Clinical characteristics and cytological changes in mucinous obstruction diagnosed by dacryoendoscopy.

To analyze the clinical characteristics of mucinous obstruction diagnosed by dacryoendoscopy and compared the cytological changes with membranous obstruction using a modified liquid-based thin prep cytology method. A retrospective chart review was conducted on 53 eyes of 51 patients with mucus obstruction based on dacryoendoscopic findings from January 2022 to October 2022. Liquid-based thin-prep cytology was performed by irrigating the inside of the nasolacrimal drainage system with saline during dacryoendoscopy-guided silicone tube intubation. Pathological findings were analyzed through a comparison of mucinous obstruction with membranous obstruction as determined by dacryoendoscopic findings. The modified liquid-based thin prep cytology technique had a higher cytology detection rate across all cases. Mucinous obstruction exhibited a significantly higher number of successful canalicular irrigation test cases compared to membranous obstruction. In mucinous obstruction, epithelial squamous cells were more frequently detected in pre-sac obstruction, whereas columnar epithelial cells were predominant in post-sac obstruction. Inflammatory cells showed a stronger correlation with primary change and post-sac obstruction. Bacterial colonies were observed exclusively in cases of mucinous obstruction. The use of a modified liquid-based thin prep cytology method enables the examination of histopathological changes in the lacrimal passage in primary acquired nasolacrimal duct obstruction (PANDO), particularly in cases of mucinous obstruction, without the need for invasive biopsies. These findings enhance the understanding of the etiopathogenesis of mucinous obstruction, complementing knowledge of membranous obstruction in PANDO.

Comparing the diagnostic accuracy of MR dacryocystography (MRD) and dacryoscintigraphy (DSG) in NLDO-related acquired epiphora.

PROPOSE: This study aimed to compare the diagnostic accuracy of MR dacryocystography (MRD) and dacryoscintigraphy (DSG) in the diagnosis of acquired epiphora related to NLDO. A total of 15 patients with acquired epiphora and suspected NLDO were included in this study. METHODS: All patients underwent MRD and DSG examinations. MRD was performed using a 3-Tesla magnetic resonance imaging (MRI) scanner, while DSG involved injection of a radiotracer into the lacrimal drainage system followed by DSG. The results of both imaging methods were compared with the reference standard that was a combination of clinical examination findings and surgical exploration. RESULTS: The results of this study showed that no abnormal findings were observed in MR-DCG in patients before the Valsalva maneuver. However, after the Valsalva maneuver, stenosis/obstruction at the canal surface was observed in all 15 patients diagnosed by DSG, giving a sensitivity of 100% for canal stenosis. Moreover, the results revealed that among these 15 patients, 9 showed stenosis or simultaneous obstruction at the level of the canal and lacrimal sac, but MR-DCG showed these lesions in only 9 patients, giving a sensitivity of 60%. The specificity of MRD and DSG were 85% and 76.7%, respectively. There was a statistically significant difference in the sensitivity of MRD and DSG (p < 0.05). CONCLUSION: This study demonstrated that MRD has a higher diagnostic accuracy in the diagnosis of acquired epiphora associated with NLDO compared to DSG. MRD showed significantly higher sensitivity and specificity than DSG. Therefore, MRD can be considered as the preferred imaging modality in the diagnosis of acquired epiphora due to NLDO. By accurately identifying the underlying cause of NLDO, MRD can help determine the most appropriate treatment approach for patients and lead to better outcomes.

Caruncle and plica hypertrophy causing mechanical secondary acquired lacrimal duct obstruction: - SALDO update study (SUP) - paper I.

