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Lacrimal System Complications In Trachoma
Lacrimal System Complications in Trachoma KHALID F. T ABBARA, MD,* ARTHUR A. BOBB, MDt
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Abstract: A clinical study of the lacrimal complications of trachoma was conducted in the eastern province of Saudi Arabia. Of the 579 Saudi Arabian patients examined, 446 (77%) showed clinical evidence of trachoma, 62 of whom had severe inactive trachoma. In this last group the following lacrimal complications were observed: dry eye syndrome, punctal phimosis, punctal occlusion, canalicular occlusion, nasolacrimal-duct obstruction, dacryocystitis, dacryocystocele, and dacryocutaneous fistula. Histopathologic examination of seven lacrimal-sac biopsies showed the same cicatrizing changes seen in 14 conjunctival biopsies. [Key words: canalicular obstruction, dry eye syndrome, dacryocystitis, punctal occlusion, trachoma.] Ophthalmology 87:298-301, 1980
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Trachoma continues to be the most frequent cause of preventable blindness in the world l - 3 and a major public health problem in many countries of the Middle East, North Africa, and Southeast Asia.4-6 It is caused by Chlamydia trachomatis and is characterized by chronic inflammation of the conjunctiva and cornea followed by scarring. In the literature, most of the described clinical signs of trachoma are related to the corneal and conjunctival changes. Little attention has been given to the lacrimal apparatus. This clinical survey studies the complications From the Department of Ophthalmology and the Francis I. Proctor Foundation for Research in Ophthalmology, San Francisco: and the Medical Department, Arabian American Oil Company, Dhahran, Saudi Arabia·t Presented at the Eighty-Fourth Annual Meeting of the American Academy of Ophthalmology, San Francisco, November 5-9, 1979. Supported in part by Grant No. 5P30-EY01597, National Eye Institute, National Institutes of Health. Reprint requests to Khalid F. Tabbara, MD, Francis I. Proctor Foundation S-315, University of California, San Francisco, CA 94143.
298
of the lacrimal system in patients with severe inactive trachoma.
METHODS A clinical study of trachoma was conducted in the eastern province of Saudi Arabia. In the eye clinic of Dhahran Health Center, we examined 579 Saudi Arabian patients for clinical evidence of inactive trachoma. In all examinations we used biomicroscopy, ophthalmoscopy, tono metry , visual acuity tests, fluorescein and Rose Bengal staining, Schirmer tests, and lacrimal irrigation. The diagnosis of severe inactive trachoma was based on the following criteria: (1) slit-lamp identification of extensive conjunctival scars typical of trachoma, pannus typical of trachoma, and Herbert's pits; and (2) absence of the principal signs of trachoma activity: conjunctival follicles, exudate, and keratitis. The lacrimal function of both eyes of all patients was assessed on the basis of the following tests: (1) Schirmer test without anesthesia; (2) irrigation of the lacrimal passages through the upper and lower canaliculi; (3) culturing of
0161-6420/80/0400/0298/$00.70
© American
Academy of Ophthalmology
Fig 1. Pa lpe bra l conjunctival scars close to lower punctum in patient with inactive trachoma .
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lacrimal-sac discharge in patients with dacryocystitis; and (4) examination of Giemsastained conjunctival scrapings . In the patients in the series that had dry eye syndrome, we determined the tear-lysozyme levels by a modification of the method described by Smolelis and Hartsell. Tears were collected on Schirmer strips , and the strips were kept in test tubes containing 3 ml of a lysozyme buffer solution for 30 minutes. The resultant tear-containing solutions were diluted serialiy and added to the substrate (heat-killed Micrococclis lysodeikticlIs). With a Bausch and Lomb spectrophotometer set at 540 /Lm, we made turbidimetric readings at 30 and 60 minutes and compared them with readings on control solutions. We performed lacrimal-sac biopsies on seven patients undergoing dacryocystorhinostomies; 14 tarsoconjunctival biopsies were also obtained from 14 other patients at the time of surgery for the correction of entropion.
