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To review the efficacy and safety of the use of intraoperative image guidance (IIG) in orbital and lacrimal surgery. A literature search of the PubMed database was last conducted in November 2023 for English-language original research that assessed the use of any image guidance system in orbital and lacrimal surgery that included at least 5 patients. The search identified 524 articles; 94 were selected for full-text analysis by the panel. A total of 32 studies met inclusion criteria. The panel methodologist assigned a level II rating to 2 studies and a level III rating to 30 studies. No study met the criteria for level I evidence. Procedures reported on were as follows: fracture repair (n = 14), neoplasm and infiltrate biopsy or excision (n = 6), orbital decompression for Graves ophthalmopathy (n = 3), dacryocystorhinostomy (n = 1), and mixed etiology and procedures (n = 8). Four studies used more than one IIG system. One study that met level II evidence criteria compared the outcomes of orbital fracture repair with IIG (n = 29) and without IIG (n = 29). Borderline better outcomes were reported in the IIG group: 2% versus 10% with diplopia (P = 0.039) and 3% versus 10% with enophthalmos (P = 0.065). The other level II study compared the repair of fractures with navigation (n = 20) and without (n = 20). The group in which navigation was used had a measured mean volume reduction of 3.82 cm3 compared with 3.33 cm3 (P = 0.02), and there was a greater measured reduction in enophthalmos in the navigation group of 0.72 mm (P = 0.001). Although the remaining 30 assessed articles failed to meet level II criteria, all alleged a benefit from IIG. No complications were reported. A small number of comparative studies suggest that there are improved outcomes when IIG is used in orbital fracture repair, but each study suffers from various limitations. No high-quality comparative studies exist for the management of lacrimal surgery, neoplastic disease, or decompression. Complications attributable to the use of IIG have not been identified, and IIG has not been analyzed for cost savings. Proprietary or commercial disclosure may be found after the references. [ABSTRACT FROM AUTHOR]

Aplasia of lacrimal and salivary glands (ALSG) is a syndromic disorder characterized by aplasia of lacrimal and salivary systems. Reported ophthalmic manifestations of ALSG include aplasia of lacrimal glands, punctal agenesis, lacrimal sac mucocele, and membranous congenital nasolacrimal duct obstruction (CNLDO). Bony CNLDO, a rare clinical entity, has not been associated with any syndromic disorder. This study investigated the relationship between genetic mutations and bony CNLDO in 3 Chinese families with ALSG. Single-center observational case study. Three Chinese families with bony CNLDO, including 7 affected and 9 healthy family members. Slit-lamp ophthalmic examination, comprehensive physical examination, orbital computed tomography (CT) imaging, cervicofacial magnetic resonance imaging, audiometry, and whole exome sequencing on periphery blood were performed. Variants were cross-referenced with 1000 control genomes and various population databases. Pathologic variants were identified using bioinformatic tools. Clinical examination, diagnostic imaging, whole exome sequencing, and bioinformatic analysis findings. Affected patients showed decreased tear production on the Schimer I test and reduced tear breakup time. Bony CNLDO was observed on CT, showing unilateral or bilateral bony termination at the middle or terminal segment of the nasolacrimal canal. Magnetic resonance imaging showed aplasia or absence of lacrimal, parotid, and submandibular glands. Physical examination revealed normal ears, digits, and facial morphology. Audiometry and dental assessment were conducted on the pediatric patients and yielded normal results. The clinical characteristics of patients aligned with a diagnosis of ALSG. Genomic analysis revealed 3 novel heterozygous missense mutations of the Fgf10 gene: c.316T→C, c.327C→G, and c.332T→G. The inheritance pattern was autosomal dominant with variable penetrance. These variants were not observed in 1000 control genomes and population databases. These variant positions also were shown to be highly conserved across various animal species. Mutated genes and proteins were predicted as deleterious with most computational models, with a few suggesting they may be benign. Bony CNLDO was identified as a novel phenotype of ALSG implicated by missense mutations of highly conserved residues in the Fgf10 gene. These cases broadened our knowledge of Fgf10 -related phenotypes and prompted clinicians to consider syndromic associations in patients with bony CNLDO. The author(s) have no proprietary or commercial interest in any materials discussed in this article. [ABSTRACT FROM AUTHOR]

To review the literature on the adjuvant use of mitomycin C (MMC) during dacryocystorhinostomy (DCR) in adults with primary nasolacrimal duct obstructions (NLDOs) to determine the efficacy in improving functional and anatomic outcomes with an acceptable level of risk. A literature search conducted in November 2020 and updated in November 2022 yielded 137 articles. Twenty-four articles met the inclusion criteria and were rated for level of evidence by the panel methodologist. Inclusion criteria required controlled studies on the effect of MMC on outcomes of external, endoscopic endonasal, or diode laser-assisted transcanalicular DCR in adults with primary acquired nasolacrimal obstruction with 6 months minimum follow-up and at least 10 participants. Six of the 24 articles were rated level I evidence, 15 level II , and 3 level III. In primary external DCR, MMC significantly improved functional outcomes in 3 of 9 series. In primary endoscopic endonasal DCR, MMC significantly improved functional outcomes in 1 of 9 series. In revision endoscopic endonasal DCR, MMC significantly improved functional success in 1 of 3 series. The use of MMC did not improve outcomes statistically in any diode laser-assisted transcanalicular DCR studies. Concentrations of MMC ranged from 0.05 to 1 mg/ml, with 0.2 mg/ml used most frequently in 12 series, with duration of application ranging from 2 to 30 minutes. Ostium size was significantly larger in MMC groups than in control groups at 6 months after surgery in 4 of 5 reporting studies. However, these larger ostia did not confer higher functional success rates. Reporting of adverse events related to MMC were rare, with delayed cutaneous wound healing reported in 1 of 750 patients. Intraoperative use of MMC in external and endoscopic endonasal DCR has been shown to improve functional and anatomic outcomes compared with controls in some series, but there is no agreement on the recommended concentration or application time for MMC in DCR. The data support that MMC use can result in a larger ostium size, decreased granulation tissue formation, and a decreased number of postoperative nasal debridements compared with controls, but this does not translate into improved functional success. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article. [ABSTRACT FROM AUTHOR]

