Endoscopic approach to diverticulum management: Scenario 1
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Lacrimal diverticula are cystic outpouchings, mostly communicating with the lacrimal sac. An abnormal cellular cord stem from the lacrimal sac region during embryogenesis could contribute to diverticula. They may present as medial orbital mass or dacryocystitis. The infero-lateral wall of the sac is a common area for the diverticula, since resistance to any expansion is least in this region as compared to other walls which have support of the periosteum and orbicularis. Diagnosis is usually by a plain dacryocystography (DCG) or by a CT or MR-DCG, and excision is performed with specific techniques for symptomatic cases.
This video elucidates fundamentals of assessing types of lacrimal sac diverticula that will help the ophthalmology and otolaryngology surgeons. The video illustrates endoscopic or combined external and endoscopic measures to manage different types of lacrimal sac diverticula.
This video serves as a useful link to the chapters with similar titles in the 2nd edition of the textbook ‘Principles and Practice of Lacrimal Surgery’ and also ‘Atlas of Lacrimal Drainage Disorders’, both edited and authored respectively by the author of this video, Dr Mohammad Javed Ali and published by Springer. The reader gets great details and bibliography, and images from these sources in addition to the surgical steps illustrated in the video for complete knowledge.
This video provides clinical details of the types of lacrimal sac diveriticula and overall management options.
About The Author
Mohammad Javed Ali is an internationally recognized clinician-scientist and currently heads the Govindram Seksaria Institute of Dacryology at the L.V. Prasad Eye Institute, India. He is currently the Hong-Leong Professor at NUHS, Singapore, and Gast Professor at FAU, Germany. Javed is among the rare recipients of the Senior Alexander Von Humboldt Award and the Shanti Swarup Bhatnagar Prize, the highest multi-disciplinary scientific award by the Government of India. He described 3 new diseases of the lacrimal system along with their classifications and clinicopathologic profiles. He was honoured by the 2015 ASOPRS Merrill Reeh Award for his path-breaking work on etiopathogenesis of punctal stenosis and 2020 American Academy-ASOPRS Lester Jones Award for outstanding contributions to the field of ophthalmic plastics and reconstructive surgery. 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. He is a section editor for 9 journals and has to his credit 429 publications at the time of this writing and has delivered 312 conference lectures, including 12 keynote addresses. He has conducted 25 instruction courses and 29 live surgical workshops and has been honored with 32 national and international awards.
About this video
- Mohammad Javed Ali
- Online ISBN
- Total duration
- 15 min
- Springer, Singapore
- Copyright information
- © Producer, under exclusive license to Springer Nature Singapore Pte Ltd. 2021
- Prof. Mohammad Javed Ali
- MD Mohammad Javed Ali
- Livio Presutti
- Francesco Mattioli
Hello, everyone. Today we will discuss a very important topic of lacrimal sac diverticulosis. And we will see how lacrimal sac diverticula presents clinically, and how we can manage.
I am Mohammad Javed Ali, and I head the Govindram Seksaria Institute of Dacryology at Bellevue Prasad Institute, and I practice lacrimal drainage sciences as my sole focus, and chemical and basic sciences-related work.
As you all know, diverticulum is nothing but an out-mulching from any tissue, and diverticula usually happen in areas which are a little weaker. Lacrimal sac diverticula are believed to occur either secondary to recurrent inflammation, or loss of bile tissue, which leads to more mobility of certain areas of the lacrimal sac wall.
Either way, what happens is that the pressure is generated within close cavities like lacrimal drainage system. Also lacrimal sac tends to get more exerted if there is a weak point in that area, and that might lead to the formation of diverticula. However, the exact etiopathogenesis is unknown. Today we will also discuss, as a part of this video series, how to go about managing diverticula externally, as well as through an endoscopic route.
The clinical presentations for lacrimal sac diverticula. Most of them are asymptomatic. Few may present with diverticulitis, which may mimic acute dacryocystitis. Lately they may be presenting following a DCR in the presence of a patent ostium, where the diverticula was missed. And then subsequently it can present as an acute dacryocystitis that is following well down this here.
If you take example of this infant, who presented initially with a very mild induration if you see the left photograph, with a complaint of it before for a few months. And a bit of induration in that area. And you see how the lacrimal sac area gets a little full with impending acute dacryocystitis in number two picture. And the picture on the right is a full blown case of acute dacryocystitis.
But look at the picture on the right. You also see a little distinct boundary between the full lacrimal sac area, and then another swelling onto the right, which is a little more towards orbit. So this should strike a bit of suspicion of someone having swelling which is a bit more laterally. Number one. Second would be in the presence of a patent lacrimal drainage system.
Like you see this particular case, when we did irrigation, it was patent. So a bit lateral swelling arising from the lacrimal sac, presenting as an acute dacryocystitis within presence of patent irrigation, diverticula should be one of the differential diagnosis. So what did we go– what did we do about this one?
So if you look at this picture on the right side, is a picture where you see that I’m removing the ball of the lacrimal sac, which was outpouched towards orbit. Subsequently, this is a picture on the left, you see that end on lacrimal sac, one of the wall is bit missing– that outpouching was missing there because we have removed it. And I subsequently removed suture the lacrimal sac walls a stent in situ.
This is an example where you see a complete suturing is completed, and histopathology is suggestive of diverticulitis. Subsequently we will also discuss endoscopic approaches, and how different ways we can approach similar problems, or in different clinical scenarios.
Differential diagnosis is important. The common differential diagnosis that I found in my practice mimicking like a diverticulum is a dermoid cyst. If you see this child who presented with the swelling below the medial canthus, and was referred by the diagnosis of a dacryocele, and the radiology showing of swelling arising from the lacrimal sac fossa. But if you go ahead and look at the picture, it was a very distinct dermoid cyst which was in very close relationship to the lacrimal sac and its lacrimal duct, and was actually compressing in but was separate from it.
If you look at this example of this young child who presented with a swelling and infection of the lower lid area. If you look at the radiology, it shows that the lesion has extended into the lower lacrimal fossa, but a little bit of air still remaining there. And if you look at the picture on to the right, the endoscopic image, which shows– actually you can see that very clearly, the lesion– yellowish lesion, which is actually a dermoid, but that was in very close relationship to the lacrimal sac and its lacrimal duct, and was attached to the lacrimal fissure that sometimes can happen in dermoids where there’s a recurrent inflammation.
So these two are top differential diagnoses, and we should keep these presentations also in mind. So I hope everything would be great, and we will learn together, and we will see a few interesting cases of how to go about managing lacrimal sac diverticulosis.