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An Eyelash Nidus for Dacryoliths of the Lacrimal Excretory and Secretory Systems
An Eyelash Nidus for Dacryoliths of the Lacrimal Excretory and Secretory Systems
Keith H. Baratz, M.D., George B. Bartley, M . D . , R. Jean Campbell, M . D . , and James A. Garrity, M . D .
We treated two patients with dacryolithiasis secondary to an eyelash. The first patient un derwent dacryocystorhinostomy for a stone within the lacrimal sac. In the second patient the dacryolith was removed from a lacrimal gland ductule. Eyelashes found in the tear film or conjunctival fornices during routine exam ination should be removed to prevent the possible occurrence of dacryolithiasis. D A C R Y O L I T H S m a y o c c u r in t h e l a c r i m a l g l a n d d u c t u l e s , c a n a l i c u l i , l a c r i m a l s a c , or n a s o l a c r i m a l duct. E x c e p t for c a n a l i c u l a r c o n c r e t i o n s c l a s s i c a l l y a s s o c i a t e d w i t h Actinomyces species i n f e c t i o n , t h e o r i g i n o f s u c h s t o n e s is n o t well understood. Early case reports of nasolacrimal duct d a c r y o l i t h s d e s c r i b e d c a s t s o f m a t e r i a l c o n t a i n i n g n u m e r o u s f u n g a l e l e m e n t s (Candida albicans).^'^ S u b s e q u e n t s t u d i e s o f l a r g e r n u m b e r s o f c a s e s v a r i e d g r e a t l y in finding a c o r r e l a t i o n b e t w e e n fungal i n f e c t i o n s a n d n a s o l a c r i m a l duct stones.'"' L i k e w i s e , l i t t l e is k n o w n a b o u t t h e p a t h o g e n e s i s o f s t o n e f o r m a t i o n in the unusual entity of lacrimal gland ductule stones.*
Case Reports Case 1 A 6 4 - y e a r - o l d w o m a n h a d e p i p h o r a from t h e left e y e o f t w o w e e k s ' d u r a t i o n . H e r h i s t o r y w a s n o n c o n t r i b u t o r y for m i d f a c i a l t r a u m a , s i n u s d i s e a s e , or s i n u s or n a s a l s u r g e r y . T h e left e y e w a s q u i e t a n d w h i t e , a n d t h e left l a c r i m a l s a c was not palpable. Irrigation of saline through t h e left i n f e r i o r c a n a l i c u l u s r e s u l t e d in n e a r t o t a l reflux w i t h o u t m u c u s or p u s t h r o u g h t h e left s u p e r i o r p u n c t u m , a l t h o u g h a s m a l l a m o u n t of i r r i g a n t p a s s e d i n t o t h e n o s e . B e c a u s e o f t h e acute onset, lack of infection, and partial ob struction, a dacryolith was suspected and treat ed by dacryocystorhinostomy. The postopera tive c o u r s e w a s u n r e m a r k a b l e . T h e d a c r y o l i t h was composed of acellular, amorphous debris s u r r o u n d e d b y an e y e l a s h n i d u s ( F i g s . 1 a n d 2 ) .
In rare i n s t a n c e s , an e y e l a s h m a y b e t h e n i d u s for s y m p t o m a t i c d a c r y o l i t h f o r m a t i o n . W e treated two patients w h o had an eyelash-asso c i a t e d d a c r y o l i t h ; in o n e p a t i e n t t h e s t o n e w a s w i t h i n t h e l a c r i m a l s a c , a n d in t h e o t h e r p a t i e n t the dacryolith formed within a lacrimal gland ductule.
Accepted for publication Feb. 21, 1 9 9 1 . From the Department of Ophthalmology (Drs. Baratz, Bartley, CampbelL and Garrity) and Section of Surgical Pathology (Dr. Campbell), Mayo Clinic and Mayo Foun dation, Rochester, Minnesota. This study was supported in part by an unrestricted grant from Research to Prevent Blindness, Inc. Reprint requests to George B. Bartley, M.D., Mayo Clinic, 2 0 0 First St. S.W., Rochester, MN 5 5 9 0 5 .
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Fig. 1 (Baratz and associates). Case 1. Dacryolith with eyelash nidus removed from the lacrimal sac (X3.5).