PURPOSE: To exclusively report the clinical category of mechanical secondary acquired lacrimal duct obstruction (SALDO) secondary to the caruncle and plica hypertrophy. METHODS: Prospective interventional case series involving 10 consecutive eyes with megalocaruncle and plica hypertrophy were enrolled in the study. All patients presented with epiphora secondary to a demonstratable mechanical obstruction of the puncta. All patients underwent high magnification slit-lamp photography and Fourier-domain ocular coherence tomography scans (FD-OCT) of the tear meniscus height (TMH) pre- and post-operatively at 1-month and 3-months. Caruncle and plica size, position, and their relationship to the puncta were noted. All patients underwent partial carunculectomy. Primary outcome measures were demonstrable resolution of the mechanical obstruction of the puncta and the reduction in the tear meniscus height. The secondary outcome measure was the subjective improvement of the epiphora. RESULTS: The mean age of the patients was 67 years (range: 63-72 years). The average TMH was 843.1 (range: 345-2049) microns pre-operatively and 195.1(91-379) microns at 1-month follow-up. All patients reported significant subjective improvement in epiphora at 6-months follow-up. One patient had bilateral granuloma at the surgical site at two weeks and was managed by simple excision and topical tapering steroids. Histopathology revealed hyperplastic epithelium with goblet cells with chronic inflammatory cells in the sub-epithelial region and the stroma. CONCLUSION: The role of the caruncle in the causation of mechanical SALDO needs to be carefully assessed in patients beyond the sixth decade. Excellent objective and subjective outcomes can be achieved by a partial carunculectomy and plica semilunaris excision.

[Concrements of the lacrimal apparatus]. / Konkremente des Tränenapparates.

Concrements of the lacrimal apparatus, known as dacryoliths, can occur at different localizations and can cause a variety of symptoms. A common clinical sign is chronic inflammation, possibly exhibiting acute exacerbation. Based on a literature review and descriptive clinical cases with histopathological correlations, this contribution summarises the most important information concerning epidemiology, aetiopathogenesis, composition, histology, and therapy of lacrimal concrements. Furthermore, factors known to affect lacrimal lithogenesis are addressed. Concrements of the lacrimal gland cause a swelling at the lateral canthus. With only mild pain, this manifests as circumscribed conjunctival hyperaemia. Histologically, the gland tissue is characterised by acute-erosive to chronic inflammation. The concrements consist of amorphic material. Inflammatory infiltration is dominated by neutrophil granulocytes. Canalicular concrements are highly correlated with chronic canaliculitis. Besides epiphora, patients present with purulent discharge at the affected canaliculus. Actinomyces are frequently found inside these deposits and form drusen-like formations. The surrounding tissue reacts with plasma-cellular and granulocytic inflammation. Dacryoliths (concrements of the lacrimal sac) are associated with dacryocystitis, whereby acute and chronic types are common. Stones can be found in up to 18% of patients undergoing dacryocystorhinostomy or dacryoendoscopy. Preoperative diagnostic testing is challenging, as many lacrimal sac stones cannot be reliably visualised by diagnostic procedures. Recurring episodes of epiphora, mucopurulent discharge, and dacryocystitis are common indicators of dacryoliths. Lacrimal syringing is often possible and shows that total blockage is not present. Histology of the lacrimal mucosa reveals lymphocytic infiltration and submucosal fibrosis. The immediate vicinity of the dacryoliths shows acute inflammation. Therapy consists of stone extraction and improving lacrimal drainage, as the latter is recognised as the main risk factor for dacryolith formation.

A Pilot Nonrandomized Controlled Trial Examining the Use of Artificial Tears on the Radioactivity of Tears After Radioactive Iodine Treatment for Thyroid Cancer.

