Congenital dacryocystocele (dacryocele, mucocele, amniotocele) is present in approximately 3% of infants with NLDO. It develops when a distal blockage causes distention of the lacrimal sac. The valve of Rosenmüller can act as a one-way valve, thereby preventing decompression of the lacrimal sac. Most patients with dacryocystoceles have associated cysts of the distal NLD, which may be seen beneath the inferior turbinate. Involvement is bilateral in 20%–30% of cases.
Clinical features and diagnosis
Dacryocystocele presents at birth or within the first few days of life as a bluish swelling just below and nasal to the medial canthus. The differential diagnosis includes hemangioma, dermoid cyst, and encephalocele. Hemangiomas are not typically present at birth. They have a vascular appearance and are generally less firm than dacryocystoceles. Dermoid cysts and encephaloceles present most often above the medial canthal tendon. The diagnosis is clinically apparent when a newborn has a nasal mass beneath the medial canthus that is associated with symptoms of NLDO (discussed later in the chapter); imaging is usually not required in this case.
Figure 19-2 Lacrimal fistula.
(Reproduced with permission from Lueder GT. Neonatal lacrimal system anomalies. Semin Ophthalmol. 1997;12(2):109.)
Dacryocystoceles are prone to infection, and acute dacryocystitis usually develops. The skin over the distended lacrimal sac becomes erythematous (Fig 19-3), and pressure applied on the sac may produce reflux of purulent material.
Infants who have large intranasal cysts may present with respiratory symptoms because infants are obligate nasal breathers. Symptoms range from difficulty during feeding (due to obstruction of the mouth) to respiratory distress.
Figure 19-3 Infected congenital dacryocystocele, right eye, in a newborn. Note the typical location and erythema overlying the distended lacrimal sac.
(Courtesy of Edward L. Raab, MD.)
Early treatment of dacryocystoceles is advised to prevent complications related to infection. Infants are relatively immunocompromised and are therefore at risk for local or systemic spread of infection. Digital massage may be attempted to decompress the dacryocystocele, as the condition occasionally resolves without surgery.
Dacryocystoceles associated with acute respiratory distress require immediate surgical intervention. If the lesions do not resolve within the first 1–2 weeks of life or if there is acute infection of the dacryocystocele, surgery is necessary. NLD probing alone may be curative, but in approximately 25% of patients, the condition persists after probing. NLD probing in conjunction with nasal endoscopy and intranasal cyst removal is effective in more than 95% of infants. Because approximately 20%–30% of patients have bilateral nasal cysts, sometimes without visible dacryocystoceles, bilateral endoscopy is appropriate. Systemic antibiotics should be used perioperatively if acute dacryocystitis is present. Surgical treatment of an infected dacryocystocele via a skin incision should be avoided because of the risk of creating a persistent fistulous tract.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.