Comparison of conjunctival microbiota of clinically normal Persian cats with and without nasolacrimal duct obstruction.

OBJECTIVE: This study was performed to determine the conjunctival microbiota of Persian cats with and without nasolacrimal duct obstruction (NLDO). ANIMALS STUDIED: Twenty-five Persian cats: 15 with bilateral NLDO (Group A) and 10 with no NLDO (Group B). PROCEDURES: All fifty eyes were assessed. Sterile swab applicators were used for the collection of specimens, which were cultured. PCR was performed on conjunctival swab and blood samples for the detection of Mycoplasma spp. and feline herpesvirus 1(FHV-1), respectively. RESULTS: FHV-1 was detected in two cats in Group A. Twelve eyes from Group A and four from Group B were Mycoplasma spp. positive based on the PCR results. Moreover, fungal culture was positive in six eyes from Group A and three eyes from Group B. The dominant fungus isolated was Aspergillus spp. (6 out of 11 fungal isolates). Other isolated fungi were Alternaria spp. and Cladosporidium spp. Twenty-three eyes had positive bacterial culture in Group A, while twelve eyes were positive in Group B. The most commonly isolated bacteria were Staphylococcus epidermidis (15 out of 38 bacterial isolates). ß-hemolytic Streptococcus spp., Corynebacterium spp., and Staphylococcus aureus were isolated in similar proportions in both groups. Escherichia coli was also present in both groups. CONCLUSIONS: Results of this study revealed same isolated fungal and bacterial spp. and in similar proportions in Persian cats with and without NLDO.

Nasolacrimal stent with shape memory as an advanced alternative to silicone products.

Epiphora is the overflow of tears typically caused by obstruction or occlusion of the nasolacrimal duct. More attention is required to address this global health issue owing to the increase in air pollution. Implantation of a silicone stent is the preferred treatment for epiphora; however, introducing a silicone stent into a narrow duct with complex geometry is challenging as it requires guidance by a sharp metal needle. Additionally, silicone can cause adverse reactions such as biofilm formation and tear flow resistance due to its extreme hydrophobicity. To overcome these problems, in this study we developed a new type of biocompatible shape memory polymer (SMP) stent with elasticity capacity for self-expansion. First, SMPs in the form of x%poly(ε-caprolactone)-co-y%poly(glycidyl methacrylate) (x%PCL-y%PGMA) were synthesized via ring opening polymerization by varying the molar ratio of PCL (x%) and PGMA (y%). Second, the shape memory and mechanical properties were tuned by controlling the crosslinking degree and concentration of x%PCL-y%PGMA solution to produce a test type of SMP stent. Lastly, this 94%PCL-06%PGMA stent exhibited more standout critical functions in a series of in vitro and in vivo experiments such as a cell growth-supporting level of biocompatibility with nasal epithelial cells without significant inflammatory responses, better resistance to biofilm formation, and more efficient capacity to drain tear than the silicone control. Overall, 94%PCL-06%PGMA can be suggested as a superior alternative to the currently used materials for nasolacrimal stents. STATEMENT OF SIGNIFICANCE: Silicone intubation (stenting) has been widely used to treat nasolacrimal duct obstruction, however, it can cause adverse clinical effects such as bacterial infection; presents procedural challenges because of the curved nasolacrimal duct structure; and shows poor drainage efficiency stemming from the highly hydrophobic nature of silicone. In this work, we describe an innovative shape memory polymer (SMP) as a superior alternative to conventional silicone-based materials for nasolacrimal duct intubation. We demonstrate the clear advantages of the SMP over conventional silicone, including a much higher drainage capacity and superior resistance to bacterial infection.

