Balloon catheter dilatation for treatment of congenital nasolacrimal duct obstruction.

PURPOSE: To determine the efficacy of balloon catheter dilatation to treat congenital nasolacrimal duct obstruction in children over 12 months of age and in children who had failed lacrimal system probing or silicone intubation. METHODS: We performed a prospective study of balloon catheter dilatation for congenital nasolacrimal duct obstruction in 61 lacrimal systems of 51 patients with an age range of 13 to 73 months (mean, 26 months). Twenty-seven lacrimal systems (44.3%) had no previous procedures, 21 lacrimal system (34.4%) had one or more failed probings, and 13 lacrimal system (21.3%) had failed silicone intubation. Infection was eliminated or suppressed preoperatively with a ten-day course of systemic and topical antibiotics. Oral and topical antibiotics were continued for ten days after surgery. Oral prednisone was administered for five days after surgery. One percent prednisolone acetate eyedrops were for ten days after surgery. Patency was defined as absence of tearing or discharge after the sixth postoperative week, a lack of discharge and a normal tear meniscus on examination, and a normal dye disappearance test. RESULTS: Twenty-six (96%) of the 27 lacrimal drainage systems that had balloon catheter dilatation as a primary procedure were patent after surgery. Thirty-two (94%) of the 34 lacrimal drainage systems that had undergone previous probing or silicone intubation were patent after balloon catheter dilatation. Overall, 58 (95%) of 61 lacrimal drainage systems were patent after balloon catheter dilatation. CONCLUSION: Balloon catheter dilatation is generally effective in the treatment of congenital nasolacrimal duct obstruction as a primary procedure in children over 12 months of age, and as a procedure after failure of lacrimal system probing or silicone intubation.

Secondary dye testing of the lacrimal system.

Using the Olympus PF-22 angioscope to examine the inferior meatus during secondary dye testing of the lacrimal system, I evaluated the efficacy of the secondary dye test to localize partial or functional obstruction of the upper or lower lacrimal excretory system. Secondary dye testing was positive (dye present in the nose) in 12 of 13 lacrimal systems (92%) with functional nasolacrimal duct obstruction, in 7 of 8 (89%) with involutional ectropion, and in 4 of 5 (80%) with facial nerve palsy. Secondary dye testing was negative in the 1 lacrimal system with canalicular stenosis and in 5 of the 6 (83%) with punctal stenosis. Secondary dye testing is helpful in differentiating punctal or canalicular stenosis from functional nasolacrimal duct obstruction; however, it cannot help differentiate ectropion or facial nerve palsy from functional nasolacrimal duct obstruction.

Eyelid level after lower lid blepharoplasty with skin excision. The relationship of intraoperative and postoperative lid levels.

Sixty-seven consecutive patients (134 lids) undergoing lower lid blepharoplasty with skin excision had preoperative, intraoperative, and postoperative photographs taken in a sitting position. There was correlation between intraoperative and postoperative lower lid levels in 119 (89%) of 134 lids. There were nine lids with normal intraoperative lower lid level but postoperative lower lid retraction (scleral show). All nine of these lids had preoperative lower lid retraction. This demonstrated a high correlation between intraoperative and postoperative lower lid levels in the sitting position in lower lid blepharoplasty with skin excision, providing preoperative lower lid retraction is not present, horizontal lid laxity is corrected, and cicatricial lid retraction does not occur.

Tricompartment model of the lacrimal pump mechanism.

BACKGROUND: The role of the lacrimal sac in the lacrimal pump mechanism is controversial. METHODS: Movements of the lateral wall of the lacrimal sac with blinking were videotaped through an endoscope in eight patients after dacryocystorhinostomy. In addition, movements of an air bubble at the opening of the nasolacrimal duct with blinking were studied in three patients with an incompetent valve of Hasner. RESULTS: The superior half of the lateral wall of the lacrimal sac moved laterally with lid closure and medially with lid opening. The inferior half of the lateral wall of the lacrimal sac moved medially with lid closure and laterally with lid opening. In patients with an incompetent valve of Hasner, the air bubble at the opening of the nasolacrimal duct bulged into the nose with lid closure and retracted into the nasolacrimal duct with lid opening. CONCLUSIONS: A tricompartment model of the lacrimal pump is presented that incorporates these findings. With lid closure, the orbicularis muscle contracts, compressing the canaliculi and pulling the superior half of the lateral wall of the lacrimal sac laterally. This creates a lower pressure in the superior sac, allowing tears to be propelled from the canaliculi into the sac. At the same time, the inferior half of the lateral sac wall moves medially, creating a positive pressure in the inferior sac and nasolacrimal duct, thus forcing tears down the duct into the nose. With lid opening, the orbicularis muscle relaxes, allowing the canaliculi to open and the superior half of the lateral sac wall to move medially. The resulting negative intracanalicular pressure allows tears to flow from the lacrimal lake into the canaliculi, and the higher pressure in the superior sac closes the valve of Rosenmueller and forces tears from the superior to inferior sac and proximal nasolacrimal duct. At the same time, the inferior half of the lateral sac wall moves laterally, resulting in a negative pressure in the inferior sac and nasolacrimal duct.

