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Editorial |
1 From the Department of Radiology, University of Pittsburgh Medical Center, Rm PUH D-132, 200 Lothrop Street, Pittsburgh, PA 15213. Received April 8, 1998; accepted April 16. Address reprint requests to the author. (e-mail: weissmanjl@radserv.arad .upmc.edu).
Index terms: Catheters and catheterization, 223.1263 • Editorials • Fluoroscopy, 223.11 • Lacrimal gland and duct, 223.1492, 223.818 • Lacrimal gland and duct, interventional procedures, 223.1262, 223.1263, 223.1267, 223.1295 • Lacrimal gland and duct, radiography, 223.11, 223.1295
Therapeutic interventions joined the diagnostic radiology armamentarium in 1964 (1). Remarkable new vistas opened immediately. Since the first reported angioplasty (1), radiologists have been augmenting and refining their ability to accomplish, without surgery or general anesthesia, procedures that previously required both (2,3). The article by Wilhelm et al (4) in the current issue of Radiology provides one more example of an ingenious nonsurgical approach to a problem previously deemed exclusively surgical.
External dacryocystorhinostomy is the traditional option to treat lacrimal sac stones (dacryolithiasis), nasolacrimal duct obstruction, and the resultant epiphora (tearing). Dacryocystorhinostomy, the surgical placement of a stent between the lacrimal sac and the nasal cavity, usually requires general anesthesia and always leaves a cutaneous scar (5,6). Other surgical options include endonasal (endoscopic) dacryocystorhinostomy and laser dacryocystorhinostomy (5).
In an elegant nonsurgical procedure, Wilhelm and colleagues crushed dacryoliths with a balloon-tipped catheter, then flushed the fragments out of the nasolacrimal duct into the nose (4). The procedure was performed with fluoroscopic observation. Some patients required intravenous sedation, but no patients required general anesthesia, and the procedure left no visible scars.
Nonsurgical fluoroscopically guided treatment of dacryoliths is the youngest child in a family of interventional radiologic procedures addressing partial and complete obstruction of the lacrimal apparatus. Hanafee and Dayton (7) dilated the nasolacrimal duct with a probe and fluoroscopic guidance in 1978. Radiologists soon were using balloons to dilate the nasolacrimal duct (8–11) and placing metal (12), plastic (13), and polyurethane (14–16) stents in the duct. Ophthalmologists jumped on the balloon bandwagon (17,18). Despite cautionary notes sounded (in this journal) by an ophthalmologist warning radiologists against instrumentation of the lacrimal sac and canaliculi (6), this journal subsequently reported successful balloon dilation of the lacrimal sac by radiologists (19). Radiologists also used balloons to dilate the lacrimal canaliculi (20,21) and placed a lacrimal canaliculus stent (22).
How important is this work? Epiphora occurs in two settings: a normal, patent lacrimal apparatus overwhelmed by a sudden flow of tears (as in crying), and a partially or completely obstructed system unable to drain a normal volume of tears. The latter brings patients to medical attention. Epiphora is a troubling problem but not a debilitating one. It is considered a common ophthalmologic problem but accounts for less than 5% of office visits (4,23).
In the United States, epiphora has not achieved the epidemic proportions or ramifications of cardiovascular disease. I conducted an informal survey of head and neck radiologists practicing in the United States and identified only one radiologist who had dilated a nasolacrimal duct. Yet to consider the utility of interventional radiology in the lacrimal apparatus solely from the perspective of patient numbers or the severity of the affliction does a disservice to this procedure and to the entire field of interventional radiology.
The inclination to design, attempt, and refine a nonsurgical solution to any clinical problem is the basis of the field of interventional radiology. After Dotter and Judkins' groundbreaking report (1), the newfound ability to treat atherosclerotic disease from within (the endovascular approach) rather than from without (surgery) fired the imaginations of radiologists. Reports of "minimally invasive procedures" (3) to treat vascular and, subsequently, nonvascular disease soon began to appear.
Today, the interventional radiology suite has replaced the operating room as the venue for a wide array of therapeutic procedures. The blood supply to aneurysms, vascular malformations, varicoceles, vascular tumors, and vessels damaged by tumor, trauma, or irradiation can be therapeutically interrupted with polyvinyl alcohol particles, gelatin sponge, glue, collagen, coils, and balloons (24–28). The patency of thrombosed vessels can be reestablished with urokinase or tissue plasminogen activator (29), as well as an array of investigational drugs and thrombectomy catheters. Angioplasty preserves or widens a lumen compromised by atherosclerosis, spasm, or irradiation (3). Balloons reestablish, and stents maintain, the patency of blood vessels, ducts (lacrimal, biliary), and hollow viscera (esophagus, bronchus, ureter) (3,30–34). Percutaneous injections obliterate or reduce vascular malformations (35); percutaneous catheters address renal and other obstructions (33). All of these procedures rely on fluoroscopy, and most are quicker, easier (for both the patient and the physician), and less invasive than existing surgical alternatives. In the era of managed care and cost containment, a less invasive procedure that is followed by a more rapid recovery has wide appeal.
The field of interventional radiology is large and continues to grow. The development of new techniques refines and advances the specialty. Applying established techniques to newly identified problems, as Wilhelm and colleagues (4) have done, is yet another way to advance the forefronts of interventional radiology and to provide evidence of the field's vitality.
To the patients affected, epiphora is not a minor problem, and these patients are no less deserving of state-of-the-art medical care because their numbers are small. The inclination to address epiphora, and other clinical problems, by modifying the existing techniques of interventional radiology is ingenious and important. Publication of this work encourages and rewards the authors and, I hope, encourages and inspires others.
Acknowledgments
The author is grateful to Sabrina L. Jennings for her good-natured and skillful manuscript preparation.
Footnotes
See also the article by Wilhelm et al (pp 365–370 ) in this issue.
References
Related Article
This article has been cited by other articles:
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  J. Asheim and E. Spickler CT Demonstration of Dacryolithiasis Complicated by Dacryocystitis AJNR Am. J. Neuroradiol., November 1, 2005; 26(10): 2640 - 2641. [Abstract] [Full Text] [PDF]
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 K. E. Wilhelm, E. T. Ilgit, D. Bor, and N. Meric Radiation Dose in Fluoroscopically Guided Dacryocystoplasty Dr Ilgit and colleagues respond: Radiology, May 1, 2001; 219(2): 577 - 578. [Full Text]
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