Epiphora in Treated Lacrimal Drainage System Malignancy Patients – When and Whom to Treat? [Letter]

Dear editor

We appreciate the survey findings by Kornhauser et al detailing the prevalent practice of delayed Jones tube placement following complete treatment of primary lacrimal drainage system malignancies (LDSM).¹ The authors have done a commendable job of surveying the 627 ASOPRS members.

The survey questionnaire does not include the extent or staging of disease at the time of treatment. Though no guidelines exist for LDSM staging under the 8th edition of the American Joint Committee on Cancer, Song et al have proposed a staging system based on 69 LDSM cases.² Only 23.19% (16/69) of LDSM cases were classified as Stages I or II and were treated with local resection with adjuvant therapy. These cases could be considered for Jones tube placement. The remaining 76.81% (53/69) cases belonging to Stages III & IV required extensive sinus debridement and/or orbital exenteration surgeries and would not be suitable candidates for Jones tube surgery.

The recommended dose of adjuvant radiotherapy for LDSM is 60–70 Gray, fractionated over 6–8 weeks.³ Acute toxicity in the form of conjunctivitis and transient watering and late sequelae of dry eye disease, lower lid ectropion, lagophthalmos, and nasolacrimal fistula are reported. The survey did not mention if any such symptoms were reported or treated in any of the included cases, prior to Jones tube placement. The survey questionnaire also fails to elicit the occurrence of significant watering among treated LDSM cases, necessitating a surgical option. Out of the 10 LDSM cases treated with local excision and proton beam therapy, Holliday et al noted significant epiphora in only 2 (20%) cases.⁴ In another case series of 17 LDSM cases treated with surgical resection and adjuvant therapy, Song et al observed transient conjunctivitis and watering in 58.8% (10/17) cases and chronic epiphora in only 11.7% (2/17) cases, requiring surgical intervention.⁵

The rarer presentation of stage I–II LDSM cases and the low incidence of significant epiphora requiring a surgical intervention, post-completion of radiotherapy, could have led to a Neyman bias in the survey. Another important aspect to be considered in this survey was the actual relief in epiphora post-surgery, and the rate of complications related to Jones tube placement, as observed by the 49 responders.

The survey stresses the need for definite guidelines for the management of LDSM. There is a need for multi-centric collaborative analysis of lacrimal sac malignancy cases for developing a consensus statement regarding the staging and treatment.