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Management and complications of congenital dacryocele with concurrent intranasal mucocele
Management and Complications of Congenital Dacryocele With Concurrent Intranasal Mucocele Evelvn A. Pavsse. MD3 David K. Coats, MD,a ToseDh M. Bernstein, Andrew L. de Jon?. MDb
MD&
Cindv
Go, MD,bd
Introduction: The association of dacryocele and intranasal mucocele has been previously reported. Its incidence and optimal treatment are unknown. Patients and Methods: A retrospective review of 22 patients with 30 dacryoceles was performed to determine the mean age at presentation, sex distribution, and prevalence of associated intranasal mucocele, associated dacryocystitis, and respiratory distress. The components of the examination, ancillary tests, treatment modalities, and treatment outcomes were then summarized. Results: Unilateral dacryoceles were seen in 16 (73%) of the infants, and bilateral dacryoceles were seen in 6 (27%) of the infants. Four (25%) of the 16 patients who initially had unilateral dacryoceles later developed bilateral dacryoceles. Dacryocystitis, preseptal cellulitis, or both were present on presentation or developed in 18 (60%) of 30 dacryoceles. Nasal endoscopy was performed on 13 (59%) of 22 patients. Nasal examination with nasal speculum and headlight was performed on 7 patients (32%). A concurrent intranasal mucocele was diagnosed in 23 (77%) of 30 dacryoceles. Respiratory distress arose in 5 (71%) of 7 patients with bilateral intranasal mucoceles and in 2 (22%) of 9 patients with a unilateral intranasal mucocele. Thirty-four procedures were performed. Seven dacryoceles (21%) were treated with nasolacrimal duct probing under topical anesthesia. Another one (3%) was treated with needle aspiration with later definitive therapy. All other procedures were managed under general anesthesia. These included 2 nasolacrimal duct probings (6%), 2 probings with silicone tube placement (6%), 10 probings with intranasal mucocele marsupialization and silicone tube placement (29%), and 12 probings with marsupialization alone (35%). Two (29%) of the 7 probings performed under topical anesthesia failed, whereas all other procedures were successful. One dacryocele spontaneously resolved. Conclusions: Congenital dacryoceles are commonly associated with intranasal mucoceles, dacryocystitis, and preseptal cellulitis. Respiratory distress is common in bilateral cases. Bilateral nasolacrimal duct probing should be considered in unilateral cases because of the high incidence of occult contralateral involvement. (J AAPOS 2000;4:46-53) ongenital nasolacrimal duct obstruction is common, affecting approximately 30% to 84% of the newborn population, depending on the source.*-3 The usual site of obstruction in congenital nasolacrimal duct obstruction is at the valve of Hasner, just before the entrance to the nasal antrum. However, obstruction can occur anywhere along the nasolacrimal duct system.
C
Franz tbc Cullen Eye Insthte, Baylor College ofMedicine, Depm~tent of Opbtbabnology mtd Pediam’a, Turns Cbildrm’s Haspitni,,’ and de Dcpamnent of Otohyngology, Baylor College ofMedicine, Trro Cbikiren’r Hospirol, Houston, Texas.. Supported in pan @ an unmhicted grant fmtr, Rrrmrcb to Prevent Elindncs~ Inc. New Ymk, NW Ymk. Presented at tbe 2Jtb Annual Meeting of tbe Atnmiatn Association of Pediatric Opbtbahnola~ and Stmbinnw Tmonto, Ontario, April IS, 1999. Submitted April 22, 1999. Revision acceincd Atuwt 1L 1999. Reprint rr&&: Eue&n A. &se, MD, Terar Cbikimzm’rHospitrrl, II02 Batrs, #300; MC 3-2700, Howton, 7x 77030 (e-mail: [email protected],rrcdtI). Copyright Q 2000 by the American Association for Pediohic Opbtbolwa$y nnd Smrbimtw. 1091-8~31/2000$12.00 + 0 75/l/102922
Impatency at the valve of Hasner has been reported in up to 73% of fetuses that underwent autopsy.4 Despite this, only 4% to 6% of newborn children are symptomatic.3J The dacryocele, also known as the congenital nasolacrimal sac mucocele, is an uncommon condition. It clinically appears as a bluish mass inferior to the medial canthal tendon. The dacryocele is a dilation of the lacrimal sac that occurs when an obstruction of the nasolacrimal duct is present above and below the lacrimal sac. Tears continue to enter the lacrimal sac, but they cannot exit the canaliculi because of a l-way valve-type obstruction in the canaliculi or at the valve of Rosenmiiller. Tears also cannot exit from below because of an obstruction in the nasolacrimal duct. Several different terms have been used to describe dacryoceles, depending on the type of fluid believed to be filling the cystic mass. Equivalent nomenclature includes amniotocele, amniocele, lacrimal sac mucocele, dacryocele, and dacryocystocele. 1~6-15 The most appropriate terms are dacryocele and congenital lacrimal sac mucocele
because histologic evaluation has shown that the fluid filling the lacrimal sac is not amniotic fluid, but epidermal debris and tears. The association of an intranasal mucocele with the dacryocele has been occasionally reported. An intranasal mucocele is composed of nasolacrimal duct and nasal mucosa that has prolapsed into the nasal antrum because of progressive overfilling of the nasolacrimal system with tears (Figure 1). We found only 30 anecdotal cases of intranasal mucocele in the literature.7-*‘.*3.‘~,*6-~0 Respiratory distress associated with dacryoceles and concurrent intranasal mucoceles has also been reported, hut its frequency and risk factors are unknown. Treatment recommendations for dacryoceles with and without intranasal mucoceles have varied widely in the literature and include warm compresses and lacrimal sac massage, topical and/or intravenous antibiotics, surgical probing of the nasolacrimal duct with or without silicone tube intubation, and marsupialization of the intranasal nlucocele.7-9~*~,13,15-1*,~1-23 Like treatment recommendations, the ancillary testing recommendations for dacryoceles have varied and have included clinical examination of the lacrimal system alone, clinical examination of both the lacrimal system and the intranasal cavity, and computed tomography (CT) or magnetic resonance imaging (Mw.S,7-12,14-19,21,22
We retrospectively reviewed all patients with dacryoceles who were treated over a 20-month period. To better understand the clinical presentation, we determined the frequency of associated intranasal mucoceles and associated respiratory distress, and determined evaluation and treatment modalities used and outcomes.
PATIENTS
AND METHODS
This is a retrospective review of 22 patients with 30 congenital dacryoceles. We determined the mean age at presentation, sex, prevalence of associated intranasal mucocele, associated dacryocystitis, and respiratory distress. The components of the examination, ancillary tests, treatment modalities, and treatment outcomes are summarized.
CASE REPORTS Case 1 G. K. is a 4-day-old girl who had swelling and erythema over the right lacrimal sac 3 days after birth. No respiratory difficulties or feeding difficulties were noted. Her neonatologist diagnosed dacryocystitis and treated her with ampicillin and gentamicin intravenously. On the initial examination by the ophthalmologist one day after she began antibiotics, she had continued mild erythema of the right lower lid and upward displacement of the right medial canthal tendon. There was continued mild swelling over the right lacrimal sac area. The results of the rest of the comprehensive ophthalmologic examination were normal. Nasal examination with a nasal speculum and headlight did
FIG 1. Diagram of a dacryocele with an associated intranasal mucocele. The intranasal mucocele is composed of prolapsed nasolacrimal duct and nasal mucosa. (Courtesy of Dr Jane C. Edmond).
not reveal an intranasal mucocele. Intravenous ampicillin and gentamicin were continued. The patient underwent a right nasolacrimal duct probing under topical anesthesia in the neonatal intensive care unit 48 hours after she started intravenous antibiotics. The swelling over the right lacrimal sac immediately decompressed. She continued to receive intravenous antibiotics for another 5 days for a total course of 7 days. There was no recurrence of the condition.
