UNASSIGNED: Proboscis lateralis (PL) is a rare congenital malformation of the craniofacial structure. On the basis of 34 reported cases, Boo-Chai developed the first classification system in 1985 based on commonly associated anomalies of the eyes, palate, and lips. Sinonasal deformity is the most prevalent systemic abnormality associated with PL, accounting for 87.9%, and concomitant ocular anomalies account for 44-70%.
UNASSIGNED: We report a case of PL in a 20-month-old female patient with a mass in the left medial canthal area, and ipsilateral symptomatic epiphora. The removal of the proboscis at 4 months without the reconstruction of the nasolacrimal duct resulted in secondary sequelae that lasted 16 months. A second operation by a multidisciplinary team released the pressure on the lacrimal sac and reconstructed the lacrimal system. External dacryocystorhinostomy (DCR) is performed through the original external incision aided by nasal endoscopic examination. The bony passage between the nasal cavity and the lacrimal sac was reconstructed, and nasal endoscopy revealed a wide opening in the nasal cavity of at least 6 mm. Follow ups ensured a patent nasal airway, without complications.
UNASSIGNED: It is instructive to learn from this case that treatment plans for PL should consider associated ocular anomalies and lacrimal drainage reconstruction, following a comprehensive and multidisciplinary approach.

BACKGROUND: To investigate the geometric morphological differences of the lacrimal punctum by analyzing its shape in relation to age and sex in a normal population.
METHODS: 960 high-magnification slit-lamp images were obtained from 320 puncta of normal asymptomatic Indian individuals across eight decades of life. Using advanced geometric morphometric techniques, including Elliptic Fourier Analysis and Principal Component Analysis, the intricate details of the lacrimal punctum\'s shape in a diverse population sample were categorized by age and sex. High-resolution images of the lacrimal punctum underwent standardization for scale and orientation, followed by precise landmark identification and coordinate data extraction.
RESULTS: The geometric morphometry of the lacrimal punctum shows significant changes as one ages. However, the gender differences, in isolation, without consideration of age, remain subtle and are not pronounced. Interestingly, detailed Principal Component scores analysis revealed potential sex- and age-related variations specifically for the left and right lower puncta, which warrant further investigation. These changes could reflect unique aging changes in the proximal lacrimal drainage system.
CONCLUSIONS: The study is a starting point for geometric morphometric analysis of the lacrimal punctum and provides valuable insights into the punctal changes in size, orientation, and overall morphology across different age groups and between sexes. These findings highlight the significance of considering individual age-wise anatomical variations to better understand the lacrimal punctum.

OBJECTIVE: In this study, we aimed to evaluate the anatomical features of the nasolacrimal groove in detail by providing a morphological classification based on morphometric evaluations of the nasolacrimal groove.
METHODS: A total of 150 sagittal dry bones in the Department of Anatomy, Faculty of Medicine, Istanbul University were evaluated. The length and the width at different points of the nasolacrimal canal were calculated. According to the widths of the nasolacrimal canal ten different morphological types were revealed.
RESULTS: The length of the canal was found as mean 13.62 ± 2.42 mm on the right and 12.44 ± 2.68 mm on the left side. The entrance, the base, the upper and the lower thirds of nasolacrimal canal were 6.22 ± 1.19 mm, 7.95 ± 1.85 mm, 5.85 ± 1.06 mm, 6.60 ± 1.54 mm, on the right and 6.08 ± 1.16 mm, 7.24 ± 1.64 mm, 5.45 ± 1.29 mm, 6.23 ± 1.48 mm, on the left side, respectively. The width of the entrance of the nasolacrimal canal was the narrowest width compared to the base, upper and lower thirds in 7/10 types of 71/150 cranial bones.
CONCLUSIONS: This comprehensive morphological classification of the nasolacrimal groove sheds new light on its complex variations. We support that the finding of this study has the potential to improve the precision of diagnostic assessments and guide specific therapeutic interventions for patients with lacrimal drainage disorders.

