(Radiology. 2000;215:300-304.)
© RSNA, 2000
Abscess of the Lacrimal Sac due to Chronic or Subacute Dacryocystitis: Treatment with Temporary Stent Placement in the Nasolacrimal Duct1
Alfred G. Janssen, MD,
Khaled Mansour, MD,
Johanna J. Bos, MSc,
Radu A. Manoliu, MD and
Jonas A. Castelijns, MD
1 From the Department of Diagnostic and Interventional Radiology, De Tjongerschans Hospital, Thialfweg 44, 8441 PW Heerenveen, the Netherlands (A.G.J.); Department of Ophthalmology, Academic Hospital, University of Groningen, the Netherlands (K.M.); Department of Medical Informatics, Epidemiology, and Biostatistics, University of Nijmegen, the Netherlands (J.J.B.); Department of Radiology, Academic Hospital, Free University of Amsterdam, the Netherlands (R.A.M., J.A.C.). Received November 2, 1998; revision requested January 5, 1999; revision received June 30; accepted July 30. Address reprint requests to A.G.J. (e-mail: ag_janssen@castel.nl).
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Abstract
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Stents were placed temporarily in 10 obstructed lacrimal systems in patients with a chronic or subacute lacrimal abscess that did not respond to conventional antibiotic therapy. In all 10 cases, the abscess was treated successfully. Long-term patency of the lacrimal system was restored in five cases. Temporary stent placement appears to be a promising method to treat a chronic or subacute lacrimal abscess.
Index terms: Lacrimal gland and duct, 223.1295, 223.1492, 223.249 • Lacrimal gland and duct, interventional procedure, 223.126 • Stents and prostheses, 223.126
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Introduction
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Chronic dacryocystitis can be the final stage of acute dacryocystitis that does not respond sufficiently to antibiotics, but it can also develop owing to an obstruction of the lacrimal system. An obstruction can develop secondary to a recognizable causative factor, such as facial trauma or surgery, sarcoidosis, Wegener granulomatosis, or neoplasms. In most cases, however, no clear cause is identified. This primary acquired nasolacrimal duct obstruction develops gradually and occurs mainly in women aged 40 years or older.
Patients frequently present with a red eye, epiphora (or tearing), and matting of the eyelashes. A complete obstruction of the lacrimal system distal to the lacrimal sac may cause a chronic lacrimal abscess, with the lacrimal sac swollen and filled with pus. In many cases, the course of chronic dacryocystitis is low-grade and almost subclinical, with intermittent exacerbations in some cases. In many cases if the obstruction of the lacrimal drainage system persists, chronic dacryocystitis fails to respond or does not respond sufficiently to treatment with antibiotics. The conventional treatment for an obstruction of the lacrimal system has been dacryocystorhinostomy, a surgical procedure in which an opening is made between the lacrimal sac and the nose. The long-term success of dacryocystorhinostomy to treat obstruction of the lacrimal system is good with a success rate of 85% (1). Because dacryocystorhinostomy is usually performed with general anesthesia and frequently affects elderly patients, however, we have sought a nonsurgical alternative procedure to treat a chronic or subacute lacrimal abscess.
Since 1990, interventional radiologists have been involved increasingly in the treatment of epiphora caused by an obstruction of the lacrimal drainage system (2–8). Epiphora can be treated with balloon dilation or stent placement in the nasolacrimal duct. The long-term results of stent placement are moderate, particularly with obstructions located proximally in the nasolacrimal duct system (9–11). If placement is performed by an experienced radiologist, long-term results of dacryocystoplasty with balloon dilation are good, and if patients are properly selected, results are comparable to those of dacryocystorhinostomy. Interventional radiologists have refrained from performing procedures in the lacrimal system in the presence of active dacryocystitis because of the risk that the infection might spread (7,8,12).
The purpose of this study was to evaluate temporary stent placement in the nasolacrimal duct supported with use of systemic and local antibiotics as a treatment for lacrimal abscesses due to chronic or subacute dacryocystitis.
