Is a bacterial biofilm in the lacrimal sac the cause of chronic refractory dacryocystitis? - A pilot study.

PURPOSE: A pilot study to identify bacterial biofilm in the lacrimal sacs of patients with chronic dacryocystitis, and in patients with epiphora but without discharge, using scanning electron microscopy. METHODS: Five patients: two with nasolacrimal duct obstruction without dacryocystitis, and three with dacryocystitis refractory to antibiotics, underwent external dacryocystorhinostomy. One control patient without infection was included. Bacterial cultures were obtained from the lumen of the lacrimal sac to analyze possible bacterial growth, including antibiotic resistance. Biopsies were taken from all lacrimal sacs and prepared for light and scanning electron microscopy. RESULTS: Scanning electron microscopy of all the lacrimal sac samples revealed structures consistent with bacterial communities and adjacent extracellular material, indicating biofilm formation. This was most prominent in one of the patients with chronic dacryocystitis. Bacteria were found not only on the luminal surface of the sac, but also within the tissue of the sac. Bacterial growth was identified in samples from two patients with chronic dacryocystitis, whereas samples from the other three patients showed no bacterial growth. CONCLUSION: Lack of patency of the lacrimal duct predisposes to bacterial growth, even in patients with no clinically confirmed infection of the lacrimal sac. The finding of a biofilm in patients with chronic dacryocystitis explains the lack of efficiency of antibiotic treatment at the concentrations used in clinical practice.

Bilateral Nasolacrimal Duct Obstruction Managed With Probing and Irrigation in a Patient With FGF10-Associated Lacrimo-auriculo-dento-digital Syndrome.

The authors report a case of lacrimo-auriculo-dento-digital syndrome in a 16-month-old boy with punctal agenesis, upper canalicular dysgenesis and polydactyly, presenting as bilateral congenital nasolacrimal duct obstruction and unilateral acute dacryocystitis. Genetic sequencing revealed a novel mutation in fibroblast growth factor 10. [J Pediatr Ophthalmol Strabismus. 2023;60(4):e38-e40.].

Infantile orbital abscess: clinical presentation, microbiological profile, and management outcomes.

PURPOSE: Orbital abscesses in children are not uncommon. Unless managed in a timely fashion, they can potentially lead to vision-threatening as well as life-threatening complications. The objective of this study is to report the clinical and microbiological profile and management outcomes in infants presenting with orbital abscesses. MATERIALS AND METHODS: A retrospective review of electronic medical records of children younger than 1 year with a diagnosis of an orbital abscess was done. The data was collected from a time period of 12 years (2007-2019). The data collected included mode of presentation, radiological, microbiological and histopathological features, and the final outcome. RESULTS: A total of nine patients met the inclusion criteria. The mean age at presentation was 19 weeks. Three patients had upper respiratory tract infection, one had a congenital nasolacrimal duct obstruction, two had sinusitis, and one patient had neonatal sepsis. All patients underwent imaging following which abscess drainage was performed. Methicillin-sensitive Staphylococcus aureus was the most common organism, which was isolated in five patients, Methicillin-resistant S. aureus was isolated in three, while one patient had Entomophthorales fungal infection. The median follow-up period was 10 months (range 5 days to 89 months). There was no recurrence in the cohort. At least one patient had visual impairment at the last follow up. CONCLUSION: Orbital abscesses in infants are rare. Imaging and prompt drainage of the abscess supplemented by appropriate antimicrobial regimen leads to a successful outcome.

CHARGE syndrome without colobomas: Ophthalmic findings.

