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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.

Purpose To investigate whether impaired lacrimal pump function is a possible cause of discharge in patients wearing an artificial eye compared with the remaining healthy eye. Methods Consecutive patients wearing unilateral ocular prosthesis for ≥6 months were included in this retrospective study. Excluded were any deformities of eyelids or nasal passage, socket complications such as entropion, ectropion, ptosis, infection, pyogenic granuloma, contracted socket, obstruction of nasolacrimal duct diagnosed with lacrimal irrigation and a difference greater than 2 mm in terms of protrusion between two eyes detected by Hertel exophthalmometry. Patients were asked to score the levels of tearing and mucopurulent discharge between 0 and 5 to assess lacrimal drainage function subjectively. Furthermore, dacryoscintigraphy was performed to assess the functional status of the lacrimal system objectively. Results Included were 32 subjects (12 females, 20 males; aged 32.94 ± 17.62, range 13-78). Mean duration of prosthetic wearing 26.41 ± 21.30 (6-72) months. The mean subjective scores of tearing and mucopurulent discharge were 1.56 ± 1.67 and 1.94 ± 1.63, respectively. The rate of functional stenosis was significantly higher in the anophthalmic socket side as compared to the healthy side (P = 0.002). The rates of a presac, preduct, and intraduct obstruction was notes as n = 9, n = 10, n = 1 and n = 0, n = 6, n = 2 in the anophthalmic side and the companion eye, respectively (P = 0.021). Conclusion Compared to paired healthy eyes, the ocular prosthesis exhibited significantly higher rates of functional lacrimal duct obstruction, especially at the presac level. The alterations in orbital volume and tear film composition in addition to reduced corneal reflex blinking may lead to the failure of lacrimal pump function in artificial eyes.

Introduction: Epiphora in the presence of patent lacrimal system (functional epiphora) has remained one of the complex lacrimal problems. There is a lack of consensus regarding its diagnostic crite...

To evaluate the clinical usefulness of the dacryoscintigraphy in patients with nasolacrimal duct obstruction prior to endoscopic dacryocystorhinostomy. One hundred thirty-five lacrimal views of endoscopic dacryocystorhinostomy (DCR) with a single surgeon for primary nasolacrimal duct obstruction (PANDO) were included. These were assigned into three groups according to the type of dacryoscintigraphy. Group 1 was a pre-sac obstruction pattern. Group 2 was an intra-sac obstruction pattern. Group 3 was post-sac obstruction pattern. Each group was evaluated for an anatomical and functional surgical success, presence of complications including granuloma, synechiae, and tube-induced inflammation at least 12 months after the surgery. Both anatomical and functional success rate showed no significant difference among the three groups (P = .297 and .472 linear by linear association). Functional failure rate (functional failure/total failure) also showed no clinically significant differences between groups. Logistic regression analysis was performed to determine the factors associated with functional success. There were no statistically significant factors in age, sex, scintigraphy type, pre-operative endoscopic grade, post-operative granuloma, and synechiae. In patients with nasolacrimal duct obstruction, preoperative evaluation of obstruction level using dacryoscintigraphy may be not useful for predicting the functional success of the endoscopic dacryocystorhinostomy.

The purpose of this study was to evaluate the correlation between the lacrimal syringing test (LST) and dacryoscintigraphy (DSG) in patients with epiphora. The authors retrospectively reviewed the clinical records of patients who underwent both LST and DSG from March 2016 to February 2018. From this, 636 eyes of 336 patients with a mean age of 61.20 ± 11.93 years (range, 22-86 years) were included. The concordance rate between LST and DSG was 43.7% (278 eyes). The sensitivity of DSG was 68.78%, and specificity was 30.99%. Factors of age and sex were analyzed in terms of concordance. The authors categorized age into 2 groups of younger and older than 65 years. Only sex was found to affect the results, with a much higher concordance rate in the female group than the male group. The lack of correlation between the tests indicates that the LST and DSG methods are complementary to each other. There is no single reliable method for testing patency of the lacrimal drainage system. Therefore, physicians should refer to these tests as complementary in a clinic setting.

A 20-year-old female patient was presented with a bilateral epiphora. She had no history of infection or trauma related to the sinus areas. On examination, her facial appearance was abnormal and fullness on the face was observed. The fluorescein dye disappearance test was positive in both eyes. The lacrimal system irrigation was patent nasolacrimal duct. However, the dacryoscintigraphy imaging scan demonstrated bilateral obstruction at the nasolacrimal duct-inferior meatus junction. Nasal endoscopy did not reveal any pathologic findings, and lateral nasal wall, septum, and nasal cavities were normal. The patient was referred to the radiology department for a computed tomography of the paranasal sinus as a preoperative diagnostic imaging for lacrimal intervention. Computed tomography revealed the absence of all paranasal sinuses on both sides as well as absence of the ostiomeatal complex and ethmoidal air cells. Both bony lacrimal canal was narrow. Epiphora may be initial sign of total paranasal sinus aplasia.

