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1.  The Association of Neonatal Dacryocystoceles and Infantile Dacryocystitis with Nasolacrimal Duct Cysts (An American Ophthalmological Society Thesis) 
To investigate whether neonatal dacryocystoceles and dacryocystitis are associated with nasolacrimal duct cysts, and to report the outcomes of treatment of these disorders.
This was a retrospective medical record review of two groups of infants with nasolacrimal duct (NLD) obstruction. The first group had dacryocystoceles with or without dacryocystitis. The second group had NLD obstruction with symptoms severe enough to require early NLD probing. All of the patients underwent NLD probing and nasal endoscopy. When present, NLD cysts were removed.
In the first group, 33 infants had dacryocystoceles. Acute dacryocystitis was present in 16 patients, 12 had noninfected dacryocystoceles that did not resolve, and 5 had dacryocystoceles that resolved but severe symptoms persisted. All of the patients had NLD cysts that were surgically removed. The symptoms resolved after surgery in 31 patients (94%). In the second group, 27 infants less than 6 months old without dacryocystoceles underwent early NLD probing and endoscopy due to severity of symptoms. Twelve (44%) of these patients had NLD cysts. The symptoms resolved in 11 (92%) of 12 patients following NLD probing and cyst removal.
Neonatal dacryocystoceles are almost always associated with NLD cysts. The success rate of NLD probing and endoscopic cyst removal in these patients is excellent. Nasolacrimal duct cysts also are present in many young infants with severe symptoms of NLD obstruction. Nasal endoscopy is an important adjunct to the management of these infants.
PMCID: PMC3671363  PMID: 23818736
2.  Uncommon Presentation of Congenital Lacrimal Duct Obstruction A Case Report of Congenital Amniontocele 
Oman Medical Journal  2007;22(3):60-61.
Congenital amniontocele also known as congenital dacryocystocele is an uncommon variant of a very common condition (Naso-Lacrimal Duct Obstruction, NLDO) that affects newborn babies. The congenital amniontocele causes obstruction of the lacrimal drainage system creating a cystic swelling of the lacrimal sac. It usually presents at birth or soon after birth, as a bluish swelling, below and nasal to the medial canthus. If the congenital amniontocele is associated with intranasal cystic swelling of the NLD and if it is large and bilateral it can cause severe respiratory distress particularly during milk feeding.
We report a case of 24 days old female newborn baby who were presented to us from pediatric clinic of Rustaq Hospital with bluish cystic swelling below the left medial canthus soon after the birth.
Congenital amniontocele is relatively rare and the literature describes a variable natural course of these lesions with resultant controversy in their management. Usually congenital amniontocele resolves spontaneously with conservative management, and if not, dacryocystitis might develop. Treatment of congenital amniontocele comprises digital sac massaging and early probing the lacrimal system,8 or some times, intranasal surgery in the form of marsupialization of the intranasal cyst, this is usually performed endoscopically.7 We report successful conservative management in our case and recommend this with oral and topical antibiotics with lacrimal sac massage for 7 to 10 days and, if there is no response, to consider surgical intervention in the form of lacrimal probing.
PMCID: PMC3294153  PMID: 22400096
Congenital amniontocele; dacryocystocele; lacrimal probing; antibiotics; conservative
3.  Congenital dacryocystocele: diagnosis and treatment 
Five children were diagnosed with congenital dacryocystocele; in all cases, the cystic lesion was unilateral; age ranged from 7 to 60 days (mean 29 days). The mean ultrasonography diameter of the cyst, at the time of the diagnosis, was 11.51 mm. Topical and systemic antibiotics and massage were prescribed. One patient had no recurrence of the dacryocystocele but 4 showed no improvement with medical treatment; they were submitted to successful probing in the first months of life under general anaesthesia. Nasal endoscopy revealed a nasolacrimal cyst in one patient. True dacryocystocele is relatively rare: ultrasound is a simple, non-invasive method that can reliably distinguish dacryocystocele from other pathological conditions. Several reports have described a variable natural course of these lesions but there are controversial opinions regarding their management. Initially, we treated this congenital anomaly with digital massage, and topical and systemic antibiotics. Probing under general anaesthesia was performed in the event of dacryocystitis or lack of resolution after a short trial period with digital massage. Particular attention was paid to nasal bilateral endoscopy to exclude a nasal obstruction caused by cystic swelling of the naso-lacrimal duct. When performed, the probing procedure was successful in all patients.