To report ophthalmic findings of patients without colobomas, and with a clinical and molecular diagnosis of CHARGE Syndrome. Retrospective study of ophthalmic findings in 67 CHARGE patients-clinically confirmed diagnosis with positive CHD7 mutation-seen in the Ophthalmology department of Cincinnati Children's Hospital Medical Center between January 1, 2008 through September 25, 2018. Criteria for inclusion in this study was absence of any form of a coloboma in either eye. In our cohort, all patients had a positive CHD7 mutation, in addition to a clinical diagnosis. 19.4% (13/67) of CHARGE patients did not have a coloboma in either eye. 69.2% (9/13) had strabismus, 76.9% (10/13) had a refractive error that warranted refractive correction, 23.1% (3/13) had amblyopia, 38.5% (5/13) had nasolacrimal duct obstruction, 30.8% (4/13) had dry eye syndrome and exposure keratopathy, 15.4% (2/13) had ptosis, 15.4% (2/13) had blepharitis, 15.4% (2/13) had Cortical Visual Impairment, 7.7% (1/13) of patients had optic nerve drusen, 7.7% (1/13) had Marcus Gunn Jaw Winking, and 7.7% (1/13) with an eyelid nevus. There are numerous ophthalmic findings in individuals with CHARGE Syndrome without colobomas. No study to date has evaluated the ophthalmic findings in CHD7 positive CHARGE patients without colobomas. These findings need to be assessed and treated to ensure optimal vision in the CHARGE patient population. Absence of coloboma does not rule out a diagnosis of CHARGE syndrome, and if there is a clinical suspicion, clinical confirmation then genetic testing would be warranted.

Ophthalmological abnormalities in Down syndrome among Brazilian patients.

Down syndrome is the most common chromosomal disorder, affecting 1/700 live births. Among the clinical findings, one constant concern is the high prevalence of visual disorders that, if left untreated, can negatively affect child development. The aim of this study was to determine the prevalence of ophthalmological findings among patients who attended an outpatient clinic for patients with Down syndrome in southern Brazil between 2005 and 2016. A cross-sectional study including 1,207 patients medical records were done, which 492 (40.8%) had some ophthalmological disorder. These data were subjected to descriptive analysis using Statistica software. Among the 492 patients with any ophthalmological disease, the need for glasses was found in 434 (36%) patients, keratoconus in 254 (42.1%), congenital cataract in 27 (15.1%), nasolacrimal duct obstruction in 25 (2.0%), strabismus in 22 (1.9%), nystagmus in four (0.3%), and juvenile cataract in two (0.2%). Two young adults with keratoconus underwent corneal transplantation. Although the prevalence of an ophthalmological disease among the present sample (40.8%) was lower than described in the current literature, it still reinforced the importance of routine and early evaluations in infants. These should begin at 6 months of age and be repeated half-year until 2 years old, annually until 7 years old, biennial in adolescents, and triennial in adults and elderly. Our findings of a high frequency of keratoconus support a detailed corneal study in such patients for early detection and treatment.

Trauma-induced exostosis of multiple suture lines causing partial bilateral nasolacrimal duct obstruction in a 7-year-old Thoroughbred mare.

A definitive diagnosis of extensive suture line exostoses affecting the nasofrontal, nasolacrimal, nasomaxillary, frontolacrimal, lacrimozygomatic and lacrimomaxillary suture lines in a 7-year-old Thoroughbred mare with chronic bilateral epiphora and facial deformation was achieved using standing computed tomography (CT) examinations. Positive contrast dacryocystorhinography using CT revealed partial bilateral obstruction of the nasolacrimal ducts. Minimally displaced depression fractures of the right nasal bone, the right maxillary bone and right frontal bone were also demonstrated. The cosmetic appearance of the periosteal reaction associated with the suture line exostosis and epiphora significantly improved within 3 months of diagnosis and treatment.

Chronic conjunctivitis as a prognosis factor of dacryocystorhinostomy: a retrospective case-controlled study.

OBJECTIVE: To determine whether the history of chronic conjunctivitis increases the likelihood of epiphora after an external dacryocystorhinostomy (Ex-DCR) and to elucidate other factors that may affect the prognosis of this surgery. METHODS: This is a retrospective case-controlled study. Patients who had epiphora after an Ex-DCR were compared with patients who did not present epiphora. Medical history of conjunctivitis, use of antiglaucomatous drops, rhinitis, and nasal pathology were evaluated. RESULTS: A total of 129 adult patients undergoing external DCR were evaluated, of which 73% had decreased tearing. Forty-five percent of the patients who continued with epiphora had a history of conjunctivitis, compared to the 20% of those who did not (p = 0.003). At the same time, the 20% of those who continued with epiphora had a history of rhinitis compared to the 8% of those who did not (p = 0.043). CONCLUSION: Patients with a history of chronic conjunctivitis are less likely to improve the epiphora after performing an Ex-DCR. We consider that it is important to evaluate this antecedent before surgery.

