Lacrimal Duct Obstruction and Infection Associated with Non-Traumatic Corneal Perforation: A Case Series

Abstract

Purpose: To report a case series of lacrimal duct obstruction and infection associated with non-traumatic corneal perforation.

Case series: This study included 6 eyes in 6 patients with non-traumatic corneal perforation treated between April 2019 and March 2021. All 6 cases were associated with lacrimal duct obstruction and infection. Purulent discharge caused by lacrimal duct infection was observed in all 6 patients (100%). However, three of the 6 patients (50%) did not show purulent discharge at initial examination and lacrimal duct obstruction was therefore not initially recognized. Dry eye was observed in five of the 6 patients (83%) and may have caused corneal deterioration, increasing susceptibility to perforation. Further, dry eye masks symptoms of lacrimal duct obstruction and infections, such as epiphora and regurgitation of purulent discharge, making the association with lacrimal duct obstruction and infection difficult to determine. All patients were treated for both corneal perforation and lacrimal duct disease, and conditions improved, with no recurrence of either corneal perforation or lacrimal duct disease.

Conclusion: In patients with a combination of lacrimal duct disease and corneal perforation, treatment of both diseases resulted in stabilization of patient condition. Dry eyes may mask symptoms of lacrimal duct diseases, such as epiphora and purulent discharge, and lacrimal duct disease may thus be underdiagnosed.

Keywords: case series; corneal perforation; dacryocystitis; dry eye; lacrimal duct infection; lacrimal duct obstruction; purulent discharge.

Figure 1

Slit lamp photographs of the perforated cornea in the 6 patients. Slit lamp photographs (A–F) show the corneal perforations in cases 1–6, respectively. All perforations occurred in the right eye. Red arrows indicate the area of corneal perforation. (A) Prior perforated area central to the inferonasal cornea with opacification and neovascularization are shown. A new perforation is observed temporal to that opacification, resulting in flattening of the anterior chamber. (B) Peripheral corneal thinning is apparent in the temporal to superior area with oval perforation in the superior area where the iris is incarcerated. The Anterior chamber is severely inflamed, with flare and severe hyperemia. (C) A small corneal perforation is observed slightly inferonasal to the corneal center. Flattening of the anterior chamber and severe hyperemia are also evident. (D) Peripheral corneal thinning in the inferonasal to temporal area is evident. A small corneal perforation is observed in the inferonasal area. (E) Inferonasal opacification of the cornea and neovascularization due to prior corneal perforation are shown. A perforation with iris fitting is apparent in the same area. (F) An oval perforation is apparent in the superior peripheral cornea. Although therapeutic SCL is applied and iris fitting has occurred, the anterior chamber is very shallow.

Figure 2

The cornea of the other eye and lacrimal disease in the perforated eye. (A and B) Slit lamp photographs of the left eye in case 6 at the time of initial examination. Although no peripheral thinning or perforation of the cornea is evident, severe SPK is observed with fluorescent staining, indicating the presence of dry eye. (C) Slit lamp photograph of the right eye in case 6 on hospital day 13. Backflow of purulent discharge from the lacrimal duct is evident. (D) Intraoperative photograph of the right eye in case 6 on hospital day 15. Percutaneous dacryocystectomy (white dotted circle) and closure of the lacrimal puncta and lacrimal canaliculi are performed. Intraoperatively, a large lacrimal concretion (red dotted circle) is detected in the lacrimal sac and extracted. The concretion consists of MSSA and suspected fungus.