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Editor,—Causes of tearing fall into two broad categories—hypersecretion and lacrimal drainage insufficiency. We present two patients in whom chronic intermittent epiphora resolved after the passage of putty-like casts of the nasolacrimal duct and sac.
A 33 year old man was referred to the Dartmouth-Hitchcock Medical Center with an 8 year history of intermittent right sided tearing. Several previous irrigations of his right lacrimal drainage system had temporarily settled the symptoms.
On examination, the patient exhibited tearing of the right eye and marked pain, tenderness, and erythema at the right medial canthus. During lacrimal irrigation through the right lower canaliculus, a mass of material entered the patient's throat. The material was a cast of putty-like consistency in the shape of the nasal lacrimal sac and duct (Fig 1A). There was immediate relief of both pain and watering. The cast grew sparse Aspergillus species. The patient declined further investigation or treatment, but continues to have intermittent recurrences of symptoms.
A 35 year old woman was referred to Moorfields Eye Hospital with a 13 year history of intermittent epiphora associated with pain at the left inner canthus. On several occasions, after spontaneous passage of material into her throat, she would note complete resolution of her symptoms. The patient retained one such specimen (Fig 1B) which was a putty-like cast of the nasolacrimal duct.
Ocular examination was entirely normal, fluorescein dye clearance was fast on both sides, and both lacrimal drainage systems were freely patent to irrigation. Dacryocystography (Fig 2) was normal, with no retention of oily contrast on the erect film to suggest an abnormality of drainage at the nasal end of the nasolacrimal duct.1The patient declined further intervention and has been asymptomatic for 2 years.
Most patients with chronic tearing have drainage insufficiency caused by abnormalities anywhere along the outflow pathway: punctal disorders, canalicular or lacrimal pump deficiencies, lacrimal sac or duct abnormalities, or intranasal pathology.2 Our cases show that dacryoliths, or putty-like casts, originating in the nasolacrimal system may cause intermittent epiphora and dacryocystitis, and that the casts can be passed relatively readily or spontaneously.
A similar case of a patient with 14 years of intermittent epiphora, relieved by the passage of a dacryolith, has been described,3 and the author suggested that such casts may comprise an extremely slow aggregation of cellular debris. Our two cases presented similar histories and presented for diagnosis in the fourth decade of life—dacryolithiasis being commoner in the young.4
The aetiology of dacryoliths is unclear, although they largely comprise protein and cellular debris. Fungus, yeast, and eyelashes have been described as possible niduses.4 5 The specimen from case 1 grew Aspergillus, which may have served as a nidus. Local stagnation or turbulent flow might allow a coalescence of debris within the lacrimal drainage system with formation of a cast.5 A dilated lacrimal sac or a diverticulum might predispose to such stagnation. However, case 2, with normal dacryocystography, would suggest that an anatomical abnormality of the lacrimal drainage system is not a necessary requirement for the formation of a dacryolith.