Case 2 J. B. is a Cday-old boy whose parents and neonatologist had noted a slowly progressive bluish mass in the right medial canthal area since birth. No respiratory abnormalities were noted. On the initial examination by the ophthalmologist, the boy had a right dacryocele with an upward displacement of the right medial canthal tendon. There was no erythema overlying the dacryocele or any purulent discharge. The boy was given ampicillin and gentamicin intravenously for 48 hours and then underwent a right nasolacrirnal duct probing under general anesthesia. Before the procedure, nasal endoscopy was performed. A large intranasal mucocele was found to be obstructing the entire right nasal antnun; the
FIG 2. Case 2, endoscopic view of the right (A) and left (6) nasal antrum. In each photograph, the nasal septum is identified by the long arrowand the inferior turbinate is identified with the short arrow. Note the large right-sided intranasal mucocele (asrerisklthat is completely obstructing the right nasal antrum.
left nasal antrum was found to be normal (Figure 2). After completing the nasolacrimal probing, marsupialization of the intranasal mucocele was performed, and the extra mucosal tissue was excised. To perform this procedure, the surgeon incises the mucocele with any of a variety of intranasal insnuments or a carbon-dioxide laser. In this case, a myringotomy blade was used. Next, the redundant mucocele tissue is excised using intranasal scissors.A large amount of mucoid material was expressed. No organisms grew in any cultures of this discharge. The patient was discharged after a f&7-day course of intravenous antibiotics. The patient was then seen again 3 weeks later with an acute left dacryocystitis. Erythema and swelling over the left lacrimal sac was noted with upward displacement of the left medial canthal tendon. The patient was again given ampicillin and gentamicin intravenously, and the dacryocele was probed under general anesthesia 48 hours later. Nasal endoscopy was performed again, and a leftsided intranasal mucocele was noted. The mucocele was marsupialized and excised. Silicone tubes were then placed in the lacrimal system (Figure 3). The patient completed a 7-day course of intravenous antibiotics. The silicone tubes were removed 6 months later. Since the last procedure, the patient has remained asymptomatic with 14 months of follow-up.
REXJETS Twenty-two patients with a total of 30 dacryoceles were identified. Fifteen were female, and seven were male. The mean age at presentation was 16 days (1 to 63 days). At the
initial presentation, 6 patients (27%) had bilateral dacryoceles, and 16 patients (73%) had a unilateral dacryocele. Four (2S%) of the patients who initially had unilateral dacryoceles eventually developed a second dacryocele on the other side. Three other patients (19%), who initially had a unilateral dacryocele, had common nasolacrimal duct obstruction on the opposite side (Table 1). Nasal endoscopy was used in the evaluation in 13 (59%) of 22 patients. A nasal speculum and headlight were used to evaluate 7 patients (32%). A nasal examination was not performed on 2 patients (9%). CT scans were obtained on 5 (23%) of 22 patients. In all cases of CT scans, an otolaryngologist had requested the scans before evaluation by an ophthalmologist. The scans confirmed the findings of an enlarged lacrimal sac and nasolacrimal duct and the presence of the intranasal cystic mass in all patients. An intranasal mucocele was present with 23 (77%) of 30 dacryoceles or in 16 (73%) of 22 patients. Of the 10 patients with bilateral dacryoceles, 5 patients (50%) had bilateral intranasal mucoceles, and 3 patients (30%) had a unilateral intranasal mucocele. Of the 12 patients with a unilateral dacryocele, 2 patients (17%) had bilateral intranasal mucoceles, and 6 patients (SO%) had a unilateral intranasal mucocele (Figure 4). Respiratory distress and feeding difficulties were noted in 5 (71%) of 7 patients with bilateral intranasal mucoceles and in 2 (22%) of 9 patients with unilateral intranasal mucoceles (Figure 5). Two patients with choanal atresia (one with a unilateral dacryocele and one with bilateral dacryoceles) had respiratory distress. Dacryocystitis or preseptal cellulitis or both
FIG 3. Case 2, A, endoscopic view of the Bowman nasolacrimal duct probe in the inferior meatus exiting from the intranasal mucocele, under the inferior turbinate (white arrow). The nasal septum is identified by the black arrow. B, The appearance of the inferior meatus after marsupialization and excision of the mucocele /white arrow), with the Bowman probe still in place. The nasal septum is identified by the black arrow. C, Silicone tubing /long arrow) passing from the decompressed intranasal mucocele (short arrow) into the nasal antrum.
were seen on presentation or developed in 18 (60%) of 30 dacryoceles and in 12 (55%) of 22 patients (Table 1). One patient had spontaneous resolution of a dacryocele at age 7 days. The 29 remaining dacryoceles (97%) were surgically treated. Thirty-four procedures were performed overall. Seven dacryoceles (2 1%) were treated with nasolacrimal duct probing under topical anesthesia. Two (29%) of these probings under topical anesthesia failed. Both of these treatment failures had an associated intranasal mucocele. These dacryoceles were retreated successfully with
nasolacrimal duct probing with marsupialization. One dacryocele (3 %) was decompressed by needle aspiration in the emergency department by an otorhinolaryngologist, followed by definitive treatment by the ophthalmologist shortly thereafter. Twenty-six procedures (76%) were performed under general anesthesia. Two dacryoceles (6%) were treated with nasolacrimal duct probing alone. Two (6%) were treated with probing and silicone, tube placement. Twelve dacryoceles (35%) were treated with nasolacrimal duct probing with intranasal mucocele mar-
50
Payne et al 100
90
Intranasal mucocele
SO
%
70 60
n
50
q
Bilateral Unilateral 1 None
40 30 20 10 0 Bilateral
Unilateral
(n=lO)
(n=12) Dacryocele
FIG 4. Dacryoceles and intranasal patients with bilateral dacryoceles
type*
mucoceles. Note that most patients had at least 1 intranasal and 17% of patients with unilateral dacryoceles had bilateral
n
Bilateral
Unilateral
(n = 7)
(n = 9)
Intranasal FIG 5. lntranasal mucoceles and respiratory with either bilateral or unilateral mucoceles.
distress.
mucocele intranasal
and that 50% of mucoceles.
Respiratory distress
mucocele It is important
supialization. Ten (29%) were treated with nasolacrimal duct probing with intranasal mucocele marsupialization and silicone tube placement. All procedures were successful, except for 2 probings under topical anesthesia. Marsupialization was performed with a carbon-dioxide laser in 7 (28%) of 25 intranasal mucoceles and was performed with conventional surgical instruments in 18 (75 %) of 2 5 intranasal mucoceles.
