of dacryocystitis External dacryocystorhinostomy … dacryocystorhinostomy outcomes in patients with a ... patients with acute or chronic ... presence of chronic low-grade inflammation

Original ArticleExternal dacryocystorhinostomy outcomes in patients with a historyof dacryocystitisDaniel R. Lefebvre, MD,

a,b Sonya Dhar, MD,

c,d Irene Lee, MD,

e Felicia Allard, MD,

f and Suzanne

K. Freitag, MDa,b

Author affiliations: aDivision of Ophthalmic Plastic Surgery, Department of Ophthalmology, Massachusetts Eye and EarInfirmary, Boston, Massachusetts;bDepartment of Ophthalmology, Harvard Medical School, Boston;cDepartment of Ophthalmology, New York University / New York Harbor Healthcare System, New York, New York;dDepartment of Ophthalmology, Moran Eye Center, Salt Lake City, Utah;eDivision of Ophthalmology, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence;fDepartment of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston

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

Methods—The medical records of all patients with acute or chronic dacryocystitis who underwent exter-nal dacryocystorhinostomy performed by the senior author over a 5-year period were retrospectivelyreviewed, 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 2months (average, 15.5 months). Surgical success was achieved in 42 systems (87%). Of 7 failures, 6 had acondition potentially associated with an increased risk of failure, including MRSA infection, Gram-nega-tive infection, rhinosinusitis, lymphoma, inflammatory bowel disease, and early loss of lacrimal stents.

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

IntroductionDacryocystitis is most often the result of an acquirednasolacrimal duct stenosis leading to outflow obstruc-tion and subsequent infection and inflammation ofretained stagnant contents within the lacrimal sac.1 Theetiology of most cases of dacryostenosis is idiopathic,although it has been hypothesized to occur secondarilyto an ascending inflammation from the nose andsinuses.2,3 The signs of acute dacryocystitis include sud-den onset of erythema, edema, and tenderness in themedial canthal area surrounding the lacrimal sac, whichitself may be distended. Chronic dacryocystitis is a moreindolent form of dacryocystitis, characterized by persis-

tent, low-grade inflammation associated with mucopuru-lent discharge from the puncta; it is differentiated fromsimple nasolacrimal obstruction, in which there is epi-phora but no sign of low-grade inflammation or dis-charge. The diagnosis of dacryocystitis establishes thediagnosis of nasolacrimal duct obstruction (NLDO).4Untreated, dacryocystitis is capable of progressing to avision or life-threatening condition, because the infec-tion may evolve to preseptal cellulitis, orbital cellulitis,meningitis, and even cavernous sinus thrombosis anddeath.5

Published September 20, 2015.Copyright ©2015. All rights reserved. Reproduction in whole or in part in any form or medium without expressed written permission of theDigital Journal of Ophthalmology is prohibited.doi:10.5693/djo.01.2014.08.001Correspondence: Suzanne K. Freitag, MD, Director, Ophthalmic Plastic Surgery, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Bos-ton, MA 02114 (email: [email protected]).Presented at the Spring meeting of the American Society of Ophthalmic Plastic and Reconstructive Surgery, May 15, 2011, Amelia Island, Flor-ida.

Digital Journal of O

phthalmology, Vol. 21



The initial treatment of acute dacryocystitis may includetopical and systemic antibiotics, with possible incisionand drainage of the lacrimal sac, which serves the func-tion of relieving lacrimal sac pressure and discomfort,evacuating what is essentially an abscess cavity, andproviding material for microbiologic culture and sensi-tivity testing.6,7 Definitive treatment is surgical.Although there have been many revisions and modifica-tions to surgical technique, the underlying principle ofsurgical treatment, reestablishing patent communicationbetween the lacrimal sac and the nasal cavity, has notchanged since dacryocystorhinostomy (DCR) was intro-duced over 100 years ago in 1904 by Toti.8

Success rates for DCR, whether performed externally orendonasally, range from 69.9% to 100%, depending onmany variables.9,10 These success rates generally reflectDCR performed for cases of obstruction both with andwithout a history of dacryocystitis. In the present study,we reviewed a series of subjects, all of whom were diag-nosed specifically with dacryocystitis (either acute orchronic) and who were treated via external DCR (ext-DCR). Cases that failed postoperatively were evaluatedfor possible associations that may be related to surgicalfailure with the goal of highlighting a pathophysiologyfor surgical failure that is not idiopathic.

