Is routine biopsy of the lacrimal sac wall indicated at dacryocystorhinostomy? A prospective study and literature review

A Case of Primary Diffuse Large B Cell Lymphoma of the Maxillary Sinus Presenting as Epiphora

Primary sinusoidal non-Hodgkin’s lymphoma (NHL) is a very rare disease. The main symptoms of sinusoidal NHL are rhinorrhea, nasal obstruction, and post-nasal drip. Symptoms such as eye protrusion, diplopia, trismus, and periorbital pain can also occur. Epiphora is a very rare symptom of sinusoidal NHL, which can lead to a misdiagnosis of dacryocystitis or dacryostenosis. The authors report the case of a 46-year-old female patient who visited hospital for symptoms of epiphora, which did not improve even after 3 months of eye treatment, leading to a final diagnosis of maxillary NHL.

Acquired nasolacrimal duct obstruction: clinical and histological findings of 275 cases

Background

Acquired nasolacrimal duct obstruction is a blockage of the lacrimal outflow system usually caused by local nonspecific inflammation of the lacrimal sac and the nasolacrimal duct. However, cases exist where the primary nasolacrimal system obstruction is caused by malignancies.

Our aim was to investigate lacrimal sac pathologies in patients with acquired nasolacrimal duct obstruction and compare their clinical manifestations.

Methods

This retrospective clinical study included 275 patients with acquired nasolacrimal duct obstruction who underwent external dacryocystorhinostomy and lacrimal sac biopsy. Cases were classified into tumor or nonspecific pathology groups and subdivided according to the level of inflammation. Histological and clinical data were analyzed.

Results

Three tumors (1.1%) (an adenoid cystic carcinoma, an eccrine spiradenoma and small B cell lymphoma) were diagnosed. Chronic nongranulomatous inflammation was the most common histological finding, corresponding to 194 cases (70.5%). The other 81 (29.5%) were subacute, acute forms of nongranulomatous inflammation, tumors and fibrosis cases. Epiphora with continuous purulent discharge was the most common clinical sign reported by 144 (52.4%) patients, and two (0.7%) patients had a palpable mass near the medial canthal tendon, which was identified as an eccrine spiradenoma and small B cell lymphoma. There was no significant difference in the clinical symptoms, duration or case history between the nonspecific pathology and tumor groups (p = 0.292).

Conclusions

Chronic nongranulomatous inflammation of the lacrimal sac was the most common finding among acquired nasolacrimal duct obstruction cases. There were no associations between the histological findings and clinical presentation. The authors recommend a lacrimal sac biopsy only in cases when a tumor is clinically suspected.

Lymphoma of the Lacrimal Sac: The Massachusetts Eye and Ear Experience With a Comparison to the Previously Reported Literature

PURPOSE

To describe the frequency, clinical features, and histologic subtypes of biopsy proven lacrimal sac lymphomas, and to compare these results to the previously published literature.

METHODS

A retrospective chart review was performed at a single institution from 2004 to 2017. Pathology reports, operative notes, and patients' medical charts were reviewed.

RESULTS

Of 566 lacrimal sacs submitted for routine histopathologic evaluation, 16 cases of lymphoma were identified. All were low-grade, non-Hodgkin B-cell lymphomas, biopsied at an average age of 71 years. Thirteen patients (81.25%) had a pre-existing lymphoma diagnosis; the average interval between the diagnosis of systemic or nonocular adnexal lymphoma and lacrimal sac lymphoma was 7.9 years (range 2-26 years; median 5.5 years). Three cases of primary lacrimal sac lymphoma were identified. Histopathology showed 3 cases (18.75%) of follicular lymphoma, 3 (18.75%) of extranodal marginal zone lymphoma, and 10 (62.5%) of chronic lymphocytic leukemia/small lymphocytic lymphoma. Primary cases presented with epiphora and nasolacrimal duct obstruction, while secondary cases predominantly manifested as dacryocystitis. All lacrimal sac neoplasms were locally responsive (without local recurrence) to chemotherapy, radiation, or both.

CONCLUSIONS

Lacrimal sac lymphoma is uncommon but should be suspected among patients with known lymphoma who develop dacryocystitis. In this series, primary lacrimal sac lymphoma most often presented as a mass or nasolacrimal duct obstruction. Chronic lymphocytic leukemia/small lymphocytic lymphoma was the most commonly identified cause of secondary lacrimal sac lymphoma. Distinguishing primary from secondary lacrimal sac lymphomas is important, as the extent of disease and histopathologic subtypes differ, which may affect patient management.

Mascara-induced nasolacrimal duct obstruction

A 35-year-old woman underwent left external dacryocystorhinostomy (DCR) following a recent bout of left acute dacryocystitis. She had a right DCR 14 years earlier. Her relatively young age of presentation prompted suspicion of secondary nasolacrimal duct obstruction and, although the left lacrimal sac appeared macroscopically normal peroperatively, a lacrimal sac biopsy was taken. Histopathology revealed florid chronic inflammation, with abundant granular brown pigment and polarisable crystals suggestive of an exogenous material in the lacrimal sac mucosa compatible with mascara. After initial improvement, her epiphora has recurred 1-year postoperatively, but her ocular discharge has resolved. Mascara-induced conjunctival pigmentation is well established. However, there are very few published reports of nasolacrimal duct obstruction due to mascara. Since cosmetic application of mascara and kohl eyeliner is widespread, patients and practitioners should be aware of their potential to migrate into the lacrimal apparatus and cause chronic inflammation with secondary nasolacrimal duct obstruction.

The predictive value of nasolacrimal sac biopsy in endoscopic dacryocystorhinostomy

BACKGROUND

During dacryocystorhinostomy (DCR), the lacrimal sac wall biopsy is not routinely performed in our hospital, but it is recommended if there is a suspicion of underlying disease other than preoperatively or intraoperatively chronic inflammation.

OBJECTIVE

Most of patients with epiphora have different causes of nasolacrimal duct obstruction (NLDO). This study aims to examine how important routine lacrimal sac biopsy is during endoscopic DCR surgery.

PATIENTS & METHODS

The study included 50 patients with chronic unilateral epiphora. All patients underwent endoscopic DCR with NLD biopsy. Histopathologic analysis was performed for each specimen.

