Dacryolithiasis: A Review

[Concrements of the lacrimal apparatus]

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.

Unveiling the Web: Exploring the Multifaceted Role of Neutrophil Extracellular Traps in Ocular Health and Disease

Neutrophil extracellular traps (NETs) play an essential role in antimicrobial defense. However, NETs have also been shown to promote and mediate a wide spectrum of diseases, including cancer, diabetes mellitus, cardiovascular diseases, and ocular diseases. Data regarding NETs in ocular diseases remain limited. In physiological conditions, NETs protect the eye from debris and cleave proinflammatory cytokines, including several interleukins. On the other hand, NETs play a role in corneal diseases, such as dry eye disease and ocular graft-versus-host disease, where they promote acinar atrophy and delayed wound healing. Additionally, NET levels positively correlate with increased severity of uveitis. NETs have also been described in the context of diabetic retinopathy. Although increased NET biomarkers are associated with an increased risk of the disease, NETs also assist in the elimination of pathological blood vessels and the regeneration of normal vessels. Targeting NET pathways for the treatment of ocular diseases has shown promising outcomes; however, more studies are still needed in this regard. In this article, we summarize the literature on the protective roles of NETs in the eye. Then, we describe their pathogenetic effects in ocular diseases, including those of the cornea, uvea, and retinal blood vessels. Finally, we describe the therapeutic implications of targeting NETs in such conditions.

Dacryolithogenesis or Dacryolithiasis-The Story So Far

The term dacryoliths refers to the concretions found within the lacrimal system. When the term dacryoliths is unspecified, it usually refers to the noninfectious dacryoliths commonly isolated from the lacrimal sac and the nasolacrimal duct. More often, they are diagnosed incidentally during a dacryocystorhinostomy, and the reported incidence among all dacryocystorhinostomy surgeries is 5.7% to as high as 18%. Dacryolithiasis is a complex process occurring within the lacrimal system, and current evidence suggests a multifactorial etiology. The sequence of events can be summarized broadly into 4 stages: stage of susceptibility, stage of initiation/trigger, stage of development, and stage of maintenance. The triggering event is the breach of the lacrimal sac or nasolacrimal duct epithelium, resulting in microtrauma with blood leakage. The blood clots act as a nidus for subsequent sequential laying of mucopeptides, cellular debris present locally, debris washed from the ocular surface, and extraneous agents in tears. This process is aided by altered rheology and composition of the tear film. After the formation of dacryoliths, extracellular neutrophil traps usually form on the surface, which help to maintain the dacryoliths (which do not dissolve). This review highlights and discusses the possible sequence of events during dacryolithiasis.

Lacrimal gland sinus generated by a retained cilium: case report and literature review

Lacrimal gland stone(s) (LGSs) are rare and usually asymptomatic. LGSs should be distinguished from dacryoliths, as the former arise in the lacrimal gland. The aetiology of LGSs in many cases is likely related to a reaction to a hair within the palpebral lobe of lacrimal gland. Eye rubbing may contribute to the migration of the hair into the lacrimal gland. This case report describes the rare occurrence of an LGS with a central hair shaft (cilium) and associated sinus formation in a 39-year-old male presenting with persistent redness of, and discharge from the right eye for 4 weeks. Examination revealed a sinus opening onto the inferonasal surface of the palpebral lobe of the right lacrimal gland. The patient was treated with surgical excision of the sinus, with rapid and complete resolution of his symptoms.

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.