Materials and MethodsThis study was conducted with the approval of the Bos-ton University Institutional Review Board, withacknowledgement by the Massachusetts Eye and EarInfirmary Institutional Review Board. The medicalrecords of consecutive patients undergoing ext-DCRperformed by a single surgeon (SKF) from July 1, 2002,to December 31, 2008, at Boston Medical Center wereretrospectively reviewed. The primary surgeon’s log wasqueried for patients who had undergone external dacryo-cystorhinostomy with an associated diagnosis of acutedacryocystitis (ADC) or chronic dacryocystitis (CDC).Patients who underwent ext-DCR for reasons other thandacryocystitis (eg, NLDO with epiphora but withoutsigns or history ADC or CDC) were excluded. ADC wasdefined clinically as symptoms of fulminant lacrimal sacinflammation/infection, erythema, pain, and dischargefor <2 weeks’ duration prior to initial presentation. CDCwas defined clinically as the presence of chronic low-grade inflammation and associated discharge that hadbeen ongoing or intermittent for >2 weeks’ duration.

Statistical AnalysisData from included cases were entered into a spread-sheet (Microsoft Excel, Microsoft, Redmond, WA) for

management and statistical analysis, which involved theχ2 test for sex and the t test for comparison of age anddifferences of preoperative duration of disease and sur-gical outcomes.

Surgical TechniqueA standard ext-DCR procedure under general anesthesiawas performed in all cases. The nasal cavity of the oper-ative side was packed with 4% cocaine solution–soakedcottonoids, and 2% lidocaine with 1:100,000 epinephr-ine was injected subcutaneously in the medial canthalarea. The skin was then incised with a #15 Bard-Parkerblade, and blunt dissection was performed until the peri-osteum of the frontal process of the maxilla was identi-fied, which was incised with a #15 Bard-Parker blade. Aperiosteal elevator was used to elevate the periosteumover the anterior lacrimal crest and into the lacrimal sacfossa, elevating the lacrimal sac and exposing the lacri-mal bone. The lacrimal bone was infractured with aclosed hemostat, with care taken to avoid violation ofthe nasal mucosa. A Kerrison rongeur was used to createan osteotomy of approximately 1 cm to 1.5 cm in diame-ter. The nasal mucosa was incised and anterior and pos-terior flaps were created. Insertion of Crawford-style,bicanalicular, silicone stents (FCI Ophthalmics, Marsh-field Hills, MA) was performed after the superior andinferior puncta were dilated. The stylets were used totent the lacrimal sac, and a #11 Bard-Parker blade wasused to incise the sac, creating anterior and posteriorflaps. The silicone stents were exteriorized through thenose. The anterior nasal and lacrimal sac mucosal flapswere anastomosed with 4-0 chromic gut. The Crawford-tube stylets were then passed through a silicone retinalsponge segment cut to approximately 1.5 cm in length toserve as an intranasal bolster to prevent postoperativestent prolapse. The incision was closed in two layers.

Postoperative CourseAll patients were prescribed an oral antibiotic to betaken 4 times daily for 5 days after surgery (cefalexin250 mg, unless the patient had a beta-lactam allergy, inwhich case ciprofloxacin or clindamycin was prescri-bed). If there were known culture results, antimicrobialtherapy was directed appropriately according to sensitiv-ity results. Erythromycin ophthalmic ointment wasapplied to the skin incision 3 times per day until the firstfollow-up appointment. Patients were seen at 1 week, 1month, and 2 months after surgery and subsequentlyaccording to clinical course. Silicone stents wereremoved at the 2-month follow-up appointment. Nopatients were prescribed steroids of any type. Surgicalsuccess was defined by resolution of infection and a lack

Lefebvre et al. 41





of symptoms, such as epiphora. Surgical failure wasdefined as persistence or recurrence of dacryocystitis orepiphora.

ResultsA total of 54 adult patients were identified who met theinclusion criteria. Of these, 4 underwent bilateral sur-gery, yielding a total of 58 nasolacrimal systems. Fivepatients (1 bilateral) were excluded for inadequate fol-low-up, bringing the total number of patients to 49, with52 nasolacrimal systems. The average follow-up timewas 15.5 months ± 17.6 (range, 2–74 months).

Of the 49 patients, 43 were female (88%; P =0.00000013 [χ2]). The average age for male patients was50.8 years ± 23.0 (range, 31–78); for females, 61.5 ±19.6 (range, 17–89). The average age for all patientscombined was 60.2 years; there was no statistically sig-nificant difference between the age of males and females(P = 0.30).

Acute dacryocystitis was present in 14 patients (13females). CDC was present in 30 females and 5 males,for an overall total of 35 patients with chronic disease(70%).

Bilateral cases occurred in 2 females and 1 male. Right-sided procedures were conducted in 28 females and 3males; left-sided procedures, in 18 females and 3 males.There was no statistically significant difference in later-ality among females (P = 0.14 [χ2]) or males.

