(Radiology. 1999;212:365-370.)
© RSNA, 1999
Vascular and Interventional Radiology |
Dacryoliths: Nonsurgical Fluoroscopically Guided Treatment during Dacryocystoplasty1
Kai E. Wilhelm, MD,
Ulrich Hofer, MD,
Hans J. Textor, MD,
Thorsten Böker, MD,
Holger M. Strunk, MD and
Hans H. Schild, MD
1 From the Departments of Radiology (K.E.W., U.H., H.J.T., H.M.S., H.H.S.) and Ophthalmology (T.B.), University Hospital Bonn, Sigmund-Freud-Strasse 25, D-53127 Bonn, Germany. From the 1997 RSNA scientific assembly. Received July 20, 1998; revision requested September 4; final revision received February 4, 1999; accepted March 1. Address reprint requests to K.E.W. (e-mail: wilhelm@uni-bonn.de).
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Abstract
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PURPOSE: To evaluate dacryocystoplasty with fluoroscopically guided nonsurgical removal of dacryoliths in the treatment of dacryolithiasis.
MATERIALS AND METHODS: Ten patients with severe epiphora due to partial (n = 8) or complete (n = 2) obstruction of the nasolacrimal duct system associated with dacryolithiasis underwent fluoroscopically guided removal of dacryoliths during dacryocystoplasty. Balloon dilation was performed initially to widen the nasolacrimal duct obstructions and to fragment dacryoliths. This was followed by forced irrigation with saline solution through the canaliculi. In patients with incomplete dacryolith washout, a 6.3-F sheath was advanced in a retrograde fashion into the nasolacrimal sac, and forced irrigation was repeated with aspiration of the fragments through the sheath. In two patients with therapy-resistant dacryoliths, additional fragmentation of the concrements was performed with a gooseneck snare.
RESULTS: Removal of dacryoliths was technically successful in all patients (complete removal, n = 6; partial removal, n = 4). During a follow-up period of up to 18 months, complete resolution of epiphora was achieved in five patients, and five patients showed partial resolution of their symptoms.
CONCLUSION: Fluoroscopically guided removal of dacryoliths during dacryocystoplasty is a feasible nonsurgical therapy with good clinical results and may be used as an alternative to dacryocystorhinostomy.
Index terms: Catheters and catheterization, 223.1263 • 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
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Introduction
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Epiphora is a common ophthalmologic problem composing 3% of clinical visits (1,2). Tearing may have several causes. There may be excessive lacrimation, neoplastic processes, or congenital malformation (1,2). Alternatively, and much more commonly, tearing is caused by obstructive epiphora, which results from complete or incomplete obstruction of the lacrimal system (1). Dacryolithiasis is a sequela of chronic infection in up to 30% of patients (3). Stasis secondary to an anatomic obstruction is likely to be the precipitating factor (4). In most cases, flushing out of the dacryoliths as a sole procedure is not a sufficient therapy because the stenosis of the nasolacrimal duct system persists or because of the size of the dacryoliths. Therefore, surgical removal of the dacryoliths along with dacryocystorhinostomy is still the standard therapy (5).
Recently, fluoroscopically guided nonsurgical dacryocystoplasty has shown encouraging results in the treatment of nasolacrimal duct obstruction (6–10). However, filling defects indicating dacryoliths on dacryocystograms are regarded as a relative contraindication for dacryocystoplasty because dacryoliths are a common cause of reobstruction (11).
Although there have been clinical reports of dacryoliths passing spontaneously through the stenosed nasolacrimal duct into the nasal cavity (12,13) or being removed by forced irrigation, to our knowledge, removal of dacryoliths has never been performed as an interventional radiologic procedure. The purpose of this study was to evaluate fluoroscopically guided nonsurgical removal of dacryoliths during dacryocystoplasty for symptomatic nasolacrimal duct obstruction associated with dacryolithiasis.
