. Kamal S, Ali MJ, Naik MN. Circumostial Mitomycin C (COS-
MMC) in external and endoscopic dacryocystorhinostomy: effi-
multiple causes for failure may be noted. In most cases, the cacy, safety profiles and outcomes. Ophthal Plast Reconstr Surg.
causes of failed DCR can be determined by lacrimal probing 2014;30:187–90.
and nasal endoscopy. Additional use of CT-DCG and dacryo- 4. Walland MJ, Rose GE. Factors affecting the success rate of open
endoscopy is reserved for complex cases. The basic principles lacrimal surgery. Br J Ophthalmol. 1994;78:888–91.
5. Konuk O, Kurtulmusoglu M, Knatova Z, et al. Unsuccessful lacri-
of any revision DCR include assessment of the location and mal surgery: causative factors and results of surgical management
extent of the past osteotomy, complete excision of the cicatrix in a tertiary referral center. Ophthalmologica. 2010;224:361–6.
if present, an efficient bone removal to achieve complete expo-
sure of the lacrimal sac, and finally a complete marsupializa-
tion of the lacrimal sac mucosa. Various adjunctive measures
including intra-operative application of mitomycin C (MMC),
and intubation with silicone stents have been proposed to
enhance the success rate of revision surgery [3]. Additional
balloon dacryoplasty has also been proposed in cases of post-
DCR internal ostium stenosis. The success rates of revision
external DCR are good and range from 80 to 90% [1–5].

462 54 Revision External Dacryocystorhinostomy
Fig. 54.1 Revision external DCR case study 1: clinical photograph of Fig. 54.4 Revision external DCR case study 1: clinical photograph
the left eye showing scar of the past external DCR demonstrating fresh osteotomy to harvest the virgin nasal mucosa
Fig. 54.2 Revision external DCR case study 1: clinical photograph Fig. 54.5 Revision external DCR case study 1: clinical photograph
demonstrating incision on the same scar and subcutaneous dissection to demonstrating fashioning of the fresh nasal mucosa
reach the periosteum
demonstrating exposed edges of the past rhinostomy demonstrating fashioning of the lacrimal sac mucosa
54 Revision External Dacryocystorhinostomy 463
Fig. 54.7 Revision external DCR case study 1: clinical photograph Fig. 54.10 Revision external DCR case study 2: clinical photograph of
demonstrating mitomycin C application a right revision DCR. Note the reflection of the periosteum to expose
the frontal process of maxilla
demonstrating anastomosis of the lacrimal sac and nasal mucosal flaps. demonstrating exposure of the edge of the past rhinostomy
Note that it is not wide and strong as in a primary DCR
demonstrating wound closure at the end of surgery demonstrating beginning of fresh osteotomy to harvest the virgin nasal
mucosa
464 54 Revision External Dacryocystorhinostomy
demonstrating progressive osteotomy demonstrating fashioning of the lacrimal sac flaps. Note the thick and
scarred anterior lacrimal sac flap
demonstrating removal of the ethmoid air cell from the ostium. demonstrating Sisler’s canalicular trephination under direct visualiza-
Ethmoidal air cells in the ostial region could be one of the factors that tion for the additional common canalicular obstruction
were discounted in the previous surgery
demonstrating salvage of the remnant inferior nasal mucosa demonstrating mitomycin C application
54 Revision External Dacryocystorhinostomy 465
demonstrating an intubation bodkin retrieval through the nasal cavity demonstrating securing of the anastomosis. Note the salvage flaps are
narrower unlike a primary external DCR
demonstrating a bicanalicular intubation demonstrating a completed mucosal flap anastomosis
Revision Endoscopic
The common causes of a DCR failure are cicatricial closure References

of the ostium, inadequately sized osteotomy, inadequate sac
opening, common canalicular obstruction, intervening eth- 1. Tsirbas A, Davis G, Wormald PJ. Revision dacryocystorhinostomy:
a comparison of endoscopic and external techniques. Am J Rhinol.
moids, inappropriately placed osteotomy with respect to the 2005;19:322–5.
lacrimal sac leading to sump syndrome, turbinoseptal syn- 2. Dave TV, Mohammad FA, Ali MJ, et al. Etiologic analysis of 100
echiae in and around the ostium, inappropriate granulation anatomically failed dacryocystorhinostomies. Clin Ophthalmol.
tissue, and internal ostium stenosis [1–5]. Not uncommonly, 2016;10:1419–22.
multiple causes for failure may be noted. In most cases, the powered endoscopic dacryocystorhinostomy. Int Forum Allergy
causes of failed DCR can be determined by lacrimal probing Rhinol. 2014;4:1016–9.
and nasal endoscopy. Additional use of CT-DCG and dacryo- 4. Lee A, Ali MJ, Wong ACW, et al. Balloon dacryoplasty in internal
endoscopy are reserved for complex cases. The basic princi- ostium stenosis after endoscopic dacryocystorhinostomy. Ophthal
ples of any revision of DCR include assessment of the 5. Penttilä E, Smirnov G, Seppä J, et al. Mitomycin C in revision
location and extent of the past osteotomy, complete excision endoscopic dacryocystorhinostomy: a prospective randomized
of the cicatrix if present, an efficient bone removal to achieve study. Am J Rhinol Allergy. 2011;25:425–8.
complete exposure of the lacrimal sac, and finally a complete
marsupialization of the lacrimal sac mucosa. Various adjunc-
tive measures including intra-operative application of mito-
mycin C (MMC) and intubation with silicone stents have
been proposed to enhance the success rate of revision sur-
gery [4]. Additional balloon dacryoplasty has also been pro-
posed in cases of post-DCR internal ostium stenosis [5]. The
advantage of any endoscopic approach revision is the chance
to simultaneously address nasal causes of DCR failure. The
success rates of revision endoscopic DCR are good and
range from 80 to 90% [1–5].

468 55 Revision Endoscopic Dacryocystorhinostomy
Fig. 55.1 Revision endoscopic DCR case study 1: endoscopic view of

the right nasal cavity demonstrating a complete cicatricial closure of the
ostium. Note the mucosal scars in the region of the previous ostium
Fig. 55.3 Revision endoscopic DCR case study 1: endoscopic view

demonstrating fashioning of the lacrimal sac flaps. Note the previous
osteotomy was adequate

demonstrating the use of mitomycin C
demonstrating the excision of the ostium cicatrix
55 Revision Endoscopic Dacryocystorhinostomy 469
Fig. 55.7 Revision endoscopic DCR case study 2: endoscopic view of

Fig. 55.5 Revision endoscopic DCR case study 1: endoscopic view the left nasal cavity demonstrating a gross turbino-ostial synechiae,
demonstrating retrieval of bodkin of a Crawford stent which was the cause of DCR failure

following a bicanalicular intubation Fig. 55.8 Revision endoscopic DCR case study 2: endoscopic view
demonstrating vertical incision to create clean planes between the syn-
echiae and the ostium

of the right nasal cavity in a case of failed DCR. Note the inferior anas-
tomosis of the lacrimal sac and nasal mucosal flaps (black arrow). The
Fig. 55.9 Revision endoscopic DCR case study 2: endoscopic view cause of failure has been an inappropriate osteotomy and inadequate
demonstrating fashioning of the lacrimal sac flaps sac marsupialization

demonstrating the clean separation of the anastomosis
demonstrating partial middle turbinoplasty. Note the area of the ostium
is now clear of the middle turbinate with well-designed lacrimal sac
flaps
Fig. 55.13 Revision endoscopic DCR case study 3: endoscopic view Fig. 55.15 Revision endoscopic DCR case study 3: endoscopic view
demonstrates the separated nasal mucosal cicatrix from the lacrimal sac demonstrating the full-length lacrimal sac marsupialization. Note the
fluorescein-stained viscoelastic in the lacrimal sac
demonstrates excision of the nasal mucosal cicatrix demonstrating the inferior horizontal lacrimal sac incision
demonstrating a well marsupialized and reflected lacrimal sac flaps demonstrating a circumostial mitomycin C injection at the superior
ostial edge
demonstrating topical application of mitomycin C demonstrating the mucosa to mucosa approximation and intubation at
the end of surgery

Fig. 55.21 Revision endoscopic DCR case study 4: endoscopic view demonstrating debridement of the chunk of the synechiae following
of the left nasal cavity of a complex and multiple etiology-failed separation
DCR. Note the gross ostio-septal synechiae superiorly and the turbino-
septal synechiae between the middle turbinate and the septum inferiorly
(from past septoplasty). In addition the patient had numerous polyps in
the past ostial area (shown in subsequent photographs) and inadequate
osteotomy. All these contributed to the failure of DCR
demonstrating the synechiolysis between the middle turbinate and the demonstrating the beginning of middle turbinoplasty
septum
demonstrating exposure of the middle turbinate air cell demonstrating a careful powered polypectomy in the ostial area
demonstrating the completed partial middle turbinoplasty resulting in demonstrating an incision on the nasal mucosa to expose the edge of the
good exposure and access to the scarred lateral wall. Note the polyps in past osteotomy
the vicinity of the ostium

Fig. 55.29 Revision endoscopic DCR case study 4: endoscopic view demonstrating the assessment of the superior boundary of osteotomy
demonstrating a powered superior osteotomy to expose the fundus of
the lacrimal sac

demonstrating a completed osteotomy, polypectomy, and exposed fun-
dus (white arrow) of the lacrimal sac

demonstrating more polyps near the fundus of the lacrimal sac (white
arrow), which were removed

demonstrating the trephination of the common canalicular scar (white
arrow)

demonstrating lacrimal sac marsupialization
demonstrating assessment of intra-sac synechiae by a fine ball probe demonstrating well marsupialized lacrimal sac flaps and the patent
following marsupialization canalicular system
demonstrating topical application of mitomycin C demonstrating well reflected lacrimal sac flaps and intubation at the end
of surgery

of the left nasal cavity in a case of failed DCR. Following the mucosal
Fig. 55.38 Revision endoscopic DCR case study 4: endoscopic view flap elevation, note the gross synechiae involving the lacrimal sac fun-
demonstrating circumostial injection of mitomycin C at the posterior dus and the axilla of the middle turbinate. Apart from the synechial
ostial edge closure of the ostium, an inappropriate osteotomy, focal superior lacri-
mal sac marsupialization, and failure to address the middle turbinate
axilla contributed to the failure

demonstrating the vertical incisions to achieve a clear plain between the
demonstrating removal of the scarred axillary portion of the middle tur-
scarred axilla and the fundus of the lacrimal sac
binate. It is important to avoid gross movement of the axillary portion
since one of its attachments is at the skull base and undue mobilization
may lead to a CSF leak

demonstrating complete clearance of the ostium
demonstrating a clear plane following synechiolysis
demonstrating a full-length lacrimal sac marsupialization demonstrating reflection of the lacrimal sac flaps. This would again fol-
low mitomycin C application and intubation as described in earlier
cases

demonstrating the endoscopic-guided common canalicular trephina-
tion. Since the past anastomosis involved the fundus area, obstructions
in front of common canaliculus are not unexpected in these cases
Lacrimal Recanalization
56
Canalicular obstructions and NLDO are therapeutic chal- References

lenges. Although multiple etiological factors are known, lac-
rimal duct obstruction is a final common pathway following 1. Sisler HA, Allarakhia L. New minitrephine makes lacrimal cana-
licular rehabilitation an office procedure. Ophthal Plast Reconstr
inflammation and fibrosis. Recanalization of the obstructed Surg. 1990;6:203–6.
lacrimal pathways is gaining more ground as an alternative 2. Steinhauer J, Norda A, Emmerich KH, et al. Laser canaliculoplasty.
to bypass procedures [1–5] The indications for lacrimal Ophthalmologe. 2000;97:692–5.
recanalization include complete or partial canalicular 3. Chen D, Li N, Wan P, et al. A novel procedure to treat canalicular
obstruction by recanaliculisation and bicanalicular intubation. Br J
obstructions, complete or partial nasolacrimal duct (NLD) Ophthalmol. 2012;96:366–9.
obstructions, patchy or multifocal canalicular or NLD stric- 4. Ali MJ, Naik MN. Efficacy of endoscopic guided anterograde
tures, and membranous canalicular obstructions following a 3 mm balloon dacryoplasty with silicone intubation in treatment
DCR. The modalities employed for recanalization include of acquire partial nasolacrimal duct obstruction in adults. Saudi J
Ophthalmol. 2014;28:40–3.
Sisler’s canalicular trephination, dacryoendoscopy-guided 5. Javate R, Pamintuan FG, Cruz RT, et al. Efficacy of endoscopic
canalicular and NLD trephination, laser dacryoplasty, micro- lacrimal duct recanalization using microendoscope. Ophthal Plast
drill canaliculoplasty, balloon canaliculoplasty, and Reconstr Surg. 2010;26:330–3.
diathermy-based recanalizations [1–5]. The fundamental
need to make recanalization a real alternative modality is
accurate understanding of the etiopathogenesis, which is still
elusive.

482 56 Lacrimal Recanalization
Fig. 56.1 The Sisler’s canalicular trephine Fig. 56.4 The disassembled Sisler’s canalicular trephine. Note the
length of the trephine and the stylet
Fig. 56.2 The trephine end of the Sisler’s trephine. Note the guide sty- Fig. 56.5 The stylet entrance within the body of the main trephine
let projecting beyond the trephine
Fig. 56.3 The hub of the Sisler’s trephine. Note the circular metallic Fig. 56.6 The Huco trephine
end of the guide stylet
56 Lacrimal Recanalization 483
Fig. 56.7 The disassembled Huco trephine. Note the main trephine Fig. 56.9 The dacryoendoscopic imaging and illumination system
and the guide stylet
Fig. 56.10 The straight dacryoendoscopy Ruido Fiberoscope®
Fig. 56.8 The complete nasal endoscopy and dacryoendoscopic Fig. 56.11 The smooth angulated dacryoendoscopy Ruido
systems Fiberoscope®
Fig. 56.12 Dacryoendoscopic image of the canaliculus showing nor-

mal mucosa but obstruction in the distance (bright shiny point)
Fig. 56.15 Dacryoendoscopic image of a partial nasolacrimal duct

obstruction secondary to the peripheral fibrosis (white patches)
Fig. 56.13 Dacryoendoscopic image of the canaliculus of the patient

in Fig. 56.8, at the site of the distal obstruction. Note the shiny fibrous
chunk filling up the entire lumen
Fig. 56.16 Nasal endoscopic image of the patient in Fig. 56.15. Note

the free passage of the probe through the nasolacrimal duct
Fig. 56.14 Dacryoendoscopic image of the canalicular stenosis.

Compare it with an obstruction in Fig. 56.13
Fig. 56.19 Technique of Sisler’s canalicular trephination: intra-

operative photograph of the left lower lid demonstrating probing before
trephination for confirmation as well as dilatation of the patent proxi-
mal segment
Fig. 56.17 Post-operative 6-week dacryoendoscopic image of the
patient in Figs. 56.15 and 56.16. Note the clear nasolacrimal lumen
devoid of any peripheral fibrotic tissue

operative photograph of the left lower lid demonstrating the assembled
Fig. 56.18 Dacryoendoscopic image of another case of patchy naso- Sisler’s trephine ready for use
lacrimal duct fibrosis (white patches)

operative photograph of the left lower lid demonstrating the vertical
entry of the trephine Fig. 56.24 Technique of Sisler’s canalicular trephination: intra-
operative photograph of another patient demonstrating the hub during
the horizontal entry into the proximal patent canaliculus. Note that the
stylet end is very close to the hub of the trephine

operative photograph of the left lower lid demonstrating the horizontal
entry of the trephine

operative photograph of the patient in Fig. 56.24. Note that the distance
of the stylet end from the trephine hub has increased because the tip of
the stylet guide has encountered a physical obstruction. The obstructed
segment is gently trephined by circular forward movements of the tre-
phine, making sure not to change the position and direction

operative photograph of the left lower lid demonstrating the technique
of lid stretch and making sure that the trephine lies flat and parallel to
the lid margin

operative photograph following trephination demonstrating the attach-
ment of a syringe to the hub of the trephine
operative endoscopic photograph of the left nasal cavity of a patient
with monocanalicular obstruction and NLDO demonstrating the well-
trephined segment of the obstructed canaliculus at the trephine end

operative photograph following trephination demonstrating the con-
stant aspiration that should be performed during the act of withdrawal
of the trephine. This is to aspirate the trephined segment of the canalicu-
lus from the bore of the trephine into the syringe

operative photograph of the left nasal cavity of a patient with monoca-
nalicular obstruction and NLDO demonstrating endoscopic-monitored
trephination. Note the Sisler’s trephine at the internal common opening
of the canaliculi
Fig. 56.30 Technique of Sisler’s canalicular trephination: intra- Fig. 56.31 Technique of Sisler’s canalicular trephination: intra-
operative photograph demonstrating the obstructed segment of the operative photograph demonstrating the trephined segment being
canaliculus in the aspiration syringe retrieved from the bore of the Sisler’s trephine
Balloon Dacryoplasty
57
Balloon dacryoplasty (BDCP) is a term used for a set of min- References

imally invasive lacrimal procedures that utilizes specially
designed balloons, targeted at different points in the lacrimal 1. Ali MJ, Naik MN, Honavar SG. Balloon Dacryoplasty: ushering
a new and routine era in minimally invasive lacrimal surgeries. Int
system for a wide range of indications. Balloon catheters are Ophthalmol. 2013;33:203–10.
specially designed with an inflatable balloon at one end of 2. Lee A, Ali MJ, Li EY, et al. Balloon dacryoplasty in internal ostium
the catheter and hub with Luer lock mechanism at the other stenosis after endoscopic dacryocystorhinostomy. Ophthal Plast
which engages the inflation device. The inflation device has Reconstr Surg. 2014;30:7–10.
3. Ali MJ, Naik MN. Efficacy of endoscopic guided anterograde
a manometer which displays the pressure reading in atmo- 3mm balloon dacryoplasty with silicone intubation in treatment
spheres. The indications of balloon dacryoplasty for congen- of acquired partial nasolacrimal duct obstruction in adults. Saudi J
ital nasolacrimal duct obstructions who failed probing, failed Ophthalmol. 2014;28:40–3.
intubation, and those with syndromic associations. The suc-
cess rates range from 76 to 83% in various large case series
[1–3]. In adults, BDCP has been used for partial nasolacri-
mal duct obstruction, primary endoscopic balloon-assisted
dacryocystorhinostomy, and revision of a stenotic ostium
following DCR. Although the primary balloon-assisted DCR
did not gain popularity, its outcomes in revision DCRs are
encouraging [1–3]. Careful patient selection and skillful
nasal endoscopy are additional important factors for success-
ful outcomes.

490 57 Balloon Dacryoplasty
Fig. 57.4 The ready inflation device filled with fluorescein-stained

saline
Fig. 57.1 A typical balloon dacryoplasty set
Fig. 57.5 The tip of a 2 mm balloon. Note the inflation end with
numerous black markings which gives the surgeon clues of the level of
catheter in the lacrimal drainage system
Fig. 57.2 A set of various balloon catheters
Fig. 57.3 The inflation device Fig. 57.6 The 5 mm balloon catheter. Note that its body is smoothly
angulated
57 Balloon Dacryoplasty 491
Fig. 57.7 The tip of a 5 mm balloon catheter Fig. 57.10 The inflation manometer
Fig. 57.8 A 9 mm balloon catheter. Note that the thick body and sharp Fig. 57.11 Body of the inflation device with guidance markings for
90° angulation of the tip filling of fluid
Fig. 57.9 The tip of a 9 mm balloon catheter Fig. 57.12 The locking mechanism of the inflation device
Fig. 57.13 The Luer lock end of the inflation device that engages with Fig. 57.16 The assembled and ready inflation device
the balloon catheter
Fig. 57.14 The filling up of inflation device Fig. 57.17 The inflated 2 mm catheter
Fig. 57.15 The assembly of the inflation device with the balloon Fig. 57.18 The ejection of fluid from the inflation device at the end of
catheter procedure
Fig. 57.19 Technique of balloon dacryoplasty: endoscopic view of a

left inferior meatus demonstrating the nasolacrimal duct opening with Fig. 57.21 Technique of balloon dacryoplasty: endoscopic view of a
an anterior mucosal fold (white arrow) left inferior meatus demonstrating the inflation phase. Note the balloon
being filled by the fluorescein-stained fluid
Fig. 57.20 Technique of balloon dacryoplasty: endoscopic view of a Fig. 57.22 Technique of balloon dacryoplasty: endoscopic view of a
left inferior meatus demonstrating the arrival of the balloon end of the left inferior meatus demonstrating the sequential inflation of the bal-
catheter loon and dilatation of the distal nasolacrimal duct
Fig. 57.23 Technique of balloon dacryoplasty: intra-operative view of

the inflation manometer showing the pressure to be approaching the
desired eight atmospheres

left inferior meatus demonstrating the slow deflation of the balloon
left inferior meatus demonstrating a fully dilated balloon catheter at left inferior meatus demonstrating the retraction of the balloon to dilate
eight atmospheres of pressure the proximal nasolacrimal duct. Note the re-inflation of the balloon
left inferior meatus demonstrating a closer view of the proximal naso- left inferior meatus demonstrating retrieval of one of the bodkin of a
lacrimal duct dilatation Crawford bicanalicular intubation

left inferior meatus demonstrating free passage of fluorescein-stained Fig. 57.30 Technique of balloon dacryoplasty: endoscopic view of a
fluid on irrigation left inferior meatus demonstrating the intubated nasolacrimal duct
opening. Note the wide diameter of the opening and the blunted effect
of the anterior fold
Fig. 57.31 Endoscopic view of left inferior meatus of another patient Fig. 57.33 Endoscopic view of the patient in Figs. 57.31 and 57.32.
demonstrating the arrival of the balloon end of the catheter from the Note the proximal nasolacrimal duct dilatation in process
nasolacrimal duct opening
Fig. 57.32 Endoscopic view of the patient in Fig. 57.31. Note the dis- Fig. 57.34 Endoscopic view of the patient in Figs. 57.31, 57.32 and
tal nasolacrimal duct dilation in process. Also note that an alternative 57.33 following balloon dacryoplasty and intubation. Note the widely
option of clear saline has been chosen rather than a fluorescein stained dilated nasolacrimal duct opening
Fig. 57.37 Endoscopic balloon-assisted primary DCR: intra-operative

Fig. 57.35 Endoscopic view of a right nasal cavity demonstrating the image of the patient in Fig. 57.36 demonstrating inflation of the inserted
use of a 5 mm balloon for revision of the stenotic DCR ostium. Note the 9 mm balloon catheter
dilatation of the stenotic ostium
Fig. 57.36 Endoscopic balloon-assisted primary DCR: intra-operative

image of a right nasal cavity demonstrating the 9 mm balloon being Fig. 57.38 Endoscopic balloon-assisted primary DCR: intra-operative
inserted into a newly created small ostium image of the patient in Figs. 57.36 and 57.37. Note the fully inflated
9 mm balloon being pulled into the nasal cavity resulting in creation of
a larger ostium
Conjunctivodacryocystorhinostomy
58
Conjunctivodacryocystorhinostomy refers to creation of a References

new passage for drainage of tears from the conjunctival cul-
de-sac directly into the nasal cavity with the help of bypass 1. Athansiov PA, Madge S, Kakizaki H, et al. A review of bypass
tubes for proximal lacrimal drainage obstruction. Surv Ophthalmol.
tubes. The procedure can be performed via an external 2011;56:252–66.
approach (external CDCR), endoscopic approach (endo- 2. Rose GE, Welham RN. Jones’ lacrimal canalicular bypass tubes:
scopic CDCR) or a minimally invasive approach (MICDCR), twenty five years’ experience. Eye. 1991;5:13–9.
or diode-laser assisted (LCDCR) and endoscopic conjunc- 3. Ali MJ, Honavar SG, Naik MN. Endoscopically guided minimally
invasive bypass tube intubation without DCR: evaluation of drain-
tivorhinostomy (CR) without a DCR [1–3]. The indication age and objective outcomes assessment. Minim Invasive Ther
for a CDCR includes punctal agenesis, canalicular agenesis, Allied Technol. 2013;22:104–9.
proximal canalicular obstructions, unsalvageable proximal
system post-trauma, post-dacryocystectomy rehabilitation,
multiple times failed DCR with canalicular obstructions, lac-
rimal pump failures, and unresolved epiphora following a
patent DCR. The contraindications are relative and include
scarred medial canthus, gross eyelid anomalies, gross nasal
deformities, early childhood, mentally unstable patients, and
unrealistic expectations or patients not keen for tube mainte-
nance. Though the procedure is useful with a success rate
hovering around 90%, large series have shown two major
complications, namely, extrusion of the tube ranging from 28
to 51% and tube malpositions ranging from 22 to 28% [1–3].
In order to avoid these complications, numerous modifica-
tions of the bypass tube have been published including addi-
tional flanges, wide medial ends, angulated tubes, and porous
polyethylene-coated tubes. The long-term outcomes are still
not very clear. Hence, a careful patient selection is of utmost
importance.