PMCID: PMC2689544  PMID: 19205594
Nasolacrimal duct; Dacryocystocele; Dacryocystitis; Nasolacrimal duct obstruction; Treatment
4.  Process of spontaneous resolution in the conservative management of congenital dacryocystocele 
To assess efficacy of the conservative management of patients with congenital dacryocystocele.
Materials and methods
This was a retrospective case series involving six sides of five infants with a dacryocystocele treated at Osaka Kaisei Hospital, Osaka, Japan. The conservative management protocol consisted of the application of warm compresses and massage over the mass, with the addition of antibiotics when dacryocystitis developed. Patient age at the time of resolution, presence of retrograde outflow of contents of dacryocystoceles from the puncta, and development of dacryocystitis were recorded.
The dacryocystocele was unilateral in four patients and bilateral in one patient. A nasal cyst was present in four patients without respiratory distress. The median patient age at the time of the diagnosis was 7 days (range 2–10 days). Conservative management was selected in all patients, and the dacryocystocele was resolved in all patients at a median patient age of 14.5 days (range 11–105 days). Two sides developed dacryocystitis, which resolved in a few days with antibiotic treatment. In those two sides, rupture of the dacryocystoceles to the common canaliculus with retrograde discharge of the contents from the puncta before the dacryocystitis developed was noted. For the other four treated sides, no such discharge or development of dacryocystitis was observed.
The findings of this study show that a dacryocystocele has a good chance of resolving spontaneously with conservative management and careful observation, and that rupture of the dacryocystocele to the common canaliculus might be an important precursor of dacryocystitis.
PMCID: PMC3942303  PMID: 24600200
dacryocystitis; congenital lacrimal obstruction; remnant; precursor; retrograde discharge
5.  Preventing Silicone Tube Extrusion after Nasolacrimal Duct Intubation in Children 
Herein we report our experience with a simple technique for reducing the rate of silicone tube extrusion after nasolacrimal duct (NLD) intubation for congenital NLD obstruction. Medical records of children older than 2 years, with or without history of failed probing, who had undergone NLD intubation with a Crawford silicone tube over a period of 4 years were reviewed. In all subjects, one end of the Crawford tube was passed through a piece of scalp vein tubing followed by applying one or two knots. All Crawford tubes were removed after 3 months. Main outcome measures included complications such as tube extrusion, nasal discharge, crust formation and pyogenic granuloma formation. Fifty-seven patients, including 49 unilateral and 8 bilateral cases with mean age of 3.8±1.6 (range, 2 to 11.5) years were operated. No complications such as tube dislodgement, significant nasal discharge, crust or pyogenic granuloma formation occurred prior to Crawford tube removal. All silicone tubes were successfully removed from the nasal cavity. In conclusion, passing one end of the Crawford tube through a small piece of scalp vein tubing before knotting it in the nasal cavity seems to decrease the rate of tube extrusion which is the most common complication following NLD intubation in children.
PMCID: PMC3381084  PMID: 22737375
Nasolacrimal Duct Intubation; Silicone Tube Extrusion; Crawford Tube; Nasolacrimal Duct Obstruction
6.  Prenatal early diagnosis of dacryocystocele, a case report and review of literature 
Dacryocystocele (mucocele, amniocele) is a relatively rare variant of nasolacrimal duct obstruction which refers to the cystic dilatation of lacrimal pathway above and below the lacrimal sac. It is a benign pathology and can be treated successfully after birth, but its prenatal detection is important, because it may be seen in numerous syndromes and may serve as their marker. Bilateral cysts have the possibility for intranasal extension and an obstruction to the nasal passages may result in neonatal respiratory distress requiring surgical intervention Unilateral cases are important for the differential diagnosis with serious facial abnormalities. We present a case of early prenatal detection of a 28 year-old G: 1 P: 0 pregnant woman with bilateral dacryocystocele. She presented a live, normally developed singleton fetus on sonographic examination at 12, 16 and 22 weeks. At 25th weeks, we diagnosed a hypoechogenic mass, that was situated inferomedially to the eyes in the fetal face with 2 and 3-D ultrasound. A 3850-g live female infant was delivered by Cesarean section due to breech presentation at 39 weeks following preterm rupture of membranes. We report the case with intranasal components studied during fetal life by 2 and 3-D ultrasound and magnetic resonance (MR) imaging.
