Botryomycosis: A surprising revelation in the lacrimal sac.

A middle aged woman presented to us with a localised well defined swelling of 3 months duration. It was located just below the lower eyelid punctum and was constantly discharging whitish granules. We suspected it to be arising from the lacrimal apparatus and posted the patient for Dacryocystectomy. On the operating table we found a swelling in the region of the lacrimal sac which was later excised. Histopathology revealed Botryomycosis and Chronic Dacryocystitis. Botryomycosis is a rare condition and requires a high index of suspicion to diagnose it. It is confirmed by histopathology and culture. Surgical debridement is the treatment of choice in such cases with an assessment of the immune status. Long term antibiotic treatment is required in all conditions as recurrence is common.

Clinical Significance of Biofilm on Silicone Tubes Removed From Patients With Nasolacrimal Duct Stenosis.

PURPOSE: To determine the relationship between the optical density of biofilms on silicone tubes and surgical outcomes. METHODS: A total of 43 silicone tubes from 33 patients with nasolacrimal duct stenosis were enrolled at 6 months after bicanalicular silicone tube intubation. The removed silicone tubes were divided into 2 segments. One segment of silicone tube was cultured while the other segment was used to measure optical density of biofilm. Each segment was divided into 3 pieces according to average normal human nasolacrimal anatomy. The first piece was located from puncta to lacrimal sac. The second piece was inside the nasolacrimal duct. The third piece was in the nasal cavity. Surgical outcome was evaluated at postoperative 12 months based on Munk score and fluorescein dye disappearance test. RESULTS: A total of 31 (72.1%) patients were surgically successful while 12 (27.9%) patients had surgical failure with persistent epiphora. In the second piece of silicone tube, the mean optical density of biofilm was 0.2654 nm in the surgical success group and 0.4472 nm in the surgical failure group. These results showed statistically significant (P < 0.01) difference. The most frequently isolated organism was Staphylococcus aureus in the surgical success group (7 of 31 patients, 22.6%). It was Pseudomonas aeruginosa in the surgical failure group (6 of 12 patients, 50%). CONCLUSION: This is the first study that determines the relationship between biofilm on silicone tube and surgical outcome. Biofilm formed on silicone tubes in nasolacrimal duct might cause surgical failure.

An unusual cause of recurrent bloody tear.

We describe a female patient who presented with watering followed by swelling in the left infraorbital area of 5 years duration. She had previously been prescribed topical antibiotics on several occasions with no improvement. On pressure over the swelling, there was blood-tinged discharge from the left eye and nostril. Magnetic resonance imaging revealed an enhancing, well-defined mass lesion in the inferomedial aspect of the left orbit, likely of nasolacrimal origin. Computed tomography dacryocystogram with three-dimensional reconstruction showed a well-circumscribed mass with an irregular surface, originating from the lacrimal sac. Gram staining and potassium hydroxide mount from the regurgitant fluid revealed thick-walled cysts with sporangia suggestive of Rhinosporidium seeberi infection. Excision biopsy of the lesion confirmed R. seeberi as the causative agent. The patient has been put on long-term dapsone therapy to prevent a recurrence and has been asked to follow-up 6 months later.

Aspergillus Mycetoma Causing Epiphora and Ipsilateral Facial Pain.

Tearing is a frequently encountered chief complaint in an ophthalmologist's office. Certain associated atypical symptoms may warrant further workup. The authors present a case of a patient presenting with painful tearing which elicited further evaluation with CT imaging. This revealed a maxillary sinus fungus ball as the cause for the patient's tearing.

Primary Powered Endoscopic Dacryocystorhinostomy in the Setting of Acute Dacryocystitis and Lacrimal Abscess.

PURPOSE: The purpose of the present study is to report authors' experience of primary powered endoscopic dacryocystorhinostomy in the setting of acute dacryocystitis and lacrimal sac abscess. METHODS: A prospective interventional case series of 20 primary powered endoscopic dacryocystorhinostomies were performed in 20 patients presenting with acute dacryocystitis and lacrimal sac abscess at a tertiary eye care center from April to December 2013. None of the patients received preoperative antibiotics. All cases were operated by single surgeon (M.J.A.) using a standard described technique. All patients were intubated for 6 weeks. A minimum follow up of 6 months after stent removal was considered for the final analysis. The main outcome measures were the resolution of infection and the anatomical and functional successes of the surgical procedure. RESULTS: The mean age at presentation was 39.2 years. Sixty percent of patients (12/20) presented with acute dacryocystitis, 35% (7/20) with a lacrimal abscess, and 5% (1/20) with a dacryopyocele following a failed probing. None of the cases received preoperative antibiotics. Ten percent of patients (2/20) underwent additional septoplasty. All the cases showed resolution of pain and swelling at 1 week follow up. Two patients were noted to have small edge granulomas of the ostium, which were successfully managed by focal excision. At the final follow up, anatomical success was achieved in 95% (19/20) and functional success in 90% (18/20) of the patients. CONCLUSIONS: Primary powered endoscopic dacryocystorhinostomy is an effective modality in the management of acute dacryocystitis and lacrimal abscess, and result in rapid resolution of the disease.