To report a series of patients who developed punctal stenosis secondary to the use of topical netarsudil 0.02% for treatment of glaucoma. Case series. Patients using topical netarsudil for management of glaucoma and noted to have punctal stenosis ipsilateral to the eye(s) being treated with netarsudil were included. Each enrolled patient's chart was reviewed, and alternative causes of punctal stenosis were sought. Photographs were obtained to document punctal stenosis for some patients. Presence of punctal stenosis after topical netarsudil use and resolution of punctal stenosis after cessation of therapy. Sixteen patients had punctal stenosis; 13 developed unilateral punctal stenosis while using netarsudil unilaterally, and 3 patients developed bilateral punctal stenosis with bilateral use. Time from initiation of netarsudil to recognition of symptoms or documentation of punctal stenosis ranged from 2 to 35 months (median, 12; mean, 14.0 ± 8.7 months). Thirteen patients endorsed tearing, but 2 had no symptoms. Ectropion was seen in 1 eye. Corneal verticillata was noted in 14 patients (87.5%). In 8 cases, netarsudil was discontinued, and the punctal stenosis was reversed, with resolution of associated symptoms. Netarsudil use can lead to the development of reversible punctal stenosis. This inflammation-mediated stenosis may cause tearing and associated symptoms and may be of sufficient severity to necessitate discontinuation of treatment. In this case series, all patients who discontinued treatment had reversal of their punctal stenosis and associated symptoms. [ABSTRACT FROM AUTHOR]

To review the published literature assessing the efficacy and safety of in-office probing compared with facility-based probing to treat congenital nasolacrimal duct obstruction (NLDO). Literature searches were conducted in March 2020 in the PubMed database with no date restrictions and limited to studies published in English and in the Cochrane Library database with no restrictions. The combined searches yielded 281 citations. Of these, 21 articles were deemed appropriate for inclusion in this assessment and assigned a level of evidence rating by the panel methodologist. Four articles were rated level I, 2 articles were rated level II, and 15 articles were rated level III. Treatments consisted of observation, in-office nasolacrimal probing, or facility-based nasolacrimal probing. Success rates and complications or recurrences were recorded from 1 week to 6 months after surgery. Complete resolution of symptoms after surgery ranged from 66% to 95.6% for office-based procedures versus 50% to 97.7% for facility-based procedures. Level I evidence indicated that 66% of cases spontaneously resolved after 6 months of observation in infants between 6 and 10 months of age. Success rates for in-office probing were lower for bilateral than for unilateral NLDO (67% vs. 82%), whereas success rates were high in both unilateral (83%) and bilateral (82%) patients who underwent facility-based probing after 6 months of observation. Cost data did not indicate a definitive cost savings of either treatment method ($562 for in-office vs. $701 for facility-based, depending on cost models predicting spontaneous resolution rates at different ages). No serious adverse events with treatment or anesthesia were reported for either treatment method. Evidence supports the efficacy and safety of both in-office and facility-based surgery for congenital NLDO. However, treating bilateral NLDO in a facility setting may be better. Because a significant percentage of children achieved resolution spontaneously before 12 months of age, deferring treatment until 12 to 18 months of age is a reasonable option. Additional research may address symptom burden on families and the impact of anesthesia and emotional trauma of nonsedated office probings on patients and may explore further the cost of treatment for each treatment method. [ABSTRACT FROM AUTHOR]

To compare incidences, ocular injury types, and treatment performed on United States and United Kingdom military service members and host nation civilians within the Iraq and Afghanistan conflicts to inform future military surgical training requirements and military medical planning. The United States routinely deployed ophthalmologists, whereas the United Kingdom did not. Retrospective cohort study of the United States and United Kingdom military Joint Theatre Trauma Registries. All patients with eye injuries treated at a deployed Military Treatment Facility between March 2003 and October 2011. An adjusted multiple logistic regression model was performed using enucleation or evisceration and primary open-globe repair as dependent variables and casualty nationality, location, and the presence of an ophthalmic surgeon as independent variables. Incidence of eye removal (enucleation or evisceration) or primary repair for open globe injury. Five thousand seven hundred nineteen of 67 586 (8%) survivors or those who died of wounds were recorded to have sustained eye injuries. The most common eye injuries were open-globe injury without intraocular foreign body (3201/5719 [56%]). Adnexal injuries (eyelid lacerations and damage to lacrimal apparatus) were recorded in 1265 of 5719 patients (22%). The odds of undergoing evisceration or enucleation for open-globe injury was highest in host nation civilians (odds ratio [OR], 9.23; P < 0.001), but there was no evidence of a difference between United States and United Kingdom military service member casualties (P = 0.38). The presence of an ophthalmic surgeon (OR, 16.3; P < 0.001) significantly affected the odds of eye removal. Eye injuries were more likely to have been treated definitively in United States Medical Treatment Facilities (MTFs), reflecting the absence of ophthalmologists in most deployed United Kingdom MTFs. The Iraq and Afghan conflicts were notable for coalition air dominance; the shape of future conflicts may mandate delays in evacuation, which may affect visual outcomes negatively, particularly if primary repair of patients with open-globe injuries is delayed. This study provides evidence to support the maintenance of specialist ophthalmic surgical competencies in deployed coalition MTFs for future conflicts. [ABSTRACT FROM AUTHOR]

Purpose To evaluate the effect of glaucoma on functional vision and on vision-related (VR) and health-related (HR) quality of life (QoL) in children up to 16 years of age. Design Cross-sectional observational study. Participants One hundred nineteen children 2 to 16 years of age (mean age, 9.4 years; standard deviation [SD], 4.56 years) with glaucoma and their parents. Methods Completion of 3 validated instruments for children to assess (1) functional visual ability (FVA) with the Cardiff Visual Ability Questionnaire for Children (CVAQC), (2) VR QoL with the Impact of Vision Impairment for Children (IVI-C), and (3) HR QoL with the Pediatric Quality of Life Inventory (PedsQL) version 4.0. Main Outcome Measures Cardiff Visual Ability Questionnaire for Children, IVI-C, and PedsQL scores. Results Scores for FVA, VR QoL, and HR QoL were reduced in children with glaucoma: median CVAQC score, –1.24 (interquartile range [IQR], –2.2 to –0.11; range, –3.00 higher visual ability to +2.80 lower visual ability); mean IVI-C score, 67.3 (SD, 14.4; normal VR QoL, 96); median PedsQL self-report, 78.8 (IQR, 67.4–90.2); parent report, 71.2 (IQR, 55.7–85.8); and family impact score, 74.3 (IQR, 56.9–88.5; normal HR QoL, 100). Psychosocial subscores were lower than physical subscores on the PedsQL. Older children reported less impairment on CVAQC, IVI-C, and PedsQL than younger children. Parents reported greater impact on their child's HR QoL than children reported themselves. Conclusions Glaucoma and its management have a marked impact on a child's FVA and QoL. Children with glaucoma report HR QoL scores similar to those described by children with severe congenital cardiac defects, who have undergone liver transplants, or who have acute lymphoblastic leukemia. [ABSTRACT FROM AUTHOR]