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Fig. 3 (Baratz and associates). Case 2. Dacryolith with eyelash nidus removed in several fragments from the lacrimal gland ductule.
fate e x p o s u r e , a n d t h e s t o n e w a s r e m o v e d in several fragments (Fig. 3 ) . A d e n s e l y calcified c a l c u l u s s u r r o u n d i n g an e y e l a s h n i d u s w a s a p parent on routine histopathologic examination ( F i g . 4 ) . A c u l t u r e for f u n g u s w a s n e g a t i v e .
Discussion
Fig. 2 (Baratz and associates). Case 1. The stone was composed of acellular, amorphous debris sur rounding the pseudofollicle from which the eyelash emerged (hematoxylin and eosin, x 8 ) .
Dacryoliths are a significant cause o f nasolac rimal obstruction requiring dacryocystorhinos t o m y . In s e v e r a l p r e v i o u s l y r e p o r t e d s e r i e s , " f e m a l e s are a f f e c t e d t h r e e t i m e s a s f r e q u e n t l y as m a l e s , a n d d a c r y o l i t h i a s i s is m o r e l i k e l y to o c c u r in p a t i e n t s y o u n g e r t h a n 5 0 y e a r s o f a g e ( T a b l e ) . In t h e s e r i e s r e p o r t e d b y J o n e s ' o f 2 5 stones in 1 8 0 d a c r y o c y s t o r h i n o s t o m i e s , only three dacryoliths were found in 1 2 3 patients
Case 2 A 37-year-old man had a one-week history of pain and swelling of his right superotemporal orbit a n d i n j e c t i o n o f a n d d i s c h a r g e from t h e right e y e . H e h a d b e e n a w a r e of a n o n t e n d e r n o d u l e in t h e r e g i o n o f t h e r i g h t l a c r i m a l g l a n d for a p p r o x i m a t e l y five y e a r s . R e c e n t l y , t h e m a s s h a d s h i f t e d in p o s i t i o n f r o m a b o v e to b e l o w t h e lateral canthal tendon. O n examination, the temporal bulbar c o n junctiva of the right eye was injected moderate ly a n d p u r u l e n t d i s c h a r g e w a s n o t e d at t h e lateral canthus. T h e temporal aspect of the right upper eyelid was edematous with tenderness o n p a l p a t i o n o f a 5 - m m , firm, m o b i l e , s u b c u t a neous mass immediately inferior to the lateral canthal tendon. With topical anesthesia, the palpebral conjunctiva adjacent to the nodule was incised. A large dacryolith was noted, al t h o u g h it c o u l d n o t b e r e m o v e d from t h i s a p p r o a c h . A l a t e r a l c a n t h o t o m y w a s d o n e to f a c i l i -
Fig. 4 (Baratz and associates). Case 2. The stone was composed of calcium and amorphous material around the eyelash nidus (arrow), which enhanced with polarization (hematoxylin and eosin, x 160).
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TABLE C L I N I C A L DATA O N PATIENTS W H O U N D E R W E N T D A C R Y O C Y S T O R H I N O S T O M Y F O R D A C R Y O L I T H I A S I S
NO. OF DACRYOLITHS IN:
STUDY
NO. OF DACRYOLITHS: NO. OF DACRYOCYSTO RHINOSTOMIES
MALE: FEMALE
YOUNGER THAN 50 YEARS: OLDER THAN 50 YEARS
Jones^ Herzig and Hurwitz* Berlin, Rath, and Rich* Wilkins and Pressly' Hawes' Bartley (present report)
25:180 14:246 11:70 16*:94 15:124 19:200
7:15* NR* 1:10 2:10 4:11 1:18
22:3 NRt 7:4 5:7 11:4 10:9
Total
100:914
15:64
55:27
'Includes only patients younger than 50 years. tNR indicates not reported. •Four patients had bilateral dacryoliths.