Background: Nasolacrimal duct obstruction (NLDO) is an adverse effect of high dose radioactive iodine (RAI) therapy for thyroid carcinoma. There are currently no established preventive measures. This study assesses whether preservative free artificial tears (PFATs) can decrease the 131I sodium iodide (131I) activity in the tears of patients following RAI therapy for thyroid carcinoma, and potentially serve as a preventive measure for RAI-associated NLDO. Methods: This non-randomized prospective pilot clinical trial recruited contact-lens wearing patients undergoing RAI therapy for thyroid cancer to self-administer PFATs into the right eye for four days starting on the day of RAI ingestion. Left eyes were the controls. While wearing contacts, patients self-administered PFATs per the following-Day 1: every 15 minutes for 2 hours, then every 30 minutes until bedtime, day 2: every hour for at least 12 hours, day 3: four times a day, and day 4: two times a day. Contact lenses were changed daily, and all lenses were collected one week later. Levels of 131I activity were measured by a well counter, decay-corrected, and converted to units of becquerel. Statistical analyses were performed to compare the 131I activities of the experimental and control eyes. Results: Sixteen eyes of eight patients treated with an average of 145.7 mCi (range 108-159) of 131I for papillary thyroid cancer were included. On day 1, artificial tears decreased the geometric mean 131I activity by 26% in the experimental eyes (p = 0.008). Artificial tears also decreased the geometric mean area under the curve over four days by 23% (p = 0.002). Conclusions: 131I is present in the tears following RAI therapy for thyroid carcinoma. Frequent PFATs starting on the day of RAI ingestion may decrease the level of 131I in the tears. This finding could have implications for lowering the risk of NLDO. Future multi-center clinical trials are needed to determine whether the use of artificial tears after RAI therapy may decrease the risk of NLDO. Clinical Trial Registration: NCT04327999.

[Dynamic pathomorphological characteristics of the nasolacrimal duct in its stenosis]. / Dinamicheskaya patomorfologicheskaya kharakteristika nososleznogo protoka pri ego stenozirovanii.

OBJECTIVE: Pathological description of the process of stenosis of the nasolacrimal duct at its various stages. MATERIAL AND METHODS: The material for the study was obtained from the wall of the nasolacrimal duct during surgery in 50 patients whose condition was attributed to the 1st, 2nd or 3rd clinical stage of dacryostenosis. The material was fixed in formalin and sent for pathohistological and immunohistochemical (IHC) studies. RESULTS: In the 1st stage, the integrity of the epithelium of the nasolacrimal duct was preserved, the density of goblet cells was reduced. Seromucinous glands were single in the lamina propria in the area of stenosis. Diffuse lymphoid-plasmacytic infiltration was observed along the periphery of the terminal sections of the glands and in the subepithelial zone. The infiltrate includes CD68+ tissue macrophages and CD20+ and CD3+ lymphocytes, with a predominance of B-lymphocytes over T-lymphocytes. In the 2nd stage, changes in the epithelial layer in the stenosis zone were detected. In the IHC study, only individual leukocytes were observed in these zones, and T cells were found mainly in the subepithelial zone, B cells - deeper, monocytes - evenly in all layers. In the adjacent zones, the picture of the infiltrate corresponded to the 1st stage. In the 3rd stage, fragments of the nasolacrimal duct wall were represented by dense fibrous connective tissue with pronounced atrophic changes, areas of squamous metaplasia or proliferation of the basal layer, goblet cells were not detected. There was no infiltrate in the area of stenosis during IHC study. In the cellular elements of the infiltrate in areas adjacent to the stenosis zone, CD20+ and CD3+ lymphocytes were present in equal proportions, the arrangement in layers corresponded to that of the 2nd stage. CONCLUSION: The results of the study showed that dacryostenosis is a progressive pathological process associated with the progredient development of chronic productive inflammation in the lacrimal ducts.

Etiopathogenesis of primary acquired nasolacrimal duct obstruction (PANDO).

Primary acquired nasolacrimal duct obstruction, or PANDO, is a common adult lacrimal drainage disorder. The current treatment modality of dacryocystorhinostomy to bypass the obstructed nasolacrimal duct has excellent outcomes. However, the understanding of the disease etiopathogenesis needs to be revisited. There are not many studies that specifically assessed any hypothesis or ones that convincingly put forth the presumed or confirmed interpretations regarding the PANDO pathogenesis or the mechanisms or pathways involved therein. Histopathological evidence points to recurrent inflammation of the nasolacrimal duct, subsequent fibrosis, and the resultant obstruction. The disease etiopathogenesis is considered multifactorial. Several implicated suspects include anatomical narrowing of the bony nasolacrimal duct, vascular factors, local hormonal imbalance, microbial influence, nasal abnormalities, autonomic dysregulation, surfactants, lysosomal dysfunction, gastroesophageal reflux, tear proteins, and deranged local host defenses. The present work reviewed the literature on the etiopathogenesis of primary acquired nasolacrimal duct obstruction (PANDO) to gain insights into the present state of the understanding and the high-value translational implications of precisely decoding the disease etiology.