Amblyopia risk factors in congenital nasolacrimal duct obstruction: A longitudinal case-control study.

PURPOSE: To investigate longitudinal changes in risk factors for amblyopia in children treated with congenital nasolacrimal duct obstruction (CNLDO). METHODS: Retrospective observational case control study. A total of 446 children under 4 years of age who underwent probing and/or intubation for CNLDO between January 2004 and January 2018, and 446 age-matched controls were included. Cycloplegic refraction and ocular alignment were investigated at the time of treatment and after at least one year of symptom improvement. Children were classified as having amblyopia risk factors on the basis of the American Association for Pediatric Ophthalmology and Strabismus guideline in 2013. MAIN OUTCOME MEASURES: The prevalence of amblyogenic refractive errors, and determinants associated with the presence of amblyogenic refractive errors in CNLDO patients. RESULTS: The prevalence of amblyogenic refractive errors in CNLDO patients (5.4%) was similar to that of the control group (6.5%) (P = 0.571). After one year of symptom improvement in CNLDO patients, the prevalence of amblyogenic refractive errors was 4.7%. There was no difference in the prevalence of amblyogenic refractive errors between unilateral and bilateral CNLDO patients. Multivariate analysis revealed that manifest strabismus was the only risk factor related with the presence of amblyogenic refractive errors (odds ratio = 6.383, confidence interval = 1.205-33.826, P = 0.029). CONCLUSIONS: This study found no evidence to suggest that the prevalence of amblyopia risk factors is higher in CNLDO patients compared with normal controls. Manifest strabismus was the only determinant associated with the presence of amblyogenic refractive errors.

Awake bedside nasal endoscopy for primary management of neonatal dacryocystoceles with intranasal cysts.

OBJECTIVE: To present outcomes of neonatal dacryocystoceles treated through endoscopic intranasal cyst marsupialization (EICM) without general anesthesia and nasolacrimal duct (NLD) probing or irrigation. METHODS: Records of eleven consecutive infants diagnosed with unilateral or bilateral congenital cysts associated with the nasolacrimal system between January 2016 and February 2019 at our institution were retrospectively reviewed. RESULTS: Age at diagnosis ranged from 0 to 56 days, and 45.5% were male. 54.5% had dacryocystitis before surgical intervention. Patients were initially treated with a combination of massage and topical antibiotics; some received parenteral antibiotics if infected. Nearly all patients (90.9%) had one or more intranasal cysts. Of these patients, two underwent lacrimal probing and EICM in the operating room. One underwent EICM only in the operating room. Another patient initially failed bedside NLD probing and subsequently underwent bedside nasal endoscopy and awake EICM. The final six patients underwent EICM without general anesthesia or NLD probing. No complications were noted. Follow-up ranged from 7 to 906 days. Complete resolution was observed in all ten patients who underwent EICM, regardless of anesthesia. CONCLUSIONS: Neonatal dacryocystoceles and/or intranasal cysts are successfully treated at the bedside through nasal endoscopy with simple awake endoscopic intranasal cyst marsupialization. Avoidance of general anesthesia and NLD probing or irrigation would greatly simplify and decrease the cost of dacryocystocele management.

Surgical Outcome of External Dacryocystorhinostomy With Silicone Intubation for Recurrent Lacrimal Abscess in Children Younger Than 6 Years.

PURPOSE: To assess the success rate of external dacryocystorhinostomy (DCR) with silicone intubation for recurrent lacrimal abscess in children younger than 6 years. METHODS: A single-center retrospective analysis of 46 eyes of 40 children who underwent DCR with silicone tube intubation for recurrent lacrimal abscess was done. Probing done previously in these cases was unsuccessful. Only those children who underwent incision and drainage of the abscess at least once with antibiotic treatment were included in the study. In all cases, silicone tube removal was done after 3 months. A successful outcome was defined as the absence of subjective complaints of pain and swelling over the medial canthal area and watering and discharge at 6 months postoperatively. Objective assessment of patency of the lacrimal apparatus was done by sac syringing at 6 months postoperatively. RESULTS: The mean age at surgery was 4.93 ± 0.93 years (range: 3 to 6 years) and the mean follow-up duration was 11.80 ± 11.87 months (range: 6 to 84 months). Intra-operative difficulties encountered were excessive perisac adhesion (n = 28) and severe bleeding/hemorrhage (n = 24). A total of 82.61% cases had a successful outcome after DCR with silicon tube intubation. One child had granuloma formation at the wound. Spontaneous tube extrusion occurred in three children. CONCLUSIONS: DCR with silicone tube intubation is a safe and effective surgical approach with satisfactory outcomes for treating recurrent lacrimal abscess with congenital nasolacrimal duct obstruction in children younger than 6 years. [J Pediatr Ophthalmol Strabismus. 2019;56(3):188-193.].