Neutrophil Extracellular Traps Drive Dacryolithiasis

Mucopeptide concretions, previously called dacryoliths, are macroscopic stones that commonly obstruct the lacrimal sac. The mechanism behind dacryolithiasis remains unclear; however, the involvement of various immune cells, including neutrophils, has been confirmed. These findings remain limited, and no information on neutrophil extracellular traps (NETs), essentially involved in the pathogenesis of other lithiases, is available yet. Here, we employ microcomputed tomography, magnetic resonance tomography, histochemistry, mass spectrometry, and enzyme activity analyses to investigate the role of neutrophils and NETs in dacryolithiasis. We classify mucopeptide concretions into three types, with respect to the quantity of cellular and acellular material, polysaccharides, and mucosubstances. We propose the role of neutrophils and NETs within the existing model of gradual formation and growth of mucopeptide concretions, with neutrophils contributing to the initial stages of dacryolithiasis, as they localized on the inner (older) parts of the tissue. As NETs localized on the outer (newer) parts of the tissue, we link their role to the late stages of dacryolithiasis, presumably maintaining the proinflammatory environment and preventing efficient clearance. An abundance of IgG on the surface indicates the involvement of the adaptive immune system later as well. These findings bring new perspectives on dacryolithiasis, in which the innate and adaptive immune system are essentially involved.

Spontaneous Extrusion of a Conjunctivolith Containing Herpes Virus Confirmed by Electron Microscopy and Energy Dispersive Spectroscopy

: This report describes the spontaneous extrusion from between the eyelids of a presumed conjunctivolith in a patient with resolving severe herpes zoster ophthalmicus. A 57-year-old man presented for ophthalmologic assessment and management due to severe left herpes zoster ophthalmicus. At one subsequent ophthalmologic assessment, a conjunctivolith spontaneously egressed the lateral commissure of the OS when the lateral fornix was inspected. The conjunctivolith was retrieved from the floor of the consulting room. Electron microscopic analysis and energy dispersive spectroscopy was undertaken to determine its composition. Scanning electron microscopy showed that the conjunctivolith was composed of carbon, calcium, and oxygen. Transmission electron microscopy diagnosed Herpes virus within the conjunctivolith. Conjunctivoliths, or possible lacrimal gland stones, are a very rare phenomenon, and their etiology is currently unclear. In this case, there was likely to have been an association between herpes zoster ophthalmicus and the conjunctivolith.

Dacryolithiasis diagnosis and treatment: a 25-year experience using nasal endoscopy

BACKGROUND

Dacryolith-induced epiphora is caused by a chronic obstruction of the nasolacrimal duct whose aetiology is often specified peroperatively. Dacryocystorhinostomy (DCR) has been often regarded as the gold standard to treat dacryolithiasis. Hasner's valve (HV) incision is a technique to evacuate lithiasis through its physiological track. The purpose of this study was to describe clinical and radiological findings associated with presence of dacryoliths in patients who underwent surgery and to assess the efficacy of these two procedures.

METHODS

This study was a comparative interventional multicentric retrospective study including patients referred for an epiphora. The primary endpoint was to determine clinical and endoscopic findings associated with dacryoliths. The secondary endpoints were to evaluate the performance of CT dacryocystography (CT-DG) in the diagnosis of dacryoliths and the success rate of the surgical treatment 6 months postoperatively.

RESULTS

4677 nasolacrimal ducts (NLDs) (78.0% female, mean age 59.2) were included in the study. 3913 underwent DCR, and 764 underwent HV incision. 291 out of 4677 NLDs (6.2%) were found to have dacryoliths. Presence of mucocele associated to a permeable lacrimal system (OR 8.17 (95% 4.62 to 14.44), p<0.01) was associated with presence of lithiasis peroperatively. Success rates at 6 months were 95.6% for endonasal DCR and 94.6% for incision of HV in dacryolithiasis group (p<0.01). CT-DG had a negative predictive value of 96.3% to detect lithiasis (p<0.01).

CONCLUSION

Strong clinical and endoscopic findings may improve the imputability of dacryoliths in epiphora. Evacuation of dacryolithiasis through its physiological track was first described in this study in adults with similar results to DCR in patients presenting with dacryolithiasis.

Concrements of the Lacrimal Apparatus

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.

