A 34-year-old man presented with 5 months history of bilateral, red, irritated eyes, epiphora, purulent ocular discharge, marked nasal congestion, nasal discharge and bleeding. Topical antibiotics had been of little benefit. The patient had recently been investigated by a dermatologist for skin changes over his right zygoma. Incisional biopsy of the skin was suggestive of sarcoidosis and the changes resolved with topical steroids.

On examination, best corrected visual acuity was 6/4 bilaterally. There was bilateral tarsal hyperaemia and sticky purulent discharge. Pressure over the lacrimal sacs bilaterally produced profuse regurgitation of mucus, suggesting bilateral lacrimal mucoceles. There was no suggestion of any lacrimal gland enlargement. Anterior segment and fundoscopy were normal.

The patient proceeded to CT (figure 1). Following ear, nose and throat (ENT) consult, the patient underwent bilateral dacrocystorhinostomy (DCR) with silicone stents and ethmoidectomy. The ethmoid sinus biopsy (figure 2) confirmed the diagnosis and the cause of the occlusion distal to the lacrimal sac.

Questions

• 1. What is a mucocele and what are the causes of a lacrimal mucocele?

• 2a. What does figure 1 show?

• 2b. Figure 2 shows the ethmoid sinus biopsy. What do the coloured arrows show and what is the most likely …