RESULTS

The findings of NLD biopsy showed chronic inflammation in 33 cases (66%), chronic dacryocystitis in 9 cases (18%), dacryolith with dacryocystitis in one case, granuloma in 4 cases (8%), rhinoscleroma in 2 cases (4%), and one case had a neoplasm. Histopathologic findings were inflammatory cellular infiltrates in 56%, 30% and 14% in mild, moderate and severe chronic inflammatory state (CIS) score, respectively. Fibrosis in 18%, 20% and 62% in mild, moderate and severe CIS score, respectively. Capillary proliferation in 64%, 32% and 4% in mild, moderate and severe CIS score, respectively. Chronic inflammatory signs in 64%, 32% and 4% in mild, moderate and severe CIS score, respectively.

CONCLUSION

Although neoplasm and granuloma are rare cause of lacrimal sac or duct obstruction requiring DCR, they were detected through nasolacrimal assessment and routine intraoperative lacrimal sac biopsy.

Orbitopalpebral and ocular sarcoidosis: what does the ophthalmologist need to know

Sarcoidosis is a chronic multisystemic disease of unknown aetiology, characterised by non-caseating granulomas. Ocular involvement rate ranges from 30% to 60% among individuals with sarcoidosis, and can vary widely, making the diagnosis a challenge to the ophthalmologist. Cutaneous manifestations occur in about 22% of sarcoidosis cases, but eyelid involvement is rare. Eyelid swelling and nodules are the most frequent forms of eyelid involvement, but other findings have been reported. The joint analysis of clinical history, ancillary exams and compatible biopsy is needed for the diagnosis, as well as the exclusion of other possible conditions. This review aims to describe the different forms of presentations, the clinical reasoning and treatment options for ocular, eyelid and orbital sarcoidosis.

Expression of LIGHT/TNFSF14 and Its Receptors, HVEM and LTβR, Correlates with the Severity of Fibrosis in Lacrimal Sacs from Patients with Lacrimal Duct Obstruction

Introduction

Fibrosis is one of the factors contributing to the development of primary acquired lacrimal duct obstruction (LDO). LIGHT (homologous to lymphotoxins, exhibiting inducible expression and competing with herpes simplex virus glycoprotein D for herpes virus entry mediator [HVEM]), a receptor expressed by T lymphocytes, has recently emerged as a new regulator of connective tissue remodeling and fibrotic response. The purpose of this study was to evaluate the role of LIGHT in the pathogenesis of LDO through: (1) assessment of expression of LIGHT and its two receptors, HVEM and LTβR (lymphotoxin β receptor), and (2) investigation of potential relationships between expression of LIGHT and its receptors and clinical and histopathologic features.

Methods

Lacrimal sacs of 30 patients undergoing endoscopic dacryocystorhinostomy because of LDO were assessed intraoperatively and histopathologically with respect to inflammation and fibrosis. Expression of LIGHT, HVEM and LTβR was assessed by immunohistochemistry using specific antibodies and evaluated semiquantitatively using a four-grade scoring system.

Results

All investigated molecules, LIGHT/TNFSF14, HVEM and LTβR, were expressed in biopsies from all patients. The most prominent expression was seen within inflammatory infiltrates. Expression of LIGH, HVEM and LTβR correlated significantly with the intensity of fibrosis and duration of the disease. In multivariate analysis only LIGHT showed a significant relationship with fibrosis (β coefficient = 0.759, p = 0.02). There was no significant correlation between expression of any molecule and other demographic or clinical features.

Conclusion

We assume that LIGHT along with its receptors may be a factor contributing to fibrosis and synechiae formation in the lacrimal sac. This assumption needs to be proven in a future study in a group of patients who fail to improve after the first operation.

Nasolacrimal Duct Obstruction: An Unusual Presentation of Sarcoidosis

Lacrimal drainage system disorders leading to epiphora are a common ophthalmologic complaint. When such a patient is identified, the ophthalmologist frequently collaborates with the otolaryngologist to perform a dacryocystorhinostomy (DCR). In rare cases, sinonasal sarcoidosis may lead to nasolacrimal duct obstruction (NLD) and dacryocystitis. A 48-year-old Caucasian female was referred to the Otolaryngology clinic for evaluation of a 6-month history of persistent right-sided nasal obstruction and epiphora. After physical examination and computerized tomography (CT) scan, she was diagnosed with right NLD with dacryocystitis. The patient underwent right endoscopic DCR. Pathology from the lacrimal bone and nasal tissue demonstrated noncaseating granulomas suggestive of sarcoidosis. Postoperative evaluation including lung CT scan confirmed systemic sarcoidosis. Nasolacrimal duct obstruction very rarely is the presenting symptom in patients with sarcoidosis. Imaging is necessary to rule out other causes of NLD, and histopathology is essential for diagnosis. Noncaseating granulomas are found along the nasal tissue and lacrimal sac, specifically in the subepithelial layer. Treatment consists of DCR, either endoscopic or external. Both approaches achieve long-lasting resolution of symptoms but may require revision from inflammation and scarring. There is no consensus on the use of intraoperative or postoperative steroids.

Inverted Papilloma of the Lacrimal Sac and Nasolacrimal Duct: A Case Report and Review of the Literature

Inverted papillomas of the lacrimal sac and nasolacrimal duct are exceedingly rare. Though histologically benign, these tumors are locally aggressive, have propensity for recurrence and are associated with a chance of malignant transformation. These tumors can present in an innocuous manner, masquerading as more common conditions such as primary acquired nasolacrimal duct obstruction. We present our experience with one such case and a review of the literature to emphasize the importance of pre-operative assessment and intra-operative vigilance, so as to aid in accurate diagnosis and early treatment.

Lacrimal sac primary squamous cell carcinoma with synchronous tonsillar primary squamous cell carcinoma

A gentleman with recurrent epiphora after two failed endonasal dacryocystorhinostomies was found to have a squamous cell carcinoma of the lacrimal sac at his third operation via an external approach. CT showed contralateral nodal involvement; however, biopsy of the node found it to be histologically distinct from the lacrimal sac lesion. A PET-CT revealed a second primary lesion located at the contralateral palatine tonsil. We discuss the histological features of squamous cell carcinomas and the impact on prognosis. This case highlights the importance of nasoendoscopy prior to lacrimal surgery. There should be a low threshold for lacrimal sac biopsy, and any anatomical or histological inconsistency should prompt further investigation.

Chronic conjunctivitis as a prognosis factor of dacryocystorhinostomy: a retrospective case-controlled study

OBJECTIVE

To determine whether the history of chronic conjunctivitis increases the likelihood of epiphora after an external dacryocystorhinostomy (Ex-DCR) and to elucidate other factors that may affect the prognosis of this surgery.