Dacryocystectomy: A fibrin glue-assisted subfascial excision.

This article describes a technique of dacryocystectomy involving dissection within the subfascial plane, in which the lacrimal sac fascia is preserved and the orbital fat remains undisturbed. The lacrimal sac cavity was directly injected with Tisseel fibrin glue mixed with trypan blue. This led to sac distension and facilitated its separation from surrounding periosteal and fascial attachments. Staining the lacrimal sac epithelium improved definition of the mucosal lining. Transverse sections of the lacrimal sac specimen were histologically analyzed, which confirmed that dissection was completed within a subfascial plane. The technique herein described facilitates en bloc excision of the lacrimal sac without breaching the fascial plane that separates the sac from orbital fat.

Lacrimal Sac Tumors: A Single-institution Experience, Including New Insights.

BACKGROUND/AIM: Lacrimal sac tumors are rare tumor types, with a long time interval from disease onset to diagnosis. We aimed to investigate the characteristics and outcomes of patients with lacrimal sac tumors. PATIENTS AND METHODS: The medical records of 25 patients with lacrimal sac tumors initially treated at the Kyushu university hospital from January 1996 to July 2020 were reviewed. RESULTS: Our analysis included 3 epithelial benign tumors (12.0%) and 22 malignant (88.0%) tumors (squamous cell carcinoma, n=6; adenoid cystic carcinoma, n=2; sebaceous adenocarcinoma, n=2; mucoepidermoid carcinoma, n=1; malignant lymphoma, n=10). The average time from symptom onset to diagnosis was 14.7 months (median=8 months; range=1-96 months). The analysis of patients revealed that lacrimal sac mass (22/25, 88.0%) was the most frequent symptom and a possible tumor marker. Most epithelial benign (n=3) and malignant epithelial (n=12) tumors were treated surgically (14/15, 93.3%). One malignant case was treated with heavy ion beam therapy. Eight patients were treated with postoperative (chemo)radiation therapy because of positive surgical margins (including one unanalyzed case). Local control was ultimately achieved in all but one case. The patient survived for 24 months with immune checkpoint inhibitors and subsequent chemotherapy for local and metastatic recurrence. CONCLUSION: We report our experience in the diagnosis and treatment of lacrimal sac tumors and analyze the clinical trends in cases involving these tumors. Postoperative radiotherapy and pharmacotherapy, including immune checkpoint inhibitors, may be useful for recurrent cases.

Lacrimal Sac Rhinosporidiosis: Clinical Profile and Gram Stain as a Method of Preoperative Diagnosis.

PURPOSE: To describe the clinical profile of lacrimal sac rhinosporidiosis and to introduce a method for preoperative microbial identification of rhinosporidiosis using Gram stain. METHODS: This is a prospective study, carried out from January 2016 to January 2022. This series included 18 patients with clinical suspicion of lacrimal sac rhinosporidiosis. All patients underwent a comprehensive eye check-up. Mucopurulent discharge collected by a sterile swab after applying pressure over the sac area and Gram staining was done. All patients underwent dacryocystectomy. The sac contents were sent for histopathology, and rhinosporidiosis was confirmed. RESULTS: A total of 18 patients over a period of 6 years with suspicion of lacrimal sac rhinosporidiosis were included. There were 11 (61.1%) male patients. Ten patients (55.5 %) had a history of either regular or occasional bathing in stagnant water. Nontender doughy swelling over the lacrimal sac region was the most common presentation. Gram staining of the mucopurulent discharge revealed thick-walled sporangia with endospores suggestive of rhinosporidiosis in all these cases. All patients underwent dacryocystectomy. Hematoxylin and eosin sections confirmed the diagnosis. Two patients had recurrence within 6 months after surgery. CONCLUSION: Regurgitation of pus mixed with whitish granular particles or blood is highly suspicious of rhinosporidiosis. In clinically suspected cases, microbial diagnosis using Gram stain is an economical, office procedure, which helps the surgeon to plan for the surgery and for better counseling.

