Multi-resistant Enterobacter cloacae dacryocystitis and preseptal cellulitis: case and review of literature.

A 61-year-old man with no significant past medical history presented to a quaternary ophthalmic referral center with acute right-sided medial canthal pain, periorbital edema, and erythema despite oral antibiotic therapy. CT imaging confirmed the presence of right preseptal cellulitis and lacrimal sac aspiration identified Enterobacter cloacae. A diagnosis of acute right-sided dacryocystitis with preseptal cellulitis was made. He was successfully treated with broadening of antibiotic therapy to intravenous meropenem. Symptomatic resolution was noted on follow-up without evidence of disease recurrence. This unusual case of Enterobacter cloacae dacryocystitis and preseptal cellulitis highlights the increasing prevalence and challenges of treating these uncommon organisms.

Natural killer T-cell lymphoma causing bilateral recurrent recalcitrant dacryocystitis.

A 35-year-old female with a history of chronic extensive rhinosinusitis, previously treated twice with functional endoscopic sinus surgery, presented with recurrent dacryocystitis despite prior dacryocystorhinostomy. Histopathological specimens taken at the most recent sinus surgery demonstrated a lymphocytic inflammatory reaction without evidence of angiodestruction or necrosis. Flow cytometry was normal. Over the following 9 months, the patient developed worsening hypertelorism and bilateral recurrent acute dacryocystitis with a fistula tract to the skin. Neuroimaging revealed a hyperintense enhancing soft tissue expansion into the periorbital regions, invading the nasolacrimal canals, and obstructing the paranasal sinuses. A skin biopsy at the fistula site revealed natural killer T-cell lymphoma. Metastatic work-up disclosed lung, spleen, and bone marrow involvement. The patient underwent chemotherapy with mixed clinical response, and ultimately passed away from metastatic disease. The authors present a rare case of natural killer T-cell lymphoma involving the nasolacrimal sac, presenting as recurrent dacryocystitis and diagnosed by skin biopsy of the fistula site.

Actinomyces ductular dacryoadenitis resulting in a lacrimal gland abscess.

Lacrimal gland ductulitis is a rare infection of the lacrimal gland ductules. Individuals affected report a history of chronic mucopurulent conjunctivitis with "stringy" discharge. All patients are clinically noted to have an inflamed lacrimal gland ductule. Prior reports have suggested Actinomyces species as the "probable" etiology.We report the findings of a 42-year-old male found to have lacrimal gland ductulitis with a lacrimal gland abscess, confirmed by radiologic studies. Surgical drainage was necessitated and performed. Histopathologic analysis confirmed colonization by Actinomyces species, as well as the presence of sulfur granules. To our knowledge, this is the first report of Actinomyces lacrimal gland ductulitis resulting in a secondary lacrimal gland abscess.

Ultrasonography of IgG4-related dacryoadenitis and sialadenitis: Imaging features and clinical usefulness.

OBJECTIVES: To clarify the ultrasonographic features of immunoglobulin G4 (IgG4)-related dacryoadenitis and sialadenitis (IgG4-DS) and their usefulness in clinical diagnostic sessions. METHODS: By re-evaluating 96 consecutive patients with IgG4-related disease, we identified 54 patients (male:female = 37:17; median age, 69.5 years) who underwent lacrimal or submandibular gland (LG or SG, respectively) ultrasonography and computed tomography (CT). Their clinical and ultrasonographic features were retrospectively analysed. Radio-pathological correlations were also examined in LG (23 cases) and SG lesions (20 cases). Additionally, the diagnostic accuracy of CT for LG/SG lesions was evaluated. RESULTS: Abnormal ultrasonographic findings were detected in 33 (LGs) and 38 (SGs) patients, and most of them were observed bilaterally. All lesions were well demarcated and demonstrated diffuse low-echoic areas (rocky pattern) or multiple low-echoic nodules surrounded by high-echoic linear shadows (cobblestone pattern) corresponding to intra-lobular inflammation and inter-lobular fibrosis. Moreover, 42% (LGs; 14/33) and 42% (SGs; 16/38) patients had glandular lesions without clinical symptoms associated with the affected glands. The diagnostic accuracy of CT was ∼80% for LG and 55% for SG. CONCLUSIONS: Ultrasonographic findings in IgG4-DS included diffuse or nodular low-echoic areas with linear high-echoic structures corresponding to inflamed lobules and inter-lobular fibrosis. These findings can help detect IgG4-DS.

