Dacryocystitis secondary to an iatrogenic foreign body in the lacrimal apparatus.

Abstract

Dacryocystitis is an infection of the lacrimal sac that is usually caused by obstruction of the nasolacrimal duct. We describe a case of iatrogenic dacryocystitis that occurred secondary to the presence of an impacted piece of a metallic dilator in the lacrimal apparatus. The foreign body was detected on dacryocystography and removed during dacryocystorhinostomy. The patient recovered uneventfully.

Introduction

Epiphora is caused by a variety of conditions that affect tear production, tear flow, and the function of the eyelids. Lacrimal syringing and probing is a common procedure in ophthalmic clinics for both diagnostic and therapeutic purposes. It is generally performed with a double-ended stainless-steel dilator. Dilation sometimes effects a cure by releasing mucous plugs or concretions in the lacrimal drainage pathway, and it occasionally provides temporary relief in cases of stenosis of the punctum.

Dacryocystitis is an infection of the lacrimal sac that lies between the inner corner of the eyelids and the nose. It is usually caused by blockage of the duct that carries tears from the tear sac to the nose. Blockage may occur secondary to a malformation of the tear duct, injury, eye infection, or trauma. The blocked duct harbors bacteria and becomes infected. Dacryocystitis may be acute (sudden onset) or chronic (frequently recurrent).

Patients generally present with intermittent epiphora, pain, and swelling in the medial canthal area.

We describe a case of iatrogenic dacryocystitis that occurred secondary to the presence of an impacted piece of a metallic dilator in the lacrimal apparatus.

Case report

A 25-year-old woman presented with recurrent painful swelling in the left medial canthus. She had a history of recurrent left dacryocystitis of several years' duration. Her symptoms first began after she had undergone probing of the left nasolacrimal apparatus under general anesthesia during treatment for epiphora in the ophthalmology unit at another facility.

Dacryocystography (figure 1) and computed tomographic dacryocystography (CT-DCG) (figure 2) showed a complete obstruction at the junction of the common canaliculus and the lacrimal sac. Imaging also detected an unidentified metallic foreign body approximately 1 cm in length within the inferior canaliculus and superior portion of the lacrimal sac.

[FIGURE 1 OMITTED]

A left endonasal dacryocystorhinostomy was performed. The frontal process of the maxilla was fractured with a 2-mm chisel and removed intranasally. Intraoperatively, the presence of fibrosis and granulation tissue made it difficult to identify the lacrimal sac, so we used a fiberoptic canaliculus intubation set (Medtronic Xomed; Jacksonville, Fla.) to localize it. The sac was incised, and the foreign body was dissected from the granulation tissue (figure 3). On close inspection, the foreign body appeared to represent the distal end of a silver nasolacrimal probe (figure 4). A stent was left behind in the duct and removed after 6 weeks.

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The patient was prescribed 1 week of an oral antibiotic and a topical steroid nasal drop. She made a good recovery and subsequently experienced complete resolution of her symptoms.

Discussion

In a series of 57 consecutive dacryocystorhinostomies performed on patients younger than 50 years, Jones found that 40% of patients had nasolacrimal blockage secondary to trauma, previous surgery, or congenital stenosis. (1) In the remaining 60% of patients, there appeared to be no obvious preoperative cause of obstruction; of these patients, 65% were found to have dacryoliths at surgery.

Patients with lacrimal foreign bodies usually present with symptoms of partial or intermittent lacrimal sac obstruction and recurrent dacryocystitis. There appear to be only 2 previously reported cases of exogenous foreign bodies in the lacrimal apparatus. (2,3) Our patient had been experiencing epiphora, which had been attributed to a blockage within the nasolacrimal sac. It would appear that the attempted dilation under general anesthesia resulted in the unrecognized displacement and impaction of the metallic nasolacrimal probe, which in turn precipitated recurrent dacryocystitis.

Plain macrodacryocystography and CT-DCG are routine preoperative investigations in our institution for patients who are being assessed for endonasal nasolacrimal surgery. These imaging studies reveal details of the anatomic relationships of the lacrimal sac, the internal features of the nasolacrimal apparatus (including the degree of obstruction), and the presence of coexistent paranasal sinus disease. (4) Our case also illustrates the value of preoperative imaging in patients who are being considered for dacryocystorhinostomy. In recent times, magnetic resonance imaging with topical contrast has been shown to identify a blocked lacrimal apparatus. (5)

It would seem prudent to closely examine any instrument used to probe the nasolacrimal apparatus following a procedure to minimize the possibility that a broken piece will be left behind, particularly in difficult cases. This is especially important when such a procedure is performed with general anesthesia. Silver probes are subject to repeated bending and therefore potential weakening. It would be sensible to discard them when distortion of their shape becomes evident.

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For patients who are undergoing revision surgery, the fiberoptic canaliculus intubation set can be a very useful tool for localizing the lacrimal sac. Finally, radiologic investigations (e.g., CT-DCG) can play an important role in diagnosing the problem, especially in revision cases.

References

(1.) Jones LT. Tear-sac foreign bodies. Am J Ophthalmol 1965;60: 111-13.

(2.) Felt DP, Frueh BR. Exogenous ballvalve in the lacrimal sac. Ophthal Plast Reconstr Surg 1985;1(2):115-17.

(3.) Lashkari MH. Metallic foreign body removed from tear duct. Am J Ophthalmol 1971;2(2):483-4.

(4.) Waite DW, Whittet HB, Shun-Shin GA. Technicalnote: Computed tomographic dacryocystography. Br J Radiol 1993;66(788):711-13.

(5.) Manfre L, de Maria M, Todaro E, et al. MR dacryocystography: Comparison with dacryocystography and CT dacryocystography. AJNR Am J Neuroradiol 2000;21(6): 1145-50.

Deepak Gupta, MS, FRCS; Heikki B. Whittet, FRCS; Salil Sood, MS, MRCS; Suchir Maitra, MS

From the Department of Otorhinolaryngology, Great Western Hospital, Swindon, U.K. (Dr. Gupta, Dr. Sood, and Dr. Maitra), and the Department of Otorhinolaryngology, Singleton Hospital, Swansea, U.K. (Dr. Whittet).

Corresponding author: Deepak Gupta, Consultant ENT Surgeon, Department of Otorhinolaryngology, Great Western Hospital, Swindon, Wiltshire SN3 6BB, UK. Phone: [phone]; fax: [phone]; e-mail: [e-mail]