older than 5 0 years, and the remaining 22 s t o n e s w e r e f o u n d in 5 7 p a t i e n t s y o u n g e r t h a n 5 0 y e a r s . N o n e o f t h e s t o n e s o c c u r r e d in p a t i e n t s w h o s e s y m p t o m s w e r e r e l a t e d to t r a u m a . Therefore, lacrimal drainage obstruction was s e c o n d a r y to a d a c r y o l i t h i n 2 2 o f 3 4 p a t i e n t s ( 6 4 . 7 % ) younger than 5 0 years without a histo ry o f t r a u m a . C o n v e r s e l y , H e r z i g a n d Hurwitz* found that half of the recovered nasolacrimal d u c t s t o n e s w e r e from p a t i e n t s w h o h a d h a d a r h i n o p l a s t y , n a s a l o r facial t r a u m a , or l a c r i m a l s y s t e m s c a r r i n g after a n a l k a l i b u r n . Dacryoliths of the lacrimal drainage system may cause recurrent dacryocystitis and sympto matic nasolacrimal duct obstruction. T h e prob l e m m a y b e c h r o n i c or i n t e r m i t t e n t . S m i t h a n d a s s o c i a t e s ' p r o v i d e d e v i d e n c e that l a c r i m a l drainage s y m p t o m s secondary to dacryolithia sis m a y b e d i f f e r e n t i a t e d from m o r e c o m m o n f o r m s o f d a c r y o c y s t i t i s . T h e y d e s c r i b e d the s y n d r o m e o f a c u t e d a c r y o c y s t i c r e t e n t i o n as p a i n ful n a s o l a c r i m a l d u c t o b s t r u c t i o n in t h e a b sence of pronounced swelling and erythema. Gonnering and Bosniak'" described a technique of p e r c u t a n e o u s d a c r y o l i t h e v a c u a t i o n as a n a l t e r n a t i v e to d a c r y o c y s t o r h i n o s t o m y t o t r e a t this entity. D a c r y o l i t h s a r e s u s p e c t e d to d e v e l o p from multiple causes. Early reports identified fungal e l e m e n t s w i t h i n t h e calculus,''^ w h e r e a s a n o t h er r e v i e w f o u n d h y p h a e o r y e a s t l i k e s t r u c t u r e s in six o f t e n s t o n e s e x a m i n e d . * S e v e r a l o t h e r s e r i e s ' " ' i d e n t i f i e d n o fungal e l e m e n t s in a n y o f t h e s t o n e s e x a m i n e d h i s t o p a t h o l o g i c a l l y or b y c u l t u r e , a l t h o u g h it s h o u l d b e n o t e d t h a t t h e
dacryoliths were not always examined with special stains nor were cultures obtained on all s p e c i m e n s . J o n e s ' c o m m e n t e d that regional var i a t i o n s in e n v i r o n m e n t m a y b e r e s p o n s i b l e f o r statistical differences between reports and not e d t h a t s o m e m y c o t i c d i s e a s e s w e r e u n u s u a l in t h e c o o l t e m p e r a t u r e s o f t h e Pacific N o r t h w e s t from w h i c h he d r e w h i s p a t i e n t b a s e . S i m i l a r l y , H a w e s ' m e n t i o n e d t h e dry C o l o r a d o c l i m a t e in w h i c h h e p r a c t i c e d as a f a c t o r a g a i n s t f u n g a l stones. Wilkins and Pressly" reported their s t u d y from H o u s t o n , T e x a s ; a h i g h e r i n c i d e n c e of fungal c a l c u l i in t h i s w a r m c l i m a t e m i g h t b e a s s u m e d b u t w a s n o t verified. A m o r e d e t a i l e d examination of dacryolith s p e c i m e n s and the epidemiologic characteristics of the patient population would be necessary before genera lizing about a fungal cause in n a s o l a c r i m a l stones. Herzig and Hurwitz" investigated tear elec trolyte levels in patients with dacryoliths, but no correlation was found. T h e role of cosmetics in s t o n e f o r m a t i o n w a s d i s c o u n t e d in o n e r e p o r t o n the b a s i s t h a t " d a c r y o l i t h s a r e r e p o r t e d e q u a l l y in b o t h s e x e s . " " T h i s s t a t e m e n t is i n c o r r e c t in t h a t s t o n e s a r e t h r e e t i m e s m o r e c o m m o n in f e m a l e s t h a n m a l e s ( T a b l e ) . A d d i t i o n a l l y , o u r o b s e r v a t i o n o f m u l t i p l e flecks o f m a k e u p w i t h i n a few d a c r y o l i t h s s u g g e s t s a possible contributory role. From a personal c o m m u n i c a t i o n from G u n d e r s e n , Garfin'^ r e p o r t e d a c a s e o f a n e y e l a s h nidus within a dacryolith o f the lacrimal drain age s y s t e m . J a y a n d L e e " f o u n d an e y e l a s h in the center of one limb of a Y - s h a p e d dacryolith.