Microbial cultures were obtained from 19 lacrimal sys-tems (39%) that were found to have purulence in the lac-rimal sac at the time of surgery. Culture results were pol-ymicrobial in 7 and monomicrobial in 11. A single casedemonstrated no growth (an 83-year-old female with apreoperative diagnosis of CDC). There were 10 Gram-positive isolates (53% of total systems cultured) and 14Gram-negative isolates (74% of total systems cultured),as well as a single identified yeast (Table 1). The mostcommon Gram-positive pathogen was Staphylococcusaureus (5 cases), followed by Streptococcal species (3)and Propionibacterium acnes (2). The most commonGram-negative pathogen was Haemophilus influenzae (5cases), followed by Proteus mirabilis (2), Pseudomonasaeruginosa (2), and others. Within the S. aureus isolateswere 3 cases of methicillin-resistant Staphylococcusaureus (MRSA): (1) an 89-year-old institutionalizedfemale with CDC, type 2 diabetes mellitus, polio, andpsychiatric illness; (2) a 51-year-old female Palestinianimmigrant with CDC of 5-years’ duration; (3) a 73-year-old male with CDC who underwent functional endo-

scopic sinus surgery approximately 1 year prior to pre-sentation.

Tissue samples were obtained for histopathologic analy-sis in 30 lacrimal systems (61%). Chronic inflammationwas seen in 26 samples (87%). Of these, 7 cases werespecifically associated with dense fibrotic tissue, 1 casewith a giant-cell foreign body reaction and 1 case with adacryolith. Two specimens were of loose connective tis-sue, without evidence of inflammation. A single caseshowed mild acute inflammatory changes. One casedemonstrated a lymphoid infiltrate consistent with lym-phoma in a patient with known systemic lymphoma.

Of 52 lacrimal systems, 45 (87%) had a successful sur-gery, defined as postoperative absence of dacryocystitisand epiphora. Symptoms recurred in 7 cases (13% [6females]). Laterality was split, with 3 right sides and 4left sides. The details of the recurrent cases, includingdisease duration, microbiology, and histopathologywhen available, and relevant past medical, surgical, andsocial history are presented in Table 2 and detailedbelow.

Recurrent CasesCase 1An 89-year-old female nursing home resident with a his-tory of type 2 diabetes mellitus, psychiatric illness,

Table 1. Microbiology of cultured, lacrimal sac contents

42





polio, and osteomyelitis, who had right-sided intermit-tent CDC of 4 months’ duration per history, developedan associated preseptal cellulitis and on presentation tothe oculoplastics clinic was treated with incision anddrainage. Culture revealed MRSA. She was treated withoral trimethoprim/sulfamethoxazole preoperatively andunderwent ext-DCR approximately 4 months followingpresentation. Lacrimal sac biopsy demonstrated densefibroconnective tissue with minimal chronic inflamma-tory changes. Two months postoperatively, she devel-oped a recurrence of dacryocystitis. She underwent revi-sion surgery 5 months after her initial operation; intrao-perative cultures again returned MRSA. Following hersecond procedure, she has been without recurrence for55 months postoperatively.

Case 2A 40-year-old healthy woman with a 2-month history ofleft-sided epiphora followed by a 3-day history of dis-charge and redness was diagnosed with acute dacryocys-titis. She received a 2-week course of cefalexin andunderwent ext-DCR 3 months after initial presentation.Intraoperative cultures were not obtained and mucosalbiopsy was not performed. The patient was withoutproblems at postoperative month 6 and did not return forfurther follow-up until she developed tearing and dis-charge at 34 months postoperatively. Revision surgerywas performed and the patient was without symptoms oftearing or infection at postoperative month 6. Intraopera-tive cultures and tissue samples were not obtained dur-ing the revision surgery.

Case 3A 51-year-old female Palestinian immigrant with hyper-tension presented with a 5-year history of right-sidedtearing and intermittent discharge and low-grade inflam-mation, consistent with CDC. Culture at presentationrevealed MRSA and Strep. viridans. The patientreceived a course of Bactrim and ext-DCR was per-formed 2 months following presentation. Intraoperativecultures demonstrated no growth. Pathology specimenswere not obtained. She presented at postoperative month15 with recurrence of CDC and underwent revision sur-gery 20 months after initial DCR. Tissue samplesshowed chronic inflammation and intraoperative cul-tures revealed H. influenzae. She was without tearing ordischarge at the time of silicone stent removal at postop-erative month 2.

Case 4A 59-year-old healthy woman presented with a 4-yearhistory of left-sided tearing, discharge, and inflamma-tion, consistent with CDC. Computed tomography (CT)revealed mild pansinusitis (mucosal thickening). Sheunderwent evaluation with an otolaryngologist, whoadvised a steroid nasal spray. Ext-DCR was performed 5months later. Cultures were not obtained. Histopathol-ogy was consistent with chronic inflammatory infiltrate.Epiphora returned 3 months postoperatively, but shedeferred further surgical treatment.