UNASSIGNED: To evaluate dynamic magnetic resonance dacryocystography (MRDCG) in eyes with functional epiphora.
UNASSIGNED: We included prospective eyes with epiphora if no alternative cause was found on clinical examination, were patent on syringing, had no obstruction or stenosis on DCG, and had an abnormal DSG. MRDCG was performed to qualitatively assess for block or patency and quantitatively measure tear transit time. We compared measurements to asymptomatic fellow eyes and to historical reference values from asymptomatic eyes.
UNASSIGNED: We included 26 symptomatic eyes of 19 patients (median age 63 years). There was a block on MRDCG in 18 (69%) eyes and patency in 8 (31%) eyes. The block occurred at the sac-nasolacrimal duct (NLD) junction in 9 (50%), proximal NLD in 5 (28%), mid-NLD in 1 (5.6%), and distal NLD in 1 (5.6%) eye(s). No contrast was observed in the lacrimal system in two eyes. For eyes patent on MRDCG, median times to the sac, NLD, inferior meatus, first 25%, and first 50% of the fundus-to-nose distance (FND) were 22, 54, 118, 34, and 84 s, respectively. Times to the sac, NLD, and to fill the first 25% and 50% of the FND were significantly longer than historical values from asymptomatic lacrimal systems (p = 0.017, 0.050, 0.035, 0.017, respectively).
UNASSIGNED: MRDCG shows a high rate of block in functional epiphora. However, DSG and MRDCG results may not always correlate. The improved temporal resolution of this emerging modality may be advantageous in the critical first 2 min of tear transit.

OBJECTIVE: To investigate the effects of lacrimal drainage obstructions on the lacrimal gland activity and if there exists a potential link between the two.
METHODS: Direct assessment of the lacrimal gland activity from the palpebral lobe was performed in consecutive patients diagnosed with unilateral primary acquired nasolacrimal duct obstruction (PANDO), along with Ocular Surface Disease Index (OSDI), non-invasive tear break up time (NIBUT; Oculus K5M), tear meniscus height and Schirmer I. The primary outcome measure was the difference in the tear flow rate between the eye with PANDO and the contralateral uninvolved eye.
RESULTS: Thirty patients (median age, 45.5 years; 25 females) with unilateral PANDO had epiphora for a mean duration of 20 months. The mean OSDI score was 6.3. NIBUT (mean 11.56 vs 11.58 s; p=0.49) and Schirmer I values (mean 18.83 vs 19.4 mm; p=0.313) were not significantly different between PANDO and non-PANDO eyes. The morphology of the palpebral lobe (size 29.3 vs 28.6 mm2, p=0.41) and the number of lacrimal ductular openings (median 2 vs 2.5) were similar between the two eyes. The mean tear flow from the lacrimal glands of the PANDO side was significantly reduced compared with the contralateral uninvolved side (0.8 vs 0.99 µL/min; p=0.014)).
CONCLUSIONS: Tear flow rate from palpebral lobes of patients with unilateral lacrimal outflow obstruction shows a significant reduction compared with the contralateral side. The potential ways of communications between the tear drainage and the tear production mechanisms need to be explored further.

The purpose of this study was to determine the frequency and associated risk factors of orbital/periocular complications in patients with sinonasal tumour with orbital invasion managed with eye-sparing treatments.
A retrospective case series of patients with primary sinonasal tumour with orbital invasion from January 2008 to December 2018. Patient factors were compared between the following groups: (1)patients with orbital/periocular complications versus those who did not and (2) patients who needed secondary oculoplastic surgical procedures versus those who did not.
Out of 80 patients, 48 had eye-sparing surgery, 8 had orbital exenteration and 24 were managed non-surgically. The most common histology was squamous cell carcinoma (n=28, 35%). Among the eye-sparing treatment group, 51/72 patients experienced one or more orbital/periocular complication(s), with motility deficit (N=26, 36%) being the most frequent. Factors associated with higher risk of complications included tumour involving the orbital floor (p=0.019), clinical disease stage III/IV (p=0.038), maxillectomy (p=0.004), resection of the orbital floor (p=0.027) and cigarette smoking (p=0.041). Tumour involving the orbital floor had an OR of 3.9 (95% CI 1.3 to 11.6, p=0.016) in predicting orbital/periocular complication. In the eye-sparing surgery group, the most frequent secondary oculoplastic procedures was dacryocystorhinostomy (n=6, 13%). The use of a free flap in reconstruction had an OR of 8.2 (95% CI 2.1 to 31.8, p=0.002) in predicting need for secondary oculoplastic surgery.
Majority of patients with sinonasal tumours and secondary orbital invasion were managed with eye-sparing multidisciplinary treatments. Preservation of the eye can lead to reasonably good functional outcome despite expected orbital and periocular complications.