500 58 Conjunctivodacryocystorhinostomy
Fig. 58.1 A set of Jones

tubes of various diameters
and lengths
Fig. 58.2 A set of Jones tube (right) and Gladstone-Putterman tube

(left). Note the beveled nasal end Fig. 58.4 The ocular flange end of a classical Jones tube without any
suture holes
Fig. 58.3 A classical Pyrex Jones tube with a plain surface
Fig. 58.5 The straight and frosted Jones tube

58 Conjunctivodacryocystorhinostomy 501
Fig. 58.6 The ocular flange of the frosted Jones tube. Note the pres-
ence of the suture hole
Fig. 58.9 A set of CDCR gold dilators
Fig. 58.7 The frosted Gladstone-Putterman tube. Note the additional

flange at the angulated neck of the tube. Compare it with Figs. 58.3 and
58.5
Fig. 58.10 The Jones tube measuring slab. The slab can measure the
outer diameter and the length
Fig. 58.8 The ocular flange of a frosted Gladstone-Putterman tube.

Note the suture hole
Fig. 58.11 The Jones tube set-up box. Note the slots for various mea-
surement Jones tubes and an inbuilt measuring slab
Fig. 58.13 Technique of endoscopic CDCR: intraoperative endo-

scopic image of a left nasal cavity following an osteotomy in a case of
a punctal and canalicular agenesis
Fig. 58.12 A typical Jones tube set up box during a surgical

procedure

scopic image of a left nasal cavity following a lacrimal sac marsupial-
ization. Note the dysgenetic lacrimal sac with thin walls
Fig. 58.15 Technique of endoscopic CDCR: intraoperative image demonstrating lifting of caruncle for the conjunctival incision
Fig. 58.16 Technique of endoscopic CDCR: intraoperative image demonstrating the sub-caruncular incision
Fig. 58.17 Technique of endoscopic CDCR: intraoperative image demonstrating the completed incision
Fig. 58.18 Technique of endoscopic CDCR: Intraoperative image demonstrating the subconjunctival dissection toward the lacrimal fossa
Fig. 58.19 Technique of endoscopic CDCR: intraoperative image

demonstrating insertion of a wide bore (No 14) needle to create a track
for the Jones tube

scopic image demonstrating the adjustment of the needle in such a posi-
tion so as to be midway between the lateral wall and the nasal septum.
When the desired position is achieved, the needle is held at the conjunc-
tival entry end and retrieved for length measurement

scopic image demonstrating the needle. It is important to make this
track through the lacrimal mucosa

demonstrating the measurement of the needle length. This corresponds
to the length of the Jones tube that would be used
Fig. 58.23 Technique of endoscopic CDCR: intraoperative image demonstrating freshly created track for the Jones tube
Fig. 58.24 Technique of endoscopic CDCR: intraoperative image demonstrating insertion of the Jones tube in the freshly created track
Fig. 58.25 Technique of endoscopic CDCR: intraoperative image demonstrating the complete insertion of Jones tube

demonstrating the endoscopic-guided adjustment of the Jones tubes
Fig. 58.27 Technique of endoscopic CDCR: intraoperative image demonstrating the final adjusted position of the Jones tubes. At this time, fluo-
rescein-stained saline is placed in the conjunctival cul-de-sac to assess drainage of the Jones tubes

scopic image demonstrating a well-functioning Jones tube

demonstrating the suture placement around the Jones tubes for the secu-
rity against movements till the healing process is completed
Fig. 58.32 Intraoperative endoscopic image of the right nasal cavity of

patient in Fig. 58.31. Note the fluorescein well conducted by the Jones
tube

demonstrating the completion of securing the Jones tubes
Fig. 58.33 Post-operative care: clinical photograph of a day 1 post

right CDCR. Note the secured Jones tube
Fig. 58.31 Intraoperative image of another patient of a right CDCR

demonstrating flooding of the ocular surface with fluorescein saline for
assessing the function of Jones tube
Fig. 58.34 Post-operative care: clinical photograph of a day 1 post

right CDCR. Note the tube is being irrigated with a blunt cannula to
flush off blood clots if any
Fig. 58.36 Post-operative care: the patient then closes the contralateral
nostril and takes a deep sniff like breath from the ipsilateral nostril. This
creates a negative pressure in the nasal cavity that will draw the fluid
from the ocular surface through the tube
Fig. 58.35 Post-operative care: The patient should preferably once

daily self-clean the tube. 2–3 drops of normal saline are placed in the
conjunctival cul-de-sac
Fig. 58.37 Post-operative care: clinical photograph showing a suture

removal at 2–3 weeks following the surgery
Fig. 58.38 Clinical photograph of a left eye demonstrating an early Fig. 58.41 Clinical photograph, higher magnification, of the right eye
post-operative inferior migration of the tube. Note the intact suture of patient in Fig. 58.40. Note the lateral migration of the Jones tube
would make the readjustment process easy
Fig. 58.39 Clinical photograph of the left eye of patient in Fig. 58.36, Fig. 58.42 Clinical photograph of the right lower lid showing inferior
after lower lid eversion. Note the inferiorly migrated Jones with fold of migration with peri-tubal evolving conjunctival granuloma
fornicial conjunctiva over it
Fig. 58.40 Clinical photograph of a right eye showing a lateral migra- Fig. 58.43 Clinical photograph, higher magnification, of the right eye
tion of the Jones tube of patient in Fig. 58.42. Note the partly visible Jones tube and the gran-
ulomatous reaction of the conjunctiva in the vicinity
Fig. 58.44 Clinical photograph of a right eye demonstrating a con- Fig. 58.46 Endoscopic view of a left nasal cavity demonstrating syn-
junctival peri-tubal granuloma echiae and granuloma around the nasal end of the Jones tube tract
Fig. 58.45 Clinical photograph of a right eye demonstrating conjunc-

tival pressure necrosis from a tight, posterior-angulated placement of
the Jones tube

very large granuloma (white arrow) superior to the Jones tube

grossly infected track of the Jones tube

Fig. 58.47. Note the bleeding base following excision of the
granuloma
Fig. 58.50, following extubation of the Jones tube. Note the purulent
discharge emanating from the surgical track
Figs. 58.46 and 58.47. Note the silver nitrate cautery stick being used
for the granuloma base to prevent its recurrence
Fig. 58.52 The extubated discolored Jones tube of the patient in Fig. 58.54 Endoscopic view of the right nasal cavity of patient in
Figs. 58.50 and 58.51 Fig. 58.53. Note the tube has now been adjusted and is away from the
septum
Fig. 58.55 Endoscopic view of a left nasal cavity of another patient

demonstrating medial and inferior migration of the tube and impaction
on to the septum
Fig. 58.53 Endoscopic view of a right nasal cavity demonstrating an

impaction of the Jones tube on to the septum (black star)
Fig. 58.57 CT scan PNS, 3D reconstruction, volume rendered, of the

patient in Fig. 58.56. Note the laterally migrated non-Jones CDCR tube
Fig. 58.56 CT scan PNS, coronal cut demonstrating a patient with a

lateral migration of a non-Jones CDCR tube. The patient was being
screened for a paranasal sinus disease
Mitomycin C (Techniques and Tissue
Effects) 59
Mitomycin C (MMC) has been used in dacryocystorhinos- References

tomy to modulate aggressive wound healings and prevent
cicatricial closure of the DCR ostium [1–5]. Various basic 1. Ali MJ, Mariappan I, Maddileti S, et al. Mitomycin C in dacryocys-
torhinostomy: the search for the right concentration and duration—
science studies have provided evidence of its effects on the a fundamental study on human nasal mucosa fibroblasts. Ophthal
nasal mucosal fibroblasts [1–5]. Clinical application is either Plast Reconstr Surg. 2013;29:469–74.
in the form of an intra-operative topical application or inject- 2. Kumar V, Ali MJ, Ramachandran C. Effect of mitomycin-C
able in the circumostial (COS) areas, a technique described on contraction and migration of human nasal mucosa fibro-
blasts: implications in dacryocystorhinostomy. Br J Ophthalmol.
as COS-MMC. Ultrastructural effects of topical MMC 2015;99:1295–300.
(0.02%, 3 min) and COS-MMC (0.2 mg/mL) on nasal 3. Nair AG, Ali MJ. Mitomycin-C in dacryocystorhinostomy: from
mucosa have been evaluated and compared with the untreated experimentation to implementation and the road ahead: a review.
naïve nasal mucosa (as controls) [5]. Detailed transmission Indian J Ophthalmol. 2015;63:335–9.
4. Kamal S, Ali MJ, Naik MN. Circumostial Mitomycin C (COS-
electron microscopic effects of standardized MMC on nasal MMC) in external and endoscopic dacryocystorhinostomy: effi-
mucosa using various modalities of drug applications have cacy, safety profiles and outcomes. Ophthal Plast Reconstr Surg.
been documented. The MMC affected all the components of 2014;30:187–90.
the mucosa including epithelium, glands, vascular, and fibro- 5. Ali MJ, Baig F, Lakshman M, et al. Electron microscopic features
of nasal mucosa treated with topical and circumostial injection of
collagenous tissues. The nasal mucosal fibroblasts show a mitomycin C: implications in dacryocystorhinostomy. Ophthal Plast
dramatic structural response to MMC, including develop- Reconstr Surg. 2015;31:103–7.
ment of intracellular edema, pleomorphic and vesicular
mitochondria, dilated smooth and rough endoplasmic reticu-
lum, and chromatin condensation. Moreover, both topical
and COS-MMC showed profound changes in nasal mucosal
fibroblasts, but the effects seem to be more marked in the
COS-MMC group without any tissue necrosis. These evi-
dences show that MMC is likely to be effective against
aggressive wound healing if used in appropriate doses with
standardized techniques.
Figures are from Ali et al. (Ophthal Plast Reconstr Surg
2013;29:469–474 and Ophthal Plast Reconstr Surg.
2015;31:103–107) and Kumar et al. (Br J Ophthalmol. 2015;
99:1295–1300).

518 59 Mitomycin C (Techniques and Tissue Effects)
Fig. 59.2 The cell cycle and MMC action. MMC acts on the S phase
of cell cycle to arrest cellular proliferation. The various subcellular
mechanisms are also listed
Fig. 59.1 The mitomycin c (MMC) vial, commonly used for lacrimal Fig. 59.3 Endoscopic view of the left nasal cavity showing topical
surgeries application of MMC in dacryocystorhinostomy (DCR)
Fig. 59.4 Circumostial MMC (COS-MMC). The MMC used is in concentration of 0.2 mg/mL. Endoscopic view of the right nasal cavity after the
sac marsupialization. Note the anterior and posterior lacrimal sac flaps (AF and PF). The black arrow are the points of MMC injection at the ante-
rior (AE), posterior (PE), superior (SE), and inferior (IE) ostial edges
59 Mitomycin C (Techniques and Tissue Effects) 519
Fig. 59.5 Endoscopic view of the left nasal cavity showing COS-
MMC into the anterior ostial edge Fig. 59.7 Endoscopic view of the left nasal cavity showing COS-
MMC into the posterior ostial edge
Fig. 59.8 Nasal mucosal harvesting for MMC studies: Harvesting a

fresh tissue during an external DCR
Fig. 59.6 Endoscopic view of the left nasal cavity showing COS-
MMC into the inferior ostial edge
Fig. 59.9 Nasal mucosal harvesting for MMC studies: Harvesting a

fresh tissue during an endoscopic DCR
Fig. 59.11 Nasal mucosal harvesting for MMC studies: The harvested
sample being immediately transferred in a cell culture transport media
Fig. 59.10 Nasal mucosal harvesting for MMC studies: The harvested
nasal mucosa which can be treated or untreated
Fig. 59.12 Phase contrast microphotograph showing the cultured

human nasal mucosal fibroblasts
Fig. 59.13 Bromodeoxyuridine MMC induced mitotic arrest

(BrdU) and propidium iodine (PI)
staining. The figure represents BrdU BrdU/Pl
BrdU/PI staining of fibroblasts
after exposure to MMC 0.2 mg/
mL for 3 min. Very few cells have
taken up BrdU label in MMC-
treated samples. Note that even in
labeled cells, the staining
intensity is very weak when
compared to untreated control
cells, suggesting MMC-induced
UT
mitotic arrest/delayed cell cycle
progression. Also note that the
cells surviving after MMC
treatment have an intact nuclear
morphology despite the lack of
BrdU label incorporation. This
suggests that desirable concentra-
tion and duration of MMC is
0.2 mg/mL for 3 min
0.2 mg/ml
Disruption of actin cytoskeleton

UT 0.2 mg/ml
Phalloidin-FITC/DAPI
Fig. 59.14 Actin-phalloidin
staining for cells treated with
0.2 mg/mL for 3 min. Note
the actin cytoskeleton is
completely disrupted in cells,
and the DAPI (4,
6-diamidino-2-phenylindole)
staining shows condensation
of chromatin (arrow heads),
the hallmarks of arrested and
apoptotic cells
Fig. 59.15 Images of

Annexin V and PI-stained
cells. Alexa-594-conjugated
Annexin V staining (red) of
cell membrane and DAPI
(blue) counterstain for
nucleus (Panels a and b).
Note that the Annexin V
staining marks the early-stage
apoptotic cells where DNA
fragmentation and nuclear
blebs are absent and the cell
membrane integrity is not
completely compromised. PI
staining marks the late
apoptotic cells (arrows) and
stains the nucleus, while the
live cells (arrow head) remain
unstained (Panels c and d)
Control 0.1 mg/ml MMC 0.2 mg/ml MMC 0.4 mg/ml MMC
3 mins
Tx
5 mins
Tx
0.1 mg/ml MMC 0.2 mg/ml MMC 0.4 mg/ml MMC
Fig. 59.16 Effect of MMC on collagen gel contraction. Image of the Treatment with MMC for 3 min reduced gel contraction significantly
gel assay and the extent of gel contraction in the presence and absence when compared to control (p < 0.05). The gel contraction was not dif-
of MMC treatment. The contraction measured in the untreated control ferent for two durations of treatment for a given concentration. This
was taken as the baseline and produced maximum contraction. again suggests that 0.2 mg/mL for 3 min of MMC is desirable
Control TGF (5ng) TGF + MMC 0.2mg TGF + MMC 0.4mg
TGF (10ng) TGF + MMC 0.2mg TGF + MMC 0.4mg
Fig. 59.17 Effect of MMC on transforming growth factor β (TGFβ)- cells increased significantly gel contraction when compared to untreated
induced collagen gel contraction: Panel A is a representative of the gel control. Pretreatment of cells with MMC (for 3 min) was able to oppose
contraction assay and shows that MMC is reducing the contraction TGFβ-induced increase in contraction. This reduction in gel contrac-
induced by TGFβ. As can be seen in panel A, the addition of TGFβ to tion was significant (p < 0.05)
Untreated TGF-β1(1ng/ml)
Fig. 59.18 Effect of TGF-β1

on alpha smooth muscle actin
(α-SMA) expression by
human nasal mucosal
fibroblasts (HNMFs). HNMFs
were treated with TGFβ of 1,
5, and 10 ng/mL for 24 hrs
and stained for α-SMA using
a specific antibody. A
concentration-dependent
increase in the expression of
this protein can be seen in the
figure with 10 ng/mL ≥ 5 ng/
mL > 1 ng/mL indicating that
treatment with TGF-β1
induces fibroblast to
myofibroblast transformation
of HNMFs. Note: red,
propidium iodide; green,
α-SMA TGF-β1(5ng/ml) TGF-β1(10ng/ml)
Untreated MMC(0.2mg/ml) MMC(0.4mg/ml)

a b c
d e f
TGF-β1(5ng/ml)
g h i
TGF-β1(10ng/ml)
Fig. 59.19 Mitomycin treatment reduces myofibroblast transformation No staining for α-SMA was detected (Panels b and c). Treatment of
of HNMFs. There were very few, if any, α-SMA-positive cells in the cells with 5 and 10 ng/mL of TGFβ on the other hand induced increased
untreated control as shown in panel a, while the actin filaments showed expression of α-SMA as can be seen in panels d and g. Pretreatment of
a uniform alignment. Treatment with MMC alone (0.2 and 0.4 mg/mL) cells with MMC for 3 min before exposure to TGFβ reduced signifi-
for 3 min led to the disruption and aggregation of the actin filaments. cantly the expression of α-SMA in these cells (panels e, f, h and i)
Fig. 59.20 MMC delays wound healing in HNMFs. Image shows an to wounding. There were no α-SMA-positive cells seen immediately
increase in the expression of α-SMA following the creation of a scratch after wounding and up to 4 h post-wounding. Some positive cells were
wound in confluent cultures of HNMFs indicating that the transforma- noted at 24 h, and more cells were noted at 48 h (Panel a–d)
tion of HNMFs to myofibroblast phenotype occurs as a normal response
Fig. 59.21 Ultrastructural effects of topical MMC treatment: Fig. 59.24 Ultrastructural effects of topical MMC treatment: TEMG
Transmission electron micrograph (TEMG) showing epithelial changes showing edematous collagen fibers (C) with a swollen fibroblast (F)
up to the basal cells (B) with inter- and intracellular edema (E), degen- with scanty electron dense granules (ED) and vesicular mitochondria
erating nuclei (N), peripheral nuclear chromatin condensation (C), and (VM) (OC ×7720)
perinuclear dilatation (PND) (OM ×6755)
Fig. 59.22 Ultrastructural effects of topical MMC treatment: TEMG Fig. 59.25 Ultrastructural effects of topical MMC treatment: TEMG
of glandular cells showing vesicular cytoplasm (V), dilated endoplas- high magnification of fibroblast (F) shows retained cellular outline on
mic reticulum (ER), nuclei (N) with widespread chromatin condensa- one side with dilated endoplasmic reticulum (ER), vesicular mitochon-
tion (C), disruption of outer nuclear membrane (ONM), and perinuclear dria (VM) with peripheral chromatin condensation (C) (OM ×13,510)
dilatations (PND) (OM ×7720)
Fig. 59.23 Ultrastructural effects of topical MMC treatment: TEMG Fig. 59.26 Ultrastructural effects of topical MMC treatment: TEMG
showing a dilated microcapillary (D) with a lumen (L) filled with erythro- high magnification showing subcellular features of fibroblast including
cytes (B). The endothelial cell (EC) is edematous with disorganized nucleus dilated endoplasmic reticulum (ER), pleomorphic mitochondria (M),
(N). Smooth muscle (SM) fibers are seen in the vicinity (OM ×2316) vesicular mitochondria (VM) with peripheral chromatin condensation
(C), and scattered electron dense (ED) granular material (OM ×28,950)
Fig. 59.27 Ultrastructural effects of COS-MMC: TEMG of COS- Fig. 59.30 Ultrastructural effects of COS-MMC: Glandular tissue
MMC-treated mucosa showing attenuated epithelium (E) with vesicu- showing thickened septa (S) with empty secretory vesicles and gross
lar nuclei (VN) and vesicular mitochondria (VM) and sparse microvilli edema (E) and disturbed endoplasmic reticulum (ER) (OM ×4825)
(M) (OM ×3860)
Fig. 59.28 Ultrastructural effects of COS-MMC: TEMG of COS- Fig. 59.31 Ultrastructural effects of COS-MMC: TEMG shows sparse
MMC-treated epithelium in a higher magnification showing vesicular and disorganized collagen fibers (C) due to widespread edema (E).
nuclei (VN) and vesicular mitochondria (VM) (OM ×4825) Fibroblast (F) shows gross intracellular edema (E) (OM ×7720)
Fig. 59.29 Ultrastructural effects of COS-MMC: TEMG showing Fig. 59.32 Ultrastructural effects of COS-MMC: TEMG showing
grossly attenuated epithelium (E) with discontinuous basement mem- fibroblasts (F) at a higher magnification to see the diffuse peri- and
brane (BM) and disorganized subepithelial tissues (D) (OM ×2316) intracellular edema (E) with peripheral chromatin condensation. Note
that one of the fibroblast has lost part of its cellular outline (OM ×9650)
Intubation Devices
60
Intubating the lacrimal drainage pathways is a common pro- References

cedure [1–3]. It is commonly achieved by placing a silicone
stent in the lacrimal passages. The silicone stent maintains 1. Crawford JS. Intubation of the lacrimal system. Ophthal Plast
the passages where it is present and is also believed to allow 2. Fayet B, Racy E, Renard G. Pushed monocanalicular intubation: a
tissue healing around itself thus maintaining lacrimal preliminary report. J Fr Ophtalmol. 2010;33:145–51.
patency. In addition, they facilitate the tear flow by capillary 3. Moscato EE, Dolmetsch AM, Silkiss RZ, Seiff SR. Silicone intuba-
action and also by reducing the resistance to flow. Indications tion for the treatment of epiphora in adults with presumed func-
tional nasolacrimal duct obstruction. Ophthal Plast Reconstr Surg.
include punctal stenosis, failed probing, complex CNLDO, 2012;28:35–9.
following balloon dacryoplasty, canalicular lacerations, ste-
nosis, or strictures in lacrimal pathways, revision DCR, poor
flap creation, or membranes at the internal common opening
during a primary DCR. The stents can be mono-canalicular
or bi-canalicular, and each has their own pediatric and adult
variants. Mono-canalicular stents include mini-monoka®,
monoka-Crawford, monoka-Ritleng, and the Masterka®.
Bicanalicular stents include the Bika, Crawford, annular, and
the Nunchaku® stents.