METHODS

This is a retrospective case-controlled study. Patients who had epiphora after an Ex-DCR were compared with patients who did not present epiphora. Medical history of conjunctivitis, use of antiglaucomatous drops, rhinitis, and nasal pathology were evaluated.

RESULTS

A total of 129 adult patients undergoing external DCR were evaluated, of which 73% had decreased tearing. Forty-five percent of the patients who continued with epiphora had a history of conjunctivitis, compared to the 20% of those who did not (p = 0.003). At the same time, the 20% of those who continued with epiphora had a history of rhinitis compared to the 8% of those who did not (p = 0.043).

CONCLUSION

Patients with a history of chronic conjunctivitis are less likely to improve the epiphora after performing an Ex-DCR. We consider that it is important to evaluate this antecedent before surgery.

Chronic dacryocystitis caused by sarcoidosis

Sarcoidosis of lacrimal sac is a very uncommon disease. When the patient has symptoms of lacrimal sac diseases, it is necessary to take into account the histological evaluation, to demonstrate the involvement of the lacrimal sac by this pathology. In patients with sarcoidosis history, the treatment is surgical and it is suggested to do an external dacryocystorhinostomy, in order to take a biopsy, to get a diagnosis and to establish the incidence of this pathology. The case is presented of a 44 year-old female, with a history of sarcoidosis lymph nodes, who presented with a right chronic dacryocystitis of one year onset.

Biopsy of recurrent nasolacrimal duct obstruction using sheath-guided dacryoendoscopy

PURPOSE

The purpose of this article is to present a novel technique, as well the histopathological findings, of dacryoendoscopic guided nasolacrimal duct (NLD) biopsy for recurrent nasolacrimal duct obstruction (NLDO).

METHODS

This study involved subjects with recurrent NLDO. Direct endoscopic probing or sheath-guided endoscopic probing was used for the initial intubation in all treated eyes, and the stent had been removed at between 2 and 11 months (mean 3.5 months) post-intubation with dacryoendoscopic confirmation of patency and mucosal regeneration. Biopsy specimens were obtained by scraping the recurrent lesion by sheath advancement. Histopathological examination and immunohistochemical (IHC) staining were performed.

RESULTS

In five patients (two males and three females, mean age: 71.2 ± 5.6 years [range: 61-78 years]) with recurrent NLDO, biopsy specimens were obtained from six ducts of six eyes, and stratified epithelium and a mixed inflammatory cell infiltrates were identified. IHC staining was positive for cytokeratin (CK)4 and CK13, and negative for paired box protein Pax-6.

CONCLUSIONS

This novel technique enabled a minimally invasive biopsy of the NLD to be obtained, and IHC staining indicated the presence of mucus epithelium, thus suggesting squamous metaplasia of the usual respiratory epithelium which likely occurs secondary to chronic inflammation.

Clinical analysis of 90 cases of malignant lacrimal sac tumor

PURPOSE

To investigate the pathology, clinical manifestations, and potential risk factors associated with the prognosis of malignant lacrimal sac tumors. In addition, the treatment outcomes and complications were also evaluated.

METHODS

Ninety cases of malignant lacrimal sac tumors were retrospectively analyzed at our hospital. Pathological classifications, clinical manifestations, risk factors, and follow-up time were documented. The outcomes and complications were evaluated and compared among the various treatment modalities.

RESULTS

The median follow-up time was 50 months (range, 3-258 months). The 5-year overall survival (OS) and progression-free survival (PFS) for all cases were 85.7 and 77.9%, respectively. The 5-year OS and PFS for 69 cases of squamous cell carcinoma were 87.6 and 76.3%, and which were 80.4 and 72.4% for 21 cases of non-squamous cell carcinoma, respectively. There was no difference of 5-year OS and PFS between squamous cell carcinoma and non-squamous cell carcinoma (p = 0.350 and p = 0.946). Positive lymph node status was associated with worse OS (p < 0.001) and PFS (p = 0.020). For the 23.3% of cases (21/90) treated with the definitive radiotherapy, the outcomes were equivalent to that of surgery combined with radiotherapy, with the incidence of treatment-related visual acuity complication not being significant. The addition of chemotherapy to the treatment course had a marginal and non-significant improvement in OS and distant metastasis-free survival.

CONCLUSIONS

Lymph node status was found to be a key factor for prognosis. Advanced tumors could benefit from multimodality treatment, with radiotherapy playing an important role. However, the role of chemotherapy requires further investigation.

Accidentally diagnosed transitional cell papilloma of the lacrimal sac

Lacrimal sac tumors are extremely rare but can be life threatening. Seventy percent of lacrimal sac tumors are of epithelial origin. Inverted transitional cell papilloma of the lacrimal sac is a rare epithelial sinonasal tumor of benign etiology with local invasion and malignant potential. These lesions may remain undiagnosed or may present with signs and symptoms of dacryocystitis or may transform to transitional cell carcinomas. Most lesions are diagnosed intra-operatively while performing a dacryocystorhinostomy. Biopsy and histopathological examination of mass lesions arising from the lacrimal sac helps in timely management of these rare tumors.

Is routine histopathological examination of dacryocystorhinostomy/dacryocystectomy specimens necessary? A tertiary eye hospital experience

PURPOSE

Limited literature documenting the incidence of unsuspected malignant neoplasm among dacryocystorhinostomy/Dacryocystectomy (DCR/DCT) specimens is reviewed to determine if routine biopsy of all the patients undergoing such procedures is required. We are evaluating if sending lacrimal sac specimens for histopathological examination is necessary as a routine patient's care standard.

STUDY DESIGN

This is a retrospective study of all lacrimal sac specimens received for histopathological examination in a tertiary eye hospital over a period of 12 years.

PARTICIPANTS

This is an institutional study of all patients who underwent lacrimal sac drainage procedure and/or lacrimal sac biopsy during the 12-years period.

METHODS

498 samples from 459 patients were included for review of the histopathological findings and tissue diagnosis. The files were checked for demographic data collection, preoperative clinical diagnosis and suspicion of malignancy.

RESULTS

Out of the 459 patients initially included, the mean age was 51.63 ± 17.8 years. Female patients constituted 70.8% while male patients accounted for 29.2%. Malignancy was suspected before surgery in 3 cases of the 498 specimens reviewed (0.6%). The remaining 495 specimens analyzed, 17 cases (3.43%) had unsuspected tissue diagnosis (other than chronic dacryocystitis) including Oncocytoma in 7, dacryolith in 7 and granulomas in 3. However, no case of malignant neoplasm was identified.