Characterization of dacryops infections.

PURPOSE: The purpose of this study was to characterize the clinical entity of dacryops infections through imaging with or without histopathology in the differential of ocular adnexal masses in the setting of infection. METHODS: A retrospective chart review was performed on 5 patients seen at 1 clinical practice in which a complete ophthalmologic examination and imaging of the lesion had been obtained. Two of these patients additionally obtained surgical intervention with histopathologic examination. RESULTS: The main lacrimal gland was involved in all 5 patients with dacryops infection presenting unilaterally. The average age of the patients was 44.6 years. Predisposing factors of eyelid margin disease, conjunctivitis, and contact lens usage were highlighted. CT provided useful information on the location and size of the lesion. Excision with or without marsupialization appears to prevent recurrence and provides a histopathologic diagnosis although spontaneous (or self-induced) drainage of the cyst in addition to antibiotic therapy can successfully manage the infection and cyst size, wherein affected individuals may not pursue further surgical management. CONCLUSIONS: Dacryops infection is a rare but important consideration in the differential of a mass lesion in the upper fornix associated with inflammation that may be confused with orbital cellulitis or abscess. Orbital imaging is helpful in delineating the extent of the lesion, whereas surgical excision with histopathology can confirm the diagnosis. The authors described 5 cases with this acute presentation and highlighted concomitant factors that may predispose certain patients to the development of infection.

Allergic fungal sinusitis involving the lacrimal sac: a case report and review.

UNLABELLED: BACKGROUNd: We report a case of allergic fungal sinusitis (AFS) involving the lacrimal sac and review the current English literature. A literature search for AFS involving the lacrimal sac revealed two reports with only one of the two cases demonstrating histological evidence of fungal elements. This is just the third such case and only the second reported case with histopathologic confirmation of fungal elements by Gomori methenamine silver (GMS) stain. MATERIALS AND METHODS: A PubMed database search was performed using combinations of the following key words: allergic fungal sinusitis, lacrimal sac, nasolacrimal duct, ophthalmology, epiphora, orbit. A 70-year-old white man with a history of chronic conjunctivitis and nasal polyps presenting with chronic epiphora was found to have dacryostenosis on the left side. A CT scan of the orbits revealed mucoperiosteal thickening completely obliterating the frontal, ethmoid and sphenoid sinuses. RESULTS: A left external dacryocystorhinostomy (DCR) was performed and the lacrimal sac contents were studied histopathologically. Microscopic examination of the lacrimal sac contents disclosed allergic mucin with laminated aggregates of eosinophils in various stages of degeneration, Charcot-Leyden crystals and rare noninvasive fungal hyphae confirming the diagnosis of AFS. Fungal elements stained positively with Gomori methenamine silver stain. CONCLUSION: Although rarely reported, AFS can affect the lacrimal sac. AFS should be suspected in patients with a history of recurrent refractory sinusitis, recurrent dacryocystitis and nasal polyposis. Early diagnosis is important for adequate treatment and prevention of recurrence.

Caruncular abscess due to actinomycosis.

The authors report a caruncular abscess caused by actinomycosis. A 47-year-old woman was admitted with persistent purulent discharge from the caruncle of the left eye for a duration of six months. Excisional drainage was performed, and 'sulfur granules' were observed, consistent with actinomyces infection. Intraoperative lacrimal probing and irrigation were performed to confirm that the abscess and canaliculus were not connected. Oral and topical antibiotics were administered postoperatively; the lesion resolved with no evidence of recurrence, and the symptom improved.

Bacterial and mucopeptide concretions of the lacrimal drainage system: an analysis of 30 cases.

