Radiography round on dacrocystography

A detailed presentation on the Dacrocystography from scratch to present.

1. Radiography Round on Dacrocystography Anjan Dangal BSc.Medical Imaging Technology 3 rd Year Student National Academy of Medical Sciences, Bir Hospital Kathmandu, Nepal

2. Dacrocystography Radiologic Imaging of the Naso- lacrimal Conventional /DS Dacrocystography Computed Tomography Dacrocystography Magnetic Resonance Dacrocystography .

3. Anatomy of Lacrimal Drainage System Consists of three major drainage system: The Canaliculi The Lacrimal sac The Lacrimal Duct

4. Anatomy of Lacrimal drainage system

5. Punctum = 0.2mm diameter Vertical canaliculi = 2 mm in length travel horizontally for 8 mm, and join to form a common canaliculus in more than 90% of individuals between the canaliculi and the lacrimal sac: valve of rosenmuller (prevents the retrograde flow of tears from the lacrimal sac back toward the globe) Lacrimal Sac: 10-15mm vertically Distal end: valve of hasner

6. Conventional Dacrocystography irrigation of contrast material through the lacrimal drainage system with subsequent serial radiography provides details about nasolacrimal duct stenosis , fistulae, mucoceles , (  dilatation of the  nasolacrimal apparatus  due to obstruction of the  nasolacrimal duct . neoplasms , and lacrimal system stones or Dacryoliths ( epithelial cells, lipids, and amorphous debris with or without calcium .)

7. Indication Epiphora : tearing is the presence of a watering eye.  two categories: reflex tearing and reduced tear outflow

8. Medial canthal masses

9. Purulent discharge from lacrimalPuncta

10. Blood discharge from lacrimal puncta

11. ContraIndication None

12. Contrast Media Bismuth subnitrate in liquid petroleum : Ewing: 1909 Lipoidol : Bollack : 1924 Lipoidol with olive oil: Spackman : 1938 Iodized oil: Fox and Blankstein : 1947 and 1952 Ethyl iodophenylundecylate ( Pantopaque ): Milder and dermorest : 1955 Neohydroil : Agrawal : 1961 Neohydroil : Nahata : 1964: Present ’ s recommendation: LOCM 300mgI/ml : 0.5 – 2ml/side

13. Materials Required Lacrimal Dilator Lacrimal cannula or 18G blunt needle with polythene catheter 2cc syringe DSA Unit

14. Patient Preperation 0.5 % bupivacaine eye drops.( Anesthetic)

15. Technique Preliminary films: Anteroposterior and lateral views of orbit are taken. Lacrimal sac is massaged to express its content prior to contrast administration. Local anesthetic drops are instilled Lower end of canaliculus is everted to locate lower canaluculus at the medial end of lid. Lower canaliculus is dilated and cannula is inserted. 2-3 ml of CM is gently injected to opacify entire nasolacrimal apparutus . Serial anterior-posterior and lateral films are taken with the patient in a sitting position immediately after injection and then 15 minutes later. normal dacryocystogram , contrast material is seen immediately flowing through the lacrimal drainage system and onto the floor of the nasal cavity . delayed films show no retention of contrast material in the lacrimal sac or nasolacrimal duct.

16. Complications Contrast Extravasation Injury to canaliculi Infection

17. Aftercare A protective eyepatch for 30-60 min may be necessary in view of local anaesthetic used.

18. Normal dacryocystogram

19. Mucocele of lacrimal sac with obstruction at junction of sac and duct

20. Mucocele of the lacrimal sac with partial block at junction of sac and duct. Some of the dye can be seen in the nasal cavity

21. Mucocele of lacrimal sac with diverticula

22. Distension-Dacrocystography In 1968, Iba and Hanafee described the technique of distension DCG. Here, fi lms are taken during injection of 0.5–1.0 mL of contrast material so that the lacrimal system is imaged in the distended state. Both sides are studied simultaneously and injection is accomplished through the placement of canalicular indwelling tapered Teflon catheters or intravenous catheter tubing. This method provides maximum visualization of the anatomic structure of the system and, because of the backpressure, gives good fi lling of the canaliculi. It is the best technique for demonstration of fi stulae,diverticula, supernumerary canaliculi, and the presence of stones and sac tumors. However, it does not reveal sac and duct dimensions under normal physiologic conditions.

