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A epífora, lacrimejamento excessivo, é uma queixa comum nos consultórios oftalmológicos, sendo a obstrução do ducto nasolacrimal a causa mais comum. A maioria dos casos de epífora tem origem desconhecida, de forma que a sua avaliação por exames de imagens se faz importante. A análise radiológica das vias lacrimais pode ser feita por ultrassonografia, dacriocintilografia, tomografia computadorizada, ressonância magnética e dacriocistografia, sendo esta última o método de imagem padrão ouro. Este ensaio iconográfico objetiva demonstrar casos de obstrução das vias lacrimais evidenciados pela dacriocistografia. Durante a dacriocistografia, o contraste é injetado sob alta pressão para preencher o sistema de drenagem lacrimal, permitindo localizar com precisão o ponto debstrução. As obstruções do sistema de drenagem lacrimal são mais comumente encontradas nos seus três estreitamentos anatômicos: as válvulas de Rosenmüller, de Krause e de Hasner. Por meio da dacriocistografia, pode-se definir de forma precisa o nível da obstrução, se alta ou baixa, sendo essa avaliação anatômica bastante útil para o planejamento cirúrgico terapêutico.

Introduction Endoscopic dacryocystorhinostomy aims to establish a patent nasolacrimal fistula. Use of silicone stent is a preferred modification to achieve long term patency of neo-ostium, though it has been blamed for granulations, synechia and punctal erosion. Present study was done to evaluate and compare the outcomes of Endoscopic dacryocystorhinostomy with and without stent. Materials and Methods 40 patients of with chronic dacryocystitis and nasolacrimal duct blockage were selected for the study. Nasal endoscopy was done for suitability of surgical access and to detect any nasal pathology. Sac syringing was done to assess the site of blockage and Dacryoscintigraphy to confirm it. 20 patients in Group A underwent Endoscopic dacryocystorhinostomy without stent and remaining 20 in Group B with silicone stent. Success rates were determined by subjective relief from epiphora and by endoscopic visualization of rhinostomy opening, granulation tissues/ synechiae at rhinostomy site and by result of sac syringing. Results In Group A, complete relief was obtained in 75% patients, significant relief in 10% and no relief in 15% patients thus recording overall success rate of 85%; whereas in Group B complete relief of symptom was obtained in 70% patients, significant relief in 10% and no symptom relief in 20% patients thus recording the overall success rate of 80%. Cases in Group B were also found to have persistent epiphora (17.5%), stenosis of ostium (25%), granulation (35%) and synechia (37.5%). Conclusion Stenting does not significantly improve the success of Endoscopic dacryocystorhinostomy but is associated with more complications.

