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EUROPEAN JOURNAL
OF RADIOLOGY

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ELSEVIER European Journal of Radiology 19 (1995) 128-131

Computed tomography dacryocystography

K. Sara~ lira , I.F. Hep~en b, H. Bayramlar b, M. Uguralp b, M. Toks6z a, T. Baysal a
aDepartment of Radiology, Inonu University Arastirma Hastanesi, 44300 Malatya, Turkey
bDepartment of Ophthalmology, Inonu University Arastirma Hastanesi, 44300 Malatya, Turkey

Received 29 August 1994; accepted 25 October 1994

Abstract

Twenty-one patients with epiphora were examined by conventional dacryocystography, using Lipiodol as a contrast medium,
and CT dacryocystography, using a water soluble contrast medium. In the latter, the material was not introduced under pressure
but three or four drops were administered, providing a physiological method of investigation. Subsequently, CT dacryocystography
provides functional information about lacrimal disorders and is easy to use.

Keywords: Contrast media, lacrimal system; Computed tomography, comparative study; Dacryocystography

1. Introduction 2. Material and methods

Abnormal changes of the lacrimal system may be
caused by anatomical or functional disorders. Fluores-
cein dye test and dacryoscintigraphy mainly shows func-
tional disturbances, whereas dacryocystography (DCG)
provides anatomical information on the lacrimal system,
since the contrast material is administered under manual
pressure, which is not considered physiologic [1].
Recently, magnetic resonance (MR) dacryocystography,
with its high soft tissue resolution, has been advocated
in the evaluation of the lacrimal system [2].
Computed tomography dacryocystography (CTDCG)
demonstrates the adjacent bone and soft tissues and may
also be used in the assessment of lacrimal disorders,
such as duct obstruction following craniofacial trauma,
congenital craniofacial deformities and lacrimal sac neo-
plasms [3,4].
In this article the findings of 21 patients with lacrimal
sac disease, examined by C T D C G and conventional
dacryocystography (DCG) are compared.
* Corresponding author.
Twenty-five lacrimal systems in 21 patients with
epiphora attending the department of Ophthalmology
between December 1993 and July 1994 were included in
the study. CTDCG scanograms were obtained in the
supine position, three or four drops of non-ionic water
soluble contrast medium were instilled into both lower
conjunctival cul-de-sacs. With the patient blinking, the
physiologic pumping mechanisms were expected to
function. On average, CT scans were obtained 3 min
after contrast medium administration. Axial slices (2-
mm) were obtained from the level of punctum to the
level of lower nasal meatus. When contrast material
passage was not observed, delayed CT scans were taken
and contrast material was again instilled into the lower
conjunctival fornix. Subsequently, anteroposterior cor-
onal 2-mm slices were obtained in the prone position.
During the axial and coronal scanning, which took
12-15 min, the contrast medium remained in the
lacrimal system.
For conventional DCG, 1.5 ml lipoid radiopacque
material (Lipiodol) was injected with a lacrimal canula
into the lower canaliculus, and Caldwell and lateral
films were taken.

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 K. Sara~ et al. / European Journal of Radiology ( 1995) 128-131 129

a b
Fig. 1. (a) DCG of a patient with epiphora does not show any passage on the left due to common canaliculus obstruction. On the right side, a
mild enlargement of the lacrimal sac is associated with duct patency. (b) Axial and coronal CTDCG show no filling on the left side. On the right
side, although the sac is filled, no contrast material passes into the duct, a functional obstruction.

3. Results In five lacrimal systems with resistant or non-resistant

Twenty-one patients, 16 females a n d five males, ages
ranging from 25 to 65 years (average 37.38 years) were
evaluated; 17 patients had unilateral a n d four had
bilateral lacrimal disease. The lavage p e r f o r m e d before
C T D C G showed n o passage in 19 o f the 25 lacrimal
systems; in six patients resistant o r non-resistant passage
was observed.
passage, in spite o f the presence o f e p i p h o r a , c o n t r a s t
m e d i u m completely o r partly passed through the in-
ferior meatus during D C G (Figs. la, 2a). C T D C G ,
however, d e m o n s t r a t e d filling o f the p r o x i m a l p o r t i o n
o f the nasolacrimal duct, w i t h o u t further passage o f
contrast m e d i u m (Figs. l b, 2b).
Sites o f o b s t r u c t i o n were detected by D C G in 20
lacrimal systems; all but two had enlarged sacs (Figs. la,