Several methods are available to examine the function and morphology of the lacrimal drainage system under physiological conditions. Radionuclide scintigraphy is a sensitive method that is not cumbersome for the patient. Dacryoscintigraphy was first introduced by Rossomondo et al. in 1972 [1]. Since then the method has been modified by several groups and its significance supported by numerous studies. Indications of dacryoscintigraphy are obstructive disorders of the lacrimal drainage system. The method is helpful in the diagnosis of tear flow disturbances and in the follow-up for the detection of therapy response [2, 3].

Importance This study assesses the interobserver agreement on dacryocystography (DCG) and dacryoscintigraphy (DSG) findings. Background There are no standard grading criteria to guide the interpretation of conventional DCG and DSG findings and therefore there may be a degree of subjectivity. This study evaluates the level of interobserver agreement in the interpretation of DCG and DSG findings. Design A retrospective observational study at the Royal Adelaide Hospital. Participants A total of 165 patients who presented with epiphora with 276 DCGs and 290 DSGs performed were included in this study. Methods DCG and DSG images were obtained, anonymized, randomized and interpreted by three independent oculoplastic surgeons. Standard grading criteria were set for both DCG and DSG images. Data from all observers were analysed for interobserver agreement using Kappa (κ) statistics, generated using a variation of Cohen's kappa for multiple observers. Main outcome measures Level of interobserver agreement (κ values) in the grading of DCG and DSG findings. Results There was an overall moderate interobserver agreement for DCG findings (κ = 0.55), with the highest agreement on interpreting canalicular obstruction (κ = 0.80), followed by proximal nasolacrimal duct obstruction (κ = 0.67) and normal patency (κ = 0.63). There was an overall fair interobserver agreement for DSG findings (κ = 0.36), with the best being moderate agreement (κ = 0.42-0.50) for interpreting pre-sac delay and post-sac proximal delay. Conclusions and relevance DCG offers good reliability in interpreting patent and obstructed systems. On the other hand, DSG has poor agreement and highlights some of the limitations in the ability to guide epiphora management.

When examining the position of the eyelids, it is essential to check the position of the eyebrows. Measuring the extent of proptosis and the difference between the two eyes can be used to differentiate between diseases causing proptosis. The unilateral proptosis indicates an intraorbital disease, while bilateral proptosis indicates a systemic disease. When the cause of epiphora is examined by slit lamp examination, digital compression of the lacrimal sac, fluorescein retention test, lacrimal duct irrigation, probing, dacryocystography, and dacryoscintigraphy.

The lacrimal drainage system is a mucous membrane-lined duct whose function results from the interplay of anatomy and physiology. The presence of epiphora depends on the balance between tear production and tear drainage, not the absolute status of either. No single evaluation test will localize the anatomic site of blockage or the physiologic basis for the imbalance between tear production and tear drainage. A detailed combination of external examination and one or more clinical tests will usually uncover the correct etiology of drainage dysfunction. In some difficult cases, imaging techniques will enhance the reliability of the diagnosis and permit an appropriate management strategy. The most common clinical tests include the dye disappearance test, the Schirmer test, and the Jones I and II tests. The most useful imaging techniques are dacryocystography, dacryoscintigraphy, CT and MRI scans, and ultrasonography.

Purpose To measure tear clearance values in patients with meibomian gland dysfunction (MGD) with a dynamic nuclear medicine method, namely, dacryoscintigraphy (DSCI). Methods Twenty-four MGD patients and 24 healthy volunteers were examined. During DSCI one drop of a solution with 100 MBq/mL99mTc sodium pertechnetate was instilled with a micropipette into the lacrimal lake of both eyes. Measurements were performed according to a dynamic data acquisition protocol, which resulted in summed DSCI images. Data were also evaluated separately in special regions of interest (ROI), and consecutive time activity curves were created. Tear clearance (T½) values were calculated based on the activity curves. In addition, tear osmolarity measurements, tear breakup time (tBUT), and Schirmer I (STI) tests were performed prior to DSCI examination. Results The T½ values were 29.91 ± 11.61 min in MGD patients and 6.26 ± 1.5 min in healthy controls. Tear osmolarity parameters were 308 ± 9.41 mOsm/L and 288.9 ± 6.4 mOsm/L, tBUT values were 5.54 ± 2.73 s and 11.4 ± 2.7 s, while the STI test values were 6.17 ± 2.78 mm and 13.58 ± 3.8 mm, respectively. The differences were significant (p Conclusions Although the MGD patients’ lacrimal drainage systems were patent their tear clearance values were significantly higher than those of healthy volunteers, which may be caused by decreased drainage of tears from the eyes towards the nasal cavity. The understanding of new features regarding the altered physico-chemical characteristics of MGD tears has been augmented by the results of this study.