530 60 Intubation Devices
Fig. 60.4 The Monoka-Ritleng monocanalicular stent
Fig. 60.1 The Mini-Monoka monocanalicular stent. Note the well-

designed monoka head for stent retention
Fig. 60.5 The Masterka® pushed mono-canalicular stent
Fig. 60.6 The Masterka® pushed mono-canalicular stent with its guide
Fig. 60.2 The Monoka-Crawford monocanalicular stent
Fig. 60.7 The pediatric and adult Bika bicanalicular intubation set
Fig. 60.3 The Monoka-Crawford monocanalicular stent. Note the

olive-tipped bodkin at one end and the monoka head on the other end
Fig. 60.8 The 23 gauge adult bicanalicular Crawford stent

60 Intubation Devices 531
Fig. 60.9 The tips of a 23 gauge adult bicanalicular Crawford stent. Fig. 60.12 The tips of a Crawford and Bika stents. Note the Bika does
Note the olive tips at the ends of bodkins not have any olive tips
Fig. 60.10 The 27 gauge pediatric bicanalicular Crawford stent Fig. 60.13 The retrieval device (blue) of the Crawford stents
Fig. 60.11 The tips of a 27 gauge pediatric bicanalicular Crawford Fig. 60.14 The retrieval device of the Crawford stents with a different
stent. Compare it with the adult tips in Fig. 60.9 tip design
Fig. 60.18 The Ritleng intubation probe
Fig. 60.15 The retrieval device in stents with straight bodkin tips.
Note the step design near the tips to engage the retriever
Fig. 60.19 The Ritleng intubation set with silk thread
Fig. 60.16 Endoscopic view of a left nasal cavity showing retrieval of Fig. 60.20 The Ritleng intubation set with Prolene thread
the Crawford stent
Fig. 60.17 A bicanalicular Crawford stent with a O’Donoghue design Fig. 60.21 Another example of a bicanalicular intubation with a
unique design but not popular
60 Intubation Devices 533
Fig. 60.22 The Nunchaku® pushed bicanalicular stent
Fig. 60.25 The bicanalicular self-retaining stent. Note the self-

retaining design at both the ends
Fig. 60.23 The Nunchaku® pushed bicanalicular stent. Note the

straight bodkins and markings on the silicone stent
Fig. 60.26 The bicanalicular self-retaining stent set
Fig. 60.24 The bicanalicular I-stent®. Note the difference in the diam-
eter of the stent segments. The thinner segment would be near the ocu-
lar surface, whereas the thicker segments within the lacrimal drainage
system
Fig. 60.27 Retrieval of the mini-monoka stent

Fig. 60.28 Retrieval of the bicanalicular stent. The ocular loop is cut
and the stent removed trans-nasally
Complications of Lacrimal Stents
61
Stents are commonly used in many pediatric and adult lac- References
rimal surgeries [1–3]. They are known to induce specific
set of complications which also include host reactions to 1. Crawford JS. Intubation of the lacrimal system. Ophthal Plast
Reconstr Surg. 1990;18:318.
them. The stent complications include tube or stent pro- 2. Ali MJ, Gupta H, Naik MN, et al. Endoscopic guided-single self-
lapse, erosion or cheese wiring due to a tightly secured linked stent in pediatric external dacryocystorhinostomy. Minim
stent, pyogenic granuloma at the punctal or nasal end, Invasive Ther Allied Technol. 2013;22:266–70.
infections, lost tubes, and tube incarceration in the cicatrix 3. Madge SN, Selva D. Intubation in routine dacryocystorhinostomy:
why do we do what we do? Clin Exp Ophthalmol. 2009;37:620–3.
[1–3]. All these complications should be identified in the
initial stages and appropriate measures instituted to obtain
favorable results. Minimal prolapse of the stents can be
observed; however, others need repositioning either
through the canalicular push technique or the nasal pull
technique under endoscopic guidance. Tube prolapsed can
be minimized by the use of clips, suture to the lateral wall
just within the vestibule or endoscopic self-linking of
stents [30]. Granulomas may require either a surgical exci-
sion or stent removal. In cases of lost tubes, the system can
be reintubated if early on in the post-operative period. The
medical versus legal implications of a lost tube should be
kept in mind.

536 61 Complications of Lacrimal Stents
Fig. 61.1 Clinical photograph of a left eye showing an early stent

prolapse
Fig. 61.4 Clinical photograph of a right eye showing a moderate stent

prolapse
Fig. 61.2 Clinical photograph of a right eye showing an early stent

prolapse
Fig. 61.5 Clinical photograph of a right eye showing a gross stent

prolapse
Fig. 61.3 Clinical photograph of a left eye showing a moderate stent

prolapse
61 Complications of Lacrimal Stents 537
Fig. 61.8 Slit lamp photograph of a right lower lid showing a gross
punctal cheese-wiring
Fig. 61.6 Clinical photograph of a right eye showing an early punctal

cheese-wiring. Note the traction on the medial edge of the punctum
from a tight stent
Fig. 61.9 Slit lamp photograph of a left lower lid showing a gross
punctal cheese-wiring with gross canalicular slitting
Fig. 61.10 Slit lamp photograph of a left eye showing grossly tight
stent that has slit both the upper and lower puncta and the canaliculi.
Also note the evolving peri-punctal granuloma
Fig. 61.7 Clinical photograph of a left lower lid showing a punctal

cheese-wiring (Photo courtesy: Nishi Gupta, SCEH, Delhi)
Fig. 61.11 Clinical photograph of a left lower lid, immediately fol- Fig. 61.14 Slit lamp photograph of a right lower lid, immediately fol-
lowing a stent extubation, showing granuloma involving the punctum lowing a stent extubation. Note the large tubal granuloma popping out
and vertical canaliculus of the punctal orifice
Fig. 61.12 Clinical photograph of a right lower lid peri-punctal and Fig. 61.15 Slit lamp photograph of the right lower lid of patient in
peri-tubal granuloma Fig. 61.14. Note the lateral edge of the punctum (black arrow) is free,
and the granuloma is arising from the depths of the canaliculus
Fig. 61.13 Clinical photograph of a left upper lid, immediately fol- Fig. 61.16 Slit lamp photograph of the right lower lid of patient in
lowing a stent extubation, showing granuloma involving the punctum Figs. 61.14 and 61.15. Note the medial edge of the punctum (black
arrow) is also free and the granuloma is arising from the depths of the
canaliculus
Fig. 61.17 Endoscopic view of a right nasal cavity showing a massive Fig. 61.19 Endoscopic view of a left nasal cavity demonstrating
stent-induced peri-tubal granuloma engulfing the entire ostium another example of a stent entrapment in a cicatrizing ostium
Fig. 61.18 Endoscopic view of a right nasal cavity demonstrating an

circumferential entrapment of the stent in the cicatrizing ostium
Fig. 61.20 Endoscopic view of a left nasal cavity demonstrating the

stent within the ostium secondary to a stent prolapse. Note the absence
of entrapment and a healthy ostium

Fig. 61.22. Note the signs of infective canaliculitis following the
intubation
Fig. 61.21 Endoscopic view of a stent with prolong retention. Note

the discolored stent with heavy physical deposits on the surface. Such
stents have also shown thick biofilms
Fig. 61.24 Clinical photograph of a right eye showing focal acquired

ankyloblepharon in the regions of punctum and proximal canaliculus,
following an intubation, in a case of punctal stenosis. This has possibly
occurred secondary to a trauma and a tight stent, keeping the medial
ends of lids in contact
Fig. 61.22 Clinical photograph of a right eye showing medial conges-

tion and discharge, one week following intubation
Fig. 61.25 Poorly designed and undesirable stents: Endoscopic photo- Fig. 61.27 Poorly designed and undesirable stents: Clinical photo-
graph of a right nasal cavity of a post-DCR patient referred to us, dem- graph demonstrating the extubated stent of the patient in Figs. 61.25
onstrating silicone stents within another large (white) stent with and 61.26
irregular edges
Fig. 61.26 Poorly designed and undesirable stents: Endoscopic photo- Fig. 61.28 Poorly designed and undesirable stents: Endoscopic photo-
graph of a right nasal cavity demonstrating the proximal portion of the graph of the external left nasal cavity demonstrating a large stent. This
large stent (green), impacted in a nearly obliterated stent was a weird stent, the details of which are unknown to the author
Fig. 61.29 Poorly designed and undesirable stents: Endoscopic photo- Fig. 61.31 Poorly designed and undesirable stents: Clinical photo-
graph of the left nasal cavity of patient in Fig. 61.28, demonstrating the graph of the extubated large stent from the patient in Figs. 61.28, 61.29,
huge stent occupying the entire nasal cavity and 61.30. The use of these stents is very counterproductive
Fig. 61.30 Poorly designed and undesirable stents: Endoscopic photo-

graph of the left nasal cavity of patient in Figs. 61.28 and 61.29, dem-
onstrating the stent to be impacted into an obliterated ostium
Lacrimal Stents and Biofilms
62
Monocanalicular and bicanalicular stents are commonly References

used in lacrimal surgeries for a variety of indications. They
are believed to maintain the lacrimal passages during the 1. Ali MJ, Baig F, Lakshman M, et al. Biofilms and physical deposits
on nasolacrimal silastic stents following dacryocystorhinostomy:
canalicular (as in lacerations) or ostial (as in DCR) healing. Is there a difference between ocular and nasal segments? Ophthal
In addition, they have been shown to be effective in func- Plast Reconstr Surg. 2015;31:452–5.
tional epiphoras since they dilate the passages and reduce the 2. Ali MJ, Baig F, Lakshman M, et al. Scanning electron microscopic
resistance to flow. When used, the duration of intubation has features of extubated monoka stents. Ophthal Plast Reconstr Surg.
2017;33:90.
always been a matter of debate. In addition, they have been 3. Ali MJ, Baig F, Naik MN. Electron microscopic features of intra-
shown to act as a nidus for harboring numerous microorgan- luminal portion of nasolacrimal silastic stents following dacryocys-
isms [1–5]. torhinostomy. Is there a need for stents without a lumen? Ophthal
Biofilm is a complex microbial community encased itself Plast Reconstr Surg. 2016;32:252–6.
4. Ali MJ, Baig F, Lakshman M, et al. Scanning electron microscopic
in a self-produced exopolysaccharide matrix that is irrevers- features of nasolacrimal silastic stents retained for prolong dura-
ibly attached to a surface [1]. Biofilms provide multiple tions following dacryocystorhinostomy. Ophthal Plast Reconstr
advantages to the microbes living in it including reduction of Surg. 2016;32:20–3.
metabolic needs and resistance to antimicrobial agents. 5. Murphy J, Ali MJ, Psaltis AJ. Biofilm quantification on nasolacri-
mal silastic stents following dacryocystorhinostomy. Ophthal Plast
Bacterial biofilms on lacrimal stents are identified on scan- Reconstr Surg. 2015;31:396–400.
ning electron microscopy by the presence of microcolony
clusters or towers consisting of bacterial bodies 0.05–5 μ,
surrounded within an exopolysaccharide matrix, complex
water channels, and 3D structures. [5]
Lacrimal stents have shown to harbor biofilms in multiple
studies [1–5]. The mean biomass has been estimated to be
0.9385 μm3/μm2 at 4 weeks from intubation [5]. The biofilms
and physical deposits have been shown to be more concen-
trated at the ocular segment loop in bicanalicular stents and
ampullary portion of the stent head in mini-monoka stents.
Mixed bacterial and fungal biofilms have been noted in the
intraluminal areas of stents. As the duration of retention
increases beyond 4 weeks, the biofilms and deposits become
denser, multilayered, and extensive. All these studies have
provided directions with regard to minimizing the duration
of stents (4 weeks) and probably the need to develop lumen-
less stents.
Figures are from Ali et al., (Ophthal Plast Reconstr Surg.
2015;31:452–455; Ophthal Plast Reconstr Surg.
2016;32:252–256; Ophthal Plast Reconstr Surg. 2016;32:20–
23 and Ophthal Plast Reconstr Surg. 2015;31:396–400) [1,
3, 4, 5].

544 62 Lacrimal Stents and Biofilms
Fig. 62.3 High magnification of a stub with mounted stent segments

coated with thin layer of gold
Fig. 62.1 Scanning electron microscope (SEM) used for studying bio-
films and physical deposits on the lacrimal stents
Fig. 62.2 Numerous SEM stubs with mounted monocanalicular and

bicanalicular stent segments
62 Lacrimal Stents and Biofilms 545
Fig. 62.4 Confocal laser scanning microscopy projection images of sample with Live/Dead BacLight stain showing a viable biofilm (fluorescence
emission 497–555 nm, Panel a), nonviable biofilm (fluorescence emission 600–700 nm, Panel b), and fluorescence channel overlay (Panel c)
Fig. 62.5 Confocal laser

scanning microscopy (CLSM)
demonstrating a projection
image of fluorescence channel
overlay displaying
polymicrobial biofilm on a
patient sample (Panel a).
CLSM image showing an
in vitro S. aureus attachment
to an experimental
O’Donoghue nasolacrimal
stent (Panel b)
Fig. 62.6 SEM image showing a 3D polysaccharide biofilms Fig. 62.7 SEM image showing planktonic bacteria on the surface of a
structure stent
Fig. 62.8 SEM image of a bacterial colony of bacilli Fig. 62.11 A monoka extubated following a prolong retention. Note
the discoloration of the stent with thick physical deposits
Fig. 62.9 SEM image of a 3D water channel with embedded bacteria Fig. 62.12 SEM image of a sterile stent surface. Note the smooth tex-
ture and absence of any material on the surface
Fig. 62.13 SEM image of a stent surface, extubated after 4 weeks.

Note the thin layer of biofilms and physical deposits. Compare it with
Fig. 62.12
Fig. 62.10 Endoscopic view of the right nasal cavity showing a stent
on prolong retention. Note the discoloration of the stent with thick
physical deposits
Fig. 62.14 SEM image of a stent surface, extubated after 1 year. Note Fig. 62.17 SEM images of a 1-year-old lacrimal stent: low magnifica-
the increasing physical deposits with integrated biofilms (SEM ×70). tion image showing focal areas of deposits and integrated biofilms
Compare it to Figs. 62.12 and 62.13 (SEM ×700)
Fig. 62.15 SEM image of a stent surface, extubated after 3 years. Note Fig. 62.18 SEM images of a 1-year-old lacrimal stent: higher magni-
the heavy deposits (SEM ×120). Compare it to Figs. 62.12, 62.13, and fication showing the multilayered, coarse deposits (SEM ×3500)
62.14
Fig. 62.16 SEM images of a 1-year-old lacrimal stent: low magnifica- Fig. 62.19 SEM images of a 1-year-old lacrimal stent: very high mag-
tion image showing numerous focal physical deposits (SEM ×70) nification showing the multilayered, coarse deposits (SEM ×20000)
Fig. 62.20 SEM images of a 1-year-old lacrimal stent: very high mag- Fig. 62.23 SEM images of a 3-year-old lacrimal stent: low magnifica-
nification showing numerous planktonic bacteria, embedded bacterial tion images showing diffuse, thick, multi-laminar, and brittle deposits
bodies (SEM ×8000) (SEM ×70). Compare with Figs. 62.13 and 62.16
Fig. 62.21 SEM images of a 1-year-old lacrimal stent: very high mag- Fig. 62.24 SEM images of a 3-year-old lacrimal stent: higher magni-
nification showing and 3D water channels with polymicrobial organ- fication of the cracked physical deposits (SEM ×1000)
isms (SEM ×20000)
Fig. 62.22 SEM images of a 3-year-old lacrimal stent: low magnifica- Fig. 62.25 SEM images of a 3-year-old lacrimal stent: very high-
tion images showing diffuse, thick, multi-laminar, and brittle deposits power images demonstrating complex 3D exopolysaccharide structures
(SEM ×70). Compare with Figs. 62.13 and 62.16 and water channels (SEM ×8000)
Fig. 62.26 SEM images of a 3-year-old lacrimal stent: high magnifi- Fig. 62.28 SEM images of the lumen of the nasal cut ends of bicana-
cation image showing integration of biofilms and physical deposits licular stents extubated at 4 weeks: note the presence of deposits with
(SEM ×7000) fungal filaments filling the lumen (SEM ×150)
Fig. 62.27 SEM images of a 3-year-old lacrimal stent: very high mag- Fig. 62.29 SEM images of the lumen of the nasal cut ends of bicana-
nification image showing polymicrobial planktonic bacteria (SEM licular stents extubated at 4 weeks: higher magnification of the lumen
×20,000) filled with fungal filaments (SEM ×350)
Fig. 62.30 SEM images of the lumen of the nasal cut ends of bicana- Fig. 62.32 SEM images of 4 weeks stents with predominant physical
licular stents extubated at 4 weeks: branched and septate fungal fila- deposits: low magnification image showing extensive surface physical
ments in the background of physical deposits (SEM ×1500) deposits with blocked lumen (SEM ×100)
Fig. 62.31 SEM images of the lumen of the nasal cut ends of bicana- Fig. 62.33 SEM images of 4 weeks stents with predominant physical
licular stents extubated at 4 weeks: mixed fungal and bacterial biofilms deposits: high magnification, end on view of the lumen filled with
with 3D water channels and planktonic bacteria within the lumen (SEM numerous physical deposits (SEM ×2200)
×1500)
Fig. 62.34 SEM images of 4 weeks stents with predominant physical Fig. 62.36 SEM images of longitudinally sectioned 4 weeks stents:
deposits: bacterial biofilms with 3D water channels and embedded bac- low magnification images showing diffuse but thinner deposits within
terial bodies (SEM ×3000) the lumen. Compare it with the two edges on either side of lumen (SEM
×100)
Fig. 62.35 SEM images of 4 weeks stents with predominant physical Fig. 62.37 SEM images of longitudinally sectioned 4 weeks stents:
deposits: very high magnification within the lumen showing planktonic another example of widespread physical deposits with dark skip areas
bacteria among irregular deposits (SEM ×8000) (SEM ×100)
Fig. 62.38 SEM images of longitudinally sectioned 4 weeks stents: Fig. 62.40 SEM images of lumen of sterile stents: cut end of a sterile
higher magnification of intraluminal surface showing areas of irregular, stent showing the dark clear lumen without any deposits (SEM ×150).
plaque-like physical deposits (SEM ×1500) Compare it with Figs. 62.28 and 62.32
Fig. 62.39 SEM images of longitudinally sectioned 4 weeks stents: Fig. 62.41 SEM images of lumen of sterile stents: end on view of a
very high magnification photograph showing 3D water channels and sterile clear lumen (SEM ×1500). Compare it with Figs. 62.28 and
embedded bacterial bodies (SEM ×10,000) 62.29
Fig. 62.42 SEM images of lumen of sterile stents: longitudinally sec- Fig. 62.44 SEM images of Monoka stents: end on view of the Monoka
tioned stents showing a clear lumen over a large stretch (SEM ×70). head showing fine physical deposits on the surface (SEM ×70)
Compare it with Figs. 62.36 and 62.37
Fig. 62.43 SEM images of lumen of sterile stents: higher magnifica- Fig. 62.45 SEM images of Monoka stents: ampullary portion of the
tion photograph of a luminal surface showing clear lumen and absence Monoka head showing numerous deposits at 6 weeks (SEM ×75)
of deposits (SEM ×150). Compare it with Figs. 62.36 and 62.37
Fig. 62.46 SEM images of Monoka stents: extensive deposits at the Fig. 62.48 SEM images of Monoka stents: very high magnification
ampullary portion at 3 months (SEM ×70) within the lumen showing 3D water channels and embedded bacterial
bodies (SEM ×3500)
Fig. 62.47 SEM images of Monoka stents: surface of the monocana- Fig. 62.49 SEM images of Monoka stents: intraluminal surfaces of
licular stent at 6 weeks showing uniform physical deposits (SEM ×100) longitudinally sectioned stents showing widespread clumps of physical
deposits and integrated biofilms with intervening lucent skip areas
(SEM ×70)
Evaluation of a Dacryocystorhinostomy
Ostium 63
Many causes of DCR failures can be attributed to ostium, the References

most common being scarring and cicatricial closure of the
osteotomy site [1–3]. The other causes related to ostium 1. Ali MJ, Psaltis AJ, Wormald PJ. Dacryocystorhinostomy ostium:
parameters to evaluate the DCR ostium scoring. Clin Ophthalmol.
include inadequate size, inappropriate location, intervening 2014;8:2491–9.
ethmoids, membranes over the internal common opening, 2. Ali MJ, Psaltis AJ, Wormald PJ. The Dacryocystorhinostomy
and ostial granulomas [1–3]. Numerous studies have focused ostium granulomas: classification, indications for treatment, man-
on the size and measurement techniques of the ostium and agement modalities and outcomes. Orbit. 2015;34:146–51.
3. Ali MJ, Psaltis AJ, Ali MJ, et al. Endoscopic assessment of dacryo-
patency tests. It is amply evident that many finer physical cystorhinostomy ostium after primary powered surgery: behavior
and functional details of the ostium need to be evaluated beyond 4 weeks. Clin Exp Ophthalmol. 2015;43:152–5.
post-operatively in an orderly manner to appreciate patho-
logical behaviors early on and institute corrective measures
toward prevention or treatment. The parameters that need
evaluation while assessing an ostium include the location,
shape, size, evolution, anatomical patency, functional endo-
scopic dye test, Ostium cicatrix if any, ostial or peri-ostial
synechiae if any, the location and movements of internal
common opening, dynamicity of stents on blinking, granulo-
mas, and organizing discharge. A ostium scoring system has
been devised and is an elaborate, yet a simple scoring system
that can be easily applied in routine clinical evaluation [1].
Figures 1–8, 51, and 52 are from Ali et al., (Clin
Ophthalmol. 2014;8:2491–2499) [1].