PMCID: PMC3939260  PMID: 24592005
Dacryocystocele; mucocele; amniocele; magnetic resonance imaging; nasolacrimal duct cyst
7.  Urgent Bilateral Endoscopic Marsupialization for Respiratory Distress due to Bilateral Dacryocystitis in a Newborn 
The Journal of Craniofacial Surgery  2014;25(3):e292-e293.
We describe an infant with respiratory distress due to bilateral dacryocystoceles and dacryocystitis who was successfully treated with urgent bilateral endoscopic marsupialization.
A male infant was brought to our outpatient department 7 days after birth, with red, acutely inflamed swellings near the medial canthal area of both eyes. From birth, there had been bluish swelling near the medial canthal area, and redness and swellings developed within 3 days. On physical examination, the child was afebrile but showed respiratory distress with coarse breathing sound. That day, the infant was admitted and treated with intravenous cefotaxime 150 mg. After withholding oral intake for appropriate preoperative fasting, urgent bilateral probing with endoscopy was done. On endoscopy, huge bilateral congenital dacryocystoceles were found. Because of its huge size, the inferior surface of the cyst was touching the nasal floor, which made probe unable to perforate the wall of dacryocystocele. Therefore, an endoscopy-assisted marsupialization of dacryocystoceles and bicanalicular silicone intubation were performed. Both swellings and erythema subsided within 48 hours postoperatively, and the patient was discharged after 72 hours from treatment.
PMCID: PMC4025628  PMID: 24799096
Bilateral dacryocystitis; bilateral dacryocystoceles; endoscopic marsupialization; respiratory distress
8.  Endoscopic Dacryocystorhinostomy with Flap Suturing 
Multiple reports have demonstrated the efficacy of endoscopic dacryocystorhinostomy (DCR). However the results of the same have varied from centre to centre. Many still regard external DCR as the gold standard. To describe an endoscopic DCR technique which anatomically simulates an external DCR and assess its results. Prospective, nonrandomized and noncomparative interventional case series. Clinical charts of patients with nasolacrimal duct obstruction based on symptomatic, clinical and radiological basis were included in the study. All surgeries were done endonasally using standard operative technique. The modification in the standard technique included creating a wide exposure of the lacrimal sac, incising the sac and the suturing the medial wall of the lacrimal sac with the lateral nasal wall. The same was achieved by using either vascular clips or 5.0 vicryl sutures. Twenty (11 females and 9 males) were included in the study. The average age of the patients was 56.86 years old (range 27–85 years old). The main presenting symptom was epiphora and 1 patient with mucocele. Successful outcome was measured in terms of relief of sympto anatomical patency assessed by sac syringing and nasal endoscopy showing a wide patent lumen. A primary success rate of 95% and ultimate rate of 100% was achieved in the cases with a nasolacrimal duct (NLD) block while an overall success rate of 82.6% was noted when the cases with NLD block and common canalicular block were considered together. Endoscopic DCR can now easily replace external DCR as a standard. It is not only minimally invasive, but has minimal complications and using this technique, we have been able to achieve very high success rates.
Electronic supplementary material
The online version of this article (doi:10.1007/s12070-011-0354-z) contains supplementary material, which is available to authorized users.
PMCID: PMC3738795  PMID: 24427653
Endoscopic surgical procedure; Dacrycystorhinostomy; Lacrimal apparatus; Lacrimal duct obstruction; Lacrimal gland; Dacryocystitis; Lacrimal apparatus disease; Lacrimal; Lacrimal duct; Mucocele
9.  Value of microbiology study in congenital nasolacrimal duct obstruction 
Saudi Journal of Ophthalmology  2012;26(2):223-228.
Evaluation of the effect of different microorganisms on congenital nasolacrimal duct obstruction (CNLDO) tightness and whether probing or silastic intubation is likely to fail in a particular microorganism infection.
The culture and sensitivity results of lacrimal drainage system (LDS) discharge samples from patients with CNLDO were reviewed. Different microorganisms were correlated with the severity of nasolacrimal duct (NLD) obstruction observed during surgical intervention. The success rates of probing and silastic intubation as a primary procedure for each identifiable microorganism were documented. Statistical analysis was conducted to correlate the type of microorganism with the tightness of CNLDO and treatment failure.