Bacteriology of lacrimal drainage system following obstruction of the nasolacrimal duct in a reference Population

Context:Lacrimal drainage system obstruction gives discomfort to patients and threatens intraocular surgeries by infection, thus, knowledge of its bacteriology leads to the choice of effective therapy.Aim:To determine the bacteriology of nasolacrimal duct obstruction in an adult Libyan patient population and to analyze the appropriate antimicrobial therapy based on susceptibility testing.Settings and Design:A prospective study was conducted at the Great River Eye hospital, Benghazi/Libya in the period between September 2005 and February 2007.Methods:Lacrimal swab materials collected from patients aged 1862 years who were diagnosed as having lacrimal passage obstruction and referred for lacrimal drainage surgery. The specimens were cultured and results analyzed.Results:Of 86 cases, 87.2% yielded a positive culture result. The majority of microorganisms were gram positive bacteria (73.3%) with Staphylococcus Aureus being the most frequently cultured species (36%) of the sample. Gram negative bacteria represented 26.7% of the isolates. The most common gram negative bacteria were Pseudomonas, Klebsiella, and E. coli which were isolated in 8% of the cases each. Staphylococcus aureus was isolated from 28.6% of cases having epiphora with no clinical signs of lacrimal drainage system infection. Ciprofloxacin (96%) and Gentamycin (94.7%) were found to be the most sensitive antibiotics against isolated organisms.Conclusions:Adult patients with lacrimal drainage system obstruction harbor microorganisms in their lacrimal sacs indicating the importance of investigating patients before planning for intraocular surgeries and considering prophylactic use of antibiotics before lacrimal drainage procedures

A Rare Complication of Oropharyngeal Tularemia: Dacryocystitis

Tularemia is a zoonotic disease caused by Francisella tularensis, a highly virulent gram-negative coccobacillus. Oropharyngeal tularemia, one of the clinical subtypes, is the most common clinical form of the disease in Eastern Europe, including Turkey. This clinical form affects mostly the head and neck region and the most common complaints of patients are mass in the neck, sore throat, and fever. This form of tularemia may be confused with tonsillitis, pharyngitis, or cervical lymphadenitis caused by other microbial agents due to the nonspecific clinical and laboratory features. In this study, we present a patient with nasolacrimal duct obstruction and dacryocystitis caused by oropharyngeal tularemia.

Primary tubercular dacryocystitis - a case report and review of 18 cases from the literature.

Tuberculosis is an airborne communicable disease primarily affecting lungs. Primary tuberculosis of the lacrimal sac is very rare. A 15-year-old girl presented with bilateral epiphora for 8 months. Examination revealed bilateral nasolacrimal duct obstruction. During dacryocystorhinostomy, bone over lacrimal sac was found partially eroded. Lacrimal sac was found filled with caseous white material. Biopsy from the lacrimal sac revealed tubercular granulomas. Patient improved after anti-tubercular therapy. Abbreviations: PCR: polymerase chain reaction; NAAT: nucleic acid amplification test.

Rare Pleurostomophora richardsiae Mass Causing Transient Nasolacrimal Duct Obstruction.

Transient nasolacrimal duct obstruction secondary to a mass lesion compressing the sac or sac-duct junction is rare. The authors report a case of a young female who presented to the authors with complaints of watering and a mass lesion in the lacrimal sac region. An organized perilacrimal mass filled with thick pultaceous material was noted during surgery. Following the drainage of the mass lesion, irrigation of the lacrimal system was freely patent. Microbiological examination and DNA sequencing targeting interspacer region was suggestive of Pleurostomophora richardsiae species. To the best of the authors' knowledge, this is only the second case report of a subcutaneous perilacrimal mass causing transient nasolacrimal duct obstruction by Pleurostomophora richardsiae.

Bacteriological profile in conjunctival, lacrimal sac, and nasal specimens and conjunctival normalization time following external, endoscopic, and transcanalicular multidiode laser dacryocystorhinostomy.

PURPOSE: To compare the conjunctival, lacrimal sac, and nasal flora cultures and conjunctival normalization time following external (EX-), endoscopic (EN-), and transcanalicular multidiode laser (TC-) dacryocystorhinostomy (DCR) and to evaluate the relationship between culture positivity and surgical success. We further performed antibiotic sensitivity analyses for lacrimal sac culture samples. METHODS: A total of 90 patients with primary acquired nasolacrimal duct obstruction were recruited and divided into EX-DCR (n=32), EN-DCR (n=28), and TC-DCR (n=30) groups. Conjunctival, nasal, and lacrimal sac cultures and antibiograms were analyzed. RESULTS: In all three groups, coagulase-negative Staphylococcus (CNS) was predominantly isolated preoperatively from the conjunctiva, nose, and lacrimal sac and postoperatively from the conjunctiva. Preoperative and postoperative conjunctival culture positivity rates were similar between all the groups (p>0.05). A statistically significant difference in the growth rate of culture in the lacrimal sac was observed between the three groups (p=0.001). CNS and Staphylococcus aureus cultures were predominantly sensitive to linezolid, teicoplanin, tigecycline, vancomycin, and mupirocin. Conjunctival normalization times were similar between the three groups (p>0.05). Anatomical and functional success rates were not found to be significantly correlated with preoperative conjunctival and lacrimal sac culture positivity (p>0.05). CONCLUSIONS: Similar rates of preoperative and 1-week postoperative conjunctival culture positivity were observed in all the groups; a significantly lower bacterial growth rate was observed in postoperative conjunctival cultures. CNS was the most commonly isolated organism. Bacterial growth rates in the lacrimal sac samples were significantly higher in the EN-DCR group. Bacterial growth rates obtained preoperatively from the conjunctival and lacrimal sac culture samples were not correlated with DCR success.