Case 5An 87-year-old woman with a history of right-sidedendoscopic DCR performed by another surgeon 3 years

Table 2. Failed case characteristics

Lefebvre et al. 43





previously had persistent epiphora and lacrimal sacenlargement, with intermittent punctal discharge andinflammation. Preoperative culture of the dischargerevealed P. aeruginosa and E. coli. Histopathology fol-lowing external revision DCR demonstrated densefibrous tissue, with chronic inflammatory changes con-sistent with her presentation of CDC. Her symptomsreturned within one month of surgery, and she opted formedical management only with oral antibiotic therapy.

Case 6An 83-year-old woman with a history of lymphoma andbreast cancer had undergone radiation therapy andtamoxifen treatment. She presented with left-sided,acute dacryocystitis and was treated preoperatively withamoxicillin/clavulanate empirically. One month afterpresentation, she underwent ext-DCR. Cultures grewCitrobacter freundii and P. aeruginosa, and histopathol-ogy demonstrated chronic inflammation despite thepatient’s apparent acute presentation. The patient didwell until 35 months postoperatively, when she devel-oped epiphora and mild purulent punctal discharge bilat-erally. She declined further intervention.

Case 7A 33-year-old man with a history of Crohn disease andlymphoma presented with a many-year history of left-sided tearing and discharge. Initial cultures and subse-quent intraoperative cultures obtained several weekslater demonstrated no growth. The bicanalicular siliconestents placed at the time of ext-DCR “fell out” at postop-erative week 4. He had a recurrence of symptoms andunderwent surgical revision at postoperative month 8.Intraoperative cultures from the second surgery revealedStrep. pneumoniae. Biopsied lacrimal sac tissue demon-strated signs of chronic inflammation. The siliconestenting remained in place until removal at postoperativemonth 2. He remained without symptoms or signs ofrecurrence at postoperative month 3.

DiscussionThe overall 87% success rate of ext-DCR in this seriesand the high proportion of female patients with NLDOand dacryocystitis (88%) are comparable to previousreports.9,11–15 Of the 7 cases of recurrent dacryocystitisafter DCR, 2 were associated with MRSA infection, 2were associated with Gram-negative bacteria, 2 carriedan associated diagnosis of lymphoma, 2 demonstratedvery dense fibrosis of the lacrimal sac on histopathology,1 had background pansinusitis demonstrated on CT, 1had a history of inflammatory bowel disease; 1 had a

history of prior endoscopic DCR performed 3 years pre-viously; and 1 had a loss of canalicular stents relativelyearly in the postoperative course. Only case 2 had noassociated systemic illnesses or perioperative events topossibly explain an increased risk of recurrence,although this case did not have cultures or biopsy per-formed, and it is therefore possible that an underlyingcausative pathology could have been missed.

Dacryocystitis represents an infection within the lacri-mal sac. Although postoperative DCR wound infectionis quite rare, such infection is associated with anincreased risk of surgical failure.14,12 The final postop-erative intranasal ostium size following ext-DCR aver-ages 1.8 mm in diameter.16 The primary anatomic causeof DCR failure has been observed to be the formation ofintranasal soft tissue adhesions.17 It therefore seems rea-sonable that the presence of bacterial colonization andincreased inflammation may contribute to closure of thenasal ostium via stenosis and adhesion formation.

Evidence has shown that postoperative DCR patientstreated with antibiotic therapy have significantly lowerrates of postoperative wound infections.12,18 Whetherall patient undergoing DCR require systemic antibiosisis debated. A recent large study of 697 external DCRsfound that prophylactic intravenous antibiotic therapy atthe time of surgery may be of benefit only in cases asso-ciated with a history of mucocele, mucopyocele, orfrank dacryocystitis, because these cases were found tohave a higher rate of positive intraoperative culture.19

It is the preference of the senior author to treat all casesof acute dacryocystitis medically with oral antibioticsfor 2 weeks prior to any surgical intervention to reducethe underlying infection and quiet inflammation prior toembarking on surgery. Some authors have proposeddacryocystorhinostomy, most recently using endoscopicdacryocystorhinostomy, as a direct treatment for acutedacryocystitis.20 In their multicenter retrospectivereview of 18 patients with acute dacryocystitis treatedvia endo-DCR, Madge et al reported a 94.4% successwith an average of 12 months’ follow-up. It should benoted, though, that all patients received either oral orintravenous antibiotics for an average of 5 days prior tosurgery, with 66.7% having documented clinicalimprovement prior to surgery.