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.

Background. To provide new and to summarize published data on endolacrimal surgery with Piffarettiʼs trephines, in particular in patients having patent lacrimal drainage system (syringing) and epiphora resistant to medical treatments. Patients and Methods. From two tertiary referral centers (Basel/Switzerland; Belo Horizonte/Brazil), 126 patients undergoing endolacrimal surgery with Piffarettiʼs trephines, combined, when clinically indicated, with other procedures known to improve epiphora (canthoplasty/pexie and/or conjunctivochalasisplasty). Results. I) A study (Basel) in 17 patients showed one-year after surgery marked epiphora symptomsʼ improvement in 88 % (15/17) of patients, 65 % (11/17) being symptom-free. II) Unpublished data (Belo Horizonte) in 42 patients found 81 % (34/42) symptom-free six-months after surgery. Dacryoscintigraphy illustrated postoperative tearsʼ clearance improvement. III) Unpublished data (Belo Horizonte) in 45 patients solely undergoing endolacrimal surgery for complete ductal obstruction found symptom-free, six-months after surgery, 27 % (8/30) of patients with preoperatively enlarged lacrimal sac and 80 % (12/15) with none-enlarged sac (p 6 mm had similar mean postoperative symptomsʼ improvement (82 ± 30 %, n = 11 vs. 76 ± 34 %, n = 11, p = 0.97, Mann-Whitney). Conclusions. Endolacrimal surgery with Piffarettiʼs trephines, sometimes combined, when clinically indicated, with other procedures also known to ameliorate epiphora, can in particular improve (different conditions, surgeons, centers) epiphoraʼs symptoms resistant to medical treatments in patients with patent lacrimal drainage system, and this apparently, even when pre-operative basal Schirmer-test values are low. By enlarged lacrimal sac, outcome is poor.

Epiphora is a common problem seen by the ophthalmologist. There are numerous etiologies of a watering eye, and the underlying diagnosis is not always clear. A variety of in-office examination techniques and procedures exist to aid with diagnosis and determination of appropriate therapy, but sometimes the diagnosis remains elusive, or an instituted therapy fails. Lacrimal imaging, particularly in these cases, can be helpful in assessing the function and anatomy of the lacrimal drainage system. This review serves to examine the literature of the last 10 years concerning imaging of the lacrimal drainage system.

Lacrimal scintigraphy (LS) or dacryoscintigraphy can demonstrate abnormalities in 80%-95% of patients with symptoms of epiphora and a patent lacrimal system on syringing and up to 40% asymptomatic individuals. Precise localization of the site of delay may not always be possible due to lack of anatomic detail on LS. LS is considered useful in patients with epiphora with delayed tear clearance and patency to syringing and suspected to have either nasolacrimal duct (NLD) stenosis or lacrimal pump failure. It remains unclear, however, as to whether LS can reliably distinguish between the two. The literature reports considerable variation in the technique, normative data, analysis, and interpretation of LS. Qualitative or visual analysis is simpler to perform and to our knowledge used more frequently in comparison to quantitative analysis. There is little extra information to be gained from LS in cases with complete NLD obstruction or severe NLD stenosis on syringing.

We reported a 6-year-old girl with a history of left-eye epiphora since 2 years ago who was referred to our nuclear medicine center for dacryoscintigraphy imaging. The scan showed obstruction in the proximal portion of the nasolacrimal duct in the left eye. Imaging also showed patent nasolacrimal duct of the right eye. Tc pertechnetate activity was seen in the esophagus and stomach owing to swallowing of the excreted tracer in the nasal cavity. This was an unequivocal sign of patent lacrimal apparatus.

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.