Amaç: Bu çal›flmada lateral nazal duvar ve sinüs patolojilerinin distallakrimal kanal t›kan›kl›¤› etiyolojisindeki rolü araflt›r›lm›flt›r.Yöntem: Nisan 1999 ile Eylül 2003 tarihleri aras›nda endoskopikendonazal dakriosistorinostomi ve silikon entübasyonu planlanan 17kad›n ve 11 erkek hasta çal›flmaya dahil edildi. Hastalar›n lakrimal kanal t›kan›kl›¤› tan›s› için göz kliniklerinde Schirmer testi, flöreseinboya kaybolma testi, Jones I-II testleri, kanaliküler irrigasyon, kanaliküler problama, dakriosistografi, dakriosintigrafi gibi genel oftalmolojik muayeneleri yap›ld›. KBB kliniklerinde nazal kavite patolojileri için anterior rinoskopi ve diagnostik nazal endoskopik muayeneleri yap›ld›. Tüm hastalarda paranazal bilgisayarl› tomografi ile ostiomeatal kompleks hastal›¤›, etmoid hücre opasifikasyonu, konka bülloza, agger nazi hücresi varl›¤› de¤erlendirilerek 50 kontrol olgusundaki bulgular ile Fisher’in ki-kare testiyle karfl›laflt›r›ld›.Bulgular: Lakrimal kanal t›kan›kl›¤›n oldu¤u tarafta agger nazi hücresi 17 (%60.7), konka bülloza 10 (%35.7), etmoid hücre opasifikasyonu 6 (%21.4), osteomeatal kompleks hastal›¤› 4 (%14.2), bir veyadaha fazla bulgu 21 (%75) hastada saptand›. Bu lateral nazal duvar vesinüs patolojileri çal›flma grubunda kontrol grubuna oranla yüksekbulunmas›na karfl›l›k istatistiksel olarak anlaml› bulunmad›(p>0.05).Sonuç: Lateral nazal duvar ve sinüs patolojilerini distal nazolakrimalsistem t›kan›kl›¤› olan hastalarda yüksek oranda bulmam›za ra¤menetiyolojisini aç›klamakta yetersiz oldu¤u ve paranazal bilgisayarl› tomografinin bu hastalar›n de¤erlendirilmesinde artan öneme sahipolaca¤› kan›s›na vard›k., Objective: In this study, the role of lateral nasal wall and sinus pathologies in the etiology of distal lacrimal duct disease has been investigated.Methods: Seventeen female and 11 male patients who were scheduledfor endoscopic endonasal dacryocystorhinostomy and silicon tube intubation between April 1999 and September 2003 were included in the study.The patients underwent general ophthalmologic examinations such asSchirmer test, fluorescein dye disappearance test, Jones I-II tests, canalicular irrigation, canalicular probing, dacryocystography, dacryoscintigraphy for the diagnosis of lacrimal duct obstruction. In the clinics of ENT,for the detection of nasal cavity pathologies, anterior rhinoscopy anddiagnostic nasal endoscopic examinations were performed. All patientswere evaluated during paranasal computed tomographic examinationsregarding osteomeatal complex disease, ethmoid cell opacification, concha bullosa and presence of agger nasi cells and data obtained were compared with findings of 50 control subjects using Fisher’s chi-square tests.Results: On the side where lacrimal duct obstruction exists, agger nasicells were detected in 17 (60.7%) patients, concha bullosa in 10 (35.7%)patients, ethmoid cell opacification in 6 (21.4%) patients, osteomeatalcomplex disease in 4 (14.2%) patients, and one or more than one symptom were detected in 21 (75%) patients. Despite higher number of lateral nasal wall and sinus pathologies in the study group when comparedwith the control group, intergroup difference was not statistically significant (p>0.05).Conclusion: We have concluded that despite the higher rates of lateral nasal wall and sinus pathologies in patients with distal nasolacrimalsystem obstruction, its etiology has not been adequately expounded andparanasal computed tomographies will have increasing importance inthe evaluation of these patients.

Aim To measure the degree of physiological patency of the tear drainage system using dacryoscintigraphy before and after external dacryocystorhinostomy (EDCR) in relation to patient complaints.Methods Prospective evaluation of 29 eyes of 24 patients with primary acquired nasolacrimal duct obstruction (PANDO) who underwent EDCR. The epiphora complaints were measured subjectively. Dacryoscintigraphy was performed in all eyes preoperatively, and was repeated 6 months after DCR together with the complaints score. For evaluation of dacryoscintigraphy, we determined T1 (percentage of administered dose still present after 1 min) and linear clearance rate (LCR), defined as: 100%(T1-T15)/T1) from the tracer disappearance curve. Dacryoscintigraphy findings were compared with the results of 20 eyes of normal volunteers without any symptoms. Scintigraphic findings were compared before and after the operation, with the change in patient complaints score as well as with normal values.Results Significant improvement occurred after the operation in the complaints score, T1 and LCR. However, despite absence of complaints (score 0) postoperative scintigraphic values were still abnormal as compared to normal individuals.Conclusion Despite almost complete remission of epiphora complaints, DCR does not result in normalization of the tear drainage system.

To prospectively evaluate the surgical outcomes of membranous and solid distal common canalicular obstructions (CCOs) following endoscopic dacryocystorhinostomy (EnDCR) and lacrimal intubation combined with either membranotomy or trephination. This was a prospective, non-randomized, consecutive interventional case series. Inclusion criteria included patients undergoing EnDCR with evidence of a membranous block or more solid obstruction of the distal common canaliculus, treated with membranotomy or canalicular trephination. Complete CCO was confirmed pre-operatively using dacryocystography and dacryoscintigraphy. All patients received bicanalicular intubation for 3 months with a minimum follow-up of 12 months. Functional and anatomical success was assessed at 4 weeks, 3 months, and 12 months following surgery. Functional success was defined as subjective improvement of epiphora and anatomical success as the presence of a patent ostium and a positive dye test on nasal endoscopy. Twenty-nine patients were included in the study with a mean age of 58 years. Twenty-one patients (72%) received a membranotomy and eight (28%) required trephination. At 12 months, the functional and anatomical success rate in the membranotomy group was 90% (19/21) and 100% (21/21), respectively, and in trephination group the functional and anatomical success rate was 63% (5/8). There were no intra-operative or lacrimal stent-related complications. Identifying and excising distal CCOs in association with EnDCR and lacrimal intubation is associated with a high degree of functional (83%) and anatomical (90%) success. The success of membranous obstructions appear be superior to outcomes for solid obstructions of the distal common canaliculus that require trephination.