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O t h e r a r t i c l e s ^ ' r e p o r t e d n o cilia w i t h i n a n y c a l c u l i , a l t h o u g h J o n e s ^ d i d find an e y e l a s h in the m u c o i d c o a t i n g s u r r o u n d i n g o n e s t o n e . In our C a s e 1, t h e c i l i u m w a s c l e a r l y at t h e c e n t e r of the d a c r y o l i t h w i t h a p s e u d o f o l l i c l e h o u s i n g the f o r e i g n b o d y . T h e rarity o f t h i s finding s u g g e s t s t h a t an e y e l a s h n i d u s is a n i n f r e q u e n t c a u s a t i v e a g e n t in n a s o l a c r i m a l d u c t s t o n e s . A l t e r n a t i v e l y , it is p o s s i b l e t h a t a n e y e l a s h c a r r i e d i n t o the l a c r i m a l s a c m a y c o n t r i b u t e to the i n i t i a l i n f l a m m a t o r y r e a c t i o n a n d s t o n e f o r mation and yet later be degraded as the dacryolith enlarges. Stones of the lacrimal gland ductules have b e e n d e s c r i b e d i n f r e q u e n t l y . B a k e r a n d Bartley* r e p o r t e d two c a s e s in w h i c h t h e c a u s e o f t h e stone was not apparent. Histopathologic exami nation of the specimens showed amorphous debris a r o u n d a n i d u s o f u n k n o w n c o m p o s i t i o n with p o l y m o r p h o n u c l e a r l e u k o c y t e s a d h e r e n t to the e x t e r n a l s u r f a c e o f t h e s t o n e s . A l i z a r i n r e d s t a i n for c a l c i u m w a s n e g a t i v e in e a c h c a s e . T h e findings in C a s e 2 d e m o n s t r a t e that a stone of the lacrimal gland may remain quies c e n t for s e v e r a l y e a r s w i t h o u t i n f l a m m a t i o n , i n f e c t i o n , or d u c t u l a r cyst f o r m a t i o n . E y e l a s h e s a r e f r e q u e n t l y o b s e r v e d floating in the t e a r film or in t h e c o n j u n c t i v a l f o r n i c e s during routine examinations. Although the finding is o f l i t t l e c l i n i c a l s i g n i f i c a n c e in nnost c a s e s , s u c h e y e l a s h e s s h o u l d b e r e m o v e d to prevent the potential unusual occurrence o f dacryolithiasis.
References 1. Fine, M., and Waring, W. S.: Mycotic obstruc tion of the nasolacrimal duct {Candida albicans). Arch. Ophthalmol. 38:39, 1947. 2. Wolter, J. R., Stratford, T., and Harrell, E. R.: Cast-like fungus obstruction of the nasolacrimal duct. Arch. Ophthalmol. 55:320, 1 9 5 6 . 3. Jones, L. T.: Tear-sac foreign bodies. Am. J. Ophthalmol. 6 0 : 1 1 1 , 1 9 6 5 . 4. Herzig, S., and Hurwitz, J. J.: Lacrimal sac cal culi. Can. J. Ophthalmol. 14:17, 1979. 5. Berlin, A. J . , Rath, R., and Rich, L.: Lacrimal system dacryoliths. Ophthalmic Surg. 11:435, 1980. 6. Wilkins, R. B., and Pressly, J. P.: Diagnosis and incidence of lacrimal calculi. Ophthalmic Surg. 11:787, 1 9 8 0 . 7. Hawes, M. J . : The dacryolithiasis syndrome. Ophthalmic Plast. Reconstr. Surg. 4:87, 1 9 8 8 . 8. Baker, R. H., and Bartley, G. B.: Lacrimal gland ductule stones. Ophthalmology 9 7 : 5 3 1 , 1 9 9 0 . 9. Smith, B., Tenzel, R. R., Buffam, F. V., and Boynton, J. R.: Acute dacryocystic retention. Arch. Ophthalmol. 9 4 : 1 9 0 3 , 1976. 10. Gonnering, R. S., and Bosniak, S. L.: Recogni tion and management of acute noninfectious dacryo cystic retention. Ophthalmic Plast. Reconstr. Surg. 5:27, 1989. 11. Maltzman, B. Α., and Favetta, J. R.: Dacryoli thiasis. Ann. Ophthalmol. 11:473, 1979. 12. Garfin, S. W.: Etiology of dacryocystitis and epiphora. Arch. Ophthalmol. 27:167, 1942. 13. Jay, J. L., and Lee, W. R.: Dacryolith formation around an eyelash retained in the lacrimal sac. Br. J. Ophthalmol. 60:722, 1 9 7 6 .