a b
Fig. 2. (a) DCG of a patient with bilateral epiphora. Contrast material passes on both sides with a mild enlargement of the sac on the right. (b)
Axial and coronal CTDCG, a functional obstruction with a small amount of contrast material in the proximal system, contrast material does not
pass through the lower part of the system on the right.
130 K. Sara~ et al. / European Journal of Radiology (1995) 128-131

a b
Fig. 3. (a) DCG of a patient with epiphora on the left side. Note the enlargement and the filling defect of the sac and the duct on the clinically
normal right side. Marked enlargement and lobulation of the sac is observed above the obstruction of the junction on the left side. (b) On axial
and coronal CTDCG on the right side, passage of contrast material is shown. On the left side the systemis not filled with contrast material+ this
may be seen as a disadvantage of CTDCG.

3a). Nasal or paranasal abnormalities, such as septum
deviation, dense ethmoid cells, mucosal hypertrophy of
the maxillary sinus and hypertrophy of the nasal con-
chae were associated with lacrimal blockage in 13 of the
21 patients.
4. Discussion
The lacrimal system abuts from the medial side of the
eye lid and continues with the upper and lower
canaliculi, the common canaliculus, the lacrimal sac and
the nasolacrimal duct, ending via the inferior meatus in
the nasal cavity. The outflow of tears is actively sup-
ported by a physiological pumping mechanism that oc-
curs when the eyes are opened and closed. When
lacrimal drainage is blocked at any level or a functional
defect occurs, epiphora occurs.
D C G may be used to assess epiphora. Its disadvan-
tage is that superimposition of bony material and insuf-
ficient imaging of the soft tissues may influence the
interpretation. With DCG, contrast material is intro-
duced manually with some pressure into the canaliculi,
subsequently the visualisation of the lacrimal outflow is
not considered physiologic and false negative findings
may result in functional situations. C T D C G has the ad-
vantage of good soft tissue resolution, a better ability to
differentiate congenital and neoplastic lesions and com-
plex abnormalities after surgery or trauma [2,4-61.
The difference between our study and others is that,
in our cases, the contrast material is administered into
the lower conjunctival sac in a physiological way by
three or four contrast medium drops. The lacrimal
outflow is established in a physiological way. Our find-
ings show that C T D C G reveals lacrimal function distur-
bances better than DCG. In some cases it was not
possible to visualise the lacrimal sac with the drops of
contrast medium in C T D C G , and D C G appeared to be
better due to the fact that the viscous Lipiodol was
injected.
Obstructions of the common lacrimal canaliculus can-
not be visualised either by D C G or C T D C G (Fig. 1).
According to Glatt et al. coronal CT provides more
information about the bony ostium in dacryocysto-
rhinostomy insufficiency [4]. Our findings, however, do
not show any difference between coronal or axial CT;
moreover, the physiological pumping mechanism
prevails over the factor gravity.
Normally, oily contrast material is used for the assess-
ment of lacrimal disorders [2]. Our findings demonstrate
that more information concerning the nature of the
lacrimal system is obtainable when water soluble con-
trast material is used. When irritation by the contrast
medium has to be avoided and also in case of suspected
extravasation [3], a water soluble contrast medium is
preferred.
References
[I] McCord CD. The lacrimal drainage system. In: Duane TD,
Jaeger EA, editors. Clinical ophthalmology.Philadelpia: Harper
& Row~ 1986: 4: 4-19.
[21 Goldberg RA, Heinz GW, Chiu L. Gadolinium magnetic
 K. Sara¢; et al. / European Journal of Radiology (1995) 128-131
resonance imaging dacryocystography. Am J Ophthalmol 1993;
115: 738-741.
[31 Katowitz JA, Cahill KV. Orbits, eyelids and lacrimal system. In:
Wilson FM, editor. Basic and clinical science course. San Fran-
cisco: American Academy of Ophthalmology, 1990; 9:206-211.
[4! Glatt H, Can AC, Barret L. Evaluation of dacryocystorhino-
storey failure with computed tomography and computed
tomographic dacryocystography. Am J Ophthalmol 1991; 112:
431-436.
131
[5] Hurwitz J J, Victor WH. The role of sophisticated radiological
testing in the assessment and management of epiphora. Oph-
thalmology 1985; 92: 407-413.
[6] Ashenhurst M, Jaffer N, Hurwitz J J, Corin SM. Combined com-
puted tomography and dacryocystography for complex lacrimal
problems. Can J Ophthalmol 1991; 26: 27-31.