Knowledge of the most common organisms associatedwith dacryocystitis is helpful in directing empiric ther-apy. In the present series, among surgical failures withavailable bacterial culture results, there were 2 caseswith Gram-negative bacteria and 2 with MRSA. Anational multicenter prospective study of 89 patients

44





examined the microbiologic spectrum of acute andCDC.10 The majority of isolates were Gram-positivespecies; the most common pathogen isolated was Staph-ylococcus aureus (28.8%). Of these, 21% were MRSA.Further, a significant proportion of cases (28.9%) werenot sensitive to the initial empiric antibiotic agentchosen. Lacrimal surgery was performed in 93% of allcases, and a success rate of 100% was reported, althoughthe follow-up time was not stated.10 There are otherexamples of successful DCR performed in the setting ofMRSA, which is notable because the incidence ofMRSA is ever increasing.6,21,22 Freidlin et al reportedan increase in the proportion of S. aureus eye infectionsthat were MRSA, starting from 4.1% in 1998 andincreasing to 16.7% in 2005.23 A case series by Kotluset al examined MRSA-associated dacryocystitis specifi-cally.22 Patients were treated preoperatively with combi-nations of oral linezolid and topical fortified vancomy-cin eyedrops. With this therapy, the authors reported100% success in the 3 patients who underwent DCR and100% failure in 4 patients who were unable to have sur-gery. Certainly there can be successful DCR outcomes inthe presence of MRSA, and even in the present studythere was a case associated with MRSA that was suc-cessful. It is likely, however, that in most cases ofMRSA, empiric antibiotics are not effective, allowing asubclinical infection to persist in the immediate postop-erative period that incites inflammation and contributesto adhesion formation, ostium closure, and subsequentsurgical failure. There are known associations thatincrease a person’s risk for MRSA colonization, includ-ing recent hospitalization or recent outpatient clinicvisit, nursing home residence, history of intravenousdrug usage, history of antibiotic usage, and chronic ill-ness.24 By noting these associated risk factors, it may bepossible to identify patients who may be more appropri-ately treated with a nonstandard empiric antibiotic regi-men or patients who should be screened for MRSA andconsidered for direct early antibiotic coverage early(either clindamycin or trimethoprime/sulfamethoxazole).We advise allowing sufficient time for antibiotic treat-ment to be effective and for all active inflammation tosettle prior to lacrimal surgery in these patients.

There may also be an increase in the prevalence ofGram-negative bacteria associated with dacryocystitis,particularly outside the US. Hartikainen et al showed a16.7% Gram-negative prevalence in their studied sam-ples from patients with lacrimal duct obstructions in Fin-land, the most common Gram-negative bacterium beingH. influenza.11 Badhu et al found 18.7% Gram-negativeprevalence in their cross-sectional study of CDC inNepal.25 CDC was associated with Gram-negative bac-

teria 26% of the time in a study from Saudi Arabia, withone-third of the Gram-negative isolates being H. influ-enza.26 The most significant Gram-negative presencehas been reported by Briscoe et al, with 61% Gram-neg-ative isolates in patients with purulent dacryocystitis inIsrael.27 In that study, the most common bacterium wasP. aeruginosa, accounting for 22% of all isolates (ie,including Gram positive and Gram negative com-bined).27 The authors noted frequent resistance of theGram-negative bacteria to the antibiotic agents routinelyselected for empiric therapy in dacryocystitis.26,27 USdata from Mills et al10 showed a 28.7% prevalence ofGram-negative bacteria, with P. aeruginosa being themost frequent. In the present study, Gram-negative bac-teria were found in 74% of the lacrimal systems cul-tured, with the most frequent being Haemophilus influ-enzae, followed by P. aeruginosa and P. mirabilis. Case3 was associated with H. influenzae (after previouslybeing MRSA positive at the time of initial surgery).Case number 5 was associated with the Gram negativesP. aeruginosa and E. coli. Cephalexin was the mostcommonly empirically prescribed antibiotic in thepresent series, and this first-generation cephalosporinhas good broad Gram-positive coverage (excludingMRSA) and does have some activity against H. influen-zae, the most commonly encountered Gram-negativebacterium in this series. Cephalexin has little activityagainst pseudomonas species and E. coli, however.Therefore, it is reasonable to prescribe cephalexin (oralternatively amoxicillin / clavulanate) as a first-lineempiric agent to treat dacryocystitis; however, culturesshould be routinely obtained (either from punctal dis-charge or from incision and drainage of the lacrimal sacfor acute dacryocystitis) and antimicrobial therapy expe-diently altered if indicated based on culture results.