Concurrent Microbial Keratitis and Nasolacrimal Duct Obstruction: Concordance, Etiopathogenesis, and Outcome.

PURPOSE: Nasolacrimal duct obstruction (NLDO) is believed to be a risk factor for microbial keratitis (MK). The primary objective of this study was to look at microbiological concordance between corneal scraping and lacrimal sac flora in patients with concurrent MK and NLDO. The secondary objective was to compare microbiological isolates from MK and NLDO, MK alone, NLDO alone, and healthy subjects. METHODS: A prospective comparative study of 146 subjects with standard microbiological analyses was performed between February 2014 and October 2017. RESULTS: Of the 146 subjects, 35 had concurrent MK and NLDO, 35 had MK, 41 had NLDO, and 35 were healthy subjects. Overall, mean age and sex distribution among groups were similar. In the MK and NLDO group, coagulase-negative staphylococci (CNS) were the most common isolates from the corneal scraping (n = 12/35, 34%) and lacrimal sac (n = 10/35, 29%) with 58% concordance. CNS were also the most common isolates from the NLDO group and healthy subjects, fungus being the most common isolate in the MK group. Anatomical success was achieved in 31 patients (89%) after dacryocystorhinostomy (DCR) in the MK and NLDO group. The difference between the number of patients who had successful DCR surgery but failure of medical therapy for MK (1/31) versus those who failed DCR and medical therapy for MK (3/4) was statistically significant (P = 0.002, Fisher exact test). CONCLUSIONS: CNS are the most common organisms in concurrent MK and NLDO (58% concordance), in patients with NLDO alone, and as commensals in healthy subjects. Persistence of NLDO may be responsible for a poorer outcome of MK in a concurrent setting.

The relationship between topical anti-glaucoma medications and the development of lacrimal drainage system obstruction / A relação entre medicamentos tópicos anti-glaucoma e o desenvolvimento de obstrução do sistema de drenagem lacrimal

ABSTRACT Purpose: To evaluate whether any topical anti-glaucoma medications increase the risk of lacrimal drainage system obstruction or whether the presence of preservatives alone is sufficient to generate obstruction. Methods: This nested case-control study compared a group of patients with lacrimal duct obstruction who received topical anti-glaucoma medications to a control group of patients without obstruction. Results: The medical records of 255 patients with glaucoma who consulted the Oculoplastic Section with complaints of watery eyes were reviewed. Among these patients, 59 exhibited lacrimal drainage obstruction. Ninety-four percent of patients with lacrimal drainage obstruction used beta-blockers, and 41% used prostaglandin analogs. A logistic regression model was used to adjust for age, sex, and the use of other medications. No significant differences were observed regarding the topical anti-glaucoma medications used between groups. Conclusion: No single topical anti-glaucoma medication demonstrated a stronger association with the development of lacrimal duct obstruction.

RESUMO Objetivo: Avaliar se algum medicamento tópico anti-glaucoma aumenta o risco de obstrução do sistema de drenagem lacrimal ou se a presença de conservantes é su fi cien te para gerar obstrução. Métodos: Este estudo de caso-controle aninhado comparou um grupo de pacientes com obstrução do ducto lacrimal que receberam medicações tópicas anti-glaucoma contra um grupo controle de pacientes sem obstrução. Resultados: Foram revistos os prontuários de 255 pacientes com glaucoma que consultaram a Seção de Oculoplástica com queixas de olhos lacrimejantes. Dentre esses pacientes, 59 apresentavam obstrução da via lacrimal de drenagem. Noventa e quatro por cento dos pacientes com obstrução usaram betabloqueadores e 41% usaram análogos de prostaglandinas. Um modelo de regressão logística foi utilizado para ajustar a idade, sexo e o uso de outros medicamentos. Não foram observadas diferenças significativas em relação às medicações tópicas anti-glaucoma usadas entre os grupos. Conclusão: Nenhum medicamento anti-glaucoma tópico único demonstrou uma associação mais forte com o desenvolvimento de obstrução do ducto lacrimal.