Dacryops with dacryolithiasis in a dog

Background

Objectives

Methods

Results

Conclusion

Symblepharon, Ankyloblepharon, and Salt Gland Dysfunction in a Loggerhead Sea Turtle (Caretta caretta)

Adhesions involving the bulbar and the palpebral conjunctiva (Symblepharon) may interfere with tear drainage, cause chronic conjunctivitis, and reduce ocular motility. This condition may be associated with adhesion of the edges of the upper and lower eyelids (ankyloblepharon). The present case describes bilateral symblepharon, ankyloblepharon and salt gland dysfunction in a juvenile Caretta caretta. The loggerhead presented both eyelids swollen, ulcerated, and not separable when rescued. Eye examination was not possible, but ultrasonography showed right bulbar integrity, while the left eye was smaller, with a thicker cornea that had lost its normal doubled lined structure. Surgical dissection of the fibrous adhesions between the palpebral and bulbar conjunctiva, cornea, and third eyelid was performed, and large dacryoliths were removed. The microscopic findings were consistent with chronic keratoconjunctivitis. Ultrastructurally, no virus-like particles were observed. In addition, tissue samples were negative for herpesvirus by qualitative PCR. The eyelids of both eyes and the corneal epithelium of the right eye healed; moreover, the vision was restored in the right eye. There were no recurrences after 12 months of follow-up, and the turtle was released 16 months after the end of treatments on the southern Tyrrhenian coast in the western Mediterranean Sea. To the authors’ knowledge, this is the first report of symblepharon with ankyloblepharon and salt gland dysfunction in Caretta caretta turtle. Ocular ultrasonography was helpful in the preliminary diagnostic work-up.

Epiphora and Dacryocystitis After Transcanalicular Laser-assisted Dacryocystorhinostomy due to an Undiagnosed Dacryolith

A 45-year-old female patient who had previously undergone endoscopic dacryocystorhinostomy (EN-DCR) at another surgical center was diagnosed with functional failure after DCR and underwent an uneventful transcanalicular laser-assisted DCR (TCL-DCR). After 5 months, the patient underwent endoscopic examination due to persistent epiphora and dacryocystitis attacks. Endonasal visualization revealed a large dacryolith that filled the ostium and sac and was removed en bloc mechanically with forceps. Carbonized material on the dacryolith's superior part indicated that it was perforated through-and-through by the laser beam during TCL-DCR. The patient's complaints were resolved completely following the removal of the dacryolith. The transcanalicular lacrimal procedures do not allow complete visualization of the contents of the lacrimal sac, and the laser beam can ablate even an undetected dacryolith and may result in unsuccessful DCR, although the surgical course may look completely uneventful.

Evaluation of Ultrasound Biomicroscopy Combined with Color Doppler Flow Imaging in the Diagnosis of Primary Lacrimal Canaliculitis

Purpose: To explore the performance of ultrasound biomicroscopy (UBM) and color Doppler flow imaging (CDFI) in the diagnosis of primary lacrimal canaliculitis.Methods: Subjects with relevant symptoms of canaliculitis were prospectively recruited. UBM and CDFI were performed for presumptive diagnosis. Microbiology and histopathology were performed for definitive diagnosis.Results: A total of 37 cases were recruited, including 25 cases of canaliculitis and 12 cases of non-canaliculitis. Pathogens were isolated in 13 canaliculitis cases, and the leading pathogens were Actinomyces (4 cases) and Streptococcus (4 cases). UBM and CDFI identified 24 canaliculitis cases (sensitivity = 96%) and 11 non-canaliculitis cases (specificity = 92%). The predictive factors for canaliculitis were lumen wall thickness >0.25 mm (P = .019) and intracanalicular concretions (P = .010). Other typical features were enlarged lumen (2.16 ± 0.25 mm) and hot-wheel sign-on CDFI (84%). These image findings were congruent with histopathologic changes.Conclusion: Ultrasonography is a valuable tool to assist the diagnosis of canaliculitis.(Clinical trial registration number: ChiCTR1900025411).