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MATERIALS AND METHODS
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Patient Population
Between July 1995 and March 1998, 60 consecutive patients (41 women, 19 men; age range, 21–85 years; mean age, 56 years) who presented with severe epiphora to the department of ophthalmology were referred for dacryocystoplasty. In 10 of these patients (eight women, two men; age range, 28–71 years; mean age, 58 years), dacryolithiasis was diagnosed at dacryocystography. For diagnostic purposes, 1–2 mL iopamidol (Solutrast 300; Bracco-Byk Gulden, Konstanz, Germany) was injected manually during the acquisition of the digital subtraction dacryocystographic series at a frame rate of 2 per second (14). In these patients, preinterventional dacryocystography demonstrated nasolacrimal duct obstruction associated with prestenotic dacryolithiasis (partial obstruction, n = 8, complete obstruction, n = 2). The obstruction was located at the junction between the lacrimal sac and the nasolacrimal duct in eight patients and at the outlet of the nasolacrimal duct near the valve of Hasner in two patients. The valve of Hasner is a mucosal constriction at the distal end of the nasolacrimal duct, just before the duct empties into the inferior meatus of the nose, beneath the inferior turbinate (Fig 1).
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Figure 1. Drawing of the anatomy of the normal nasolacrimal drainage system of the right eye viewed frontally.
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The obstructions were due to idiopathic inflammation and scarring in all patients. At the time of dacryocystoplasty, however, no active inflammation was present. Lacrimal fistula or diverticula, neoplastic processes, or other abnormalities of the lid were not observed. In our study, epiphora was evaluated subjectively according to a scale similar to that of Munk et al (15); in our scale, the grade 4 defined by Munk et al was divided into grades 4 and 5. All patients complained of severe epiphora. Three required dabbing more than 10 times a day (grade 4), and seven had constant tearing (grade 5). The history of epiphora varied 1–4 years (mean, 2.5 years). The patients gave their written informed consent to dacryocystoplasty, which is an established procedure in our hospital, after they had been informed about the interventional procedure, risks, and alternatives.
Technique
Dacryocystoplasty was performed on an outpatient basis after the administration of topical anesthesia. For this, two to four drops of benoxinate hydrochloride 0.4% (Novesine 0.4; CIBA Vision Ophthalmics, Germering, Germany) were applied to the conjunctival sac followed by an irrigation of the nasolacrimal duct system with 1 mL benoxinate hydrochloride 0.4% through the canaliculi. For local anesthesia of the nasal mucosa, a nasal pack was placed in the inferior nasal meatus. This pack consisted of two cotton pledgets moistened with oxybuprocaine hydrochloride 1% (Novesine Wander 1%; Wander Pharma, Nürnberg, Germany) and was left in place for 5–10 minutes. Infratrochlear nerve block was performed with the subcutaneous injection of 1–2 mL of mepivacaine hydrochloride 2% (Scandicain 2%; Astra, Wedel, Germany). Additional sedation with 5 mg of midazolam hydrochloride (Dormicum 5/1 mL; Hoffmann-La Roche, Grenzach-Wyhlen, Germany) was administered intravenously in two patients during fragmentation of the dacryoliths.
For diagnostic purposes and to plan the intervention, dacryocystography was performed in anteroposterior (Fig 1) and lateral views after intubation of the inferior canaliculus with a 27-gauge polyvinyl chloride tubing catheter with a stainless steel cannula (dacryocystography catheter; Cook Europe, Bjaerverskov, Denmark).
In patients with incomplete obstructions (n = 8), a 5-F salivary gland catheter with a 23-gauge tapered tip (Rüschelit; Rüsch, Kernen, Germany) was introduced into the superior canaliculus. Recanalization of the stenoses was performed with lateral fluoroscopic guidance by using a 0.014-inch flexible wire (Skipper steerable guide wire; Invatec, Concesio, Italy), which was advanced through the catheter. The guide wire was advanced through the stenoses into the inferior meatus of the nasal cavity. Subsequently, the guide wire was grasped with a 6.0-F gooseneck snare (Amplatz Goose Neck snare; Microvena, White Bear Lake, Minn) with fluoroscopic control and pulled out of the external nares.