CONCLUSIONS

There were no unsuspected malignant cases in the current series. Therefore routine histopathological examination of DCR specimens is not considered to be essential. It should be reserved only for selected suspicious cases. Careful intra-operative assessment in these cases is also warranted.

Clinical significance of routine lacrimal sac biopsy during dacryocystorhinostomy: A comprehensive review of literature

The main purpose of this paper is to provide the information about the incidence and types of pathology of secondary acquired obstructions of the lacrimal excretory outflow system caused by primary lacrimal sac non-neoplastic and neoplastic lesions. After a thorough literature search, 17 case-control studies were found and selected, data were extracted and categorized, to evaluate specific lacrimal sac pathology mimicking inflammation. A total of 3865 histopathologically examined lacrimal sac wall biopsy specimens from 3662 patients, taken during dacryocystorhinostomy for clinically presumed primary chronic dacryocystitis, were analyzed. The most common reported histopathological finding was non-specific chronic inflammation with or without fibrosis (94.15% of cases). Lacrimal sac-specific pathologies were present in 226 (5.85%) cases. Unsuspected lacrimal sac-specific pathologies were present in 55/226 (24.34%) cases. Almost 45% of primary lacrimal sac malignant neoplasms were not suspected, preoperatively and intraoperatively. Tumor-like lesions of the lacrimal sac were the most common pathology found: (1) lacrimal stones-dacryoliths, (2) pyogenic granuloma, (3) granulation tissues, (4) reactive lymphoid hyperplasia, and (5) lacrimal sac-specific inflammation (Wegener's granulomatosis and sarcoidosis). Neoplastic pathology was found in 55/3865 (1.42%) lacrimal sac wall biopsy specimens; of those, malignant cases were 2.24 times more frequent than benign. Lymphoma was the most common preoperatively unsuspected or intraoperatively unexpected neoplastic pathology. This analysis of the relevant literature highlights the value of routine lacrimal sac biopsy during surgery for clinically presumed primary acquired nasolacrimal duct obstruction.

Preoperative Computed Tomography Findings for Patients with Nasolacrimal Duct Obstruction or Stenosis

Purpose

To identify and analyze the role of preoperative computed tomography (CT) in patients with tearing symptoms with nasolacrimal duct obstruction (NLDO).

Methods

We retrospectively reviewed the medical records and CT results on 218 patients who complained of tearing symptoms with NLDO between January 2014 and December 2014. All patients were recruited from Kim's Eye Hospital's outpatient clinic and assessed by clinical history, examination, and CT to evaluate periocular pathology and nasolacrimal drainage system. Patients with abnormal findings assessed by preoperative CT were further reviewed.

Results

CT was performed on 218 patients (average age, 58.2 ± 11.9 years). Of these, 196 (89.9%) had endonasal dacryocystorhinostomy, 14 (6.4%) declined surgery, and 8 (3.7%) were inoperable due to abnormal CT findings. Soft tissue opacity was the most common finding which 243 cases (85.9%) of 283 obstructed nasolacrimal duct and 89 cases (81.7%) of 109 non-obstructed nasolacrimal duct showed it. Thirty-nine (17.8%) of 218 patients showed either maxillary sinusitis or ethmoidal sinusitis and 32 (14.7%) of 218 patients presented with periocular inflammation. Other abnormal CT findings included septal deviations, previous fractures, masses, and structural abnormalities of nasal cavity.

Conclusions

Preoperative CT imaging is useful in the assessment of both nasolacrimal drainage and nearby anatomical structures. This information will be helpful in planning surgical interventions and management of NLDO.

Role of Histomorphology and Chronic Inflammation Score in Chronic Dacryocystitis

INTRODUCTION

Diseases of lacrimal drainage system account for nearly 3% of visits to eye clinic. Chronic dacryocystitis is a frequently encountered disorder among these patients. Histomorphology of specimens obtained after Dacryocystorhinostomy (DCR) is a pertinent indicator of prognostic outcome.

AIM

The aim of the study was to evaluate histopathology of specimens obtained after DCR and to elucidate patterns and score of chronic inflammation encountered.

MATERIALS AND METHODS

The study was conducted for a period of one year. Total of 50 patients who were clinically diagnosed as Chronic Dacryocystitis and underwent DCR were included. Following DCR, specimens of lacrimal sac, nasal mucous membrane and nasal bone were collected. Histopathological slides were examined for chronic inflammatory cell infiltration, fibrosis and capillary proliferation and were graded according to severity, in each specimen. A Chronic Inflammation Score (CIS) was recorded for each case.

RESULTS

The average age of patients was 39.04±14.22 years and their age ranged between 13 and 62 years. There were 28 (56%) females and 22 (44%) males in the study group. The nasal bone did not reveal any abnormality in any case. The nasal mucous membrane showed mild chronic inflammatory cell infiltration in 46 (92%) cases and moderate degree in 4 (8%) patients. Chronic inflammation with granulation tissue formation was noted in lacrimal sacs of all patients. The CIS revealed that 14 (28%) cases belonged to "mild" group, 26 (52%) to "moderate" group and 10 (20%) to "severe" category.

CONCLUSION

The inclusion of CIS in histomorphological evaluation of DCR specimens is recommended since it is one of the parameters that influence course of the disease.

Incidence of neoplasia in patients with unilateral epiphora

BACKGROUND

Nasolacrimal duct obstruction is common and is usually a result of benign stricture formation.Although neoplasia near or around the lacrimal system may produce epiphora, the incidence of neoplasia from within the lacrimal system as a cause of nasolacrimal duct obstruction is not well documented.

METHODS

A retrospective study was performed on all patients undergoing dacryocystorhinostomy with a history of epiphora. The incidence of patients with operative findings of intra-lacrimal neoplasm was sought. Histopathologically confirmed cases were included.

RESULTS

The study comprised 537 patients, who underwent a total of 631 endoscopic dacryocystorhinostomy procedures between January 1998 and July 2013. Non-stenotic causes of nasolacrimal duct obstruction were encountered in 3.01 per cent of dacryocystorhinostomy procedures, and included neoplastic, inflammatory and infectious pathologies. Inverted papilloma was the most common cause, encountered in 0.79 per cent of dacryocystorhinostomy operations.

CONCLUSION

These findings suggest that neoplasia is an uncommon but not a rare cause of nasolacrimal duct obstruction. Surgical teams performing high numbers of dacryocystorhinostomy procedures should be aware of such pathology and patients counselled appropriately.