23. DSA-Dacrocystography technique adopted from subtraction angiography that eliminates confusing bonyshadows. Digital subtraction contrast dacryocystogram. Patient with normal passage of contrast through the left nasolacrimal system and complete blockage of the right proximal nasolacrimal duct and mild dilation of the right nasolacrimal sac.

24. A scout film is taken before injecting contrast material and is used to produce bone-free images of the dacryocystogram. The contrast medium is injected and a digital subtraction run at one image per second is obtained. This allows for a dynamic study in real time.

25. CT - Dacrocystography CT–DCG provide additional crosssectional information in comparison to conventional DCG. CT–DCG delineates not only the patency of the lacrimal drainage system , but also the adjacent soft tissue and osseous abnormalities seen with pathologic conditions like sinusitis , mucoceles , nasal polyposis , and dacryoliths . Study of choice for evaluating the patency of the ostomy in a patient after a dacryocystorhinostomy

26. Axial CT scan shows the normal nasolacrimal duct ( ND,arrow ). Note uncinate process (arrows) and its attachment to the lacrimal bone. The infundibulum (arrowheads) is visualized lateral to the uncinate process. ( B) Coronal CT scan shows the normal lacrimal sac fossa (arrow). ( C) Reformatted sagittal CT reconstructions show the osseous nasolacrimal canal (arrowheads) entering into the inferior meatus .

27. Axial CT–DCG demonstrating contrast-fi lled lacrimal sacs(arrowheads). The left system is dilated compared with the right.

28. When epiphora follows trauma and subsequent clinical studies indicate nasolacrimal duct obstruction, CT may reveal orbital rim or maxillary fractures compressing the sac or duct. In cases of congenital lacrimal amniocele, CT will reveal the dilated duct, often associated with bony changes. It is essential to differentiate this soft, near-midline dilated sac from a meningocele. In most cases of suspected malignancy, especially if there is a history of bloody epiphora or pain, a CT scan may demonstrate soft tissue masses of the sac or adjacent paranasal sinuses.

29. three-dimensional reconstruction technology have improved the diagnostic accuracy for patients with partial obstructions of the nasolacrimal system by allowing the surgeon to view a three-dimensional image of the entire system

30. CBCT- Dacrocystography Disadvantages reported with CT-DCG are the lack of a dynamic contrast passage and increased radiation exposure. MRI-DCG can show the function of the nasolacrimal apparatus under physiologic conditions after topical application of a contrast medium and visualizes subtle soft-tissue changes, such as early malignancies. Long imaging time, poor delineation of bony ductal components, and lack of anatomical detail has prevented this imaging technique from being routinely used

31. CBCT-Dacrocystography For the direct syringing technique, all patients initially received 1 drop topical anesthetic (oxybuprocain 0.4%, Thereafter, the inferior punctum was catheterized with a 26-G microcatheter (Vasculon Plus; Becton Dickinson AG, and 1 to 2ml of a nonionic, water-soluble contrast was slowly injected manually until the patients reported either feeling the solution in their nasal antrum and/or pharynx or when the liquid refluxed out of the lower or upper punctum. For the passive technique, the patients received a total of 3 drops of Iopamiro 300 into the conjunctival sac of OU after 0, 5, and 10 minutes, and they were told not to rub their eyes. Thereafter, CBCT was immediately performed.

32. Dacryocystography with direct application of contrast medium using cone beam CT in a 64-year-old female patient withbilateral obstruction of the nasolacrimal system. A, In the axial slice, no contrast medium is visible, indicating the blockage of both nasolacrimal ducts at the canalicular level. B, In the coronal slice, the contrast medium is visible as being pooled in the left lacrimal sac. C, Sagittal slice of the right nasolacrimal system exhibiting contrast medium in the common nasolacrimal canaliculus. D, Sagittal slice of the left nasolacrimal system showing blockage at the lacrimal sac.