Purpose To determine the application of imaging the stenotic lacrimal punctum with infrared photographs and optical coherence tomography (OCT) and to identify characteristics of the lacrimal punctum in patients who benefit from punctoplasty. Design Case-control study. Participants Twenty patients with epiphora who were listed for punctoplasty and 20 healthy controls. Methods Prospectively, 20 patients listed for punctoplasty were asked to rate their epiphora, using the Munk score, before and after punctoplasty. They also underwent preoperative OCT and infrared imaging of the affected punctum. They were divided into 2 groups, depending on whether the epiphora improved, and were compared with 20 healthy controls. Main Outcome Measures Measurements of puncta from infrared and OCT images were obtained along with Munk scores of patient epiphora. Results The infrared image measurements were significantly smaller in those patients whose epiphora improved compared with those whose did not in both the area of the punctal aperture and in the maximum punctal diameter. Additionally, those patients with improvement in epiphora had a significantly smaller preoperative punctal diameter at 100 μm depth on OCT compared with healthy controls; this was not observed in patients whose epiphora failed to improve. There was no significant difference in the punctum diameter among the 3 groups at the punctum surface entrance or at 500 μm depth. Patients with epiphora had a higher tear meniscus within the punctum compared with healthy controls. Conclusions Lacrimal punctum infrared and OCT imaging may be helpful in predicting patients more likely to benefit symptomatically from punctoplasty, with patients with smaller puncta having greater symptomatic improvement. However, the results suggest that inner punctum diameter (not readily measurable by slit-lamp examination), rather than the surface diameter, is correlated with outcome. Additionally, OCT measurements of the tear meniscus height within the punctum may be related to the degree of epiphora. [ABSTRACT FROM AUTHOR]

Purpose To describe the involvement of the lacrimal gland (LG) in blepharophimosis-ptosis-epicanthus inversus syndrome (BPES). Design Observational, cross-sectional study. Participants Twenty-one patients with BPES (10 female, 11 male) aged on average 15 years (range, 2–39 years), from 3 Brazilian medical centers and 1 Portuguese medical center. Methods Patients had their ocular surface evaluated with slit-lamp biomicroscopy, and tear production quantified with the Schirmer test I. The LG volumes were measured on computed tomography (CT) scans in the BPES sample and in a group of age-matched subjects imaged for nonorbital diseases. Sixteen patients were screened for mutations in the FOXL2 gene. Main Outcome Measures Lacrimal meniscus height, Schirmer test I, presence of superficial punctate keratopathy (SPK), LG volume, and molecular analysis of the FOXL2 gene. Results Absence of LG was detected bilaterally in 9 patients (42.8%) and unilaterally in 2 patients (9.5%). When considering only patients with measurable LG, the median volume was 0.22 cm 3 in the right eye (range, 0.06–0.36 cm 3 ) and 0.24 cm 3 in the left eye (range, 0.08–0.34 cm 3 ). These values were significantly lower than those for the age-matched controls (median = 0.54 right eye and 0.53 left eye; P < 0.05). There was a significant association between deficiency of tear production and LG volume reduction and agenesis. Molecular analysis of the FOXL2 gene revealed the presence of 8 distinct mutations, 4 of them novel ones. A significant reduction of LG size or agenesis was associated with mutations affecting protein size (due to underlying changes in the stop codon location) or the DNA-binding forkhead domain (Fisher exact test, P = 0.021). In 3 probands, the underlying genetic defect was not found. Conclusions This is the first study reporting LG volumes in BPES, describing a significant number of patients with LG agenesis. The association between alacrima and BPES is not incidental, and a thorough evaluation of tear production is recommended especially if ptosis surgery is planned. [ABSTRACT FROM AUTHOR]

Purpose: To study genetic alterations in lacrimal gland pleomorphic adenoma (PA) and carcinoma ex pleomorphic adenoma (Ca-ex-PA) with focus on copy number changes and expression patterns of the trans- location target genes PLAG1, HMGA2, and CRTC1-MAML2 in relation to clinical data. Design: Experimental study. Participants: A total of 36 tumors from 32 patients with lacrimal gland PA or Ca-ex-PA were included in the study. Methods: Genome wide, high-resolution array-based comparative genomic hybridization (arrayCGH) and immunohistochemistry were used to study the genomic profiles and expression patterns of the translocation targets PLAG1, HMGA2, and CRTC1-MAML2. Main Outcome Measures: Copy number alterations (gains/losses) and protein expression of PLAG1, HMGA2, and CRTC1-MAML2. Results: Genome-wide arrayCGH analysis revealed normal genomic profiles in 10 of 17 PA samples. The average number of genomic imbalances per tumor was 3.25 (range, 1-7) in primary and recurrent PAs with alterations compared with 7.7 (range, 4-12) in Ca-ex-PAs. Five recurrent copy number alterations were identified in PAs, including losses of 1pter-p31.3, 6q22.1-q24.3, 8q24.22-q24.3, and 13q21.31-q21.33, and gain of 9p23- p22.3. Gain of 9p23-p22.3 also was seen in a Ca-ex-PA. In Ca-ex-PA, gain of 22q12.3-qter was the only recurrent alteration. Detailed analysis of the array data identified NFIB and PDGFB as the 2 major candidate target oncogenes that may be activated as a result of copy number gains involving 9p and 22q. Both genes have been implicated in the pathogenesis of PA and other types of salivary gland tumors. Immunohistochemical analysis revealed frequent overexpression of the translocation target gene PLAG1 in PAs and in 1 Ca-ex-PA. In contrast, overexpression of HMGA2 was observed in only a small subset of PAs. The CRTC1-MAML2 fusion oncoprotein was overexpressed in 2 mucoepidermoid Ca-ex-PAs. Conclusions: Lacrimal and salivary gland PAs and Ca-ex-PAs have similar genomic profiles and frequently overexpress the PLAG1 oncoprotein. Copy number gains involving 9p23-p22.3 (NFIB) and 22q12-qter (PDGFB) may be of importance for disease progression in a subset of lacrimal gland PAs. [ABSTRACT FROM AUTHOR]