Out of 181 specimens, 22 had no growth (12.1%). LDS with positive culture had 76.6% successful probing (n = 49) and 82.1% successful silastic intubation (n = 78). Gram-positive and Gram-negative species were almost equally detected. The most prevalent organisms were Streptococcus pneumoniae and Hemophilus influenzae (48.1% and 39.2%, respectively). Tight CNLDO was more prevalent in Serratia marcescens (n = 2; 100%) and Staphylococcus aureus (n = 4; 33.3%) infections with a 7.75 Odds ratio [95% confidence interval (CI), 1.67–34.63]. Staphylococcus aureus had 37.5% successful probing; however, success was achieved in all cases with silastic intubation. Serratia marcescens infections had 100% successful silastic intubation.
Microbiology study can predict tight CNLDO and helps in choosing the most successful treatment option. CNLDO with Staphylococcus infection and Serratia marcescens were likely to have tight NLD obstruction and silastic intubation had better outcomes.
PMCID: PMC3729323  PMID: 23960996
Microbiology; Congenital; Nasolacrimal duct; Obstruction
10.  Prevalence and clinical characteristics of congenital dacryocystocele 
To report the prevalence, clinical findings, and outcomes in children diagnosed with congenital dacryocystocele in a well-defined population over a 20-year period.
The medical records of all Olmsted County, Minnesota, patients diagnosed with congenital dacryocystocele from January 1, 1988, through December 31, 2007, were retrospectively reviewed.
A total of 9 children were diagnosed with dacryocystocele during the 20-year period, yielding an incidence of 1 in 3884 live births. The median age at diagnosis was 12 days (range, birth to 40 days); 7 (78%) were female. Eight patients (89%) had unilateral disease. Clinical findings included a cystic mass in all 9, dacryocystitis in 3 (33%), intranasal cysts in 3 (33%), and 1 (11%) each with facial cellulitis and dacryocystocele-induced astigmatism. Conservative treatment resolved the obstruction in 3 (33%), while the remaining 6 (67%) each underwent one surgery. Complete resolution was observed in all 9 patients.
Congenital dacryocystocele is an uncommon unilateral condition of predominantly neonatal females. Clinical findings support a relatively high incidence of complications such as dacryocystitis and intranasal cysts as well as a less common finding of astigmatism that resolved without evidence of amblyopia. One-third of the cases were successfully managed with conservative treatment alone; most patients required surgical intervention.
PMCID: PMC3115742  PMID: 21035068
11.  Clinical, Radiological, Microbiological, and Histopathological Aspects of Acquired Dacryocystoceles 
Journal of Ophthalmology  2014;2014:396782.
Purpose. The aim of this study is to investigate the etiology and the clinical, microbiological, histopathological, and radiological findings of acquired dacryocystoceles. Methods. In this retrospective study, we reviewed the clinical records of 10 eyes of 8 patients with dacryocystoceles who underwent external dacryocystorhinostomy (DCR) surgery. Etiology, presenting symptoms and radiological findings as well as microbiological and histopathological assessment results and outcome were analyzed. Results. The records of 8 patients with dacryocystoceles were included in this study. In the histopathological evaluations of the samples collected from the lacrimal sac wall, chronic inflammation was found in all biopsied samples and fibrosis was observed in two histopathological evaluations. Computerized tomography (CT) imaging showed fluid collection separated from adjacent tissues by a thin rim, corresponding to dacryocystoceles in the sac. In the microbiological culture examination of samples collected from the fluid within the cyst, no bacterial growth in 5 eyes, gram-negative bacillus growth in 3 eyes, and gram-positive cocci growth in 2 eyes were found. Conclusions. Acquired dacryocystoceles were observed extremely rarely and a definite pathogenic agent could not be identified in any of the cases, either microbiologically or histologically, whereas chronic inflammation was detected in all cases in our study.
PMCID: PMC4074962  PMID: 25018880
12.  A Case of Recurrent Schneiderian Papilloma of the Lacrimal Sac Invading the Nasal Cavity 
A 44-year-old man presented with a history of chronic epiphora, discharge from the right eye, and a palpable mass in the medial canthal area. Irrigation of the lacrimal system revealed bloody discharge. Orbital magnetic resonance imaging (MRI) showed a well-defined heterogeneous enhanced mass filling the lacrimal sac and upper nasolacrimal duct (NLD). A wide excision and surgical biopsy were performed. Histopathology showed the tumor to be an exophytic Schneiderian papilloma with moderate to severe dysplasia. Three months later, the mass was found to be invading the nasal cavity through the NLD. Endoscopic histopathological evaluation confirmed that it was identical to the originally identified papilloma.