556 63 Evaluation of a Dacryocystorhinostomy Ostium

well-healed ostium. Note the anterior (A), posterior (P), superior (S),
and inferior (I) edges of the ostium. Also note the base (B) of the ostium Fig. 63.3 Endoscopic view of the right nasal cavity of the patient in
and the middle turbinate (MT) Fig. 63.2. Note the positive fluorescein endoscopic dye test
Fig. 63.2 Endoscopic view of a right nasal cavity showing a deep base Fig. 63.4 Evolution of a dacryocystorhinostomy ostium—case study
(B), anterior, posterior, and inferior edges of the ostium and the middle 1: endoscopic intra-operative view of a right nasal cavity demonstrating
turbinate (MT) the well-fashioned DCR ostium with a mucosa to mucosa approxima-
tion at the end of the surgery
63 Evaluation of a Dacryocystorhinostomy Ostium 557
Fig. 63.5 Evolution of a dacryocystorhinostomy ostium—case study Fig. 63.7 Evolution of a dacryocystorhinostomy ostium—case study
1: endoscopic view of a right nasal cavity, day 1, demonstrating gross 1: endoscopic view of a right nasal cavity, week 2, demonstrating gran-
mucosal edema preventing a good view ulation tissue at the edges of mucosa to mucosa approximation with
mild crusting. Note the in situ stents
1: endoscopic view of a right nasal cavity, day 5, demonstrating reduced 1: endoscopic view of a right nasal cavity, week 2, higher magnifica-
mucosal edema and well-epithelized surfaces tion, demonstrating the well-developing normal granulation tissue at
the anastomosis interfaces
1: endoscopic view of a right nasal cavity, week 3, demonstrating 1: endoscopic view of a right nasal cavity, week 4, demonstrating a
reduction in the interface granulation tissue. Note the size has shrunken well-healed ostium and stents in situ. The stents are removed at 4 weeks,
as compared to the intra-operative period since the healing is nearly complete
1: endoscopic view of a right nasal cavity, week 3, higher magnifica- 1: endoscopic view of a right nasal cavity, week 6, demonstrating the
tion, demonstrating well-approximated tissue interfaces final appearance of the ostium with a deep base. Note the stents have
been extubated at week 4
Fig. 63.15 Evolution of a dacryocystorhinostomy ostium—case study

2: endoscopic view of a left nasal cavity, week 1, higher magnification,
demonstrating the healing of approximated anterior lacrimal and nasal
mucosal edges (white arrow)
1: endoscopic view of a right nasal cavity, week 6, higher magnifica-
tion, demonstrating the continuity of posterior edge of the ostium with
the nasal tissues

2: endoscopic view of a left nasal cavity, week 2, demonstrating the
shrinking ostium, in situ stents, and the healing edges

2: endoscopic view of a left nasal cavity, week 1, demonstrating shrink-
ing ostium, crusting, and granulation tissue at the edges of mucosal
interfaces

demonstrating an evolving superior edge granuloma (white arrow). The
Fig. 63.17 Evolution of a dacryocystorhinostomy ostium—case study stent was extubated at this visit
2: endoscopic view of a left nasal cavity, week 3, demonstrating the
well-epithelized mucosal surfaces with a single continuity
2: endoscopic view of a left nasal cavity, week 4, demonstrating a partly 2: endoscopic view of a left nasal cavity, week 6, demonstrating a well-
shrunken but well-healed ostium on all sides developed superior edge granuloma. However, there is no threat to ICO;
hence, this was conservatively managed with steroids

round ostium with a deep base and ICO (white arrow) near the superior
edge
2: endoscopic view of a left nasal cavity, week 7, demonstrating a gross
reduction in the superior edge granuloma (white arrow)

demonstrating the good response of granuloma to steroids. Note the
ICO (long arrow) is even far away from the resolving granuloma (short Fig. 63.24 Endoscopic view of a left nasal cavity demonstrating an
arrow) oval ostium
Fig. 63.25 Endoscopic view of a right nasal cavity demonstrating a Fig. 63.27 Endoscopic view of a right nasal cavity showing an oblong
crescentic ostium ostium with a very deep base
Fig. 63.26 Endoscopic view of the right nasal cavity of patient in Fig. 63.28 Endoscopic view of a left nasal cavity demonstrating a cir-
Fig. 63.25. Note the crescentic ostium and positive fluorescein endo- cular ostium with a deep base
scopic dye disappearance test
Fig. 63.29 Endoscopic view of a right nasal cavity demonstrating a Fig. 63.31 Endoscopic view of a left nasal cavity demonstrating
shallow base ostium another example of a shallow base with positive fluorescein endoscopic
dye test
Fig. 63.30 Endoscopic view of the right nasal cavity of patient in Fig. 63.32 Endoscopic view of a right nasal cavity demonstrating a
Fig. 63.29. Note the positive fluorescein endoscopic dye test vertically slit but patent ostium

positive endoscopic fluorescein dye test from a vertically slit ostium Fig. 63.35 Endoscopic view of a right nasal cavity demonstrating a
(white arrow) good ostium with a shallow base and contracting agger nasi opening
(white arrow)

post-acute dacryocystitis DCR ostium. Note the jagged edges of the
ostium (white arrow)
Fig. 63.34 Endoscopic view of a left nasal cavity demonstrating

opened up ethmoids (black arrows) adjacent to a well-functioning
ostium
Fig. 63.39 Dynamicity of internal common opening (ICO): endo-

Fig. 63.37 Endoscopic view of a right nasal cavity demonstrating a scopic view demonstrates the ICO (white arrow). Note the width of the
DCR ostium with subtle edges and a positive fluorescein endoscopic ICO
dye test
Fig. 63.38 Endoscopic view of a left nasal cavity demonstrating one Fig. 63.40 Dynamicity of internal common opening (ICO): endo-
of the many methods of measuring an ostium (using the measured paper scopic view demonstrates the fluid conduction. Note the decrease in the
scale) diameter of the peri-ICO area (white arrow). Compare it with Fig. 63.39

Fig. 63.41 Dynamicity of internal common opening (ICO): endo- non-interfering superior ostial edge cicatrization
scopic view demonstrates the fluorescein dye being pumped into the
ostium by the active blink mechanism. Note the even narrower peri-
ICO area (white arrow). Compare it with Figs. 63.39 and 63.40

mucosal plug (white arrow) obstruction of the internal common Fig. 63.44 Endoscopic view of a right nasal cavity demonstrating a
opening good ostium but with excess superior ostial healing and synechiae

Fig. 63.44 demonstrating the superior ostial synechiae (non-interfering Fig. 63.47 Endoscopic view of a left nasal cavity demonstrating an
with ICO) abnormal location of the ostium which is posterosuperior to the axilla
of the middle turbinate
Fig. 63.46 Endoscopic view demonstrating complete involvement of Fig. 63.48 Endoscopic view of a left nasal cavity demonstrating a
the ostium with interfering synechiae. Compare these synechiae with mini-ostium (black arrow)
those of Fig. 63.45
Fig. 63.49 Endoscopic view of a right nasal cavity demonstrating Fig. 63.51 Endoscopic view of a right nasal cavity demonstrating a
another example of a mini-ostium pseudo-cicatricial ostium in a case of lacrimal sac within the ethmoid
sinus. This can be mistaken for a progressive cicatricial closure of the
ostium or a mini-ostium
Fig. 63.50 Endoscopic view of a right nasal cavity demonstrating a Fig. 63.52 Endoscopic view of the right nasal cavity of patient in
normally functioning mini-ostium Fig. 63.51. Note that when a close look is taken from the edge of the
pseudo-cicatricial ostium, one would find a larger ostium inside with a
positive fluorescein endoscopic dye test
Fig. 63.53 Endoscopic view of a right nasal cavity demonstrating Fig. 63.55 Endoscopic view of a right nasal cavity demonstrating
another example of a pseudo-cicatricial ostium (Photo courtesy: Nishi another example of a complete cicatricial closure of the ostium. Note
Gupta, SCEH, Delhi) the absence of an ostium and the whitish scars (black arrow)

complete cicatricial closure of the ostium. Note the absence of an
ostium and linear whitish scars (black arrow)
Dacryocystorhinostomy Ostium
Granulomas 64
Ostial granulomas are occasionally encountered since a good References

endoscopic DCR with mucosa-to-mucosa approximation
and primary intention healing prevent their occurrence. 1. Ali MJ, Wormald PJ, Psaltis AJ. The dacryocystorhinostomy
ostium granulomas: classification, indications for treatment, man-
However aggressive healing or contact granulomas second- agement modalities and outcomes. Orbit. 2015;34:146–51.
ary to stents may be noted [1–3]. Most of the granulomas 2. Ali MJ, Psaltis AJ, Wormald PJ. Dacryocystorhinostomy ostium:
resolve with topical ocular and nasal steroids. Granulomas parameters to evaluate the DCR ostium scoring. Clin Ophthalmol.
threatening the internal common opening (ICO) or entrap- 2014;8:2491–9.
3. Dave TV, Mohammed FA, Ali MJ, et al. Etiological analysis of 100
ping a stent within them may require a careful surgical anatomically failed dacryocystorhinostomies. Clin Ophthalmol.
removal. Recently eight different types of ostial and peri- 2016;10:1419–22.
ostial granulomas have been described, each with their char-
acteristic features [1]. They include edge granuloma, basal
granuloma, peri-ICO granuloma, bang-on ICO granuloma,
peri-tubal granuloma, edge-to-edge or bridge granuloma,
combined granuloma, and diffuse granuloma. There has
been an effort to standardize the management of each of
these granulomas based on the experience in dealing with
each one of them.
Figures 1, 2, 7, 8, 10, 14, and 18–25 are from Ali et al.,
(Orbit 2015;34:146–151) [1].

572 64 Dacryocystorhinostomy Ostium Granulomas
1. Edge granuloma
2. Basal granuloma
3. Peri – ICO granuloma
4. Bang on ICO granuloma
5. Peritubal granuloma
6. Edge to Edge or Bridge granuloma
7. Combined granuloma
8. Diffuse granuloma
Fig. 64.1 A table proposing the broad classification of the dacryocys-

torhinostomy ostium granulomas
Is it Bang on / Bridge granuloma?
YES NO Is it a Recurrent granuloma?
Excision Biopsy YES NO Is it peritubal granuloma YES
Is it Basal / Peri ICO granuloma Stent removal

NO YES
Initiate topical nasal steroids Initiate topical nasal + ocular steroids
Assess response at 4 weeks
Responsive Non- Responsive / Progressive
Intralesional steroid
Taper medication and observe
Assess response at 2 weeks
Good response Partial response No response
Consider Repeat intralesional
Fig. 64.2 A flowchart proposing the logical sequence of managing DCR ostium granulomas
64 Dacryocystorhinostomy Ostium Granulomas 573

superior edge granuloma
Fig. 64.5 Endoscopic view of a left nasal cavity demonstrating an

inferior edge granuloma
Fig. 64.6 Endoscopic view of a left nasal cavity, high magnification,

demonstrating the surface features of a granuloma. Note the extensive
vascularity
Fig. 64.4 Endoscopic view of a right nasal cavity demonstrating
another example of a superior edge granuloma
Fig. 64.9 Endoscopic view of a left nasal cavity demonstrating a pos-

terior edge granuloma which is also in the peri-ICO region. The ICO is
being shown by the white arrow
Fig. 64.7 Endoscopic view of a left nasal cavity demonstrating a com-

bined granuloma of the superior and inferior ostium edges
Fig. 64.8 Endoscopic view of a left nasal cavity demonstrating a peri- Fig. 64.10 Endoscopic view of a left nasal cavity demonstrating a
internal common opening (ICO) granuloma. Note the ICO is being basal granuloma (black arrow)
shown by the white arrow

bridge granuloma (black arrow) and a positive fluorescein endoscopic
dye test
tubal granuloma
Fig. 64.12 Endoscopic view of a right nasal cavity demonstrating the Fig. 64.14 Endoscopic view of a right nasal cavity demonstrating a
bridge granuloma (black arrow) diffuse granuloma
Fig. 64.15 Endoscopic view of a left nasal cavity demonstrating an Fig. 64.17 Endoscopic view of a left nasal cavity demonstrating a
ICO-threatening granuloma. Note the positive fluorescein endoscopic bang-on granuloma
dye test
Fig. 64.16 Endoscopic view of a left nasal cavity demonstrating an Fig. 64.18 Endoscopic view of a right post-operative ostium demon-
ICO-threatening granuloma. Note the positive fluorescein endoscopic strating a superior edge granuloma
dye test
Fig. 64.19 Endoscopic view of a right post-operative ostium of the

patient in Fig. 64.18. Note the resolution of the granuloma with topical Fig. 64.21 Intralesional triamcinolone therapy: endoscopic view of
nasal steroids the left nasal cavity demonstrating intralesional injection of triamcino-
lone using a long intravenous catheter needle
Fig. 64.20 Intralesional triamcinolone therapy: endoscopic view of

the left nasal cavity demonstrating a large overhanging superior edge
granuloma (white arrow). Note the visibility of the ostium is restricted
to only its lower half
the left nasal cavity demonstrating the response at 1 week post injec-
tion. Note the increase visibility of the underlying ostium
Fig. 64.23 Intralesional triamcinolone therapy: endoscopic view of Fig. 64.25 Intralesional triamcinolone therapy: endoscopic view of
the left nasal cavity demonstrating the response at 2 weeks post injec- the left nasal cavity demonstrating the nearly resolved granuloma
tion. Note the granuloma is much reduced and restricted to the superior
edge alone

the left nasal cavity demonstrating the second injection of triamcino- Fig. 64.26 Excision and silver nitrate therapy: endoscopic view of a
lone therapy right nasal cavity demonstrating a large tubal granuloma engulfing the
entire ostium. The base of it was at the anterior and superior edges of
the ostium
Fig. 64.27 Excision and silver nitrate therapy: clinical photograph Fig. 64.29 Excision and silver nitrate therapy: endoscopic view of the
demonstrating the excised granuloma from the patient in Fig. 64.26 right nasal cavity of the patient in Figs. 64.26, 64.27, and 64.28, imme-
diately following silver nitrate base cautery. Note the cauterized grayish
black areas and a positive fluorescein endoscopic dye test
Fig. 64.30 Aspiration and silver nitrate therapy: endoscopic view of a

Fig. 64.28 Excision and silver nitrate therapy: endoscopic view of the right nasal cavity demonstrating a large peri-tubal granuloma
right nasal cavity of patient in Figs. 64.26 and 64.27. Note the silver
nitrate base cautery is being performed for the superior and anterior
edges. This would control the bleeding from the granuloma base as well
as help prevent recurrences

right nasal cavity demonstrating progressive aspiration of the
right nasal cavity demonstrating the beginning of the gentle and con-
granuloma
trolled aspiration using a powered suction, after extubating the stent
Fig. 64.32 Aspiration and silver nitrate therapy: endoscopic view of a Fig. 64.34 Aspiration and silver nitrate therapy: endoscopic view of a
right nasal cavity demonstrating progressive aspiration of the granu- right nasal cavity demonstrating the large posterior pedicle of the gran-
loma, exposing its inferior edge attachment uloma at the posterior edge
right nasal cavity demonstrating the well-exposed ostium upon comple- right nasal cavity demonstrating the immediate post-cautery picture.
tion of the granuloma aspiration Note the entire posterior and inferior edges have been cauterized using
the silver nitrate, while sparing the ostium per se
right nasal cavity demonstrating the silver nitrate base cautery to the right nasal cavity demonstrating the positive fluorescein endoscopic
posterior edge dye test. Note the area of silver nitrate cautery does not involve the base
of the ostium and is away from the internal common opening
Adjunctive Endoscopic Procedures:
Endoscopic Septoplasty 65
Endoscopic dacryocystorhinostomy is a common lacrimal References

procedure. It is not uncommon to encounter anatomical vari-
ations during an endoscopy and may need to be addressed 1. Ali MJ, Psaltis AJ, Wormald PJ. The frequency of concomitant
adjunctive nasal procedures in powered endoscopic dacryocysto-
simultaneously with endoscopic DCR for ease of surgery rhinostomy. Orbit. 2015;34:142–5.
and better outcomes. Additional adjunctive procedures were 2. Champagne C, Ballivet de Régaloix L, Genestier L, Crambert
required in almost half of the lacrimal patients in a rhinology A, Maurin O, Pons Y. Endoscopic vs conventional septoplasty: a
practice [1]. Most of these procedures are aimed at improv- review of the literature. Eur Ann Otorhinolaryngol Head Neck Dis.
2016;133:43–7.
ing access to the lateral nasal wall such as septoplasty and 3. Ali MJ, Psaltis AJ, Wormald PJ. Long-term outcomes in revision
middle turbinoplasty [1–3]. Deviated nasal septum is not powered endoscopic dacryocystorhinostomy. Int Forum Allergy
uncommon and those precluding complete visualization of Rhinol. 2014;4:1016–9.
the axilla of middle turbinate should be addressed. Before
performing a septoplasty, the operating surgeon should be
familiar with the anatomy of the septum and important
regions that must be respected to avoid compromising struc-
tural support. The three major principles in endoscopic sep-
toplasty, which the author follows, are, first, good and clean
elevation of the mucoperichondrium; second, spare the ante-
rior cartilage and never twist the bony septum beyond the
level of the middle turbinate; and, finally, be careful never to
create a through-and-through tear to avoid septal perforation
and its sequelae. Complications include bleeding, infection,
septal hematoma or abscess formation, septal perforation,
cosmetic complications, loss of structural support, tip ptosis,
paresthesia of the upper teeth, and cerebrospinal fluid leak.
Hence it is very important for a proper training of surgeons
before embarking on adjunctive endoscopic procedures.

584 65 Adjunctive Endoscopic Procedures: Endoscopic Septoplasty

gross anterior deviation of the septum precluding any view
Fig. 65.1 Endoscopic view of a left nasal cavity showing a normal
septum. Note that middle turbinate and its axilla are clearly visualized
Fig. 65.2 Endoscopic view of the right nasal cavity demonstrating an

anterior deviation of the septum
high anterior deviation of the septum
65 Adjunctive Endoscopic Procedures: Endoscopic Septoplasty 585
Fig. 65.7 Endoscopic view of the left nasal cavity showing a sharp
antero-inferior septal spur

high posterior deviation of the septum
Fig. 65.7. Note the extent of the inferior septal spur

diffuse high deviation of the septum
Fig. 65.12 The tip of the Wormald elevator. Note that it is devised to
enable elevation as well as cutting in addition to simultaneous suction
Fig. 65.9 CT scan PNS, coronal cut, demonstrating a right deviated

nasal septum. Note the deviation is high and accompanied by right infe-
rior turbinate hypertrophy
Fig. 65.13 The straight and blunt suction elevator
Fig. 65.10 The additional basic instruments for a septoplasty
Fig. 65.14 The instrument shaper, which can be used for achieving
desired shapes and angulations of malleable instruments
Fig. 65.11 The Wormald septoplasty suction elevator®. This is a mal-

leable instrument
Fig. 65.15 Cadaveric
dissection demonstrating
principles of endoscopic
septoplasty: mid-sagittal
cadaveric image showing an
intact septum (black star)
cadaveric image showing a
Killian’s incision at the
mucocutaneous junction
cadaveric image
demonstrating a sub-
mucoperichondrial dissection
cadaveric image showing a
clear elevation of the
mucoperichondrium
septoplasty: Mid-sagittal
cadaveric image
demonstrating exposure of the
bony-cartilage junction
(pointed by the elevator) after
reflection of the mucosal flap.
It is important to note that
there is no reflection of this
flap in patients and is done
here for demonstrating
anatomical details
cadaveric image
demonstrating the
perpendicular plate of the
ethmoid (pointer)
cadaveric image
demonstrating the vomer
(pointer)
cadaveric image
demonstrating the initial
bony-cartilage disassociation
cadaveric image
demonstrating the removal of
anterior most bone to
facilitate the separation of the
mucosa on the other side
cadaveric image
demonstrating removal of the
bone to achieve reduction of
the septal deviation
cadaveric image
demonstrating the end of
septoplasty. Note the two
septal mucosal flaps (black
stars) will oppose each other
and adhere
Fig. 65.26 Endoscopic septoplasty procedure: endoscopic view of the Fig. 65.27 Endoscopic septoplasty procedure: endoscopic view of the
left nasal cavity demonstrating a gross deviation precluding a good left nasal cavity demonstrating infiltration anesthesia at the mucocuta-
view of the middle turbinate neous junction
Fig. 65.30 Endoscopic septoplasty procedure: endoscopic view dem-

onstrating creation of a plane between the incised flap from the underly-
ing cartilage
Fig. 65.28 Endoscopic septoplasty procedure: endoscopic view of the

left nasal cavity demonstrating the Killian’s incision at the mucocutane-
ous junction
Fig. 65.29 Endoscopic septoplasty procedure: endoscopic view of the Fig. 65.31 Endoscopic septoplasty procedure: endoscopic view dem-
left nasal cavity demonstrating the Killian’s incision. Note that the inci- onstrating a clean elevation of the mucoperichondrium with the help of
sion should not injure the underlying quadrilateral cartilage and should Wormald suction elevator®
ideally be full length

onstrating progressive mucoperichondrial elevation to expose the bony-
onstrating disarticulation of the bony-cartilage junction
cartilage junction
Fig. 65.33 Endoscopic septoplasty procedure: endoscopic view dem- Fig. 65.35 Endoscopic septoplasty procedure: endoscopic view dem-
onstrating progressive mucoperichondrial elevation to expose the bony- onstrating removal of the anterior bone using Blakesley forceps
cartilage junction and a little beyond it
onstrating the Wormald elevator separating the mucoperichondrium on onstrating mucoperichondrial elevation posterior to the bony-cartilage
the opposite side junction
onstrating the progressive mucoperichondrial elevation on the opposite onstrating the removal of the perpendicular plate of the ethmoid
side to clear the deviated bone of any mucosa on either side before
removing it
onstrating the vomer bone inferiorly onstrating repositioning of the flaps for the quilt suture
Fig. 65.41 Endoscopic septoplasty procedure: Endoscopic view at the Fig. 65.43 Endoscopic septoplasty procedure: Endoscopic view at the
end of septoplasty. Note the entire quadrilateral cartilage is spared and end of septoplasty. Note the amount of space and ease of access that has
there is no bleeding been created. Compare it to pre-operative image in Fig. 65.26
Fig. 65.44 Endoscopic view during a septoplasty in a post-trauma set-

ting. Note the synechiae and one must be careful to avoid septal perfo-
ration. Also note the increased bleeding as compared to a routine case
described earlier Fig. 65.46 Endoscopic view of the right nasal cavity at the end of sep-
toplasty of patient in Fig 65.45. Note the achievement of the ease of
access to lateral wall and the full visibility of middle turbinate
Fig. 65.45 Endoscopic view of the right nasal cavity showing a high
posterior deviated nasal septum. Note the medial surface of the middle
turbinate and its axilla is not visible
Middle Turbinoplasty 66
Endoscopic dacryocystorhinostomy is a common lacrimal References

procedure. It is not uncommon to encounter anatomical vari-
ations during an endoscopy and may need to be addressed 1. Ali MJ, Psaltis AJ, Wormald PJ. The frequency of concomitant
adjunctive nasal procedures in powered endoscopic dacryocystorhi-
simultaneously with endoscopic DCR for ease of surgery nostomy. Orbit. 2015;34:142–5.
and better outcomes. Additional adjunctive procedures were 2. Stallman JS, Lobo JN, Som PM. The incidence of concha bullosa
required in almost half of the lacrimal patients in a rhinology and its relationship to nasal septal deviation and paranasal sinus dis-
practice [1]. Most of these procedures are aimed at improv- ease. AJNR Am J Neuroradiol. 2004;25:1613–8.
ing access to the lateral nasal wall such as septoplasty and powered endoscopic dacryocystorhinostomy. Int Forum Allergy
middle turbinoplasty [1–3]. Pneumatization of the middle Rhinol. 2014;4:1016–9.
turbinate is not an uncommon occurrence. The reported inci-
dence of concha bullosa ranges anywhere between 14 and
53% with the variation in incidence reflective of differing
anatomical definitions [2]. A recent study reported the neces-
sity for a concurrent middle turbinoplasty in up to 6% of
endoscopic DCR cases [1]. Numerous techniques for reduc-
ing a middle turbinate concha bullosa have been described.
All share a common principle of resection of the lateral
aspect or lamella, with preservation of as much of the medial
lamella as possible. Excessive manipulation of this medial
portion should be avoided at all times given its insertion into
the skull base.