Selection bias may have contributed to the relativelyhigh proportion of Gram-negative isolates identified inthe present study. Cases that appeared “worse” or hadmore discharge may have prompted culture over caseswithout such a clinical picture. Hartikainen et al11

showed that there is a qualitative difference in the puru-lent discharge found in Gram-negative cases of dacryo-cystitis (being more copious and thicker) in comparisonto Gram-positive infections. It is possible that thisthicker discharge may contribute to the surgical sitemilieu and could potentially cause persistent inflamma-tion and adhesion formation during the postoperativeperiod following DCR. Another aspect of Gram-nega-tive infection is that frequently empiric antibiotics (first-generation cephalosporin in the present study) are rela-tively ineffective against Gram-negative organisms. Thepresence of a relatively thick and copious discharge

Lefebvre et al. 45





could therefore direct the clinician to potentially selectan empiric antimicrobial with greater Gram-negativecoverage while awaiting culture results.

Inflammation may also be associated with lacrimalobstruction as well as with lacrimal surgery failure.Inflammatory bowel disease (IBD)—either Crohn dis-ease or ulcerative colitis—has been documented to havean increased association with lacrimal drainage obstruc-tion. McNabb et al showed a higher prevalence of IBD(2%) in a cohort of patients with lacrimal drainageobstruction compared to the estimated prevalence in thegeneral Australian population (0.3%).28 When the out-comes of 9 post-DCR patients with IBD were assessed,there was 1 case with partial success and 1 with recur-rence of symptoms within the first postoperative year.28

There was also a high prevalence of sinonasal diseaseamong these patients, 2 of whom showed significantsinus disease on CT.28 In fact, granulomatous inflamma-tory changes have been directly observed in the conjunc-tiva and nasal mucosa of patients with Crohn dis-ease.29,30 The overall prevalence of sinonasal diseasehas been reported to be as high as 48% in patients withIBD.31 It is plausible that since increased sinonasalinflammation appears to play a role in the developmentof lacrimal system obstruction, it may also play a role inpost-DCR failure. In the present study there was a failedsurgery in a patient with chronic pansinusitis identifiedon CT and a patient with Crohn disease.

The lacrimal drainage system functions as a mucosal-associated lymphoid tissue and is thus capable of har-boring malignant hematologic neoplasms and lymphoidinfiltrates.32 Such infiltration can cause lacrimal drain-age system obstruction.33 Obstruction may be unilateralor bilateral, as occurred during the post-DCR time-period for case 6 in the present study. Slonim and Olderdocumented a case of bilateral DCR failure in a patientwith a history of chronic lymphocytic leukemia; the casewas peculiar in that the patient with leukemia had thedevelopment of biopsy-proven solid lymphoma at bothDCR sites.34 It is important to maintain vigilance inpatients with a history of such malignancy. A biopsy ofthe lacrimal tissue at the time of DCR may reveal activedisease in someone thought to be in remission.

There is debate regarding whether routine biopsy of lac-rimal sac or nasal mucosal tissue is indicated at the timeof DCR. Anderson et al analyzed 377 DCR lacrimal sacspecimens and found 85% non-granulomatous inflam-mation.35 The next most common pathology was sarcoi-dosis (2.1%), followed by lymphoma (1.9%).35 Moreunusual neoplasms occurred in isolation. Previouslyundiagnosed malignancies were diagnosed in 2.1% of

cases, and the authors concluded that routine biopsy oflacrimal sac tissue ought to be performed during allcases of DCR surgery.35 A later prospective study of193 consecutive endoscopic DCR lacrimal sac speci-mens found non-specific inflammation in 76% and nor-mal results in 23%; only 1.2% had a specific pathology.The authors concluded that routine biopsy should not beperformed.36 The present study had similar rates ofbland inflammatory changes in lacrimal sac samples,with only a single, specific pathology identified (lym-phoma); interestingly, not in one of the recurrent dacryo-cystitis cases. Specific pathologies, while rare in relationto the majority of lacrimal system stenosis cases, doexist and can be found on tissue biopsy performed dur-ing DCR, such as a recently reported case of bilateralnasopharyngeal amyloidosis.37 It therefore seems pru-dent to leave the decision of whether or not to biopsy tothe discretion of the operating surgeon, who can relatethe clinical picture to the patient’s history.

