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Endoscopic Features of Varices Involving Lacrimal Sac and Nasolacrimal Duct Mohammad Javed Ali, F.R.C.S., and Shweta Gupta, M.D. Govindram Seksaria Institute of Dacryology, L.V. Prasad Eye Institute, Hyderabad, India
FIG. 1. Lacrimal sac and nasolacrimal duct varices. A, Endoscopic photograph of the left lacrimal sac following osteotomy. Note the dilated and tortuous vessels involving the lacrimal sac wall and a large dilated varix involving the nasolacrimal duct. B, Endoscopic close up photograph showing the details of the tortuous vessels and the underlying bluish hue of the lacrimal sac wall. C, Microphotograph of the lacrimal sac wall showing large dilated vessels with thin walls without any vascular proliferation and filled with pool of red blood cells. Also note the chronic inflammatory changes of the sac wall.
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arices are abnormally dilated and tortuous vessels of an existing venous structure. A female patient, 58 years of age, presented with right-sided epiphora of 5-year duration and leftsided epiphora of 1-year duration. Clinical examination revealed bilateral punctal and canalicular stenosis with right-sided primary acquired nasolacrimal duct obstruction and left-sided partial primary acquired nasolacrimal duct obstruction. There was no history of hemolacria. Lacrimal sacs were not palpable. Bilateral endoscopic dacryocystorhinostomy with bicanalicular Crawford intubation was advised. Right-sided dacryocystorhinostomy was uneventful. However, during the surgery for the left side, following osteotomy, the lacrimal sac and nasolacrimal duct walls were noted to have focal areas of grossly dilated and tortuous vessels. Their location was on the antero-inferior wall of the lacrimal sac and medial wall of the nasolacrimal duct (Fig. 1A). The lacrimal sac varices were more tortuous, whereas that of nasolacrimal duct (black arrow, Fig. 1A) were more
dilated. The underlying lacrimal sac wall was bluish in color reflecting a full thickness variceal presence (Fig. 1B). Nasal mucosa did not show any varices. Hemostasis was achieved following sac marsupialization by compression, and a portion of the anterior sac wall was sent for histopathologic examination. Microscopic examination revealed large dilated vascular structures with the sac wall showing features of chronic inflammation (Fig. 1C). The vessel walls lacked gross muscular elements without any proliferative features and were dilated with a pool of red blood cells, suggestive of varices. Lacrimal drainage system varices can be an unusual cause of a hemolacria and can result from an increased venous congestion. They could possibly also represent a step in the pathogenesis of primary acquired nasolacrimal duct obstruction, where congestion of the venous plexus is implicated as a trigger mechanism, and this theory is supported by the clinical finding of partial primary acquired nasolacrimal duct obstruction in this case.
Accepted for publication July 26, 2017. M.J.A. received support from the Alexander von Humboldt Foundation for his research, and he also received royalties from Springer for the textbook “Principles and Practice of Lacrimal Surgery.” The authors have no conflicts of interest to disclose. Address correspondence and reprint requests to Mohammad Javed Ali, F.R.C.S., L.V. Prasad Eye Institute, Road No 2, Banjara Hills, Hyderabad-34, India. E-mail: [email protected] DOI: 10.1097/IOP.0000000000001006
Ophthal Plast Reconstr Surg, Vol. XX, No. XX, 2017
1
Copyright © 2017 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Endoscopic Features of Varices Involving Lacrimal Sac and Nasolacrimal Duct Mohammad Javed Ali, F.R.C.S., and Shweta Gupta, M.D. Govindram Seksaria Institute of Dacryology, L.V. Prasad Eye Institute, Hyderabad, India
FIG. 1. Lacrimal sac and nasolacrimal duct varices. A, Endoscopic photograph of the left lacrimal sac following osteotomy. Note the dilated and tortuous vessels involving the lacrimal sac wall and a large dilated varix involving the nasolacrimal duct. B, Endoscopic close up photograph showing the details of the tortuous vessels and the underlying bluish hue of the lacrimal sac wall. C, Microphotograph of the lacrimal sac wall showing large dilated vessels with thin walls without any vascular proliferation and filled with pool of red blood cells. Also note the chronic inflammatory changes of the sac wall.
V
arices are abnormally dilated and tortuous vessels of an existing venous structure. A female patient, 58 years of age, presented with right-sided epiphora of 5-year duration and leftsided epiphora of 1-year duration. Clinical examination revealed bilateral punctal and canalicular stenosis with right-sided primary acquired nasolacrimal duct obstruction and left-sided partial primary acquired nasolacrimal duct obstruction. There was no history of hemolacria. Lacrimal sacs were not palpable. Bilateral endoscopic dacryocystorhinostomy with bicanalicular Crawford intubation was advised. Right-sided dacryocystorhinostomy was uneventful. However, during the surgery for the left side, following osteotomy, the lacrimal sac and nasolacrimal duct walls were noted to have focal areas of grossly dilated and tortuous vessels. Their location was on the antero-inferior wall of the lacrimal sac and medial wall of the nasolacrimal duct (Fig. 1A). The lacrimal sac varices were more tortuous, whereas that of nasolacrimal duct (black arrow, Fig. 1A) were more
dilated. The underlying lacrimal sac wall was bluish in color reflecting a full thickness variceal presence (Fig. 1B). Nasal mucosa did not show any varices. Hemostasis was achieved following sac marsupialization by compression, and a portion of the anterior sac wall was sent for histopathologic examination. Microscopic examination revealed large dilated vascular structures with the sac wall showing features of chronic inflammation (Fig. 1C). The vessel walls lacked gross muscular elements without any proliferative features and were dilated with a pool of red blood cells, suggestive of varices. Lacrimal drainage system varices can be an unusual cause of a hemolacria and can result from an increased venous congestion. They could possibly also represent a step in the pathogenesis of primary acquired nasolacrimal duct obstruction, where congestion of the venous plexus is implicated as a trigger mechanism, and this theory is supported by the clinical finding of partial primary acquired nasolacrimal duct obstruction in this case.
Accepted for publication July 26, 2017. M.J.A. received support from the Alexander von Humboldt Foundation for his research, and he also received royalties from Springer for the textbook “Principles and Practice of Lacrimal Surgery.” The authors have no conflicts of interest to disclose. Address correspondence and reprint requests to Mohammad Javed Ali, F.R.C.S., L.V. Prasad Eye Institute, Road No 2, Banjara Hills, Hyderabad-34, India. E-mail: [email protected] DOI: 10.1097/IOP.0000000000001006
Ophthal Plast Reconstr Surg, Vol. XX, No. XX, 2017
1
Copyright © 2017 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
