Nasolacrimal Duct

One of the most important aspects of this surgery is to first make sure that the primary pathology is due to distal obstruction of the nasolacrimal system (Fig. 14.1a, b). If there is proximal obstruction, then surgery will fail. Often distal obstruction is mixed with a varying degree of proximal obstruction and this needs to be taken into consideration when counseling the patient about their expectations from surgery. Syringing and probing is the main way to define the site of obstruction.

A dacryocystogram is indicated if there is any mass within the sac. Scintigraphy helps to define a functional problem. A bloody discharge from the punctum is a symptom that needs investigating to exclude malignancy in the sac. The common symptoms are epiphora, recurrent dacryocystitis, or swelling from a mucocele (Fig. 14.2). Epiphora causes not only tearing but an al-

Dacryocystogram

Fig. 14.1 a Right dacryocystitis. b A right lacrimal mucocele.

Fig. 14.1 a Right dacryocystitis. b A right lacrimal mucocele.

Congenital Large Lacrimal Mucocele
Fig. 14.2 An axial CT scan in a neonate with a congenital nasolacrimal mucocele (*).

teration in refraction that requires the patient to repeatedly blink or wipe their eye. Its prevalence is much more common with aging. It is unusual for intranasal pathology to be responsible, but conditions such as Wegener granulomatosis and sarcoidosis can affect this (Fig. 14.3 a). Nasolacrimal duct obstruction can occur a b a c

Nasolacrimal Duct Obstruction Scan

rmmnriBmn b

Fig. 14.3 a Wegener granulomatosis causing nasolacrimal duct obstruction as well as a mass in the orbit. b An axial CT scan showing a bony spicule going into the sac following a facial fracture (arrow). c An axial CT scan showing stenosis of the nasolacrimal sac (*) caused by excessive bony resection for nasal polyposis.

rmmnriBmn b

Fig. 14.3 a Wegener granulomatosis causing nasolacrimal duct obstruction as well as a mass in the orbit. b An axial CT scan showing a bony spicule going into the sac following a facial fracture (arrow). c An axial CT scan showing stenosis of the nasolacrimal sac (*) caused by excessive bony resection for nasal polyposis.

a c following a middle-third facial fracture (Fig. 14.3b). When this is the case, it can pose a surgical problem as the bone in the region of the lacrimal fossa may be thicker owing to callus formation or a concertina effect of the facial bones. Distal nasolacrimal obstruction can also occur secondary to endoscopic sinus surgery if back-biters used to remove the uncinate process are used too far forward (Fig. 14.3c). A contraindication to DCR is the presence of a benign or malignant lesion in the lacrimal system or the surrounding tissues and active Wegener granulomatosis.

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