Dacryology is the study of the lacrimal system of the human body.Dr. Rohit RaoandDr. Bindu Malini fromeOphthaspoke toDr. Javed Ali, one of the pioneers in the field of dacryology. We hope this discussion would shed light on the field of dacryology and would answer some common queries pertaining to the surgical management of dacryocystitis.
Dr. Javed Ali is theHead, Govindram Seksaria Institute of Dacryology, LVPEI, Hyderabad. He is also serving as the Hong-Leong Professor, University of Singapore, Singapore. and Professor, Friedrich Alexander University, Nuremberg, Germany, Adjunct Associate Professor, University of Rochester, New York, Senior Von Humboldt Scientist, FAU, Nurnberg, Germany. He completed his basic medical education and MS Ophthalmology from NTR University of Health Sciences, Hyderabad. He obtained his fellowship of Royal College of General Practitioners (FRCGP), UK in 2003 and fellowship of Royal College of Physicians and Surgeons of Glasgow (FRCS) in 2008. He also completed his fellowship in Orbital Surgery in 2008, followed by a second fellowship in Ophthalmic Plastic Surgery and Ocular Oncology and Aesthetic Facial Plastic Surgery in 2010. He later trained in Rhinology with World leader Peter-John Wormald from Australia. Javed is one among the rare recipients of The Experienced Researcher Senior Alexander Von Humboldt Fellowship Award, one of the pinnacle awards in the Research World. He completed his working PhD on glycobiology of lacrimal drainage system in 2018 from University of Hyderabad. He is a recipient of the Shanti Swarup Bhatnagar Prize and also the highest scientific award by the Government of India. He also received Dr P Siva Reddy Gold Medal in Ophthalmology, Dr Pathak Medal in Ophthalmology, Mazher Foundation Award for outstanding academic performance, Vengal Rao Medal, Raghavachary medal, Ranga Reddy Endowment award, Honavar award and Sunayna Medal. He described 3 new diseases of the lacrimal system along with their classifications and clinicopathologic profiles. He was honored by Healthcare Leadership Award 2012 for his research and innovations in Dacryology and also received the 2015 ASOPRS Merrill Reeh Award for his path-breaking work on etiopathogenesis of punctal stenosis. His textbook Principles and Practice of Lacrimal Surgery is considered to be the most comprehensive treatise on the subject and his other treatise Atlas of Lacrimal Drainage Disorders, is the first of its kind.
eOphtha:Hello Prof. Ali,we welcome you to this interview titled ‘Contemplating Dacryology’ and hope to learn from you.
Dr. Javed Ali:Thank you for having me on this platform. I hope to answer all your questions to the readers' satisfaction. In addition, I would provide youreferencesfrom my own publications to support what I am saying.
eOphtha:How to overcome the problem of incomplete sac flap marsupialization- tips for beginners
Dr. Javed Ali: Incomplete or inadequate sac marsupialization is among the common contributory causes of a DCR failure; accounting for 60.2% of external and 77% of endoscopic approach failures.1,2,3,4, 5One of the primary reasons why a surgeon struggles with this step is inadequate osteotomy to completely expose the lacrimal sac from the fundus to the nasolacrimal duct. Once a complete exposure is achieved, it would be a good idea for the beginners to fill up the lacrimal sac with fluorescein stained visco-elastic, which is easily available in any ophthalmic practice. The next step would be to tent the medial wall of the lacrimal sac with a probe. It’s a good idea to begin marsupialization at the sac-duct junction. With a knife or a crescent blade, penetrate the lacrimal sac carefully till a green viscoelastic is noted. Stay in the plane and extent the incision right up to the fundus to achieve a complete sac marsupialization.
eOphtha:How to manage acute dacryocystitis with an abscess in infants?
Dr. Javed Ali:This depends on what one knows about the NLD status of the child. The correct term would be ‘Pediatric acute dacryocystitis’ or PAD, which is a distinct entity.6 What I meant by the first statement is whether the child had already undergone a prior Irrigation and probing prior to PAD. If there is no such history, then one can have the option of treating it conservatively with antibiotics – control the infection – do an early probing.7In the setting of lacrimal abscess in an infant, I would prefer to rule out congenital dacryocystopyocele. Hence a quick endoscopy would tell us if there is an associated intranasal cyst, marsupialization of which can take care of both the abscess and cure the NLD obstruction.8,9External drainage of the lacrimal abscess is also an option, which I do not prefer to avoid subsequent lacrimal fistulas or scars.