600 66 Adjunctive Endoscopic Procedures: Middle Turbinoplasty
Fig. 66.1 Endoscopic view of the left nasal cavity demonstrating a Fig. 66.3 Endoscopic view of the right nasal cavity demonstrating a
normal middle turbinate concha bullosa. Note the extent of the nasal cavity that is occupied by
the concha and compare it to those of Figs. 66.1 and 66.2
Fig. 66.2 Endoscopic view of the left nasal cavity demonstrating a

normal middle turbinate
66 Adjunctive Endoscopic Procedures: Middle Turbinoplasty 601
Fig. 66.4 CT scan PNS,

coronal cut, demonstrating a
left-sided concha bullosa.
Compare it with the normal
right side
Fig. 66.5 Cadaveric
principles of middle
turbinoplasty: mid-sagittal
cadaveric image of the lateral
wall demonstrating the
incision on the head of the
middle turbinate
Fig. 66.6 Cadaveric
submucosal dissection to
isolate the bony concha
Fig. 66.7 Cadaveric
exposed bony concha
Fig. 66.8 Cadaveric
removal of the bony concha
Fig. 66.9 Cadaveric
wall demonstrating the ready
to collapse concha
wall demonstrating the rolling
of the elevated mucosa over
the collapsed concha. Note
the reduced size of the MT
head and compare it to that in
Fig. 66.5
Fig. 66.11 Technique of middle turbinoplasty: endoscopic view of the Fig. 66.12 Technique of middle turbinoplasty: Endoscopic view of the
right nasal cavity demonstrating the vertical incision on the head of the right nasal cavity demonstrating submucosal opening of the concha
middle turbinate
Fig. 66.13 Technique of middle turbinoplasty: endoscopic view of the Fig. 66.15 Technique of middle turbinoplasty: endoscopic view of the
right nasal cavity demonstrating enlargement of the conchal opening right nasal cavity demonstrating debulking of the concha with the help
of a powered debrider
Fig. 66.14 Technique of middle turbinoplasty: endoscopic view of the Fig. 66.16 Technique of middle turbinoplasty: Endoscopic view at the
right nasal cavity demonstrating debulking of the concha with the help end of turbinoplasty. Note the reduction in the size achieved
of a powered debrider
Fig. 66.17 Technique of middle turbinoplasty: Endoscopic view at

1 week after turbinoplasty. Note the gross reduction in the size of the
head of middle turbinate
Inferior Turbinoplasty 67
It is not uncommon to encounter anatomical variations dur- References

ing an endoscopy and may need to be addressed simultane-
ously with lacrimal surgeries for ease of surgery and better 1. Fradis M, Golz A, Danino J, et al. Inferior turbinectomy versus
submucosal diathermy for inferior turbinate hypertrophy. Ann Otol
outcomes. Proper patient assessment and a trial of medical Rhinol Laryngol. 2000;109:1040–5.
therapy should be performed before the decision is made to 2. Hamerschimidt R, Hamerschmit R, Moreira AT, et al. Comparison
reduce the turbinates. In those patients that fail medical ther- of turbinoplasty surgery efficacy in patients with and without aller-
apy and in whom other contributing factors have been elimi- gic rhinitis. Braz J Otorhinolaryngol. 2016;82:131–9.
3. Brunworth J, Psaltis AJ, Wormald PJ. Adjunctive endonasal proce-
nated (allergies, sinus disease, etc.), turbinate reduction is a dures with dacryocystorhinostomy. In: Ali MJ, editor. Principles and
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and frequently in their quality of life [1–3]. Occasionally the
inferior turbinate may be grossly hypertrophied and one may
need a turbinoplasty to gain a comfortable space for other
procedures like septoplasty or even balloon lacrimal proce-
dures of the NLD in adults.

608 67 Adjunctive Endoscopic Procedures: Inferior Turbinoplasty
Fig. 67.1 Endoscopic view of the right nasal cavity showing a normal Fig. 67.3 Endoscopic view of the left nasal cavity showing hypertro-
inferior turbinate phy of the inferior turbinate
Fig. 67.2 Endoscopic view of the right nasal cavity showing a normal Fig. 67.4 Endoscopic view of the left nasal cavity demonstrating a
inferior turbinate gross hypertrophy of the inferior turbinate
67 Adjunctive Endoscopic Procedures: Inferior Turbinoplasty 609
Fig. 67.5 Inferior turbinoplasty technique: endoscopic view of left Fig. 67.7 Inferior turbinoplasty technique: intra-operative view fol-
nasal cavity demonstrating a hypertrophied inferior turbinate lowing submucosal dissection to isolate the IT bone and its subsequent
removal
Fig. 67.6 Inferior turbinoplasty technique: intra-operative view of the Fig. 67.8 Inferior turbinoplasty technique: intra-operative image dem-
left nasal cavity demonstrating incision and submucosal debridement at onstrating lateral rolling of the mucosal edge. Note the reduction in size
the head of the inferior turbinate and space gain in the nasal cavity
Dacryocystectomy
68
Dacryocystectomy or DCT refers to a complete surgical exceptional indications for an endoscopic DCT as well [3].
extirpation of the lacrimal sac. Indications for dacryocystec- Following extirpation all the lacrimal sacs should be sub-
tomy include malignant tumors of the lacrimal sac, recurrent jected to a histopathological examination.
dacryocystitis in the presence of severe dry eyes or cicatriz- Figures are from Ali MJ. (Ophthal Plast Reconstr Surg.
ing autoimmune disorders like Wegener’s granulomatosis, 2014;30:512–516) [1].
patients with debilitating systemic comorbidities and bleed-
ing diathesis, multiple time failed dacryocystorhinostomies,
and severe atrophic rhinitis. Only malignant tumors are an References
absolute indication; the rest are relative [1–3]. There are two
clear goals of dacryocystectomy procedure. First is to have a 1. Ali MJ. Dacryocystectomy: Goals, indications, techniques, and
complications. Ophthal Plast Reconstr Surg. 2014;30:512–6.
clear plane of sac excision and avoid injury to periorbita and 2. Pujari A, Ali MJ, Mulay K, Naik MN, et al. The black lacrimal sac:
surrounding bones. Second is to have a complete excision of a clinicopathological correlation of a malignant melanoma with
the sac along with the nasolacrimal duct without leaving any anterior lacrimal crest infiltration. Int Ophthalmol. 2014;34:111–5.
remnants behind. Since both these purposes are well served 3. Shams PN, Selva D. An endoscopic endonasal approach to dacryo-
cystectomy. Orbit. 2013;32:134–6.
by an external route, it is the preferred approach. There are

612 68 Dacryocystectomy
Fig. 68.1 Technique of dacryocystectomy: intra-operative photograph Fig. 68.3 Technique of dacryocystectomy: intra-operative photograph
demonstrating a right infratrochlear anesthesia block demonstrates the marking of the curvilinear incision below the medial
canthus
Fig. 68.2 Technique of dacryocystectomy: intra-operative photograph Fig. 68.4 Technique of dacryocystectomy: intra-operative photograph
demonstrating local infiltration anesthesia demonstrates separation of the subcutaneous tissues by a tenotomy
forceps
68 Dacryocystectomy 613

dacryocystectomy: intra-
operative photograph
demonstrating a periosteal
incision

demonstrating dissection at
the medial canthus to obtain
the entire lacrimal sac
including the fundus

demonstrating lateral
reflection of the lacrimal sac
along with the periosteum

demonstrating lateral
dissection to separate the
lateral wall of the lacrimal sac
from the periorbita

demonstrating dissection at
the sac-duct junction

demonstrating amputation of
the lacrimal sac
Fig. 68.11 Technique of dacryocystectomy: intra-operative photo-

graph demonstrating the extirpated right lacrimal sac

graph demonstrating the whitish discoloration of the right upper punc-
tum after cautery

graph demonstrating the lacrimal sac fossa following
dacryocystectomy

graph demonstrates wound closure and end of the procedure

graph demonstrating the technique of cauterization of the canaliculus
and the internal common opening with the help of a probe
Fig. 68.16 Gross specimen of a routine post-dacryocystectomy sac

Fig. 68.19 Extended dacryocystectomy: Gross specimen photograph

showing the black mass in the lacrimal sac. Note the extended soft tis-
Fig. 68.17 Microphotograph of a chronic dacryocystitis. Note the sue margins obtained
chronic inflammatory features on histopathology
Fig. 68.18 Extended dacryocystectomy: intra-operative photograph

showing additional removal of the frontal process of maxilla in a case
of a malignant melanoma of lacrimal sac involving the bone Fig. 68.20 Immunohistochemistry microphotograph of the excised
lesion in Fig. 68.19. Note HMB-45 showing positive staining of the
tumor cells, consistent with a diagnosis of malignant melanoma of the
lacrimal sac (HMB-45 ×400)
Masquerades of Lacrimal Drainage
Disorders 69
Masquerades of lacrimal drainage disorders are not very sion and histopathological confirmation. Very rarely lacrimal
uncommon [1–3]. They may simulate either an external gland choristoma within the lacrimal sac can also manifest
manifestation of a lacrimal disorder or may mimic the pre- like a dacryocele; however, the usual associated eyelid
sentations. Among the common masquerades of congenital anomalies give a clue with regard to the possible diagnosis.
nasolacrimal duct obstructions include other subtle lacrimal Dermoid cysts are also notorious for masquerading like a
disorders like incomplete punctal canalization and canalicu- mucocele in the pediatric age groups of even in adults with
lar wall dysgenesis, which can be easily missed, erroneously neglected dermoid cysts. Rarely mascara or eye makeup
labeling the patient as a possible CNLDO [3]. Nasal condi- materials may be washed in tears and chronically deposit in
tions like allergic rhinitis, lacrimal wall maldevelopment, or the epithelium and subepithelial areas of the lacrimal sac and
other nasal mucosal inflammatory disorders may also mimic may appear as a bluish to black discolored areas. Most of
a CNLDO. Ocular conditions like buphthalmos, neonatal them are flat, but occasionally, few may be raised a bit lead-
conjunctivitis, and ocular surface inflammatory disorders ing to suspicion of malignancy. Any lesion found suspicious
can also present with neonatal onset of epiphora and dis- during an accidental discovery should be biopsied, and fur-
charge. Occasionally subtle medial most ankyloblepharon ther management is dictated by the histopathological results.
can also be mistaken for a CNLDO. Figures 21–32 are from Ali et al., (Ophthal Plast Reconstr
Numerous conditions can mimic a congenital dacryocys- Surg. 2015;31:e26–28 and Ophthal Plast Reconstr Surg.
tocele and include dermoid cysts, encephalocele, meningo- 2016;32:e165) [1, 2].
cele, nasal glioma, deep hemangiomas, and lymphangiomas.
Glial heterotopia is a rare lesion in the head and neck region
that results from choristoma of mature central nervous sys- References
tem tissues in various locations without any continuity with
the nervous system as such. If this occurs in the region of the 1. Ali MJ, Kamal S, Vemuganti GK, et al. Glial heterotropia or ecto-
pic brain manifesting as a dacryocystocele. Ophthal Plast Reconstr
lacrimal sac fossa, it may mimic like a dacryocele, although Surg. 2015;31:e26–8.
it does not have any communication with the lacrimal drain- 2. Ali MJ, Mishra DK. Lacrimal sac wall granuloma simulating a neo-
age system [1]. Hence it is important to keep this in the dif- plasm. Ophthal Plast Reconstr Surg. 2016;32:e165.
ferential diagnosis of dacryocele and would need a good 3. Kamal S, Ali MJ, Gupta A, et al. Lacrimal and nasal masquerades
of congenital nasolacrimal duct obstructions: etiology, management
imaging to confirm its isolation and extent followed by exci- and outcomes. Int Ophthalmol. 2015;35:807–10.

620 69 Masquerades of Lacrimal Drainage Disorders
1. Punctal agenesis
2. Incomplete punctal canalisation
3. Punctal Stenosis
4. Canalicular wall dysgenesis
5. Mono-canalicular obstructions
6. Pre-saccal stenosis
7. Allergic rhinitis
8. Lateral wall mal-development
9. Glial heterotropia
10. Functional epiphora Fig. 69.4 Clinical photograph of the patient in Figs. 69.2 and 69.3,
high magnification, clearly delineating the ankyloblepharon
Fig. 69.1 The common lacrimal and nasal masquerades of congenital
nasolacrimal duct obstruction
Fig. 69.2 Clinical photograph of both eyes showing that subtle medial Fig. 69.5 Case study of dermoid cyst mimicking a lacrimal sac muco-
ankyloblepharon in a pediatric age group can be easily mistaken for a cele: clinical photograph showing a left-sided swelling in the region of
CNLDO lacrimal sac with palpatory findings similar to a mucocele
Fig. 69.3 Clinical photograph of the right eye of the patient in Fig. 69.6 Case study of dermoid cyst mimicking a lacrimal sac muco-
Fig. 69.2. Note the ankyloblepharon cele: clinical photograph showing the swelling to become more promi-
nent on ocular movements, giving a clue against the mucocele
69 Masquerades of Lacrimal Drainage Disorders 621
Fig. 69.7 Case study of dermoid cyst mimicking a lacrimal sac muco-
cele: clinical photograph of the patient in Figs. 69.5 and 69.6. Note the Fig. 69.9 Case study of dermoid cyst mimicking a lacrimal sac muco-
greater details of the lesion on a close-up image cele: CT scan, axial cut at the level of nasolacrimal duct. Note here now
that the lesion is separated from the bony NLD with an enhancing rim.
Hence it is important to study all the section carefully to assess the
separate nature of this lesion
Fig. 69.8 Case study of dermoid cyst mimicking a lacrimal sac muco-
cele: CT scan, coronal cut, showing the lesion to be in the lacrimal sac
fossa and does not clearly distinguish it from the underlying lacrimal
tissues, which may misguide the surgeon to believe it to be a mucocele
Fig. 69.10 Case study of dermoid cyst mimicking a lacrimal sac

mucocele: endoscopic view of the left nasal cavity showing normal
endoscopic findings of the middle turbinate and area in front of the
axilla

mucocele: intra-operative photograph showing a superficial cutaneous
incision over the lesion to avoid rupturing it

mucocele: endoscopic view of the left inferior meatus, showing no
abnormality of the nasolacrimal duct

mucocele: intra-operative photograph showing the lesion to be well dis-
sected all around

mucocele: endoscopic view of the left inferior meatus, showing patent
nasolacrimal ducts to irrigation Fig. 69.15 Case study of dermoid cyst mimicking a lacrimal sac
mucocele: intra-operative photograph showing cryotherapy assisted
delivery of the lesion
Fig. 69.16 Case study of dermoid cyst mimicking a lacrimal sac Fig. 69.19 Intra-operative photograph of the patient in Fig. 69.18,
mucocele: gross specimen of the excised dermoid cyst for higher magnification image, showing the focal areas of discoloration.
histopathology Note one of them is slightly raised
Fig. 69.20 Gross specimen of the raised pigmented lesion, biopsied,

Fig. 69.17 Case study of dermoid cyst mimicking a lacrimal sac that turned out to be pigment deposits
mucocele: fifth day post-operative image showing resolution of the con-
dition. Compare this with those of Figs. 69.5 and 69.6
Fig. 69.18 Intra-operative photograph of a right lacrimal sac showing Fig. 69.21 Glial heterotopia mimicking a dacryocele: clinical photo-
bluish-black discoloration graph of an infant showing a lesion in the area of left lacrimal sac
Fig. 69.24 Glial heterotopia mimicking a dacryocele: Endoscopic

Fig. 69.22 Glial heterotopia mimicking a dacryocele: CT scan, axial view after excision of the lesion. Note the defect in the underlying bone
cut of the patient in Fig. 69.21. Note the lesion is in close relation but is and the normal lateral wall mucosa
separate from the lacrimal drainage system
Fig. 69.25 Glial heterotopia mimicking a dacryocele: gross specimen

of the excised lesion
Fig. 69.23 Glial heterotopia mimicking a dacryocele: endoscopic
view of the left nasal cavity showing normal findings without any mass
lesion
Fig. 69.26 Glial heterotopia mimicking a dacryocele: microphoto- Fig. 69.28 Glial heterotopia mimicking a dacryocele: microphoto-
graph showing mature neural tissue interspersed with fibrous tissue (H graph showing the positive immunoreactivity to glial fibrillary acidic
& E ×100) protein (GFAP ×400)
Fig. 69.29 Lacrimal sac granuloma mimicking a malignancy: Clinical

photograph of the left eye of a patient who presented with a rapidly
Fig. 69.27 Glial heterotopia mimicking a dacryocele: microphoto- growing lacrimal sac lesion. Note the fullness of the lacrimal sac fossa
graph showing numerous oval astrocytes in the eosinophilic fibrillary below the medial canthal tendon
network (H & E ×400)
Fig. 69.32 Lacrimal sac granuloma mimicking a malignancy: micro-

photograph showing a chronic inflammatory infiltrate and fibrosis of
the sac wall with surrounding organized granuloma (H & E ×100)
Fig. 69.30 Lacrimal sac granuloma mimicking a malignancy: gross

pathology specimen showing lacrimal sac wall (L) and the mass lesion
arising from the wall (black arrow)
Fig. 69.33 Clinical photograph of a right medial canthal furuncle

mimicking an acute dacryocystitis
Fig. 69.31 Lacrimal sac granuloma mimicking a malignancy: Whole

mount section showing the lacrimal sac wall (L) and the lesion (black
arrow)

Fig. 69.33. A careful history and a meticulous examination would rule
out an acute dacryocystitis
Arhinia and Lacrimal Disorders
70
Congenital arhinia or arhinogenesia is an extremely rare References

anomaly characterized by the absence of soft tissues of the
nose and nasal structures and can be associated with numer- 1. Ali MJ. Bilateral lacrimal mucoceles in a setting of congenital
arhinia. Ophthal Plast Reconstr Surg. 2014;30:e167.
ous craniofacial and ocular anomalies [1–3]. Congenital 2. Sherafat H, Mehta JS, Rose GE. Dacryocystorhinostomy in patients
arhinia can be complete or partial. Numerous ocular anoma- lacking ipsilateral nasal cavity. Br J Ophthalmol. 2007;91:307–9.
lies have been reported to be associated with arhinia and 3. Ali MJ, Singh S, Naik MN. Image-guided lacrimal drainage sur-
include microphthalmos, microcornea, uveal coloboma, lens gery in congenital arhinia-microphthalmia syndrome. Orbit.
2017;36:137.
dislocation, canthal dystopia, hypertelorism, synophrys,
blepharophimosis, broad superior orbital fissure, and rarely
anophthalmos [1–3]. Lacrimal disorders commonly noted
are mucocele, absence of nasolacrimal ducts with blind end-
ing of lacrimal sacs, and nondevelopment of lacrimal bones.
The lacrimal disorders in complete arhinia are very difficult
to manage and are taken up following nasal reconstruction.
Dacryocystorhinostomy into the contralateral nasal cavity
has been successfully performed in unilateral arhinia cases
[2]. Image-guided lacrimal drainage surgeries have recently
been successfully reported for this condition [3].
Figures are from Ali et al., (Ophthal Plast Reconstr Surg.
2014;30:e167 and Orbit 2017;36:137) [1, 3].