In patients with complete obstruction (n = 2), a 0.018-inch rigid, double-ended, ball-tipped guide wire (Cook) was used for recanalization. With lateral tension on the lid to prevent kinking of the canaliculus, the guide wire was advanced through the canaliculus to the nasal wall of the lacrimal sac. The guide wire was slightly withdrawn and rotated 90° to point the ball-tipped end caudad. With lateral fluoroscopic guidance, the guide wire was advanced gently across the obstruction into the inferior meatus. The ball-tipped guide wire was then grasped, with lateral fluoroscopic guidance, with a retrieval hook (Cook) and pulled out. The distal ball tip was then cut with a wire-cutting scissors (Storz, St Louis, Mo).
With lateral fluoroscopic guidance, a 3-mm-diameter angioplasty balloon catheter (Cook) was passed retrograde over the wire into the nasolacrimal duct and nasolacrimal sac. Dilation of the stenoses was performed by repeated inflation of the balloon for approximately 15 seconds in all 10 patients. After removal of the balloon catheter, washout of the dacryoliths was performed by means of forced antegrade irrigation with saline solution.
In patients with failed dacryolith washout (n = 8) due to dacryolith size, additional balloon dilation was performed to crush the dacryoliths. After the procedure, a 6.3-F sheath (Cook) was passed retrograde over the wire across the stenosed nasolacrimal duct until the tip of the dilator was lying in the nasolacrimal sac below the dacryolith. After withdrawal of the guide wire, the dilator was removed from the sheath, and stone removal was followed by repeated forced irrigation with saline solution with active aspiration of the fragments at the distal end of the sheath with a 50-cm3 syringe (Plastipak; Becton Dickinson, Drogheda, Ireland).
In two patients with nonfragmented dacryoliths in the nasolacrimal sac after balloon dilation, additional fragmentation of the dacryoliths was performed with a gooseneck snare (Amplatz Snare) (Fig 2). The gooseneck catheter was passed transnasally through the 6.3-F sheath into the nasolacrimal sac, and stone fragmentation was performed by twirling the snare with lateral fluoroscopic control. Afterward, forced irrigation with saline solution was repeated with active aspiration of the fragments at the distal end of the sheath.
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Figure 2. Photograph of a 6.0-F gooseneck snare with a radiopaque loop (arrow), 15-mm loop diameter, and a multipurpose catheter (arrowhead).
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In patients with preinterventional complete obstruction of the nasolacrimal duct system, stent (nasolacrimal duct stent; SNDS-600 Song; Cook Australia, Brisbane, Queensland, Australia) implantation was performed according to the technique described by Song et al (7) to restore drainage function and patency. Control dacryocystography was performed in all patients immediately after the procedure.
Prophylactic local antibiotic therapy was performed postinterventionally with gentamicin sulfate antibiotic eyedrops (Refobacin; Merck, Darmstadt, Germany) four times a day. In addition, patients were treated with xylometazoline hydrochloride decongestant eyedrops (Otriven; Zyma, Munich, Germany) for at least 1 week (two drops, four to five times a day) to avoid mucosal swelling. Follow-up dacryocystography and clinical examination were performed 2 weeks and at intervals of 3 months after dacryocystoplasty to assess the function and patency of the nasolacrimal duct system. In addition, clinical success was evaluated by interviewing the patients at the end of the follow-up period (June 5, 1998).