Bacteriological profile in conjunctival, lacrimal sac, and nasal specimens and conjunctival normalization time following external, endoscopic, and transcanalicular multidiode laser dacryocystorhinostomy / Perfil bacteriológico e tempo de normalização conjuntival de espécimes de conjuntiva, saco lacrimal e nasais após dacriocistorrinostomia externa, endoscópica e transcanalicular com laser de multi diodo

ABSTRACT Purpose: To compare the conjunctival, lacrimal sac, and nasal flora cultures and conjunctival normalization time following external (EX-), endoscopic (EN-), and transcanalicular multidiode laser (TC-) dacryocystorhinostomy (DCR) and to evaluate the relationship between culture positivity and surgical success. We further performed antibiotic sensitivity analyses for lacrimal sac culture samples. Methods: A total of 90 patients with primary acquired nasolacrimal duct obstruction were recruited and divided into EX-DCR (n=32), EN-DCR (n=28), and TC-DCR (n=30) groups. Conjunctival, nasal, and lacrimal sac cultures and antibiograms were analyzed. Results: In all three groups, coagulase-negative Staphylococcus (CNS) was predominantly isolated preoperatively from the conjunctiva, nose, and lacrimal sac and postoperatively from the conjunctiva. Preoperative and postoperative conjunctival culture positivity rates were similar between all the groups (p>0.05). A statistically significant difference in the growth rate of culture in the lacrimal sac was observed between the three groups (p=0.001). CNS and Staphylococcus aureus cultures were predominantly sensitive to linezolid, teicoplanin, tigecycline, vancomycin, and mupirocin. Conjunctival normalization times were similar between the three groups (p>0.05). Anatomical and functional success rates were not found to be significantly correlated with preoperative conjunctival and lacrimal sac culture positivity (p>0.05). Conclusions: Similar rates of preoperative and 1-week postoperative conjunctival culture positivity were observed in all the groups; a significantly lower bacterial growth rate was observed in postoperative conjunctival cultures. CNS was the most commonly isolated organism. Bacterial growth rates in the lacrimal sac samples were significantly higher in the EN-DCR group. Bacterial growth rates obtained preoperatively from the conjunctival and lacrimal sac culture samples were not correlated with DCR success.

RESUMO Objetivo: Comparar a flora conjuntival, do saco lacrimal e nasal com o tempo de normalização após dacriocistorrinostomia (DCR) externa (EX-), endoscópica (EN-) e transcanalicular a laser de multi diodo (TC-) para correlacionar a positividade da cultura com o sucesso cirúrgico, assim como identificar a sensibilidade aos antibióticos em amostras de saco lacrimal. Métodos: Neste estudo prospectivo, 90 pacientes com obstrução do canal nasolacrimal adquirida primária foram incluídos e divididos em grupos EX-DCR (n=32), EN-DCR (n=28) e TC-DCR (n=30). Culturas e antibiogramas conjuntivais, nasais e do saco lacrimal foram analisados. Resultados: Staphylococcus coagulase-negativo (CNS) foi o organismo predominante isolado no pré-operatório (conjuntiva e nariz), no transoperatório (saco lacrimal) e pós-operatório (conjuntiva), nos 3 grupos. Taxas de positividade de cultura da conjuntiva pré- e pós-operatórias nos três grupos foram semelhantes (p>0,05). A diferença nas taxas de crescimento do saco lacrimal dos três grupos foi estatisticamente significativa (p=0,001). CNS e S. aureus foram mais sensíveis a linezolida, teicoplanina, a tigeciclina, vancomicina e mupirocina. O tempo de normalização conjuntival foi semelhante nos três grupos (p>0,05). Não houve relação estatisticamente significativa entre as taxas de sucesso anatômicas e funcionais e a positividade da cultura conjuntival e de saco lacrimal pré-operatória (p>0,05). Conclusões: Pacientes submetidos a EX-DCR, EN-DCR, e TC-DCR apresentaram positividades de cultura conjuntival semelhantes no pré-operatório e na 1a semana pós-operatória. Houve uma redução significativa na taxa de crescimento das culturas da conjuntiva pós-operatórias. O organismo mais comumente isolado foi o CNS. A taxa de crescimento de bactérias a partir do saco lacrimal foi significativamente maior no grupo PT-DCR. O crescimento bacteriano da conjuntiva no pré-operatório e de amostras do saco lacrimal no transoperatório não se relacionaram com o sucesso da DCR.