Purpose: To investigate genetic alterations in lacrimal gland adenoid cystic carcinomas (ACCs) with emphasis on the MYB-NFIB fusion oncogene and its downstream targets, MYB rearrangements, and copy number alterations in relation to clinical data and survival. Design: Experimental study. Participants and Controls: Fourteen patients with primary lacrimal gland ACC were included. As a control, we also studied the expression of MYB-NFIB in 19 non-ACC lacrimal gland tumors. Methods: The expression and identity of MYB-NFIB fusion transcripts were studied using reverse transcriptase polymerase chain reaction (RT-PCR) and nucleotide sequence analyses. Quantitative polymerase chain reaction (PCR) and immunohistochemistry were used to evaluate the expression of MYB/MYB-NFIB target genes. High-resolution array-based comparative genomic hybridization (arrayCGH) and fluorescence in situ hybridization were used to study copy number alterations and MYB rearrangements. Main Outcome Measures: mRNA or protein expression of MYB-NFIB, MYB, and its down stream targets; copy number alterations; and genomic rearrangements. Results: The median age of the patients was 43 years (equal gender distribution), and the median time of survival was 8.6 years. The MYB-NFIB fusion was expressed in 7 of 14 ACCs. In contrast, all non-ACC tumors were fusion-negative. All 13 ACCs tested stained positive for the MYB protein, and for the MYB targets KIT and BCL2, 12 were positive for MYC and CCNE1, and 9 were positive for CCNB1. Rearrangements of MYB were detected in 8 of 13 cases, including 2 cases with gain of an apparently intact MYB gene. The arrayCGH analysis revealed recurrent copy number alterations with losses involving 6q23-q27, 12q12-q14.1, and 17p13.3-p12, and gains involving 19q12, 19q13.31-qter, 8q24.13-q24.21, 11q12.3-q14.1, and 6q23.3. Neither MYB-NFIB fusion nor any copy number alteration correlated with survival. Conclusions: Lacrimal gland ACCs are frequently positive for the MYB-NFIB fusion, overexpress MYB and its downstream targets, and have genomic profiles characterized by losses involving 6q, 12q, and 17p, and gains involving 19q, 8q, and 11q. Our findings show that lacrimal gland ACCs are genetically and clinically similar to their salivary gland counterparts and that MYB-NFIB is a clinically useful diagnostic biomarker for ACC. Our data also suggest that MYB and its downstream targets are potential therapeutic targets for these tumors. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. [Copyright &y& Elsevier]

Purpose: To assess the impact of recurrent unilateral herpetic keratitis (HK) on the tear secretion of the unaffected fellow eye. Design: Prospective, noninterventional study. Participants and Controls: Thirty-five patients with a history of recurrent unilateral HK (clinically quiescent for at least 3 months) (HK group) and 35 patients who were age- and sex-matched with no history of corneal disease (control group). Methods: Tear osmolarity, tear instability (tear break-up time [TBUT]), tear reflex (Schirmer's I test), and central corneal sensitivity with the Cochet–Bonnet esthesiometer (Luneau, France) were measured in the HK and control groups. Main Outcome Measures: Tear osmolarity, TBUT, Schirmer's I, and central corneal sensitivity were compared between the affected and unaffected eyes of the HK and control groups. Results: Tear osmolarity and tear secretion reflex were similar between the affected and unaffected eyes of the HK group. Corneal sensitivity and TBUT were statistically lower in the affected eyes compared with the unaffected eyes in the HK group (P = 0.001 and P <0.001, respectively). The central corneal sensitivity of unaffected eyes in the HK group was not significantly different from that in the control group (P >0.05). The tear stability and tear secretion reflex were decreased and tear osmolarity was increased in the unaffected eyes of the HK group compared with the control group (P <0.05, all cases). The difference between unaffected and control eyes varied according to the type of HK. All 4 tests were modified in patients with neurotrophic keratitis (KN). In the keratouveitis subgroup, only corneal sensitivity was normal, whereas Schirmer's I results were also normal in patients with archipelago keratitis. Tear osmolarity was consistently affected in both eyes of herpetic patients. Conclusions: Tear function is impaired in the unaffected eyes of patients with unilateral recurrent HK, even when the disease is apparently quiescent. The higher severity of results in the unaffected fellow eye of patients with KN in comparison with other herpes subgroups suggests that recurrent HK induces a reduction in the afferent pathways of the tear secretion reflex from the affected eye, leading to tear dysfunction in the unaffected eye. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. [Copyright &y& Elsevier]

Purpose: To describe the incidence of canalicular closure with powered endonasal dacryocystorhinostomy (DCR) without canalicular intubation in primary acquired nasolacrimal duct obstruction (PANDO). Design: A single-surgeon, prospective, nonrandomized, noncomparative, interventional case series. Participants: Consecutive patients attending a specialist clinic of an oculoplastic surgeon (DS) with radiologically confirmed diagnosis of PANDO. Cases of canalicular disease were excluded. Methods: Patients with radiologically confirmed PANDO without canalicular involvement underwent endonasal DCR without intubation. The operation was performed by 1 surgeon (DS) and follow-up was at 4 weeks and 12 months. Main Outcome Measures: Outcomes were recorded as subjective symptomatic relief at 12 months and endoscopic evidence of ostium patency and canalicular patency. Results: There were 132 cases that fulfilled the inclusion criteria. Three cases were lost to follow-up. Preoperatively, 96.3% of cases had Munk scores of >2. Of the 129 cases, 127 (98.5%) had endoscopic evidence of a patent ostium with a positive endoscopic dye test at the 12-month follow-up. All cases had a patent canalicular system as demonstrated by syringing and probing. Of the 129 cases, 117 (90.7%) had subjective improvement of epiphora at 12 months with 88.4% of cases reporting Munk scores of ≤1. Conclusions: In this prospective series of nonintubation for PANDO, there were no cases of canalicular closure or stenosis at 12 months. Anatomic and functional success was similar to reported outcomes for DCR with intubation for PANDO. We advocate that routine intubation for the purpose of maintaining canalicular patency is not necessary when performing endonasal DCR in PANDO. Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references. [Copyright &y& Elsevier]

Purpose: To compare the long-term outcomes after intra-arterial cytoreductive chemotherapy (IACC) with conventional treatment for lacrimal gland adenoid cystic carcinoma (ACC). Design: Retrospective case series. Participants: Nineteen consecutive patients treated with IACC, followed by orbital exenteration, chemo-radiotherapy, and intravenous chemotherapy. Interventions: Analyses of the histologic characteristics of biopsy specimens, extent of disease at the time of diagnosis, diagnostic surgical procedures, incidence of locoregional recurrences or distant metastases, disease-free survival time, response to IACC, tumor margins at definitive surgery, and toxicity and complications. Main Outcome Measures: Disease relapse, disease-free survival, and chemotherapeutic complications. Results: Eight patients with an intact lacrimal artery had significantly better outcomes for survival (100% vs. 28.6% at 10 years), cause-specific mortality, and recurrences (all P = 0.002, log-rank test) than conventionally treated patients from the University of Miami Miller School of Medicine. These 8 patients (group 1) had cumulative 10-year disease-free survival of 100% compared with 50% for 11 patients (group 2) who had an absence of the lacrimal artery or deviated from the treatment protocol (P = 0.035) and 14.3% for conventionally treated patients (P<0.001). Likewise, group 2 was associated with lower cause-specific mortality than the institutional comparator group (P = 0.038). Prior tumor resection with lateral wall osteotomy, delay in IACC implementation or exenter-ation, and failure to adhere to protocol are risk factors for suboptimal outcomes. Conclusions: Neoadjuvant IACC seems to improve overall survival and decrease disease recurrence. An intact lacrimal artery, no disruption of bone barrier or tumor manipulation other than incisional biopsy, and protocol compliance are factors responsible for favorable outcomes. The chemotoxicity complication rate is limited and manageable. [ABSTRACT FROM AUTHOR]

