A rare case of complete acquired atresia of lacrimal sac and nasolacrimal duct
1Assistant Professor, 2Professor, 3Professor and Head, Department of Ear Nose and Throat, 4Professor and Head, Department of Ophthalmology, Kamineni Institute of Medical Sciences, Narketpally, Nalgonda, Telangana State, India.
Nasolacrimal Duct (NLD) obstruction leads to excess flow of tears called Epiphora. Distal obstruction converts lacrimal sac into stagnant pool, which easily becomes infected leading to chronic dacryocystitis with epiphora and purulent discharge.1 It can be either congenital or Acquired.Congenital is often due to imperforate membrane at valve of Hasner.2
Acquired obstruction is due to involutional stenosis, dacryolith or cast formation within lacrimal sac, previous sinus surgery, trauma with Naso–orbital fracture, inflammatory diseases, lacrimal plugs and neoplasm.2 Idiopathic inflammatory stenosis or Primary Acquired Nasolacrimal Duct Obstruction (PANDO) most likely affects middle aged and elderly women.3 A technique of excisional biopsy of soft tissue contents within Nasolacrimal canal during external DacryoCystoRhinostomy (DCR) is presented. Biopsies revealed a spectrum of changes that correlated with duration of symptoms. Early cases revealed active chronic inflammation along the entire length of NLD. Intermediate cases revealed focal resolution of the inflammatory process with fibrosis,while late cases showed fibrous obliteration of entire duct. Although the first event in PANDO remains uncertain, clinicopathologic correlation suggests that compression of duct by inflammatory infiltrates and edema precedes clinical chronic dacryocystitis.3
It is however noticeable that many people tolerate Lacrimal Duct obstruction for many years without clinical infection representing simple stenosis of lacrimal duct (SSLD).4
Obstruction may be secondary to trauma, infection, inflammation, neoplasm or mechanical obstruction. This is called as Secondary acquired Lacrimal Drainage Obstruction (SALDO).5
The standard approach to treat epiphora caused by naso lacrimal duct obstruction is Dacryocystorhinostomy. When pathological condition lies in upper lacrimal passage, alternate bypass or reconstructive options must be considered. Conjunctivo-dacryocystorhinostomy using jones tube can effectively bypass upper tract, but the technique may be complicated by granulation tissue formation, infection from unopposed mucosal flaps, and ineffective passage of tears through scar as a result of healing by secondary intention. Conjunctivorhinostomy provides total lacrimal bypass and has advantages of bipedicled mucosal flap apposition, temporary stenting, and symptomatic improvement of epiphora.6
One of the problems with conventional Jones tube is that the end of jones tube has to be manipulated by the surgeon so that the tube resides within the nasal cavity while not touching the middle turbinate and septum. High deviated nasal septum (DNS), paradoxical middle turbinate have inadequate space in nasal cavity. Therefore, require septoplasty and turbinectomy prior to conjunctivo rhinoplasty. To overcome this problem, author connected a size 4 French rubber tube to the tip of jones tube. This helps the tube to reside within the nasal cavity without foreign body reaction and granulation tissue complication. There is no need to change the tube to make up for loss of tube length because of post operative tissue contracture.7
The present techniques of conjunctivorhinostomy require perforation of frontal process of maxillary bone to open a passway between conjunctival sac and nasal fossa. A relatively complex operation and horizontal conduit is left, whose flow is rarely good. A new technique of conjunctivorhinostomy obviates necessity for osseous perforation by passing a tube beneath soft tissues of face just superficial to maxillary bone between lacrimal lake and nasal atrium. External diameter of tube is never more than 2mm to avoid elevation on surface of face. The almost vertical position of tube and placement of internal opening in zone of maximal respiratory flow ensure good drainage of tears.8 DCR is treatment of choice for most patients with acquired NLD obstruction. Surgical indication include recurrent dacryocystitis, chronic mucoid reflux, painful distension of lacrimal sac and bothersome epiphora.2
A 23 year old lady presented to ENT outpatient department with watering of left eye since 10 years. The patient gave history of recurrent pain around medial canthus of left eye. There was no regurgitation of pus on pressing around medial canthus. The patient was evaluated for all causes of epiphora both in the eye as well as in the nose. Probing with bowman’s probe (0 size) was a hard stop, but syringing revealed regurgitation from the upper punctum. Jones dye test I and II were performed which revealed complete organic block in the nasolacrimal duct. Computerized Tomograph (CT) scan paranasal sinus showed obliteration of nasolacrimal duct on left side (fig. 1).