RESULTS We found 446 (77%) of the 579 Saudi Arabian patients had trachoma, and 62 of the 446 had severe inactive trachoma (Fig 1). Table 1 shows the results of the Schirmer test without anesTable 1. Results of Schirmer Tests of 124 Eyes with Severe Inactive Trachoma No. Eyes Schirmer Tests < 5mm/5 min 5-< 10 mm/5 min 10- 15 mm/5 min > 15 mm/5 min
15 31 28 50
(12%) (25%) (27%) (40%)
thesia in the 124 eyes of these 62 patients. In 46 eyes (37%), the Schirmer test showed less than 10 mm/5 min, and in these 46 eyes we determined the tear-lysozyme levels: in 7 eyes (15%) there was no tear-lysozyme, and in 22 (48%) there was reduced tear-lysozyme. Table 2 shows the nasolacrimal complications that occurred in the 62 patients. Canalicular obstruction, the most frequent complication, was found in 47 of the 124 eyes (38%) (Fig 2), 17 of which were in male patients and 30 in female patients. Table 3 shows a strongly positive correlation between canalicular obstruction on the one hand and entropion and trichiasis on the other. Patients with trichiasis had the highest incidence of canalicular obstruction, 60%, incidence among patients with entropion but no trichiasis was 26%. Nasolacrimal-duct obstruction (Fig 3), which was the most serious complication, occurred in 23 of the 124 eyes (19%). Seven of the 23 had evidence of dacryocystitis, and from all 7, bacteria were recovered in culture. Table 4 shows the incidence of punctal occlusion (Fig 4) in the 34 eyes with trichiasis; 8 of the 34 (24%) had punctal occlusion compared with none of the 90 patients without trichiasis.
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Table 2. Nasolacrimal Complications in 124 Eyes with Severe Inactive Trachoma No. Eyes Complication Canalicular obstruction Nasolacrimal-duct obstruction Dacrocystitis Dacryocystocele Cutaneous fistula Inner canthal fistula Punctal occlusion
47 (38%) 23 (19%) 7 (6%)
2 (2%) 2 (2%) 1 (1%)
8 (6%)
299
Fig 2. A 48-year-old woman with inactive trachoma and bilateral entropion, trichiasis, canalicular obstruction, and corneal scarring.
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Fig 3. A 75-year-old man with inactive trachoma, obstructed nasolacrimal duct, and a dacryopyocele.
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Fig 4. Complete punctal obliteration in patient with severe inactive trachoma.
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Table 3. Canalicular Obstruction with and without Entropion and Trichiasis in 124 Eyes with Inactive Trachoma No . Eyes Examined No entropion or trichiasis (73/124 eyes) Entropion without trichiasis (171124 eyes) Trichiasis (34/124 eyes) Total
No. Eyes with Canalicular Obstruclion Male Female 4
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7/47 (15%)
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12147 (26%)
8 17
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26'47 (60%)
30
47
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Table 5. Etiology of Punctal and/or Canalicular Occlusion
II.
III.
All seven lacrimal-sac biopsies showed the same extensive scarring observed in the 14 tarsoconjunctival biopsies.
IV. V.
DISCUSSION This study focuses attention on the common complications of the lacrimal passages that can occur in severe trachoma. Although trachoma has been recognized as a cause of nasolacrimal-duct obstruction,7 it and other lacrimal-passage complications have been generally overlooked in the literature. But trachoma can cause chronic inflammation of the mucosal surfaces of the lacrimal passages , and this may lead to the cicatrization of any site in the lacrimal system. Scarring of the lacrimal ductules, either directly or indirectly (as a result of extensive conjunctival scarring), can so reduce the tears as to cause dry eye syndrome. In 29 of the 46 eyes in our study in which the Schirmer test showed less than 10 mm/5 min, tear lysozyme was absent or reduced, and none of these patients showed any evidence of Sjogren's syndrome. Another cause of reduced tears and dry eye syndrome in trachoma is the loss of goblet cells (mucus deficiency) secondary to extensive conjunctival cicatrization. Complete canicular obstruction, which was the commonest lacrimal-passage obstruction, served a good purpose in the patients with dry eye syndrome. Occlusion of the puncti occurred in eight eyes, all of which also had trichiasis. A number of other eyes had punctal phimosis without complete occlusion . Several other conditions may result in punctal and canalicular occlusion ; these are summarized in Table 5. Table 4. Correlation of Punctal Occlusion with Trichiasis in 124 Eyes with Severe Inactive Trachoma
VI.