Objective: To describe the clinical characteristics and management of a group of patients who had chronic mucopurulent conjunctivitis that was probably due to Actinomyces infection of the lacrimal gland ductules. Design: A retrospective, interventional case series. Participants: Seven patients (2 male; 29%) between 34 and 52 years of age (mean, 48.7 years; median, 49 years) who presented to the lacrimal clinic. Intervention: Surgical excision of the infective focus (6 cases) or fenestration and expression of infective debris (1 case) from the affected lacrimal gland ductule—typically the most inferolateral of the ductules. Main Outcome Measures: The clinical features of this previously unrecognized cause of chronic conjunctivitis and its response to treatment. Results: All cases settled rapidly after surgery. There was often a major delay in diagnosis, with the patients having symptoms for between 2 and 42 months before referral (mean, 13.3 months; median, 9 months); 5 patients received prolonged or ineffectual topical medical therapy before referral. Conclusions: Infective lacrimal gland ductulitis, commonly from Actinomyces infection, should be considered in patients with unexplained chronic mucopurulent conjunctivitis; the condition settles rapidly with surgery. Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references. [ABSTRACT FROM AUTHOR]

Purpose: To report a unique case of primary undifferentiated large cell carcinoma (LCCA) of the lacrimal gland, a tumor not previously described in the ophthalmic literature. Design: Single interventional case report. Participants: A patient affected by undifferentiated LCCA of the lacrimal gland. Methods: A 65-year-old white man with a 3-month history of a painful mass in the left lacrimal gland fossa underwent an incisional biopsy that revealed a “high-grade” epithelial malignancy. Systemic workup revealed enlargement of the regional lymph nodes, and subsequently the patient underwent extended exenteration with clear histologic margins and radical neck lymphadenectomy followed by adjunctive radiotherapy. Fifteen months postoperatively, the patient is alive and well without evidence of local recurrence or metastatic disease. Main Outcome Measures: Treatment result, evidence of local recurrences or distant metastasis, and follow-up. Results: Histologic examination revealed a poorly circumscribed tumor composed of large cells invading orbital fat, lateral rectus muscle, and peripheral nerves. The surrounding orbital bone was infiltrated, but the surgical margins were clear. The cell population was composed of large cells (>30 μm) with eosinophilic cytoplasm and ovoid and irregular nuclei containing a prominent nucleoli and coarse chromatin. The cell borders were well defined. Mitosis figures were abundant, and Ki-67 was positive in more than 60% of the cells. The cells were arranged in cords and trabeculae or irregular sheets of discohesive cells. The immunophenotype analysis showed positivity for cytokeratin but negative cytokeratin 20 stains, which is considered a distinctive feature of LCCA. Conclusions: Undifferentiated LCCAs are rare tumors of the major salivary glands, especially the parotid gland. Primary undifferentiated LCCA of the lacrimal gland has never been reported in the literature. Differential diagnosis must include a primary source in another organ. Given the aggressive nature of the tumor, radical surgery followed by radiotherapy is recommended, but evidence-based indications regarding the preferred line of treatment are lacking and the prognosis remains guarded. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. [Copyright &y& Elsevier]

Purpose: To report the first known case of intravascular lymphoma (IVL), a rare disease, diagnosed via lacrimal gland biopsy. Design: Interventional case report. Participants: Single patient case report. Intervention: Bedside lacrimal gland biopsy. Main Outcome Measures: Clinicopathologic diagnosis of IVL, a neoplasm with only a few prior reports of ophthalmic manifestations, via a novel biopsy site. Results: A 70-year-old Chinese man with 6 months of progressive paraplegia complained of blurred vision in both eyes. He had unremarkable cerebrospinal fluid studies and magnetic resonance imaging that showed abnormal thoracic cord signal and periventricular brain white matter changes with a normal pituitary gland and stalk. Dilated fundus examination showed multifocal areas of intra- and subretinal hemorrhage with serous retinal detachment. The workup included serologies and 2 normal bone marrow biopsies but did not reveal the underlying etiology. Because of the continued high suspicion for a malignant process, we performed bedside transconjunctival biopsy of the lacrimal gland. This demonstrated large, atypical CD20-positive B cells confined to the vessel lumina, consistent with IVL, an unusual form of large B-cell lymphoma. Conclusions: This case represents the first time that IVL has been detected via lacrimal gland biopsy, which may be a useful way to investigate cryptogenic neurologic processes. Furthermore, it is one of the only reported cases of ophthalmic IVL diagnosed before autopsy. IVL is a rare disease but has protean manifestations involving the central nervous system, skin, bone marrow, liver, and spleen. The eye should also be considered an end organ for involvement. [ABSTRACT FROM AUTHOR]

Objective: To measure the height, anteroposterior, and transverse diameters of the nasolacrimal duct (NLD) in normal children between 2 weeks and 34 months of age and to compare the development of the NLD with the maxilla. Design: Retrospective case series. Participants: Thirty-eight children with no history of NLD abnormalities who underwent prior axial computed tomography (CT) facial scans of 0.50 to 0.625 mm resolution. Methods: Consecutive cases of CT facial series over a 16-month period at a single institution were studied. Main Outcome Measures: Height, anteroposterior and transverse diameters, and volume of the NLD; height of the maxillary sinus. Results: The height of the bony NLD increases 1.8-fold, the average diameter increases 1.4-fold, and the volume increases 4.6-fold between 2 weeks and 34 months of age. The dimensional increases of the NLD are nonlinear, with most of the increase occurring in the first 6 months of life. The increase in height of the NLD is highly correlated with postnatal growth of the maxilla. Conclusions: Spontaneous resolution of NLD obstruction in normal infants is coincident with elongation, limited radial extension, and the resulting volume expansion of the NLD. We propose that increases in hydrostatic pressure within the fluid column of the NLD combined with central cavitation of the epithelial core can account for the patency of the NLD in normal infants. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. [ABSTRACT FROM AUTHOR]