The other scenario is if the infant with PAD already had irrigation and probing earlier and was a refractory complex CNLDO with or without associated syndromes.10,11In this setting, once can manage it conservatively and buy time for a subsequent DCR. However, if there is a recurrence of PAD, it would be an indication for an endoscopic DCR.12,13
eOphtha: Personal experience on probing after 2-3 years of age in CNLDO
Dr. Javed Ali:Personally, I believe probing can have a role even up to 10 years of age, even though the outcomes may below. There is more probability of finding complex CNLDO’s as the age advances.10 But with endoscopy guidance, most of these can be taken care of, and hence for CNLDO, we would always give a chance to probing. For the sake of argument, even if someone presumes the success rate is, say <10% at 8 years; I would say that, well we may prevent a DCR in this minority. We are currently looking at this aspect and will soon come out with a paper on ages beyond 5 years.
eOphtha:Is it ideal to use Mitomycin C in all cases of DCR?
Dr. Javed Ali:Well, this is a controversial topic, but we need to take a stand based on the current evidence-based guidelines. As Margaret Thatcher once said ‘Standing in the middle of the road is very dangerous, you get knocked down by the traffic from both sides’. We have provided both clinical and basic science evidence that it works in our patients.14,15,16,17So, personally, I use it for all the cases in a concentration of 0.02 mg% for 3 minutes. In certain cases of revision DCR and post-traumatic DCR, we also shown benefits of using a new injectable technique called circumostial mitomycin C (COS-MMC).18,19
eOphtha:How difficult is it to shift to subciliary incision for external dacryocystorhinostomy (DCR) & it’s superiorly over the conventional incision or subconjunctival incision?
Dr. Javed Ali:Subciliary approach DCR is a good option from an aesthetic standpoint.20However, I would not advise it to beginners or those without good aesthetic training since there is a possibility to traumatize the Horner’s muscle with this approach.
eOphtha: How to manage persistent postoperative bleeding
Dr. Javed Ali:Well, persistent postoperative epistaxis is rare. Mild and self-limiting epistaxis can be expected. If someone is having persistent epistaxis postoperatively, it could be a sign of a serious infection or vascular trauma. The basics of Rose position and nasal packing are the first steps. If it continues, the patient needs an endoscopic evaluation of the nasal cavity. Here, the help of an ENT surgeon is very useful, if one is not confident of this exploration and further management.
eOphtha:Which is better according to you, retrograde intubation V/S Sisler’s trephine for proximal Canalicular obstructions in terms of technical difficulties and outcomes.
Dr. Javed Ali:I do not believe in Retrograde intubation since I have not found myself or anyone ever being able to precisely enter a canaliculus from the CC. In addition, many of those who undergo trephination for such obstructions21,22demonstrate either diffuse severe stenosis of the distal canaliculi or patchy multiple obstructions, which again precludes the so-called retrograde intubation.
eOphtha:How the early case of failed DCR can be taken up for revision procedure
Dr. Javed Ali:Good question! Well, how early I would take depends on the cause of the failure.2,5If there is a cicatricial closure of the ostium, it can be revised at a time mutually convenient for the patient and surgeon. However, if the failure is secondary to organizing granuloma threatening the ICO23 or an evolving canalicular issue, I would take them on a high priority.
eOphtha:Shifting from external DCR to Endoscopic DCR, What obstacles one should anticipate?
Dr. Javed Ali:Oh! Age-old question! I think the biggest obstacle is one's own mind. Every surgery has its learning curve and Endoscopic DCR is much easier than learning a cataract. I think if one is able to get a good teacher, learn good anatomy, and put in sincere efforts, it's easy to learn.24, 25The issue of cost is not any more important with the availability of several good Chinese and Indian brands. My papers on training and outcomes of less experienced surgeons would give you more insights.
eOphtha:In the COVID era, how to modify our dacryology practice, as there is a strong debate going on against the use of cautery, diamond burr, etc
Dr. Javed Ali:Good Question. COVID-19 era is an unprecedented one with serious risks to global health. While lock-down is good and important, an indefinite one is going to seriously affect the healthcare system, whose economic losses are usually ignored during times of pandemic. Hence, a safe, gradual resumption of services after lockdown needs well thought of strategies. As of now only real emergencies of Dacryology practice are being catered to with the use of full personal protective equipment. Yes, it's good to avoid powered instruments of any sort since they risk generating aerosols and enhance the virus transmission risk. A team of 16 experts from the country has brainstormed to come to certain guidelines for Oculoplasty practice, which I hope would be online by the time someone is reading this.26
- Dave TV, Mohammed FA, Ali MJ, Naik MN. Etiologic analysis of 100 anatomically failed dacryocystorhinostomies. Clin Ophthalmol 2016;10:1419-1422.
- Ali MJ, Psaltis AJ, Wormald PJ. Long-term outcomes in revision powered endoscopic dacryocystorhinostomy. Int Forum Allergy Rhinol 2014;4(12):1016-1019.
- Ali MJ, Psaltis AJ, Bassiouni A, Wormald PJ. Long term outcomes in primary powered endoscopic dacryocystorhinostomy. Br J Ophthalmol 2014;98(12):1678-1680.
- Li E, Yuen H, Ali MJ. Revising a failed dacryocystorhinostomy. In “Principles and Practice of Lacrimal Surgery”, 2nd edition, Ali MJ (ed). Springer, Singapore, 2018, pp 271-283.