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RESULTS
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Fluoroscopically guided dacryocystoplasty was technically successful in all patients. During dacryocystoplasty, complete removal of dacryoliths was achieved in six patients, and partial removal was achieved in four patients. The average fluoroscopy time of the procedure was 5.7 minutes (range, 3.1–11.5 minutes). There were no major complications. All patients described mild pain during fragmentation of the dacryoliths with the balloon catheter or gooseneck snare. Three patients had slightly blood-stained nasal discharge during and after dacryocystoplasty, which stopped spontaneously within 1–2 hours after the procedure.
The dacryoliths were flushed out completely in two patients, without having to deal with the dacryoliths directly (Figs 3, 4). However, both patients needed dilation of the obstructed nasolacrimal duct segment prior to flushing so that the dacryoliths could be passed.
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Figure 3a. (a) Dacryocystogram (frontal view) of the right nasolacrimal duct system shows a large filling defect (arrowhead) in an abnormally dilated lacrimal sac. (b) Dacryocystogram (frontal view) after balloon dilation of the stenosed nasolacrimal duct demonstrates improvement of the passage of contrast medium (arrow) through the nasolacrimal duct system. (c) Photograph of the dacryolith spontaneously washed out by forced irrigation with saline solution.
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Figure 3b. (a) Dacryocystogram (frontal view) of the right nasolacrimal duct system shows a large filling defect (arrowhead) in an abnormally dilated lacrimal sac. (b) Dacryocystogram (frontal view) after balloon dilation of the stenosed nasolacrimal duct demonstrates improvement of the passage of contrast medium (arrow) through the nasolacrimal duct system. (c) Photograph of the dacryolith spontaneously washed out by forced irrigation with saline solution.
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Figure 3c. (a) Dacryocystogram (frontal view) of the right nasolacrimal duct system shows a large filling defect (arrowhead) in an abnormally dilated lacrimal sac. (b) Dacryocystogram (frontal view) after balloon dilation of the stenosed nasolacrimal duct demonstrates improvement of the passage of contrast medium (arrow) through the nasolacrimal duct system. (c) Photograph of the dacryolith spontaneously washed out by forced irrigation with saline solution.
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Figure 4a. (a) Dacryocystogram (frontal view) of the left nasolacrimal duct system shows a discrete rounded prestenotic filling defect (solid arrow) at the outlet of the nasolacrimal duct near the valve of Hasner (open arrow). (b) Dacryocystogram (lateral view) demonstrates the dacryolith (arrow) in a dependent (posterior) position in the nasolacrimal duct, not floating in the lacrimal sac. (c) Control dacryocystogram (lateral view) shows a patent nasolacrimal duct system after balloon dilation and removal of the dacryolith. The small filling defect near the upper end of the duct represents an air bubble (arrow) inadvertently injected during dacryocystography.
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Figure 4b. (a) Dacryocystogram (frontal view) of the left nasolacrimal duct system shows a discrete rounded prestenotic filling defect (solid arrow) at the outlet of the nasolacrimal duct near the valve of Hasner (open arrow). (b) Dacryocystogram (lateral view) demonstrates the dacryolith (arrow) in a dependent (posterior) position in the nasolacrimal duct, not floating in the lacrimal sac. (c) Control dacryocystogram (lateral view) shows a patent nasolacrimal duct system after balloon dilation and removal of the dacryolith. The small filling defect near the upper end of the duct represents an air bubble (arrow) inadvertently injected during dacryocystography.
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Figure 4c. (a) Dacryocystogram (frontal view) of the left nasolacrimal duct system shows a discrete rounded prestenotic filling defect (solid arrow) at the outlet of the nasolacrimal duct near the valve of Hasner (open arrow). (b) Dacryocystogram (lateral view) demonstrates the dacryolith (arrow) in a dependent (posterior) position in the nasolacrimal duct, not floating in the lacrimal sac. (c) Control dacryocystogram (lateral view) shows a patent nasolacrimal duct system after balloon dilation and removal of the dacryolith. The small filling defect near the upper end of the duct represents an air bubble (arrow) inadvertently injected during dacryocystography.