The relationship between topical anti-glaucoma medications and the development of lacrimal drainage system obstruction.

PURPOSE: To evaluate whether any topical anti-glaucoma medications increase the risk of lacrimal drainage system obstruction or whether the presence of preservatives alone is sufficient to generate obstruction. METHODS: This nested case-control study compared a group of patients with lacrimal duct obstruction who received topical anti-glaucoma medications to a control group of patients without obstruction. RESULTS: The medical records of 255 patients with glaucoma who consulted the Oculoplastic Section with complaints of watery eyes were reviewed. Among these patients, 59 exhibited lacrimal drainage obstruction. Ninety-four percent of patients with lacrimal drainage obstruction used beta-blockers, and 41% used prostaglandin analogs. A logistic regression model was used to adjust for age, sex, and the use of other medications. No significant differences were observed regarding the topical anti-glaucoma medications used between groups. CONCLUSION: No single topical anti-glaucoma medication demonstrated a stronger association with the development of lacrimal duct obstruction.

Is gastroesophageal reflux disease associated with primary acquired nasolacrimal duct obstruction?

PURPOSE: To determine if patients with primary acquired nasolacrimal duct obstruction (PANDO) have an increased prevalence of gastroesophageal reflux disease (GERD) compared to the general population. METHODS: Cross-sectional case-control study. The Mayo Clinic Reflux Disease Questionnaire (RDQ) is used to help physicians diagnose GERD. The retrospective group consisted of patients who previously had a dacryocystorhinostomy (DCR) over a 4-year period by one surgeon (JTH) at one institution. The prospective group included consecutive patients undergoing DCR over an 8-month period for PANDO. The control group consisted of patients at our institution who did not have complaints related to nasolacrimal duct obstruction (NLDO) or a known history of NLDO. The RDQ score or a previous diagnosis of GERD was recorded for each patient. The prevalence of patients with GERD in each of the groups was compared to that in the control group using the Fisher exact test. RESULTS: Nine (7.7%) of 117 patients in the control group were found to have GERD. Twenty-four of 65 (36.9%) patients in the retrospective cohort were found to have GERD. Twelve of 18 (66.7%) patients in the prospective cohort were found to have GERD. When the prospective and retrospective groups were compared to the control group, the presence of GERD was higher in patients with NLDO (p < .0001). CONCLUSION: Based on the results of this study and compared to the general population, GERD has an increased prevalence in patients with PANDO. GERD may have a role in the development of PANDO.

The presentation, clinical features, complications, and treatment of congenital dacryocystocele.

PurposeTo determine the incidence and presenting features of congenital dacryocystocele in the United Kingdom. To report on those cases complicated by dacryocystitis, respiratory compromise, and the treatment undertaken.MethodsA prospective observational study of cases of congenital dacryocystocele presenting in the United Kingdom between September 2014 and October 2015. Infants <3 months of age presenting with a cystic swelling in the medial canthal area were included. Cases were identified via the British Ophthalmology Surveillance Unit (BOSU) reporting system.ResultsA total of 49 cases were reported during the study period. This gives an incidence of 1 in 18 597 live births. There was a 71% response rate to the questionnaire. The average age at presentation was 16.94 days. Dacryocystoceles were unilateral in 91% of cases. Dacryocystitis was a complicating factor in 49% of patients and 17% had respiratory distress. Uncomplicated dacryocystocele responded well to conservative measures in 86%. Surgical intervention was required in 23% of patients. Those cases complicated by dacryocystitis (29%) and nasal obstruction (17%) were more likely to require surgical intervention compared to those with dacryocystocele alone (14%). Digital massage appears to reduce the likelihood of requiring surgical intervention. The mean time to resolution was 19 days.ConclusionsCongenital dacryocystocele is a rare presentation in the United Kingdom. Dacryocystitis and respiratory compromise commonly complicate a dacryocystocele. The use of digital massage as an early intervention is advocated and conservative measures may be sufficient in cases of uncomplicated dacryocystocele.