DISCUSSION Congenital nasolacrimal duct obstruction is common, affecting approximately 30% to 84% of the populationl-3 In 1 study, approximately 75% of fetuses that underwent autopsy had a membranous obstruction of the nasolacrimal system.4 The nasolacrimal duct system arises from an invagination of ectoderm between the maxillary process
to note that respiratory
distress
can occur
in patients
and the lateral nasal process. An ectodermal cord canalizes at approximately 14 weeks gestation, and the distal end is the last area to canalize, thus making it the most common site for the nasolacrimal duct obstruction.4J4 Less frequently, nasolacrimal duct obstruction is due to a narrowed lacrimal duct or bony obstruction. Even though there is a high prevalence of lacrimal duct obstruction found in fetuses that underwent autopsies, only 6% of term neonates are symptomatic from nasolacrimal duct obstruction, and most of these obstructions spontaneously resolve by the time the infant is 6 months of age. 2J Peterson and Robb2s reported an 85% spontaneous opening rate by 1 year of age. Because of the high spontaneous resolution rate, treatment for common nasolacrimal duct obstruction usually consists of lacrimal sac massage for the first 4 to 6 months of life or more. Many*b-‘8 currently recommend nasolacrimal duct
3ounzal CfAAPOS T/obme 4 Nunzl~er
1 Felnxmy
TABLE 1. Demographics
2000
Payne et al
and miscellaneous
Age at presentation Sex (M/F) Dacryocele laterality (no. of patients) Bilateral initially Unilateral initially Late contralateral dacryocele Late contralateral NLD obstruction Always unilateral Dacryocystitis NLO, Nasolacrimal duct.
TABLE 2. Indications ocele
6 d (l-63 d) l/15 6 16 4 3 9 18
(27%1 (73%) (25%) (19%) (56%) (60%)
probing under topical anesthesia in the office if the obstruction has not resolved at age 6 to 12 months in an attempt to decrease the need for using general anesthesia later for these procedures. The dacryocele is an uncommon abnormality of the nasolacrimal duct system. It occurs when there is an obstruction of the lacrimal duct system above and below the lacrimal sac.r*2*6 Most ophthalmologists believe that the proximal obstruction occurs at the level of the valve of Rosenmiiller, such that a l-way valve effect occurs, allowing tears to enter the lacrimal sac but not reflux back out in a retrograde fashion.3 On the other hand, Jones and Wobigr believe that the common canaliculus is aberrantly absent in patients with dacryoceles, causing the upper and lower canaliculi to enter the lacrimal sac at an acute angle, producing a functional “trapdoor.” The distal obstruction in a dacryocele is similar to that found in common nasolacrimal duct obstruction at the level of the valve of Hasner. The differential diagnosis of congenital dacryocele includes meriingoencephalocele or encephalocele, capillary hemangioma, solid dermoid, dermoid cyst, mucocele,. and sudoriferous cyst.29-36 Diagnostic aids to help differentiate these entities include CT, MRI, transillumination, ultrasound, and dacryocystography. It is important to differentiate a dacryocele from an encephalocele or meningoencephalocele to avoid unnecessary probing and possible violation of brain tissue. Features suggesting encephalocele or meningoencephalocele include hypertelorism, reducibility of the mass without expression of fluid from the puncta, pulsation synchronous with the heartbeat, and a nasal bridge defect. Five (23 %) of 22 patients in this study had CT scans. All of these CT scans were ordered by otolaryngologists for the evaluation of respiratory distress before ophthalmologic evaluation. Otolaryngologists are usually called before an ophthahnologist in cases of dacryodele when respiratory distress is present. In these cases, a CT scan is considered the standard of care for the otolaryngologist to (1) define nasal (bony) anatomy, which may be used as a surgical “road map” if surgical intervention is required or planned; (2) rule out other causes of respiratory distress such as choanal atresia; and (3) better define the intranasal mass that is causing the respiratory distress. Atypical presentations, such as swelling above the medial canthal tendon and
for neuroimaging
in patients with apparent
51
dacrocy-
Reducibility of the mass without expression of fluid per puncta Pulsation of the mass Hypertelorism Associate facial clefting syndrome Nasal bridge defect Broad nasal root Palpable bony defects Unusually large lesion Atypical location Extension above the medial canthai tendon Known CNS anatomic abnormality (eg, spina bifida) Lack of epiphora CNS, Central nervous system.
swelling associated with hypertelorism, would also warrant CT and MRI before surgical intervention (Table 2). The prevalence of intranasal mucoceles in association with dacryoceles is unknown. In our study, we examined 91% of the patients with either nasal endoscopy or nasal speculum and headlight and found that more than 77% had intranasal mucoceles. It is possible that previous studies may have overlooked this association if a nasal examination was not routinely performed. Additionally, we found that an intranasal mucocele can occur either before or after the dacryocele presentation. For example, Patient 2 was initially seen with a right congenital dacryocele with an associated intranasal mucocele and a normal left nasal cavity by nasal endoscopic examination. He was seen again 3 weeks later with a left dacryocele and intranasal mucocele. We also found the presence of intranasal mucoceles without an associated dacryocele in 2 patients. Presence of bilateral intranasal mucoceles can cause respiratory distress in the neonate. Neonates are obligate nasal breathers during the first 6 to 12 weeks of life. Eighteen (60%) of 30 previously reported patients with intranasal mucoceles had respiratory distress.7~ll~l4~16-‘9~21 We also found that respiratory distress was common in our patient population, especially in those with bilateral intranasal mucoceles, being present in 71%. Respiratory distress was less frequent in unilateral cases (22%), but nevertheless, it did occur. Respiratory distress probably occurred when the intranasal mucoceles became large enough to obstruct nasal air flow. We had 2 patients with choanal atresia and respiratory distress. One had a unilateral intranasal mucocele, whereas the other hadbilateral involvement. It is not possible to determine ,which probe lem (ie, the intranasal mucoceles or the chaamil atresia) contributed more to this respiratory compromise. Several previous studies have shown good success rates treating dacryoceles with conservative medical treatment alone. Schnall and ChristhuG described 17 ,patieqts-with 21 dacryoceles who were treated con.servatiwzIy. Six&n (76%) of the 21 dacryoceles resolvedwithi&days..of&nservative management, which included the titiati!olii of
3ou??ullof AAPOS 52
Payne et al
Volume 4 Numbs
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2000
1 Nasal examination, prefer nasal endoscopy 1
Probe/marsupialization/tubes FIG 6. Recommended
dacryocele
evaluation
and management
approach.