Behavior and outcomes of 70 adult lacrimal sac mucoceles.

Purpose: To study the clinical profile and outcomes in adults with lacrimal sac mucoceles.Methods: A retrospective, interventional study on consecutive adult patients with lacrimal sac mucoceles who underwent dacryocystorhinostomy (DCR)/dacryocystectomy surgery. Primary outcome measure was subsidence of lacrimal sac swelling after intervention. Secondary outcome measure was anatomical patency of the lacrimal system.Results: A total of 70 patients were studied, mean age of the group being 49.2 ± 13.5 years. Majority of the patients were female (n = 49; 70%) and all had unilateral disease. An appreciable number (n = 14; 20%) presented with acute dacryocystitis of which 6(8%) developed a lacrimal sac fistula. Encystment of the lacrimal sac mucocele was seen in 47 (67%) patients, 3(4%) developed preseptal cellulitis and 3(4%) needed imaging. Resolution of sac swelling after intervention was seen in 70 (100%) patients. Definitive management was DCR in 57 (81%) patients, of which anatomical patency was achieved in 55 (96%) patients, mean duration of follow up of the group being 138 ± 70.2 days. A trend to prefer adjuvants like Mitomycin-C and/or intubation was noted in 56 (98%) of patients.Conclusions: Adult lacrimal sac mucocele is more commonly seen in females and unilaterally. Complications of this entity include encysted mucocele (67%), acute dacryocystitis (20%), lacrimal sac fistula (8%), and preseptal cellulitis (4%). It is essentially a clinical diagnosis and favourable outcomes are seen with DCR surgery.

Relationship Between Lacrimal Bone Thickness and Lacrimal Sac in Chronic Dacryocystitis.

BACKGROUND: Chronic inflammation in the lacrimal sac may lead to thickening of the surrounding bony tissues. This study aimed to assess the thickness of lacrimal bone surrounding the lacrimal sac, and the thickness of maxilla, based on the presence of purulent secretion in the lacrimal sac in patients who underwent EDCR. MATERIAL AND METHODS: Lacrimal bone thickness and the maximum and midpoint maxillary bone thickness of 70 patients (mean age of 49.07 years) who underwent EDCR, were assessed along 3 planes (upper, middle, and lower) using CT of the paranasal sinus. The patients were divided into 2 groups: the 1 who had purulent secretion in the lacrimal sac during the intraoperative period (Group 1) and another who did not have purulent secretion (Group 2). RESULTS: No significant difference was detected between the 2 groups in terms of maximum and midpoint maxillary bone thickness. The increase in the thickness of lacrimal bone in Group 1 was statistically significant in all the 3 planes as compared to that in Group 2. Cutoff values for the thickness of the upper, middle, and lower plane of lacrimal bone were detected to be 0.710 mm, 0.685 mm, and 0.675 mm, respectively. CONCLUSION: The presence of purulent secretion in the lacrimal sac, along with the detected increase in the thickness of the lacrimal bone, as assessed by CT, offers an insight on the lacrimal sac before the surgery.

Two cases of epidemic keratoconjunctivitis-associated dacryocystitis.

This report presents two cases of epidemic keratoconjunctivitis (EKC)-associated dacryocystitis. Both patients presented with preseptal edema. Orbital computed tomography (CT) scans were performed out of concern for orbital cellulitis and revealed soft tissue edema involving the preseptal aspect of the eyelids and also the lacrimal sac. Both patients were initially diagnosed with bacterial preseptal cellulitis with dacryocystitis and admitted for treatment with intravenous antibiotics. After no improvement on antibiotics, both patients were noted to have exam findings consistent with viral conjunctivitis, and one patient had a positive conjunctival swab for adenovirus. Both patients were subsequently treated with topical steroids, and symptoms improved. EKC has previously been identified as a cause of acquired nasolacrimal duct obstruction and canalicular stenosis, and acute inflammation of the lacrimal apparatus may explain this link. Dacryocystitis may also be contributory to the copious tearing seen in patients with epidemic keratoconjunctivitis.

Bilateral dacryocystitis complicated by unilateral retrobulbar abscess in a five-week-old infant.

