Dacryocystography: CT or MRI ?

Poster No.: C-0828

Congress: ECR 2018
Type: Scientific Exhibit
Authors: J. PONNATAPURA SATYANARAYANA; BANGALORE, KA/IN
Keywords: Ear / Nose / Throat, CT, MR, Dacryocystography
DOI: 10.1594/ecr2018/C-0828

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Page 1 of 16
Aims and objectives

Epiphora is defined as overflow of tears caused by imperfect drainage of the tear-

conducting passages (Fig. 1) and is a common ophthalmic problem, accounting for 3%
of ambulatory clinic visits [1].

The etiology of the epiphora is usually benign; however, in some cases malignant
nasolacrimal duct (NLD) obstruction occurs. Most primary acquired obstructions are
due to idiopathic inflammation, fibrosis, and scarring of the nasolacrimal duct [1]. NLD
obstruction can occur at any level along the lacrimal drainage: punctum, canaliculus, sac,
nasolacrimal duct, or nasal ostium.

To choose the proper surgical management, it is important to know the etiology and
"positional diagnosis" [2] of the obstruction.

Ewing in 1909 [3] employed conventional radiographic dacryocystography, the imaging

techniques for evaluation of lacrimal tract abnormalities, which is invasive, requires
cannulation and has associated risks with it. Since then, chemical contrast media
such as iodinated contrast media for radiography and CT dacryocystography (CTD), or
gadolinium chelates for MR dacryocystography (MRD) imaging has been used [4-9].

The risk of ionization is reflected by calculating the absorbed dose to the lens, which is
0.04 to 0.2 mSv for dacryocystography, 1.8 to 2.6 mSv for CTD, and up to 1.09 mGy/
MBq for dacryoscintigraphy [10-12].

The purpose of this study was to evaluate the practicability of administering topical
contrast material during helical CT dacryocystography and topical saline solution
during MR dacryocystography to assess the positional diagnosis of nasolacrimal duct
obstruction in patients with epiphora.

Page 2 of 16
Images for this section:

Fig. 1: Diagram shows normal nasolacrimal drainage system from frontal view of left eye.
SC = superior canaliculus, IC = inferior canaliculus, LS = lacrimal sac, ND = nasolacrimal
duct, VR = valve of Rosenmüller, VK = valve of Krause, VH = valve of Hasner.

© Takehara Y et al. Dynamic MR dacryocystography: a new method for evaluating

nasolacrimal duct obstructions. AJR Am J Roentgenol 2000;175:469-473.

Page 3 of 16
Methods and materials

Patient population:

This was a prospective study and was approved by our institutional review board.
Informed consent was obtained form all patients before the procedure. For a period
of two years, 20 patients (11 women and 9 men; mean age 60.4 years; range 32-74
years) with clinically suspected nasolacrimal duct obstruction were selected. Out of 20
subjects, 10 randomly chosen patients underwent CT dacryocystography (CTD) after
tropical instillation of iodinated contrast media and rest 10 patients underwent MR
dacryocystograph (MRD) after tropical instillation of sterile saline.

Subsequently after 5 hours of imaging examination, topical iodinated contrast media

was instilled to 10 patients who underwent MRD and topical sterile saline was instilled
to 10 patients who underwent CTD for evaluation of ophthalmic discomfort in both
study groups. Each subject was questioned about the relative discomfort of contrast
material and saline solution and any side effects of contrast material or saline solution
instillation. Patients with nasolacrimal duct obstruction related to neoplasms and previous
dacryocystorhinostomy were excluded from this study.

CT imaging techniques:

Two to three drops of iopamidol (iodinated contrast) were instilled onto the medial aspect
of the eye every minute for a total of 5 min while the subject was in the supine position.
Subjects underwent scanning immediately after instillation. CTD was performed on 128-
slice CT scanner. Coronal reformations were obtained.

MR imaging techniques:

Before MRD, conventional T1- and T2-weighted images with soft-tissue contrast were
acquired to rule out tumors. Then two to three drops of sterile saline were instilled onto
the medial aspect of the eye every minute for a total of 5 min while the subject was
in the supine position. Subjects underwent MRD immediately after final eye drop on
1.5T MRI scanner using a 5-inch (12.7 cm) surface coil secured anteriorly over the face
and centered on the lacrimal drainage apparatus. Repeated acquisitions of thick-slice
(20-30 mm) heavily T2-weighted images were obtained in coronal oblique and axial
planes. Dynamic analysis was also done using fat-saturated T2 weighted single shot TSE
sequence in coronal oblique plane.

Image analysis:

Page 4 of 16
Two 10 years experienced radiologists who were unaware of clinical data or information
evaluated MRD and CTD separately for the detection of obstructed points and degree of
obstruction in the nasolacrimal drainage system according to three levels (canaliculus,
lacrimal sac and nasolacrimal duct).

Statistical analysis:

Interobserver agreement of obstructed points in the nasolacrimal drainage system

between the two radiologists was also evaluated by using weighted # statistics. #
values were interpreted as follows: less than 0.20 indicates poor agreement, 0.21-0.40
indicates fair agreement, 0.41-0.60 indicates moderate agreement, 0.61-0.80 indicates
good agreement, and 0.80 or higher indicates excellent agreement. Statistical analyses
were performed using SPSS for Windows version 22.0 software. P < 0.05 was considered
statistically significant.

The sensitivity and specificity of CTD and MRD were evaluated investigated. Surgical
confirmation (dacryocystorhinostomy) as a standard of reference was performed 1-2
weeks after the examination in all the patients affected by epiphora.