Purpose: To investigate whether American Joint Committee on Cancer (AJCC) classification at initial diagnosis of lacrimal gland adenoid cystic carcinoma predicts outcome of treatment on local recurrence. Design: Retrospective chart review. Participants: Consecutive patients with adenoid cystic carcinoma of the lacrimal gland treated at 8 institutions between January 1986 and December 2007. Methods: Clinical records, including pathology reports and imaging studies, were reviewed. Main Outcome Measures: AJCC classification, histologic subtype, local recurrence rate, and survival. Results: AJCC classification at initial diagnosis was assessable for 53 patients and was as follows: T1N0M0, 7 patients; T2N0M0, 8 patients; T3aN0M0, 14 patients; T3aNxM0, 1 patient; T3aN0M1, 1 patient; T3bN0M0, 13 patients; T3bN0M1, 1 patient; T4aN0M0, 2 patients; T4bN0M0, 4 patients; T4bN0M1, 1 patient; and T4bNXM0, 1 patient. Thirty-eight (72%) of the 53 patients had >T3 tumors at presentation. Of the 38 patients with >T3 tumors, 20 were treated with orbital exenteration and postoperative adjuvant radiotherapy (RT), 6 were treated with orbital exenteration without RT, and 12 were treated with globe-preserving surgery (10 with RT and 2 without RT). Of the 15 patients with T3 tumors, the risk of local recurrence (in the orbit or skull base) was higher in patients treated with conservative surgery as opposed to orbital exenteration and RT. Only 4 (20%) of the 20 patients treated with orbital exenteration and RT had local recurrence, compared with 3 (50%) of the 6 patients treated with orbital exenteration without RT and 8 (67%) of the 12 patients treated with globe-preserving surgery. Overall, 17 (45%) of the 38 patients with >T3 tumors and only 1 (7%) of the 15 patients with T3 disease at initial diagnosis correlates with worse outcomes than does AJCC

Purpose: To report the outcome of oral chlorambucil as a single treatment in patients with orbital mucosa-associated lymphoid tissue (MALT) lymphoma. Design: Retrospective nonrandomized clinical study. Participants: Thirty-three patients with isolated orbital MALT lymphoma. Methods: Medical records of all patients with histology-verified orbital MALT lymphoma treated with oral chlorambucil at the Royal Melbourne Hospital were reviewed. Main Outcome Measures: Complete clinical response, partial response, local relapse, systemic extension (distant relapse), and survival. Results: Thirty-three patients (19 female; mean age, 69 years) participated in the study. Patients received an average of 4 courses of oral chlorambucil with a mean total dose of 600 mg. The lacrimal gland was the most frequent site of occurrence (24%), followed by the conjunctiva, eyelid, and superior orbit. Orbital mass, swelling, and diplopia were common presenting signs. Complete response was noted in 26 patients (79%). In 2 of the patients with complete clinical response, mild residual thickening was noted on follow-up orbital imaging studies. Four patients (12%) showed disease recurrence or relapse. Mean follow-up time was 32 (±20) months (range, 8 months–6 years; median, 26 months). None of the patients developed granulocytopenia secondary to chemotherapy, and none suffered significant nausea or vomiting. One patient with malignant transformation died 12 months after diagnosis and initial treatment. Conclusions: Systemic chemotherapy with chlorambucil is a reasonable option in patients with orbital MALT lymphoma. It is associated with minimal to no side effects. Additionally, it may be well tolerated by elderly patients and also may treat subclinical disease elsewhere. [Copyright &y& Elsevier]

Objective: To report the case of a 59-year-old man with a right lacrimal gland mass, subsequently diagnosed as primary ductal adenocarcinoma of the lacrimal gland. Design: Interventional case report. Methods: We report the clinical presentation, histopathologic and immunohistochemical features, and treatment of a patient with primary ductal adenocarcinoma of the lacrimal gland. The current literature regarding this uncommon neoplasm also is reviewed. Results: Excisional biopsy revealed primary ductal adenocarcinoma of the lacrimal gland. The patient subsequently underwent extensive local resection of the tumor and is awaiting radiotherapy to the orbit and neck. A literature search revealed only 3 prior reports of primary ductal adenocarcinoma of the lacrimal gland. Conclusions: Although uncommon, primary ductal adenocarcinoma of the lacrimal gland displays characteristic histologic and immunohistochemical findings that allow its distinction from the other primary lacrimal gland adenocarcinomas. Awareness and recognition of this rare malignancy may aid in further delineation of its biologic behavior, management, and prognosis. [Copyright &y& Elsevier]

Purpose: To review the clinical, radiologic, serologic, histopathologic, immunohistochemical, and molecular genetic features of patients having Sjögren’s syndrome (SS) with lacrimal gland enlargement. Design: Retrospective case series review. Participants: Fourteen patients histopathologically diagnosed with SS with lacrimal enlargement. Twenty-three age- and gender-matched controls were used for comparison on radiologic analysis. Methods: Clinical and serologic data were determined directly or by chart review. Computed tomography images from patients were compared with those from the control group. Histopathologic sections were reviewed and graded using the Chisholm-Mason scale, and quantitative immunohistochemical analysis was applied. Main Outcome Measures: Clinically, patients were assessed for age, gender, onset, symptoms and signs, systemic features, treatment, and outcome. Existing histologic specimens were reviewed according to the Chisholm-Mason scale, and then the percentages of plasma cells containing immunoglobulin (Ig) A, IgG, and IgM were determined. Imaging was assessed for lacrimal gland thickness, prolapse, density, and margin contour; extraocular muscle size; orbital tissue displacement; and proptosis. Results: Clinical and histopathological data fulfilled the revised American-European criteria for primary SS in 79% of patients. Compared with other large series of primary SS patients, similarities were found with age, xerophthalmia, parotidomegaly, and articular involvement. Differences included a lower incidence of autoantibodies, xerostomia, and extraglandular features and a higher male-to-female ratio. In almost all patients (93%), the percentage of plasma cells positive for IgA was less than 70%, consistent with SS. Compared with controls, the lacrimal glands were enlarged significantly (P<0.0001) and prolapsed (P<0.001). Involved glands had blurred margins (P<0.007), caused displacement of adjacent tissues (P = 0.03), and were associated with hyperdense fat (P = 0.007). Lymphocytic infiltration of orbital fat was present in all patients for whom fat biopsy results were available. Three patients had monoclonal infiltrates, and 1 patient experienced subsequent extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue type, 4 years after presentation. Conclusions: The criteria used to diagnose primary SS are controversial, but both diagnostic and quantitative immunohistochemical criteria suggest that these patients, with lacrimal gland enlargement resulting from lymphocytic infiltration, represent a new subtype of primary SS. This is clinically important in view of the increased risk of lymphoma associated with SS, compared with idiopathic nonspecific lacrimal inflammation. [Copyright &y& Elsevier]

