Search

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.

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.

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.

By utilizing 61 lacrimal scans, 26 patients who had received radiotherapy for inner canthus and lid lesions were evaluated. Results indicate that the membranous lacrimal passages are relatively immune to radiation therapy. Although dacryoscintigraphy did not delineate the anatomical features quite as well as contrast dacryocystography, it yielded very useful information about flow mechanisms and tear transit times. The study is rapid, simple, non-hazardous, and particularly helpful in documenting the status of the lacrimal drainage system before and after radiotherapy to the inner canthus region.

Calculations of the radiation dose to the lens for 99mTcO4- in dacryoscintigraphy are developed in some detail. The results indicate that the absorbed dose to the germinal epithelium of the lens is 2.2 X 10(-5) to 1.4 X 10(-4) rad/microCi (5.9 x 10(-12) to 3.8 x 10(-11) Gy/Bq) 99mTcO4- under physiological conditions. With blockage of the lacrimal drainage apparatus, the dose to the lens could increase to 4 X 10(-3) rad/microCi (1 X 10(-9) Gy/Bq).

We have used dacryoscintigraphy to study the efficiency of the lacrimal system following the repair of a divided lower canaliculus in 4 children. This test has been reliable in evaluating lacrimal function and suggests that a canaliculus can be repaired and splinted satisfactorily. Our experience with dacryoscintigraphy confirms that it is a safe comfortable, and reliable method for studying the patency of the lacrimal drainage system.

Nuclear dacryocystography is a simple, relatively harmless method of evaluating patients suspected of having abnormalities of the nasolacrimal drainage system. A drop of normal saline containing approximately 100 μ Ci of 99m Tc-pertechnetate is placed on the conjunctiva near the lateral canthus, and serial scintigrams are obtained as the pertechnetate flows along the tear strips, through the nasolacrimal drainage system, into the nasal fossa. By using a pinhole collimator with a very small aperture (1 mm), the canaliculi, the nasolacrimal sac, and the nasolacrimal duct are readily visualized. When flow is impaired, the site of obstruction can often be identified. Contrast dacryocystography provides similar information but requires the injection of contrast material directly into a canaliculus. Nuclear dacryocystography provides good functional assessment of nasolacrimal drainage but has serious shortcomings in defining pathologic anatomy. Contrast dacryocystography outlines the anatomy well but often misses minor obstructions. The two studies are complementary and together provide an effective means of evaluating the nasolacrimal drainage system.

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.

Studies evaluating the relative importance of the upper and lower canaliculi in tear drainage have been many and varied, and at times the application of the data to clinical situations is difficult. In order to evaluate the relative tear flow in the upper and lower canaliculi and to quantitatively evaluate the different tear flow rates by a physiologic method, we have studied 11 patients using partial canalicular obstructions and dacryoscintigraphy. The authors found no statistical difference in tear flow between the upper and lower canalicular systems. This information has clinical application when deciding whether to repair an isolated canalicular injury.

Radionuclide dacryoscintigraphy is an accurate physiologic method for evaluating the nasolacrimal drainage apparatus. The following case report illustrates the role of this procedure in the initial workup of epiphora, as well as its value in assessing response to therapy with pseudoephedrine.

During a one-year period 53 patients were referred for the investigation of epiphora. All underwent bilateral dacryoscintigraphy. Following the isotope study the patients had either bilateral or unilateral macrodacryocystography; a total of 66 tear ducts were shown by this procedure. The scintigraphs were more sensitive for obstruction (51/66 systems or 77%) than radiography (33/66 systems or 51%). Normal dacryoscintigraphy was always associated with duct patency on dacryocystography. We have concluded that scintigraphy should always be the first investigation and that, if this is normal, radiography is not necessary. The use of digital subtraction imaging for the lacrimal passages is discussed. It is suggested that this may provide information obtained at present only by combining dacryoscintigraphy with conventional contrast radiography.

Dacryoscintigraphy was performed in 34 pediatric patients aged between 13 months and 20 years. Twenty-six were 12 years of age or younger. The study is easy to perform and provides useful information regarding the function of the nasolacrimal system. The radiation dose to the lens of the eye, estimated to be 4-14m rads/100 uCi of technetium pertechnetate, is considerably less than that of a skull x-ray or dacryocystography. Of the 74 nasolacrimal systems studied, the findings were in agreement with the clinical observations and other methods of testing in 63. In nine instances, the findings altered the clinical management while the results were inconclusive or misleading in the remaining two. Dacryoscintigraphy was found to be a useful physiological test in the evaluation of children with epiphora.