Lacrimal Intrasaccal Polyp With Inspissated Mucopeptide Concretions

Lacrimal sac mucopeptide concretions are not uncommon and usually identified following the lacrimal sac marsupialization during a dacryocystorhinostomy. A 39-year-old female presented with epiphora and discharge of 8 months duration and was diagnosed as primary acquired nasolacrimal duct obstruction. During the endoscopic dacryocystorhinostomy, a large intrasaccal polyp arising from the posterosuperior wall of the lacrimal sac with multiple inspissated mucopeptide concretions was noted. The lesion was excised, and the mucopeptide concretions were removed. Histopathology was suggestive of an intrasaccal polypoidal granuloma. To the best of the authors' knowledge, this is the first report of an intrasaccal polyp-like lesion secondary to a granulomatous response to a lacrimal sac mucopeptide concretion. It is important to be aware of this entity. The retrieval of mucopeptide concretion or lacrimal sac dacryoliths should prompt the surgeon to initiate an intraoperative endoscopic assessment of the sac before proceeding with the surgery.

Tränenwegsstenosen im Erwachsenenalter

Zur Aufrechterhaltung der okulären Oberflächenhomöostase und damit den Erhalt der optischen Eigenschaften sind Tränenproduktion, -verteilung und -abtransport essenzielle physiologische Funktionen. Störungen dieser funktionellen Einheit gehen mit starken Beschwerden und einem hohen Leidensdruck bei den Patienten einher. Da etwa 3% unserer Patienten eine Tränenabflussstörung aufweisen, ist die Thematik von hohem klinischem Interesse.

[Lacrimal Duct Obstruction in Adults]

The tearing eye (epiphora) is the guiding symptome of nasolacrimal duct obstruction. Depending on the localization of stenosis, mucopurulent lacrimal discharge occurs additionally. These symptoms induce alterations of the optical system and can cause severe complications such as acute phlegmonous dacryocystitis. The grade of suffering in these patients is very high. For the diagnosis, patient's history, ocular surface conditions and inspection (macro-/microscopically) as well as palpation of the lacrimal region are essential examinations. Moreover, functional and anatomical tests enable a classification of nasolacrimal duct obstruction regarding grade of stenosis (incomplete vs. complete), type (functional vs. mechanical), and localization (pre-, intra-, postsaccal). ENT consultation prior to lacrimal surgery is obligate. Through this, a purposeful therapeutic intervention is warranted. Surgical methods consist of minimally invasive transcanalicular procedures or anastomosing surgeries. Dependent on the clinical findings, these treatment options can be applied in a patient centered therapeutic concept.

[Formation of concrements in the lacrimal excretory system]

Studying the pathogenesis of concrements formation in lacrimal ducts is of fundamental and practical importance. This article attempts to analyze available information related to the pathogenesis of this phenomenon, provides information on the etiopathogenesis, physical and chemical properties of concrements obtained from horizontal and vertical parts of the lacrimal duct, and considers in detail bacteriological and mycotic composition of concrements, as well as various theories of their formation. The analysis helped justify the need to separate the concrements formed in the horizontal and vertical parts of the lacrimal ducts on the basis of differences in their pathogenesis. Actinomycotic infection is the cause of concrements formation in the horizontal part of the lacrimal duct in the overwhelming majority of cases. The process of concrements formation in the vertical part of the lacrimal duct in some cases occurs as a result of previous clinical events, but in many other cases the trigger mechanisms remain unknown. To date, the role of the initial narrowing of the lacrimal ducts in the pathogenesis of concrements is not clearly defined. The accumulated knowledge regarding the pathogenesis of concrements is currently not enough to formulate a complete theory of the development of this phenomenon. Further studies of the pathogenesis of concrements will help develop new diagnostic and therapeutic measures aimed at restoring the patency of the lacrimal ducts.