Purpose: To clarify the relationship between the orbicularis oculi muscle, lacrimal canaliculus, and lacrimal sac and to propose a new theory of the lacrimal drainage system. Design: Dissection study. Participants: Sixteen Asian cadavers (29 upper eyelids). Methods: Gross dissections of the orbicularis oculi muscle in the medial canthus of 10 Asian cadavers were performed, and the relationship between the orbicularis oculi muscle, lacrimal canaliculus, and lacrimal sac was examined. The upper eyelids of the remaining 6 cadavers were dissected grossly, and sections of the lacrimal sac, common lacrimal canaliculus, and upper canaliculus were examined microscopically. The relationship between the lacrimal passage and its surrounding tissues also was examined. Results: The lacrimal canaliculus and sac both were divided into 2 distinct compartments in relation to the Horner''s muscle. The upper half of the lacrimal sac was related to the Horner''s muscle through the posterior branch of the medial canthal tendon and connective tissue, and the lower half was related to the capsulopalpebral fascia and orbital fat. The lateral part of the lacrimal canaliculus was covered with the Horner''s muscle. The medial part of the lacrimal canaliculus, namely the common lacrimal canaliculus, was not covered by the Horner''s muscle, but was covered by the preseptal and orbital parts of the orbicularis oculi muscle on the anterior surface. Conclusions: The lacrimal canaliculus and sac were divided into 2 distinct compartments by the Horner''s muscle, and it is possible that both contribute to the lacrimal drainage system. [Copyright &y& Elsevier]

Purpose: To evaluate patients with lacrimal dysgenesis.Design: Retrospective, nonrandomized, comparative case series.Participants: Fifty patients with lacrimal dysgenesis managed between 1992 and 2003.Testing/intervention: The diagnosis of lacrimal outflow dysgenesis was made based on the following criteria: absent or hypoplastic punctum, canaliculus, lacrimal sac, and nasolacrimal duct, appearing in isolation or combination. Our management algorithm included observation, punctoplasty with intubation, or open lacrimal surgery, with or without intubation.Main outcome measure: Success, partial success, or failure of treatment.Results: Lacrimal dysgenesis in our 50 patients (23 male and 27 female) involved 83 eyes, distributed as follows: proximal in 74 eyes (89%), distal in 27 (33%), and both in 18 (22%). Thirty (60%) patients presented with isolated lacrimal dysgenesis, and 20 (40%) presented with a systemic syndrome or dysmorphism. Thirty-three (66%) patients had bilateral involvement. Epiphora was the most common presenting symptom. Eighteen (36%) patients had a positive family history. Open lacrimal surgery was performed in a total of 29 (35%) of the 83 eyes: 25 had success, 3 had partial success, and 1 had failure.Conclusion: Both sporadic and hereditary forms of lacrimal outflow dysgenesis may present as an isolated finding or a part of a systemic syndrome or dysmorphism, occurring usually with bilateral involvement and presenting at a younger age in the setting of systemic anomalies. Proximal and distal lacrimal outflow systems may be involved with epiphora as the most common presenting symptom. The algorithm we have presented provides a systematic approach to the management of lacrimal outflow dysgenesis. [Copyright &y& Elsevier]

: PurposeTo report the success rate of endoscopically assisted balloon dacryoplasty (EADCP) for treatment of acquired incomplete nasolacrimal duct obstructions (NLDOs).: DesignRetrospective, noncomparative case series.: ParticipantsRecords of patients treated for incomplete NLDOs with EADCP by one of the authors (WLW) were reviewed. Diagnosis of incomplete NLDO was based upon subjective complaints of tearing, dye disappearance testing, clinical evidence of epiphora, and nasolacrimal duct irrigation. Endoscopically assisted balloon dacryoplasty was performed for incomplete obstructions identified.: MethodsOne hundred forty-two nasolacrimal systems in 103 patients with incomplete NLDOs underwent EADCP for treatment of incomplete obstructions. A 3×15-mm balloon was utilized in all procedures, with silicone lacrimal tubes placed in 131 systems. Patients received postoperative topical antibiotic–steroid drops for 2 weeks and a 1-week tapering dosage of systemic methylprednisolone.: Main outcome measuresPatients were assessed at their last postoperative visit by nasolacrimal system irrigation, dye disappearance testing, and subjective complaints of epiphora.: ResultsEighty systems (56%) experienced complete resolution of symptoms after surgery. Forty-eight additional systems (34%) showed improvement but still experienced periodic epiphora. Fourteen systems (10%) showed no improvement. The average time before follow-up was 7.5 months.: ConclusionEndoscopically assisted balloon dacryoplasty as a treatment for incomplete NLDOs provides complete relief or substantial improvement in a significant percentage of patients. Nasal videoendoscopy adds significantly to the understanding of this procedure and its potential for success. Endoscopically assisted balloon dacryoplasty should be considered an appropriate treatment option for selected patients with incomplete NLDOs. [Copyright &y& Elsevier]

: PurposeTo classify the periorbital deformities of adult orbitotemporal neurofibromatosis (NF) and describe new clinical findings, and to recommend guidelines for surgical treatment and management of surgical complications.: DesignRetrospective noncomparative case series.: ParticipantsThirty-three patients over age 16 with orbitotemporal NF.: MethodsRetrospective surgical case record and serial photographic review recording the laterality and the severity of periorbital involvement, the presence of complications from previous surgery, the surgical techniques undertaken, and the surgical outcome and complications.: Main outcome measuresComparison of preoperative and postoperative level of deformities.: ResultsNew classification of periorbital deformities: (1) brow ptosis, (2) upper lid infiltration with ptosis, (3) lower lid infiltration, (4) lateral canthal disinsertion, and (5) conjunctival and lacrimal gland infiltration. Two patients had bilateral and 31 patients (94%) had unilateral orbitotemporal NF. All patients had upper and 19 patients (58%) had lower lid involvement. Six (18%) patients had significant brow infiltration. Fourteen (42%) patients had a dropped lateral canthus requiring surgical reattachment, 28 (85%) required anterior levator resection for ptosis, and 28 (85%) had lid-debulking surgery. New findings included severe brow infiltration, lacrimal gland involvement, and functional nasolacrimal duct obstruction. Complications from previous surgery included residual ptosis, ptosis overcorrection, poor lid contour, dry eye, corneal exposure, and upper and lower lid entropion/ectropion.: ConclusionsThe periorbital appearance and comfort of patients with NF type 1 who have orbitotemporal NF can be significantly improved through oculoplastic surgery. [Copyright &y& Elsevier]

: PurposeTo report a patient with a cystadenocarcinoma of the lacrimal gland, a tumor not previously described in the ophthalmic literature. Salivary gland cystadenocarcinomas constitute a distinct group of epithelial malignancies characterized by an invasive, predominantly cystic pattern of growth that have an indolent behavior and a low incidence of metastases and recurrences.: DesignSingle interventional case report.: MethodsThe clinical findings, results of imaging studies, and pathologic findings are presented.: ResultsA 67-year-old man presented with a 5-year history of ptosis in the right upper eyelid. A lacrimal fossa tumor was found. The tumor was excised with an intact capsule, and the histopathologic diagnosis was primary cystadenocarcinoma of the lacrimal gland. The patient received no other form of treatment and has been observed for 1 year without evidence of recurrence or metastatic disease.: ConclusionsUntil recently, primary adenocarcinomas of the lacrimal gland were not further subclassified. Current knowledge gained from salivary gland tumors indicates that primary adenocarcinoma encompasses a group of tumors with separate morphologic features and varied biologic behavior. [Copyright &y& Elsevier]