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Materials and Methods
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Patient Population
Between January 1997 and January 1998, nine patients (eight women and one man; mean age, 70.1 years; age range, 45–95 years) were referred to our departments by ophthalmologists for treatment of a chronic or subacute abscess of the lacrimal sac that failed to respond or that responded inadequately to systemic antibiotics (Table). All cases involved an active inflammation with pus in the swollen lacrimal sac. In six patients, an abscess of the right lacrimal sac was treated; in two patients, an abscess of the left lacrimal sac; and in one patient, an abscess of both the right and left lacrimal sacs (patients 8a and 8b). Patients presenting with acute dacryocystitis were not selected for the treatment.
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Patient Data and Results in 10 Cases of Drainage of a Chronic or Subacute Lacrimal Abscess Treated with Temporary Stent Placement in the Nasolacrimal Duct
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In 10 abscesses, dacryocystography prior to abscess drainage revealed an obstruction of the lacrimal drainage system at the junction between the lacrimal sac and the nasolacrimal duct distal to the abscess. In patients 3, 4, and 6, there was an additional long obstruction of the nasolacrimal duct. Prior to treatment, all patients had experienced severe epiphora for an average period of 12.4 years (range, 2–50 years). During this period, each of the patients had experienced one or more episodes of active dacryocystitis. In patients 2 and 5, external dacryocystorhinostomy had been performed to treat the epiphora 1–2 years before abscess drainage, and in both cases this had not been successful.
Technique
Prior to the intervention, the procedure was fully explained to the patients, and written informed consent was obtained. The procedure was performed with the patient in the supine position, without sedation, with local anesthesia by applying a few drops of 0.4% oxybuprocaine hydrochloride (Monofree R; Bournonville-Pharma, Almere, the Netherlands) to the conjunctival sac. First, the abscess of the lacrimal sac was drained. In some cases, it was possible to expel pus from a chronic abscess by applying gentle pressure to the lacrimal sac, which caused drainage of the pus via the canaliculi to the eye. In some cases, however, expulsion of pus from a lacrimal abscess was impossible owing to kinking of the common canaliculus caused by severe swelling of the lacrimal sac. In these cases, the common canaliculus was straightened with a guide wire that was carefully advanced via the canaliculi into the lacrimal sac with fluoroscopic guidance.
We used an atraumatic, flexible, hydrophilic coated, 0.025-inch, shapeable guide wire with a length of 150 cm (NaviGuide; Medi-tech/Boston Scientific, Maastricht, the Netherlands). Before insertion, the most distal 4–5 mm of the guide wire was shaped by hand into a J-shaped curve that enabled guidance of the wire by means of rotation (Fig 1). When the guide wire reached the lacrimal sac in some cases, spontaneous drainage of the abscess occurred along the guide wire via the canaliculi. In most cases, however, we needed to pass a vascular sheath over the guide wire into the lacrimal sac via the canaliculi. Subsequently, the pus was aspirated and the lacrimal sac carefully rinsed with saline solution. We used a 20-gauge plastic vascular sheath with a length of 51 mm (Abbocath; Abbott Ireland, Sligo). Before the procedure, the vascular sheath was also curved over a wire loop and then immersed first in hot and then in cold water. In this way the J-shaped curve was made at the tip of the vascular sheath, which enabled easy passage over the guide wire into the lacrimal sac (Fig 1). The technique of passing a vascular sheath into the lacrimal sac is similar to the technique used in lacrimal balloon dilation, which has been described extensively elsewhere (7,13).
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Figure 1. Photograph shows the equipment used in this method: the atraumatic hydrophilic coated guide wire, shaped by hand at the most distal 4-5 mm (1); the 20-gauge vascular sheath shaped by hand by curving it over a wire loop and immersing it in hot water (2); the balloon catheter with a balloon 3 mm in diameter and 20 mm long (3); the lacrimal stent made from the most distal 4.5 cm of a 6- or 8-F polyurethane enteral feeding tube (4); and the pusher, made from the remaining part of the enteral feeding tube (5).
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The second step of the procedure involved imaging of the obstruction of the lacrimal system that contributed to the abscess. Subtraction dacryocystography was performed with a water-soluble, nonionic contrast medium (Ultravist 300 R; Schering, Berlin, Germany) mixed with a small amount of lidocaine (Xylocaine 1%; Astra, Rijswijk, the Netherlands) and carefully applied to the lacrimal sac via the vascular sheath (Fig 2a). Care was taken to avoid overfilling because of the risk of spreading the infection.