Nasolacrimal duct obstruction caused by lymphoproliferative infiltration in the course of chronic lymphocytic leukemia

Background:

Endoscopic dacryocystorhinostomy (DCR) is the standard treatment of nasolacrimal duct obstruction. Only in rare cases, blockage may be caused by malignant tumors and even more exceptionally by lymphatic neoplasms so that biopsies are not routinely taken for diagnostic purposes.

Methods:

A computerized retrieval system was used for this retrospective study to identify all patients with histologically documented lymphoproliferative infiltration in the lacrimal drainage system from 2001 to 2009.

Results:

In four of 191 patients (2.1%), infiltration of the nasolacrimal sac mucosa with a small lymphocytic lymphoma (SLL)/chronic lymphatic leukemia (CLL) was found. Patients who develop symptoms like epiphora within the course of known CLL are highly suspicious for lymphoproliferative infiltration of the lacrimal drainage associated lymphoid tissue.

Conclusion:

A proactive approach with ophthalmologic consultation and DCR should be followed in these patients to avoid dacryocystitis.

The Role of Routine Biopsy of the Lacrimal Sac During Dacryocystorhinostomy Surgery

PURPOSE

To assess the role of routine histopathological evaluation of the lacrimal sac wall when performing dacryocystorhinostomy (DCR) surgery.

METHODS

A retrospective review was conducted of the histology findings in lacrimal sac biopsies, taken routinely, in an external-approach DCR series. This is a single surgeon (RB), single pathologist (AG) consecutive series. The histopathology reports were reviewed and collated. Each patient's medical history and risk factors for malignancy were recorded. The surgeon documented any abnormal lacrimal sac appearance at the time of surgery.

RESULTS

No patient in this series of 245, in whom 254 histology specimens were taken, recorded a significant pathological result that was not anticipated from pre-operative assessment, or from the appearance of the lacrimal sac intra-operatively.

CONCLUSION

The reported recommendation for routine histopathological evaluation of the lacrimal sac wall when performing DCR surgery is not supported by this consecutive series. The authors recommend histopathological evaluation only in the setting of pre-existing clinical suspicion of malignancy, or an abnormal intra-operative appearance of the lacrimal sac.

External dacryocystorhinostomy outcomes in patients with a history of dacryocystitis

PURPOSE

To investigate nonidiopathic causes of external dacryocystorhinostomy (DCR) failure.

METHODS

The medical records of all patients with acute or chronic dacryocystitis who underwent external dacryocystorhinostomy performed by the senior author over a 5-year period were retrospectively reviewed, with attention to microbiology, pathology, and associated medical and history.

RESULTS

A total of 52 lacrimal systems of 49 patients were included, with a minimum follow-up of 2 months (average, 15.5 months). Surgical success was achieved in 42 systems (87%). Of 7 failures, 6 had a condition potentially associated with an increased risk of failure, including MRSA infection, Gram-negative infection, rhinosinusitis, lymphoma, inflammatory bowel disease, and early loss of lacrimal stents.

CONCLUSIONS

External DCR is a successful procedure for the treatment of nasolacrimal obstruction associated with dacryocystitis. Various factors may affect surgical success, and awareness of these factors may enable better patient counseling and surgical planning.

[Dacryocystorhinostomy as part of the interdisciplinary treatment of lacrimal duct]

INTRODUCTION AND METHODS

Epiphora, which leads to blurry vision, is the leading symptom for intra- and/or postsaccal lacrimal duct stenosis. Due to the anatomy of the tear duct system, which lies between the fields of ophthalmology and otorhinolaryngology, and due to newly available techniques in interventional radiology to diagnose and treat patients with intra- and postsaccal lacrimal duct stenosis, various methods for diagnosis and treatment are available. We report the results of 107 patients who underwent endonasal dacryocystorhinostomy (DCR) between 2005 and 2011.

RESULTS

Prior to the DCR, dacryocystography was performed in 95 of the 107 patients. In 68 of these 95 cases, balloon dilatation was unsuccessful. Histological examination of 64 patients showed chronic inflammation in 61 patients, non-Hodgkin's lymphoma was diagnosed in 2 patients and aspergilloma in1 patient. Over a follow-up time of 6 months to a maximum of 7 years we revised 15 of 107 patients, due to reocclusion after removal of the stent. None of these patients showed recurrence of epiphora.

DISCUSSION

In comparison to transcutaneous DCR, endonasal DCR has certain benefits: it is less invasive, no visible scars occur because of the endonasal approach, and the function of the lacrimal pump remains uneffected. Furthermore, the possibility of co-treatment of endonasal pathologies during DCR exists. We observed no serious adverse events in our study group and the success rate was similar to other studies.

[Lacrimal sac tumors presenting as lacrimal obstruction. Retrospective study in Mexican patients 2007-2012]

OBJECTIVE

To determine the demographic and clinical data of primary tumors of the lacrimal sac presenting as lacrimal obstruction.

METHODS

Retrospective and descriptive study was conducted between the years 2007 to 2012 on all patients undergoing surgery for low lacrimal obstruction at Dr. Luis Sanchez Bulnes Hospital, an Association for the prevention of blindness in Mexico IAP.

RESULTS

Primary tumors of the lacrimal sac represented 2.5% of all lacrimal obstructions, being more common in women than in men (8:1). The large majority (89%) of the cases were non-epithelial, with lymphoid lesions being the most frequent. Benign tumors were presented at a younger age (50 years old) than malignant (70 years old). One-third (33%) of cases were unexpected findings during surgery (100% benign). Just over half (55%) were malignant tumors (1.4% of obstructions), all of them lymphoproliferative lesions. The most frequent clinical tumor was in the inner edge, either with or without epiphora. The progression time varied according to the degree of aggressiveness of the lymphoma (3 months-10 years).

CONCLUSIONS

Lacrimal sac tumors are rare, but they must be taken into account in patients with an unusual clinical presentation of lacrimal obstruction.

Multidisciplinary management of lacrimal sac/nasolacrimal duct carcinomas

PURPOSE

To determine the rates of globe-sparing treatment and useful final visual function in patients with primary lacrimal sac/nasolacrimal duct carcinomas treated with multidisciplinary therapy.

METHODS

The medical records of 14 patients with primary lacrimal sac/nasolacrimal duct carcinoma treated at 1 institution were retrospectively reviewed.