Keith H. Baratz, M.D., George B. Bartley, M . D . , R. Jean Campbell, M . D . , and James A. Garrity, M . D .
We treated two patients with dacryolithiasis secondary to an eyelash. The first patient un derwent dacryocystorhinostomy for a stone within the lacrimal sac. In the second patient the dacryolith was removed from a lacrimal gland ductule. Eyelashes found in the tear film or conjunctival fornices during routine exam ination should be removed to prevent the possible occurrence of dacryolithiasis. D A C R Y O L I T H S m a y o c c u r in t h e l a c r i m a l g l a n d d u c t u l e s , c a n a l i c u l i , l a c r i m a l s a c , or n a s o l a c r i m a l duct. E x c e p t for c a n a l i c u l a r c o n c r e t i o n s c l a s s i c a l l y a s s o c i a t e d w i t h Actinomyces species i n f e c t i o n , t h e o r i g i n o f s u c h s t o n e s is n o t well understood. Early case reports of nasolacrimal duct d a c r y o l i t h s d e s c r i b e d c a s t s o f m a t e r i a l c o n t a i n i n g n u m e r o u s f u n g a l e l e m e n t s (Candida albicans).^'^ S u b s e q u e n t s t u d i e s o f l a r g e r n u m b e r s o f c a s e s v a r i e d g r e a t l y in finding a c o r r e l a t i o n b e t w e e n fungal i n f e c t i o n s a n d n a s o l a c r i m a l duct stones.'"' L i k e w i s e , l i t t l e is k n o w n a b o u t t h e p a t h o g e n e s i s o f s t o n e f o r m a t i o n in the unusual entity of lacrimal gland ductule stones.*
Case Reports Case 1 A 6 4 - y e a r - o l d w o m a n h a d e p i p h o r a from t h e left e y e o f t w o w e e k s ' d u r a t i o n . H e r h i s t o r y w a s n o n c o n t r i b u t o r y for m i d f a c i a l t r a u m a , s i n u s d i s e a s e , or s i n u s or n a s a l s u r g e r y . T h e left e y e w a s q u i e t a n d w h i t e , a n d t h e left l a c r i m a l s a c was not palpable. Irrigation of saline through t h e left i n f e r i o r c a n a l i c u l u s r e s u l t e d in n e a r t o t a l reflux w i t h o u t m u c u s or p u s t h r o u g h t h e left s u p e r i o r p u n c t u m , a l t h o u g h a s m a l l a m o u n t of i r r i g a n t p a s s e d i n t o t h e n o s e . B e c a u s e o f t h e acute onset, lack of infection, and partial ob struction, a dacryolith was suspected and treat ed by dacryocystorhinostomy. The postopera tive c o u r s e w a s u n r e m a r k a b l e . T h e d a c r y o l i t h was composed of acellular, amorphous debris s u r r o u n d e d b y an e y e l a s h n i d u s ( F i g s . 1 a n d 2 ) .
In rare i n s t a n c e s , an e y e l a s h m a y b e t h e n i d u s for s y m p t o m a t i c d a c r y o l i t h f o r m a t i o n . W e treated two patients w h o had an eyelash-asso c i a t e d d a c r y o l i t h ; in o n e p a t i e n t t h e s t o n e w a s w i t h i n t h e l a c r i m a l s a c , a n d in t h e o t h e r p a t i e n t the dacryolith formed within a lacrimal gland ductule.
Accepted for publication Feb. 21, 1 9 9 1 . From the Department of Ophthalmology (Drs. Baratz, Bartley, CampbelL and Garrity) and Section of Surgical Pathology (Dr. Campbell), Mayo Clinic and Mayo Foun dation, Rochester, Minnesota. This study was supported in part by an unrestricted grant from Research to Prevent Blindness, Inc. Reprint requests to George B. Bartley, M.D., Mayo Clinic, 2 0 0 First St. S.W., Rochester, MN 5 5 9 0 5 .
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Fig. 1 (Baratz and associates). Case 1. Dacryolith with eyelash nidus removed from the lacrimal sac (X3.5).
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Fig. 3 (Baratz and associates). Case 2. Dacryolith with eyelash nidus removed in several fragments from the lacrimal gland ductule.
fate e x p o s u r e , a n d t h e s t o n e w a s r e m o v e d in several fragments (Fig. 3 ) . A d e n s e l y calcified c a l c u l u s s u r r o u n d i n g an e y e l a s h n i d u s w a s a p parent on routine histopathologic examination ( F i g . 4 ) . A c u l t u r e for f u n g u s w a s n e g a t i v e .
