A Surprise in the Lacrimal Sac.

To present a case with recurrent dacryocystitis as an unusual complication of medial orbital wall fracture repair with cartilage tissue graft. A 20-year-old male had facial trauma and underwent surgery to reconstruct right medial orbital wall fracture. During follow-up, he presented with continuous epiphora, mucopurulent discharge from the right eye. A thorough history taking indicated that medial orbital fracture was reconstructed with postauricular cartilage. We planned a standard external dacryocystorhinostomy (DCR). During the creation of lacrimal sac flaps, hard tissue was noted in the lacrimal sac. This tissue was excised and sent for pathological examination. The pathological examination revealed cartilage tissue. There were no further ipsilateral symptoms or complications after DCR. In patients with lacrimal system injury related to orbital wall fracture, iatrogenic foreign bodies in the lacrimal sac should be considered in patients with recurrent dacryocystitis who had reconstructive surgery for facial and orbital trauma.

INTRODUCTION

The medial wall of the orbit (ethmoid, lacrimal, and frontal bones) is very thin. Therefore, it is more likely to be affected by trauma. Different surgical methods using various autogenic and alloplastic implant materials have been used for the reconstruction of orbital wall fractures.

Anatomically, the lacrimal sac is adjacent to the medial wall. It may be expected that trauma and reconstruction surgeries in the medial orbital wall region may cause lacrimal system injury.

Here, we describe a case of recurrent dacryocystitis due to cartilage tissue graft following orbital medial wall fracture repair.

CASE REPORT

A 20-year-old man presented with continuous epiphora and mucopurulent discharge from the right eye and painful hyperemic swelling in the medial canthal region of the right lower eyelid. One year before presentation, the patient was involved in a physical alteration and received facial trauma. The patient had undergone surgery for the trauma to reconstruct right medial orbital wall fracture. Unfortunately, his medical documents were not available but a thorough history taking indicated that medial orbital fracture was reconstructed with postauricular cartilage. Shortly after surgery, the patient had permanent epiphora and several recurrent bouts of dacryocystitis. In his external examination, the right lower eyelid was severely erythematous with swelling in the medial canthal area, conjunctival injection, and edema.

His visual acuity, pupillary examination, and ocular motility were normal in both eyes. The patient was diagnosed as acute dacryocystitis and oral amoxicillin and nonsteroid anti-inflammatory drugs. At the 2-week follow-up, acute dacryocystitis was resolved. Irrigation of saline through the upper lacrimal punctum revealed regurgitation of the purulent discharge from the lower lacrimal punctum. Subsequent lacrimal probing revealed a hard stop in the right nasolacrimal duct. Recurrent symptoms of dacryocystitis motivated us to perform dacryocystorhinostomy (DCR).

A standard external DCR incision in the nasojugal fold of the right lower eyelid was used to approach the lacrimal sac. Osteotomy was made using a Kerrison punch. During the creation of lacrimal sac flaps, hard tissue was noted in the lacrimal sac [Figure 1]. This tissue was excised and sent for pathological examination. Bicanalicular silicone stent intubation was performed after suturing of the posterior flaps. Suturing of the anterior flaps was followed by subdermal and skin suturing. Nasal packing was inserted in the nose and removed 1 day after surgery. One day postoperatively, saline passed into the nose during irrigation and no reflux from the canaliculus was detected. The pathological examination revealed cartilage tissue.

Figure 1

Cartilage tissue in the lacrimal sac between anterior and posterior flaps

There were no further ipsilateral symptoms or complications 3 months after removal of the silicone tube.

DISCUSSION

Orbital fractures can involve four walls of the orbit and can be related to intracranial, optic nerve, lacrimal system, eyelid, and globe injuries. Isolated medial orbital wall fractures account for up to 55% of orbital wall fractures. With combined orbital floor and medial orbital wall fracture, the incidence increases to 84%.1 To correct and restore the orbital shape and volume with autogenous biomaterials such as cartilage is often used. Nasoseptal and conchal auricular cartilage are usually preferred. The most common complications even after a successful orbital fracture reconstruction is restriction of eye movements, diplopia, dermatomal sensory loss, enophthalmos, and orbital dystopia.2

Orbital medial wall and lacrimal system are located closely. Orbital medial wall fractures and surgical interventions for the fractures may affect the lacrimal system. In the current literature, we have not encountered any case with lacrimal system injury related with orbital wall fracture surgery. To the best of our knowledge, there is no report about cartilage tissue in the lacrimal sac after orbital fracture repair.

However, there are reports of foreign bodies in the lacrimal apparatus. To date, a piece of metallic dilator, silicone stent, and punctal plug that was accidentally inserted into the lacrimal system, self-insertion of a fishing line, gauze, and retained Griffiths’ collar button were detected in the lacrimal system.345678910 Similar to our case, Choi et al. reported a case of acute dacryocystitis that developed after same sided ethmoidal sinus reconstruction because of facial trauma.7 During endoscopic transnasal DCR, severe necrosis around the lacrimal sac, and silastic sheet within the purulent discharge were found. In our patient, cartilage tissue was used for reconstruction of orbital fracture. We are unsure, but it might be inserted into the lacrimal sac iatrogenically. Foreign bodies can migrate, and it is possible that this material might have migrated after surgery. Removal of the cartilage tissue during DCR surgery was curative in our patient.

Iatrogenic foreign bodies in the lacrimal sac should be considered in patients who had reconstructive surgery for facial and orbital trauma.

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Nil.

Conflicts of interest

There are no conflicts of interest.