RESULTS

The patients were 9 men and 5 women; the median age at diagnosis was 58.5 years (range, 45-73 years). Seven patients presented with epiphora, 7 with a palpable mass in the inferomedial orbit, and 2 with dacryocystitis. In 3 patients, the diagnosis of cancer was not considered until during or after dacryocystorhinostomy. Seven patients had squamous cell carcinoma, 2 transitional cell carcinoma, 2 adenoid cystic carcinoma, and 1 each adenocarcinoma, poorly differentiated carcinoma, and inverted papilloma with carcinoma in situ transformation. Nine patients underwent surgical resection of the lacrimal sac and nasolacrimal duct and resection of the medial upper and lower eyelids, including canaliculi, partial ethmoidectomy, and medial maxillectomy. One patient underwent lacrimal sac biopsy only as another primary malignancy was discovered during the work-up for systemic disease. Four patients underwent orbital exenteration because of extensive involvement of the orbital soft tissue. Radiotherapy was recommended for 13 patients; in 1 patient, radiotherapy was not recommended because the patient had an inverted papilloma with carcinoma in situ transformation that was completely excised. The median radiation dose was 60 Gy. Eight patients received chemotherapy either concurrent with radiation therapy (5 patients), as neoadjuvant treatment (1 patient), or for progressive or metastatic disease (3 patients). The median follow-up time was 27 months (range, 6-96 months). In 10 patients, the globe was spared. In 9 of these 10 patients, visual acuity was the same as at baseline or better than 20/40 at last follow up.

CONCLUSIONS

With multidisciplinary therapy, the eye can be spared and reasonable visual function can be preserved in most patients with primary lacrimal sac/nasolacrimal duct carcinomas.

Pathological, immunohistochemical and microbiologicalal analysis of lacrimal sac biopsies in patients with chronic dacrocystitis

AIM

To analyze cases of obstruction of the nasolacrimal duct which creates a fertile environment for secondary bacterial infection and can result in dacryocystitis, which is a constant threat to cornea and orbital soft tissue and a potential source of endophthalmitis following intraocular surgery. The majority of obstructions of the lacrimal excretory outflow system are acquired ones occurring in adulthood and involving the distal parts of the system. Acquired obstruction may be primary/idiopathic or secondary to a wide variety of infectious, inflammatory, traumatic, mechanical, toxic or neoplastic causes mimicking idiopathic inflammation. These cases are treated by dacryocystorhinostomy (DCR).

METHODS

The present study was conducted to determine the histopathologic, immunohistochemical and current microbiologic characteristics of lacrimal sac specimens in patients undergoing external dacryocystorhinostomy.

RESULTS

Non-specific lacrimal sac pathology was present in all 33 cases and 81.8% of the cases showed moderate chronic inflammation with a chronic inflammatory score (CIS) ranging between 4 and 6, whereas 12.12% showed severe inflammatory changes with a CIS of 7. Mild degree of inflammation was seen in 6.06% with a CIS of 3. The total prevalence of gram-positive, gram-negative, and culture-negative samples were 59.4%, 37.5%, and 3% respectively.

CONCLUSION

Non-specific chronic inflammation with fibrosis is indeed the most commonly reported histopathological finding in lacrimal sac wall biopsy specimens.

Transitional neoplasms of the naso-lacrimal system: A review of the histopathology and histogenesis

Transitional papilloma (inverted papilloma, Schneiderian papilloma) is a relatively common, benign epithelial neoplasm of the sinonasal tract that also occurs in the lacrimal drainage system. The name transitional papilloma is recommended because it reflects the key histological features required for pathological diagnosis, as well as the histogenesis of the tumour. The histogenesis of the tumour is reviewed, together with its natural history, which is characterized by bone remodelling and destruction, a tendency to recur and to undergo malignant transformation. Biomarkers associated with these features have been identified in the sinonasal tumours and may also be of relevance to the lacrimal sac tumours, although the necessary studies have not yet been undertaken.

Endonasal dacryocystorhinostomy for nasolacrimal duct obstruction in patients with sarcoidosis

PURPOSE

To evaluate the outcomes of endonasal dacryocystorhinostomy (EN-DCR) surgery in patients with sarcoidosis.

METHODS

Retrospective chart review of all patients with sarcoidosis undergoing EN-DCR in 6 practices from 1999-2011.

RESULTS

We included 18 procedures in 14 patients (8 female, 6 male) who underwent EN-DCR for acquired NLDO secondary to sarcoidosis. The mean age was 53.7 (range 38-82). The presenting symptom in all cases was epiphora. Eight patients (57%) complained of having additional nasal congestion. Surgery was performed using endoscopic powered-type DCR with flaps in 12/18 (67%) and non-endoscopic mechanical EN-DCR in 6/18 (33%). In 15 (83%) cases the lacrimal sac and nasal mucosa appeared abnormally yellowish, crusty, oedematous and friable. Five patients were treated with pre-operative oral steroid and overall 8 patients had oral prednisolone post operatively, 30-60 mg tapered within 10 days-8 weeks. One patient had difficulties in tapering down the oral steroids at 6 months of follow-up. All patients were free of epiphora and patent to syringing, with nasal endoscopy revealing free flow of fluorescein through the ostium at a mean follow-up of 11.3 months (median follow-up 9 months).

CONCLUSIONS

All 18 cases of acquired nasolacrimal duct obstruction secondary to sarcoidosis were treated successfully with EN-DCR. An abnormal appearance of the nasal mucosa is an important sign. Nasal congestion is a frequent sign. A successful outcome may not depend on intensive long-term therapy with local or systemic steroids. Mechanical or powered EN-DCR for nasolacrimal duct obstruction secondary to sarcoidosis achieves encouraging medium-term outcomes.

[Sarcoidosis of the lacrimal sac as a cause of dacriostenosis]

Sarcoidosis is a systemic granulomatous disease of unknown aetiology. The course of sarcoidosis ranges from asymptomatic to severe. It could affect people of all ages. The disease affects predominantly the lungs and lymph nodes, skin, abdominal organs or eyes. Sarcoidosis of lacrimal sac is very uncommon. We describe a young man with lacrimal sac and nasal mucosa sarcoidosis present with epiphora. Few years before the onset of dacriocystitis the patient was treated because of lymph nodes sarcoidosis. The lacrimal sac sarcoidosis developed five years after systemic disease remission. An endoscopic dacriocystorhinostomy with intubation of nasolacrimal duct was performed. We used postoperatively systemic and local steroids for 3 months period. The patient is under observation for over four years with good health. The abnormal looking nasal or lacrimal sac mucosa could be associated with granulomatous disease as sarcoidosis and Wegener's or malignancies. If the sarcoidosis is established, it could be the first manifestation of sarcoidosis leading to future systemic sarcoidosis development or it may develop many years after the onset of systemic disease. Endoscopic dacriocystorhinostomy with intubation followed by intensive therapy with systemic and local corticosteroids may be helpful to maintain lacrimal drainage patency.