Infections A. Chlamydial: Trachoma B. Fungal: Aspergillus C. Bacterial: Actinomyces, Diphtheria, Streptococci D. Viral: Herpes zoster, Herpes simplex Injuries A. Trauma: Lacerations B. Chemical Burns: Alkali C. Irradiation Cicatrizing Diseases A. Ocular Pemphigoid (BMMP) B. Stevens-Johnson Syndrome C. Ligneous Tumors of the Conjunctiva Iatrogenic A. Cautery B. Chemicals: Conc. AgN0 3 C. Drugs: IDU, phospholine iodide, epinephrine, prolonged use of eye drops Idiopathic, Congenital
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Because of its frequent association with dacryocystitis, the most serious complication in our series was obstruction of the nasolacrimal duct. Seven of the 23 eyes that had nasolacrimal-duct obstruction also had dacryocystitis, and bacteria were recovered in cultures from all seven. The high frequency of dacryocystitis in trachoma-endemic areas is no doubt due to the high frequency of nasolacrimal-duct obstruction in patients with late trachoma. To recapitulate, trachoma can cause chronic inflammation of the mucosal surfaces of the lacrimal passages, which can lead to cicatrization and obstruction of the lacrimal-gland ductules, puncti, canaliculi, common canaliculi, and nasolacrimal ducts.
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REFERENCES 1. Ta rizzo ML. Chemotherapy of trachoma . WHO Chron
1972; 26:99-101. 2. Tarizzo ML. ed. Field Method s for the Control of Trachoma. Geneva: World Health Organization, 1973. 3. Dawson CR. Trachoma-a publi c health problem . Rev Int Trach 1976, 1-2:82-90. 4. World Health Organization Statistics Report. Trac homa, 1955-1969. 1971 ; 24 :275-329. 5. Nichols RL, Bobb AA , Haddad NA , and McComb DE. Immunofluorescent studies of the microbiologic epidemiology of trachoma in Saudi Arabia. Am J Ophthalmol 1967; 63 : 1372-1408 . Dawson CR . Daghfous T, Messadi M, et al.Severe endemic trac homa in Tunisia. Br J Ophthalmol 1976;
60:245-52. Dawson CR. Lids, conjunctiva, and lacrimal aparatu s: eye infections with Chlamydia. Arch Ophthalmol 1975;
93:854-62.
301
•
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Abstract: A clinical study of the lacrimal complications of trachoma was conducted in the eastern province of Saudi Arabia. Of the 579 Saudi Arabian patients examined, 446 (77%) showed clinical evidence of trachoma, 62 of whom had severe inactive trachoma. In this last group the following lacrimal complications were observed: dry eye syndrome, punctal phimosis, punctal occlusion, canalicular occlusion, nasolacrimal-duct obstruction, dacryocystitis, dacryocystocele, and dacryocutaneous fistula. Histopathologic examination of seven lacrimal-sac biopsies showed the same cicatrizing changes seen in 14 conjunctival biopsies. [Key words: canalicular obstruction, dry eye syndrome, dacryocystitis, punctal occlusion, trachoma.] Ophthalmology 87:298-301, 1980
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Trachoma continues to be the most frequent cause of preventable blindness in the world l - 3 and a major public health problem in many countries of the Middle East, North Africa, and Southeast Asia.4-6 It is caused by Chlamydia trachomatis and is characterized by chronic inflammation of the conjunctiva and cornea followed by scarring. In the literature, most of the described clinical signs of trachoma are related to the corneal and conjunctival changes. Little attention has been given to the lacrimal apparatus. This clinical survey studies the complications From the Department of Ophthalmology and the Francis I. Proctor Foundation for Research in Ophthalmology, San Francisco: and the Medical Department, Arabian American Oil Company, Dhahran, Saudi Arabia·t Presented at the Eighty-Fourth Annual Meeting of the American Academy of Ophthalmology, San Francisco, November 5-9, 1979. Supported in part by Grant No. 5P30-EY01597, National Eye Institute, National Institutes of Health. Reprint requests to Khalid F. Tabbara, MD, Francis I. Proctor Foundation S-315, University of California, San Francisco, CA 94143.
298
of the lacrimal system in patients with severe inactive trachoma.