PMCID: PMC2694284  PMID: 19568358
Lacrimal sac; Recurrent exophytic papilloma; Schneiderian papilloma
13.  Development of the Lacrimal Apparatus in the Rabbit (Oryctolagus cuniculus) and Its Potential Role as an Animal Model for Humans 
Anatomy Research International  2011;2011:623186.
Rabbits have been proposed as a model organism for the human lacrimal apparatus (LA), including the nasolacrimal duct (NLD), based principally on comparative studies of adult morphology; however, little is known about its development. The NLD first appears as an incomplete primordium in the subcutaneous region of the primordial eyelid and subsequently elongates to reach the naris. One posterior and three anterior orbital glands are present fetally although one of the anterior glands is soon lost. The NLD follows a tortuous path and passes through a bony canal consisting of lacrimal, maxilla, and maxilloturbinal bones at different regions. Although early developmental similarities exist to haplorhine primates, the narial opening of the NLD resembles strepsirrhines. This distinction, along with the ductal and glandular differences at the orbital end of the NLD, indicates that rabbits may be a poor model for LA drainage in primates, specifically humans.
PMCID: PMC3335492  PMID: 22567296
14.  Plasmacytoma of the Nasolacrimal Duct Simulating Dacryocystitis: An Uncommon Presentation for Extramedullary Relapse of Multiple Myeloma 
Case Reports in Oncology  2012;5(1):119-124.
The most common site for localized forms of plasma cell neoplasms (extramedullary plasmacytoma; EMP) is the upper respiratory tract, including the oropharynx, nasal cavities, sinuses and larynx. A 50-year-old woman with a history of myeloma in complete remission after autologous stem cell transplantation complained of two weeks of epiphora of the left eye with subsequent diplopia, bloody nasal discharge and progressive swelling around the nasolacrimal sac. A solitary mass in the left sinonasal area, extending to the nasolacrimal duct (NLD) was detected on MRI, whose histopathological examination was consistent with plasmacytoma. Further clinical investigation ruled out multiple myeloma (MM). The patient underwent debulking surgery and adjuvant chemotherapy followed by local radiotherapy in an attempt to achieve complete response. Despite being a rare entity, EMP of the NLD should be considered in the differential diagnosis of epiphora and dacryocystitis. To our knowledge, this is the first case of a plasmacytoma of the NLD presenting as isolated extramedullary relapse of MM. The follow-up in EMPs should include appropriate imaging studies, a systemic workup to rule out MM.
PMCID: PMC3364047  PMID: 22666199
Dacryocystitis; Multiple myeloma; Nasolacrimal duct; Plasmacytoma
15.  Improving Results in Endoscopic DCR 
The aim of presenting this article is to highlight the factors causing failure in endoscopic dacryocystorhinostomy (DCR). Understanding these factors will lead to an enhancement in the success rate of endoscopic DCR. Out of 600 cases done in a period of 10 years (from 1998 to 2008), 60 were revision cases. 60 patients referred over a period of 10 years, were selected. The aim was to study the factors causing failure in each case. The cases included were revised in a period of 10 years from 1998 to 2008. These were the cases that were unsuccessful for one or the other reason. The author presents a series of failed DCR cases referred over a period of 10 years. Patients had undergone primary surgery elsewhere and were referred due to the persistence of symptoms. Assessment of all the cases was done with the examination of Eyes and lids for any obvious deformity, watering or purulent discharge in the medial canthal area. ROPLAS test was done as a spot diagnosis for NLD block. This was followed by probing and syringing in the outdoor. All the cases were revised and the likely causes leading to failure of the first surgery were analyzed. It was found that the improper selection of cases accounted for 3.3% of total failed cases; Low rhinostomy accounted for 28.3% cases, inadequate sac opening for 38.3% cases, Pre existing canaliculitis for 1.6% of cases, contracture at the rhinostomy site in 10% cases. Laser burn canalicular scarring for 3.3% of total cases and laxity of the lids and atonic sac was responsible for failure in 3.3% cases. Most of the above factors are secondary to the false localization of the sac, inadequate removal of the sac wall, too much of mucosal removal leading to synaechia formation at the surgical site and inability to detect any additional block with NLD (Nasolacrimal duct) block.
