Acquired nasolacrimal duct obstruction: clinical and histological findings of 275 cases

Abstract

Background: Acquired nasolacrimal duct obstruction is a blockage of the lacrimal outflow system usually caused by local nonspecific inflammation of the lacrimal sac and the nasolacrimal duct. However, cases exist where the primary nasolacrimal system obstruction is caused by malignancies. Our aim was to investigate lacrimal sac pathologies in patients with acquired nasolacrimal duct obstruction and compare their clinical manifestations.

Methods: This retrospective clinical study included 275 patients with acquired nasolacrimal duct obstruction who underwent external dacryocystorhinostomy and lacrimal sac biopsy. Cases were classified into tumor or nonspecific pathology groups and subdivided according to the level of inflammation. Histological and clinical data were analyzed.

Results: Three tumors (1.1%) (an adenoid cystic carcinoma, an eccrine spiradenoma and small B cell lymphoma) were diagnosed. Chronic nongranulomatous inflammation was the most common histological finding, corresponding to 194 cases (70.5%). The other 81 (29.5%) were subacute, acute forms of nongranulomatous inflammation, tumors and fibrosis cases. Epiphora with continuous purulent discharge was the most common clinical sign reported by 144 (52.4%) patients, and two (0.7%) patients had a palpable mass near the medial canthal tendon, which was identified as an eccrine spiradenoma and small B cell lymphoma. There was no significant difference in the clinical symptoms, duration or case history between the nonspecific pathology and tumor groups (p = 0.292).

Conclusions: Chronic nongranulomatous inflammation of the lacrimal sac was the most common finding among acquired nasolacrimal duct obstruction cases. There were no associations between the histological findings and clinical presentation. The authors recommend a lacrimal sac biopsy only in cases when a tumor is clinically suspected.

Keywords: Dacryocystitis; Dacryocystorhinostomy; Lacrimal sac biopsy; Lacrimal sac tumors.

Fig. 1

Hematoxylin/eosin (H/E) staining of the specimens. A Chronic inflammation: dense infiltration of plasmocytes (arrows) with some lymphocytes (short arrows in the lower right part) under a desquamated epithelium. H/E. B Acute inflammation: necrotic debris with some epithelium (in the center), granulocytes (below; short arrows), and calcification granules (arrow in the upper part). H/E. C Active chronic inflammation: mixed inflammation (plasmocytes – arrows, lymphocytes – short arrows, granulocytes – arrowheads) in the subepithelial stroma and some intraepithelial granulocytes (stars). H/E. D Fibrosis: fibrotic tissue with calcification (arrow) in the center without any inflammatory cells. H/E

Fig. 2

Tumor histological findings. A. Eccrine spiradenoma. Magnified image of hematoxylin/eosin (H/E)-stained tissue. B. The epithelial cell Ki67 proliferative index of the eccrine spiradenoma was 4%. C. Adenoid cystic carcinoma. Magnified image of H/E-stained tissue with secretion in the ductal structure lumens. D. Adenoid cystic carcinoma cells were positive for CD117

Fig. 3

Chronic lymphocytic leukemia/small lymphocytic lymphoma. A-B Tear sac tissue section illustrating a diffuse and focally nodular pattern of lymphocytic infiltration composed of small and round lymphocytes, with distinct clumped chromatin. (H/E). Immunophenotype: CD20+ (C), CD5+ (D), CD23+ (E), Ki67 proliferative activity <15% (F)