Epiphora Secondary to Dacryolith Obstruction of the Canaliculi

An 84-year-old male presented with a history of dry eye and chronic irritation. His ocular health history included bilateral cataract surgery with intraocular lens implantation. He reported recently experiencing epiphora and injection in his left eye. His general health history included well-controlled hypertension.

Presenting visual acuities were 20/25 OD and OS. Biomicroscopy revealed bilateral pseudophakia with clear media, reduced tear volume in the right eye, and epiphora with slight injection in the left eye. Dilation and irrigation of the right eye showed no restriction of outflow in either the upper or lower canaliculi. The same procedures performed on the left eye revealed no stenosis in the upper canaliculus but significant restriction in the lower canaliculus. Repeated dilation and irrigation of the lower left canaliculus eventually cleared the blockage, and two small dacryoliths were expelled. At his one-week follow-up visit, the patient reported complete resolution of his complaints.

Etiology and Signs/Symptoms

Nasolacrimal duct obstruction may be congenital or acquired. The primary categories of acquired etiologies include infectious, inflammatory, neoplastic, traumatic, and mechanical causes.¹ Infectious forms are classified by causative organisms, i.e., bacterial, viral, fungal, or parasitic.¹ In our patient, because there was no recent history suggesting infection or trauma, the most likely underlying contributor was chronic dry eye.

Yazici et al evaluated the statistical correlation between patients who had dacryoliths and those who did not relative to gender, age, duration of epiphora, and history of acute dacryocystitis as well as previous use of topical anti-glaucoma medications. In their study, dacryoliths and lacrimal sac distension were more likely to be associated with male gender. Their results also revealed a relatively increased risk for dacryolith formation in cigarette smokers.²

Presentations that are suggestive of lacrimal duct obstruction—and therefore possibly of the presence of dacryoliths—include increased tear lake, epiphora, and fluorescein pooling.¹ Sweeney et al reported that individuals who perpetually carry tissues with them and have chronically red eyes may suffer from dacryolith-induced epiphora.

Epiphora may be considered a relatively benign sign/symptom; however, in rare cases, it may suggest a more serious underlying pathophysiology. Swati and Javed performed a PubMed search of articles relating to lymphoma/leukemia of the lacrimal sac and the nasolacrimal duct.³ They reported that lymphoma/leukemia of the lacrimal sac presents at a mean age of 55 years and that in 63% of the lesions, the primary location was the lacrimal sac. The most common findings were epiphora (96%), edema in the lacrimal sac region (75%), and acute dacryocystitis (31%).³ This study reveals the potentially serious implications of failing to investigate any unexplained presentation of recent-onset epiphora.

References

1. Sweeney A, Harris SJ, Yen MT. Secondary Acquired Nasolacrimal Duct Obstruction. American Academy of Ophthalmology EyeWiki. Updated Oct. 18, 2021. Available at https://eyewiki.aao.org/Secondary_Acquired_Nasolacrimal_Duct_Obstruction#Etiolog . Accessed Oct. 19, 2021.
2. Yazici B, Hammad AM, Meyer DR. Lacrimal sac dacryoliths: predictive factors and clinical characteristics. Ophthalmology. 2001 Jul;108:1308-1312.
3. Singh S, Javed Ali M. Lymphoproliferative tumors involving the lacrimal drainage system: a major review. Orbit. 2020 Aug;39:276-284.