33. Dacryocystography after passive application of contrast medium using cone beam CT in a 37-year-old female patient with theobstruction of the left nasolacrimal system at the level of the lacrimal sac. A, In the axial slice, no contrast medium is visible in the left nasolacrimal duct, indicating a blockage at the distal end of the lacrimal sac. B, In the coronal slice, the contrast medium is observed through the whole right nasolacrimal system, with traces in the nasal antrum, whereas on the left site, pooling of the contrast agent is visible at the lacrimal sac. C, Sagittal slice of the right nasolacrimal system. D, Sagittal slice of the left nasolacrimal system showing blockage at the lacrimal sac.

34. Both techniques proved to be simple procedures with good delineation of the bone, soft tissue, and the contrast medium in the lacrimal system. No side effects were noted. CBCT-DCG has potential for evaluating patients with epiphora and a tentative diagnosis of complete obstruction of the nasolacrimal system prior to surgical intervention. Advantages of the CBCT-DCG include short image acquisition time and good delineation of bone and soft tissue at a lower irradiation dose than conventional CT. Furthermore, CBCT-DCG is performed in an upright position, allowing physiologic examination of the lacrimal system.

35. MR- Dacrocystography MR imaging alone can be helpful in identifying the subtle lacrimal drainage anatomy and determining the extent and specific type of pathology when soft tissue lesions such as neoplasms , papillomas , and mucoceles are suspected .

36. The first MR-DCG was performed in 1993 using 0.5% gadolinium contrast media . Functional and morphological aspects of lacrimal pathways without any radiation exposure and ability to acquire series of images are advantages of MR-DCG. High cost, Longer Acquisition time and motion artifacts are limitations. Cannulation and Topical Instillation of contrast have been tried . Topical Instillation: 1 drops every three minuted for 15 to 20 min. Use Sequences: Fast Spin Echo (FSE) Single Shot TSE 3D Fast recovery fast spin echo ( FRSE) Imaging Time : Dropped from 20-30min to 7-12 min Dynamic MR DCG,: capture of passage of contrast media across Lacrimal Ductal system MR DCG Sensitivity: 90.5 % , Specificity: 89.3% to DCG

37. Normal saline alone or in combination with 0.5% lidocaine have also reproduced comparable imaging feature to Gadolinium. But another study found that more accurate information was obtained with gadolinium than saline. Tear Flow Dynamics was clearly seen with Saline solution than Gadonium in MR-DCG.

38. Ultrasonography Although ultrasonography is not ideal for the evaluation of canaliculi or the nasolacrimal duct, it can be used to examine the lacrimal sac and surrounding tissues as a diagnostic adjunct or in postoperative situations .

39. Pathological Findings Congenital Abnormalities Infectious disease Inflammatory disease Neoplastic disease of Lacrimal Drainage System

40. common congenital abnormality = partial or complete obstruction at the distal end of the nasolacrimal duct as the result of an impatent valve of Hasner or osseous obstruction. With complete obstruction of the valve of Hasner, a sterile accumulation of mucus or amniotic fluid may become trapped in the lacrimal sac and nasolacrimal duct. This entity has been named a congenital dacryocele, mucocele, dacrocystocele, or amniotocele, even bilaterally Congenital Findings

41. Congenital atresia of the lacrimal puncta = the puncta are absent but the remaining lacrimal drainage system is patent, duplication of a canaliculus, and diverticulae of the lacrimal drainage system may all be seen in young patients as well as in older individuals.

42. Bilateral congenital dacryoceles (mucoceles). Axial CT scan shows marked dilation of both nasolacrimal ducts (arrowheads).

43. Infectious Disease most common infectious process is dacryocystitis. obstruction at some level of the lacrimal drainage system that causes decreased tear outflow, bacteria proliferation, and infection. foreign bodies, such as lashes and deposits from certain eye drops containing epinephrine, may cause obstruction of the lacrimal drainage apparatus. The most common infectious agents responsible for dacryocystitis are Streptococcus pneumoniae, Staphylococcus, and Pseudomonas bacterial strains.

44. Nasolacrimal duct obstruction. Following DCG, contiguous axial (A–C) and coronal (D) CT scans demonstrate retainedcontrast in the dilated right nasolacrimal duct (arrows), right lacrimal sac (white arrowhead), and inferior lacrimal canaliculus (black arrowheads) consistent with right nasolacrimal duct obstruction in a patient who subsequently required a right dacryocystorhinostomy.