To study the discriminatory ability of dacryoscintigraphy in differentiating between patients with epiphora and volunteers using a simple method. Twenty eyes in ten volunteers and 66 eyes in 55 patients with severe epiphora were studied. Dacryoscintigraphy (15 frames of 1 min) was performed after administration of 4 MBq 99mTc-pertechnetate (10 μl) in both eyes. By mapping a single region of interest (ROI) over the conjunctival sac we determined T1 (%dose in first minute) and linear clearance rate (LCR, defined as $$100\% {\left( {T1 - T15} \right)}/T1$$ from the tracer disappearance curve. Reproducibility was determined in volunteers. Conjunctival resorption was determined from completely obstructed systems. Sensitivity and specificity were calculated and receiver operating characteristics (ROC) analysis was conducted. In volunteers mean T1 was 52.8±11.9% (95% CI 47.1–58.4%), and LCR was 74.2±11.1% (95% CI 69.0–79.4%). Reproducibility was good (mean difference 4.1±13.3% for T1 and 0.7±17% for LCR). Epiphora patients had clearly higher T1 (82.1±15.2%, P

Purpose: To evaluate the results of endoscopic transnasal dacryocystorhinostomy (ETDCR) combined with bicanalicular silicone tube intubation (BSTI) performed in 49 patients with nasolacrimal canal obstructions secondary to chronic dacryocystitis. Material and Methods: ETDCR combined with BSTI was applied as a primary procedure in 47 cases, and as a secondary procedure in 2 cases. All patients underwent dacryocystography, and 41 patients underwent radionuclide dacryoscintigraphy before the surgery. Silicone tubes were left in place for about 6.2 months. The patency of the lacrimal passages was controlled with a clinical examination, nasolacrimal canal lavage, and dacryoscintigraphy. Results: Patients were followed up for a mean period of 25.1 months after the removal of the tubes. The epiphora symptom disappeared and a successful drainage could be maintained in 43 out of 49 cases (87.7%). The obstruction rate found in the dacryoscintigraphy performed 15 days after extubation was 22.9%, while it was found to be 14.2% in the nasolacrimal canal lavage. Conclusion: ETDCR combined with BSTI proved to be an effective surgical method in chronic dacryocystitis. The sensitivity and specificity of the postoperative dacryoscintigraphy in determining the surgical success were lower than those of the nasolacrimal canal lavage.

Purpose: The purpose of the study was to evaluate the functional success rates using dacryoscintigraphy (DSG) after transcanalicular diode laser dacryocystorhinostomy (TDL-DCR). Methods: In this retrospective study, we investigated the records of 56 patients who underwent TDL-DCR for unilateral primary acquired nasolacrimal duct obstruction and anatomic patency was achieved. The lacrimal drainage systems of the other eyes of the patients were normal and were selected as control group. The functional success was evaluated with tear transit time (TT) on DSG and epiphora complaints’ score (ECS) at postoperative 6 months. Results: Twenty-two (39%) of the patients were male and 34 (61%) were female, with a mean age of 46.6 (21–64). The dacryoscintigraphic findings of the operated and healthy eyes showed that there was statistically insignificant prolongation in the tear TT at the operated side at postoperative 6th month (P > 0.05). The mean ECS of operated eyes was 0.89. Functional success was achieved in 43 (76.8%) patients when the ECS of 0 and 1 was accepted as successful. A statistically significant delay in drainage was observed in DSG in all of the cases with epiphora score of 2 and 3 (P < 0.05). The tear TT was prolonged with the age increase (P < 0.05), but there was no significant difference concerning the gender. Conclusion: DSG is an effective tool to evaluate the functional success of TDL-DCR.

Obstruction of the lacrimal drainage system requires careful clinical and sometimes radiographic evaluation to determine the etiology. The site of obstruction, anywhere from the puncta to the nasolacrimal ostium in the inferior nasal meatus must be accurately determined in order to offer appropriate management. Tearing symptoms can also result from, or be exacerbated by, dysfunction of the tear drainage pump mechanism due to eyelid laxity or punctal dystopia. This chapter reviews the various clinical, ultrasound, X-ray, CT, and MRI studies that can help determine the causes of epiphora and guide the clinician toward an appropriate therapeutic plan.

Disorders of the lacrimal system are not uncommon. The spectrum of disease varies from congenital absence or aberrant anlage to acquired stenosis and obstructions of adult onset. Primary acquired nasolacrimal duct obstruction with associated infection is relatively common, whereas certain other disorders such as primary sac and duct tumors are very rare. Radiologic evaluation of the lacrimal system has evolved over the past decades to include a variety of studies ranging from plain dacryocystography (Fig. 10.1) to digital subtraction dacryocystography (DCG), nuclear medicine isotope studies (dacryoscintigraphy (DSG)), lacrimal ultrasonography (USG), computed tomography (CT), combined CT-DCG, and magnetic resonance imaging DCG (MR-DCG) [1]. Technological advances and enhanced imaging processing has allowed development of techniques that provide three-dimensional visualization of the nasolacrimal duct system.

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.