PMCID: PMC3109973  PMID: 22319715
Dacryocystorhinostomy (DCR); Nasolacrimal duct (NLD); Endoscopic; Regurgitation of pus on pressure over lacrimal sac (ROPLAS)
16.  Prevalence of amblyopia in children undergoing nasolacrimal duct irrigation and probing 
Indian Journal of Ophthalmology  2013;61(12):698-700.
To investigate ambylopia and amblyopia risk factors of children who underwent nasolacrimal duct (NLD) irrigation and probing for congenital nasolacrimal duct obstruction (CNLDO).
Materials and Methods:
The medical records of patients who had undergone NLD irrigation and probing for CNLDO at an age of 3 years or younger were reviewed, and 51 of the patients were recalled between October 1 and December 31, 2011 for a detailed ophthalmic examination to determinate amblyopia or amblyopia risk factors. Amblyopia was accepted as difference in visual acuity of two or more Snellen lines between the two eyes or visual acuity of 20/30 or worse in either eye.
The median age of the 51 patients to whom NLD irrigation and probing were attempted for CNLDO was 23 months. CNLDO affected a total of 70 eyes. All patients were reviewed for best-corrected visual acuity, refractive errors, and strabismus at a median age of 70.5 months (range 31-95 months). Amblyopia or amblyopia risk factors were identified in 14 patients (27.5%). One child (7.15%) had only strabismus, six children (42.8%) had only amblyogenic refractive errors, two (14.3%) had a combination of two, one child (7.15%) had a family history for amblyopia, but four children (28.6%) had no amblyopia risk factors but had amblyopia.
Amblyogenic risk factors are found higher in patients with CNLDO and patients undergoing NLD irrigation and probing in comparison to normal population. Therefore, we recommend these children to routinely undergo cycloplegic refractions and full ophthalmic examinations.
PMCID: PMC3917385  PMID: 24413822
Amblyopia; nasolacrimal duct obstruction; probing
17.  The Surgical Outcome of Endoscopic Dacryocystorhinostomy According to the Obstruction Levels of Lacrimal Drainage System 
Many factors influence the outcome of endoscopic dacryocystorhinostomy (DCR). One of the most important prognostic factors is the level of obstruction in the lacrimal drainage system. The main objective of this report is to evaluate both the frequency of obstruction by anatomical region of the lacrimal drainage system on dacryocystography (DCG) and the surgical outcome of endoscopic DCR according to the obstruction level.
A retrospective series of 48 patients (60 eyes) who had undergone endoscopic DCR from January 2005 to November 2007 were enrolled. Preoperative evaluation consisted of a standard examination which included lacrimal irrigation, probing, DCG and osteomeatal unit (OMU) computed tomography. Patients were classified into four groups according to the obstruction level on DCG. Surgical outcome was evaluated postoperatively by subjective improvement of epiphora and patent rhinostomy opening on nasal endoscopic exam.
Of 60 eyes, the levels of obstruction were the common canaliculus in 14 eyes (23.3%), the lacrimal sac in 13 eyes (21.7%), the duct-sac junction in 13 eyes (21.7%) and the nasolacrimal duct (NLD) in 20 eyes (33.3%). The ductsac junction obstruction was treated most successfully (100%), followed by NLD obstruction (90%), common canaliculus obstruction (78.6%) and saccal obstruction (69.2%).
In patients with lacrimal drainage system obstruction, preoperative evaluation of obstruction level using DCG may be helpful for predicting the surgical outcome of endoscopic DCR. The saccal obstruction may have a worse prognosis than the other obstruction levels.
PMCID: PMC2751879  PMID: 19784407
Lacrimal sac; Lacrimal duct obstruction; Epiphora; Dacryocystorhinostomy
18.  Bilateral Congenital Lacrimal Fistula in Down Syndrome 
Congenital lacrimal fistulae are rare in Down syndrome and bilateral presentation is very unusual. It can be associated with nasolacrimal duct obstruction. We report a 3-year-old female with Down syndrome who presented with watering and discharge from both eyes and bilateral fistulous openings present inferonasal to the medial canthus. Upon examination, the lacrimal sac regurgitation test was positive on both sides. Our case report documents a distinctive case of bilateral congenital lacrimal fistulae in association with Down syndrome. It was managed successfully by primary fistulectomy and nasolacrimal duct probing.