628 70 Arhinia and Lacrimal Disorders
OD
Fig. 70.1 Arhinia case study 1: clinical photograph of a patient with

complete arhinia or absence of nose with bilateral lacrimal sac
mucoceles
Fig. 70.4 Arhinia case study 1: ultrasound B-scan of the right eye of
patient in Fig. 70.1. Note the associated choroidal colobama
Fig. 70.2 Arhinia case study 1: clinical photograph of the right eye of
patient in Fig. 70.1. Note the lacrimal sac mucocele and the
microphthalmos
Fig. 70.3 Arhinia case study 1: clinical photograph of the left eye of Fig. 70.5 Arhinia case study 1: clinical photograph of the patient in
patient in Fig. 70.1. Note the gross epiphora, lacrimal mucocele, and Fig. 70.1. Note the high arched palate and abnormal dentition
microphthalmos
70 Arhinia and Lacrimal Disorders 629
Fig. 70.8 Arhinia case study 2: clinical photograph, worm eye view,
showing the left-sided partial arhinia with hypoplastic nares and upper
lip scar of the past cleft lip surgery. Also note the left microphthalmos
Fig. 70.6 Arhinia case study 1: clinical photograph of the patient in

Fig. 70.1, following the first step of reconstruction. Lacrimal anomalies
will be dealt after nasal reconstruction

Fig. 70.8, showing a high arched palate

Fig. 70.1, following the first step of reconstruction. Note the airway
device
Fig. 70.10 Arhinia case study 2: clinical photograph of the patient in Fig. 70.12 Arhinia case study 2: clinical photograph of the left eye of
Fig. 70.8, signs of ongoing treatment for dental malalignment patient in Fig. 70.8, showing a gross mucoid regurgitation on pressure
over the left lacrimal sac
Fig. 70.11 Arhinia case study 2: ultrasound B-scan of the microph-

thalmic left eye, showing a choroidal coloboma
Fig. 70.13 Arhinia case study 2: endoscopic view of the left atretic
nasal cavity and absence of nasal structures with a tiny atretic posterior
choanae. Note the malformed septum with an antero-inferior defect
Fig. 70.15 Arhinia case study 2: CT scan, 3D reconstruction of the

craniofacial bones showed gross left-sided maxillary and bony nasal
hypoplasia
Fig. 70.14 Arhinia case study 2: endoscopic view of the right nasal
cavity showed well developed structures with a gross hypertrophy of
the middle and inferior turbinates
Fig. 70.16 Arhinia case study 2: CT scan, coronal cut, showing left-sided absence of maxillary and ethmoid sinuses. Note the irregular left frontal
process of maxilla fusing apically with the nasal process of frontal bone near the glabella
Fig. 70.17 Arhinia case study 2: CT scan axial cut showing grossly malformed and deviated septum and ipsilateral absent sinuses
Fig. 70.18 Arhinia case

study 2: the navigation
computer’s 3D reconstruction
of the facial features.
Compare it with Fig. 70.8

study 2: A CT scan, coronal
cut, demonstrating the path
chosen by the surgeon for the
computer for the DCR
creation into the contralateral
cavity through the nasal
septum. Other than the
navigation benefit, the
computer will now alert the
surgeon if he deviates from
this path

study 2: the navigation
computer’s 3D reconstruction
of the proposed surgical
anastomosis path
Fig. 70.21 Arhinia case study 2: endoscopic view showing the thick
and flat bone in front and above the left lacrimal sac
Fig. 70.22 Arhinia case study 2: active intra-operative stereotaxis. the cross hairs in coronal, axial, and sagittal CT cuts, denoting the fron-
Image guidance confirmed this bone to be the frontal process of maxilla tal process and its apical fusion
that was fusing apically under the glabella. Note the meeting point of
Fig. 70.23 Arhinia case study 2: active intra-operative stereotaxis. the pre-existing septal defect. Note the positions of the cross hairs in all
Image guidance following the osteotomy showing the exposed nasal the CT cuts as well as the level of opening into the right nasal cavity
mucosa to be that of the malformed nasal septum, supero-posterior to
Fig. 70.24 Arhinia case study 2: endoscopic view showing comple- Fig. 70.26 Arhinia case study 2: endoscopic view of the right nasal
tion of partial right middle turbinoplasty, performed to clear the area in cavity following a 23 gauge Crawford lacrimal intubation through the
front of the proposed septal window septal window
Fig. 70.25 Arhinia case study 2: endoscopic view showing the raised Fig. 70.27 Arhinia case study 2: endoscopic view of the right nasal
anterior septal (pointed by the probe) and anterior lacrimal sac flaps cavity at 4 weeks. Note the presence of stent and well-healed and con-
tiguous mucosa
Fig. 70.28 Arhinia case study 2: endoscopic view with 70° telescope
showing the ostium within the septum and a positive fluorescein endo-
scopic dye test
Fig. 70.29 Arhinia case study 2: endoscopic view with a 70° telescope
at 6 months showing the stable ostium and internal common opening on
the septal wall
Lacrimal Interventions and Bacteremia
71
Bacteremia can be defined as the presence of viable bacteria References

in the bloodstream. Probing is one of the established modali-
ties of management for congenital nasolacrimal duct obstruc- 1. Ganguly A, Ali MJ, Padmaja K, et al. Bacteremia following naso-
lacrimal duct probing: is there a role of preoperative antibiotic pro-
tions. Bacteremia is a possibility in view of intervention into phylaxis? Ophthal Plast Reconstr Surg. 2016;32:90–2.
mucosal tissues, and implications can be serious because 2. Baskin DE, Reddy AK, Chu YI, et al. The timing of antibiotic
most patients are in the range of 1–3 years. Bacteremia has administration in the management of infant dacryocystitis. J
been documented following probing in multiple studies and AAPOS. 2008;12:456–9.
3. Grech V, Sammut P, Parascandolo R, et al. Bacterial endocarditis
the incidence ranged from 4 to 22.5% [1–5]. Organisms iso- following lacrimal duct probing. J Pediatr Ophthalmol Strabismus.
lated include Staphylococcus aureus, Streptococcus viridans, 2001;38:49–50.
Streptococcus pneumonia, and broad categories of alpha and 4. Ali MJ. Pediatric acute dacryocystitis. Ophthal Plast Reconstr Surg.
gamma Streptococci and Haemophilus influenzae [1–4]. 2015;31:341–7.
5. Ali MJ, Ayyar A, Motukupally SR. Bacteremia during dacryocysto-
Since most of these organisms are known to be etiological rhinostomy: results of intra-operative blood cultures. J Ophthalmic
factors in infective endocarditis, prophylactic antibiotics Inflamm Infect. 2014;4:27–30.
are advocated if intervention is planned in a pediatric acute
dacryocystitis or for high-risk cases like those with cardiac
anomalies. On the other hand, bacteremia has not been dem-
onstrated in cases of routine dacryocystorhinostomy, and
hence, routine post-operative systemic antibiotic prophylaxis
may not be necessary following uneventful surgeries [5].
Figures 4–10 are from Ali et al., J Ophthalmic Inflamm
Infect. 2014;4:27–30 [5], and Ganguly et al., Ophthal Plast
Reconstr Surg. 2016;32:90–92 [1].

640 71 Lacrimal Interventions and Bacteremia
Fig. 71.1 Susceptible cases for bacteremia: clinical photograph of an Fig. 71.4 Bacteremia diagnosis: the Columbia broth (left) and the dual
infant with acute dacryocystitis media culture bottles
Fig. 71.2 Susceptible cases for bacteremia: clinical photograph of an Fig. 71.5 Bacteremia diagnosis: various durations post-inoculation of
infant with a left-sided spontaneous fistula of a left lacrimal abscess dual medial culture bottles
Fig. 71.3 Susceptible cases for bacteremia: clinical photograph of a

neonate with bilateral dacryocystoceles
Fig. 71.6 Bacteremia diagnosis: subcultures being taken from the

inoculated dual medial culture bottle
71 Lacrimal Interventions and Bacteremia 641
Fig. 71.9 BacT® culture bottles. Note the difference in the colors of

the gas permeable sensors at the base
Fig. 71.7 A BacT® culture bottle. Note the gas permeable sensor at the
base
Fig. 71.10 Console of the BacT® microbial detection system, flagging

a positive result
Fig. 71.8 The BacT® microbial detection system. Note that multiple
bottles can be housed at any given time

Instrument Fracture
72
Instrument fractures during surgeries are rarely reported References

[1–3], and the prevalence is estimated to be 0.18–0.35% in
the orthopedic literature. Intra-operative instrument fracture 1. Ali MJ, Naik MN. Intraoperative instrument fracture during endo-
scopic dacryocystorhinostomy. Ophthal Plast Reconstr Surg.
can be a serious complication especially during endoscopic 2017;33:e27.
procedures. The author has experience with one such fracture 2. McGuigan MB, Louca C, Duncan HF. The impact of frac-
during the superior osteotomy step of an endoscopic dacryo- tured endodontic instruments on treatment outcome. Br Dent J.
cystorhinostomy. The involved instrument was the 15°, high- 2013;214:285–9.
3. Angmo D, Khokar SK, Ganguly A. Intraoperative fracture of phaco-
speed DCR burr (Medtronic, Jacksonville, USA). During the emulsification tip. Middle East Afr J Ophthalmol. 2014;21:86–8.
active osteotomy, there was a sudden fracture of the instru-
ment at the junction of its proximal two thirds and distal one
third. The tip of the distal fractured bit fortunately got stuck in
the frontal process of maxilla, arresting its movements, soon
after the fracture. The broken end of the distal bit, which was
in contact with the septum, was carefully removed, and the
metallic debris that was smeared all over was gently aspirated
and patiently removed. It is important to understand that the
first priority soon after any instrument fracture is to make sure
not to lose the fractured loose bit. A careful assessment of
the tissues all along should be performed to assess any tis-
sue damage that may need immediate attention. Every such
incident needs to be documented in the OR logbook, and the
causes should be ascertained. There should also be a peri-
odic examination of all the instruments used to assess for any
signs of metal fatigue or any minor distortion of shapes. It is a
healthy practice to notify the manufacturers, for them also to
investigate and take stock of the situation.
Figures 4, 7, and 10 are from Ali et al., Ophthal Plast
Reconstr Surg. 2017;33:e27 [1].

644 72 Instrument Fracture
Fig. 72.3 Endoscopic view of the right nasal cavity. Note the other end
Fig. 72.1 Endoscopic view of the right nasal cavity, immediately after of the fractured distal end touching the septum
the instrument fracture. Note the distal broken end of the high-speed
DCR burr
Fig. 72.2 Endoscopic view of the right nasal cavity. Note the tip of the Fig. 72.4 Endoscopic view of the right nasal cavity. Note a careful
broken distal end is within the frontal process of maxilla removal of the fractured burr with the help of straight Blakesley
forceps
72 Instrument Fracture 645
Fig. 72.7 A normal 15° high-speed DCR burr with a protective sleeve
which also channels the irrigation
Fig. 72.5 Endoscopic view of the right nasal cavity. As the tip of the
fractured bit is withdrawn, the tissues in the vicinity were noted to have
escaped any trauma
Fig. 72.6 Endoscopic view of the right nasal cavity. The smearing of
the metallic debris can be appreciated
Fig. 72.8 The disassembly of the instrument parts following the
fracture
646 72 Instrument Fracture
Fig. 72.9 Close-up view showing the fractured segments and the dis-
associated irrigation channel
Tumors of the Lacrimal Drainage
System 73
Tumors arising from the proximal lacrimal drainage system References

are uncommon and when they do occur are usually benign,
especially at the punctal orifices. However, tumors of the lac- 1. Heindl LM, Junemann AGM, Kruse FE, et al. Tumors of the lacri-
mal drainage system. Orbit. 2010;29:298–306.
rimal sac and nasolacrimal ducts are rare, and in general, 2. Pe’er JJ, Stefanyszyn M, Hidayat AA. Nonepithelial tumors of the
30–40% are benign and 60–70% are malignant [1–3]. lacrimal sac. Am J Ophthalmol. 1994;118:650–8.
Seventy percent of the tumors are of epithelial origin. Most 3. Stephanyszyn MA, Hidayat AA, Pe’er JJ, et al. Lacrimal sac
benign lesions are squamous papillomas. Malignant epithe- tumours. Ophthal Plast Reconstr Surg. 1994;10:169–84.
4. Pujari A, Ali MJ, Mulay K, et al. The black lacrimal sac: a clinico-
lial tumors commonly include squamous cell carcinoma and pathological correlation of malignant melanoma with anterior lacri-
transitional cell carcinomas. Secondary involvement from mal crest infiltration. Int Ophthalmol. 2014;34:111–5.
sino-nasal tumors or systemic malignancies is also known 5. Mishra DK, Ali MJ, Bhargava A, et al. Acute dacryocystitis as
[1–5]. a presenting sign of chronic lymphocytic leukemia. Clin Exp
Ophthalmol. 2016;44:67–9.
Lacrimal sac tumors constitute only a minority of head
and neck tumors. At their early stages, they are rarely sus-
pected or diagnosed and often missed in patients with mini-
mal symptoms. The most common clinical presentation is
fullness, presenting as a mass, usually both below and above
the medial canthal tendon. It may be associated either with
epiphora or not infrequently a chronic dacryocystitis [1–5].
Almost always unilateral, the presence of bloody tears, full-
ness of the medial canthal area, and partial patency of the lac-
rimal drainage system on irrigation should raise a suspicion.
Telangiectasia or ulceration of the overlying skin, globe dis-
placement (supero-laterally), and regional lymphadenopathy
are late presentations, although not uncommon [1–5]. Early
diagnosis can be made with the help of a high degree of sus-
picion, imaging, and a low threshold to perform a biopsy.
Figures 12–16 and 44–65 are from Ali et al., Int
Ophthalmol. 2014; 34:111–115 [4], Int Ophthalmol 2017
(Epub), and Mishra et al., Clin Exp Ophthalmol. 2016;44:
67–69 [5].

648 73 Tumors of the Lacrimal Drainage System
Fig. 73.1 Clinical photograph of the left eye of the patient, who pre-
sented with a firm, growing mass in the lacrimal sac area
Fig. 73.4 Gross specimen of one of the lacrimal sac walls excised on
suspicion of a mass lesion. Note the raised reddish-black lesion in the
center. This also later proved to be granuloma with intralesional
hemorrhages
Fig. 73.2 Gross specimen photograph of the excised lesion of the

patient in Fig. 73.1
Fig. 73.5 Intra-operative photograph of a right-sided external dacryo-

cystorhinostomy. Following sac marsupialization, raised black lesion
was noted and excised on suspicion
Fig. 73.3 Microphotograph of the excised lesion of the patient in

Figs. 73.1 and 73.2. The histopathological features were consistent with
a lacrimal sac wall granuloma
73 Tumors of the Lacrimal Drainage System 649
Fig. 73.6 Gross specimen of the excised lesion of the patient in

Fig. 73.5. This later proved to be pigment deposits possibly due to Fig. 73.9 Slit lamp photograph of a punctum. Note the dilated punc-
chronic eye makeup use. Pigmented mucosa is not an uncommon find- tum with a pigmented squamous papilloma in the inferior canaliculus
ing; however, elevation of the lesion made it suspicious
Fig. 73.7 Clinical photograph of a left medial canthal basal cell Fig. 73.10 Slit lamp photograph of the patient in Fig. 73.9. A more
carcinoma end-on view better delineates the pigmented papilloma
Fig. 73.8 Clinical photograph of the patient in Fig. 73.8. Higher mag-

nification image shows the proximal lacrimal system to be completely
engulfed by the tumor
Fig. 73.11 Slit lamp photograph of a left lower lid, showing a gelati-
nous papilloma protruding out of the punctum
Skin
Vc
Amp
M
Fig. 73.12 Canalicular pigmented squamous papilloma: slit lamp
photograph of a left lower punctum showing a dilated punctum, with a Vc
pigmented mass brimming up to the surface
Fig. 73.14 Canalicular pigmented squamous papilloma: schematic

diagram representing the HD-DEN photo in Fig. 73.13. Note the verti-
cal canaliculus (Vc), ampulla (Am), and the mass lesion (M)
Fig. 73.13 Canalicular pigmented squamous papilloma: high-

definition dacryoendoscopic photograph showing an end-on view into
the vertical canaliculus. Note the brownish red lesion near the medial
wall of the vertical canaliculus extending deep down. Also note the
grossly dilated ampulla
Fig. 73.15 Canalicular pigmented squamous papilloma: high-

definition dacryoendoscopic photograph of the horizontal canaliculus
showing the mass to extend into the distal canaliculus. Note the pro-
gressive occupation of the lumen by the lesion as it extends to the distal
end
Hc
Hc
Fig. 73.18 Multifocal and extensive canalicular papillomatosis: slit

lamp photograph of a right upper punctum. Note the circumferential
enlargement of the peri-punctal area secondary to an internal mass
lesion
Fig. 73.16 Canalicular pigmented squamous papilloma: schematic

diagram representing the HD-DEN photo in Fig. 73.15. Note the lining
of the horizontal canaliculus (Hc) and the mass lesion (M)
Fig. 73.19 Multifocal and extensive canalicular papillomatosis: high-

definition dacryoendoscopic photograph of the patient in Fig. 73.18,
Fig. 73.17 Canalicular pigmented squamous papilloma: microphoto- showing an end-on view into the proximal horizontal canaliculus. Note
graph of the lesion in Figs. 73.12 and 73.13, confirming the diagnosis of the multilobed, papillomatous, pinkish white lesion filling the entire
a squamous papilloma. Note the numerous intraepithelial pigment lumen of the canaliculus. Also note the intervening reddish spots of
deposits. (H&E ×100) vascular fronds on the surface
N
P
Hc
P V
V
P
P
Hc
Hc
Fig. 73.20 Multifocal and extensive canalicular papillomatosis: sche- Fig. 73.22 Multifocal and extensive canalicular papillomatosis: sche-
matic diagram of Fig. 73.19. Note the horizontal canalicular walls (Hc), matic diagram of Fig. 73.21, showing the engaged needle (N) entering
multilobed papillomas (P), and the vascular fronds (V) from the roof, papillomas (P), and vascular fronds (V)
Fig. 73.21 Multifocal and extensive canalicular papillomatosis:

dacryoendoscopy-guided transcanalicular injection of interferon alpha
2b. Note the tip of the 30 gauge needle entering the lumen from the roof
Fig. 73.23 Multifocal and extensive canalicular papillomatosis: high-

definition dacryoendoscopic photograph of the patient in Fig. 73.21.
Note the horizontal canaliculus at the end of 1 month, post-interferon
therapy, showing the mass to consolidate. Note that the lesion has now
become round with decreased vascular fronds. The lesion however did
not respond further to multiple subsequent interferon therapies and was
excised
Hc

higher magnification microphotograph confirming the diagnosis of a
squamous papilloma
Hc
Fig. 73.24 Multifocal and extensive canalicular papillomatosis: sche-

matic diagram of Fig. 73.23. Note the consolidated lesion (P), its
rounded nature and the walls of the horizontal canaliculus (Hc), and
loss of the typical vascular fronds
Fig. 73.27 Clinical photograph of a patient with left-sided peri-

punctal swelling involving the punctum

microphotograph of the excised lesions of the patient in Fig. 73.23.
Note the polypoidal proliferation and papillary fronds of the stratified
squamous epithelium of the canaliculus with the underlying stroma
showing proliferation of thin-walled vascular channels and lympho-
plasmacytic infiltration
Fig. 73.28 Clinical photograph of the patient in Fig. 73.27. Higher

magnification shows a mass lesion in the medial most portion of the
upper eyelid involving the punctum and peri-punctal area, with other-
wise normal lids. The lesion was biopsied
Fig. 73.29 Microphotograph of the biopsied lesion in Fig. 73.28.

Characteristic comedo pattern of sebaceous gland carcinoma was diag- Fig. 73.32 Multifocal and extensive squamous papillomas involving the
nosed which involved the medial eyelid and proximal lacrimal drainage lacrimal drainage system: clinical photograph showing the papillomatosis
system (H&E ×100) extensively involving the left nasal cavity and protruding out of the nostril
Fig. 73.30 Microphotograph of the biopsied lesion in Fig. 73.28. Note

the characteristic positive staining with oil red O of the sebaceous gland
carcinoma. (oil red O ×40) Fig. 73.33 Multifocal and extensive squamous papillomas involving
the lacrimal drainage system: endoscopic view of the left nasal cavity.
Note the mass filling up the nasal cavity
Fig. 73.31 Multifocal and extensive squamous papillomas involving

the lacrimal drainage system: clinical photograph of the left eye show-
ing multifocal extensive squamous papillomas involving the eyelids,
proximal lacrimal system, and the ocular surface

the lacrimal drainage system: gross specimen of one of the lacrimal sac
walls showing extensive papillomatosis. The patient underwent com-
bined management with interferons and surgical excision

the lacrimal drainage system: post-operative endoscopic view of the left
nasal cavity of the patient in Figs. 73.31, 73.32, 73.33, and 73.34. Note
the clear nasal cavity

the lacrimal drainage system: post-operative clinical photograph of the
patient in Figs. 73.31, 73.32, 73.33, and 73.34. Note the clear left nostril
and compare it with Fig. 73.32
Fig. 73.38 Clinical photograph of a patient referred as left acute dac-

ryocystitis with facial cellulitis. Absent past history of epiphora, pain-
less but rapid growth, and absent tenderness were against the referred
diagnosis

the lacrimal drainage system: post-operative clinical photograph of the
left eye of the patient in Figs. 73.31, 73.32, 73.33, and 73.34. Compare
it with Fig. 73.31
Fig. 73.39 Clinical photograph of the left eye of the patient in Fig. 73.42 Clinical photograph of the patient following treatment of
Fig. 73.38. Higher magnification shows an irregular mass lesion involv- NHL. Compare it with Fig. 73.38
ing the lacrimal sac area above and below the medial canthus
Fig. 73.43 Clinical photograph of the patient following treatment of