Discussion
Fig. 2 (Baratz and associates). Case 1. The stone was composed of acellular, amorphous debris sur rounding the pseudofollicle from which the eyelash emerged (hematoxylin and eosin, x 8 ) .
Dacryoliths are a significant cause o f nasolac rimal obstruction requiring dacryocystorhinos t o m y . In s e v e r a l p r e v i o u s l y r e p o r t e d s e r i e s , " f e m a l e s are a f f e c t e d t h r e e t i m e s a s f r e q u e n t l y as m a l e s , a n d d a c r y o l i t h i a s i s is m o r e l i k e l y to o c c u r in p a t i e n t s y o u n g e r t h a n 5 0 y e a r s o f a g e ( T a b l e ) . In t h e s e r i e s r e p o r t e d b y J o n e s ' o f 2 5 stones in 1 8 0 d a c r y o c y s t o r h i n o s t o m i e s , only three dacryoliths were found in 1 2 3 patients
Case 2 A 37-year-old man had a one-week history of pain and swelling of his right superotemporal orbit a n d i n j e c t i o n o f a n d d i s c h a r g e from t h e right e y e . H e h a d b e e n a w a r e of a n o n t e n d e r n o d u l e in t h e r e g i o n o f t h e r i g h t l a c r i m a l g l a n d for a p p r o x i m a t e l y five y e a r s . R e c e n t l y , t h e m a s s h a d s h i f t e d in p o s i t i o n f r o m a b o v e to b e l o w t h e lateral canthal tendon. O n examination, the temporal bulbar c o n junctiva of the right eye was injected moderate ly a n d p u r u l e n t d i s c h a r g e w a s n o t e d at t h e lateral canthus. T h e temporal aspect of the right upper eyelid was edematous with tenderness o n p a l p a t i o n o f a 5 - m m , firm, m o b i l e , s u b c u t a neous mass immediately inferior to the lateral canthal tendon. With topical anesthesia, the palpebral conjunctiva adjacent to the nodule was incised. A large dacryolith was noted, al t h o u g h it c o u l d n o t b e r e m o v e d from t h i s a p p r o a c h . A l a t e r a l c a n t h o t o m y w a s d o n e to f a c i l i -
Fig. 4 (Baratz and associates). Case 2. The stone was composed of calcium and amorphous material around the eyelash nidus (arrow), which enhanced with polarization (hematoxylin and eosin, x 160).
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TABLE C L I N I C A L DATA O N PATIENTS W H O U N D E R W E N T D A C R Y O C Y S T O R H I N O S T O M Y F O R D A C R Y O L I T H I A S I S
NO. OF DACRYOLITHS IN:
STUDY
NO. OF DACRYOLITHS: NO. OF DACRYOCYSTO RHINOSTOMIES
MALE: FEMALE
YOUNGER THAN 50 YEARS: OLDER THAN 50 YEARS
Jones^ Herzig and Hurwitz* Berlin, Rath, and Rich* Wilkins and Pressly' Hawes' Bartley (present report)
25:180 14:246 11:70 16*:94 15:124 19:200
7:15* NR* 1:10 2:10 4:11 1:18
22:3 NRt 7:4 5:7 11:4 10:9
Total
100:914
15:64
55:27
'Includes only patients younger than 50 years. tNR indicates not reported. •Four patients had bilateral dacryoliths.