Current dacryoscintigraphy methods have several potential pitfalls, the most important of which is the outflow of tears. Another is the difficulty in fixing the head with the patient seated. To overcome these difficulties, a new method was applied.The study included 77 persons: 43 controls and 34 patients with epiphora. Two methods were applied to the two groups. In the first, protocol 1 (the current conventional protocol), the patient was seated in front of a gamma camera and one drop (50 microl) Tc-99m pertechnetate containing 50 to 100 microCi radioactivity was instilled in the inferior fornix or outer canthus of the eye and dynamic and static images were obtained for approximately 15 to 20 minutes. In the other, protocol 2 (our protocol), 100 microCi (10 microl) Tc-99m pertechnetate was instilled in the outer canthus of the eye using a micropipette with the patient in the supine position under the gamma camera. Dynamic images were taken for only 5 minutes.The pitfalls and difficulties seen with protocol 1 were lessened to a great degree in protocol 2.

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.

BACKGROUND Paranasal sinus infections and nasolacrimal duct obstructions are commonly encountered problems. However the relationship between these two conditions is not yet clear. Trauma, surgery, tumors, and systemic diseases are among the causes of acquired nasolacrimal duct obstructions but most of the cases are idiopathic. In this study patients diagnosed with chronic paranasal sinus infection were examined with 99mTc lacrimal dacryoscintigraphy to assess their nasolacrimal duct function. METHODS Twenty-four patients diagnosed with chronic paranasal sinus infection are included in the study. These patients were observed for at least three months awaiting surgical treatment following unsuccessful medical treatment. The control group included 16 persons admitted to the ophthalmology department without any nasolacrimal duct disease. Nasal endoscopy and paranasal sinus CT revealed normal findings. The age of the patients with chronic paranasal sinus infection and examined in regard to nasolacrimal duct function was between 15 to 17 with a mean age of 34.2 years. Fourteen patients were male and 10 patients were female. The control group included 9 male and 7 female patients between 18 to 60 years with a mean of 30.5 years. RESULTS The dacryoscintigraphic examination of 48 nasolacrimal ducts in 24 patients with chronic paranasal sinus infection revealed 7 complete and 18 partial obstructions of the duct, and 23 normal findings. In the control group with 32 nasolacrimal ducts of 16 patients, there was no complete obstruction. Partial obstruction (10.6, 12.0, 14.7 minutes) was be observed in three cases. The statistical workup resulted in a significant difference between paranasal sinus patients and control group (x2 = 15,840 p < 0.001). The paranasal sinus CTs of the patients with paranasal sinus disease were staged using the Lund-Mackay staging system: There is no correlation between the staging score of the paranasal sinus infection and the degree of the obstruction the nasolacrimal duct. CONCLUSION This study shows that chronic paranasal sinus disease plays an important role in the pathogenesis of nasolacrimal duct obstructions. The presence of infection has an influence on the nasolacrimal drainage system, but the distribution (staging) of the infection does not appear to correlate with the degree of nasolacrimal duct obstruction. Partial obstruction cases that may progress to complete obstruction may be detected by dacryoscintigraphy, and the treatment of chronic paranasal sinus disease may help to overcome the lacrimal drainage problems in these cases.

Both dacryocystography and dacryoscintigraphy are well established in the evaluation of stenoses of the lacrimal drainage system. They provide limited information about the ductal anatomy itself and about periductal structures. MR imaging was evaluated for its capability to directly visualize the lacrimal drainage system in detail and simultaneously provide functional characterization of dacryostenosis. Subjects and methods: Twenty-seven lacrimal drainage systems of 23 patients suffering from epiphora were examined in an MR unit before and after conjunctival and intravenous application of Gd-DTPA using a surface coil. Results: Dacryostenosis was found in 23 of 27 lacrimal systems. Stenoses were localized to the canalicular (n = 3), saccular (n = 8), and ductal (n = 12) level, and were classified as stenosis or occlusion. Conclusion: MR imaging with conjunctival contrast application allows within one examination both detailed morphological and functional assessment of the lacrimal drainage system with depiction of surrounding structures. Limitations arise mainly from demands on technical and patient-related preconditions.