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Figure 2a. Patient 8a. (a) Posteroanterior digital subtraction dacryocystographic image shows complete obstruction at the level of the junction between the lacrimal sac and duct. A large quantity of pus was found in the swollen lacrimal sac. The contrast medium was administered via a vascular sheath in the inferior canaliculus (1). The image also depicts the superior canaliculus (2), the common canaliculus (3), the distended lacrimal sac (4), and the obstruction at the level of the junction (5). (b) Posteroanterior radiograph of the lacrimal duct system shows the radiopaque stent (6) in the tract from the top of the lacrimal sac to the nasal floor. (c) Posteroanterior digital subtraction dacryocystographic image shows good patency of the stent. Contrast medium is running through and along the stent (6) into the nose (7). (d) Follow-up posteroanterior digital subtraction dacryocystographic image was obtained 4 months after removal of the stent. The lacrimal system is morphologically normal, and passage of contrast material is good. The image shows the lacrimal sac (4), which has returned to its normal size and shape; a patent junction (5); a morphologically normal nasolacrimal duct (8); and a patent valve of Hasner (9). The contrast medium is seen to spread between the lateral wall of the nose and the inferior turbinate (10).
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Figure 2b. Patient 8a. (a) Posteroanterior digital subtraction dacryocystographic image shows complete obstruction at the level of the junction between the lacrimal sac and duct. A large quantity of pus was found in the swollen lacrimal sac. The contrast medium was administered via a vascular sheath in the inferior canaliculus (1). The image also depicts the superior canaliculus (2), the common canaliculus (3), the distended lacrimal sac (4), and the obstruction at the level of the junction (5). (b) Posteroanterior radiograph of the lacrimal duct system shows the radiopaque stent (6) in the tract from the top of the lacrimal sac to the nasal floor. (c) Posteroanterior digital subtraction dacryocystographic image shows good patency of the stent. Contrast medium is running through and along the stent (6) into the nose (7). (d) Follow-up posteroanterior digital subtraction dacryocystographic image was obtained 4 months after removal of the stent. The lacrimal system is morphologically normal, and passage of contrast material is good. The image shows the lacrimal sac (4), which has returned to its normal size and shape; a patent junction (5); a morphologically normal nasolacrimal duct (8); and a patent valve of Hasner (9). The contrast medium is seen to spread between the lateral wall of the nose and the inferior turbinate (10).
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Figure 2c. Patient 8a. (a) Posteroanterior digital subtraction dacryocystographic image shows complete obstruction at the level of the junction between the lacrimal sac and duct. A large quantity of pus was found in the swollen lacrimal sac. The contrast medium was administered via a vascular sheath in the inferior canaliculus (1). The image also depicts the superior canaliculus (2), the common canaliculus (3), the distended lacrimal sac (4), and the obstruction at the level of the junction (5). (b) Posteroanterior radiograph of the lacrimal duct system shows the radiopaque stent (6) in the tract from the top of the lacrimal sac to the nasal floor. (c) Posteroanterior digital subtraction dacryocystographic image shows good patency of the stent. Contrast medium is running through and along the stent (6) into the nose (7). (d) Follow-up posteroanterior digital subtraction dacryocystographic image was obtained 4 months after removal of the stent. The lacrimal system is morphologically normal, and passage of contrast material is good. The image shows the lacrimal sac (4), which has returned to its normal size and shape; a patent junction (5); a morphologically normal nasolacrimal duct (8); and a patent valve of Hasner (9). The contrast medium is seen to spread between the lateral wall of the nose and the inferior turbinate (10).
