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Dacryoceles, also known as lacrimal sac mucocele, amniocele, amniotocele, or dacryocystocele, are a rare form of congenital nasolacrimal duct obstruction with both proximal and distal obstruction resulting in lacrimal sac enlargement. Usually presenting at birth, there is significant risk for infection. Probing and excision of an associated intranasal cyst under general anesthesia may be needed. We present 2 infants who underwent probing for a unilateral dacryocele who subsequently developed a dacryocele on the unaffected side. We suggest that if a unilateral dacryocele is probed under general anesthesia it may be prudent to evaluate the contralateral side, even if asymptomatic. Probing and excision of an intranasal cyst, if present on the asymptomatic side, may prevent development of a dacryocele and a second anesthesia.
Report of Cases
An otherwise well, full-term, 6-day-old girl was referred for evaluation of a purple mass present since birth near the left medial canthus. The parents noted yellowish discharge from both eyes. She was feeding well without dyspnea.
External examination (B.N.W.) revealed an approximately 1-cm mass just inferior and lateral to the left medial canthus (Figure 1A). The overlying skin was erythematous and the lesion firm. The right medial canthus was minimally erythematous, but without mass. The remaining anterior segment and retinal examinations were normal bilaterally.
Case 1. A, Newborn female with initial presentation of a left dacryocele with minimal redness on the right. B, Sequential right dacryocele days later, after successful probing and irrigation of the left lacrimal system.
The patient underwent a left nasolacrimal probing and irrigation in the office with topical anesthetic. Copious yellow-white material was expressed via the lower puncta when the No. 0 Bowman probe was passed into the lacrimal sac and then into the nasolacrimal duct. No attempt was made to accomplish intranasal “metal-on metal” contact. The lacrimal system was irrigated with normal saline. The patient was prescribed moxifloxacin and tobramycin/dexamethasone drops, administered each alternating hour while awake. The parents were instructed to perform nasolacrimal sac massage.
One day later, the parents reported discharge from both eyes. Massage and eye drop administration were continued. Five days later, examination revealed a new right dacryocele without infection but with persistent discharge bilaterally (Figure 1B). The child was afebrile and feeding well. Office right nasolacrimal probing and irrigation was performed, again producing copious discharge. One day later, the right dacryocele had recurred. Gentle massage failed to decompress the dacryocele. Repeated office probing and irrigation was performed. The next day, the dacryocele returned. There was persistent discharge from the left eye, despite apparent resolution of the left dacryocele.
The patient was hospitalized, where probing and irrigation were performed under general anesthesia. Intranasal endoscopy revealed bilateral intranasal cysts (Figure 2), which were excised. All symptoms were resolved on follow-up examination 1 month later.
Case 1. Intranasal endoscopy reveals right (A) and left (B) intranasal cysts under the inferior turbinates.
An otherwise healthy, full-term, 2-day-old baby was observed to have swelling of the left lower eyelid medially. The parents reported “yellow pus” draining from the left eye since 4 days of age, which then stopped at 10 days of age. Subsequently, the left lower eyelid swelling became firm and developed surrounding erythema. Oral amoxicillin was prescribed by the pediatrician. On initial examination by Ophthalmology (B.M.S.) at 12 days old, a firm, erythematous, cystlike lesion inferior and lateral to the medial canthus, causing an upward distortion of the eyelid margin, (Figure 3A) consistent with an infected dacryocele was seen.
Case 2. A, Initial left dacryocele. B, Sequential right dacryocele at 40 days of age (note upslanting of the right eyelid fissure nasally).
Attempted decompression by moderate pressure failed. The lacrimal system was probed into the lacrimal sac without passing the probe down the nasolacrimal duct. Copious greenish-yellowish material drained. The parents were instructed to continue lacrimal sac compression and oral antibiotics. Two days later, the dacryocele was decreased in size and the erythema resolved. Compression by the ophthalmologist yielded approximately 2 to 3 mL of discharge and the dacryocele decompressed. Subsequently, the dacryocele recurred.
At 29 days old, the patient underwent left nasolacrimal probing and intranasal cyst excision with intranasal endoscopy under general anesthesia for a persistent dacryocele. Immediately after probing and cyst excision, the dacryocele resolved and did not recur.
At 40 days old, discharge was first noted from the right eye. At 61 days old, a firm swelling was found just inferolateral to the medial canthus (Figure 3). Approximately 2 to 3 mL of yellowish material was expressed with digital pressure. Massage and moxifloxacin drops were prescribed. After 3 weeks of medical treatment, the dacryocele resolved and did not recur over 6 months of follow-up.
A dacryocele is a lacrimal sac swelling from nasolacrimal duct blockage at the inferior meatus, causing a proximal ball-valve effect at the canalicular junction to the lacrimal sac allowing fluid to enter, but not to leave, the sac. Dacryoceles occur in 0.08% to 0.1% of newborns with congenital nasolacrimal duct obstruction.1,2 Approximately 25% are bilateral,3-5 although initial presentation may be unilateral.5 Intranasal cysts are almost invariably present.3,5 The swollen sac presents as a bluish, cystic, firm mass inferolateral to the medial canthus, sometimes with signs of infection including overlying erythema.1-3 The swollen sac displaces the medial canthal tendon upward, resulting in an eyelid fissure that slants upward nasally. Patients may also have respiratory distress and difficulty feeding secondary to the intranasal cyst.1-3,5 Differential diagnosis includes encephalocele, hemangioma, dermoid, and glioma.1
Medical treatment with massage, warm compresses, and topical antibiotic drops may yield success in up to 76% of babies within 1 week.4 Citing risks of infection and potentially life-threatening sepsis, some authors3 recommend immediate probing at the bedside5 or under general anesthesia.5 The latter, with marsupialization of the intranasal cyst, results in the lowest recurrence rates1,5 and may be indicated for medical management or probing failures1,5 or as initial treatment.3 Intranasal cysts may remain even when the external appearance has normalized and the symptoms resolve, as in our case 1. Although neonates are obligate nasal breathers, this patient had bilateral, large intranasal cysts without respiratory distress, even while feeding. Persistent ocular discharge may indicate that the nasal pathology remains.
Our cases demonstrate that patients with a unilateral dacryocele are at risk for developing dacryoceles contralaterally even if minimal (case 1) or no (case 2) symptoms of nasolacrimal duct obstruction are present. Paysse and coworkers5 reported that 4 of 16 patients with a unilateral dacryocele later developed contralateral dacryoceles. They recommend consideration of bilateral nasolacrimal probing in unilateral cases. Our experience supports this approach, particularly so that intranasal endoscopy can identify contralateral occult intranasal cysts. This would reduce the potential risk of neonatal infection and need for a second general anesthesia to treat a sequential dacryocele. Bilateral office probe and irrigation may be prudent on initial presentation.
Correspondence: Dr Wasserman, 100 Canal Pointe Blvd, Ste 112, Princeton, NJ 08540 (firstname.lastname@example.org).
Financial Disclosure: None reported.
Funding/Support: This work was supported in part by the Foerderer Fund.
Additional Contributions: We are grateful for the role played by research assistant Saundra Ehrlich, BS, MS, in the preparation of the manuscript.
Wasserman BN, Schnall BM, Levin AV. Sequential Bilateral Dacryocele. Arch Ophthalmol. 2011;129(1):102–105. doi:10.1001/archophthalmol.2010.326
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