Dacryocystitis due to Sporothrix brasiliensis: a case report of a successful clinical and serological outcome with low-dose potassium iodide treatment and oculoplastic surgery.

Sporothrix brasiliensis is the main species of the S. schenckii complex implicated in the zoonotic epidemics of sporotrichosis in Rio de Janeiro, Brazil. Epidemiological features have been already described, such as zoonotic transmission by cats and increased frequency of atypical clinical aspects. The involvement of the face by contact with cats is common in childhood; as a result, ophthalmic manifestations have increased. We report a case of acute dacryocystitis in a 9-year-old girl. A calmodulin-based molecular phylogeny was used to identify the agent as S. brasiliensis. This is a rare type of presentation, usually complicated with nasolacrimal duct occlusion. The patient was cured without sequelae after treatment with a low dose of saturated solution of potassium iodide and decompressive oculoplastic surgery. Therapeutic options and considerations of aetiological agents and serology are discussed.

Bacterial spectrum and antimicrobial susceptibility patterns in acquired and connatal lacrimal duct stenosis.

PURPOSE: (1) To determine the current bacteriological spectrum in connatal and acquired lacrimal duct obstruction (cLDO and aLDO, respectively) and (2) to analyze the antimicrobial susceptibility patterns of the recovered isolates. MATERIALS AND METHODS: In a prospective study, 463 samples (30% bilateral LDO) were obtained from the lacrimal ducts of 132 infants and 192 adult patients with symptomatic LDO between 2007 and 2012 at a tertiary eye-care center. The samples were cultured for aerobic and anaerobic bacteria, which were subsequently identified using standard microbiological techniques. Antimicrobial susceptibility testing was performed for each isolate using the disk diffusion method. Data were analyzed using SPSS and chi-square test for significance testing. RESULTS: (1) Among 463 samples investigated, 333 samples were positive, i.e. at least one bacterial isolate was recovered. A total of 72% were recovered (97% of samples from children and 56% of samples from adults), yielding a total of 654 bacterial isolates. Co-colonization with up to five different bacterial species was observed in a large proportion of the samples from children (87%), but in only 20% of those from adults and with a maximum of three different bacteria. Gram-positive bacteria were identified in 72% of the positive samples in both aLDO and cLDO. The most common Gram-positive species in cLDO was Streptococcus pneumoniae (29%), while that in cLDO was Staphylococcus aureus (60%). The most prevalent Gram-negative species were Moraxella catarrhalis (8%) and Haemophilus influenzae (9%) in cLDO and Pseudomonas aeruginosa in aLDO (12%). (2) Susceptibility testing revealed chloramphenicol to be the most active antibiotic with resistance rates of 3% in cLDO and 6% in aLDO, followed by ciprofloxacin (1% and 6%). Erythromycin and gentamicin were the least active of all, with resistances of 41% and 22%, respectively, in cLDO, and 23% and 11% in aLDO. CONCLUSIONS: Bacterial colonization occurs regularly in LDO, with Gram-positive bacteria being found in 97% of cLDO samples and 56% of aLDO samples. A remarkable number of different species were found to co-colonize in cLDO. The most common bacteria in LDO are highly susceptible in vitro to chloramphenicol and ciprofloxacin.