Purpose The aim of this study was to evaluate the effectiveness of simultaneous lateral tarsal strip procedure (LTS) and endonasal dacryocystorhinostomy (DCR) for the treatment of nasolacrimal duct obstruction and lower lid laxity. Methods We conducted a retrospective, interventional study of concurrent DCR with LTS for patients with nasolacrimal duct obstruction and lower lid laxity performed between March 2009 and July 2011 by a single surgeon (S.H.B.). Patient age, sex, the results of dacryoscintigraphy, time of tube removal, follow-up duration, and cause of failed surgery were recorded. Lower eyelid laxity was evaluated by a medial distraction test. Results A total of 29 eyes in 17 patients were included in the study. The mean age was 61.1 ± 11.8 years (range 41 to 81 years). The mean degree of lower lid laxity was 2.4 ± 0.5. Dacryoscintigraphy showed presac delay in 22 eyes (75.9%). The tube was removed after 11.3 ± 1.9 weeks. The primary anatomical success rate was 89.5% (27 eyes) and the functional success rate was 86.2% (25 eyes). Membranous obstructions were the cause of failed surgery in 2 patients, but both patients remained symptom free after revision surgery with a diode laser. Conclusions Concurrently performed DCR with LTS can be an effective tool for the treatment of nasolacrimal duct obstruction and lower lid laxity. It is recommended for examining lid laxity carefully using lid distraction test in patients with epiphora.

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.

Obstruction of the lacrimal drainage apparatus may result in excessive tearing or epiphora. This may occur as a result of a traumatic injury or accumulation of debris, mucus, or pus. In nuclear dacryoscintigraphy, a radioactive solution is introduced into the conjunctival sac by pipette and allowed to follow the flow of the tear solution through the lacrimal drainage system. This article will review normal lacrimal anatomy and indications for nuclear dacryoscintigraphy in oral and maxillofacial surgery.

Epiphora, an abnormal overflow of tears, is commonly caused by tear drainage system anomalies including nasolacrimal duct obstruction. To assess morphologic abnormalities, dacryocystography by CT is used when CT contrast material is syringed into the lacrimal drainage system. To evaluate the function of the system, dacryoscintigraphy is the most readily available noninvasive method. In the case presented, a 43-year-old man was referred to our clinic with an 8 months' history of indefinite left side epiphora. After performing dacryoscintigraphy, we acquired SPECT/CT images during dacryocystography by CT to establish the surgical indication.

Background: Magnetic resonance imaging (MRI) has excellent spatial and soft tissue resolution in the periocular and orbital region, especially when combined with surface coil techniques. Other methods, including computed tomography, dacryocystography, and dacryoscintigraphy provide limited information in the area of the lacrimal drainage system. Magnetic resonance imaging was used in conjunction with other imaging modalities to compare the anatomic detail and clinically relevant information obtained about various pathologic processes in the lacrimal drainage area. Methods: Patients with a variety of lacrimal drainage disorders underwent MRI with either head or surface coils. Contrast agents also were used in selected cases. Seven case reports are presented. Results: Magnetic resonance imaging provided detailed information about local anatomy, extent of pathology, and, in some cases, etiology of the pathology. Conclusions: Magnetic resonance imaging with surface coils provides detailed soft tissue information when compared with dacryocystography and computed tomography in the area of the lacrimal drainage system. In selected cases of lacrimal drainage system pathology, MRI may provide data that affect patient management.

BACKGROUND AND AIM Dacryoscintigraphy is a grossly underutilized nuclear medicine procedure for assessing the patency of nasolacrimal ducts. It is an alternate noninvasive modality requiring no added expertise when compared with dacryocystography, an invasive radiological counterpart. Dacryocystorhinostomy (DCR) is a surgical procedure in which a patent rhinostomy is made so that a low-pressure lacrimal bypass system is created, thus relieving epiphora, dacryocystitis or mucocele. DCR has been accepted as a highly successful procedure in the management of epiphora from nasolacrimal duct obstruction; however, adverse local effects can reproduce epiphora. This study highlights the utility and simplicity of dacryoscintigraphy in the postoperative setting of DCR, apart from showcasing its high sensitivity and accuracy in localizing the sites of lacrimal drainage obstruction. MATERIALS AND METHODS Fifty-five postoperative patients of DCR were screened. Ten volunteers constituted the control group. One drop (10 μl) of technetium pertechnetate (TcO4) was instilled simultaneously in the outer canthus of both eyes (50-100 μCi). Upright dynamic (8 min) and anterior static images of the eyes (up to 20 min) were acquired on a gamma camera fitted with a high-resolution collimator. Physiological interventions that were used in this study were eye blinking, saline intervention, and lacrimal sac massaging. RESULTS Out of 40 symptomatic DCR patients, 22 had complete obstruction at the presac level and 18 patients had partial obstruction. Quantitative parameters like tear transit time and lacrimal sac half-life were also calculated. After massage of the lacrimal sac, progression of the tracer was observed in five patients. Premassage and postmassage tear column measurements showed a relative increase of 30.1%. Massage of eight clinically normal ducts showed a relative increase of 2.4% (P=0.06). Statistical analysis using the Fisher test shows very significant concordance between clinical symptoms and dacryoscintigraphy findings in postoperative DCR patients (P