- Ali MJ. Etiology of failed dacryocystorhinostomy. In: ‘Atlas of Lacrimal Drainage Disorders’. Springer, Singapore, 2019, pp 447-453.
- Ali MJ. Pediatric Acute Dacryocystitis. Ophthalmic Plast Reconstr Surg 2015;31(5):341-347.
- Kamal S, Ali MJ, Gauba V. Congenital nasolacrimal duct obstruction. In “Principles and Practice of Lacrimal Surgery”, 2nd edition, Ali MJ (ed). Springer, Singapore, 2018, pp 147–161.
- Singh S, Ali MJ. Congenital Dacryocystocele: A major review. Ophthalmic Plast Reconstr Surg 2019;35(4):309-317.
- Ali MJ, Singh S, Naik MN. Long-term outcomes of cruciate marsupialization of intra-nasal cysts in patients with congenital dacryocele. Int J Pediatr Otorhinolaryngol 2016;86:34-36.
- Ali MJ, Kamal S, Gupta A, Ali MH, Naik MN. Simple vs complex congenital nasolacrimal duct obstructions: etiology, management and outcomes. Int Forum Allergy Rhinol 2015;5(2):174-177.
- Ali MJ, Paulsen F. Syndromic and non-syndromic systemic associations of congenital lacrimal drainage anomalies: A major review. Ophthalmic Plast Reconstr Surg 2017;33(6):399-407.
- Singh S, Selva D, Nayak A, Psaltis A, Ali MJ. Outcomes of primary powered endoscopic dacryocystorhinostomy in syndromic congenital nasolacrimal duct obstruction. Orbit 2020;39(1):1-4.
- Chong KK, Abdulla HAA, Ali MJ. An update on endoscopic mechanical and powered dacryocystorhinostomy in acute dacryocystitis and lacrimal abscess. Ann Anat 2020;227:151408.
- Ali MJ, Mariappan I, Maddileti S, Ali MH, Naik MN. Mitomycin C in dacryocystorhinostomy: the search for the right concentration and duration – a fundamental study on human nasal mucosa fibroblasts. Ophthalmic Plast Reconstr Surg 2013;29(6):469-474.
- Kumar V, Ali MJ, Ramachandran C. Effect of mitomycin-C on contraction and migration of human nasal mucosa fibroblasts: implications in dacryocystorhinostomy. Br J Ophthalmol 2015;99(9):1295-1300.
- Nair AG, Ali MJ. Mitomycin-C in dacryocystorhinostomy: From experimentation to implementation and the road ahead: A review. Indian J Ophthalmol 2015;63:335-339.
- Ali MJ, Baig F, Lakshman M, Naik MN. Electron microscopic features of nasal mucosa treated with topical and circumostial injection of mitomycin C: Implications in dacryocystorhinostomy. Ophthalmic Plast Reconstr Surg 2015;31(2):103-107.
- Kamal S, Ali MJ, Naik MN. Circumostial injection of Mitomycin C (COS-MMC) in external and endoscopic dacryocystorhinostomy: Efficacy, safety profile and outcomes. Ophthalmic Plast Reconstr Surg 2014;30(2):187-90.
- Singh M, Ali MJ, Naik MN. Long term outcomes of circumostial mitomycin C (COS-MMC) in dacryocystorhinostomy. Ophthalmic Plast Reconstr Surg 2015;31(5):423-424.
- Dave TV, Javed Ali M, Sravani P, Naik MN. Subciliary incision for external dacryocystorhinostomy. Ophthalmic Plast Reconstr Surg 2012;28(5):341-345.
- Ali MJ. Canalicular and nasolacrimal duct recanalization. In “Principles and Practice of Lacrimal Surgery”, 2nd edition, Ali MJ (ed). Springer, Singapore, 2018, pp 349–357.
- Ali MJ, Paulsen F. Human lacrimal drainage system reconstruction, recanalization and regeneration. Curr Eye Res 2020;45(3):241-252.
- Ali MJ, Psaltis AJ, Murphy J, Wormald PJ. Outcomes in primary powered endoscopic dacryocystorhinostomy: comparison between experienced versus less experienced surgeons. Am J Rhinol Allergy 2014;28(6):514-516.
- Kamal S, Ali MJ, Nair AG. Outcomes of endoscopic dacryocystorhinostomy: Experience of a fellowship trainee at a tertiary eye care center. Indian J Ophthalmol 2016;64(9):648-653.
- Ali MJ, Wormald PJ, Psaltis AJ. The Dacryocystorhinostomy ostium granulomas: Classification, indications for treatment, management modalities and outcomes. Orbit 2015;34(3):146-151.
- Ali MJ, Hegde R, Nair AG, et al. Guidelines for oculoplastic procedures in the COVID-19 pandemic and resumption of surgeries. Indian J Ophthalmol 2020 (Epub).