Conjunctival bacterial flora in nasolacrimal duct obstruction and its changes after successful dacryocystorhinostomy surgery.

PURPOSE: To evaluate the results of conjunctival culture in patients with nasolacrimal duct obstruction (NLDO) and its changes after successful dacryocystorhinostomy surgery. METHODS: In this prospective study, 71 adult patients with NLDO and 41 age- and sex-matched controls without NLDO were evaluated. The patients were divided in 2 groups based on clinical examination; group A with purulent regurgitation and group B without purulent regurgitation. Dacryocystorhinostomy surgery was performed, and the silicon tube was inserted in patients with upper lacrimal drainage system stenosis and when the lacrimal sac or nasal mucosal flap was inadequate for suitable anastomosis. Before surgery, microbiologic specimens were taken from the conjunctiva. Postoperative conjunctival sampling was continued weekly until the culture became negative or the colony count reached to the range of the control group. RESULTS: There were 38 and 33 patients in groups A and B, respectively. Silicone tube was inserted for 17 patients (23.9%). The culture was positive for bacterial growth in all cases. The conjunctival culture in the control group was positive in 17 eyes (41.4%). The mean count of colonies in a sample unit was 5274 ± 6300, 1167 ± 1504, and 9.5 ± 1.5 for group A, group B, and controls, respectively. The mean time of normalization of specimens was 3.3 ± 1.3 weeks (range 1-7). Pathogenic bacterial growth, higher colony counts, the presence of silicone tube, and purulent regurgitation were significantly associated with longer normalization time (p = 0.007, p = 0.0001, p = 0.0001, and p = 0.01, respectively). CONCLUSIONS: This study suggests that after successful dacryocystorhinostomy surgery, a waiting period of 7 weeks is enough for conjunctival bacterial cultures to become negative or reach the level of the normal eyes.

Allergic fungal sinusitis causing nasolacrimal duct obstruction.

INTRODUCTION: Allergic fungal sinusitis is thought to represent a chronic autoimmune reaction directed against fungal elements within the sinuses, and is commonly seen in individuals with a history of chronic sinusitis that is refractory to medical therapy. The authors present a case of allergic fungal sinusitis involving the lacrimal drainage system. CASE: A 54-year-old woman initially presented with recurrent erythema and induration of the left nasolacrimal sac due to dacryocystitis, which was unresponsive to treatment with topical and systemic antibiotics. Radiological evaluation demonstrated the presence of multiple soft tissue masses along the medial canthi. During subsequent endoscopic dacryocystorhinostomy, significant amounts of allergic mucin were found within the sinuses and marked eosinophilia was present within tissue obtained from the lacrimal sac, findings highly suggestive of allergic fungal sinusitis. CONCLUSION: A diagnosis of allergic fungal sinusitis should be considered in patients presenting with epiphora in the appropriate clinical context. However, involvement of the lacrimal drainage system is an exceedingly unusual presentation.

Giant dacryocystomucopyocele in an adult: a review of lacrimal sac enlargements with clinical and histopathologic differential diagnoses.

Dacryocystocele is an umbrella term that refers to any diffuse, centrifugal enlargement of the lacrimal sac that results from combined proximal and distal obstructions in the tear drainage system. In adults, the presence of mucus in the cyst's contents leads to the modified term of dacryocystomucocele. If infection supervenes, which almost always occurs in protracted cases and adds the clinical dimension of a dacryocystitis, then a dacryocystomucopyocele is created. Dacryocystocele and its congeners are much rarer in adults than in children. We describe a 95-year-old woman with an acquired, enormous dacryocystomucopyocele, larger than any previously reported, that developed over 25 years and produced globe displacement with an associated conspicuous enlargement of the nasolacrimal duct. The aspirated sac fluid was mucopurulent and harbored low-virulence bacterial organisms of the Prevotella and Petosteptococcus species. In infants, dacryocystoceles are transitory as the result of spontaneously reversible factors. In adults, secondary proximal irreversible fibrotic strictures or bony changes around the nasolacrimal duct typically arise from chronic inflammation or low grade infection. Other possible causations of duct obstruction, in addition to florid mucosal edema, include encroachment on the duct by enlarged contiguous ethmoid air cells; a sinus mucocele or sinusitis; idiopathic, post-traumatic or dysplastic bony remodeling of the wall of the duct; and a neoplasm-all of which require some form of surgical intervention, typically dacryocystorhinostomy. The differential diagnosis of medial canthal swellings centered on the lacrimal sac spans malformations, diverticula, dermoid/epidermoid cysts, sac inflammations/infections causing swelling without generalized sac enlargement, encephaloceles and primary epithelial tumors, as well as extrinsic tumors impinging on the sac.