Results of nonendoscopic endonasal dacryocystorhinostomy

BACKGROUND

Surgical scarring on the face and disrupted anatomy in the medial canthal area following external dacryocystorhinostomy (DCR) can be avoided by an endonasal approach. This study examined the outcome of direct visualization endonasal DCR, performed by young surgeons and residents.

METHODS

A retrospective case series of 75 consecutive endonasal DCRs performed under direct visualization from July 2002 to July 2004 were reviewed. Surgery was performed by surgeons and residents who had received no special training in the procedure. Full success was defined as no symptoms of tearing after surgery and anatomical patency with fluorescein flow on nasal endoscopy or patency to lacrimal syringing. Partial success was defined as a tearing decrease compared with prior to surgery and with anatomical patency, and failure was defined as no significant improvement in persistent tearing. The average follow-up duration was 26.83 ± 16.26 (range 6-55) months.

RESULTS

Seventy-five DCRs were performed on 63 patients (four male, 59 female) of mean age 49.44 ± 16.63 (range 21-85) years. The surgery was successful in 54/75 eyes (72%), 37/54 eyes (68.5%), and 30/42 eyes (71.4%) at 6, 12, and 24 months, respectively. Partial success was achieved in 13/75 (17.3%), 9/54 (16.7%), and 9/42 (21.4%), and the failure rates were 10.7%, 14.8%, and 7.1% at 6, 12, and 24 months, respectively. The overall functional success with this technique was 74.7% and the overall anatomical patency was 92.0%. There were no serious complications arising from the surgery; three minor complications were documented, ie, an incorrectly placed silicone tube in the lower canaliculus, tube prolapse, and postoperative bleeding which needed nasal packing and eventually a developed retention cyst in the nasal cavity.

CONCLUSION

Endonasal DCR under direct visualization is a simple technique with minimal complications and a low learning curve, without the necessity for expensive instruments.

Chronic inflammation: a poor prognostic factor for endoscopic dacryocystorhinostomy

Endoscopic endonasal dacryocystorhinostomy (En-DCR) success can be affected by many factors. In this study, we aimed to determine the effect of chronic inflammation on the surgical outcome of En-DCR. A series of 25 primary En-DCR cases and their lacrimal sac specimens were involved in the study. The surgical outcomes were assessed subjectively (satisfied and unsatisfied) and objectively (successful and unsuccessful). All the specimens were examined for the chronic inflammation related histopathological features (inflammatory cell infiltration, fibrosis and capillary proliferation) and graded according to their severity. Moreover, a "chronic inflammation score" was established to determine the intensity of chronic inflammation using the grade of histopathological features. A quantitative and statistical analysis of histopathological features and chronic inflammation were performed between patients with satisfactory and unsatisfactory outcome; and patients with successful and unsuccessful outcome. The overall success rate according to subjective and objective assessment was 60%. However, 9 of 10 patients with unsatisfactory and/or unsuccessful outcome (90%) had severe chronic inflammation of lacrimal sac. In subjective assessment, inflammatory cell infiltration (p = 0.050), fibrosis (p = 0.037), capillary proliferation (p = 0.007) and chronic inflammation (p = 0.003) had a statistically significant difference between patients with satisfactory and unsatisfactory outcome. In objective assessment, statistically significant differences were detected between patients with successful and unsuccessful outcome when they compared according to inflammatory cell infiltration (p = 0.027), capillary proliferation (p = 0.007) and chronic inflammation (p = 0.003). Chronic inflammation related histopathological features of variable degree may have a role on En-DCR outcome. Chronic inflammatory score can be used as an indicator of En-DCR success.

Plasmacytoma associated with canaliculitis

Plasmacytomas are plasma cell neoplasms that rarely involve ocular adnexal tissues as a primary lesion or secondary manifestation of plasma cell myeloma. Only one case of plasmacytoma involving the lacrimal drainage system, to our knowledge, is described in the literature. The clinical presentation of ocular adnexal primary plasmacytoma typically relates to its mass effect. In this clinicopathologic report, we describe an unusual presentation of primary plasmacytoma of the lacrimal canaliculus as infectious canaliculitis.

[Selective lacrimal sac biopsy for external dacryocystorhinostomy: a clinical pathological study]

BACKGROUND

Tumors of the lacrimal drainage system are rare but potentially life-threatening. The purpose of this study was to investigate the applicability of selective lacrimal sac biopsy in 500 cases of external dacryocystorhinostomy for acquired dacryostenosis.

PATIENTS AND METHODS

Lacrimal sac biopsy was obtained selectively for atypical clinical and/or intraoperative findings. The frequency and spectrum of biopsies were recorded and correlated with the follow-up results.

RESULTS

Lacrimal sac biopsy was performed in 19 external dacryocystorhinostomies (3.8%) including non-Hodgkin B-cell lymphoma (3), squamous carcinoma (2), mucoepidermoid carcinoma (1), malignant melanoma (1), oncocytoma (1), pyogenic granuloma (4), Wegener's granulomatosis (4) and sarcoidosis (3). Within 5 years none of the patients without biopsy developed systemic inflammatory diseases or lacrimal neoplasms. The 5-year survival was 87% in patients with significant lacrimal sac pathology and 96% in patients without significant pathology.

CONCLUSION

External dacryocystorhinostomy with selective biopsy for atypical clinical and intraoperative findings allows safe diagnosis and management of potentially life-threatening lacrimal lesions.

Analysis of Functional and Anatomic Success following Endonasal Dacryocystorhinostomy

Objectives:

The aim of this study was to assess the concomitant perioperative procedures, the causes of nasolacrimal duct obstruction, the success rate, and the complications associated with endonasal dacryocystorhinostomy (ENDCR).

Methods:

In this single-center retrospective study, 98 patients underwent 104 ENDCRs between January 1994 and February 2006. There were 78 patients with 84 nasolacrimal duct obstructions who were included in this study.

Results:

The overall functional success rate with improvement in symptoms was 94.9% for primary surgery (59 of 84 obstructions) and 63.6% for salvage surgery after failure of primary surgery performed in another hospital (25 of 84 obstructions). The mean follow-up time was 36.8 ± 17.11 months. Primary surgery showed better results, with a complete success rate of 93.2%, than did salvage surgery, with a success rate of only 68%. Persistent symptoms, despite an open rhinostomy, were found in 1.7% of patients with primary surgery and in 12% of those with salvage surgery. Failure of ENDCR was observed in 3.4% of patients after primary surgery and in 20% after salvage surgery. We encountered only minimal perioperative complications, and these were essentially related to lacrimal intubation.