Purpose: To investigate the diagnostic effectiveness of dacryoscintigraphy in children with tearing; to evaluate tear clearance rate as a diagnostic factor of dacryoscintigraphy in children with tearing; and to analyze the results of treatment according to dacryoscintigraphic findings in children with tearing. Methods: Between January 2010 and April 2014, 176 eyes of 88 children with tearing (49 boys and 39 girls; mean age, 23.81 ±14.67 months; range, 12 to 72 months) were studied retrospectively. Of these, 37 of 88 children with tearing were bilateral cases, and 51 were unilateral cases. None of the patients had a history of craniofacial disorder or trauma. The chief complaint of tearing with or without eye discharge and delivery mode, past history of neonatal conjunctivitis, syringing, or probing were collected from parents, grandparents, or previous hospital data. The drainage pattern of the nasolacrimal duct was analyzed, and the clearance rate of 50 μCi 99m technetium pertechnetate was measured by dacryoscintigraphy. Results: According to the dacryoscintigraphy results, 98 of 125 eyes (78.4%) with tearing showed nasolacrimal obstruction and 29 of 51 eyes (56.9%) without tearing showed patency. There was a significant difference between tearing eyes and normal eyes (p = 0.001). The clearance rate difference after 3 and 30 minutes was 16.41 ± 15.37% in tearing eyes and 23.57 ±14.15% in normal eyes. There was a significant difference between epiphoric eyes and normal eyes (p = 0.05). Based on the dacryoscintigraphic findings, nasolacrimal-duct obstruction was treated with probing or silicone-tube intubation. The majority of patients showed symptom improvement (75.2%) during the two months of follow-up. Conclusions: Dacryoscintigraphy is a non-invasive method of qualitatively and quantitatively diagnosing nasolacrimal duct obstruction in children with tearing.

AIM It appears from the literature that no standardised examination exists for patients with functional nasolacrimal duct obstruction. The role of dacryocystography and lacrimal scintigraphy was compared in the diagnosis and management of these patients. METHOD Patients who were clinically diagnosed as having unilateral or bilateral functional nasolacrimal duct obstruction were prospectively entered into the study and data collected over 12 months in Moorfields Eye Hospital and Whipps Cross Hospital, London. All cases had, on separate occasions, a standardised dacryocystogram with delayed erect films and a lacrimal drainage scintigram. RESULTS 45 lacrimal systems of 32 patients (mean age 62 years; 59% male) fulfilled the inclusion criteria. Abnormalities were detected with dacryocystography in 93% of systems and with lacrimal drainage scintigraphy in 95% of systems. Based on the results of previous quantitative studies, the positive scintigrams were subdivided into those demonstrating prelacrimal sac delay (13%), delay at the lacrimal sac/duct junction (35%), or delay within the duct (47%). Combining the two imaging techniques increased the sensitivity to 98%. CONCLUSIONS Both investigations are very sensitive at detecting abnormalities in patients with a clinical diagnosis of functional nasolacrimal duct obstruction. Lacrimal drainage scintigraphy is a slightly more sensitive test, but missed an abnormality detected by dacryocystography in two (4%) systems. A combination of the two techniques gives the highest sensitivity with maximum anatomical and physiological information but, in clinical practice, it is reasonable to perform a dacryocystogram initially and proceed to scintigraphy only if contrast radiography is normal.

Purpose: To evaluate the clinical manifestations of tear production, distribution and drainage in the essential blepharospasm patients, and to analyse the changes after botulinum toxin A injection in these patients. Methods: This prospective study was performed in 23 patients with essential blepharospasm treated with Botulinum neurotoxin A (BoNT-A; Dysport, Ipsen Biopharm, UK) from November 2010 to February 2011. Ocular examinations, including frequency and severity of blepharospasm, tear break up time (BUT), Schirmer’s test, lower lid tear meniscus height (TMH) measured by optical coherence tomography (OCT, rtvue software version 3.5; Optovue Inc., Fremont, CA, USA), and dacryoscintigraphy using 99m technetium pertechnetate, were performed before and 2 weeks after BoNT-A injection. We asked all patients about changes in the dry eye symptom score, before and after treatment. Results were analysed with independent t-test using spss software version 12.0 for Windows XP, (SPSS Inc., Chicago, IL, USA). Results: Botulinum neurotoxin A treatment relieved blepharospasm in all patients. Mean injection dose was 38 ± 5.6 units. After injection, mean tear BUT was significantly increased from 4.7 ± 4.9 to 6.6 ± 1.6 seconds (p = 0.001) Lower TMH increased in all three points and most notably at the lateral point (p = 0.05). On dacryoscintigraphy, tear drainage velocity was not affected by BoNT-A treatment. But Tc-99m 50% clearance time in interpalpebral fissure significantly increased from 1564 to 2220 seconds on the time activity curve (p = 0.027). Subjective dry eye symptoms also improved in 16 patients (70%) after injection. Conclusion: Tear film stability and TMH increased, but tear drainage velocity was not affected by BoNT-A treatment. Overall Tc-99m 50% clearance time in interpalpebral fissure significantly increased, and tear storage from mild lateral lower eyelid laxity increased after BoNT-A injection. Botulinum neurotoxin A injection was also effective for combined dry eye symptom in the essential blepharospasm patients.