PMCID: PMC3757640  PMID: 24014994
Down Syndrome; Fistulectomy; Lacrimal Fistula; Nasolacrimal Duct
19.  Nasolacrimal Duct Closure Modulates Ocular Mucosal and Systemic CD4+ T-Cell Responses Induced following Topical Ocular or Intranasal Immunization ▿  
Both topical ocular and topical intranasal immunizations have been reported to stimulate the ocular mucosal immune system (OMIS) and the systemic immune system. Nasolacrimal ducts (NLDs) are the connecting bridges between the OMIS and nasal cavity-associated lymphoid tissue (NALT). These ducts drain topical ocularly administrated solutions into the inferior meatus of the nose to reach the NALT. Inversely, NLDs also drain intranasally administrated solutions to the mucosal surface of the eye and thus the OMIS. This unique anatomical connection between the OMIS and NALT systems provoked us to test whether the OMIS and NALT are immunologically interdependent. In this report, we show that both topical ocular administration and topical intranasal administration of a mixture of immunodominant CD4+ T-cell epitope peptides from herpes simplex virus type 1 (HSV-1) glycoprotein D (gD) emulsified with the CpG2007 mucosal adjuvant are capable of inducing local (in conjunctiva) as well as systemic (in spleen) HSV-peptide-specific CD4+ T-cell responses. Interestingly, surgical closure of NLDs did not significantly alter local ocular mucosal CD4+ T-cell responses induced following topical ocular immunization but did significantly enhance systemic CD4+ T-cell responses (as measured by both T-cell proliferation and gamma interferon (IFN-γ) production; P < 0.005). In contrast, NLD closure significantly decreased ocular mucosal, but not systemic, CD4+ T-cell responses following intranasal administration of the same vaccine solution (P < 0.001). The study suggests that NALT and the OMIS are immunologically interconnected.
PMCID: PMC2837957  PMID: 20089796
20.  A Case of Congenital Dacryocystocele 
Annals of Dermatology  2010;22(1):54-56.
A 6-day-old infant presented with a deeply bluish cystic mass below the right medial canthus. She had been born healthy. Under the impression of a hemangioma brain computed tomography was conducted. As a result, a diagnosis of congenital dacryocystocele was made. We present this case to show that it is important for a dermatologist to correctly identify congenital dacryocystoceles and appropriately refer the infant to a pediatric ophthalmologist prior to performing invasive measures.
PMCID: PMC2883398  PMID: 20548882
Congenital dacryocystocele; Nasolacrimal obstruction
21.  A rare cause of nasolacrimal duct obstruction: Dentigerous cyst in the maxillary sinus 
Indian Journal of Ophthalmology  2009;57(6):465-467.
The most common abnormality of the lacrimal drainage system is congenital or acquired nasolacrimal duct obstruction. The causes of acquired nasolacrimal duct obstruction may be primary or secondary. The secondary acquired obstructions may result from infection, inflammation, neoplasm, trauma or mechanical causes. The maxillary sinus cysts usually obstruct the nasolacrimal duct mechanically. Dentigerous cysts are one of the main types of maxillary cysts. These cysts are benign odontogenic cysts which are associated with the crowns of unerupted teeth. The clinical documentations of mechanical nasolacrimal duct obstructions due to a dentigerous cyst in the maxillary sinus are very rare in literature. In this case report, we describe a dentigerous cyst with a supernumerary tooth in the maxillary sinus in an 11-year-old male child causing an obstruction to the nasolacrimal duct. The case was successfully managed surgically by Caldwell Luc approach.
PMCID: PMC2812769  PMID: 19861752
Caldwell Luc approach; dentigerous cyst; nasolacrimal duct
22.  Memory and comprehension deficits in spatial descriptions of children with non-verbal and reading disabilities 
Frontiers in Psychology  2015;5:1534.
The present study investigated the difficulties encountered by children with non-verbal learning disability (NLD) and reading disability (RD) when processing spatial information derived from descriptions, based on the assumption that both groups should find it more difficult than matched controls, but for different reasons, i.e., due to a memory encoding difficulty in cases of RD and to spatial information comprehension problems in cases of NLD. Spatial descriptions from both survey and route perspectives were presented to 9–12-year-old children divided into three groups: NLD (N = 12); RD (N = 12), and typically developing controls (TD; N = 15); then participants completed a sentence verification task and a memory for locations task. The sentence verification task was presented in two conditions: in one the children could refer to the text while answering the questions (i.e., text present condition), and in the other the text was withdrawn (i.e., text absent condition). Results showed that the RD group benefited from the text present condition, but was impaired to the same extent as the NLD group in the text absent condition, suggesting that the NLD children’s difficulty is due mainly to their poor comprehension of spatial descriptions, while the RD children’s difficulty is due more to a memory encoding problem. These results are discussed in terms of their implications in the neuropsychological profiles of children with NLD or RD, and the processes involved in spatial descriptions.
