Using relevant articles listed in PubMed, researchers looked at the evaluation and management of chemotherapy-induced epiphora, punctal and canalicular stenosis and nasolacrimal duct obstruction. Researchers selected abstracts based on the following keywords: epiphora; tearing; punctal stenosis; canalicular stenosis; nasolacrimal duct obstruction; chemotherapy; 5-FU; docetaxel; S-1; mitomycin C; capecitabine; imatinib; and radioactive iodine. If the corresponding article was deemed relevant and appropriate, it was included for review.

The relevant studies demonstrated that the chemotherapeutic drugs best documented to cause epiphora are 5-flourouracil and docetaxel, and that the main mechanism underlying epiphora is canalicular stenosis. The drugs that are less-commonly reported to cause epiphora include S-1, capecitabine imatinib, topical mitomycin C and radioactive iodine treatment of papillary thyroid carcinoma. Despite the above-mentioned drugs’ association with epiphora, some drugs and administration schedules cause only punctal and canalicular inflammation, whereas others cause significant canalicular stenosis. Weekly administration of docetaxel is far more likely to cause canalicular stenosis than administrating it every three weeks, researchers found. S-1 and radioactive iodine have been reported to cause nasolacrimal duct obstruction. Early recognition of punctal and canalicular stenosis or nasolacrimal duct blockages, and early intervention with topical steroids and canalicular stenting in patients at risk for permanent canalicular scarring, are important to avoid the need for more invasive and complicated procedures, say the researchers.

The investigators say that the broad study of research from PubMed clearly demonstrates that a variety of chemotherapeutic agents have been reported to cause epiphora, and some of these drugs have also been found to cause obstructions of the lacrimal drainage system. They add that early recognition and management of epiphora is important because it leads to better outcomes.

Ophthal Plast Reconstr Surg 2017;33:9-12
Mansur C, Pfeiffer M, Esmaeli B.

Outcomes of LOVIT II
In a follow-up to its first trial, the Veterans Affairs Low Vision Intervention Trial II sought to determine the value of low-vision rehabilitation with a therapist. compared with LV services without intervention. LOVIT II complemented LOVIT by comparing the outcomes of two types of LV programs for veterans less severely visually impaired from the effects of macular diseases.

This randomized clinical trial looked at 323 veterans with macular diseases and best corrected distance visual acuity of 20/50 to 20/200. Anonymous interviewers administered questionnaires by telephone before and after LV treatment. Using an intention-to-treat design, participants were randomized to receive LV devices with no therapy or LV devices with a rehabilitation therapist providing instruction and homework on the use of LV devices, eccentric viewing and environmental modification. Visual ability was measured in dimensionless log-odd units (a 0.14-logit change in visual ability corresponds to the change expected from a one-line change in visual acuity).

Of the 323 participants, the mean age was 80 years, and 314 were male. Basic LV was effective in improving visual ability. However, the LV rehabilitation group improved more in all visual function domains except mobility. Differences were 0.34 logit in reading (p=0.05), 0.27 logit in visual information (p=0.04), 0.37 logit for visual motor tasks (p=0.01) and 0.27 logit overall (p=0.01). In stratified analyses, the LV rehabilitation group with best-corrected distance visual acuity in the better eye between 20/63 and 20/200 improved more in visual ability (reading, visual motor and overall). Differences were 0.56 logit in reading ability (p=0.02), 0.40 logit for visual motor tasks (p=0.04) and 0.34 logit overall (p=0.02). There was no significant difference between treatment groups for those with better eye BCDVA of 20/50 to 20/63.

Based on these results, both basic LV alone and LV combined with rehabilitation were effective, but the added LV rehabilitation only increased the effect for patients whose BCDVA in the better eye was between 20/63 and 20/200. Researchers say basic LV services may be sufficient for most LV patients with mild visual impairment.

JAMA Ophthalmol 2017;135(2):96-104
Stelmack J, Tang C, Wei Y, et al.

Cross-Linking for Keratoconus
In a retrospective, single-center, non-randomized study, researchers sought to report the long-term outcomes of corneal collagen cross-linking for progressive keratoconus in pediatric patients. Spectacle-corrected distance visual acuity, retinoscopy, topography and tomography pre- and postop at three and six months, one year and annually thereafter.

A total of 377 eyes of 336 pediatric patients (aged 8 to 18 years) with progressive keratoconus underwent epithelium-off CXL. Of these, 194 eyes had a follow-up beyond two years and up to 6.7 years. At last follow-up, there was significant improvement in mean CDVA from 0.33 ±0.22 to 0.27 ±0.19 logMAR (p≤0.0001); a reduction in mean topographic astigmatism from 7.22 ±3.55 to 6.13 ±3.28 D (p=0.0001); a mean flattening of 1.20 ±3.55 D in maximum keratometry (p=0.0002); and a mean corneal thinning of 31.1 ±36 μm (p<0.0001). The mean change in Kmax was most significant in moderately advanced keratoconus (average keratometry 48 to 53 D). Central cones showed more corneal flattening than peripheral cones. Stabilization or flattening of Kmax was seen in 85 percent of eyes at two years and in 76 percent after four years. Stabilization or improvement of CDVA was seen in 80.1 percent of eyes at two years and 69.1 percent after four years.

In a majority of pediatric eyes, CXL remains an effective way to stabilize keratoconus for longer than two years. Flattening of Kmax was greater in moderately advanced keratoconus and in central cones. Long-term follow-up beyond four years, however, revealed that a few eyes showed features suggestive of the reversal of CXL.

Cornea 2017;36:138-143
Padmanabhan P, Reddi S, Rajagopal R, et al.