1990, The British Journal of Radiology, 63, 337-339 The role of dacryocystography in the management of patients with epiphora By J. Nixon, MB, ChB, BSc, *l. W. J. Birchall, MRCP, FRCR and *J. Virjee, FRCR Bristol University Medical School and "Department of Radiodiagnosis, Bristol Royal Infirmary, Bristol (Received August 1989 and in revised form November 1989) Abstract. A retrospective study has been carried out on 114 patients who have undergone dacryocystography (DCG) for epiphora, to assess the role of DCG in their management. It was found that 16/66 (24%) patients who were offered surgery after DCG refused it or were assessed as unfit for surgery, demonstrating the need for careful counselling and assessment of patients prior to investigation. The presence of lacrimal system obstruction on DCG was an important factor in determining whether a patient underwent lacrimal surgery. However, the actual level of the obstruction influenced neither the likelihood of a patient undergoing lacrimal surgery nor the form of lacrimal surgery undertaken. This suggests that, unless the surgical approach will be modified in the light of the anatomical information furnished by DCG, DCG is not necessary. Lacrimal scintigraphy would provide sufficient information for the practical management of epiphora. Syringing of the lacrimal system correlates poorly with DCG in detecting obstruction. Epiphora is a common but rarely serious condition in ophthalmological practice. Abnormalities of the lacrimal drainage system (Fig. 1) are a common cause of epiphora. Before any radiological investigation is under- taken, the system can be syringed with saline (normally by cannulating the lower punctum). Free flow is taken to show that the system is not obstructed. It may not be possible to determine the level of obstruction by syringing; in this case an imaging technique is required: dacryocystography (DCG) or lacrimal scintigraphy. DCG is carried out by cannulating the lower punctum and injecting contrast medium into the lacrimal drain- age system (Chapman & Nakielny, 1986), a technique first described by Ewing (1909). Campbell (1964) improved the technique of macrodacryocystography by geometric magnification of the image. Bone free images can be obtained by photographic or digital subtraction techniques. DCG gives precise anatomical definition of any blockage or stenosis of the system (Lloyd & Welham, 1974). It is possible to distinguish medial from lateral common canalicular obstruction. Methods Records of DCGs performed on patients referred for epiphora to the Diagnostic Radiology Department of the Bristol Royal Infirmary between February 1984 and January 1987 were reviewed and correlated with the medical records to ascertain both the result of syringing the lacrimal system prior to any DCG and the treatment subsequently given. The patients were grouped according to the result of their DCG: 1 Normal 2a Blockage or stenosis at the common canaliculus 2b Blockage or stenosis at the lacrimal sac 2c Blockage or stenosis at the nasolacrimal duct. The treatment given to the patients can be grouped as follows: 1 Dacryocystorhinostomy (DCR) 2 Minor procedures—3 or 1 snip procedures, probing, retropunctal cautery, lacrimal gland electrolysis 3 Medical treatment—eyedrops 4 No treatment (includes those who refused surgery). Results A total of 180 DCGs were performed on 133 patients. Of these, six DCGs on six patients were technical failures and a further 16 DCGs on 13 patients were excluded since the subsequent clinical notes were unavailable. The results of the DCGs in those patients who were followed up are shown in Tables I, II and III. Table I shows the results in patients with unilateral DCG, and Table II shows the results in patients with bilateral DCG. Figure 2 shows the overall number of DCGs and sites of obstruction. Table III shows the treatment given to each lacrimal system, broken down by result of DCG. Table IV compares the results of syringing lacrimal systems with the result obtained by DCG. superior canaliculus lacrimal gland common canaliculus •lacrimal sac inferior canaliculus nasolacrimal duct nasal cavity inferior turbinate inferior meatus Figure 1. Anatomy of the lacrimal system. Vol. 63, No. 749 337
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