Objective: To compare endoscopic dacryocystorhinostomy (EnDCR) with and without silicone lacrimal stenting through subjective (patients\') and objective (surgeons\') outcome parameters. Methodology: Following defined selection criteria, EnDCR was performed on patients with primary chronic dacryocystitis with post-saccal stenosis. Every alternate patient had silicone lacrimal stenting (group A: no stenting; group B: with stenting); stents were removed at three months. At six months (minimum follow-up period), patients\' responses on symptom relief (through a five-point score) and naso-endoscopic evaluation (visualization of rhinostome; presence of granulations and synechiae; lacrimal drainage patency by estimating methylene blue flow pattern) were compared between the groups. Results: Each group had 20 patients. There was no statistically significant difference in group-wise follow-up periods. Five-point score at six months revealed 85% and 95% of patients in groups A and B, respectively, experienced \"success\"; among them, 60% and 75% were \"symptom-free\". The majority (75%) in group B experienced no discomfort from stenting. Naso-endoscopy revealed 80% patients in group A and 65% in group B had well-delineated rhinostome, albeit with granulations in 25% and 50%, respectively. Spontaneous dye flow was achieved, respectively, in 75% and 90%. The difference in none of the subjective and endoscopic parameters achieved statistical significance. None had synechia; fibrosis was seen in the four patients with no dye flow even with pressure/massaging. Conclusion: There was no statistically significant difference in EnDCR with and without silicone lacrimal stenting in the overall outcome of symptomatic improvement and endoscopic assessment of the surgical site.

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To study the fungal microbiome (mycobiome) and the virome of the lacrimal sacs in patients with primary acquired nasolacrimal duct obstruction (PANDO).
A prospective study was performed on 10 consecutive samples of the lacrimal sac contents obtained from patients with PANDO. The samples were obtained from the lacrimal sacs under endoscopy guidance and immediately transported on ice to the laboratory. Following DNA extraction and library preparation, a whole shotgun metagenome sequencing was performed on the Illumina platform (NOVASEQ 6000). The fungal internal transcript spacer analysis was performed using the PIPITS v2.7 . The viral taxonomy profiling was performed using Kraken2 against the virus database.
The taxonomic hit distribution across the lacrimal sac samples showed rich fungal diversity (4 phyla, 12 classed, 21 families and 26 genera). The major phyla were Ascomycota and Basidiomycota, and the key genera identified were Alternaria, Hyphopichia, Malassezia, Aspergillus and Epicoccum. The virome analysis identified 13 phyla, 15 classes and 27 families. The viruses were commonly from the families Poxviridae, Retroviridae, Siphoviridae and Myoviridae, Poxviridae being the most prevalent family. The BeAn 58058 virus, a member of the Poxviridae family, was the most abundant in all the samples.
The present study is the first whole metagenome sequencing exclusively of the fungal microbiome and virome from the lacrimal sacs of patients with PANDO. The lacrimal sacs harbour diverse fungal and viral communities with distinct ecosystem dynamics. Further studies of their functions and interactions with the hosts would provide valuable insights.

Medial eyelid tumours may result in the loss of the proximal lacrimal system during staged excision and delayed reconstruction, to achieve tumour margin clearance. The remnant canaliculus was marsupialised during reconstruction. The aim was to understand how many patients experienced symptomatic epiphora as a consequence of this.
A retrospective study including patients over a 15-year period with medial eyelid tumours, where the proximal lacrimal system was sacrificed to achieve tumour margin clearance. Included were all who had marsupialisation of the remnant distal stump as part of their delayed reconstruction. All who had pre-existing epiphora were excluded. The primary objective was the rate of epiphora following the procedure. A systematic literature review of postoperative epiphora occurring in patients with lid tumours requiring lacrimal system injury/sacrifice during tumour excision.
There were 22 eyes (22 patients). All were basal cell carcinomas except for 1 (4.5%) tarsal conjunctival squamous cell carcinoma. All cases involved the lower lid. There were two (9.1%) patients who developed epiphora. One patient underwent a superior three-snip punctoplasty, botulinum toxin to the lacrimal gland and conjunctivodacryocystorhinostomy with Lester Jones tube insertion. The other patient was not overly troubled and did not require further treatment. The literature review showed the median postoperative rate of epiphora in these patients was 12.5% (range 0%-100%).
Marsupialisation of the remnant canaliculus during delayed reconstruction is a straightforward and effective surgical option, which may help prevent postreconstruction epiphora when the proximal lacrimal system is sacrificed for tumour margin clearance.
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