Study on the effectiveness of antibiotic prophylaxis in external dacryocystorhinostomy: a review of 697 cases.

PURPOSE: To evaluate the prophylactic use of antibiotics in external dacryocystorhinostomy for the prevention of postoperative complications. METHODS: This study included 697 patients diagnosed with distal nasolacrimal duct obstruction and who were operated on by the same surgeon. Direct culture of the lacrimal sac content was carried out. Data were collected regarding clinical signs and symptoms, use of intraoperative antibiotics, results of culture samples obtained during surgery, and antibiogram analysis. Also, the postoperative period was analyzed with regard to the presence of postoperative complications. RESULTS: Out of 697 patients, 536 were women. The mean age at surgery was 67.0 ± 13.3 years. Prior to surgery, 19.5%, 18.5%, 11%, and 17.8% of patients showed recurrent conjunctivitis, mucocele, mucopyocele, and episodes of acute dacryocystitis, respectively. Seventy-three patients did not receive prophylactic treatment during surgery. A total of 8.3% of lacrimal sacs were culture positive, the most commonly isolated organism being Staphylococcus aureus. The use of antibiotics during surgery was not associated with a lower rate of postoperative complications. A statistically significant association was found between some clinical pictures, such as mucocele, mucopyocele, and dacryocystitis, and a higher rate of positive cultures. CONCLUSIONS: This study questions the generalized use of prophylactic antibiotics for external dacryocystorhinostomy, while providing evidence to indicate their use for patients who have had prior episodes of mucocele, mucopyocele, or acute dacryocystitis.

[Bacteriology of occluded nasolacrimal ducts in infants]. / Bakterielles Keimspektrum bei kindlichen Tränenwegsstenosen.

BACKGROUND: Connatal lacrimal duct stenosis (cLDO) commonly causes purulent bacterial dacyrocystitis. The recommended treatment of choice is up to the sixth month of life a conservative antimicrobiological therapy. After the sixth month lacrimal duct irrigation with silicone tube intubation remains the gold standard. Our purpose was to analyse the current bacterial spectrum in cLDO and to compile a bacterial resistogram in order to specify antimicrobiological therapy. METHODS: 66 samples from the lacrimal duct of 6- to 16-month-old children (41 female, 25 male) were obtained by collecting the refluxing liquids with cotton wool swabs after irrigation of the lacrimal drainage system with sterile saline during lacrimal duct surgery. Cultures were incubated aerobically and anaerobically and the infectious agents were isolated. Sensitivity testing was performed for each isolate, testing 8 different commonly used local antibiotics. Data were statistically analysed using SPSS. RESULTS: Cultures were positive in cLDO in 97 %, showing co-colonisation in 87 % with up to five bacterial strains. Gram-positive bacteria were seen in 72 % of the isolates in cLDO with Streptococcus pneumoniae (31 %) being the most abundant strain, followed by Staphylococcus aureus (13 %) and S. epidermidis (13 %). In 85 % of the samples at least one Gram-negative rod was present, most often Branhamella (12 %), followed by Haemophilus influenzae (11 %). Sensitivity testing revealed chloramphenicol, fusidic acid and ciprofloxacin/levofloxacin to be the most effective drugs in cLDO, whereas erythromycin and gentamycin turned out to be insufficient in treating cLDO. CONCLUSION: Bacterial colonisation plays a crucial role in cLDO, showing a positive culture in 97 % with frequent co-colonisation of several bacterial strains (often in combination with at least one Gram-negative strain). The sampling of a microbiological probe of the lacrimal duct is recommended at least in therapy-refractory cases. Current bacteria in cLDO can be effectively treated with chloramphenicol, fusidic acid and ciprofloxacin. The commonly used antibiotics erythromycin and gentamicin are inappropriate as monotherapeutics.

Mucormycosis infection of the lacrimal sac.