45. Nasolacrimal duct obstruction. After DCG, axial (A) and coronal (B) CT scans with a reformatted sagittal CT reconstruction ( show retained contrast in the right inferior canaliculus (white arrowhead), lacrimal sac (arrow), and nasolacrimal duct (black arrowheads) consistent with distal nasolacrimal duct obstruction of lacrimal sac. Axial (D) and coronal (E) follow-up CT scans demonstrate postsurgical osteotomy changes 8 months status post right dacryocystorhinostomy in the same patient.

46. Inflamatory disease Sarcoidosis may involve almost every organ system, including multiple ocular and orbital sites as well as the lacrimal drainage system Orbital and lacrimal symptoms associated with sarcoidosis include pain, tearing, exophthalmos, restricted motility, palpable masses, conjunctival masses. DCG findings are nonspecific and may show partial or complete obstruction of the lacrimal drainage system.

47. Another inflammatory disease associated with significant lacrimal drainage pathology is Wegener granulomatosis. It is a multisystem disease, but typically presents with severe upper respiratory tract findings Eye manifestations occur in 50% of patients presenting with dacryocystitis, lacrimal sac masses, and tearing

48. Wegener granulomatosis. (A) Coronal CT scan demonstrates postsurgical changes after a right dacryocystorhinostomy (arrowheads) and a dilated left lacrimal sac (arrow). (B) Coronal CT scan demonstrates posteriorly the postsurgical changes of the nasal cavities, soft tissue thickening of the left nasal cavity, and opacification of the left ethmoid air cells in this patient with Wegener granulomatosis. (C) Reformatted sagittal CT reconstruction in same patient demonstrates the dilated lacrimal sac (white arrowheads) and fluid within the nasolacrimal duct (black arrowheads). (D) Axial CT scan in another patient with Wegener granulomatosis shows a dilated and fluid-filled right lacrimal sac (arrow).

49. Neoplastic disease Lacrimal drainage system tumors are extremely rare. Patients with lacrimal drainage system tumors present with symptoms of epiphora, bloody epiphora, nasal obstruction, and purulent or bloody discharge. With larger or more aggressive tumors, the presentation includes a medial canthal or lacrimal sac mass; inflammation;, dysmotility, and globe displacement

50. Axial postcontrast CT scan demonstrates an enhancing right lacrimal sac tumor (black arrowhead) invading the adjacent orbit, including the right medial rectus muscle, consistent with pathologically proven squamous cell carcinoma. (B) Coronal postcontrast CT scan shows a large enhancing tumor in the left nasal cavity extending into and involving the left lacrimal sac (white arrowheads)

51. Conclusion Dacryocystography has been used for illustrating the morphological and functional aspects of the lacrimal drainage system (LDS). Subtraction DCG is goldstandard provides the precise location of the alterations and acceptably delineates stenosis or an obstruction. Low osmolality iodinated contrast media are tolerated well for DS-DCG and CT-DCG. However, normal saline either mixed with lidocaine or alone provided similar image quality as obtained with gadolinium for MR-DCG. CT-DCG provides useful information in complex orbitofacial trauma and lacrimal tumors. MR-DCG allows better 3D visualization of the LDS, surrounding soft tissue and dynamic functional evaluation. Sensitivity of CT-DCG and MR-DCG are mostly similar in identifying an LDS obstruction

52. References 1. Pathology and Imaging of the Lacrimal Drainage System Sameer A. Ansari, MD, PhD, John Pak, MD, PhD, Marc Shields, MD, 2.Dacryocystography Using Cone Beam CT in Patients With Lacrimal Drainage System Obstruction Markus Tschopp, M.D.*†, Michael M. Bornstein, D.M.D.‡§, Pedram Sendi, D.M.D., M.D.║, Reinhilde Jacobs, D.D.S., Ph.D.§, and David Goldblum, M.D.* 3. Dacrocystography: From Theory to current practise, Annals of Anatomy : 2019 4. Nick Watson and Chapman: A guide to Radiologic Procedures.