intravenous antibiotics, warm compresses,and lacrimal sac the congenital dacryocele in our patient population, we curmassage.However, 4 (24%) of their 17 patients had dacryrently recommend prompt surgical intervention, including ocystitis. Dacryoceles have a high reported risk of secondary preoperative nasal examination, preferably with a nasal infection, including dacryocystitis, preseptal cellulitis, and endoscopy to aid in surgical decision making. CT or other other serious infections. Isolated casesof meningitis, sepsis, imaging can be used in atypical cases.One should consider and even brain abscesshave been reported.d8~9~12~13~15,16,19bilateral nasolacrimal duct probing in all casesbecause of In our group of 22 patients, we found a 60% incidence of the high rate of late or occult second-side involvement. dacryocystitis on presentation or soon after presentation. Bacterial infections in the neonatal age group can be life References threatening, and they typically require hospitalization, 1. Jones LT, Wobig JL. Surgery of the eyelids and lacrimal system. New intravenous antibiotics, and a sepsis evaluation. We also York: Aesculapius Publishing Co; 1976. p. 157-73. found a relatively high rate of late second-side dacryocele 2. Scott WE, Fabre JA, Ossionig KC. Congenital mucocele of a development (25%) and common nasolacrimal duct lacrimal sac. Arch Ophthalmol 1979;97:1656-8. 3. Guery D, Kendig EL. Congenital impatency of the nasolacrimal obstruction (19%). Because of the high risk of associated duct. Arch Ophthalmol 1948;39:1993-6. infections noted in our patient population and the serious 4. CassidyTV: Dacryocysdtis in infancy. Am J Ophthalmol1948;39:773-8. complications that can potentially follow, we believe that 5. Rand PK, Ball WS Jr, K&in DR. Congenital nasolacrimal mucoearly surgical intervention is the most prudent treatment. celes: CT evaluation. Radiology 1989;173:691-4. Additionally, one should consider bilateral nasolacrimal 6. Tanenbaum M, McCord CD. The lacrimal drainage system. In: Tasman W, editor. Duane’s clinical ophthalmology. Vol. 4, chap 13. Philadelphia: duct probing, even in unilateral cases,because of the high Lippincott-Raven; 1997. p. 7. risk of late or occult second-side involvement. 7. Edmond JC, Keech RV. Congenital nasolacrimal sac mucocele assoThe surgical approach we recommend is stair-stepped, ciated with respiratory distress. J Pediatr Ophthalmol Strabismus depending on the severity of the lacrimal duct stenosis and 1991;28:287-9. the presence or absence of an intranasal mucocele; The 8. Hulka GF, K&in DR, Weeks SM, Cotton RT. Congenital lacrimal sac mucoceles with innanasal extension. Otolatyngol Head Neck approach first starts with nasolacrimal duct probing alone Sorg 1995;113:651-5. for dacryoceleswithout intranasal mucoceles. Nasolacrimal 9. Divine RD, Anderson RL, Bumsted RM. Bilateral congenital duct probing with silicone tube placement is performed if lacrimal sac mucoceles with nasal extension and drainage. Arch the nasolacrimal duct is extremely stenotic or inflamed or if Ophthalmol 1983;101:246-8. the lacrimal sacrefills with irrigation after probing, signify10. Demaerel P, Casteels I, Peene P, Maudgal PC, Wdms G. Unilateral congenital nasolacrimal mucocele. Pediatr Radio1 1991;2 15.51. ing the continued presence of 2 functional l-way valves. 11. Casdllo M, Merten DF, Weissler MC. Bilateral nasolacrimal duct Marsupialization of an intranasal mucocele is performed mucocele, a rare cause of respiratory distress: CT findings in two whenever one is present (Figure 6). newborns. Am J Neuroradiol 1993;14:1011-3. In conclusion, because of the high risk of dacryocystitis 12. Schnall BM, Christian CJ. Conservative treatment of congenital dacryocele. J Pediaa Ophthamol Strabismus 1996;33:2 19-2 1. and the strong association of the intranasal mucocele with
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15. 16.
17.
18.
19.
20. 21.
22. 23. 24.
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Mansour AM, Cheng KP, Mumma JV, Stager DR, Harris GJ, Patrinely JR, et al. Congenital dacryocele: a collaborative review. Ophthalmology 1991;98:1744-51. Hepler KM, Woodson GE, Kearns DB. Respiratory distress in the neonate: sequela of a congenital dacryocystocele. Arch Otolaryngol Head Neck Surg 1995;121:1423-5. Sullivan TJ, Clarke MP, Morin JD, Pashby RC. Management of congenital dacryocystocele. Aust N Z J Ophthalmol 1992;20:105-8. Yee SW, Seibert RW, Bower CM, Glasier CM. Congenital nasolacrimal duct mucocele: a cause of respiratory distress. Int J Pediatr Otorhinolaryngol 1994;29:151-8. Lusk RP, Muntz HM. Nasal obstruction in the neonate secondary to nasolacrimal duct cysts. Int J Pediatr Otorhinolaryngol 1987;13: 315-22. Mazzara CA, Respler DS, Jahn AF. Neonatal respiratory distress: sequela of bilateral nasolacrimal duct obstruction. Int J Pediatr Otorhinolaryngol 1993;25:209-16. Righi PD, Hubbell RN, Lawlor PI! Respiratory distress associated with bilateral nasolacrimal duct cysts. Int J Pedian Otorhinolaryngol 1993;26:199-203. Grin TR, Mertz JS, Stass-Isern N. Congenital nasolacrimal duct cysts in dacryocele. Ophthalmology 1991;98:1238-42. Goralowny AM, Tarantowicz W. Imperforation of the nasolacrimal duct as a cause of nasal obsauction in the newborn. Rhinology 1979; 17:173-s. Levy NS. Conservative management of congenital amniotocele of the nasolacrimal sac. J Pedian Ophthalmol Strabismus 1979;16:254-6. Jackson H, Lambert TD. Congenital mucocele of the lacrimal sac. Br J Ophthalmol 1963;1949:690-1. Duke-Elder S, Cooke C. Normal and abnormal ash development embryology. In: Duke-Elder S, editor. System of ophthalmology. St Louis: CV Mosby Co; 1993. p. 241-S.
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25. Peterson RA, Robb RM. The natural course of congenital obstruction of the nasolacrimal duct. J Pediatr Ophthalmol Strabismus 1973;14:246-50. 26. Katowia JA, Welsh MG. Timing of initial probing and irrigation in congenital nasolacrimal duct obstruction. Ophthalmology 1987;94: 698-705. 27. Paul TO, Shepherd R. Congenital nasolacrimal duct obstruction: natural history and the timing of optimal intervention. J Pediatr Ophthalmol Strabismus 1994;3 1:362-7. 28. Stager D, Baker JD, Frey T, Weakley DR, Birch EE. Office probing of congenital nasolacrimal duct obstruction. Ophthalmic Surg 1992; 23:482-4. 29. Rashid ER, Bergstrom TJ, Evans RM, Arnold AC. Anterior encephalocele presenting as nasolacrimal obstruction. Ann Ophthahnol 1986;18:132-6. 30. Chohan BS, Chandra P, Parmar IPS, Sharma JL. Orbital meningoencephalocele communicating with the lacrimal sac. Clin Pediatr 1974;13:330-2. 31. Chohan BS, Parmar IPS, Bhada JN. Anterior orbital meningoencephalocele. Am J Ophthalmol 1969;68:144-6. 32. Hurwia JJ, Rodgers J, Doucet TW. Dermoid tumor involving the lacrimal drainage pathway: a case report. Ophthalmic Surg 1982; 13:377-9. 1962;53: 33. Dayal Y, Hameed S. Periorbital dermoid. Am J Ophrhahuol 1013-6. 34 Robertson DM, Henderson JW. Unilateral proptosis secondary to orbital mucocele in infancy. Am J Ophthalmol 1969;68:845-7. 35 Mints J, Rodrigues M, Calhoun J. Sudoriferous cyst of the orbit. Can J Ophthalmol 1977;12:155-6. 36. Saunders JF. Congenital sudoriferous cyst of the orbit. Arch Ophthalmol 1973;89:205-6.