A 37-year-old man presented with symptoms of air and mucus reflux from the right medial canthus on blowing his nose. Examination showed crepitus in the region overlying the right lacrimal sac, and he was able to produce bubbles in his conjunctival lake on instillation of topical 2% fluorescein. Dacryoscintigraphy showed symmetrical slow passage of tracer from the lacrimal sac in the nasolacrimal duct indicating delay at the postsac level. Dacryocystography showed that the right lacrimal system contained round filling defects, suggesting the presence of soft tissue tumors. However, a CT scan showed an enlarged right lacrimal fossa with air in the nasolacrimal duct and no evidence of a mass. Following lower punctal plug occlusive canaliculoplasty on the right, using a preloaded silicone plug, the patient noted an immediate resolution of reflux symptoms.

Several tests and examinations are necessary for an accurate diagnosis of disorders of the lacrimal drainage system. The AA studied 100 patients with epiphora, divided in two groups. Forty patients, first group (I), aged between 4 and 78 years old (mean age 47.8 +/- 9.6 years), were examined using the classical tests for the study of epiphora, sequential dacryoscintigraphy (SD) and conventional subtraction macrodacryocystrography (CSMD). In the second group (II), 60 patients (aged 45.5 +/- 8.7 years) were studied using the classical tests and by digital subtraction macrodacryocystography (DSMD). The results showed that when functional epiphora is present, there is no difference between a simple clinical approach and sequential dacryoscintigraphy. However, when information is needed regarding choice of surgical approach, DSMD appears to give the best results.

To investigate the histopathological results of lacrimal sac biopsies in patients with primary acquired nasolacrimal duct obstruction.In this prospective non-comparative study, 205 consecutive patients, who were diagnosed as primary acquired nasolacrimal duct obstruction, were included. Patients with history of trauma and/ or surgery in the periorbital area, punctum or canalicular obstruction were excluded from the study. 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.Forty-seven male and 158 females with age ranging from 6 to 81 years (mean 47.5 ± 16.2 years) were included in the study. Only one patient had the diagnosis of chronic leukemia, others had no preexisting history of systemic disease. Pathologic examination revealed chronic inflammation (n= 178), fibrosis without inflammation (n= 19), normal mucosa (n= 4), and lymphoid hyperplasia (n= 1). Three patients had abnormal pathology: Lymphoproliferative disease in the patient with chronic leukemia, granulomatous inflammation, and basosquamous cell carcinoma.In primary nasolacrimal duct obstruction, pathological examination of the lacrimal sac revealed chronic inflammatory changes in most patients. Even though rare, malignant or systemic disease in patients with neither specific history nor clinical or radiological finding might be observed in these cases. Thus, we recommend taking biopsy if any suspicion of abnormality of the lacrimal sac exists.

We report a 37-year-old patient with the history of bilateral epiphora, who was referred to our department for dacryoscintigraphy imaging. The patient had bilateral obstruction of the lacrimal apparatus at the sac-duct level on the scintigraphy images. Delayed imaging showed Tc-99m pertechnetate uptake in the thyroid due to systemic absorption of the tracer from the conjunctiva. We recommend using tracers with large particle size and lower possibility of mucosal absorption for dacryoscintigraphy in order to decrease unnecessary thyroid radiation.

Dacryoscintigraphy is a noninvasive method frequently used for assessment of the lacrimal drainage system. Sometimes conflicting results with patients' complaints are obtained, which have no clear explanation. In our hypothesis, follow-up of patients evaluated with dacryoscintigraphy could be helpful in determining possible explanations for these conflicting results.Thirty-eight consecutive patients (76 eyes) who had not previously undergone dacryocystorhinostomy or probing were entered in the study. Following instillation of 4 MBq (99m)Tc-pertechnetate, a routine procedure of dacryoscintigraphy was performed. After a mean follow-up time of 1.2 +/- 0.3 years (range 0.9-1.6 years), all patients were reassessed clinically.Using initial patients' symptoms as the gold standard, the sensitivity, specificity, NPV, and PPV of dacryoscintigraphy were calculated to be 82.1%, 75%, 60%, and 90.1%, respectively. The kappa value as a measure of agreement was 0.52. Considering the follow-up study as the gold standard, the sensitivity, specificity, NPV, and PPV were calculated as follows, respectively: 96.3%, 90.4%, 96.3%, and 90.4%. The kappa value was 0.86. There were three initially symptom-free eyes with obstructive pattern on the scans, which developed epiphora on the follow-up. In fact, these eyes were initially classified as false positive, but follow-up assessment showed that they were true-positive scans in a subclinical state.Despite certain drawbacks inherent to the technique, dacryoscintigraphy provides valuable independent information and allows more accurate management decisions. In some patients, data obtained from lacrimal scintigraphy could be predictive, and it makes possible determination of subclinical nasolacrimal duct obstructions.