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In patients with failed dacryolith washout (n = 8) due to dacryolith size, additional balloon dilation was performed to crush the dacryoliths. Fragmentation of the dacryoliths was achieved in six patients. Complete removal of the crushed dacryoliths was achieved by aspirating the fragments in three patients. Partial removal of the crushed dacryoliths was achieved in three patients.
In the two patients with unsuccessful balloon fragmentation, additional fragmentation of the dacryoliths with a gooseneck snare was performed (Fig 5). Fragmentation of the dacryoliths was achieved by using the snare in both patients. Complete removal of the crushed dacryoliths was achieved by aspirating the fragments in one patient.
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Figure 5a. (a) Dacryocystogram (frontal view) shows complete obstruction of the left nasolacrimal duct system at the junction between the lacrimal sac and the nasolacrimal duct, with prestenotic filling defects (arrowheads) representing dacryoliths. (b) Dacryocystogram (lateral view) shows a gooseneck snare (arrow) has been passed transnasally through the 6.3-F sheath in the nasolacrimal sac, and fragmentation of the dacryoliths is performed by twirling the snare. (c) Dacryocystogram (lateral view) obtained during forced irrigation and aspiration at the distal end of the sheath shows fragmented dacryoliths (arrows) flowing through the sheath. (d) Dacryocystogram (frontal view) obtained after stent implantation shows good passage of the contrast medium (arrows) through the stent into the nasal cavity. (e) Photograph shows multiple small fragments aspirated into the syringe.
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Figure 5b. (a) Dacryocystogram (frontal view) shows complete obstruction of the left nasolacrimal duct system at the junction between the lacrimal sac and the nasolacrimal duct, with prestenotic filling defects (arrowheads) representing dacryoliths. (b) Dacryocystogram (lateral view) shows a gooseneck snare (arrow) has been passed transnasally through the 6.3-F sheath in the nasolacrimal sac, and fragmentation of the dacryoliths is performed by twirling the snare. (c) Dacryocystogram (lateral view) obtained during forced irrigation and aspiration at the distal end of the sheath shows fragmented dacryoliths (arrows) flowing through the sheath. (d) Dacryocystogram (frontal view) obtained after stent implantation shows good passage of the contrast medium (arrows) through the stent into the nasal cavity. (e) Photograph shows multiple small fragments aspirated into the syringe.
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Figure 5c. (a) Dacryocystogram (frontal view) shows complete obstruction of the left nasolacrimal duct system at the junction between the lacrimal sac and the nasolacrimal duct, with prestenotic filling defects (arrowheads) representing dacryoliths. (b) Dacryocystogram (lateral view) shows a gooseneck snare (arrow) has been passed transnasally through the 6.3-F sheath in the nasolacrimal sac, and fragmentation of the dacryoliths is performed by twirling the snare. (c) Dacryocystogram (lateral view) obtained during forced irrigation and aspiration at the distal end of the sheath shows fragmented dacryoliths (arrows) flowing through the sheath. (d) Dacryocystogram (frontal view) obtained after stent implantation shows good passage of the contrast medium (arrows) through the stent into the nasal cavity. (e) Photograph shows multiple small fragments aspirated into the syringe.
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Figure 5d. (a) Dacryocystogram (frontal view) shows complete obstruction of the left nasolacrimal duct system at the junction between the lacrimal sac and the nasolacrimal duct, with prestenotic filling defects (arrowheads) representing dacryoliths. (b) Dacryocystogram (lateral view) shows a gooseneck snare (arrow) has been passed transnasally through the 6.3-F sheath in the nasolacrimal sac, and fragmentation of the dacryoliths is performed by twirling the snare. (c) Dacryocystogram (lateral view) obtained during forced irrigation and aspiration at the distal end of the sheath shows fragmented dacryoliths (arrows) flowing through the sheath. (d) Dacryocystogram (frontal view) obtained after stent implantation shows good passage of the contrast medium (arrows) through the stent into the nasal cavity. (e) Photograph shows multiple small fragments aspirated into the syringe.