Evaluation of epiphora by topical contrast-enhanced CT and MR dacryocystography: which one to choose?

BACKGROUND: Our study aims to compare non-invasive imaging such as topical computed tomography dacryocystography (CTD) and topical magnetic resonance dacryocystography (MRD) in patients with epiphora. PURPOSE: To evaluate the practicability of topical contrast media during helical CTD and topical saline during MRD to reveal obstruction in the nasolacrimal drainage system (NLDS). MATERIAL AND METHODS: Twenty participants with nasolacrimal duct obstruction were observed for two years. Ten participants underwent CTD and the other 10 participants underwent MRD. Images were analyzed by two radiologists. Participants were also asked about the level of discomfort of the contrast material versus the saline solution. RESULTS: The NLDS was seen on both CTD and MRD. Very good agreement between the two observers (κ value > 0.81) was seen according to the κ statistics. CTD multiplanar and 3D images allowed for precise diagnosis of the point of obstruction whereas, the MRD did not require any contrast material and showed the point of obstruction. Saline was more comfortable for the patients than topical contrast (P < 0.05). CONCLUSION: Topical CTD and MRD are non-invasive techniques that can visualize the degree and level of obstruction in the NLDS than conventional invasive cannulation dacryocystography. CTD is useful in visualizing the point of obstruction and smaller drainage structures. However, it is a source of ionizing radiation to the lens. The benefit of MRD is that it requires no contrast or radiation; however, it is poor in depicting the bone anatomy and smaller drainage structures. Finally, saline was better tolerated by patients than topical contrast.

Metagenomics of the lacrimal sac in primary acquired nasolacrimal duct obstruction: the Lacriome paper 1.

BACKGROUND: The purpose is to study the metagenomics of the microbes isolated from the lacrimal sac of patients with primary acquired nasolacrimal duct obstruction (PANDO). METHODS: A prospective study was performed on ten consecutive lacrimal sac samples obtained for the metagenomic analysis from the patients with PANDO, who underwent endoscopic dacryocystorhinostomy at a tertiary care Dacryology service. The samples were collected intraoperatively soon after a full-length lacrimal sac marsupialisation and immediately transported on ice to the laboratory. Following DNA extraction and library preparation, a whole shotgun metagenome sequencing was performed on the Illumina platform. The downstream processing and bioinformatics of the samples were performed using multiple software packaged in the SqueezeMeta pipeline and MG-RAST pipeline. RESULTS: The taxonomic hit distribution across the samples showed that bacteria were the most common isolates (mean-97.56%), followed by viruses (mean-0.29%), archaea (0.04%) and others. The five major phyla identified across the samples of PANDO were proteobacteria, Bacteroidetes, Fusobacteria, Actinobacteria and Firmicutes. The prevalent organisms include Acinetobacter johnsonii, Porphyromonas catoniae, Cutibacterium acnes, Pseudomonas alcaliphila, Escherichia coli, Haemophilus influenzae, Enhydrobacter aerosaccus, Fusobacterium nucleatum, Moraxella osloensis, Butyricimonas virosa and Variovorax paradoxus, among few others. The alpha diversity of the ten sample datasets ranged from 60 to 175 species. CONCLUSION: This is the first whole metagenome sequencing of the lacrimal sac contents from PANDO patients. Lacrimal sacs harbour diverse microbial communities, including bacteria, viruses, and archaea. Further Lacriome studies may provide clues for a better understanding of the disease aetiopathogenesis.

Blood-stained tears-a red flag for malignancy?