Electron Microscopic Features of Canalicular Concretions

PURPOSE

The aim of this study was to examine electron microscopic features of canalicular concretions obtained from patients with canaliculiths.

METHODS

Canalicular concretions were obtained from 10 patients diagnosed as canaliculiths and were immediately fixed for ultrastructural analysis. Surface structure and transmission electron microscopical sections were studied. Multiple longitudinal and transverse ultrathin sections were obtained at different levels and all were studied using standard protocols of scanning electron microscopy and transmission electron microscopy.

RESULTS

Three different types of canalicular concretions were noted; predominantly coccoid and bacilloid, predominantly filamentous, and mixed varieties. The surfaces and the cut sections showed typical and distinctive features for each of the concretion types. The filamentous subtypes were common accounting for 50% (5/10) of all canalicular concretions. The surface of predominantly filamentous concretions revealed typical honeycomb patterns, the walls and base of which were formed by definitive and peculiar arrangement of Actinomyces. Transmission electron microscopy confirmed the findings of scanning electron microscopy and demonstrated typical structural features of Actinomyces and some other bacteria undergoing binary fission. The most interesting feature was the lack of immune cells and blood products within the substance of canalicular concretions as compared with the mucopeptide concretions.

CONCLUSIONS

Ultrastructural features of canalicular concretions reveal 3 distinct microbial subtypes and opens up avenues toward better understanding of the etiopathogenesis of canaliculiths and possible structural resistance to host defenses or antibiotics.

Value of ultrasound biomicroscopy in assessment of small masses at medial canthal region

PURPOSE

Conventional imaging techniques are not sensitive enough to reveal detailed structures of lacrimal drainage system (LDS) and its surrounding tissue (ST). Our study aimed to explore utility of ultrasound biomicroscopy (UBM) in assessment of small masses at the medial canthal region and compare performance of UBM with conventional imaging techniques.

METHODS

We prospectively recruited cases with small mass (long axis < 1 cm) at the medial canthal region (upper LDS-located area) from June 2017 to October 2018. UBM ± color Doppler flow imaging (CDFI) and conventional imaging techniques (computed tomography, magnetic resonance imaging, and dacryocystography) were conducted by four independent practitioners. Results were analyzed against gold standards with Cohen's kappa test in three aspects including LDS patency, mass location, and presumptive diagnosis. Corresponding gold standards were syringe and dacryocystography, intraoperative findings, and pathological/empirical diagnosis.

RESULTS

Seventy-two cases were recruited, including 20 cases of LDS lesions and 52 cases of ST lesions. Female (odds ratio 7.14) and age ≥ 37 (odds ratio 9.80) were risk factors for LDS lesion, and age range of 15-25 (odds ratio 9.17) was a risk factor for inflammatory ST lesion. In terms of LDS patency, UBM results were reliable for the detection of pre-saccal obstruction (kappa = 0.920), but were not reliable for intra-saccal and post-saccal obstruction (kappa = 0.106). In terms of mass location, the UBM (kappa = 0.766) performed better than conventional techniques (except for dacryocystography) to sort out ST lesions, with sensitivity of 93.8% and specificity of 83.3%. In terms of diagnosis, the UBM (kappa = 0.882) outweighed conventional techniques (except for magnetic resonance imaging) to distinguish cysts from nodules, with sensitivity of 93.8% and specificity of 94.4%. Notably, the UBM + CDFI achieved better performance than the UBM when screen out inflammatory lesions (kappa = 0.926 vs kappa = 0.689) and LDS-adjacent lesions (kappa = 0.815 vs kappa = 0.673), resulting in sensitivity of 91.7% and specificity of 100% for both testing items. If deep lesions (at the lacrimal sac-harbored area) were excluded, UBM reliability to detect inflammatory lesions (kappa = 0.915) and LDS-adjacent lesions (kappa = 0.770) improved, achieving sensitivity of 90.0% and 88.9%, and specificity of 100.0% and 92.7%, respectively.

