Isolated sarcoidosis of the lacrimal sac without systemic manifestations

Chronic dacryocystitis caused by sarcoidosis

Sarcoidosis of lacrimal sac is a very uncommon disease. When the patient has symptoms of lacrimal sac diseases, it is necessary to take into account the histological evaluation, to demonstrate the involvement of the lacrimal sac by this pathology. In patients with sarcoidosis history, the treatment is surgical and it is suggested to do an external dacryocystorhinostomy, in order to take a biopsy, to get a diagnosis and to establish the incidence of this pathology. The case is presented of a 44 year-old female, with a history of sarcoidosis lymph nodes, who presented with a right chronic dacryocystitis of one year onset.

Ocular Sarcoidosis

Sarcoidosis is one of the leading causes of inflammatory eye disease. Ocular sarcoidosis can involve any part of the eye and its adnexal tissues and may cause uveitis, episcleritis/scleritis, eyelid abnormalities, conjunctival granuloma, optic neuropathy, lacrimal gland enlargement, and orbital inflammation. Glaucoma and cataract can be complications from inflammation itself or adverse effects from therapy. Ophthalmic manifestations can be isolated or associated with other organ involvement. Patients with ocular sarcoidosis can present with a wide range of clinical presentations and severity. Multidisciplinary approaches are required to achieve the best treatment outcomes for both ocular and systemic manifestations.

Endonasal dacryocystorhinostomy for nasolacrimal duct obstruction in patients with sarcoidosis

PURPOSE

To evaluate the outcomes of endonasal dacryocystorhinostomy (EN-DCR) surgery in patients with sarcoidosis.

METHODS

Retrospective chart review of all patients with sarcoidosis undergoing EN-DCR in 6 practices from 1999-2011.

RESULTS

We included 18 procedures in 14 patients (8 female, 6 male) who underwent EN-DCR for acquired NLDO secondary to sarcoidosis. The mean age was 53.7 (range 38-82). The presenting symptom in all cases was epiphora. Eight patients (57%) complained of having additional nasal congestion. Surgery was performed using endoscopic powered-type DCR with flaps in 12/18 (67%) and non-endoscopic mechanical EN-DCR in 6/18 (33%). In 15 (83%) cases the lacrimal sac and nasal mucosa appeared abnormally yellowish, crusty, oedematous and friable. Five patients were treated with pre-operative oral steroid and overall 8 patients had oral prednisolone post operatively, 30-60 mg tapered within 10 days-8 weeks. One patient had difficulties in tapering down the oral steroids at 6 months of follow-up. All patients were free of epiphora and patent to syringing, with nasal endoscopy revealing free flow of fluorescein through the ostium at a mean follow-up of 11.3 months (median follow-up 9 months).

CONCLUSIONS

All 18 cases of acquired nasolacrimal duct obstruction secondary to sarcoidosis were treated successfully with EN-DCR. An abnormal appearance of the nasal mucosa is an important sign. Nasal congestion is a frequent sign. A successful outcome may not depend on intensive long-term therapy with local or systemic steroids. Mechanical or powered EN-DCR for nasolacrimal duct obstruction secondary to sarcoidosis achieves encouraging medium-term outcomes.

[Sarcoidosis of the lacrimal sac as a cause of dacriostenosis]

Sarcoidosis is a systemic granulomatous disease of unknown aetiology. The course of sarcoidosis ranges from asymptomatic to severe. It could affect people of all ages. The disease affects predominantly the lungs and lymph nodes, skin, abdominal organs or eyes. Sarcoidosis of lacrimal sac is very uncommon. We describe a young man with lacrimal sac and nasal mucosa sarcoidosis present with epiphora. Few years before the onset of dacriocystitis the patient was treated because of lymph nodes sarcoidosis. The lacrimal sac sarcoidosis developed five years after systemic disease remission. An endoscopic dacriocystorhinostomy with intubation of nasolacrimal duct was performed. We used postoperatively systemic and local steroids for 3 months period. The patient is under observation for over four years with good health. The abnormal looking nasal or lacrimal sac mucosa could be associated with granulomatous disease as sarcoidosis and Wegener's or malignancies. If the sarcoidosis is established, it could be the first manifestation of sarcoidosis leading to future systemic sarcoidosis development or it may develop many years after the onset of systemic disease. Endoscopic dacriocystorhinostomy with intubation followed by intensive therapy with systemic and local corticosteroids may be helpful to maintain lacrimal drainage patency.

Is routine biopsy of the lacrimal sac wall indicated at dacryocystorhinostomy? A prospective study and literature review

OBJECTIVE

To determine whether routine biopsy of the lacrimal sac wall at dacryocystorhinostomy (DCR) is indicated.

METHODS

A prospective study and literature review. In 193 consecutive endoscopic DCRs performed on 164 patients (108 females and 56 males) part of the medial wall of the lacrimal sac was sent for histological examination. The mean age of the patients was 64 years with a range of 2.5-89 years. Previous reported series were reviewed.

RESULTS

Of the 193 specimens, 44 (23%) showed normal histology, 146 (76%) showed varying degrees of non-specific chronic inflammation, and three (1.2%) showed specific pathology. Of the three specimens that showed specific pathology two showed sarcoidosis and one showed transitional cell papilloma. The two specimens with sarcoidosis were obtained from one patient who underwent bilateral surgery. In this and the six previous reported series only seven of 1294 specimens (0.5%) showed specific pathology, which was definitely not suspected preoperatively or intraoperatively, and only one of these (0.08%) was found to be malignant (a lymphoma).

CONCLUSIONS

Biopsy of the lacrimal sac wall at DCR is not indicated routinely and is only indicated if there is a reason to suspect pathology other than chronic inflammation preoperatively or intraoperatively.