older than 5 0 years, and the remaining 22 s t o n e s w e r e f o u n d in 5 7 p a t i e n t s y o u n g e r t h a n 5 0 y e a r s . N o n e o f t h e s t o n e s o c c u r r e d in p a t i e n t s w h o s e s y m p t o m s w e r e r e l a t e d to t r a u m a . Therefore, lacrimal drainage obstruction was s e c o n d a r y to a d a c r y o l i t h i n 2 2 o f 3 4 p a t i e n t s ( 6 4 . 7 % ) younger than 5 0 years without a histo ry o f t r a u m a . C o n v e r s e l y , H e r z i g a n d Hurwitz* found that half of the recovered nasolacrimal d u c t s t o n e s w e r e from p a t i e n t s w h o h a d h a d a r h i n o p l a s t y , n a s a l o r facial t r a u m a , or l a c r i m a l s y s t e m s c a r r i n g after a n a l k a l i b u r n . Dacryoliths of the lacrimal drainage system may cause recurrent dacryocystitis and sympto matic nasolacrimal duct obstruction. T h e prob l e m m a y b e c h r o n i c or i n t e r m i t t e n t . S m i t h a n d a s s o c i a t e s ' p r o v i d e d e v i d e n c e that l a c r i m a l drainage s y m p t o m s secondary to dacryolithia sis m a y b e d i f f e r e n t i a t e d from m o r e c o m m o n f o r m s o f d a c r y o c y s t i t i s . T h e y d e s c r i b e d the s y n d r o m e o f a c u t e d a c r y o c y s t i c r e t e n t i o n as p a i n ful n a s o l a c r i m a l d u c t o b s t r u c t i o n in t h e a b sence of pronounced swelling and erythema. Gonnering and Bosniak'" described a technique of p e r c u t a n e o u s d a c r y o l i t h e v a c u a t i o n as a n a l t e r n a t i v e to d a c r y o c y s t o r h i n o s t o m y t o t r e a t this entity. D a c r y o l i t h s a r e s u s p e c t e d to d e v e l o p from multiple causes. Early reports identified fungal e l e m e n t s w i t h i n t h e calculus,''^ w h e r e a s a n o t h er r e v i e w f o u n d h y p h a e o r y e a s t l i k e s t r u c t u r e s in six o f t e n s t o n e s e x a m i n e d . * S e v e r a l o t h e r s e r i e s ' " ' i d e n t i f i e d n o fungal e l e m e n t s in a n y o f t h e s t o n e s e x a m i n e d h i s t o p a t h o l o g i c a l l y or b y c u l t u r e , a l t h o u g h it s h o u l d b e n o t e d t h a t t h e
dacryoliths were not always examined with special stains nor were cultures obtained on all s p e c i m e n s . J o n e s ' c o m m e n t e d that regional var i a t i o n s in e n v i r o n m e n t m a y b e r e s p o n s i b l e f o r statistical differences between reports and not e d t h a t s o m e m y c o t i c d i s e a s e s w e r e u n u s u a l in t h e c o o l t e m p e r a t u r e s o f t h e Pacific N o r t h w e s t from w h i c h he d r e w h i s p a t i e n t b a s e . S i m i l a r l y , H a w e s ' m e n t i o n e d t h e dry C o l o r a d o c l i m a t e in w h i c h h e p r a c t i c e d as a f a c t o r a g a i n s t f u n g a l stones. Wilkins and Pressly" reported their s t u d y from H o u s t o n , T e x a s ; a h i g h e r i n c i d e n c e of fungal c a l c u l i in t h i s w a r m c l i m a t e m i g h t b e a s s u m e d b u t w a s n o t verified. A m o r e d e t a i l e d examination of dacryolith s p e c i m e n s and the epidemiologic characteristics of the patient population would be necessary before genera lizing about a fungal cause in n a s o l a c r i m a l stones. Herzig and Hurwitz" investigated tear elec trolyte levels in patients with dacryoliths, but no correlation was found. T h e role of cosmetics in s t o n e f o r m a t i o n w a s d i s c o u n t e d in o n e r e p o r t o n the b a s i s t h a t " d a c r y o l i t h s a r e r e p o r t e d e q u a l l y in b o t h s e x e s . " " T h i s s t a t e m e n t is i n c o r r e c t in t h a t s t o n e s a r e t h r e e t i m e s m o r e c o m m o n in f e m a l e s t h a n m a l e s ( T a b l e ) . A d d i t i o n a l l y , o u r o b s e r v a t i o n o f m u l t i p l e flecks o f m a k e u p w i t h i n a few d a c r y o l i t h s s u g g e s t s a possible contributory role. From a personal c o m m u n i c a t i o n from G u n d e r s e n , Garfin'^ r e p o r t e d a c a s e o f a n e y e l a s h nidus within a dacryolith o f the lacrimal drain age s y s t e m . J a y a n d L e e " f o u n d an e y e l a s h in the center of one limb of a Y - s h a p e d dacryolith.