BACKGROUND: Blood-stained tears can indicate occult malignancy of the lacrimal drainage apparatus. This study reviews data on patients presenting with blood in their tears and the underlying cause for this rare symptom. METHODS: Patients presenting with blood in their tears, identified over a 20-year period, were retrospectively collected from a single tertiary ophthalmic hospital's database and analysed. RESULTS: 51 patients were identified, the majority female (58%) with a mean age of 55 years. Most cases were unilateral (96%) with blood originating from the nasolacrimal drainage system in 53%. The most common diagnosis for blood-stained tears was a lacrimal sac mucocele (n = 16) followed by a conjunctival vascular lesion (n = 4). Three patients had systemic haematological disorders. The rate of malignancy was 8% (n = 4), with 2 patients having lacrimal sac transitional cell carcinomas, one with a lacrimal sac plasmacytoma and the other with chronic lymphocytic leukaemia and bilateral orbital infiltration (with bilateral bloody tears). One patient had a lacrimal sac inverted papilloma, a premalignant lesion. Four patients had benign papillomas (of the lacrimal sac, conjunctiva and caruncle). CONCLUSION: Haemolacria was a red flag for malignancy in 8% of patients (and tumours in 18% of patients). A thorough clinical examination including lid eversion identified a conjunctival, caruncle, eyelid or canalicular cause in 27% of cases.

Clinical Analysis of Primary Malignant Lacrimal Sac Tumors: A Case Series Study With a Comparison to the Previously Published Literature.

PURPOSE: To report management of a series of patients with primary malignant lacrimal sac tumors and to compare these results to the previously published literature. MATERIALS AND METHODS: A total of 27 patients with pathologically confirmed primary malignant lacrimal sac lesions were enrolled into this study. Pathological classifications, clinical characteristics, various treatment modalities and follow-up time, including tumor recurrence, were documented. The outcome measures included overall survival, progression-free survival, and median survival time. RESULTS: Among 27 eligible cases, 33.33% (9/27) of the tumor was non-Hodgkin B-cell lymphoma, and 33.33% (9/27) was squamous cell carcinoma; both were the most common tumor in this series, followed by adenocarcinoma 18.52% (5/27), then melanoma 7.41% (2/27). Treatment modalities included surgery, radiotherapy, and/or chemotherapy, the overall survival rate of 27 patients was 70.37%, with a median follow-up of 45 months (range: 7 mo-16 y), 8 patients had died from metastatic disease, but 13 patients remained without evidence of recurrent tumor. The 5-year overall survival and progression-free survival for all cases were 73.33% and 66.67%, respectively. The median survival time for 5 deceased patients with interstitial brachytherapy was 98 months, and 5-year survival rate was 60%. CONCLUSIONS: In this series, among primary malignant lacrimal sac tumors, the proportion of lymphoma had increased when compared with the previously published literature, and multidisciplinary therapy may lead to a good prognosis in the majority of patients with the tumors and patients may benefit more from interstitial brachytherapy than external beam radiotherapy.

Effect of Topical 5-Fluorouracil on Lacrimal Drainage System: Histopathological Evidence From Animal Experiments and Potential Clinical Implications.

PURPOSE: The purpose of this study is to investigate the histopathological changes in the lacrimal drainage system of rabbits following the application of 1% topical 5-fluorouracil (5-FU) for 4 weeks. METHODS: Ten eyes of 10 healthy New Zealand white rabbits were subjected to topical instillation of 1% (10 mg/mL) 5-FU, 1 drop 4 times a day for 4 weeks. Rabbits underwent a detailed ocular examination including eyelids, ocular surface, punctal, peri-punctal changes, and nasolacrimal duct patency at baseline and after 4 weeks of 5-FU. The rabbits were then sacrificed, and the eyelid, conjunctiva, lacrimal gland, and the entire lacrimal drainage system were retrieved for histopathological analysis as per standard protocols. RESULTS: Clinically demonstrable peripunctal changes and canalicular stenosis were noted in 6 (60%, 6/10) rabbits. Two of these (20%, 2/10) had additional complete regurgitation of clear fluid, indicating a nasolacrimal duct obstruction. The remaining 4 (40%, 4/10) clinically did not demonstrate lacrimal drainage changes and were patent on irrigation. The conjunctiva showed focal loss of goblet cells in several areas. Significant changes were noted in the canalicular, lacrimal sac, and the nasolacrimal duct tissues in the form of epithelial hyperplasia, subepithelial inflammation, edema, dilated and congested vessels, and fibrosis. The lacrimal gland, eyelid tissue (excluding tarsal conjunctiva), and cornea showed no significant histopathological changes. CONCLUSIONS: Clinical and histopathological changes were noted in the lacrimal drainage system of rabbits subjected to topical 5-FU application. These findings can have potential clinical implications for patients receiving 5-FU therapy.