Retrobulbar orbital abscess in children is a rare condition, and diagnosis and management can be challenging. We report the case of a 5-week-old male infant with retrobulbar orbital abscess secondary to acute dacryocystitis developed from a dacryocystocele. The patient presented with respiratory difficulty, sepsis and progressive clinical findings suggestive of post-septal cellulitis. He was successfully treated with endonasal incision of subturbinate dacryocystoceles followed by probing of the lacrimal ducts. Congenital dacryocystocele must be considered a differential diagnosis in infants with respiratory difficulty and may develop into a vision- and life-threatening condition requiring immediate intervention.

The diagnostic utility of submandibular gland sonography and labial salivary gland biopsy in IgG4-related dacryoadenitis and sialadenitis: Its potential application to the diagnostic criteria.

Objectives: In this study, we investigated the diagnostic utility of submandibular gland (SMG) sonography and labial salivary gland (LSG) biopsy as a less invasive procedure for diagnosing IgG4-related dacryoadenitis and sialadenitis (IgG4-DS)Methods: Sixty-eight patients with suspected IgG4-DS by presenting swelling of elevated serum IgG (>1747 mg/dl) and/or swelling glands underwent SMG sonography, LSG biopsy and measurement for serum IgG4. SMG sonographic diagnosis was determined by the following characteristic changes; 'hypoechoic areas of a nodal pattern with high vascularity' and/or 'hypoechoic areas of a reticular pattern in the superficial part'.Results: Thirty-one patients were diagnosed with IgG4-DS, 5 with IgG4-RD unaccompanied by lacrimal and salivary gland lesions, 28 with Sjögren's syndrome, and 4 with malignant lymphoma. The sensitivity, specificity, and accuracy of SMG sonography and LSG biopsy were 100%, 83.8%, 91.2% and 64.5%, 73.8%, 75.0%, respectively. Moreover, those of SMG sonography and LSG biopsy combined with serum IgG4 concentration (>135 mg/dl) were 100%, 94.6%, 97.1% and 64.5%, 91.9%, 79.4%, respectively.Conclusion: LSG biopsy needs to be extremely careful to diagnose IgG4-DS because of its low sensitivity. SMG sonography is sufficient for the diagnosis of IgG4-DS, especially when combined with serologic analysis. Thus, SMG sonography could adapt to the diagnostic criteria of IgG4-DS as a non-invasive method.

Ultrasonography-guided removal of plant-based foreign bodies from the lacrimal sac in four dogs.

BACKGROUND: Dacryocystitis is an inflammation of the lacrimal drainage system. One of the most common causes of dacryocystitis in dogs is due to plant-based foreign bodies typically located in the lacrimal sac. The aim of this case series was to describe an ultrasonography-guided technique for dogs with plant-based foreign bodies in the lacrimal sac, as both a diagnostic and therapeutic tool. CASE PRESENTATION: Four dogs with clinically suspected plant-based foreign body in the lacrimal sac (with a total of five eyes affected) were evaluated by ultrasound with a multifrequency (8-14 MHz) linear probe. Under general anesthesia, the foreign body was removed using Hartmann alligator forceps inserted thorough the upper puncta. Ultrasound was used to guide the forceps in grasping the foreign body. Ultrasound was positive in four out of five lacrimal sac diseases. All identified foreign bodies were successfully removed by the ultrasonography-guided technique. CONCLUSIONS: The results show that ultrasound is a fast, non-invasive, and inexpensive method for the assessment of dacryocystitis due to foreign bodies in dogs. Ultrasound is also useful not only for identification, but also in the non-invasive removal of the foreign body from the lacrimal sac. To the best of authors' knowledge, this is the first study to describe the sonographic approach to the palpebral medial cantus as an initial diagnostic step in canine dacriocystitis.

Application of a full model-based iterative reconstruction (MBIR) in 80 kVp ultra-low-dose paranasal sinus CT imaging of pediatric patients.

