External Dacryocystorhinostomy Outcomes in Patients With A History of Dacryocystitis
External Dacryocystorhinostomy Outcomes in Patients With A History of Dacryocystitis
External Dacryocystorhinostomy Outcomes in Patients With A History of Dacryocystitis
c,d
Author affiliations: aDivision of Ophthalmic Plastic Surgery, Department of Ophthalmology, Massachusetts Eye and Ear
Infirmary, Boston, Massachusetts;
bDepartment
cDepartment
of Ophthalmology, New York University / New York Harbor Healthcare System, New York, New York;
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
Abstract
PurposeTo investigate nonidiopathic causes of external dacryocystorhinostomy (DCR) failure.
MethodsThe 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.
ResultsA 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.
Introduction
Dacryocystitis is most often the result of an acquired
nasolacrimal duct stenosis leading to outflow obstruction and subsequent infection and inflammation of
retained stagnant contents within the lacrimal sac.1 The
etiology of most cases of dacryostenosis is idiopathic,
although it has been hypothesized to occur secondarily
to an ascending inflammation from the nose and
sinuses.2,3 The signs of acute dacryocystitis include sudden onset of erythema, edema, and tenderness in the
medial canthal area surrounding the lacrimal sac, which
itself may be distended. Chronic dacryocystitis is a more
indolent form of dacryocystitis, characterized by persis-
tent, low-grade inflammation associated with mucopurulent discharge from the puncta; it is differentiated from
simple nasolacrimal obstruction, in which there is epiphora but no sign of low-grade inflammation or discharge. The diagnosis of dacryocystitis establishes the
diagnosis of nasolacrimal duct obstruction (NLDO).4
Untreated, dacryocystitis is capable of progressing to a
vision or life-threatening condition, because the infection may evolve to preseptal cellulitis, orbital cellulitis,
meningitis, and even cavernous sinus thrombosis and
death.5
Lefebvre et al.
This study was conducted with the approval of the Boston University Institutional Review Board, with
acknowledgement by the Massachusetts Eye and Ear
Infirmary Institutional Review Board. The medical
records of consecutive patients undergoing ext-DCR
performed by a single surgeon (SKF) from July 1, 2002,
to December 31, 2008, at Boston Medical Center were
retrospectively reviewed. The primary surgeons log was
queried for patients who had undergone external dacryocystorhinostomy with an associated diagnosis of acute
dacryocystitis (ADC) or chronic dacryocystitis (CDC).
Patients who underwent ext-DCR for reasons other than
dacryocystitis (eg, NLDO with epiphora but without
signs or history ADC or CDC) were excluded. ADC was
defined clinically as symptoms of fulminant lacrimal sac
inflammation/infection, erythema, pain, and discharge
for <2 weeks duration prior to initial presentation. CDC
was defined clinically as the presence of chronic lowgrade inflammation and associated discharge that had
been ongoing or intermittent for >2 weeks duration.
Statistical Analysis
Data from included cases were entered into a spreadsheet (Microsoft Excel, Microsoft, Redmond, WA) for
41
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Results
Digital Journal of Ophthalmology, Vol. 21
Bilateral cases occurred in 2 females and 1 male. Rightsided procedures were conducted in 28 females and 3
males; left-sided procedures, in 18 females and 3 males.
There was no statistically significant difference in laterality among females (P = 0.14 [2]) or males.
Microbial cultures were obtained from 19 lacrimal systems (39%) that were found to have purulence in the lacrimal sac at the time of surgery. Culture results were polymicrobial in 7 and monomicrobial in 11. A single case
demonstrated no growth (an 83-year-old female with a
preoperative diagnosis of CDC). There were 10 Grampositive isolates (53% of total systems cultured) and 14
Gram-negative isolates (74% of total systems cultured),
as well as a single identified yeast (Table 1). The most
common Gram-positive pathogen was Staphylococcus
aureus (5 cases), followed by Streptococcal species (3)
and Propionibacterium acnes (2). The most common
Gram-negative pathogen was Haemophilus influenzae (5
cases), followed by Proteus mirabilis (2), Pseudomonas
aeruginosa (2), and others. Within the S. aureus isolates
were 3 cases of methicillin-resistant Staphylococcus
aureus (MRSA): (1) an 89-year-old institutionalized
female with CDC, type 2 diabetes mellitus, polio, and
psychiatric illness; (2) a 51-year-old female Palestinian
immigrant with CDC of 5-years duration; (3) a 73-yearold male with CDC who underwent functional endo-
Recurrent Cases
Case 1
An 89-year-old female nursing home resident with a history of type 2 diabetes mellitus, psychiatric illness,
Lefebvre et al.
43
polio, and osteomyelitis, who had right-sided intermittent CDC of 4 months duration per history, developed
an associated preseptal cellulitis and on presentation to
the oculoplastics clinic was treated with incision and
drainage. Culture revealed MRSA. She was treated with
oral trimethoprim/sulfamethoxazole preoperatively and
underwent ext-DCR approximately 4 months following
presentation. Lacrimal sac biopsy demonstrated dense
fibroconnective tissue with minimal chronic inflammatory changes. Two months postoperatively, she developed a recurrence of dacryocystitis. She underwent revision surgery 5 months after her initial operation; intraoperative cultures again returned MRSA. Following her
second procedure, she has been without recurrence for
55 months postoperatively.
Case 2
A 40-year-old healthy woman with a 2-month history of
left-sided epiphora followed by a 3-day history of discharge and redness was diagnosed with acute dacryocystitis. She received a 2-week course of cefalexin and
underwent ext-DCR 3 months after initial presentation.