PMCID: PMC4285864  PMID: 25610417
non-verbal learning disability; reading disability; spatial descriptions; spatial perspective
23.  Primary Treatment of Nasolacrimal Duct Obstruction with Probing In Children Less Than Four Years Old 
Ophthalmology  2007;115(3):577-584.e3.
To report the outcome of nasolacrimal duct probing as the primary treatment of congenital nasolacrimal duct obstruction (NLDO) in children less than 4 years of age
Prospective, non-randomized observational multicenter study (44 sites)
Nine hundred fifty-five eyes of 718 children aged 6 to <48 months at the time of surgery, with no prior nasolacrimal surgical procedure, and with at least one of the following clinical signs of NLDO present: epiphora, mucous discharge and/or increased tear lake.
Probing of the nasolacrimal system of the affected eye
Main outcome measure
Treatment success was defined as no epiphora, mucous discharge or increased tear lake present at the outcome visit one month after surgery.
The proportion of eyes treated successfully was 78% (95% confidence interval (CI) = 75% to 81%) overall and was 78% for the 421 eyes in children aged 6 to <12 months, 79% for the 421 eyes in children aged 12 to <24 months, 79% for the 37 eyes in children aged 24 to <36 months, and 56% for the 11 eyes in children aged 36 to <48 months. The probability of treatment success was lower in eyes operated in an office setting compared with in a surgical facility (adjusted relative risk 0.88 [95% CI = 0.80 to 0.96]), with success reported in 72% (95% CI = 66% to 78%) of probings performed in an office and in 80% (95% CI = 77% to 84%) of probings performed in a facility. The probability of treatment success was also lower in eyes of patients with bilateral disease (adjusted relative risk 0.88 [95% CI = 0.81 to 0.95]).
In children 6 to <36 months of age, probing is a successful primary treatment of NLDO in about three-fourths of cases with no decline in treatment success with increasing age. The study enrolled too few children aged 36–<48 months to allow a conclusion regarding the probability of treatment success in this age group.
PMCID: PMC2409584  PMID: 17996306
24.  Extracting complexity waveforms from one-dimensional signals 
Nonlinear methods provide a direct way of estimating complexity of one-dimensional sampled signals through calculation of Higuchi's fractal dimension (1
In this work we propose a new and simple way to estimate FD for N < 100 by introducing 'normalized length density' of a signal epoch,
where yn(i) represents the ith signal sample after amplitude normalization. The actual calculation of signal FD is based on construction of a monotonic calibration curve, FD = f(NLD), on a set of Weierstrass functions, for which FD values are given theoretically. The two existing methods, Higuchi's and consecutive differences, applied simultaneously on signals with constant FD (white noise and Brownian motion), showed that standard deviation of calculated window FD (FDw) increased sharply as the epoch became shorter. However, in case of the new NLD method a considerably lower scattering was obtained, especially for N < 30, at the expense of some lower accuracy in calculating average FDw. Consequently, more accurate reconstruction of FD waveforms was obtained when synthetic signals were analyzed, containig short alternating epochs of two or three different FD values. Additionally, scatter plots of FDw of an occipital human EEG signal for 10 sample epochs demontrated that Higuchi's estimations for some epochs exceeded the theoretical FD limits, while NLD-derived values did not.
The presented approach was more accurate than the existing two methods in FD(t) extraction for very short epochs and could be used in physiological signals when FD is expected to change abruptly, such as short phasic phenomena or transient artefacts, as well as in other fields of science.
PMCID: PMC2739215  PMID: 19682385
Dacryocystorhinostomy (DCR) remains the surgery of choice for the treatment of epiphora secondary to nasolacrimal duct (NLD) obstruction. It involves creating a direct soft‐tissue anastomosis between the lacrimal sac and the ipsilateral nasal cavity, via an osteotomy created by removal of the floor of the lacrimal fossa and surrounding bone. Successful surgery clearly requires the presence of a nasal space and absence of this poses a surgical challenge.
We describe three patients with absent nasal cavity on the side of lacrimal obstruction, where DCR was performed by the creation of an anastomosis between the lacrimal sac and the contralateral nasal space.
PMCID: PMC1857647  PMID: 17035281

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