Vol. I l l , No. 5
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Eyelash Nidus for Dacryoliths
O t h e r a r t i c l e s ^ ' r e p o r t e d n o cilia w i t h i n a n y c a l c u l i , a l t h o u g h J o n e s ^ d i d find an e y e l a s h in the m u c o i d c o a t i n g s u r r o u n d i n g o n e s t o n e . In our C a s e 1, t h e c i l i u m w a s c l e a r l y at t h e c e n t e r of the d a c r y o l i t h w i t h a p s e u d o f o l l i c l e h o u s i n g the f o r e i g n b o d y . T h e rarity o f t h i s finding s u g g e s t s t h a t an e y e l a s h n i d u s is a n i n f r e q u e n t c a u s a t i v e a g e n t in n a s o l a c r i m a l d u c t s t o n e s . A l t e r n a t i v e l y , it is p o s s i b l e t h a t a n e y e l a s h c a r r i e d i n t o the l a c r i m a l s a c m a y c o n t r i b u t e to the i n i t i a l i n f l a m m a t o r y r e a c t i o n a n d s t o n e f o r mation and yet later be degraded as the dacryolith enlarges. Stones of the lacrimal gland ductules have b e e n d e s c r i b e d i n f r e q u e n t l y . B a k e r a n d Bartley* r e p o r t e d two c a s e s in w h i c h t h e c a u s e o f t h e stone was not apparent. Histopathologic exami nation of the specimens showed amorphous debris a r o u n d a n i d u s o f u n k n o w n c o m p o s i t i o n with p o l y m o r p h o n u c l e a r l e u k o c y t e s a d h e r e n t to the e x t e r n a l s u r f a c e o f t h e s t o n e s . A l i z a r i n r e d s t a i n for c a l c i u m w a s n e g a t i v e in e a c h c a s e . T h e findings in C a s e 2 d e m o n s t r a t e that a stone of the lacrimal gland may remain quies c e n t for s e v e r a l y e a r s w i t h o u t i n f l a m m a t i o n , i n f e c t i o n , or d u c t u l a r cyst f o r m a t i o n . E y e l a s h e s a r e f r e q u e n t l y o b s e r v e d floating in the t e a r film or in t h e c o n j u n c t i v a l f o r n i c e s during routine examinations. Although the finding is o f l i t t l e c l i n i c a l s i g n i f i c a n c e in nnost c a s e s , s u c h e y e l a s h e s s h o u l d b e r e m o v e d to prevent the potential unusual occurrence o f dacryolithiasis.
References 1. Fine, M., and Waring, W. S.: Mycotic obstruc tion of the nasolacrimal duct {Candida albicans). Arch. Ophthalmol. 38:39, 1947. 2. Wolter, J. R., Stratford, T., and Harrell, E. R.: Cast-like fungus obstruction of the nasolacrimal duct. Arch. Ophthalmol. 55:320, 1 9 5 6 . 3. Jones, L. T.: Tear-sac foreign bodies. Am. J. Ophthalmol. 6 0 : 1 1 1 , 1 9 6 5 . 4. Herzig, S., and Hurwitz, J. J.: Lacrimal sac cal culi. Can. J. Ophthalmol. 14:17, 1979. 5. Berlin, A. J . , Rath, R., and Rich, L.: Lacrimal system dacryoliths. Ophthalmic Surg. 11:435, 1980. 6. Wilkins, R. B., and Pressly, J. P.: Diagnosis and incidence of lacrimal calculi. Ophthalmic Surg. 11:787, 1 9 8 0 . 7. Hawes, M. J . : The dacryolithiasis syndrome. Ophthalmic Plast. Reconstr. Surg. 4:87, 1 9 8 8 . 8. Baker, R. H., and Bartley, G. B.: Lacrimal gland ductule stones. Ophthalmology 9 7 : 5 3 1 , 1 9 9 0 . 9. Smith, B., Tenzel, R. R., Buffam, F. V., and Boynton, J. R.: Acute dacryocystic retention. Arch. Ophthalmol. 9 4 : 1 9 0 3 , 1976. 10. Gonnering, R. S., and Bosniak, S. L.: Recogni tion and management of acute noninfectious dacryo cystic retention. Ophthalmic Plast. Reconstr. Surg. 5:27, 1989. 11. Maltzman, B. Α., and Favetta, J. R.: Dacryoli thiasis. Ann. Ophthalmol. 11:473, 1979. 12. Garfin, S. W.: Etiology of dacryocystitis and epiphora. Arch. Ophthalmol. 27:167, 1942. 13. Jay, J. L., and Lee, W. R.: Dacryolith formation around an eyelash retained in the lacrimal sac. Br. J. Ophthalmol. 60:722, 1 9 7 6 .