Fig 1: CT scan Para Nasal Sinuses coronal view of patient showing left lacrimal fossa (Black arrow) and thickened lacrimal bone. White arrow showing absent / atretic left Naso-lacrimal Duct.
The patient was taken up for endonasal dacrocystorhinostomy under general anesthesia. Mucoperichondrial flap was elevated over lacrimal bone. The lacrimal bone was identified and removed using a DCR drill as it was thickened. The lacrimal sac could not be identified even with the help of a lacrimal light probe inserted through the lower punctum. Adjuvant procedures like Middle Meatal Antrostomy and Anterior ethmoidectomy were done in view of searching for the sac, but in vain. The procedure was abandoned. On first post operative day syringing was repeated and to our surprise, revealed a partial relief of block of nasolacrimal duct i.e., syringing fluid is reaching oropharynx partly and partly regurgitating from upper punctum and decrease in epiphora. The patient was followed up in post operative period every weekly for 2 months followed by once in 15 days for 6 months. In each follow up she was given antibiotic and steroid eye drops and instructions of massaging the lacrimal system. Syringing is done through lower punctum of left eye. The patient showed improvement in epiphora in every follow up visit.
In this case, epiphora in left eye was since 10 years with no history of frank pus discharge at medial canthus. Probing revealed hard stop indicating there was no canalicular block or soft tissue in sac. Syringing revealed regurgitation from opposite punctum. This shows that there is an obstruction anywhere from distal common canaliculus to opening of NLD in inferior meatus of nose. Pre operative CT scan paranasal sinus (PNS) revealed lacrimal fossa present with obliterated and calcified NLD. This case was taken up for Endonasal Dacryocystorhinostomy assuming the probability of NLD obstruction. Intraoperatively to our surprise we found empty lacrimal fossa with absent sac and obliterated NLD. This indicates probably long standing idiopatic inflammation leading to complete resorption of the lacrimal sac and nasolacrimal duct (PANDO) is the cause of Epiphora.1 Intra operative syringing after removal of lacrimal bone covering common canaliculus to proximal portion of obliterated and calcified NLD revealed partial patency of common canaliculus which is now opened into the nose. This made us to abandon the procedure rather than proceeding to conjunctivorhinostomy. Post operative massaging of lacrimal system and syringing made the epiphora to disappear in 2-3 weeks.
Every case of epiphora should be evaluated in detail to detect the site and nature of obstruction in lacrimal apparatus before posting the case for dacryocystorhinostomy. Preoperative CT scan of para nasal sinuses is a must to evaluate status of NLD and lateral wall changes in the nose which can be addressed simultaneously in the same surgical sitting. Atresia of lacrimal sac with empty lacrimal fossa is a very rare entity which need to be kept in mind during Dacryo Cysto Rhinostomy. Intraoperative syringing if does not reveal the patency of NLD, conjunctivorhinostomy should be done.
- Traquair HM. Chronic Dacryocystitis. Its causation and treatment. Arch Opthalmol 1941;26:165-80.
- Myron Yanoff, Jay S. Duker. Ophthalmology. 3rd ed. Mosby Elsevier. 2009. p.1482-1487. ISBN 9780323043328.
- Linberg JV,Mc Cormick SA. ‘primary acquired nasolacrimal duct obstruction.A clinicopathological report and biopsy technique. Ophthalmology 1986;93(8):1055-63. PMID 3763155
- Linberg JV. Disorders of lower excretary system in the lacrimal system. eds Milder B, Weil BA (Appleton –Century – Crofts, New York), 1983. p.1-134
- Bartley GB. Acquired Lacrimal Drainage obstruction: an etiological classification system, case reports, and a review of literature. part – 1. Opthal plast Reconstr Surg 1992;8:237-42. [cross ref][Medline]
- Arden RL, Mathog RH, Nesi FA. Flap reconstruction techniques in conjunctivorhinostomy, Otolaryngol Head Neck Surgery 1990;102(2):150-5.
- Chung YJ,Kim G, Sohn BK. conjunctivorhinostomy with rubber-tipped Jones tube. Ann Plast Surg. 2004;52(1):68-71.
- J Murube del castillo. Conjunctivorhinostomy without osteal perforation. Ach ophthalmol. 1982;100(2):310-11.