An Eye on the Arts - The Arts on the Eye
For Same, sight furnished the perceptual model for all senses,and the imagination itself thrived on visual experience. “I think with my eyes,” he adm$ted. When, in his old age, Same became blind, he described himself as a “ hving corpse,” unable to interact with the world. Despite his critique of the tyranny of sight, it would seem in the end for Sartre the only alternative to seeing was “nothingness.” -Constance Classen (from The Color ofAngels p 139)
MD&
Cindv
Go, MD,bd
Introduction: The association of dacryocele and intranasal mucocele has been previously reported. Its incidence and optimal treatment are unknown. Patients and Methods: A retrospective review of 22 patients with 30 dacryoceles was performed to determine the mean age at presentation, sex distribution, and prevalence of associated intranasal mucocele, associated dacryocystitis, and respiratory distress. The components of the examination, ancillary tests, treatment modalities, and treatment outcomes were then summarized. Results: Unilateral dacryoceles were seen in 16 (73%) of the infants, and bilateral dacryoceles were seen in 6 (27%) of the infants. Four (25%) of the 16 patients who initially had unilateral dacryoceles later developed bilateral dacryoceles. Dacryocystitis, preseptal cellulitis, or both were present on presentation or developed in 18 (60%) of 30 dacryoceles. Nasal endoscopy was performed on 13 (59%) of 22 patients. Nasal examination with nasal speculum and headlight was performed on 7 patients (32%). A concurrent intranasal mucocele was diagnosed in 23 (77%) of 30 dacryoceles. Respiratory distress arose in 5 (71%) of 7 patients with bilateral intranasal mucoceles and in 2 (22%) of 9 patients with a unilateral intranasal mucocele. Thirty-four procedures were performed. Seven dacryoceles (21%) were treated with nasolacrimal duct probing under topical anesthesia. Another one (3%) was treated with needle aspiration with later definitive therapy. All other procedures were managed under general anesthesia. These included 2 nasolacrimal duct probings (6%), 2 probings with silicone tube placement (6%), 10 probings with intranasal mucocele marsupialization and silicone tube placement (29%), and 12 probings with marsupialization alone (35%). Two (29%) of the 7 probings performed under topical anesthesia failed, whereas all other procedures were successful. One dacryocele spontaneously resolved. Conclusions: Congenital dacryoceles are commonly associated with intranasal mucoceles, dacryocystitis, and preseptal cellulitis. Respiratory distress is common in bilateral cases. Bilateral nasolacrimal duct probing should be considered in unilateral cases because of the high incidence of occult contralateral involvement. (J AAPOS 2000;4:46-53) ongenital nasolacrimal duct obstruction is common, affecting approximately 30% to 84% of the newborn population, depending on the source.*-3 The usual site of obstruction in congenital nasolacrimal duct obstruction is at the valve of Hasner, just before the entrance to the nasal antrum. However, obstruction can occur anywhere along the nasolacrimal duct system.
C
Franz tbc Cullen Eye Insthte, Baylor College ofMedicine, Depm~tent of Opbtbabnology mtd Pediam’a, Turns Cbildrm’s Haspitni,,’ and de Dcpamnent of Otohyngology, Baylor College ofMedicine, Trro Cbikiren’r Hospirol, Houston, Texas.. Supported in pan @ an unmhicted grant fmtr, Rrrmrcb to Prevent Elindncs~ Inc. New Ymk, NW Ymk. Presented at tbe 2Jtb Annual Meeting of tbe Atnmiatn Association of Pediatric Opbtbahnola~ and Stmbinnw Tmonto, Ontario, April IS, 1999. Submitted April 22, 1999. Revision acceincd Atuwt 1L 1999. Reprint rr&&: Eue&n A. &se, MD, Terar Cbikimzm’rHospitrrl, II02 Batrs, #300; MC 3-2700, Howton, 7x 77030 (e-mail: [email protected],rrcdtI). Copyright Q 2000 by the American Association for Pediohic Opbtbolwa$y nnd Smrbimtw. 1091-8~31/2000$12.00 + 0 75/l/102922
Impatency at the valve of Hasner has been reported in up to 73% of fetuses that underwent autopsy.4 Despite this, only 4% to 6% of newborn children are symptomatic.3J The dacryocele, also known as the congenital nasolacrimal sac mucocele, is an uncommon condition. It clinically appears as a bluish mass inferior to the medial canthal tendon. The dacryocele is a dilation of the lacrimal sac that occurs when an obstruction of the nasolacrimal duct is present above and below the lacrimal sac. Tears continue to enter the lacrimal sac, but they cannot exit the canaliculi because of a l-way valve-type obstruction in the canaliculi or at the valve of Rosenmiiller. Tears also cannot exit from below because of an obstruction in the nasolacrimal duct. Several different terms have been used to describe dacryoceles, depending on the type of fluid believed to be filling the cystic mass. Equivalent nomenclature includes amniotocele, amniocele, lacrimal sac mucocele, dacryocele, and dacryocystocele. 1~6-15 The most appropriate terms are dacryocele and congenital lacrimal sac mucocele
because histologic evaluation has shown that the fluid filling the lacrimal sac is not amniotic fluid, but epidermal debris and tears. The association of an intranasal mucocele with the dacryocele has been occasionally reported. An intranasal mucocele is composed of nasolacrimal duct and nasal mucosa that has prolapsed into the nasal antrum because of progressive overfilling of the nasolacrimal system with tears (Figure 1). We found only 30 anecdotal cases of intranasal mucocele in the literature.7-*‘.*3.‘~,*6-~0 Respiratory distress associated with dacryoceles and concurrent intranasal mucoceles has also been reported, hut its frequency and risk factors are unknown. Treatment recommendations for dacryoceles with and without intranasal mucoceles have varied widely in the literature and include warm compresses and lacrimal sac massage, topical and/or intravenous antibiotics, surgical probing of the nasolacrimal duct with or without silicone tube intubation, and marsupialization of the intranasal nlucocele.7-9~*~,13,15-1*,~1-23 Like treatment recommendations, the ancillary testing recommendations for dacryoceles have varied and have included clinical examination of the lacrimal system alone, clinical examination of both the lacrimal system and the intranasal cavity, and computed tomography (CT) or magnetic resonance imaging (Mw.S,7-12,14-19,21,22
We retrospectively reviewed all patients with dacryoceles who were treated over a 20-month period. To better understand the clinical presentation, we determined the frequency of associated intranasal mucoceles and associated respiratory distress, and determined evaluation and treatment modalities used and outcomes.
PATIENTS
AND METHODS
This is a retrospective review of 22 patients with 30 congenital dacryoceles. We determined the mean age at presentation, sex, prevalence of associated intranasal mucocele, associated dacryocystitis, and respiratory distress. The components of the examination, ancillary tests, treatment modalities, and treatment outcomes are summarized.
CASE REPORTS Case 1 G. K. is a 4-day-old girl who had swelling and erythema over the right lacrimal sac 3 days after birth. No respiratory difficulties or feeding difficulties were noted. Her neonatologist diagnosed dacryocystitis and treated her with ampicillin and gentamicin intravenously. On the initial examination by the ophthalmologist one day after she began antibiotics, she had continued mild erythema of the right lower lid and upward displacement of the right medial canthal tendon. There was continued mild swelling over the right lacrimal sac area. The results of the rest of the comprehensive ophthalmologic examination were normal. Nasal examination with a nasal speculum and headlight did
FIG 1. Diagram of a dacryocele with an associated intranasal mucocele. The intranasal mucocele is composed of prolapsed nasolacrimal duct and nasal mucosa. (Courtesy of Dr Jane C. Edmond).
not reveal an intranasal mucocele. Intravenous ampicillin and gentamicin were continued. The patient underwent a right nasolacrimal duct probing under topical anesthesia in the neonatal intensive care unit 48 hours after she started intravenous antibiotics. The swelling over the right lacrimal sac immediately decompressed. She continued to receive intravenous antibiotics for another 5 days for a total course of 7 days. There was no recurrence of the condition.