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Figure 5e. (a) Dacryocystogram (frontal view) shows complete obstruction of the left nasolacrimal duct system at the junction between the lacrimal sac and the nasolacrimal duct, with prestenotic filling defects (arrowheads) representing dacryoliths. (b) Dacryocystogram (lateral view) shows a gooseneck snare (arrow) has been passed transnasally through the 6.3-F sheath in the nasolacrimal sac, and fragmentation of the dacryoliths is performed by twirling the snare. (c) Dacryocystogram (lateral view) obtained during forced irrigation and aspiration at the distal end of the sheath shows fragmented dacryoliths (arrows) flowing through the sheath. (d) Dacryocystogram (frontal view) obtained after stent implantation shows good passage of the contrast medium (arrows) through the stent into the nasal cavity. (e) Photograph shows multiple small fragments aspirated into the syringe.
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Postinterventional dacryocystography showed adequate widening of all incomplete obstructions after balloon dilation (n = 8). Nasolacrimal duct stents were deployed successfully in the two patients with preexistent complete nasolacrimal duct obstruction after complete extraction of the dacryoliths (n = 2).
The clinical results of the procedure were evident after dacryocystoplasty in all cases. Within a follow-up period up to 18 months (average follow-up, 6 months; range, 3–18 months), five patients showed complete resolution of epiphora, and the remaining five patients showed partial resolution. In three of these patients, the procedure resulted in epiphora requiring dabbing less than twice a day (grade 1, according to Munk et al [15]), and two patients demonstrated occasional epiphora that required dabbing two to four times a day (grade 2, according to Munk et al [15]). In these two patients, clinical examination results demonstrated chronic infective canaliculitis and scarring of the canaliculi.
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DISCUSSION
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Dacryolithiasis has been considered a clinically important cause of lacrimal duct occlusion (16,17). Cranial movement of free dacryoliths will allow free flow of tears, while caudal movement of the dacryoliths creates a ball-valve effect that results in complete nasolacrimal obstruction (17,18). Patients complain of chronic intermittent epiphora frequently associated with mucopurulent discharge (17,19,20). Stasis secondary to an anatomic irregularity is a frequent predisposing factor (21,22). Additional chronic infective canaliculitis is frequently associated with dacryolithiasis because organisms, such as an Actinomyces species or, less frequently, Staphylococcus aureus, form filamentous aggregates (sulfur granules) (17,23).
Dacryocystography frequently shows dilatation and irregularity of the affected nasolacrimal duct system with an appearance of sacculation, beading, or diverticula (17). Prestenotic filling defects representing dacryoliths typically are located in the lacrimal sac (Figs 3a, 5a) (11,14). However, air bubbles injected into the nasolacrimal system during dacryocystography represent an artifact that can simulate dacryoliths. In these cases, a crosstable lateral view will demonstrate the air bubble floating in the lacrimal sac, while dacryoliths tend to settle in the more dependent (posterior) position (Fig 4b) (17).
In 1995, Song et al (5) reported nonsurgical management of dacryolithiasis in a 51-year-old woman with epiphora caused by a complete obstruction of the nasolacrimal duct system. Preinterventional dacryocystography showed an obstruction at the level of the neck of the lacrimal sac at its junction with the nasolacrimal duct, with filling defects in the prestenotic dilated nasolacrimal sac. During stent implantation, the authors discovered that the concrements were broken into fragments. While the lacrimal system was irrigated with saline solution, the fragments passed into the pharynx. The authors were unable to save the dacryoliths because the patient swallowed them during the irrigation.