Lacrimal intubation in DCR surgery has a varied historyand is also the subject of some debate.38 The seniorauthor prefers to place a silicone lacrimal stent at thetime of DCR in all cases, and this is routinely removedat postoperative month 2. Case 7 in the present study,associated with Crohn disease and lymphoma, was fur-ther confounded by an early loss of bicanalicular stent-ing. Sodhi et al reviewed 25 cases of patients at high-risk for DCR failure; all cases were stented, and 100%postoperative success was achieved when the stentsremained in place for at least 6 months, while there were2 failures occurring with loss of stents at postoperativeweek 3 and 1 failure with loss of stents at postoperativemonth 3.39 Case 7 in our study could have been consid-ered at high risk for DCR failure given his past medicalhistory, and it is possible that his early loss of lacrimalstenting contributed to the failure.3

The present study is limited by the relatively short fol-low-up period and by other weaknesses inherent to a ret-rospective review (eg, selection bias, nonuniform inter-ventions, etc). Postoperative lacrimal irrigation was notperformed in all subjects, because it is the seniorauthor’s practice to not instrument lacrimal systems inpatients who are without complaint or signs of epiphorabecause doing so exposes them to unnecessary proce-dural intervention. Intraoperative tissue biopsy was notperformed in all cases in this retrospective study; how-ever, 100% tissue analysis may be considered advisablein a future prospective study.

In conclusion, ext-DCR is a successful treatment forpatients with acute or chronic dacryocystitis; however,there are certain identifiable factors that may affect the

46





surgical outcome. Furthermore, there is still debateregarding optimal surgical technique and the effect ofvarious perioperative factors on surgical outcome. Oneproblem is that the literature displays a wide range inoutcome assessments and follow-up timeframes. Thereis a significant inverse correlation between DCR suc-cess-rate and length of follow-up.15 Variables have beenhighlighted in the present study that surgeons may wishto consider when counseling and treating patients withdacryocystitis, and these topics deserve further review.

References1. Olver, J., editor. Color Atlas of Lacrimal Surgery. Oxford: Butter-

worth-Heinemann; 2001. p. 2-23.2. DeAngelis D, Hurwitz J, Oestreicher J, Howarth D. The pathogene-

sis and treatment of lacrimal obstruction: the value of lacrimal sacand bone analysis. Orbit 2001;20:163-72.

3. Traquair H. Chronic dacryocystitis: its causation and treatment.Arch Ophthalmol 1941;26:165-80.

4. Nerad, JA. Techniques in Ophthalmic Plastic Surgery with DVD: APersonal Tutorial. Philadelphia: Saunders; 2010. p. 267.

5. Mauriello JA, Wasserman BA. Acute dacryocystitis: an unusualcause of life-threatening orbital intraconal abscess with frozenglobe. Ophthal Plast Reconstr Surg 1996;12:2945.

6. Cahill KV, Burns JA. Management of acute dacryocystitis in adults.Ophthal Plast Reconstr Surg 1993;9:38-41.discussion 42.

7. Barrett RV, Meyer DR, ASOPRS Acquired Lacrimal Fistula StudyGroup. Acquired lacrimal sac fistula after incision and drainage fordacryocystitis: a multicenter study. Ophthal Plast Reconstr Surg2009;25:455-7.

8. Toti A. Nuovo metodo cormervatore di cad/tale suppttrazioni cro-niehe de1 8a∞ o lacrimale (dacrioeis—toriocotomla). Clin Mod Pisa1904

9. Yigit O, Samancioglu M, Taskin U, Ceylan S, Eltutar K, Yener M.External and endoscopic dacryocystorhinostomy in chronic dacryo-cystitis: comparison of results. Eur Arch Otorhinolaryngol2007;264:879-85.

10. Mills DM, Bodman MG, Meyer DR, Morton AD, ASOPRSDacryocystitis Study Group. The microbiologic spectrum ofdacryocystitis: a national study of acute versus chronic infection.Ophthal Plast Reconstr Surg 2007;23:302-6.

11. Hartikainen J, Lehtonen OP, Saari KM. Bacteriology of lacrimalduct obstruction in adults. Br J Ophthalmol 1997;81:37-40.

12. Walland MJ, Rose GE. Factors affecting the success rate of openlacrimal surgery. Br J Ophthalmol 1994;78:888-91.

13. Heindl LM, Junemann A, Holbach LM. A clinicopathologic studyof nasal mucosa in 350 patients with external dacryocystorhinos-tomy. Orbit 2009;28:7-11.

14. Dolman PJ. Comparison of external dacryocystorhinostomy withnonlaser endonasal dacryocystorhinostomy. Ophthalmology2003;110:78-84.

15. Erdöl H, Akyol N, Imamoglu HI, Sözen E. Long-term follow-up ofexternal dacryocystorhinostomy and the factors affecting its suc-cess. Orbit 2005;24:99-102.

16. Linberg JV, Anderson RL, Bumsted RM, Barreras R. Study ofintranasal ostium external dacryocystorhinostomy. Arch Ophthal-mol 1982;100:1758-62.

17. Warren JF, Seiff SR, Kavanagh MC. Long-term results of externaldacryocystorhinostomy. Ophthalmic Surg Lasers Imaging2005;36:446-50.