Case 2 J. B. is a Cday-old boy whose parents and neonatologist had noted a slowly progressive bluish mass in the right medial canthal area since birth. No respiratory abnormalities were noted. On the initial examination by the ophthalmologist, the boy had a right dacryocele with an upward displacement of the right medial canthal tendon. There was no erythema overlying the dacryocele or any purulent discharge. The boy was given ampicillin and gentamicin intravenously for 48 hours and then underwent a right nasolacrirnal duct probing under general anesthesia. Before the procedure, nasal endoscopy was performed. A large intranasal mucocele was found to be obstructing the entire right nasal antnun; the
FIG 2. Case 2, endoscopic view of the right (A) and left (6) nasal antrum. In each photograph, the nasal septum is identified by the long arrowand the inferior turbinate is identified with the short arrow. Note the large right-sided intranasal mucocele (asrerisklthat is completely obstructing the right nasal antrum.
left nasal antrum was found to be normal (Figure 2). After completing the nasolacrimal probing, marsupialization of the intranasal mucocele was performed, and the extra mucosal tissue was excised. To perform this procedure, the surgeon incises the mucocele with any of a variety of intranasal insnuments or a carbon-dioxide laser. In this case, a myringotomy blade was used. Next, the redundant mucocele tissue is excised using intranasal scissors.A large amount of mucoid material was expressed. No organisms grew in any cultures of this discharge. The patient was discharged after a f&7-day course of intravenous antibiotics. The patient was then seen again 3 weeks later with an acute left dacryocystitis. Erythema and swelling over the left lacrimal sac was noted with upward displacement of the left medial canthal tendon. The patient was again given ampicillin and gentamicin intravenously, and the dacryocele was probed under general anesthesia 48 hours later. Nasal endoscopy was performed again, and a leftsided intranasal mucocele was noted. The mucocele was marsupialized and excised. Silicone tubes were then placed in the lacrimal system (Figure 3). The patient completed a 7-day course of intravenous antibiotics. The silicone tubes were removed 6 months later. Since the last procedure, the patient has remained asymptomatic with 14 months of follow-up.
REXJETS Twenty-two patients with a total of 30 dacryoceles were identified. Fifteen were female, and seven were male. The mean age at presentation was 16 days (1 to 63 days). At the
initial presentation, 6 patients (27%) had bilateral dacryoceles, and 16 patients (73%) had a unilateral dacryocele. Four (2S%) of the patients who initially had unilateral dacryoceles eventually developed a second dacryocele on the other side. Three other patients (19%), who initially had a unilateral dacryocele, had common nasolacrimal duct obstruction on the opposite side (Table 1). Nasal endoscopy was used in the evaluation in 13 (59%) of 22 patients. A nasal speculum and headlight were used to evaluate 7 patients (32%). A nasal examination was not performed on 2 patients (9%). CT scans were obtained on 5 (23%) of 22 patients. In all cases of CT scans, an otolaryngologist had requested the scans before evaluation by an ophthalmologist. The scans confirmed the findings of an enlarged lacrimal sac and nasolacrimal duct and the presence of the intranasal cystic mass in all patients. An intranasal mucocele was present with 23 (77%) of 30 dacryoceles or in 16 (73%) of 22 patients. Of the 10 patients with bilateral dacryoceles, 5 patients (50%) had bilateral intranasal mucoceles, and 3 patients (30%) had a unilateral intranasal mucocele. Of the 12 patients with a unilateral dacryocele, 2 patients (17%) had bilateral intranasal mucoceles, and 6 patients (SO%) had a unilateral intranasal mucocele (Figure 4). Respiratory distress and feeding difficulties were noted in 5 (71%) of 7 patients with bilateral intranasal mucoceles and in 2 (22%) of 9 patients with unilateral intranasal mucoceles (Figure 5). Two patients with choanal atresia (one with a unilateral dacryocele and one with bilateral dacryoceles) had respiratory distress. Dacryocystitis or preseptal cellulitis or both
FIG 3. Case 2, A, endoscopic view of the Bowman nasolacrimal duct probe in the inferior meatus exiting from the intranasal mucocele, under the inferior turbinate (white arrow). The nasal septum is identified by the black arrow. B, The appearance of the inferior meatus after marsupialization and excision of the mucocele /white arrow), with the Bowman probe still in place. The nasal septum is identified by the black arrow. C, Silicone tubing /long arrow) passing from the decompressed intranasal mucocele (short arrow) into the nasal antrum.
were seen on presentation or developed in 18 (60%) of 30 dacryoceles and in 12 (55%) of 22 patients (Table 1). One patient had spontaneous resolution of a dacryocele at age 7 days. The 29 remaining dacryoceles (97%) were surgically treated. Thirty-four procedures were performed overall. Seven dacryoceles (2 1%) were treated with nasolacrimal duct probing under topical anesthesia. Two (29%) of these probings under topical anesthesia failed. Both of these treatment failures had an associated intranasal mucocele. These dacryoceles were retreated successfully with
nasolacrimal duct probing with marsupialization. One dacryocele (3 %) was decompressed by needle aspiration in the emergency department by an otorhinolaryngologist, followed by definitive treatment by the ophthalmologist shortly thereafter. Twenty-six procedures (76%) were performed under general anesthesia. Two dacryoceles (6%) were treated with nasolacrimal duct probing alone. Two (6%) were treated with probing and silicone, tube placement. Twelve dacryoceles (35%) were treated with nasolacrimal duct probing with intranasal mucocele mar-
50
Payne et al 100
90
Intranasal mucocele
SO
%
70 60
n
50
q
Bilateral Unilateral 1 None
40 30 20 10 0 Bilateral
Unilateral
(n=lO)
(n=12) Dacryocele
FIG 4. Dacryoceles and intranasal patients with bilateral dacryoceles
type*
mucoceles. Note that most patients had at least 1 intranasal and 17% of patients with unilateral dacryoceles had bilateral
n
Bilateral
Unilateral
(n = 7)
(n = 9)
Intranasal FIG 5. lntranasal mucoceles and respiratory with either bilateral or unilateral mucoceles.
distress.
mucocele intranasal
and that 50% of mucoceles.
Respiratory distress
mucocele It is important
supialization. Ten (29%) were treated with nasolacrimal duct probing with intranasal mucocele marsupialization and silicone tube placement. All procedures were successful, except for 2 probings under topical anesthesia. Marsupialization was performed with a carbon-dioxide laser in 7 (28%) of 25 intranasal mucoceles and was performed with conventional surgical instruments in 18 (75 %) of 2 5 intranasal mucoceles.
