Congenital lacrimal sac diverticulum.

Congenital lacrimal sac diverticulum is an uncommon pathology which may present as infantile epiphora. A female patient, aged 6 months, presented with a swelling over the right lacrimal sac of 2 months duration (Panel A). Epiphora from the right eye was noted for 2 weeks. There was no history of trauma or any episodes of infections. There was a moderately tense swelling below the medial canthus extending towards the inferomedial orbit. The lesion was not mobile, however the skin over the lesion was normal (Panel A). Pressure over the swelling did not show any regurgitation nor was it reducible. Computed tomography scan showed enlargement of the lacrimal fossa with a large lacrimal sac extending into the inferomedial orbit (Panel B). There was a peripheral rim enhancement of the lesion with air displacement towards the orbital side (Panel B). Irrigation of the lacrimal system was patent bilaterally. Exploration of the lesion revealed a lacrimal sac diverticula arising from the lateral wall and extending into the orbit (Panel C). The other eye was normal on clinical examination. The outpouching was excised up to the surface of the normal portion of the lacrimal sac. The lumen was inspected and found to be normal (Panel D). The exposed cut ends of the lacrimal sac wall were approximated with sutures (Panel E). Irrigation following anatomical restoration of the lacrimal sac was patent. At 3 months follow up, the infant was symptom free.

Histopathological examination of the excised wall showed it to be lined by flattened columnar epithelium with underlying stroma showing lymphoplasmacytic infiltration and fibrosis (Panel F). The histopathological features were consistent with those of a lacrimal sac. Although uncommon, congenital lacrimal sac diverticula should be one of the differential diagnoses of a medial canthal swelling presenting epiphora in an infant (see Fig. 1).

Figure 1

Panel A – External photograph of the upper face showing right sided fullness over the lacrimal sac area with upward displacement of the medial canthus. Panel B – CT scan, coronal cut, showing the dilated bony lacrimal fossa with a well defined lacrimal sac lesion extending into the orbit. Note the peripheral rim enhancement and displacement of air towards the orbital portion of the lesion. Panel C – Photograph taken through a pediatric nasal endoscope showing the lacrimal sac diverticulum. Panel D – End on view of the lumen of lacrimal sac following excision of the diverticula. Panel E – Anatomical restoration of the lacrimal sac. Note the sutures on the lateral side of the sac and the sharp anterior lacrimal crest on the other side. Panel F – Microphotograph showing the lining of the wall by flattened columnar epithelium with stromal lymphoplasmacytic infiltration and fibrosis.

Comment

Diverticula of the lacrimal sac can be congenital, inflammatory or post-traumatic. Congenital lacrimal sac diverticula are rare anomalies that may present with epiphora, recurrent acute dacryocystitis and medial orbital mass.1, 2, 3 A high suspicion, careful examination and imaging would help in diagnosis. Management usually consists of excision of the outpouching with or without a surgical bypass.

Conflict of interest

The authors declared that there is no conflict of interest.