18. Hurley LD, Westfall CT, Shore JW. Prophylactic use of antibioticsin oculoplastic surgery. Int Ophthalmol Clin 1992;32:165-78.

19. Pinar-Sueiro S, Fernández-Hermida R-V, Gibelalde A, Martínez-Indart L. Study on the effectiveness of antibiotic prophylaxis inexternal dacryocystorhinostomy: a review of 697 cases. OphthalPlast Reconstr Surg 2010;26:467-72.

20. Madge SN, Chan W, Malhotra R, et al. Endoscopic dacryocystorhi-nostomy in acute dacryocystitis: a multicenter case series. Orbit2011;30:1-6.

21. Kubo M, Sakuraba T, Arai Y, Nakazawa M. Dacryocystorhinos-tomy for dacryocystitis caused by methicillin- resistant Staphylo-coccus aureus: report of four cases. Jpn J Ophthalmol2002;46:177-82.

22. Kotlus BS, Rodgers IR, Udell IJ. Dacryocystitis caused by com-munity-onset methicillin-resistant Staphylococcus aureus. OphthalPlast Reconstr Surg 2005;21:371-5.

23. Freidlin J, Acharya N, Lietman TM, Cevallos V, Whitcher JP,Margolis TP. Spectrum of eye disease caused by methicillin-resist-ant Staphylococcus aureus. Am J Ophthalmol 2007;144:313-5.

24. Salgado CD, Farr BM, Calfee DP. Community-acquired methicil-lin-resistant Staphylococcus aureus: a meta-analysis of prevalenceand risk factors. Clin Infect Dis 2003;36:131-9.

25. Badhu BP, Karki BS, Khanal B, Dulal S, Das H. Microbiologicalpatterns of chronic dacryocystitis. Ophthalmology2006;113:2377.e1-2.

26. Chaudhry IA, Shamsi FA, Al-Rashed W. Bacteriology of chronicdacryocystitis in a tertiary eye care center. Ophthal Plast ReconstrSurg 2005;21:207-10.

27. Briscoe D, Rubowitz A, Assia EI. Changing bacterial isolates andantibiotic sensitivities of purulent dacryocystitis. Orbit2005;24:95-8.

28. Satchi K, McNab AA. Lacrimal obstruction in inflammatory boweldisease. Ophthal Plast Reconstr Surg 2009;25:346-9.

29. Blase WP, Knox DL, Green WR. Granulomatous conjunctivitis ina patient with Crohn’s disease. Br J Ophthalmol 1984;68:901-3.

30. Kinnear W. Crohn’s disease affecting the nasal mucosa. J Otolar-yngol 1985

31. Book DT, Smith TL, McNamar JP, Saeian K, Binion DG, ToohillRJ. Chronic sinonasal disease in patients with inflammatory boweldisease. Am J Rhinol 2003;17:87-90.

32. Linberg, JV., editor. Contemporary Issues in Ophthalmology. 5.New York: Churchill Livingstone; 1988. Lacrimal Surgery; p. 348.

33. Yip C-C, Bartley GB, Habermann TM, Garrity JA. Involvement ofthe lacrimal drainage system by leukemia or lymphoma. OphthalPlast Reconstr Surg 2002;18:242-6.

34. Slonim CB, Older JJ. Bilateral lymphocytic infiltrates causingdacryostenosis after bilateral successful dacryocystorhinostomies.Ophthal Plast Reconstr Surg 1988;4:105-8.

35. Anderson NG, Wojno TH, Grossniklaus HE. Clinicopathologicfindings from lacrimal sac biopsy specimens obtained duringdacryocystorhinostomy. Ophthal Plast Reconstr Surg2003;19:173-6.

36. Merkonidis C, Brewis C, Yung M, Nussbaumer M. Is routinebiopsy of the lacrimal sac wall indicated at dacryocystorhinos-tomy? a prospective study and literature review. Br J Ophthalmol2005;89:1589-91.

37. Geller E, Freitag SK, Laver NV. Localized nasopharyngeal amyloi-

Lefebvre et al. 47





dosis causing bilateral nasolacrimal duct obstruction. OphthalPlast Reconstr Surg 2011;27:e64-7.

38. Madge SN, Selva D. Intubation in routine dacryocystorhinostomy:why we do what we do. Clin. Experiment. Ophthalmol2009;37:620-3.

39. Sodhi PK, Pandey RM, Malik KPS. Experience with bicanalicularintubation of the lacrimal drainage apparatus combined with con-ventional external dacryocystorhinostomy. J CraniomaxillofacSurg 2003;31:187-90.

48





Documents

of dacryocystitis External dacryocystorhinostomy … dacryocystorhinostomy outcomes in patients with a ... patients with acute or chronic ... presence of chronic low-grade inflammation