OBJECTIVE: To evaluate the clinical application of a full model-based iterative reconstruction (MBIR) algorithm in the ultra-low-dose paranasal sinus CT imaging of children. MATERIALS AND METHODS: In the first phase, 16 low-dose CT dacryocystography (DCG) (80 kV/64 mAs) scans were reconstructed with MBIR and filtered back-projection (FBP) to demonstrate noise reduction capability of MBIR. MBIR images were also compared with the images of 21 standard-dose paranasal sinus patients reconstructed with adaptive statistical iterative reconstruction (ASIR) algorithm. In the second phase, 14 pediatric tumors patients (images with ASIR in the initial scan) who came for follow-up paranasal sinus CT scan were prospectively enrolled with reduced radiation and MBIR algorithm. In both study phases, image noise and the contrast noise ratio (CNR) of sphenoid was measured; and subjective image quality was evaluated. CTDIvol and DLP were recorded, and effective dose calculated. RESULTS: The CTDIvol value for the DCG group was 63.9% lower than the standard-dose sinus group (1.09 ± 0.01 mGy vs. 3.02 ± 0.35 mGy). Compared with the ASIR reconstruction in the standard-dose sinus patient group, images with MBIR in the ultra-low-dose DCG group had 39.9% lower noise (9.5 ± 0.8HU vs. 15.8 ± 3.3HU) and 63.6% higher CNR (14.4 ± 4.7 vs. 8.8 ± 2.2), with similar subjective image quality score. For the tumor patients, 65.5% dose reduction was achieved. Subjective quality scores were similar between the initial and follow-up scans. Objective noise was significantly lower for the follow-up group. CONCLUSION: MBIR provided equal or better image quality with significantly reduced radiation dose in paranasal sinus CT imaging of pediatric patients compared with standard-dose CT with ASIR algorithm.

Usefulness of colour Doppler flow imaging in the management of lacrimal gland lesions.

OBJECTIVE: To assess the role of colour Doppler flow imaging (CDFI) in the diagnosis and management of lacrimal fossa lesions. METHODS: Institutional ethical committee approval was obtained. Fifty-one patients with 62 lacrimal fossa lesions were retrospectively included from 2003-2015. All patients underwent conventional ultrasonography and CDFI, with a qualitative and quantitative analysis of the vascularization. All patients had lacrimal gland surgery. Definitive diagnosis was based on pathological examination. RESULTS: The study included 47 non-epithelial lesions (NEL) and 15 epithelial lesions (EL), with 24 (39 %) malignant lesions and 38 (61 %) benign lesions. NEL were significantly more likely to present with septa (p < 0.001), hypoechogenicity (p < 0.001), high vascular intensity (p < 0.001), both central and peripheral vascularization (p < 0.001), tree-shape vascularization (p < 0.05) and a low resistance index (RI) (p < 0.0001). EL were significantly more likely to present with the presence of cysts (p < 0.001), and a higher RI. Receiver operating characteristic curves identified a RI value of 0.72 as the best cut-off to differentiate NEL from EL, with a sensitivity and specificity of 100 %. CONCLUSION: CDFI is a valuable tool in the differential diagnosis of lacrimal fossa lesions. Resistance index measurement enables substantial distinction between EL and NEL, thus providing crucial data for surgical management. KEY POINTS: • CDFI is a valuable tool in lacrimal fossa lesions. • Resistance Index measurement enables substantial distinction between epithelial and non-epithelial lesions. • Management of patients becomes more appropriate.

Usefulness of Ultrasonography in the Diagnosis of Neonatal Dacryocystocele.

Neonatal dacryocystocele is an uncommon process that may evolve into acute dacryocystitis within the first weeks of life. Neonatal acute dacryocystitis must be treated promptly to avoid potential severe infectious complications. High-frequency ultrasound is a noninvasive method of diagnosing dacryocystocele, facilitating early therapeutic intervention.

Lacrimal gland abscesses: Case series and literature review.

Acute dacryoadenitis with abscess formation has been rarely described. We describe four cases that resolved with incision and drainage. This includes a retrospective case series of four patients with radiologically confirmed lacrimal gland abscesses and a review of the reported cases in the literature. Computed tomography showed characteristic rim enhancing collections with central attenuation in all four cases. All patients presented with ptosis, upper eyelid erythema, and severe pain similar to scleritis. Injection of the conjunctiva and sclera was present in two patients, and a third patient presented with expression of purulent discharge onto the ocular surface upon palpation of the lacrimal gland. All patients were treated with intravenous antibiotics and underwent incision and drainage with subsequent improvement. All were monitored for 24 to 48 hours and discharged on oral antibiotics. There were no complications or recurrences. Lacrimal gland abscess formation is a rare complication of dacryoadenitis, and in our experience these patients respond well to incision and drainage in combination with systemic antibiotics.