Page 5 of 16
Results

No complications were encountered in the study. Analysis of interobserver agreement

between the two reviewers regarding the obstructed points and degree of obstruction
in the nasolacrimal drainage system demonstrated a # value of 0.912 and 0.908
respectively, indicating excellent agreement.

Point of obstruction:

Smaller drainage structures like canaliculi and membranous part of NLD were seen more
consistently on CTD than on MRD.

The frequency of point of obstruction/stenosis of the drainage apparatus on MR and

CT dacryocystography is shown in Table 1. Table 2 shows the comparison of point of
obstruction on topical helical CTD with operative findings.The sensitivity of CTD was
100% at all the levels. Fig 2 shows complete obstruction of right nasolacrimal duct on
CTD. Fig 3 shows complete obstruction of right nasolacrimal junction on MRD.

The sensitivity of MRD was 100% at canalicular level, however it was 90% at lacrimal
level as one patient had stenosis at lacrimal sac, which was incorrectly interpreted at
nasal ostium on MRD. This misinterpretation may be due to presence of adjacent mucosal
disease in the paranasal sinuses, which also appears as hyperintensity on T2 weighted
sequences. Fig 4 shows high intensity mucosal fluid in the left maxillary sinus making it
difficult to asses the nasolacrimal duct.

Stenosis/obstruction was confirmed on surgery in all 20 patients. Stenosis/obstruction

involved at the canalicular level in 5 patients, at the lacrimal sac level in 8, and at the
nasolacrimal duct or nasal ostium level in 7 patients. The outcome of surgical intervention
was favorable in all patients.

Degree of obstruction:

Both CTD and MRD were 100% sensitive in detecting the degree of obstruction (as partial
or complete) in patients with epiphora.

Topical administration:

Topical saline solution caused less discomfort than topical contrast material in all the 20
subjects who received both saline solution and contrast material. No subject reported
discomfort or side effects from saline solution administration. Eighteen of 20 subjects
(90%) complained of slight burning, irritation, or eye dryness caused by instillation of the

Page 6 of 16
iodinated contrast material. The disparity in comfort between saline solution and contrast
material was statistical significance on the chi-square test (p < 0.05).

Page 7 of 16
Images for this section:

Fig. 1: Diagram shows normal nasolacrimal drainage system from frontal view of left eye.
SC = superior canaliculus, IC = inferior canaliculus, LS = lacrimal sac, ND = nasolacrimal
duct, VR = valve of Rosenmüller, VK = valve of Krause, VH = valve of Hasner.

© Takehara Y et al. Dynamic MR dacryocystography: a new method for evaluating

nasolacrimal duct obstructions. AJR Am J Roentgenol 2000;175:469-473.

Page 8 of 16
Table 1: The frequency of point of obstruction/stenosis of the drainage apparatus on MR
and CT dacryocystography

© KEMPEGOWDA INSTITUTE OF MEDICAL SCIENCES - BANGALORE/IN

Table 2: Comparison of point of obstruction on topical helical CTD with operative findings

© KEMPEGOWDA INSTITUTE OF MEDICAL SCIENCES - BANGALORE/IN

Table 3: Advantages and disadvantages of topical CT dacryocystography and topical

MR dacryocystography

© KEMPEGOWDA INSTITUTE OF MEDICAL SCIENCES - BANGALORE/IN

Page 9 of 16
Fig. 2: Coronal reformation of CT dacryocystography shows complete obstruction at the
nasolacrimal duct on the right side (red arrow)

© KEMPEGOWDA INSTITUTE OF MEDICAL SCIENCES - BANGALORE/IN

Page 10 of 16
Fig. 3: Coronal MR dacryocystography shows complete obstruction of the right
nasolacrimal junction (red arrow) with dilatation of the nasolacrimal sac.

© KEMPEGOWDA INSTITUTE OF MEDICAL SCIENCES - BANGALORE/IN

Page 11 of 16
Fig. 4: Coronal dynamic MR dacryocystogram before fluid injection. Mucosal fluid (M) is
reflected by high intensity in left maxillary sinus

© Takehara Y. Dynamic MR dacryocystography: a new method for evaluating

nasolacrimal duct obstructions. AJR Am J Roentgenol 2000;175:469-473.

Page 12 of 16
Conclusion

Topical helical CTD and MRD reproducibly and noninvasively visualize the lacrimal
drainage apparatus and precisely identify the degree of obstruction and their levels in
patients with epiphora.

In comparison with cannulation dacryocystography, topical helical CT or MR imaging has

several potential advantages and few limitations, which are enlightened in table 3.

The operative surgeon may benefit from the detailed multiplanar and three-dimensional
images in preoperative planning. Topical CTD and MRD could be used as a reliable
preoperative method prior to surgery and can be added to the standard orbital imaging
protocol when lacrimal system involvement is clinically suspected.

Page 13 of 16
Personal information

Dr. Janardhana Ponnatapura Satyanarayana

Assistant Professor

Department of Radiology

Kempegowda Institute of Medical Sciences

Bangalore 560070

India

psjanardhan@yahoo.com

Page 14 of 16
References

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3. Ewing AE. Roentgen ray demonstration of the lacrimal abscess cavity. Am J

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10. Gmelin E, Rinast E, Bastian GO, et al. Dacryocystography and sialography with digital
subtraction. Rofo 1987;146:643-646.

11. Hahnel S, Jansen O, Zake S, Sartor K. Spiral CT in the diagnosis of stenoses of the
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