METHODS A clinical study of trachoma was conducted in the eastern province of Saudi Arabia. In the eye clinic of Dhahran Health Center, we examined 579 Saudi Arabian patients for clinical evidence of inactive trachoma. In all examinations we used biomicroscopy, ophthalmoscopy, tono metry , visual acuity tests, fluorescein and Rose Bengal staining, Schirmer tests, and lacrimal irrigation. The diagnosis of severe inactive trachoma was based on the following criteria: (1) slit-lamp identification of extensive conjunctival scars typical of trachoma, pannus typical of trachoma, and Herbert's pits; and (2) absence of the principal signs of trachoma activity: conjunctival follicles, exudate, and keratitis. The lacrimal function of both eyes of all patients was assessed on the basis of the following tests: (1) Schirmer test without anesthesia; (2) irrigation of the lacrimal passages through the upper and lower canaliculi; (3) culturing of
0161-6420/80/0400/0298/$00.70
© American
Academy of Ophthalmology
Fig 1. Pa lpe bra l conjunctival scars close to lower punctum in patient with inactive trachoma .
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~
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~
a:
I-
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lacrimal-sac discharge in patients with dacryocystitis; and (4) examination of Giemsastained conjunctival scrapings . In the patients in the series that had dry eye syndrome, we determined the tear-lysozyme levels by a modification of the method described by Smolelis and Hartsell. Tears were collected on Schirmer strips , and the strips were kept in test tubes containing 3 ml of a lysozyme buffer solution for 30 minutes. The resultant tear-containing solutions were diluted serialiy and added to the substrate (heat-killed Micrococclis lysodeikticlIs). With a Bausch and Lomb spectrophotometer set at 540 /Lm, we made turbidimetric readings at 30 and 60 minutes and compared them with readings on control solutions. We performed lacrimal-sac biopsies on seven patients undergoing dacryocystorhinostomies; 14 tarsoconjunctival biopsies were also obtained from 14 other patients at the time of surgery for the correction of entropion.
RESULTS We found 446 (77%) of the 579 Saudi Arabian patients had trachoma, and 62 of the 446 had severe inactive trachoma (Fig 1). Table 1 shows the results of the Schirmer test without anesTable 1. Results of Schirmer Tests of 124 Eyes with Severe Inactive Trachoma No. Eyes Schirmer Tests < 5mm/5 min 5-< 10 mm/5 min 10- 15 mm/5 min > 15 mm/5 min
15 31 28 50
(12%) (25%) (27%) (40%)
thesia in the 124 eyes of these 62 patients. In 46 eyes (37%), the Schirmer test showed less than 10 mm/5 min, and in these 46 eyes we determined the tear-lysozyme levels: in 7 eyes (15%) there was no tear-lysozyme, and in 22 (48%) there was reduced tear-lysozyme. Table 2 shows the nasolacrimal complications that occurred in the 62 patients. Canalicular obstruction, the most frequent complication, was found in 47 of the 124 eyes (38%) (Fig 2), 17 of which were in male patients and 30 in female patients. Table 3 shows a strongly positive correlation between canalicular obstruction on the one hand and entropion and trichiasis on the other. Patients with trichiasis had the highest incidence of canalicular obstruction, 60%, incidence among patients with entropion but no trichiasis was 26%. Nasolacrimal-duct obstruction (Fig 3), which was the most serious complication, occurred in 23 of the 124 eyes (19%). Seven of the 23 had evidence of dacryocystitis, and from all 7, bacteria were recovered in culture. Table 4 shows the incidence of punctal occlusion (Fig 4) in the 34 eyes with trichiasis; 8 of the 34 (24%) had punctal occlusion compared with none of the 90 patients without trichiasis.
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Table 2. Nasolacrimal Complications in 124 Eyes with Severe Inactive Trachoma No. Eyes Complication Canalicular obstruction Nasolacrimal-duct obstruction Dacrocystitis Dacryocystocele Cutaneous fistula Inner canthal fistula Punctal occlusion
47 (38%) 23 (19%) 7 (6%)
2 (2%) 2 (2%) 1 (1%)
8 (6%)
299
Fig 2. A 48-year-old woman with inactive trachoma and bilateral entropion, trichiasis, canalicular obstruction, and corneal scarring.
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Fig 3. A 75-year-old man with inactive trachoma, obstructed nasolacrimal duct, and a dacryopyocele.
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Fig 4. Complete punctal obliteration in patient with severe inactive trachoma.