Extrusion of enucleation implants: treatment with secondary implants and autogenous temporalis fascia or fascia lata patch grafts.

We performed one autogenous fascia lata graft and 11 autogenous temporalis fascia grafts in eight patients with extrusion of an orbital enucleation implant and in four patients with a bulging implant who could not wear a prosthesis. Excluding one patient with inadequate follow up, 10 of the 11 patients (91%) successfully retained their implant. One patient had severe conjunctivitis followed by anterior migration of his implant 2 1/2 years after patch grafting, necessitating replacement of the implant. We conclude that autogenous temporalis fascia patch grafting is an effective treatment for orbital enucleation implant extrusion or a bulging implant.

Balloon catheter dilatation in pediatric patients.

Balloon catheter dilatation was performed in five children with nasolacrimal duct obstruction who had failed probing or silicone intubation, or who were 6 years of age or older. A patent lacrimal system was achieved in four of these children. Balloon catheter dilatation may offer an alternative to silicone intubation in children with nasolacrimal duct obstruction who fail probing or who are at least 2 years old.

Punctal occlusion and blepharoplasty in patients with dry eye syndrome.

Blepharoplasty and inferior punctal occlusion were performed on 24 consecutive patients with dry eye syndrome. Fifteen patients (62.5%) had symptomatic dry eye syndrome preoperatively and nine patients (37.5%) had asymptomatic dry eye syndrome diagnosed during the preoperative workup (subclinical dry eye syndrome). After surgery, nine patients (37.5%) had improvement of their dry eye syndrome, 10 patients (42%) were unchanged, and two patients (8%) had worsening of their dry eye syndrome. A third patient had worsening of the dry eye syndrome 6 months postoperatively when her puncta reopened. Two patients (8%) had increased irritation only when wearing contact lenses, but in one patient this resolved 6 months after surgery. Thus, although a significant number are improved, a few patients will have worsening of dry eye syndrome after blepharoplasty and inferior punctal occlusion.

Flexible endoscopy in primary dye testing of the lacrimal system.

The Olympus PF-22 angioscope was used to examine the inferior meatus during primary dye testing in 80 lacrimal systems in 48 patients. Dye testing was done bilaterally in 32 subjects with no known abnormalities of lacrimal excretory function; it also was performed on the apparently normal contralateral side of 16 patients with unilateral epiphora. Dye was observed in the nose in 79 of 80 lacrimal systems (99%). Dye was not observed in one patient, who appeared to have a dysfunctional lacrimal excretory system. Primary dye testing of the lacrimal system is reliable when the Olympus PF-22 angioscope is used to examine the inferior meatus.

Nasal endoscopy in dye testing after dacryocystorhinostomy.

Dye testing with a nasal speculum and nasopharyngoscope was performed in 45 consecutive cases after dacryocystorhinostomy. Testing was positive in 60% of cases with a patent dacryocystorhinostomy when the nasal speculum alone was used to examine the nose. When the nasopharyngoscope was used, however, dye testing was positive in 98% of cases. In 2% of cases with a functioning dacryocystorhinostomy, the dye test was negative and the nasal ostium could not be visualized. The nasal ostium could not be visualized in 16% of cases because of severe nasal septal deviation or other nasal anatomic change. It is concluded that dye testing is a reliable measure of lacrimal drainage function after dacryocystorhinostomy when nasal endoscopy is performed and when the nasal ostium and surrounding nasal mucosa can be visualized.

Balloon catheter dilatation in lacrimal surgery.

We performed balloon catheter dilatation in four patients with a failed dacryocystorhinostomy. Epiphora was relieved and a patent lacrimal drainage system was achieved after the procedure in three of the four. The fourth patient had a transient partial response. Epiphora recurring in one patient 3 1/2 months after the procedure responded to a second dilatation.

Dacryocystorhinostomy without flaps.

In a series of 50 consecutive cases, a modification of the Kasper technique of dacryocystorhinostomy without flaps resulted in a success rate of 90%. The success rate was 92.5% in patients with nasolacrimal duct obstruction alone, but only 80% in those with both nasolacrimal duct obstruction and canalicular disease. The results of this study indicate that equivalent results are achieved with or without the use of flaps. The elimination of flaps shortens and simplifies the procedure.