Cutaneous eyelid melanoma with lacrimal sac metastasis: the potential role of lacrimal fluid as a metastatic pathway.

Here we present a patient with cutaneous eyelid melanoma patient with lacrimal sac metastasis. Clinicopathological findings in this case support the theory that lacrimal fluid can be a metastatic pathway for tumour cells. Dermatologists should be aware of the possibility that cutaneous eyelid melanoma may involve the nasolacrimal system and should examine it during the perioperative period and in postoperative follow-up.

Rhinosporidiosis of the lacrimal sac in a tertiary care hospital of India - A retrospective case study.

Purpose: Though rhinosporidiosis of the lacrimal sac is a rare disease across the globe, the frequency with which these patients come to the outpatient department in western Odisha is quite alarming. This study was undertaken to upgrade the knowledge about the clinical profile and management of rhinosporidiosis of the lacrimal sac. Methods: This is a retrospective study comprising 32 clinically diagnosed and histopathologically proved cases of lacrimal sac rhinosporidiosis who were managed with dacryocystectomy with meticulous excision. Intraoperative copious irrigation with 5% povidone-iodine for 5 min and postoperative dapsone therapy for 3-6 months had been administered to all the patients. The mean follow-up period was 16.7 months. The study was conducted over 5 years from August 2015 to July 2020. Results: Rhinosporidium seeberi, an aquatic protistan parasite, was found to be the causative agent. Males and females were affected equally. Children less than 10 years of age comprised 56.2% (18 cases). History of pond bathing was found in 100% of cases. The most common presentation was boggy swelling over the lacrimal sac. The involvement was unilateral in all the cases. None of the patients were found to have nasal involvement. In 65.6%, the lesion was limited within the sac. Recurrence was noted in 25% of cases. Conclusion: Rhinosporidiosis of the lacrimal sac should be excluded in all patients presenting with boggy swelling of the lacrimal sac with a history of pond bath. The recurrence can be minimized by meticulous excision, intraoperative betadine, and postoperative dapsone therapy.

Antineutrophil Cytoplasmic Antibody-Associated Vasculitis With Immunoglobulin G4 Involvement in Lacrimal Sac Squamous Cell Carcinoma.

Lacrimal sac squamous cell carcinoma is a rare but life-threatening disease that is often a delayed diagnosis secondary to difficulty in differentiating from other causes of dacrocystitis and acquired nasolacrimal duct obstruction. Chronic inflammation, including that of an underlying autoimmune disease, prior instrumentation, and poor wound healing, may be risk factors in the development to lacrimal sac squamous cell carcinoma. The authors present the first case of lacrimal sac squamous cell carcinoma associated with antineutrophil cytoplasmic antibody-associated vasculitis and immunoglobulin G4 positivity. Rather than an overlap syndrome between antineutrophil cytoplasmic antibody-associated vasculitis and immunoglobulin G4-related disease, high immunoglobulin G4 positivity may be considered an inflammatory marker of disease severity in the setting of antineutrophil cytoplasmic antibody-associated vasculitis and underlying malignancy. Inflammation-mediated tumorangiogenesis should be considered in the development of malignancy and red flags of chronic uncontrolled inflammation should warrant a lower threshold for further workup.

Solitary fibrous tumour of lacrimal sac masquerading as lacrimal sac mucocele: a diagnostic and surgical dilemma.

Swellings in medial canthal area in eye most often involve the lacrimal sac, the commonest aetiology being chronic dacryocystitis. Very rarely, there is a deviation in the routine diagnosis when the pathology comes out to be a lacrimal sac tumour. We report the case of a young man who presented with a medial canthal mass not extending above the medial canthal ligament. The clinical presentation was typical for a lacrimal sac mucocele, however on histopathological evaluation was diagnosed as a rare case of solitary fibrous tumour of lacrimal sac. We recommend radiological investigation in medial canthal masses where there is negative regurgitation on pressure over lacrimal sac area to avoid misdiagnoses.