NHL. Compare it with Fig. 73.39
Fig. 73.40 Immunohistochemistry microphotograph from an incision
biopsy of the lesion in Figs. 73.38 and 73.39. Note the diffuse positive
reactivity to leucocyte common antigen (LCA)
Fig. 73.44 Malignant melanoma of the lacrimal sac: clinical photo-

graph of the patient referred to us with a suspicion of lacrimal malig-
Fig. 73.41 Immunohistochemistry microphotograph from an incision nancy following a subcutaneous incision biopsy. Note the past scar over
biopsy of the lesion in Figs. 73.38 and 73.39. Note the strong reactivity lacrimal sac area and fullness over and above the medial canthal
to Ki-67. The final diagnosis was consistent with a non-Hodgkin’s tendon
lymphoma
Fig. 73.45 Malignant melanoma of the lacrimal sac: clinical photo-

graph of the right cheek of the patient in Fig. 73.44. Note the numerous
cutaneous nevi
Fig. 73.46 Malignant melanoma of the lacrimal sac: CT scan orbit,
axial cut, of the patient in Fig. 73.44. Note the enlargement of the lacri-
mal sac with an isodense lesion
Fig. 73.47 Malignant melanoma of the lacrimal sac: CT scan orbits,

coronal cut, bone window, of the patient in Figs. 73.44, 73.45, and
73.46, showing irregular lesion over the anterior lacrimal crest with
superficial infiltration
Fig. 73.48 Malignant melanoma of the lacrimal sac: gross specimen

of the en bloc excised lacrimal sac of the patient in Figs. 73.44, 73.45,
73.46, and 73.47. Note the lacrimal sac with the black tumor and wide
surgical margins
Fig. 73.49 Malignant melanoma of the lacrimal sac: intra-operative

photograph following excision of the lacrimal sac, showing a blackish
mass over the anterior lacrimal crest. Note the wide surgical margins
taken around the lesion
Fig. 73.52 Malignant melanoma of the lacrimal sac: endoscopic view

of the right nasolacrimal duct, at the end of extended dacryocystectomy,
shows no residual tumor in the vicinity
Fig. 73.50 Malignant melanoma of the lacrimal sac: gross specimen

of the bony lesion following its removal
Fig. 73.53 Malignant melanoma of the lacrimal sac: endoscopic view

of the middle meatus, at the end of extended dacryocystectomy, shows
a normal nasal examination
Fig. 73.51 Malignant melanoma of the lacrimal sac: intra-operative

view of the field following wide surgical excision of the bony lesion
Fig. 73.54 Malignant melanoma of the lacrimal sac: microphotograph Fig. 73.56 Malignant melanoma of the lacrimal sac: microphotograph
of the excised lesion in Fig. 73.48, showing sheets of tumor cells with of the excised lesion in Fig. 73.48. Intracytoplasmic pigment is not seen
intracytoplasmic melanin pigment (H&E ×100) after permanganate bleach confirming the melanocytic nature of the
pigment (H&E ×100)
Fig. 73.55 Malignant melanoma of the lacrimal sac: microphotograph Fig. 73.57 Malignant melanoma of the lacrimal sac: immunohisto-
of the excised bone lesion in Fig. 73.50, showing infiltration of marrow chemistry microphotograph of the excised lesion in Fig. 73.48. Note
spaces by the pigmented tumor cells, replacing the marrow elements HMB-45 showing positive staining of the tumor cells (HMB-45 ×400)
(H&E ×40)
Fig. 73.58 Chronic lymphocytic leukemia (CLL) presenting as acute

dacryocystitis: clinical photograph of a patient presenting with left-
sided acute dacryocystitis, not responsive to conservative management Fig. 73.60 CLL presenting as acute dacryocystitis: microphotograph
of a peripheral smear of the patient in Fig. 73.58. Note the gross lym-
phocytosis (Lieshman ×100)
Fig. 73.61 CLL presenting as acute dacryocystitis: microphotograph

of the bone marrow of the patient in Fig. 73.58. Note the marked lym-
phocytosis (Giemsa ×400)
Fig. 73.59 CLL presenting as acute dacryocystitis: endoscopic view

of the left nasal cavity of the patient in Fig. 73.58. Note the normal
study
Fig. 73.62 CLL presenting as acute dacryocystitis: microphotograph

of the lacrimal sac wall showing diffuse subepithelial lymphocytic infil-
trates (H&E ×100)
Fig. 73.66 Transitional cell carcinoma of lacrimal sac: clinical photo-

graph showing a large mass lesion in the right medial canthal lesion
Fig. 73.63 CLL presenting as acute dacryocystitis: immunohisto- with extension above the medial canthus
chemistry microphotographs of the lacrimal sac wall showing positive
reactivity with CD20 (CD 20 ×100)
Fig. 73.67 Transitional cell carcinoma of lacrimal sac: clinical photo-

graph, high magnification of the patient in Fig. 73.66. Note the charac-
teristic extent of this lesion
Fig. 73.64 CLL presenting as acute dacryocystitis: immunohisto-
chemistry microphotographs of the lacrimal sac wall showing positive
reactivity with CD5 (CD5 ×100)
Fig. 73.68 Transitional cell carcinoma of lacrimal sac: CT scan, axial

Fig. 73.65 CLL presenting as acute dacryocystitis: immunohisto- cut, of the patient in Figs. 73.66 and 73.67. Note the large mass lesion
chemistry microphotographs of the lacrimal sac wall showing positive in the lacrimal sac fossa
reactivity with CD23 (CD23 ×400)
Fig. 73.69 Transitional cell carcinoma of lacrimal sac: CT scan, coro-

nal cut, demonstrating the lacrimal sac mass to specifically extent along
the bony NLD in the maxilla into the inferior meatus
Fig. 73.71 Transitional cell carcinoma of lacrimal sac: endoscopic
view of the right nasal cavity of the patient in Fig. 73.66. Note the large
vascular mass in the inferior meatus, and correlate this radiologically in
Figs. 73.69 and 73.70
Fig. 73.72 Transitional cell carcinoma of lacrimal sac: microphoto-

graph of the incision biopsy of the lesion of patient in Figs. 73.66,
Fig. 73.70 Transitional cell carcinoma of lacrimal sac: CT scan, sagit- 73.67, 73.68, 73.69, 73.70, and 73.71, showing multilayered epithelium
tal cut, demonstrating a large lacrimal sac mass traversing the bony with loss of maturity sequence and infiltration by neoplastic cells with
NLD in maxilla into the inferior meatus disturbed polarity, moderate pleomorphism, and numerous mitoses
Fig. 73.73 Lacrimal drainage involvement with squamous cell carci-

noma: clinical photograph of a patient with left-sided mild proptosis
with superior dystopia. Note the fullness over the lacrimal sac area
noma: CT scan, axial cut, of the patient in Figs. 73.73 and 73.74. Note
the dilated left distal bony nasolacrimal duct, and compare it with the
healthy right side

noma: microphotograph of incision biopsy of the patient in Figs. 73.73,
Fig. 73.74 Lacrimal drainage involvement with squamous cell carci- 73.74, and 73.75. Note the moderately differentiated squamous cell car-
noma: CT scan, coronal cut, of the patient in Fig. 73.73. Note the left cinoma with cohesive sheets of tumor cells (H&E ×100)
inferior orbital mass, expanded lacrimal sac, and a large lesion in the
lacrimal sac fossa with extension into the proximal bony NLD

noma: microphotograph of a moderately differentiated squamous cell
carcinoma showing mild pleomorphism and scattered mitoses
Fig. 73.80 CT scan, coronal cut, of the patient in Fig. 73.79. Note the
gross right sino-orbital lesion involving the lacrimal drainage system.
Biopsy proved it to be a squamous cell carcinoma

noma: microphotograph of a moderately differentiated squamous cell
carcinoma showing polygonal cells, mild pleomorphism, and scattered
mitoses
Fig. 73.81 Clinical photograph showing fullness of the left lacrimal
sac area with proptosis and dystopia
Fig. 73.79 Clinical photograph of a patient with mild right proptosis,

epiphora, and mild dystopia
Fig. 73.82 CT scan, coronal cut, of the patient in Fig. 73.81. Note the
gross left sino-orbital lesion involving the lacrimal drainage system.
Biopsy proved it to be a squamous cell carcinoma Fig. 73.84 CT scan, axial cut, of the patient in Fig. 73.83. Note the
bony NLD is in the center of the lesion, completely surrounded by the
mass lesion
Fig. 73.85 Lacrimal drainage involvement in fibrous dysplasia: clini-

cal photograph of a patient with epiphora, right-sided telecanthus, dys-
topia, and fullness of the lacrimal sac area
Fig. 73.83 CT scan, coronal cut, of a patient of sino-nasal non-
Hodgkin’s lymphoma with an orbital extension and involvement of the
lacrimal drainage system
Fig. 73.86 Lacrimal drainage involvement in fibrous dysplasia: clini-

cal photograph of the patient in Fig. 73.85, profile view, showing the
fullness of the lacrimal sac fossa
Fig. 73.88 Lacrimal drainage involvement in fibrous dysplasia: CT

scan, axial cut, of the patient in Figs. 73.85, 73.86, and 73.87 demon-
strating the extent of the ossified mass lesion
Fig. 73.89 Lacrimal drainage involvement in fibrous dysplasia:

microphotograph of the biopsied lesion in Figs. 73.87 and 73.88 was
consistent with the diagnosis of the psammomatoid variant of fibrous
Fig. 73.87 Lacrimal drainage involvement in fibrous dysplasia: CT dysplasia (H&E ×100)
scan, coronal cut, of the patient in Figs. 73.85 and 73.86. Note the
involvement of the ethmoid sinus, orbit, and lacrimal drainage system
with the ossified mass lesion
Fig. 73.90 Lacrimal drainage involvement in fibrous dysplasia: high-

magnification microphotograph of the biopsied lesion in Figs. 73.87
and 73.88 was consistent with the diagnosis of the psammomatoid vari-
ant of fibrous dysplasia (H&E ×400)
Fig. 73.92 Endoscopic NLD and peri-NLD biopsy: CT dacryocystog-

raphy, coronal cut, of the patient in Fig. 73.91 showing normal filling of
the lacrimal sac
Fig. 73.93 Endoscopic NLD and peri-NLD biopsy: CT dacryocystog-

Fig. 73.91 Endoscopic NLD and peri-NLD biopsy: CT scan, axial raphy, axial cut, of the patient in Fig. 73.91 showing uniform filling of
cut, at the level of nasolacrimal duct of a 14-year-old patient presenting the lacrimal sac
with acquired nasolacrimal duct obstruction. Note the diffuse, ill-
defined mass lesion involving the peri-NLD area with a posterior wall
dehiscence of the bony NLD and involvement of the soft tissue NLD
Fig. 73.94 Endoscopic NLD and peri-NLD biopsy: endoscopic view Fig. 73.96 Endoscopic NLD and peri-NLD biopsy: a rectangular
of the right nasal cavity of the patient in Fig. 73.91. Note the horizontal reflection of the mucosa, exposing the bony NLD
incision at the level of the bony NLD. Note the far-up position of the
middle turbinate
Fig. 73.97 Endoscopic NLD and peri-NLD biopsy: an endoscopic

Fig. 73.95 Endoscopic NLD and peri-NLD biopsy: the vertical inci- punch to take the bony NLD biopsy
sion at the level of bony NLD
Fig. 73.100 Endoscopic NLD and peri-NLD biopsy: appreciate the

Fig. 73.98 Endoscopic NLD and peri-NLD biopsy: the exposed soft
rectangular excision of the medial NLD wall, being grasped by the eth-
tissue NLD after the bony punch
moid forceps
Fig. 73.99 Endoscopic NLD and peri-NLD biopsy: a rectangular inci- Fig. 73.101 Endoscopic NLD and peri-NLD biopsy: repositioning of
sion on the medial wall of the soft tissue NLD for the biopsy the initial nasal mucosal flap back for a primary intention healing
Stereotactic Lacrimal Surgeries
74
Accuracy and precision in surgery are most desired by any sur- References
geon to have better outcomes. Stereotactic technology helps
exactly to achieve this goal. The term “image-guided dacry- 1. Day S, Hwang TN, Pletcher SD, et al. Interactive image-guided dac-
ryocystorhinostomy. Ophthal Plast Reconstr Surg. 2008;28:338–40.
olocalization” or IGDL encompasses the use of stereotactic 2. Ali MJ, Naik MN. Image-guided dacryolocalization (IGDL) in trau-
navigation for lacrimal disorders [1–5]. Numerous systems are matic secondary acquired lacrimal drainage obstructions (SALDO).
available for navigation guidance, and there are two modes Ophthal Plast Reconstr Surg. 2015;31:406–9.
of performing navigation, the electromagnetic mode and the 3. Ali MJ, Singh S, Naik MN. Image-guided lacrimal drainage surgery
in congenital arhinia-microphthalmia syndrome. Orbit. 2017;36:137.
optical mode. The electromagnetic systems utilize a field mag- 4. Ali MJ, Singh S, Naik MN, et al. Interactive navigation-guided
netic generator which is in very close vicinity to the surgical ophthalmic plastic surgery: navigation enabling of endoscopes
area, and the setup includes a head-mounted marker coil that and their use in endoscopic lacrimal surgeries. Clin Ophthalmol.
needs to be wrapped around the patient’s forehead. The optical 2016;10:2319–24.
5. Ali MJ, Singh S, Naik MN, et al. Interactive navigation-guided oph-
mode utilizes the infrared rays for navigation, and it does not thalmic plastic surgery: the utility of 3D-CT DCG guided dacryo-
need an elaborate head bands; hence the setup is much easier. localization in secondary acquired lacrimal duct obstructions. Clin
The imaging data is uploaded into the software, and the patient Ophthalmol. 2017;11:127–33.
location is then registered using multiple points to set up the
machine ready for navigation. The outcomes of image-guided
surgery are very encouraging in secondary acquired lacrimal
duct obstructions; a major chunk of which are post-traumatic
cases. Image-guided powered endoscopic dacryocystorhinos-
tomy is possible in cases with grossly distorted endoscopic
anatomy, malpositioned lacrimal sacs, breached periorbita,
encephalocele in the vicinity, and post-maxillectomy cases.
Stereotaxis allowed accurate localization of lacrimal sac in
all these cases. Useful clues were obtained with regard to the
need for modification of any step during the surgery.
Figures 21–48 are from Ali et al., Clin Ophthalmol.
2016;10:2319–2324; Clin Ophthalmol. 2017;11:127–133
and Orbit 2017;36:137 [3–5].

672 74 Stereotactic Lacrimal Surgeries
Fig 74.3 The electromagnetic navigation system: numerous areas on

the band are sensitive and can be used as a touch screen to complete the
calibration process
Fig 74.1 The electromagnetic navigation system: the EM system in

action. Note the large electromagnetic coil (black) which is placed near
the head of the patient Fig 74.4 The electromagnetic navigation system: the registration pro-
cess in action. The activated tracker needs to be placed at predesignated
points or traced across predesignated pathway for the computer to ori-
ent itself to the patient anatomy. Note the tracker is at the tip of the nose
Fig 74.2 The electromagnetic navigation system: the navigation head

band is used in the EM system. Image shows the beginning of the cali-
bration process by placing the tracker point at a designated place in the
center of the band Fig 74.5 The electromagnetic navigation system: registration process
where the tracker is being traced toward the medial canthus via the
external lateral nasal wall
74 Stereotactic Lacrimal Surgeries 673
Fig 74.6 The electromagnetic navigation system: registration process

where the tracker is at the medial canthus
Fig 74.8 The electromagnetic navigation system: the step of accuracy

verification as shown in this image occurs after a registration. The
bridge of the nose is being touched by the tracker here. If it is not satis-
factory, one may have to repeat the registration process
Fig 74.9 The electromagnetic navigation system: integration of the

Fig 74.7 The electromagnetic navigation system: the console of the
navigation and the endoscopic systems
EM system calculating registration once all the predesignated points on
the patient have been identified by the computer. Note the traced track
in green
Fig 74.10 A modern lacrimal operating suite with integrated naviga-

tion, endoscopic, and drill systems
Fig 74.11 The optical navigation system: the optical system does not Fig 74.13 The EM tracker in an integrated navigation system
mandatorily need an elaborate head band, and a small-secured circular
disc is enough. Compare this with the band in Fig. 74.2
Fig 74.14 The optical system tracker with its unique head band.
Compare it with EM trackers in Figs. 74.2 and 74.13
Fig 74.15 The optical navigation signal receivers which interact with
the position of the tracker at one end and the main system at the other
Fig 74.12 The electromagnetic modality in an integrated (opti-

cal + EM) navigation system
Fig 74.16 The console of the integrated StealthStation S7® Fig 74.17 The console of the integrated StealthStation S7®. Numerous
modes (e.g., head neck or otolaryngology) can be selected, and pro-
grams can be customized to the surgeon’s needs
Fig 74.18 Intra-operative image guidance window in a case of a rou- (bottom left), and the endoscopic image showing the tracker location.
tine primary acquired nasolacrimal duct obstruction. Navigation views Note the tracker is at the axilla of the middle turbinate and adjacent to
are integrated with the endoscopic system. The four windows are CT the lacrimal sac fossa. The exact location of the tracker is displayed by
coronal image (top left), CT sagittal image (top right), CT axial image the meeting point of cross hairs (green lines) in the CT images
Fig 74.19 Intra-operative image guidance window in a case of secondary acquired nasolacrimal duct obstruction. The surgeon is assessing the
safe inferior extent of the osteotomy
Fig 74.20 Intra-operative image guidance window in a case of secondary acquired nasolacrimal duct obstruction. The surgeon is assessing the
safe superior extent of the osteotomy
Fig 74.21 IGDL (image-guided dacryolocalization) in traumatic

SALDO: clinical photograph showing gross collapse of the nasal
bridge, facial scars, right-sided telecanthus, and exotropia
Fig 74.23 IGDL in traumatic SALDO: endoscopic view of the right

nasal cavity of the patient in Figs. 74.21 and 74.22. Note the gross dis-
torted anatomy with fractured middle turbinate and synechiae
Fig 74.22 IGDL in traumatic SALDO: CT scan, coronal cut, bone

window image showing gross naso-orbito-ethmoid and skull base frac-
tures. Note the large left-sided encephalocele
Fig 74.24 IGDL in traumatic SALDO: endoscopic view of the right

nasal cavity of the patient in Fig. 74.23. Note the presence of
pseudo-ostia
Fig 74.25 IGDL in traumatic SALDO: intra-operative image-guided tion of the tracking probe with relation to the head of middle turbinate.
view of the patient in Figs. 74.21, 74.22, 74.23, and 74.24, depicting the The probe was passed through the pseudo-ostium (arrowhead). Also
altered position of the nasolacrimal duct. Note the posterolateral direc- note the gross distorted lateral nasal wall anatomy
Fig 74.26 IGDL in traumatic

SALDO: intra-operative
image-guided view of the
patient in Figs. 74.21, 74.22,
74.23, 74.24, and 74.25,
showing the tracking of the
thick frontal process of
maxilla adjacent to the
malpositioned lacrimal sac
fossa

74.23, 74.24, 74.25, and
74.26, showing the active
tracking of the lacrimal sac
fossa. Note the probe of the
common canaliculus is at a
very high level adjacent to the
opening of the frontal sinus

74.23, 74.24, 74.25, 74.26,
and 74.27, showing the
location of the exposed
lacrimal sac (lacrimal probe)
adjacent to the frontal sinus
drainage pathway (shown by
the navigation tracking probe)
Fig 74.29 Navigation in SALDO secondary to ethmoid mucocele:

endoscopic view of the right nasal cavity showing a large ethmoid
mucocele obliterating the middle meatus
Fig 74.30 Navigation in SALDO secondary to ethmoid mucocele: image-guided view following marsupialization of the mucocele. Note the
tracking probe is touching the middle turbinate which is accurately being displayed in all the sections of the CT scan
Fig 74.31 Navigation in SALDO secondary to ethmoid mucocele: image-guided view of the patient in Figs. 74.29 and 74.30. Note the radiologi-
cal and endoscopic tracker location within the mucocele cavity
Fig 74.32 Navigation in SALDO secondary to ethmoid mucocele: image-guided view of the patient in Figs. 74.29, 74.30, and 74.31. Note the
tracker currently located at the very important landmark of the skull base
Fig 74.33 CT-DCG-guided stereotactic surgery: endoscopic photo- Fig 74.34 CT-DCG-guided stereotactic surgery: the 3D CT-DCG of
graph of the right nasal cavity showing the palatal defect, exposed bone the patient in Fig 74.33, showing absent right maxilla with right dilated
of the lateral wall in the area of maxillary sinus, and altered anatomy of lacrimal sac and an abrupt obstruction at the sac-duct junction. The
the lateral wall. The patient has a SALDO secondary to maxillectomy DCG findings of the left lacrimal apparatus are normal
for a sinus malignancy
Fig 74.35 CT-DCG-guided stereotactic surgery: image-guided dac- images and the endoscopic view (lower right). Note that the intersec-
ryolocalization view of the patient in Figs. 74.33 and 74.34, showing tion of cross hairs shows the simultaneous endoscopic localization of
the coronal (upper left), sagittal (upper right), and axial (lower left) CT the contrast-filled lacrimal sac
Fig 74.36 CT-DCG-guided stereotactic surgery: intra-operative structed virtual model of the DCG (lower right panel). Note the sac
image-guided view of the patient in Figs. 74.33, 74.34, and 74.35, being delineated as the red lesion being actively tracked by the blue
depicting the image-guided dacryolocalization using the 3D recon- endoscopic probe
Fig 74.37 Navigation guidance for endoscopic DCR in Arhinia: CT

scan, 3D reconstruction of the craniofacial bones showed gross left-
sided maxillary and bony nasal hypoplasia
Fig 74.38 Navigation guidance for endoscopic DCR in Arhinia: CT scan, coronal cut, showing left-sided absence of maxillary and ethmoid
sinuses. Note the irregular left frontal process of maxilla fusing apically with the nasal process of frontal bone near the glabella
Fig 74.39 Navigation
guidance for endoscopic DCR
in Arhinia: a CT scan, coronal
cut, demonstrating the path
chosen by the surgeon for the
computer for the DCR
creation into the contralateral
cavity through the nasal
septum. Other than the
navigation benefit, the
computer will now alert the
surgeon if he deviates from
this path
Fig 74.40 Navigation guidance for endoscopic DCR in Arhinia: glabella. Note the meeting point of the cross hairs in coronal, axial, and
active intra-operative stereotaxis. Image guidance confirmed this bone sagittal CT cuts, denoting the frontal process and its apical fusion
to be the frontal process of maxilla that was fusing apically under the
Fig 74.41 Navigation guidance for endoscopic DCR in Arhinia: nasal septum, supero-posterior to the pre-existing septal defect. Note
active intra-operative stereotaxis. Image guidance following the oste- the positions of the cross hairs in all the CT cuts as well as the level of
otomy showing the exposed, nasal mucosa to be that of the malformed opening into the right nasal cavity
Fig 74.42 Navigation enabling of endoscopes and look-ahead proto- Fig 74.43 Navigation enabling of endoscopes and look-ahead proto-
cols: external photograph showing the routine 4 mm 0° Hopkins® tele- cols: navigation-enabled telescope with the electromagnetic stylet well
scope mounted on a three-chip endoscopic camera head. The thin secured on its surface with multiple adhesive dressings
electromagnetic neuronavigation shunt stylet lies adjacent to the
telescope
Fig 74.44 Navigation enabling of endoscopes and look-ahead proto-

cols: end-on, high-magnification photograph showing the tip of the sty-
let in line with the edge of the telescopic mirror
Fig 74.45 Navigation enabling of endoscopes and look-ahead proto-

cols: the navigation-enabled telescope in action during a powered endo-
scopic DCR
Fig 74.46 Navigation enabling of endoscopes and look-ahead proto- The subsequent three windows show anatomical structures at 5 mms
cols: A typical CT scan axial cut screen during routine use of the “look- (upper right), 10 mms (lower left), and 15 mms (lower right), respec-
ahead” software. The first window (upper left) shows the current tively, from the current location. Note that the lacrimal sac in this case
location of the tip of the stylet or in this study, the tip of the telescope. would be encountered 10 mms ahead from the current location
Fig 74.47 Navigation enabling of endoscopes and look-ahead proto- ahead in the same direction from the current location of the endoscope
cols: The “look-ahead” software window with simultaneous endo- (extreme right window)
scopic view. Note the bony nasolacrimal duct is to be expected 15 mms
Fig 74.48 Navigation enabling of endoscopes and look-ahead proto- cross hair passing through the center of the lacrimal sac. This means the
cols: The “look-ahead” software window with simultaneous endo- tissue encountered 5 mms ahead is the lacrimal sac. Correlate this with
scopic view. Note the CT window at 5 mms (right upper) showing the the endoscopic location (extreme right window)
Lacrimal Gland-Targeted Therapies
75
Certain subsets of lacrimal disorders are recalcitrant and References

constantly trouble the patients with frustrating epiphora [1–
5]. There are also certain patients who do not opt for major 1. Singh S, Ali MJ, Paulsen F. A review on use of botulinum toxin
for intractable lacrimal drainage disorders. Int Ophthalmol 2017
surgeries like CDCR and their associated problems. Yet, (Epub)
there are others who had repeated DCR or CDCR failures. 2. Ziahosseini K, Al-Abbadi Z, Malhotra R. Botulinum toxin injection
When all else fails, there comes the role of lacrimal gland- for the treatment of epiphora in lacrimal outflow obstruction. Eye
targeted therapies to reasonably reduce the production of (Lond). 2015;29:656–61.
3. Eustis HS, Baiuch A. Use of botulinum toxin injections to the
tears. Two modalities in this regard are the botulinum toxin lacrimal gland for epiphora in children with proximal obstruction
injection into the lacrimal gland (LG) and the LG debulking of lacrimal drainage system. J Pediatr Ophthalmol Strabismus.
[1–5]. The lacrimal gland is innervated by the cholinergic 2012;16:e15–6.
fibers of the seventh cranial nerve. Injection of botulinum 4. Kaynak P, Karabulut GO, Ozturker C, et al. Comparison of botuli-
num toxin-A injection in lacrimal gland and conjunctivodacryocys-
toxin A (BTA) in the lacrimal gland is hypothesized to torhinostomy for treatment of epiphora due to proximal lacrimal
decrease the tear production by blocking presynaptic release system obstruction. Eye (Lond.). 2016;20:1–7.
of acetylcholine into neuromuscular end plates of choliner- 5. Hornblass A, Guberina C, Herschon BJ. Palpebral dacryoadenec-
gic nerve fibers. Therefore injection of BTA into the lacrimal tomy for epiphora. Ophthal Plast Reconstr Surg. 1988;4:227–30.
gland can be an alternative treatment for epiphora due to
severe gustatory hyperlacrimation, unsalvageable proximal
lacrimal drainage system obstructions, and refractory func-
tional epiphora. Results of BTA injections in patients with
epiphora owing to obstruction of proximal lacrimal appara-
tus have been encouraging and so have been the efficacy of
BTA injection into the lacrimal gland was compared with
conjunctivodacryocystorhinostomy (CDCR) [1–4]. The
other modality of LG debulking has not gained wider accep-
tance specifically the palpebral dacryoadenectomy. The
author however believes that palpebral lobectomy should not
be performed, and instead a partial orbital debulking may
have a role in certain exceptional conditions.