DISCUSSION Congenital nasolacrimal duct obstruction is common, affecting approximately 30% to 84% of the populationl-3 In 1 study, approximately 75% of fetuses that underwent autopsy had a membranous obstruction of the nasolacrimal system.4 The nasolacrimal duct system arises from an invagination of ectoderm between the maxillary process
to note that respiratory
distress
can occur
in patients
and the lateral nasal process. An ectodermal cord canalizes at approximately 14 weeks gestation, and the distal end is the last area to canalize, thus making it the most common site for the nasolacrimal duct obstruction.4J4 Less frequently, nasolacrimal duct obstruction is due to a narrowed lacrimal duct or bony obstruction. Even though there is a high prevalence of lacrimal duct obstruction found in fetuses that underwent autopsies, only 6% of term neonates are symptomatic from nasolacrimal duct obstruction, and most of these obstructions spontaneously resolve by the time the infant is 6 months of age. 2J Peterson and Robb2s reported an 85% spontaneous opening rate by 1 year of age. Because of the high spontaneous resolution rate, treatment for common nasolacrimal duct obstruction usually consists of lacrimal sac massage for the first 4 to 6 months of life or more. Many*b-‘8 currently recommend nasolacrimal duct
3ounzal CfAAPOS T/obme 4 Nunzl~er
1 Felnxmy
TABLE 1. Demographics
2000
Payne et al
and miscellaneous
Age at presentation Sex (M/F) Dacryocele laterality (no. of patients) Bilateral initially Unilateral initially Late contralateral dacryocele Late contralateral NLD obstruction Always unilateral Dacryocystitis NLO, Nasolacrimal duct.
TABLE 2. Indications ocele
6 d (l-63 d) l/15 6 16 4 3 9 18
(27%1 (73%) (25%) (19%) (56%) (60%)
probing under topical anesthesia in the office if the obstruction has not resolved at age 6 to 12 months in an attempt to decrease the need for using general anesthesia later for these procedures. The dacryocele is an uncommon abnormality of the nasolacrimal duct system. It occurs when there is an obstruction of the lacrimal duct system above and below the lacrimal sac.r*2*6 Most ophthalmologists believe that the proximal obstruction occurs at the level of the valve of Rosenmiiller, such that a l-way valve effect occurs, allowing tears to enter the lacrimal sac but not reflux back out in a retrograde fashion.3 On the other hand, Jones and Wobigr believe that the common canaliculus is aberrantly absent in patients with dacryoceles, causing the upper and lower canaliculi to enter the lacrimal sac at an acute angle, producing a functional “trapdoor.” The distal obstruction in a dacryocele is similar to that found in common nasolacrimal duct obstruction at the level of the valve of Hasner. The differential diagnosis of congenital dacryocele includes meriingoencephalocele or encephalocele, capillary hemangioma, solid dermoid, dermoid cyst, mucocele,. and sudoriferous cyst.29-36 Diagnostic aids to help differentiate these entities include CT, MRI, transillumination, ultrasound, and dacryocystography. It is important to differentiate a dacryocele from an encephalocele or meningoencephalocele to avoid unnecessary probing and possible violation of brain tissue. Features suggesting encephalocele or meningoencephalocele include hypertelorism, reducibility of the mass without expression of fluid from the puncta, pulsation synchronous with the heartbeat, and a nasal bridge defect. Five (23 %) of 22 patients in this study had CT scans. All of these CT scans were ordered by otolaryngologists for the evaluation of respiratory distress before ophthalmologic evaluation. Otolaryngologists are usually called before an ophthahnologist in cases of dacryodele when respiratory distress is present. In these cases, a CT scan is considered the standard of care for the otolaryngologist to (1) define nasal (bony) anatomy, which may be used as a surgical “road map” if surgical intervention is required or planned; (2) rule out other causes of respiratory distress such as choanal atresia; and (3) better define the intranasal mass that is causing the respiratory distress. Atypical presentations, such as swelling above the medial canthal tendon and
for neuroimaging
in patients with apparent
51
dacrocy-
Reducibility of the mass without expression of fluid per puncta Pulsation of the mass Hypertelorism Associate facial clefting syndrome Nasal bridge defect Broad nasal root Palpable bony defects Unusually large lesion Atypical location Extension above the medial canthai tendon Known CNS anatomic abnormality (eg, spina bifida) Lack of epiphora CNS, Central nervous system.
swelling associated with hypertelorism, would also warrant CT and MRI before surgical intervention (Table 2). The prevalence of intranasal mucoceles in association with dacryoceles is unknown. In our study, we examined 91% of the patients with either nasal endoscopy or nasal speculum and headlight and found that more than 77% had intranasal mucoceles. It is possible that previous studies may have overlooked this association if a nasal examination was not routinely performed. Additionally, we found that an intranasal mucocele can occur either before or after the dacryocele presentation. For example, Patient 2 was initially seen with a right congenital dacryocele with an associated intranasal mucocele and a normal left nasal cavity by nasal endoscopic examination. He was seen again 3 weeks later with a left dacryocele and intranasal mucocele. We also found the presence of intranasal mucoceles without an associated dacryocele in 2 patients. Presence of bilateral intranasal mucoceles can cause respiratory distress in the neonate. Neonates are obligate nasal breathers during the first 6 to 12 weeks of life. Eighteen (60%) of 30 previously reported patients with intranasal mucoceles had respiratory distress.7~ll~l4~16-‘9~21 We also found that respiratory distress was common in our patient population, especially in those with bilateral intranasal mucoceles, being present in 71%. Respiratory distress was less frequent in unilateral cases (22%), but nevertheless, it did occur. Respiratory distress probably occurred when the intranasal mucoceles became large enough to obstruct nasal air flow. We had 2 patients with choanal atresia and respiratory distress. One had a unilateral intranasal mucocele, whereas the other hadbilateral involvement. It is not possible to determine ,which probe lem (ie, the intranasal mucoceles or the chaamil atresia) contributed more to this respiratory compromise. Several previous studies have shown good success rates treating dacryoceles with conservative medical treatment alone. Schnall and ChristhuG described 17 ,patieqts-with 21 dacryoceles who were treated con.servatiwzIy. Six&n (76%) of the 21 dacryoceles resolvedwithi&days..of&nservative management, which included the titiati!olii of
3ou??ullof AAPOS 52
Payne et al
Volume 4 Numbs
1 February
2000
1 Nasal examination, prefer nasal endoscopy 1
Probe/marsupialization/tubes FIG 6. Recommended
dacryocele
evaluation
and management
approach.