Intraoperative cultures were not obtained and mucosal
biopsy was not performed. The patient was without
problems at postoperative month 6 and did not return for
further follow-up until she developed tearing and discharge at 34 months postoperatively. Revision surgery
was performed and the patient was without symptoms of
tearing or infection at postoperative month 6. Intraoperative cultures and tissue samples were not obtained during the revision surgery.
Case 3
A 51-year-old female Palestinian immigrant with hypertension presented with a 5-year history of right-sided
tearing and intermittent discharge and low-grade inflammation, consistent with CDC. Culture at presentation
revealed MRSA and Strep. viridans. The patient
received a course of Bactrim and ext-DCR was performed 2 months following presentation. Intraoperative
cultures demonstrated no growth. Pathology specimens
were not obtained. She presented at postoperative month
15 with recurrence of CDC and underwent revision surgery 20 months after initial DCR. Tissue samples
showed chronic inflammation and intraoperative cultures revealed H. influenzae. She was without tearing or
discharge at the time of silicone stent removal at postoperative month 2.
Case 4
A 59-year-old healthy woman presented with a 4-year
history of left-sided tearing, discharge, and inflammation, consistent with CDC. Computed tomography (CT)
revealed mild pansinusitis (mucosal thickening). She
underwent evaluation with an otolaryngologist, who
advised a steroid nasal spray. Ext-DCR was performed 5
months later. Cultures were not obtained. Histopathology was consistent with chronic inflammatory infiltrate.
Epiphora returned 3 months postoperatively, but she
deferred further surgical treatment.
Case 5
An 87-year-old woman with a history of right-sided
endoscopic DCR performed by another surgeon 3 years
44
Discussion
The overall 87% success rate of ext-DCR in this series
and the high proportion of female patients with NLDO
and dacryocystitis (88%) are comparable to previous
reports.9,1115 Of the 7 cases of recurrent dacryocystitis
after DCR, 2 were associated with MRSA infection, 2
were associated with Gram-negative bacteria, 2 carried
an associated diagnosis of lymphoma, 2 demonstrated
very dense fibrosis of the lacrimal sac on histopathology,
1 had background pansinusitis demonstrated on CT, 1
had a history of inflammatory bowel disease; 1 had a
history of prior endoscopic DCR performed 3 years previously; and 1 had a loss of canalicular stents relatively
early in the postoperative course. Only case 2 had no
associated systemic illnesses or perioperative events to
possibly explain an increased risk of recurrence,
although this case did not have cultures or biopsy performed, and it is therefore possible that an underlying
causative pathology could have been missed.
Dacryocystitis represents an infection within the lacrimal sac. Although postoperative DCR wound infection
is quite rare, such infection is associated with an
increased risk of surgical failure.14,12 The final postoperative intranasal ostium size following ext-DCR averages 1.8 mm in diameter.16 The primary anatomic cause
of DCR failure has been observed to be the formation of
intranasal soft tissue adhesions.17 It therefore seems reasonable that the presence of bacterial colonization and
increased inflammation may contribute to closure of the
nasal ostium via stenosis and adhesion formation.
Evidence has shown that postoperative DCR patients
treated with antibiotic therapy have significantly lower
rates of postoperative wound infections.12,18 Whether
all patient undergoing DCR require systemic antibiosis
is debated. A recent large study of 697 external DCRs
found that prophylactic intravenous antibiotic therapy at
the time of surgery may be of benefit only in cases associated with a history of mucocele, mucopyocele, or
frank dacryocystitis, because these cases were found to
have a higher rate of positive intraoperative culture.19
It is the preference of the senior author to treat all cases
of acute dacryocystitis medically with oral antibiotics
for 2 weeks prior to any surgical intervention to reduce
the underlying infection and quiet inflammation prior to
embarking on surgery. Some authors have proposed
dacryocystorhinostomy, most recently using endoscopic
dacryocystorhinostomy, as a direct treatment for acute
dacryocystitis.20 In their multicenter retrospective
review of 18 patients with acute dacryocystitis treated
via endo-DCR, Madge et al reported a 94.4% success
with an average of 12 months follow-up. It should be
noted, though, that all patients received either oral or
intravenous antibiotics for an average of 5 days prior to
surgery, with 66.7% having documented clinical
improvement prior to surgery.
Knowledge of the most common organisms associated
with dacryocystitis is helpful in directing empiric therapy. In the present series, among surgical failures with
available bacterial culture results, there were 2 cases
with Gram-negative bacteria and 2 with MRSA. A
national multicenter prospective study of 89 patients
Lefebvre et al.
45
46
The lacrimal drainage system functions as a mucosalassociated lymphoid tissue and is thus capable of harboring malignant hematologic neoplasms and lymphoid
infiltrates.32 Such infiltration can cause lacrimal drainage system obstruction.33 Obstruction may be unilateral
or bilateral, as occurred during the post-DCR timeperiod for case 6 in the present study. Slonim and Older
documented a case of bilateral DCR failure in a patient
with a history of chronic lymphocytic leukemia; the case
was peculiar in that the patient with leukemia had the
development of biopsy-proven solid lymphoma at both
DCR sites.34 It is important to maintain vigilance in
patients with a history of such malignancy. A biopsy of
the lacrimal tissue at the time of DCR may reveal active
disease in someone thought to be in remission.
There is debate regarding whether routine biopsy of lacrimal sac or nasal mucosal tissue is indicated at the time
of DCR. Anderson et al analyzed 377 DCR lacrimal sac
specimens and found 85% non-granulomatous inflammation.35 The next most common pathology was sarcoidosis (2.1%), followed by lymphoma (1.9%).35 More
unusual neoplasms occurred in isolation. Previously
undiagnosed malignancies were diagnosed in 2.1% of
Lefebvre et al.
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