300
Table 3. Canalicular Obstruction with and without Entropion and Trichiasis in 124 Eyes with Inactive Trachoma No . Eyes Examined No entropion or trichiasis (73/124 eyes) Entropion without trichiasis (171124 eyes) Trichiasis (34/124 eyes) Total
No. Eyes with Canalicular Obstruclion Male Female 4
3
I.
7/47 (15%)
5
7
12147 (26%)
8 17
20
26'47 (60%)
30
47
-
Table 5. Etiology of Punctal and/or Canalicular Occlusion
II.
III.
All seven lacrimal-sac biopsies showed the same extensive scarring observed in the 14 tarsoconjunctival biopsies.
IV. V.
DISCUSSION This study focuses attention on the common complications of the lacrimal passages that can occur in severe trachoma. Although trachoma has been recognized as a cause of nasolacrimal-duct obstruction,7 it and other lacrimal-passage complications have been generally overlooked in the literature. But trachoma can cause chronic inflammation of the mucosal surfaces of the lacrimal passages , and this may lead to the cicatrization of any site in the lacrimal system. Scarring of the lacrimal ductules, either directly or indirectly (as a result of extensive conjunctival scarring), can so reduce the tears as to cause dry eye syndrome. In 29 of the 46 eyes in our study in which the Schirmer test showed less than 10 mm/5 min, tear lysozyme was absent or reduced, and none of these patients showed any evidence of Sjogren's syndrome. Another cause of reduced tears and dry eye syndrome in trachoma is the loss of goblet cells (mucus deficiency) secondary to extensive conjunctival cicatrization. Complete canicular obstruction, which was the commonest lacrimal-passage obstruction, served a good purpose in the patients with dry eye syndrome. Occlusion of the puncti occurred in eight eyes, all of which also had trichiasis. A number of other eyes had punctal phimosis without complete occlusion . Several other conditions may result in punctal and canalicular occlusion ; these are summarized in Table 5. Table 4. Correlation of Punctal Occlusion with Trichiasis in 124 Eyes with Severe Inactive Trachoma
VI.
Infections A. Chlamydial: Trachoma B. Fungal: Aspergillus C. Bacterial: Actinomyces, Diphtheria, Streptococci D. Viral: Herpes zoster, Herpes simplex Injuries A. Trauma: Lacerations B. Chemical Burns: Alkali C. Irradiation Cicatrizing Diseases A. Ocular Pemphigoid (BMMP) B. Stevens-Johnson Syndrome C. Ligneous Tumors of the Conjunctiva Iatrogenic A. Cautery B. Chemicals: Conc. AgN0 3 C. Drugs: IDU, phospholine iodide, epinephrine, prolonged use of eye drops Idiopathic, Congenital
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Because of its frequent association with dacryocystitis, the most serious complication in our series was obstruction of the nasolacrimal duct. Seven of the 23 eyes that had nasolacrimal-duct obstruction also had dacryocystitis, and bacteria were recovered in cultures from all seven. The high frequency of dacryocystitis in trachoma-endemic areas is no doubt due to the high frequency of nasolacrimal-duct obstruction in patients with late trachoma. To recapitulate, trachoma can cause chronic inflammation of the mucosal surfaces of the lacrimal passages, which can lead to cicatrization and obstruction of the lacrimal-gland ductules, puncti, canaliculi, common canaliculi, and nasolacrimal ducts.
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REFERENCES 1. Ta rizzo ML. Chemotherapy of trachoma . WHO Chron
1972; 26:99-101. 2. Tarizzo ML. ed. Field Method s for the Control of Trachoma. Geneva: World Health Organization, 1973. 3. Dawson CR. Trachoma-a publi c health problem . Rev Int Trach 1976, 1-2:82-90. 4. World Health Organization Statistics Report. Trac homa, 1955-1969. 1971 ; 24 :275-329. 5. Nichols RL, Bobb AA , Haddad NA , and McComb DE. Immunofluorescent studies of the microbiologic epidemiology of trachoma in Saudi Arabia. Am J Ophthalmol 1967; 63 : 1372-1408 . Dawson CR . Daghfous T, Messadi M, et al.Severe endemic trac homa in Tunisia. Br J Ophthalmol 1976;
60:245-52. Dawson CR. Lids, conjunctiva, and lacrimal aparatu s: eye infections with Chlamydia. Arch Ophthalmol 1975;
93:854-62.
301