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.

Dacryoscintigraphy was first introduced in 1972 as a method to detect and localize obstructions of lacrimal drainage under physiologic conditions.1 It has since become commonly used in the evaluation of epiphora.2–7 Briefly, about 50–100 μCi of Technetium Tc-99m sodium pertechnetate or Tc-99m sulfur colloid in a volume of about 10–15 μL is placed on the surface of the eye.3,5 The transport of the radioactive tracer from the conjunctiva into the lacrimal drainage system and flow through the drainage duct to the nasal cavity can then be followed through images obtained using a gamma camera. This radiopharmaceutical dose has customarily been administered onto the surface of the eye using a micropipette.2–6,8–12 Although feasible for administration, dispensing of the radioactive dose in this manner is problematic, especially related to issues of sterility and radioactive contamination. Using a micropipette necessarily requires withdrawal of the radiopharmaceutical solution from an open container into an unsealed pipette tip, which makes sterility difficult to maintain. Leakage of radiopharmaceutical solution from the unsealed pipette tip, resulting in radioactive contamination of the immediate surroundings, may be difficult to avoid. Because these sterility and radioactive contamination issues preclude transportation of the loaded micropipette, it must be filled with the radiopharmaceutical at the immediate location of use. Hence, dispensing (and administration) of the radiopharmaceutical dose in a closed, sterile apparatus taken from a sealed, sterile source would be desirable. The purpose of this study was to evaluate alternative devices for dispensing and administration of radiopharmaceuticals for dacryoscintigraphy.

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.

* BACKGROUND AND OBJECTIVE: To evaluate lacrimal drainage in patients who have undergone successful dacryocystorhinostomy using quantitative dacryoscintigraphy. * PATIENTS AND METHODS: This study included 72 eyes of 72 patients. There were 26 males and 46 females, with a mean age of 39.6 years (range, 8 to 67 years). The patients were subdivided into three groups. Group 1 consisted of 35 eyes with external dacryocystorhinostomy, group 2 consisted of 1 5 eyes with endoscopic dacryocystorhinostomy, and group 3 consisted of 22 eyes with conjunctival dacryocystorhinostomy with a Jones tube. There was no epiphora in patients and the lacrimal drainage systems were patent by irrigation. The other normal eyes of the patients were evaluated as controls. * RESULTS: In groups 1 and 2, the mean T,/2 values for the palpebral aperture were lower than those for normal eyes, and this difference was statistically significant (P < .01). In group 3, no significant difference was detected in the mean T17, values for the palpebral aperture. * CONCLUSIONS: Tear flow was slower in patients who had had external and endoscopic dacryocystorhinostomy, but conjunctival dacryocystorhinostomy did not affect T1/2 values for the palpebral aperture. [Ophthalmic Surg Lasers Imaging 2004;35:3740.]

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.

To document the change in drainage of tears that occurs with blinking, the authors evaluated 17 lacrimal systems of 12 individuals with dacryoscintigraphy. A significant difference in tear drainage was found by keeping the eyelids closed during the first 2 minutes after drop placement (P less than 0.03), but not from 2 to 5 minutes (P greater than 0.4). Retardation of tear drainage after droplet placement can be achieved by simple eyelid closure for 2 minutes.

Between November 1990 and November 1993, 580 children with lacrimal outflow obstruction were examined at the Children's Hospital of Philadelphia. After excluding patients previously treated for nasolacrimal duct obstruction, we obtained a prospectively selected series of 20 children for this study. These patients underwent dacryoscintigraphy before and immediately after lacrimal sac massage to investigate the effect of external compression on fluid movement within the lacrimal outflow system. In 12 patients, tracer did not enter the lacrimal outflow system on the side(s) of obstruction. The absence of radiopharmaceutical correlated with clinical obstruction. In eight patients, tracer was noted to enter the lacrimal sac. After massage of the lacrimal sac, we observed progression of the tracer in five of the eight subjects. In these eight subjects, the pre- and postmassage tear column measurements showed a relative increase of 34.3%. Massage of eight clinically normal ducts showed a relative increase of 2.4% (p = 0.06). We conclude that progression of the tear column after lacrimal massage can be demonstrated on dacryoscintigraphy.