Chapter 19
Nasolacrimal Duct Obstruction and Lacrimal
Surgery in Cancer Patients
Aaron Savar and Bita Esmaeli
Abstract Nasolacrimal duct obstruction is often seen in patients with cancer. Iatrogenic causes such as surgery, radiation therapy, and chemotherapy are among the most common causes. Primary lacrimal drainage tumors are less common causes. The evaluation of patients with suspected nasolacrimal duct obstruction should include a thorough history and a comprehensive ophthalmic examination, including probing and irrigation of the lacrimal drainage apparatus and a Schirmer’s test. Imaging studies may also be necessary. Treatment depends on the degree and location of the obstruction and may consist of probing and irrigation alone; balloon dilation; intubation of the drainage system with silicone stents; or dacryocystorhinostomy, usually with placement of silicone stents to maintain duct patency during healing.
19.1 Introduction
Obstruction of the nasolacrimal drainage apparatus can occur in cancer patients for a variety of reasons. Patients typically present with epiphora, which can be extremely bothersome. Indeed, it can be one of the most troubling symptoms experienced by patients as it can interfere with vision and appearance.
19.2 Anatomy
Tears drain from the ocular surface to the nose via the lacrimal drainage apparatus (Fig. 19.1). Tears enter the superior and inferior puncta and pass into the lacrimal canaliculi, which join to form the common canaliculus. The valve of Rosenmüller
A. Savar (B)
Section of Ophthalmology, Department of Head and Neck Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
e-mail: asavar@gmail.com
B. Esmaeli (ed.), Ophthalmic Oncology, M.D. Anderson Solid Tumor |
243 |
Oncology Series 6, DOI 10.1007/978-1-4419-0374-7_19,
C Springer Science+Business Media, LLC 2011
244 |
A. Savar and B. Esmaeli |
Fig. 19.1 Anatomic components of the lacrimal drainage apparatus
separates the common canaliculus from the nasolacrimal sac. Once in the sac, tears pass inferiorly into the nasolacrimal duct, cross the valve of Hasner, and enter the nose under the inferior turbinate.
19.3 Causes of Obstruction
Causes of nasolacrimal duct obstruction in cancer patients include primary obstruction from a malignancy and secondary obstruction as a result of therapies, such as surgical manipulation, radiation therapy, and chemotherapy [1–3].
Lacrimal drainage system neoplasms are uncommon. A study of 202 lacrimal sac specimens obtained at the time of dacryocystorhinostomy (DCR) from patients thought to have primary acquired nasolacrimal duct obstruction showed no evidence of neoplasia in any of the specimens [4]. On rare occasions, however, nasolacrimal duct obstruction can occur secondary to neoplasia. Epiphora is the most common presentation of tumors of the lacrimal drainage system [5]. In a series of 115 patients with lacrimal sac tumors, 53% presented with epiphora, 37% had dacryocystitis, and 36% had a lacrimal sac mass [6]. Epithelial tumors—including transitional, squamous cell, mucoepidermoid, and basaloid carcinomas—are the most common type of lacrimal drainage system malignancy (Fig. 19.2) [5]. Other, less common malignancies include lymphomas and leukemias [7], melanoma [5], and metastases from primary tumors at other sites [8].
19 Nasolacrimal Duct Obstruction and Lacrimal Surgery in Cancer Patients |
245 |
Fig. 19.2 Computed tomography scan in a patient with a primary squamous cell carcinoma of the left lacrimal sac
Secondary causes of nasolacrimal duct obstruction are commonly seen in patients with head and neck cancer. Resection of midface tumors may require removal of portions of the nasolacrimal drainage system or nearby tissues. Treatment with external-beam radiation therapy can damage the mucosa of the nasolacrimal drainage system, as can chemotherapy. In many patients with head and neck cancer, the cause of obstruction is a combination of damage from surgery, radiation therapy, and chemotherapy [9].
Treatment of thyroid carcinoma with radioactive iodine (I-131) is also known to cause nasolacrimal duct obstruction [10, 11]. Iodine is taken up in the thyroid gland by the sodium iodide symporter. This transport protein is also present in the basolateral surface of the epithelium of the lacrimal sac and nasolacrimal duct [12]. Treatment with I-131 can result in fibrosis of these tissues, causing nasolacrimal duct obstruction. Kloos et al. [10] looked at a large cohort of 390 patients who had received I-131 treatment and found 10 with nasolacrimal duct obstruction.
A number of chemotherapy drugs have been shown to cause nasolacrimal stenosis and obstruction, including 5-fluorouracil, docetaxel, mitomycin C, and S-1.
5-Fluorouracil is a pyrimidine analog used in the treatment of a variety of malignancies. Systemic 5-fluorouracil was first reported to cause lacrimal outflow obstruction by Haidak et al. [13]. The mechanism of this effect is thought to be due to chronic inflammation leading to stenosis of the lacrimal drainage system caused by 5-fluorouracil secreted in the tears [14, 15]. While tearing may be seen in 27% of patients treated with systemic 5-fluorouracil, punctal–canalicular stenosis is seen only in 6% [15].
Docetaxel is an antimitotic chemotherapy drug used in the treatment of metastatic carcinomas, frequently breast and prostate cancer. Secreted in tears, docetaxel has
246 |
A. Savar and B. Esmaeli |
been shown to cause nasolacrimal duct obstruction in a dose-dependent manner [16]. Histopathologic analysis of tissue from the lacrimal drainage system and nasal mucosa of patients with nasolacrimal duct obstructions due to docetaxel has shown fibrosis and chronic inflammation [17]. The risk of obstruction is greatest in patients receiving weekly doses and is much less frequent in patients receiving doses every third week (Fig. 19.3a) [18]. A high index of suspicion for this complication is important, and all patients receiving weekly doses of docetaxel should have a baseline ophthalmic examination and monthly follow-up examinations. If epiphora develops, prophylactic silicone intubation is recommended (Fig. 19.3b). In patients who develop epiphora while receiving doses of docetaxel every third week, frequent probing and irrigation and a taper of topical steroids is sufficient to address epiphora in the majority of patients [19]. In advanced cases and in patients who are evaluated after many months of treatment with weekly doses of docetaxel, a DCR and placement of a Pyrex glass tube (“Jones tube”) (Fig. 19.3c) may be the only way to alleviate epiphora [20].
Paclitaxel has also been reported to cause nasolacrimal duct obstruction, though only in a single case report of a patient who had also received radiation therapy [21]. We have evaluated many patients complaining of epiphora associated with the use of paclitaxel but to date have not observed anatomic closure of the puncta and canaliculi in association with paclitaxel’s use.
Fig. 19.3 (a) Obvious epiphora in a patient treated with weekly doses of docetaxel for several months. (b) A silicone tube can be used as a stent for bicanalicular intubation. (c) A Pyrex glass tube (“Jones tube”)