Removal of dacryoliths as a sole procedure is not a sufficient therapy because the stenosis of the duct system persists and results in continued epiphora. Therefore, surgical removal of dacryoliths along with dacryocystorhinostomy has still been necessary (5). Dacryocystorhinostomy, however, usually requires general anesthesia combined with hospitalization of the patient and may leave a permanent facial scar. Moreover, failure still occurs in 6%–13% (13 of 103) of patients (21,24). The previous studies (15,21) of nasolacrimal duct stent implantation or balloon dilation showed encouraging results in the treatment of the obstructed nasolacrimal duct system. However, the extraction of associated dacryoliths was not mentioned as an interventional radiologic procedure in these reports.
In cases of dacryolithiasis associated with an incomplete obstruction of the nasolacrimal duct system, patients may be treated by means of balloon dilation followed by forced irrigation with saline solution. In these cases, balloon dilation primarily is used to widen the stenosed lacrimal duct segment so that dacryoliths can pass into the nasal cavity. If stone passage is not achieved because of the size of the dacryoliths, or because of a persistent stenosis of the nasolacrimal duct system, balloon dilation also may be used to crush the concrements. In cases of incomplete washout of concrements by means of forced irrigation with saline solution, a 6.3-F sheath is advanced retrograde over the wire, across the stenosed nasolacrimal duct, until the tip of the dilator is lying below the dacryolith. After the guide wire is withdrawn, repeated forced irrigation with saline solution is performed with active aspiration of the fragments through the sheath.
During these procedures, fluoroscopy is necessary to avoid damage of the nasolacrimal duct system, to observe the position of the balloon catheter and sheath, and to control the aspiration of the fragmented dacryoliths. When bending of the sheath occurs or fragments are too large to pass through the sheath, attempts of stone removal may be ineffective. However, according to our observations, aspiration of the fragments during forced irrigation with saline solution is sufficient in most cases.
In a few cases, control dacryocystography will show persistent concrements in the lacrimal sac. In these cases, additional fragmentation with a gooseneck snare is possible. A snare is passed transnasally through a 6.3-F sheath into the lacrimal sac, and stone fragmentation is performed by twirling the snare (Fig 5b). During this intervention, fluoroscopy is necessary to identify the exact level of the dacryolith so that the twirling of the gooseneck snare is effective and to avoid damage of the nasolacrimal duct system. The procedure is very effective but causes more discomfort for the patients than balloon dacryocystoplasty alone. Therefore, in addition to the routinely administered topical anesthesia, the patient should be sedated. After the fragmented dacryoliths have been completely washed out, control dacryocystography must be performed to verify nasolacrimal duct patency. In cases of preinterventional complete obstruction of the nasolacrimal duct system, stent implantation is necessary to restore the drainage function.
In conclusion, the results of our study demonstrate that dacryocystoplasty is a feasible form of therapy with good clinical outcome even in nasolacrimal duct obstructions associated with dacryolithiasis. This procedure offers the following advantages over the invasive surgical procedure: General anesthesia is not needed, there is no alteration of the anatomy, the therapy is feasible on an outpatient basis, and no facial scar is produced. The interventional radiologic procedure we describe should be considered as an alternative to dacryocystorhinostomy in the treatment of dacryolithiasis, and dacryocystorhinostomy can be used in case of failure.
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Acknowledgments
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We thank William P. Gray, MD, FRCSI, FRCS(SN), Senior Lecturer, University Department of Clinical Neurosciences, Southampton General Hospital, Southampton, England, for correcting the manuscript.
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Footnotes
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See also the editorial by Weissman (pp 305–306
) in this issue.
Author contributions: Guarantors of integrity of entire study, all authors; study concepts and design, K.E.W., U.H., T.B.; definition of intellectual content, all authors; literature research, K.E.W.; clinical studies, K.E.W., U.H., T.B., H.J.T.; data acquisition, K.E.W., T.B.; data analysis, K.E.W., U.H., T.B.; manuscript preparation, K.E.W.; manuscript editing and review, all authors
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Abstract
Introduction