Conclusions:

Because of the possibility of treating concomitant sinonasal disorders, the cosmetic advantages, and the excellent results, ENDCR represents the procedure of choice for treating nasolacrimal duct obstructions. The main challenge lies in the exact preoperative assessment, as well as postoperative evaluation in case of failure.

A 7-year prospective study of routine histopathological evaluation of the lacrimal sac wall incisional biopsy specimens obtained during external dacryocystorhinostomy in adults and a review of the literature

The most common lacrimal sac pathology is chronic inflammation with or without occlusive fibrosis. However, a substantial number of lacrimal sac-specific pathologies were reported throughout the literature which may mimic chronic inflammation and be misdiagnosed. From a tertiary ophthalmic care centre in Serbia, in a single ophthalmic pathology laboratory, during a 7-year period (January 2004 to October 2010), a 599 consecutive lacrimal sac wall biopsy samples routinely obtained during external dacryocystorhinostomy in adult patients with clinically presumed primary acquired lacrimal drainage system obstruction were analysed. Although non-specific lacrimal sac pathology was present in the vast majority of cases (578 biopsy specimens; 96.49%), this report also reveals a relatively substantial number (21 biopsy specimens; 3.51%) of clinically non-suspected or intraoperatively unexpected primary lacrimal sac-specific pathology--among them, six lesions with malignant biological behaviour were identified: one microinvasive squamous cell carcinoma and five malignant lymhoproliferative lesions. Usefulness of routine lacrimal sac wall biopsy during surgery for primary acquired lacrimal drainage system obstruction is undoubtful and commensurate with the constant need for better understanding of the pathological processes that involve lacrimal drainage system.

Nasolacrimal duct obstruction: clinicopathologic analysis of 205 cases

PURPOSE

To investigate the histopathological results of lacrimal sac biopsies in patients with primary acquired nasolacrimal duct obstruction.

METHODS

In this prospective non-comparative study, 205 consecutive patients, who were diagnosed as primary acquired nasolacrimal duct obstruction, were included. Patients with history of trauma and/ or surgery in the periorbital area, punctum or canalicular obstruction were excluded from the study. Patients were evaluated for age, gender, history, and presenting symptoms. Lacrimal drainage system abnormalities were assessed. Lacrimal system irrigation, dacryocystography, and in selected cases dacryoscintigraphy was performed. All patients underwent external dacryocystorhinostomy. Biopsy specimens were obtained from the posterior inferior flap and examined by the same pathologist.

RESULTS

Forty-seven male and 158 females with age ranging from 6 to 81 years (mean 47.5 ± 16.2 years) were included in the study. Only one patient had the diagnosis of chronic leukemia, others had no preexisting history of systemic disease. Pathologic examination revealed chronic inflammation (n= 178), fibrosis without inflammation (n= 19), normal mucosa (n= 4), and lymphoid hyperplasia (n= 1). Three patients had abnormal pathology: Lymphoproliferative disease in the patient with chronic leukemia, granulomatous inflammation, and basosquamous cell carcinoma.

CONCLUSION

In primary nasolacrimal duct obstruction, pathological examination of the lacrimal sac revealed chronic inflammatory changes in most patients. Even though rare, malignant or systemic disease in patients with neither specific history nor clinical or radiological finding might be observed in these cases. Thus, we recommend taking biopsy if any suspicion of abnormality of the lacrimal sac exists.

Tumors of the lacrimal drainage system

Tumors of the lacrimal drainage system are rare, but potentially life-threatening. They comprise a large and variable spectrum of entities grouped into three major categories of primary epithelial, primary nonepithelial and inflammatory lesions. The most common primary epithelial tumors include papilloma, squamous cell carcinoma and transitional cell carcinoma, the most frequent primary nonepithelial tumors fibrous histiocytoma, malignant lymphoma and malignant melanoma, and the most common inflammatory lesions sarcoidosis, Wegener granulomatosis and pyogenic granuloma. This review outlines the incidence, types, management and prognosis of tumors affecting the lacrimal drainage system.

Clinicopathological study of lacrimal sac specimens obtained during DCR

PURPOSE

To determine the histopathologic characteristics of lacrimal sac specimens in adult patients undergoing external dacryocystorhinostomy (DCR) for acquired nasolacrimal duct obstruction.

METHODS

A total of 471 lacrimal sac biopsies were obtained from 449 patients undergoing external DCR for symptoms or signs of acquired nasolacrimal duct obstruction and examined histopathologically.

RESULTS

A total of 449 subjects including 283 (63%) female and 166 (37%) male subjects with mean age of 50.02 years underwent DCR and histopathologic examination of specimens. Presenting symptoms were epiphora in 411 patients (91%), history of acute dacryocystitis in 17 patients (4%) and obstruction revealed during ophthalmic examinations in 21 patients (5%). Histopathologic findings included: chronic inflammation in 450 patients (95.5%), fibrosis in 18 patients (3.8%), lymphoma in two patients (0.4%) and reactive lymphoid hyperplasia in one patient (0.2%). Lacrimal sac appearance during surgery was grossly abnormal in two cases: one case of lymphoma and one instance of reactive lymphoid hyperplasia.

CONCLUSIONS

Chronic inflammation and fibrosis are the most common histopathologic findings in lacrimal sac specimens obtained during DCR. Only two cases of lymphoma (0.4%) were encountered in the series, one of which had a suspicious lacrimal sac appearance during surgery while the other case (0.2% of all specimens) was unsuspected. The rate of malignant etiology for NLD obstruction is low enough to justify lacrimal sac biopsy only in suspicious cases.

Mucormycosis infection of the lacrimal sac

Biopsy of the lacrimal sac for patients with primary acquired nasolacrimal duct obstruction has been a topic of debate for many years. The authors present a case of a 72-year-old immunocompetent woman with a 2-month history of epiphora secondary to nasolacrimal duct obstruction. During an uneventful dacryorhinocystostomy, a routine lacrimal sac biopsy was performed and revealed mucormycosis. After appropriate infectious disease consultation, intensive antifungal therapy was given uneventfully. The patient has not had any signs of active Mucor infection after treatment in 6 months of follow up. This case demonstrates the utility of routine lacrimal sac biopsy and stands as an example of the potential to miss a serious diagnosis.