Purpose: To analyze the histopathological results of lacrimal sac biopsies in primary acquired nasolacrimal canal obstruction. Methods: 150 consecutive patients who were diagnosed as primary acquired nasolacrimal canal obstruction were included in this prospective non-comparative study. Previous history of trauma and surgery to the periorbital area was accepted as exclusion criteria. Patients were evaluated for age, gender, history, and presenting symptoms. Lacrimal drainage system abnormalities were assessed. Lacrimal system irrigation, dacryocystography, and in selected cases dacryoscintigraphy was performed. All patients underwent external dacryocystorhinostomy. Biopsy specimens were obtained from the posterior inferior flap and examined by the same pathologist. Results: The results of 27 male and 123 females with age ranging from 6 to 80 years (mean 47.7 ± 15.8 years) were analyzed. None of the patients had preexisting history of systemic disease. Ninteen patients had grossly abnormal or infectious appearing sac at the time of surgery. Of these, one patient had granulomatous inflammation of the lacrimal sac and was diagnosed with sarcoidosis during postoperative examination. One patient with normal appearing sac had basosquamous cell carcinoma and underwent dacryocystectomy. The remaining specimens showed chronic inflammation (n= 124), fibrosis (n= 19), normal mucosa (n= 4), or lymphoid hyperplasia (n= 1). Conclusions: Pathological examination of the lacrimal sac in primary nasolacrimal canal obstruction revealed chronic inflammatory changes in most of the patients. Although rare, granulomatous inflammation or tumour of the lacrimal sac might be observed in such cases. We recommend to biopsy all cases with nasolacrimal canal obstruction.

Purpose: Dacryoscintigraphy is widely known to be an effective modality in diagnosing abnormalities of the lacrimal system that cause epiphora (pathological overflow of tear). However, dacryoscintigraphy rarely serves beyond the simple diagnostic use for lacrimal duct obstruction. In our study, dacryoscintigraphy results of patients with functional lacrimal duct obstruction are newly classified into three types, the effects and prognoses of silicone tube intubation are noted according to each type, and the role of dacryoscintigraphy in determining appropriate surgical approaches is evaluated.Methods: Subjects were 36 eyes of 29 patients complaining of epiphora who had increased tear meniscus, but showed no sign of obstruction on duct syringing. Impression of functional lacrimal duct obstruction was made through dacryoscintigraphy, and silicone tubes were inserted.Results: Patients were classified according to the results of dacryoscintigraphy; those with delayed secretion in the distal nasolacrimal duct were typed as class I; those with delays in the proximal nasolacrimal duct class II; and delayed secretion from the pre-lacrimal sac to the lacrimal sac as class III. All patients had silicone tube intubations together with selective punctoplasty. Symptomatic improvement was observed in all 6 cases of distal nasolacrimal duct obstruction (100%), 14 of 18 proximal obstruction cases (77.8%), and 8 of 12 pre-lacrimal obstructions (66.7%).Conclusions: Functional lacrimal duct obstruction is easily diagnosed with dacryoscintigraphy. Furthermore, its may be classified by types of obstruction to predict post-operative results of silicone tube insertion. Cases suspicious of pre-lacrimal sac obstructions in particular may achieve better operative results with adjuvant treatments in addition to silicone tube insertion.