: PurposeTo describe structural abnormalities of the lacrimal drainage system and outcomes after treatment for lacrimal outflow obstruction in children with Down’s syndrome.: DesignRetrospective comparative interventional case series.: ParticipantsThirty-eight eyes of 22 consecutive Down’s syndrome patients who underwent surgical treatment for nasolacrimal drainage obstruction (mean age, 32 months) and 59 eyes of 44 non–Down’s syndrome patients who underwent surgical treatment after 2 years of age.: Main outcome measuresResolution of symptoms after surgery and presence of anatomic abnormalities of the lacrimal drainage system other than persistent Hasner’s membrane.: ResultsAmong the Down’s syndrome eyes, complete or partial resolution was noted in 34 (89%) of 38 eyes; 7 (18%) eyes underwent more than 1 procedure. Twenty-eight (74%) of 38 eyes had anatomic anomalies other than persistent Hasner’s membrane; anomalies proximal to the nasolacrimal sac predominated. In comparison, 50 (85%) non–Down’s syndrome eyes experienced complete or partial resolution, and 19 (32%) had anatomic abnormalities other than persistent Hasner’s membrane; anomalies distal to the nasolacrimal sac predominated.: ConclusionsCompared with older non–Down’s syndrome patients, nasolacrimal outflow obstruction in Down’s syndrome patients is more often complicated by anomalies of the lacrimal drainage system proximal to the lacrimal sac. Despite this, surgery can be similarly successful. Awareness of the possible peculiarities of lacrimal outflow obstruction in Down’s syndrome patients may allow better selection and use of available treatment options. [Copyright &y& Elsevier]

: ObjectiveWe compared outcomes after dacryocystorhinostomies (DCRs) performed by the traditional external approach (EX-DCR) or by a nonlaser, nonendoscopic endonasal approach (EN-DCR).: DesignRetrospective, nonrandomized, comparative interventional case series.: ParticipantsA total of 354 consecutive cases of DCR were reviewed in 349 patients performed by one surgeon over a 4-year period with a minimum 1 year of follow-up using either EX-DCR or EN-DCR. Only patients with primary nasolacrimal duct obstruction and no eyelid, lacrimal sac, or canalicular pathology were included.: InterventionA total of 153 EX-DCR and 201 EN-DCR patients were identified. EX-DCR was performed under sterile conditions, and EN-DCR was performed with a clean setup. Silicone stents were placed for 3 months.: Main outcome measuresPatency of the lacrimal system as assessed by history and irrigation. Outcomes were graded as full success, partial success, or failure. Operative durations and postoperative complications were recorded from hospital charts.: ResultsThere was no significant difference in age or gender distribution between the two groups. The mean operative duration was 34.3 minutes for EX-DCR and 18.5 minutes for EN-DCR (P < 0.0001, t test). Full success was achieved in 90.2% of EX-DCRs and 89.1% of EN-DCRs. Partial success was recorded in 2.0% of EX-DCRs and 4.0% of EN-DCRs. The failure rate was 7.8% for EX-DCR and 7.0% for EN-DCR. There was no statistical significance between these outcomes with a two-sample test for equality of proportions with continuity correction (P = 0.914, power = 80% for α = 0.05 to detect a decreased success rate of 12%). Eleven of the failed cases in each group underwent revision EN-DCR surgery, with 90.9% success in each group. Epistaxis requiring perioperative nasal packing occurred in 7 (4.6%) EX-DCR patients and 11 (5.5%) EN-DCR patients. Wound complications in EX-DCR included bruising in four patients, localized infections in two patients, and punctal eversion in six patients. In EN-DCR, inadvertent incision of the periorbita occurred in five patients. One patient reported transient diplopia after the medial rectus was inadvertently pulled during an EN-DCR. Five patients had an EX-DCR on one side and an EN-DCR on the other side. All five reported retrospectively that they preferred the endonasal approach.: ConclusionsThe EN-DCR approach is more rapid than the traditional external approach, has an equivalent surgical success rate, and was preferred by patients who had alternative techniques performed on opposite sides. [Copyright &y& Elsevier]

: PurposeTo determine the efficacy of lacrimal balloon catheter dilatation in treating congenital nasolacrimal duct obstruction (CNLDO) as a primary procedure in children more than 18 months of age and in children who have failed lacrimal probing or silicone intubation.: DesignRetrospective, interventional case series.: ParticipantsFifty-nine patients, ranging in age from 15 months to 9 years (mean, 35.6 months), with 73 lacrimal systems diagnosed with CNLDO who underwent nasolacrimal balloon catheter dilatation. Thirty-four lacrimal systems (46.5%) had no previous procedures, whereas 39 lacrimal systems (53.5%) had failed probing, silicone intubation, or both.: InterventionBalloon catheter dilatation was performed following standard protocol, with a simplified regimen in most patients.: Main outcome measuresClinical patency of the nasolacrimal duct after balloon dilatation was the main outcome measure and was defined as complete resolution of signs and symptoms (crusting, discharge, and increased tear meniscus). Age, inferior turbinate infracture, and Downe’s syndrome as related to the main outcome measure were also analyzed.: ResultsOverall, 56 of the 73 lacrimal systems (76.7%) had complete resolution of symptoms. Twenty-seven of all 34 primary balloon catheter dilatations (79.4%) remained clinically patent, whereas 29 of all 39 secondary balloon catheter dilatations (74.4%) remained clinically patent after surgery (P = 0.8165). Thirty-nine of 47 lacrimal systems (82.9%) in children older than 24 months remained clinically patent, whereas 17 of 26 lacrimal systems (65.4%) in children younger than 24 months remained clinically patent (P = 0.1573). The mean age of patients with successful outcomes was 37 months, whereas the mean age of patients with failed balloon catheter dilatations was 32 months (P = 0.3924). In the secondary procedure group, analysis showed that the mean age of success (32 months) was greater than the mean age of failure (18 months; P = 0.0491). Within the secondary group, 16 of 17 lacrimal systems (94.1%) older than 24 months were successful, whereas 13 of 22 lacrimal systems (59.1%) younger than 24 months were successful (P = 0.0344).: ConclusionsBalloon catheter dilatation is an effective treatment for congenital nasolacrimal duct obstruction. In particular, balloon catheter dilatation in older children who failed previous probing is highly successful. [Copyright &y& Elsevier]