CONCLUSIONS

The UBM is a valuable tool to assess superficial masses at the medial canthal region regarding pre-saccal obstruction, mass location, and presumptive diagnosis.

TRIAL REGISTRATION

This work was registered on Chinese Clinical Trial Registry website with registration number ChiCTR1800018956 .

Actinomycetes canaliculitis complicating congenital nasolacrimal duct obstruction in an infant

Actinomyces israelii is a Gram-positive anaerobic organism commonly associated with canaliculitis in adults. Pediatric canaliculitis is relatively rare, especially in infancy. We report the case of an 11-month-old boy who presented with co-existing canaliculitis and congenital nasolacrimal obstruction. The presenting signs included epiphora, discharge, conjunctival congestion, and matting of lashes. On examination, punctual pouting, regurgitation, and yellow canaliculiths were noted. A punctoplasty and canalicular curettage were performed along with nasolacrimal probing. Microbiological tests confirmed the organisms to be A. israelii. We discuss the clinical features and management of Actinomyces-associated canaliculitis and review the available literature on pediatric canaliculitis.

Proteomic Analysis of Dacryoliths from Patients with or without Topical Rebamipide Treatment

Background

A dacryolith mainly contains organic material, but its specific protein content is unknown. We observed a unique dacryolith formation in patients with long-term use of rebamipide eye drops and tried to identify the differences in protein compositions of dacryoliths from patients with or without use of rebamipide eye drops using novel proteomic analysis.

Methods

Dacryolith samples were obtained from 7 patients (4 samples were without rebamipide usage, 3 were with rebamipide usage) who underwent endo-dacryocystorhinostomy or lacrimal endoscopic surgery and were subjected to protein identification and metaproteomic analysis.

Results

The proteomic analysis revealed that most core proteins of dacryoliths are involved in immune and inflammatory responses and rebamipide-related proteins participated in several biological processes, including immune response, receptor-mediated endocytosis, and negative regulation of endopeptidase activity. Metaproteomic analysis of taxonomic diversity of dacryolith proteomes suggested less involvement of bacterial infections in dacryoliths from patients with long-term use of rebamipide.

Conclusion

This is the first report to clinically detect the different features of dacryoliths related with long-term use of rebamipide eye drops with proteomic analysis. It is possible that lacrimal protein alteration may be accelerated by topical rebamipide treatment with less bacterial infection involvement, but this requires further study. Long-term rebamipide eye drop use may be restricted in patients with nasolacrimal duct obstruction.

Recognition and Management of Acute Dacryocystic Retention

PURPOSE

Acute noninfectious dacryocystic retention is an under-recognized condition heralded by painful lacrimal sac swelling, obstruction, and epiphora. This longitudinal chart review aimed to estimate the incidence of this condition in an urban Australian population, while further defining the signs and symptoms of the disease and options for management.

METHODS

We retrospectively reviewed the charts of 1,593 consecutive patients presenting with acquired nasolacrimal duct obstruction and epiphora between 1990 and 2015. The records of patients with acute dacryocystic retention were analyzed for age, gender, clinical features, and management.

RESULTS

Of all patients presenting with nasolacrimal duct obstruction, 20 were found to have acute dacryocystic retention. The mean age was 42.2 ± 9.3. There was an equal distribution of laterality, and only 2 cases (10%) were bilateral. There was a statistically significant female predominance, and most patients presented reporting 2 to 3 previous episodes. At presentation, 30% of patients reported spontaneous passage of a dacryolith. Despite this, 70% of affected patients required surgical management, with a 64% incidence of stones noted at the time of dacryocystorhinostomy.

CONCLUSIONS

Acute dacryocystic retention is an uncommon, but even less frequently identified condition, most common in middle-aged women. Improved understanding of this condition and its natural history is likely to enhance patient counseling and avoid ineffective use of antibiotics in affected patients.