PURPOSE: To demonstrate the histopathologic characteristics of different types of lacrimal drainage system concretions with clinical correlations. METHODS: Thirty lacrimal drainage system concretions submitted to the Cogan Eye Pathology Laboratory at the Massachusetts Eye and Ear Infirmary over a 2-year period were reviewed. Concretions were studied in detail using their histopathologic staining features as revealed with hematoxylin and eosin, Gomori methenamine silver, periodic acid-Schiff, iron stain, and Brown-Hopps tissue gram stain. A separate retrospective chart review was conducted for each patient to identify any clinical correlations. RESULTS: Two major forms of concretions were identified histopathologically: mucopeptide (7) and bacterial (20). Mucopeptide concretions were found exclusively within the lacrimal sac, while bacterial concretions were found chiefly in the canaliculus. A third category of "mixed" concretions with substantial mucopeptide and bacterial characteristics comprised 3 specimens. Bacterial concretions consisted of large matted masses of filamentous, presumed Actinomyces organisms that were easily identified with the Grocott's methenamine silver stain; they were frequently cocolonized at their edges with coccal bacterial forms. Mucopeptide concretions were generally devoid of cellular elements and were composed of broad bland whorls of diffusely eosinophilic, acellular, periodic acid-Schiff-positive material punctuated by lacunae. They were often cocolonized by small numbers of bacterial cocci and occasional fungi. Culture results disclosed low virulence species. All 3 types of concretions predominated in women. Patients with bacterial concretions frequently had dry eye symptoms. CONCLUSIONS: The 2 major types of lacrimal system concretions differ in their primary location and histopathologic composition. Further characterization may lead to an understanding of the mechanisms for their formation. Mucopeptide concretion is more appropriate than terms such as "dacryolith" and "mucolith," and bacterial concretion is a more appropriate term than "canaliculith," because of the absence of significant calcium or stone-like density in these masses.

Lacrimal gland ductulitis caused by probable Actinomyces infection.

OBJECTIVE: To describe the clinical characteristics and management of a group of patients who had chronic mucopurulent conjunctivitis that was probably due to Actinomyces infection of the lacrimal gland ductules. DESIGN: A retrospective, interventional case series. PARTICIPANTS: Seven patients (2 male; 29%) between 34 and 52 years of age (mean, 48.7 years; median, 49 years) who presented to the lacrimal clinic. INTERVENTION: Surgical excision of the infective focus (6 cases) or fenestration and expression of infective debris (1 case) from the affected lacrimal gland ductule--typically the most inferolateral of the ductules. MAIN OUTCOME MEASURES: The clinical features of this previously unrecognized cause of chronic conjunctivitis and its response to treatment. RESULTS: All cases settled rapidly after surgery. There was often a major delay in diagnosis, with the patients having symptoms for between 2 and 42 months before referral (mean, 13.3 months; median, 9 months); 5 patients received prolonged or ineffectual topical medical therapy before referral. CONCLUSIONS: Infective lacrimal gland ductulitis, commonly from Actinomyces infection, should be considered in patients with unexplained chronic mucopurulent conjunctivitis; the condition settles rapidly with surgery. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Plasmacytoma associated with canaliculitis.

Plasmacytomas are plasma cell neoplasms that rarely involve ocular adnexal tissues as a primary lesion or secondary manifestation of plasma cell myeloma. Only one case of plasmacytoma involving the lacrimal drainage system, to our knowledge, is described in the literature. The clinical presentation of ocular adnexal primary plasmacytoma typically relates to its mass effect. In this clinicopathologic report, we describe an unusual presentation of primary plasmacytoma of the lacrimal canaliculus as infectious canaliculitis.

Allergic fungal sinusitis with massive intracranial extension presenting with tearing.

A 24-year-old male presented with tearing, and subsequent workup and imaging showed a mass with fluid involving the nasopharynx, the paranasal sinuses, and the posterior dehiscence of the left frontal sinus intracranially compressing the frontal lobe significantly. Microscopic examination confirmed the diagnosis of allergic fungal sinusitis. Endoscopic drainage and sinostomy was performed by the otolaryngology (ear-nose-throat) service. The patient was followed 9 months postoperatively and did well with resolution of the epiphora. Although epiphora alone is an unusual presentation of allergic fungal sinusitis, ophthalmologists need to be aware of this entity, as it may invade the orbit through the sinus cavities or compress on the nasolacrimal duct before it causes other mass-related symptoms. Radiology and the characteristic histopathologic findings are the most useful in establishing the correct diagnosis.

[Fusobacterium nucleatum isolated from a patient presenting lachrymal canaliculitis]. / Fusobacterium nucleatum isolé chez un patient présentant une canaliculite.

A 68-year-old woman presented with a painless inflammation of the right superior eyelid that had started several weeks before. The clinical diagnosis concluded in canaliculitis and the solid concretions were surgically extracted from the superior canalicula. The anaerobic bacteria Fusobacterium nucleatum sp. nucleatum was isolated. Signs dramatically regressed two weeks after surgery followed by one course of oral amoxicillin and clavulanic acid associated with topical tobramycin. The clinical signs had disappeared two months later.