692 75 Lacrimal Gland-Targeted Therapies
Fig. 75.1 Clinical photograph showing Schirmer’s test. It is important Fig. 75.4 Botulinum toxin injection technique: 2.5 units in 0.1 ml is
to note the tear production before to optimize the LG-targeted loaded onto a 1 ml syringe with fine gauge needle (27 or 30G) and
therapies preferably entered midway into the gland to avoid spillover in the
vicinity
Fig. 75.2 Clinical photograph showing a Fluorescein dye disappear- Fig. 75.5 Botulinum toxin injection technique: the needle is within the
ance test. This test can also help us to monitor the tear reduction follow- substance of the lacrimal gland. Slow injection is preferred
ing therapies
Fig. 75.3 Botulinum toxin injection technique: the right upper lid is Fig. 75.6 Botulinum toxin injection technique: note the little balloon-
lifted, and the patient is asked to look in the inferomedial direction to ing of the lacrimal gland after the injection. It is important not to mas-
expose the lacrimal gland sage the area after injection to avoid any spillover
75 Lacrimal Gland-Targeted Therapies 693
Fig. 75.7 Botulinum toxin injection technique: another example of the Fig. 75.9 Botulinum toxin injection technique: note the little balloon-
left lacrimal gland injection ing of the lacrimal gland soon after the injection
Fig. 75.8 Botulinum toxin injection technique: the needle within the
substance of the lacrimal gland
Fig. 75.10 Anterior segment

ocular coherence tomography
(AS-OCT) image showing the
preinjection tear meniscus
height (TMH). TMH at
predefined points (at central
papillary axis as in this case)
can be used for monitoring
the efficacy of botulinum
toxin on the lacrimal gland
functions
Fig. 75.11 One week,

post-injection AS-OCT image
of the TMH of patient in
Fig. 75.10. Note the
decreasing TMH in response
to botulinum toxin
75 Lacrimal Gland-Targeted Therapies 695
Fig. 75.12 Four weeks,

post-injection AS-OCT image
of the TMH of patient in
Figs. 75.10 and 75.11. Note
the decreased TMH in
response to botulinum toxin
LPS
OL
PL
PL
OL
Fig. 75.14 Lacrimal gland debulking: schematic diagram showing the

target of debulking is only the orbital lobe. Technique shown here is
transverse lobectomy (area under green). (Photo courtesy: Swati Singh,
LJEI, Ambala)
anterior palpebral lobe (PL) and posterior orbital lobe (OL) of the lacri-
mal gland. (Photo courtesy: Swati Singh, LJEI, Ambala)
LPS
PL
OL

technique of longitudinal lobectomy (area under green). (Photo cour-
tesy: Swati Singh, LJEI, Ambala)
Quality of Life and Lacrimal Disorders
76
Lacrimal disorders need not necessarily always have only a References

physical or a functional dimension; there may be emotional,
social, and economic or a combination of these aspects to 1. Holmes JM, Leske DA, Cole SR, et al. A symptom survey and qual-
ity of life questionnaire for nasolacrimal duct obstruction in chil-
them. Understanding the different facets of patient and dren. Ophthalmology. 2006;113:1675–80.
the caregiver’s perspectives of the disease before and after 2. Bakri SJ, Carney AS, Robinson K, et al. Quality of life outcomes
medical or surgical interventions contributes significantly to following dacryocystorhinostomy: external and endonasal laser
overall patient satisfaction. Rather than objective anatomical techniques compared. Orbit. 1999;18:83–8.
3. Mansour K, Sere M, Oey AG, et al. Long term patient satisfac-
outcomes of a surgery alone, patient satisfaction is what all tion of external dacryocystorhinostomy. Ophthalmologica.
the surgeons should ideally aim for. It is in this context that 2005;219:97–100.
the validated quality of life (QOL) questionnaires help the 4. Ali MJ, Honavar SG. Assessment of patient satisfaction following
health-care providers [1–5]. They are also a very useful tool external versus transcanalicular dacryocystorhinostomy. Curr Eye
Res. 2012;37:853.
for clinical research and standardization of outcomes. 5. Ali MJ, Iram S, Ali MH, et al. Assessing the outcomes of pow-
Figures 76.6 and 76.7 are from Ali et al., Ophthal Plast ered endoscopic dacryocystorhinostomy in adults using the lacri-
Reconstr Surg. 2017;33:65–68 [5]. mal symptom (Lac-Q) questionnaire. Ophthal Plast Reconstr Surg.
2017;33:65–8.

698 76 Quality of Life and Lacrimal Disorders
Fig. 76.1 The brief Holmes questionnaire 1. Tears ‘well up’ in my child’s eye(s) (Has 4 subtypes and 5 parameters to score).
designed specifically for congenital 2. Tears run down my child’s cheek.
nasolacrimal duct obstructions (CNLDO) 3. My child has gunk in the corner of the eye(s).
4. My child’s eye(s) looks glassy.
5. The skin around my child’s eye(s) is red.
6. My child’s eyeball is red.
7. My child rubs his or her eye(s).
8. The appearance of one or both of my child’s eyeballs bothers me.
9. The appearance of one or both of my child’s eyelids bothers me.
10. Child is bothered by his or her eye(s)
11. Child’s eye condition interferes with his or her daily activities.
12. Child’s eye condition interferes with my daily activities.
13. I feel fine about my child’s eye(s).
14. I worry about my child’s eye(s).
15. Other people comment about my child’s eye(s).
16. I feel fine about the way my child’s eye(s) appears in photos.
17. Other children tease my child about his/her eye(s).
Fig. 76.2 The brief Glasgow benefit 1. Has the result of operation/intervention affected the things you do?
inventory questionnaire. This gives a 2. Has the result of the operation made your overall life better or worse?
general quality of life assessment 3. Since your operation, have you felt more or less optimistic about the future?
rather than a very specific lacrimal 4. Since your operation, do you feel more or less embarrassed when with people?
assessment 5. Since your operation, do you have more or less self confidence?
6. Since your operation, do you find easier or harder to deal with company?
7. Since your operation, do you have more or less support from your friends?
8. Have you been to your family doctor, more or less since operation?
9. Since your operation, do you feel more or less confident about job opportunities?
10. Since your operation, do you feel more or less self conscious?
11. Since your operation, are there more or fewer people who really care about you?
12. Since you had the operation, do you catch colds or infections much or less often?
13. Have you taken more or less medicine for any reason, since your operation?
14. Since your operation, do you feel better or worse for any reason?
15. Since your operation, do you have more or less support from your family?
16. Since your operation, are you more or less inconvenienced by health problem?
17. Since your operation, have you participated in more or fewer social activities?
18. Since your operation, are you more or less inclined to withdraw from social situations?
Fig. 76.3 The NLDO symptom score parameters questionnaire. This is a simple and specific for 1. Tearing (0-10 scale scoring for each)
nasolacrimal duct obstructions 2. Irritation
3. Pain
4. Discharge
5. Swelling
6. Visual acuity
Fig. 76.4 The brief Lacrimal questionnaire (Lac-Q). Note Lacrimal Parameters Social Parameters
it is more comprehensive than NLDO symptom
score questionnaire, yet retains its simplistic nature. 1. Watery eye 1. Watery eye comment by family or friends
This is increasingly getting a popular modality 2. Soreness of eyelids. 2. Watery eye causing embarrassment.
among the lacrimal surgeons 3. Sticky eye. 3. Watery eye interfering with daily activities.
4. Swelling at medial canthus 4. Watery eye causing blurred vision
5. Medical consultation for watery eye.
76 Quality of Life and Lacrimal Disorders 699
Fig. 76.5 The ocular surface disease index questionnaire, which utilizes vision related and emotional 1. Reading
components of an epiphora, however, is not very specific for lacrimal disorders per se 2. Daytime driving
3. Nighttime driving
4. Working at a computer
5. Watching
6. Work-related activities
7. Household activities
8. Outdoor activities
9. Interpersonal relations
10. General happiness
Fig. 76.6 Quality of life

30
assessment before and after a
powered endoscopic
dacryocystorhinostomy. Note Visit 1
25 Visit 2
the total scores of 50
individuals and the score Visit 3
change over three visits
20
Total Score
15
10
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49
Patient No
Fig. 76.7 Quality of life

assessment before and after a Visit 1
powered endoscopic 6 Visit 2
dacryocystorhinostomy. Note Visit 3
the social parameter scoring
of 50 individuals and the 5
score change over three visits
4
Social Score
1 3 5 7 9 12 15 18 21 24 27 30 33 36 39 42 45 48
Patient No
Atlas Exercises
77
Clinical atlas has the potential to play an important role

in clinical practice, when one encounters similar patients.
Exercises at the end of a clinical atlas are therefore important
not only for assessment of the knowledge but also for retain-
ing the new knowledge in the memory. Thirty photographs
have been selected with difficulty levels ranging from begin-
ners to advance level. A key is provided at the end where one
can verify their answers.
Fig. 77.3 Name the structure and its pathology indicated by the red
arrow
Fig. 77.1 Name the structures that are indicated by the red arrow,
black arrow and the black star
Fig. 77.2 Name the peri-punctal lesion? How does the probe help in Fig. 77.4 This is a classical sign encountered during canalicular lac-
prognosis eration evaluation or repair. What is it called?

702 77 Atlas Exercises
Fig. 77.8 Name this Pyrex tube
Fig. 77.5 Identify this syndromic association of a complex congenital

nasolacrimal duct obstruction
Fig. 77.9 What is the diagnosis?
Fig. 77.6 Identify what is being evacuated following a lacrimal sac

marsupialization
Fig. 77.7 Name these important landmarks in DCR, indicated by the

black star and black arrow
Fig. 77.10 Identify the cause (black arrow) of the DCR failure
77 Atlas Exercises 703
Fig. 77.11 Identify three abnormalities that you notice in this figure
Fig. 77.14 Name the incision and in which surgery it is used
Fig. 77.12 Comment on this image

Fig. 77.15 Comment on this image
Fig. 77.13 Identify this hand-piece

Fig. 77.16 Name the surgical procedure being demonstrated
Fig. 77.18 Endoscopic image of a neonatal inferior meatus. What is

the diagnosis?
Fig. 77.17 What does that arrow point during evaluation of a post-
operative DCR ostium?
Fig. 77.19 Interpret the lacrimal diagram

Fig. 77.23 Identify the surgical procedure
Fig. 77.20 Comment on this 3D CT-DCG image
Fig. 77.24 Comment on the procedure being demonstrated?
Fig. 77.21 Name the structure indicated by the arrow and its impor-
tance during a routine endoscopic DCR
Fig. 77.25 Identify the structure indicated by the arrow and its
significance
Fig. 77.22 Identify the stent

Fig. 77.26 Comment on the modification to the telescope
Fig. 77.27 What is happening during this step in an external DCR and
its significance?
UT 0.2 mg/ml
Phalloidin-FITC/DAPI
Fig. 77.28 What does this

basic science experiment
demonstrate with regards to
effect of 0.2 mg/ml of
Mitomycin C as compared to
the untreated (UT)?
Fig. 77.29 Identify the procedure and significance of using many

probes simultaneously
Fig. 77.30 Identify the structure being marked and the diagnosis
Fig. 77.32 Name the procedure being demonstrated
Fig. 77.31 A post-operative ostium evaluation. What is the diagnosis?
Fig. 77.33 Endoscopic view of the inferior meatus in a child with

CNLDO. What is the image demonstrating
Fig. 77.34 Comment on this ocular coherence tomography image of

the punctum
Fig. 77.35 Identify the marked structure and what it does signify
Key to Atlas Exercises Fig. 77.18: Congenital dacryocele with a large intranasal
cyst.
Fig. 77.1: Red arrow—posterior lacrimal crest; black Fig. 77.19: Irrigation from the lower punctum shows par-
arrow—anterior lacrimal crest; black star—sutura notha; tial regurgitation of fluid from the lacrimal fistula and partly
“F”—bony lacrimal fossa. draining through the nasolacrimal duct.
Fig. 77.2: Peripunctal or circumpunctal nevus. The punc- Fig. 77.20: 3D CT-DCG, volume rendered, demonstrating
tum remains patent in a nevus; however, it is not so in the a patent right lacrimal system and obstruction at the post-
rare instance of a malignant conversion. saccal level on the left side.
Fig. 77.3: Middle turbinate; concha bullosa. Fig. 77.21: Agger nasi. Opening up of agger nasi also
Fig. 77.4: Calamari sign. indicates that one has reached the fundus of the lacrimal
Fig. 77.5: Congenital arhinia-microphthalmia syndrome. sac.
Fig. 77.6: Lacrimal sac dacryolith. Fig. 77.22: Nunchaku pushed bicanalicular stent.
Fig. 77.7: Black arrow—lacrimal sac; black star- agger nasi. Fig. 77.23: Three snip punctoplasty.
Fig. 77.8: Gladstone-Putterman CDCR tube. Fig. 77.24: Botulinum toxin injection into the lacrimal
Fig. 77.9: Papilloma involving the punctum and vertical gland for refractory epiphora.
canaliculus. Fig. 77.25: The structure is the nasolacrimal duct, which
Fig. 77.10: Turbino-ostial synechiae. is being preserved in a pre-lacrimal approach to maxillary
Fig. 77.11: Tight silicone stent; punctal and canalicular sinus lesion.
cheese-wiring and peri-punctal granulomatous response. Fig. 77.26: The telescope is sleeved in a self-cleaning sys-
Fig. 77.12: Dacryoendoscopic image of the nasolacrimal tem, which avoids the need to manually clean the telescope
duct showing a mucosal fold on one of the walls in the distance. during the surgery.
Fig. 77.13: The piezoelectric handpiece used for ultra- Fig. 77.27: The lacrimal sac is being inflated by visco-
sonic dacryocystorhinostomy. elastic so as to achieve a good marsupialization and avoid
Fig. 77.14: Killian’s incision for the endoscopic septoplasty. injury to the lateral wall of the sac.
Fig. 77.15: Scanning electron microscopic image of a 3D Fig. 77.28: Disruption of the actin cytoskeleton in
bacterial biofilm. response to mitomycin C.
Fig. 77.16: Balloon dacryoplasty. Fig. 77.29: Fistulectomy. The probes in the upper and
Fig. 77.17: Mucosal plug obstruction of the internal com- lower canaliculi are placed so as to protect them from inad-
mon opening. vertent injury during the procedure.
77 Key to Atlas Exercises 709
Fig. 77.30: Lacrimal sac. The entire lacrimal sac is within Fig. 77.34: FD-OCT image demonstrating non-canalized
the boundaries of ethmoid sinus. punctum with multiple areas of hyper-reflectivity just beneath.
Fig. 77.31: Bang-on ostium granuloma. These are classical features of a punctal keratinizing cyst.
Fig. 77.32: Endoscopic monitoring of a Sisler’s canalicu- Fig. 77.35: Endoscopic image demonstrating the cut end
lar trephination during an endoscopic DCR. of the nasolacrimal duct just above its entry into the infe-
Fig. 77.33: The endoscopic image is demonstrating the rior meatus. This mostly occurs following a surgery and is
probe in the nasolacrimal duct and stretch of the inferior end of an iatrogenic cause of secondary acquired nasolacrimal duct
the NLD, suggestive of impending recanalization of the NLD. obstruction.

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Mohammad Javed Ali (Auth.) - Atlas of Lacrimal Drainage Disorders (2018, Springer Singapore) PDF

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Mohammad Javed Ali

Atlas of Lacrimal Drainage

ISBN 978-981-10-5615-4 ISBN 978-981-10-5616-1 (eBook)

Library of Congress Control Number: 2017960805

© Springer Nature Singapore Pte Ltd. 2018

Printed on acid-free paper

This Springer imprint is published by Springer Nature

The Lacrimal Drainage System: The Reason for My Existence!

Jeffrey Jay Hurwitz, M.D., F.R.C.S.(C)

Hyderabad, India Mohammad Javed Ali, M.D., F.R.C.S., F.R.C.G.P.

Mohammad Javed Ali, M.D., F.R.C.S., F.R.C.G.P.

23. Kakizaki H, Ichinose A, Takahashi Y et al (2012) Anatomical relationship of Horner’s

1 Embryology of the Lacrimal Drainage System . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

18 CT Scans in Lacrimal Pathologies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

39 Lacrimal Sac Diverticulum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341

60 Intubation Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529

Mohammad Javed Ali, M.D., F.R.C.S., F.R.C.G.P.

The understanding of lacrimal embryology is very crucial to References

© Springer Nature Singapore Pte Ltd. 2018 1

Fig. 1.3 Schematic diagram of lacrimal drainage development. Note

Fig. 1.1 Schematic diagram of lacrimal drainage development. The earli-

Fig. 1.4 Schematic diagram of lacrimal drainage development. Note

Fig. 1.2 Schematic diagram of lacrimal drainage development. The dia-

Fig. 1.8 Clinico-embryological correlations: Lacrimal drainage agen-

Fig. 1.5 Schematic diagram of lacrimal drainage development. The

Fig. 1.9 Clinico-embryological correlations: Left eye showing focal

Fig. 1.11 Clinico-embryological correlations: An ectopic punctum in

Fig. 1.14 Clinico-embryological correlations: A left congenital lacri-

Fig. 1.12 Clinico-embryological correlations: A right upper punctal

Fig. 1.13 Clinico-embryological correlations: A right lower eyelid

Fig. 1.18 Clinico-embryological correlations: Ectopic lacrimal gland

Fig. 1.16 Clinico-embryological correlations: Endoscopic view of the

Fig. 1.19 Clinico-embryological correlations: Ectopic lacrimal gland

Fig. 1.17 Clinico-embryological correlations: The lower most non-­

Fig. 1.20 Clinico-embryological correlations: Ectopic lacrimal gland

Fig. 1.21 Clinico-embryological correlations: Microphotograph con-

© Springer Nature Singapore Pte Ltd. 2018 7

Fig. 2.17 Cadaveric right mid-sagittal section. Upon eversion of the

Fig. 2.18 Cadaveric right mid-sagittal section. Upon removing the

Fig. 2.20 Radiological anatomy of the lacrimal drainage system: CT

Fig. 2.23 Radiological anatomy of the lacrimal drainage system: CT

Fig. 2.46 Relationships of the lacrimal drainage system

Fig. 2.60 Histology of a normal lacrimal drainage system:

Fig. 2.63 Histology of a normal lacrimal drainage system:

Fig. 2.69 Histology of a normal lacrimal drainage system:

Fig. 2.71 Histology of a normal lacrimal drainage system:

Fig. 2.70 Histology of a normal lacrimal drainage system:

Fig. 2.72 Histology of a normal lacrimal drainage system:

Fig. 2.74 Histology of a normal lacrimal drainage system:

Ultrastructural studies help in understanding the tissue func- References

© Springer Nature Singapore Pte Ltd. 2018 39

Fig. 3.3 The TEM viewing system

Fig. 3.1 A transmission electron microscope (TEM)

Fig. 3.4 The TEM software console

Fig. 3.7 Harvesting of the entire lacrimal drainage system

Fig. 3.5 The ultrathin samples mounted on copper grids

Fig. 3.12 Numerous lacrimal stents (monoka and bicanalicular)

Fig. 3.10 A scanning electron microscope (SEM)

Fig. 3.13 A higher magnification of sample stub with mounted lacri-

Fig. 3.11 Lacrimal tissues mounted on the sample stubs. Compare

Fig. 3.41 TEM image of a normal nasal mucosa: Electron micro-

Fig. 3.40 TEM image of a normal nasal mucosa: Electron micrograph

© Springer Nature Singapore Pte Ltd. 2018 49

Hyderabad, India Mohammad Javed Ali, M.D., F.R.C.S., F.R.C.G.P.

1 Embryology of the Lacrimal Drainage System . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

18 CT Scans in Lacrimal Pathologies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

39 Lacrimal Sac Diverticulum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341

60 Intubation Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529

Fig. 1.17 Clinico-embryological correlations: The lower most non-

Fig. 4.15 A modern telescope assembly with a three-chip high-

Fig. 5.63 Other causes of epiphora: Clinical photograph of Stevens-