intravenous antibiotics, warm compresses,and lacrimal sac the congenital dacryocele in our patient population, we curmassage.However, 4 (24%) of their 17 patients had dacryrently recommend prompt surgical intervention, including ocystitis. Dacryoceles have a high reported risk of secondary preoperative nasal examination, preferably with a nasal infection, including dacryocystitis, preseptal cellulitis, and endoscopy to aid in surgical decision making. CT or other other serious infections. Isolated casesof meningitis, sepsis, imaging can be used in atypical cases.One should consider and even brain abscesshave been reported.d8~9~12~13~15,16,19bilateral nasolacrimal duct probing in all casesbecause of In our group of 22 patients, we found a 60% incidence of the high rate of late or occult second-side involvement. dacryocystitis on presentation or soon after presentation. Bacterial infections in the neonatal age group can be life References threatening, and they typically require hospitalization, 1. Jones LT, Wobig JL. Surgery of the eyelids and lacrimal system. New intravenous antibiotics, and a sepsis evaluation. We also York: Aesculapius Publishing Co; 1976. p. 157-73. found a relatively high rate of late second-side dacryocele 2. Scott WE, Fabre JA, Ossionig KC. Congenital mucocele of a development (25%) and common nasolacrimal duct lacrimal sac. Arch Ophthalmol 1979;97:1656-8. 3. Guery D, Kendig EL. Congenital impatency of the nasolacrimal obstruction (19%). Because of the high risk of associated duct. Arch Ophthalmol 1948;39:1993-6. infections noted in our patient population and the serious 4. CassidyTV: Dacryocysdtis in infancy. Am J Ophthalmol1948;39:773-8. complications that can potentially follow, we believe that 5. Rand PK, Ball WS Jr, K&in DR. Congenital nasolacrimal mucoearly surgical intervention is the most prudent treatment. celes: CT evaluation. Radiology 1989;173:691-4. Additionally, one should consider bilateral nasolacrimal 6. Tanenbaum M, McCord CD. The lacrimal drainage system. In: Tasman W, editor. Duane’s clinical ophthalmology. Vol. 4, chap 13. Philadelphia: duct probing, even in unilateral cases,because of the high Lippincott-Raven; 1997. p. 7. risk of late or occult second-side involvement. 7. Edmond JC, Keech RV. Congenital nasolacrimal sac mucocele assoThe surgical approach we recommend is stair-stepped, ciated with respiratory distress. J Pediatr Ophthalmol Strabismus depending on the severity of the lacrimal duct stenosis and 1991;28:287-9. the presence or absence of an intranasal mucocele; The 8. Hulka GF, K&in DR, Weeks SM, Cotton RT. Congenital lacrimal sac mucoceles with innanasal extension. Otolatyngol Head Neck approach first starts with nasolacrimal duct probing alone Sorg 1995;113:651-5. for dacryoceleswithout intranasal mucoceles. Nasolacrimal 9. Divine RD, Anderson RL, Bumsted RM. Bilateral congenital duct probing with silicone tube placement is performed if lacrimal sac mucoceles with nasal extension and drainage. Arch the nasolacrimal duct is extremely stenotic or inflamed or if Ophthalmol 1983;101:246-8. the lacrimal sacrefills with irrigation after probing, signify10. Demaerel P, Casteels I, Peene P, Maudgal PC, Wdms G. Unilateral congenital nasolacrimal mucocele. Pediatr Radio1 1991;2 15.51. ing the continued presence of 2 functional l-way valves. 11. Casdllo M, Merten DF, Weissler MC. Bilateral nasolacrimal duct Marsupialization of an intranasal mucocele is performed mucocele, a rare cause of respiratory distress: CT findings in two whenever one is present (Figure 6). newborns. Am J Neuroradiol 1993;14:1011-3. In conclusion, because of the high risk of dacryocystitis 12. Schnall BM, Christian CJ. Conservative treatment of congenital dacryocele. J Pediaa Ophthamol Strabismus 1996;33:2 19-2 1. and the strong association of the intranasal mucocele with
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15. 16.
17.
18.
19.
20. 21.
22. 23. 24.
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Mansour AM, Cheng KP, Mumma JV, Stager DR, Harris GJ, Patrinely JR, et al. Congenital dacryocele: a collaborative review. Ophthalmology 1991;98:1744-51. Hepler KM, Woodson GE, Kearns DB. Respiratory distress in the neonate: sequela of a congenital dacryocystocele. Arch Otolaryngol Head Neck Surg 1995;121:1423-5. Sullivan TJ, Clarke MP, Morin JD, Pashby RC. Management of congenital dacryocystocele. Aust N Z J Ophthalmol 1992;20:105-8. Yee SW, Seibert RW, Bower CM, Glasier CM. Congenital nasolacrimal duct mucocele: a cause of respiratory distress. Int J Pediatr Otorhinolaryngol 1994;29:151-8. Lusk RP, Muntz HM. Nasal obstruction in the neonate secondary to nasolacrimal duct cysts. Int J Pediatr Otorhinolaryngol 1987;13: 315-22. Mazzara CA, Respler DS, Jahn AF. Neonatal respiratory distress: sequela of bilateral nasolacrimal duct obstruction. Int J Pediatr Otorhinolaryngol 1993;25:209-16. Righi PD, Hubbell RN, Lawlor PI! Respiratory distress associated with bilateral nasolacrimal duct cysts. Int J Pedian Otorhinolaryngol 1993;26:199-203. Grin TR, Mertz JS, Stass-Isern N. Congenital nasolacrimal duct cysts in dacryocele. Ophthalmology 1991;98:1238-42. Goralowny AM, Tarantowicz W. Imperforation of the nasolacrimal duct as a cause of nasal obsauction in the newborn. Rhinology 1979; 17:173-s. Levy NS. Conservative management of congenital amniotocele of the nasolacrimal sac. J Pedian Ophthalmol Strabismus 1979;16:254-6. Jackson H, Lambert TD. Congenital mucocele of the lacrimal sac. Br J Ophthalmol 1963;1949:690-1. Duke-Elder S, Cooke C. Normal and abnormal ash development embryology. In: Duke-Elder S, editor. System of ophthalmology. St Louis: CV Mosby Co; 1993. p. 241-S.
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25. Peterson RA, Robb RM. The natural course of congenital obstruction of the nasolacrimal duct. J Pediatr Ophthalmol Strabismus 1973;14:246-50. 26. Katowia JA, Welsh MG. Timing of initial probing and irrigation in congenital nasolacrimal duct obstruction. Ophthalmology 1987;94: 698-705. 27. Paul TO, Shepherd R. Congenital nasolacrimal duct obstruction: natural history and the timing of optimal intervention. J Pediatr Ophthalmol Strabismus 1994;3 1:362-7. 28. Stager D, Baker JD, Frey T, Weakley DR, Birch EE. Office probing of congenital nasolacrimal duct obstruction. Ophthalmic Surg 1992; 23:482-4. 29. Rashid ER, Bergstrom TJ, Evans RM, Arnold AC. Anterior encephalocele presenting as nasolacrimal obstruction. Ann Ophthahnol 1986;18:132-6. 30. Chohan BS, Chandra P, Parmar IPS, Sharma JL. Orbital meningoencephalocele communicating with the lacrimal sac. Clin Pediatr 1974;13:330-2. 31. Chohan BS, Parmar IPS, Bhada JN. Anterior orbital meningoencephalocele. Am J Ophthalmol 1969;68:144-6. 32. Hurwia JJ, Rodgers J, Doucet TW. Dermoid tumor involving the lacrimal drainage pathway: a case report. Ophthalmic Surg 1982; 13:377-9. 1962;53: 33. Dayal Y, Hameed S. Periorbital dermoid. Am J Ophrhahuol 1013-6. 34 Robertson DM, Henderson JW. Unilateral proptosis secondary to orbital mucocele in infancy. Am J Ophthalmol 1969;68:845-7. 35 Mints J, Rodrigues M, Calhoun J. Sudoriferous cyst of the orbit. Can J Ophthalmol 1977;12:155-6. 36. Saunders JF. Congenital sudoriferous cyst of the orbit. Arch Ophthalmol 1973;89:205-6.
An Eye on the Arts - The Arts on the Eye
For Same, sight furnished the perceptual model for all senses,and the imagination itself thrived on visual experience. “I think with my eyes,” he adm$ted. When, in his old age, Same became blind, he described himself as a “ hving corpse,” unable to interact with the world. Despite his critique of the tyranny of sight, it would seem in the end for Sartre the only alternative to seeing was “nothingness.” -Constance Classen (from The Color ofAngels p 139)