Endoscopic ultrasonic dacryocystorhinostomy: clinical profile and outcomes.

Ultrasonic endoscopic dacryocystorhinostomy (UEnDCR) is emerging alternative modality of managing nasolacrimal duct obstructions. The aim of this study was to report the clinical profile and outcomes with a UEnDCR with mitomycin C and silicone intubation. Prospective interventional case series performed on all consecutive patients undergoing an ultrasonic endoscopic dacryocystorhinostomy over a 1-year period from September 2013 to October 2014. All surgeries were performed by a single surgeon (MJA). Data collected include demographics, presentation, indications for surgery, past interventions, intraoperative and post-operative complications and outcomes. The main outcome measures were anatomical and functional success of the surgery. 44 procedures were performed in 41 patients. The mean age was 31.6 years. Children with complex congenital nasolacrimal duct obstructions refractory to probing and intubation accounted for 17 % (7/41) of the cohort. Past history of acute dacryocystitis was noted in 35.6 % (15/41). Two patients (4.9 %, 2/41) had failed external DCR. A minimal follow-up of 6 months following surgery was taken for final analysis. Complications included intraoperative focal epithelial burn in one patient that healed spontaneously and post-operative ostium granulomas in 15.9 % (7/44) of the ostia. At the 6-month follow-up, anatomical and functional successes were noted in 93.1 % (41/44) and 88.6 % (39/44), respectively. Ultrasonic dacryocystorhinostomy is a safe and effective alternative modality in the management of nasolacrimal duct obstructions in pediatric and adult age groups. Setup was easy and no additional technical difficulties were observed.

The stiff elastographic change of submandibular glands rapidly improves after the introduction of glucocorticoid treatment in patients with IgG4-related dacryoadenitis and sialoadenitis.

In three patients with immunoglobulin G4-related dacryoadenitis and sialoadenitis (IgG4-DS), we assessed the changes in the hardness of affected submandibular glands by the real-time tissue elastography at baseline and 2 weeks after the initiation of treatment with oral glucocorticoids. Elastography revealed "blue" meaning to be a hard tissue matched the hypoechoic areas inside the enlarged submandibular glands before treatment. The stiff elastographic changes rapidly improved after 2 weeks. This may relate with the reversibility of salivary function by glucocorticoid treatment in patients with IgG4-DS.

Chronic, recurrent dacryocystitis from a BB in the lacrimal sac.

Metallic foreign bodies in the lacrimal outflow tract are a rarely reported cause of nasolacrimal duct obstruction. Among the few cases in the literature, 1 consisted of a BB in the nasolacrimal duct. This case report presents a second case of chronic, recurrent dacryocystitis in a child, which occurred secondary to a BB that had become lodged in the lacrimal sac. The metallic foreign body was identified on CT and successfully removed surgically. Exogenous sources of lacrimal sac foreign bodies should be considered in patients with a history of periorbital trauma and signs of chronic nasolacrimal duct obstruction. Evaluation with CT is recommended. Removal of the foreign body, with dacryocystorhinstomy as needed, is curative.

Recurrent dacryocystitis and lacrimocutaneous fistula caused by a retained Griffiths' collar button stent.

A 42-year-old man presented with a white plastic-like material exposed in the left medial canthal area, with a fistula and purulent discharge. He had undergone endonasal dacryocystorhinostomy 7 years earlier for left eye epiphora; he had persistent postoperative epiphora and recurrent dacryocystitis despite multiple drainage attempts and antibiotics elsewhere. Computed tomography showed bilateral enlarged cystic lacrimal sacs, with a well-defined contoured tunnel-like hole at the center of the left sac. Treatment included excision of the foreign body, which was a Griffiths' collar button nasolacrimal stent, excision of the fistula tract, and revision dacryocystorhinostomy with implantation of bicanalicular silicone stent. He recovered with no further symptoms or complications. This case highlights the importance of follow-up for removal of an implanted Griffiths' stent after dacryocystorhinostomy. Patients with recurrent dacryocystitis may benefit from a detailed history of previous surgery, careful examination, and imaging to evaluate for endogenous and exogenous foreign bodies such as lacrimal sac calculi, and retained lacrimal sac stents.