Biopsy of the lacrimal sac for patients with primary acquired nasolacrimal duct obstruction has been a topic of debate for many years. The authors present a case of a 72-year-old immunocompetent woman with a 2-month history of epiphora secondary to nasolacrimal duct obstruction. During an uneventful dacryorhinocystostomy, a routine lacrimal sac biopsy was performed and revealed mucormycosis. After appropriate infectious disease consultation, intensive antifungal therapy was given uneventfully. The patient has not had any signs of active Mucor infection after treatment in 6 months of follow up. This case demonstrates the utility of routine lacrimal sac biopsy and stands as an example of the potential to miss a serious diagnosis.

Lacrimal excretory system concretions: canalicular and lacrimal sac.

PURPOSE: To characterize the demographics of patients with dacryolithiasis and to compare patients who have canalicular concretions with patients who have lacrimal sac and duct dacryoliths. DESIGN: Comparative case series study and literature review. PARTICIPANTS: A total of 327 consecutive patients undergoing external dacryocystorhinostomy (DCR) between 1998 and 2008 at the University of Wisconsin-Madison. Fifteen consecutive patients with the diagnosis of canaliculitis during this period were also included. METHODS: The charts of all patients were reviewed for age, sex, laterality, duration of symptoms, history of dacryocystitis, history of lacrimal system intervention, history of smoking, examination findings, result of canalicular probing and irrigation, and histopathologic evaluation of the dacryolith or canalicular concretion. If applicable, the canaliculus involved was noted, as was any history of purulent canalicular drainage or canalicular injury. MAIN OUTCOME MEASURES: Patient demographics, duration of symptoms, history of dacryocystitis, history of smoking, presence of fungi, or Actinomyces on histopathologic evaluation. Findings were compared with prior studies reported in the literature. RESULTS: Of the 327 patients undergoing DCR, 22 (6.7%) had dacryoliths; 11 of 15 patients (73.3%) with canaliculitis had canalicular concretions. Patients with canalicular concretions were older than those with dacryoliths at DCR: 70.6 years versus 51.1 years (P = 0.003). Women made up the majority of both groups: 9 of 11 patients (81.8%) with canalicular concretions and 13 of 22 patients (59.1%) with dacryoliths at DCR (P = 0.26). The mean duration of symptoms was 20.2 months among patients with canalicular concretions and 30.5 months in patients with dacryoliths at DCR (P = 0.66); 1 of 11 patients (9.1%) with canalicular concretions smoked, compared with 9 of 21 patients (42.9%) with dacryoliths at DCR (P = 0.11). Actinomyces was isolated from 10 of 11 canalicular concretions (90.9%) and only 3 of 22 dacryoliths (13.6%) from DCR (P<0.001). In none of the 11 canalicular concretions were fungi identified, compared with 2 of 22 dacryoliths (9.1%) from DCR (P = 0.54). CONCLUSIONS: The demographics of patients with dacryoliths and the histopathology of their concretions vary with the location of the dacryolith in the lacrimal excretory system.

Normalization of conjunctival flora after dacryocystorhinostomy.

PURPOSE: To determine the time of normalization of conjunctival flora after successful dacryocystorhinostomy. METHODS: Forty consecutive adult patients with nasolacrimal duct obstruction and chronic dacryocystitis who had been referred for dacryocystorhinostomy were included in the study. Conjunctival cultures were obtained preoperatively from the involved and normal sides of each patient. Cultures from the lacrimal sac contents were obtained at the time of dacryocystorhinostomy. Postoperatively, conjunctival specimens were obtained from the operated side weekly until the result of the cultures was negative or the colony count was less than that of the normal side. RESULTS: The mean time of normalization was 4.5 weeks (range, 3-8 weeks). The time of normalization was significantly related to the type of organisms (p = 0.04) and the colony count (p < 0.001). The mean time of normalization was 3.5 weeks in patients with a colony count <10 and 4.93 weeks in patients with a colony count > or =10. The time of normalization was significantly related to the presence of a silicone tube (p < 0.0001). The mean time of normalization was 6.2 weeks and 3.9 weeks in patients with and without a silicone tube, respectively. CONCLUSION: A few weeks is needed for the conjunctival flora to normalize after dacryocystorhinostomy. The time of normalization is related to the type of bacteria, colony count, and presence of silicone tube.