Aim : To study the effectiveness of the two procedures Dacrocystography and Dacryoscintigraphy for diag- nosing of blockage of Nasolacrimal Duct system. Methods and Material : The prospective study included 33 patients with 40 eyes and was carried out for 1 year at our ter- tiary care teaching hospital. Patient with unilateral/bilateral epiphora were selected for both the tests after screening them for nasolacrimal duct system block by sac syringing. Other causes of epiphora were excluded. Nuclear scintigraphy using technetium 99 DTPA was performed followed by dacrocystography using water soluble dye in all patients. Results: Scintigraphy showed 92.68% positive results and 7.31 % negative (false negative) for the block and dacrocystogra- phy gave 78.04% positive and 21.95 % negative(false negative). Conclusion: Nuclear scintigraphy can be used effectively as a valuable diagnostic tool for diagnosing functional and mechanical obstruction in patients before doing a Dacrocystorhinostomy and can be used as first line of investigation for diagnosis. Introduction: Tearing process was first studied with radioisotopes in 1973. Epiphora is the presenting complaint of patients with block- age of nasolacrimal duct system. Both ophthalmologists and otorhinolaryngologists deal with the diagnosis and treatment of nasolacrimal duct block. The surgical intervention is a Dac- rocystorhinostomy in case of nasolacrimal duct block, done endoscopically by an Otorhinolaryngologist and externally by an ophthalmologist. There are various tests performed to diagnose the level of nasolacrimal duct block such as fluorescien dye test, dacro - cystography, nuclear lacrimal scintigraphy , CTscan and MRI. It is not necessary to conduct the whole battery of tests to diagnose the level of Nasolacrimal duct system block. Clini- cally reflux from same punctum or opposite punctum on sac syringing indicates blockage of nasolacrimal duct system. Dacrocystography gives anatomical orientation of the nasol- acrimal duct system whereas scintigraphy shows the 'func- tional integrity' of the nasolacrimal duct system. In our study we have attempted to study the effectivity of the following procedures sac syringing, dacrocystography and dacroscintigraphy in diagnosing correctly the condition of nasolacrimal duct blockage and thus treat patient effectively. Material and methods: Ours was a prospective study of one year involving 33 pa- tients who attended the ENT OPD in a tertiary care hospital with the complaint of watering of eyes (unilateral / bilateral). Inclusion criteria: Patients with epiphora with normal lid posi- tion and no other ocular disease were included in the study. The study also included patients with congenital dacrocys- titis. Patient with failure of dacrocystorhinostomy surgery were also included. Exclusion criteria: Patient with ectropion, other ocular conditions resulting in epiphora and pregnant females were excluded.

Lacrimal scintigraphy (LS) was performed in 860 lacrimal drainage systems (LDS) in 188 patients with bilateral epiphora and 226 patients with unilateral epiphora. A very high incidence of canalicular obstruction was found in these patients, the incidence being higher in the group with unilateral epiphora. It is suggested that a canalicular block is a commoner cause of obstructive epiphora than has been recognised previously and that LS is a reliable method of studying the canalicular function. A significant number (42%) of the opposite asymptomatic eyes of patients with unilateral epiphora were found to have an abnormality in the LDS, which supports the view that abnormalities in the LDS tend to be bilateral. Only 25% of these asymptomatic systems showed a normal drainage, confirming that physiological obstruction can exist below the lacrimal sac in normal lacrimal drainage systems.

Quantitative lacrimal scintillography, using 99mTc sulphur colloid, a high resolution gamma camera, and quantification using a digital computer, is a highly effective way of assessing lacrimal physiology, and of establishing normal flow and drainage values against which pathological cases may be compared.

Epiphora is commonly caused by a relative or complete occlusion in the lacrimal drainage system (LDS), principally a nasolacrimal duct obstruction (NLDO). Dacryoscintigraphy (DSG), an extensively assessed imaging technique in diagnosing its abnormalities, can provide only planar images, according to which it needs to be improved. Our aim was to evaluate clinical utility of simultaneous DSG and single-photon emission computed tomography/computed tomography (SPECT/CT) combined with computed tomographic dacryocystography (CT-DCG) in the evaluation of LDS. Dynamic imaging with DSG was performed, and tracer radioactivity was detected by a gamma camera. Successively, SPECT/CT images of the involved region were gained, followed by CT-DCG, during which a contrast medium was syringed into the affected LDS, and finally contrast CT scans were obtained again from the same region. Fifty-seven patients, mean age 54.25 (± 18.26) years all with unilateral NLDO and 32 control subjects, all with patent LDS, mean age 49.88 (± 18.61) years were evaluated in the study. Delayed outflow of tearing eyes was exposed to DSG compared to the fellow and control eyes. The highest value for sensitivity was observed for SPECT/CT, followed by CT-DCG and DSG techniques, while combining DSG with SPECT/CT, DSG with CT-DCG, and SPECT/CT with CT-DCG, the sensitivity increased to 96.49%, 92.98%, and 94.73%, respectively. Although DSG is a sensitive nuclear medicine method, it only provides useful clinical data when simultaneously supplemented with SPECT/CT and CT-DCG trials as they jointly can offer valuable information about the localization of an abnormality and verify stenosis or obstruction.