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Figure 2d. Patient 8a. (a) Posteroanterior digital subtraction dacryocystographic image shows complete obstruction at the level of the junction between the lacrimal sac and duct. A large quantity of pus was found in the swollen lacrimal sac. The contrast medium was administered via a vascular sheath in the inferior canaliculus (1). The image also depicts the superior canaliculus (2), the common canaliculus (3), the distended lacrimal sac (4), and the obstruction at the level of the junction (5). (b) Posteroanterior radiograph of the lacrimal duct system shows the radiopaque stent (6) in the tract from the top of the lacrimal sac to the nasal floor. (c) Posteroanterior digital subtraction dacryocystographic image shows good patency of the stent. Contrast medium is running through and along the stent (6) into the nose (7). (d) Follow-up posteroanterior digital subtraction dacryocystographic image was obtained 4 months after removal of the stent. The lacrimal system is morphologically normal, and passage of contrast material is good. The image shows the lacrimal sac (4), which has returned to its normal size and shape; a patent junction (5); a morphologically normal nasolacrimal duct (8); and a patent valve of Hasner (9). The contrast medium is seen to spread between the lateral wall of the nose and the inferior turbinate (10).
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The third step of the procedure was dilation of the obstruction. The nasal mucosa was anesthetized with a nebulizer with 10% lidocaine (Xylocaine R spray 10%; Astra), and the guide wire was carefully passed through the obstruction with fluoroscopic guidance. When the guide wire was past the obstruction, it was advanced until it extended from the nose, and the vascular sheath was passed over the guide wire via the obstruction into the nose. The 0.025-inch wire was replaced with a 0.018-inch wire with a flexible, curved tip (Terumo, Tokyo, Japan) and, with fluoroscopic guidance, a balloon catheter was introduced retrogradely over the guide wire until it reached the place of the obstruction. Changing of the 0.025-inch wire was necessary because the balloon catheter was adjusted to a 0.018-inch wire. The-0.025 inch wire was used initially because of its excellent shapeability, pushability, and visibility with fluoroscopy. This part of the procedure has also been described in detail elsewhere (7,13). For balloon dilation, we preferred use of a flexible 3-mm-diameter 3.4-F catheter and a 20-mm-long balloon (No Tip Bijou 3.0-20; Schneider [Europe], Bulach, Switzerland) (Fig 1). We dilated the stenosis only once for a short time (10–20 seconds), just long enough to tear the fibrotic component of the obstruction, with an inflation pressure of 10 bar.
The fourth step of the procedure was placement of a stent in the nasolacrimal duct, immediately after removal of the balloon catheter. The stents were made of an 8- or 6-F polyurethane enteral feeding tube (Flocare R; Nutricia Nederland, Zoetermeer, the Netherlands). Before use, the tube was shortened to 4.5 cm (Fig 1) to ensure that the stent was visible just below the inferior turbinate after the procedure to enable easy removal after some weeks either via a nose speculum with pincers or with use of a wire loop and fluoroscopic guidance. The stent was passed retrogradely over the guide wire into the lacrimal system with use of the remaining part of the enteral feeding tube as a pusher (Fig 2b). If the mucosal fold at the distal end of the nasolacrimal duct, known as the valve of Hasner, could not be passed with the stent, an 8- or 6-F sheath was passed into the lacrimal system by using a well-tapered dilator. Finally, the lacrimal drainage system was flushed with contrast medium (Fig 2c) and saline solution to test the patency of the stent and to achieve maximum drainage of pus from the lacrimal system.
The treatment was supported with use of systemic and local antibiotics. We prescribed oral doxycycline (100 mg two times a day for 10 days) and eyedrops with 1 mg/mL dexamethasone and 3 mg/mL gentamicin sulfate (one drop four to six times daily in the involved eye for 10 days).
After several weeks, the stent was removed (average interval, 4.2 weeks; range, 2–6 weeks) (Table). Average follow-up after stent removal was 7.2 months (range, 2–13 months). At the end of the follow-up period, patients were asked whether epiphora had persisted, and they were examined by the referring ophthalmologist for any signs of inflammation of the lacrimal system. Patency and morphologic characteristics of the lacrimal duct system were evaluated with subtraction dacryocystography after stent removal and at the end of follow-up (Fig 2d).
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Results
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At stent removal after several weeks, dacryocystitis was cured in all patients, and there was no epiphora. Dacryocystography showed good patency in all cases, and dilatation of the lacrimal sac had disappeared. Figure 2 shows a representative lacrimal drainage system before, during, and after treatment.
At the end of the follow-up period, no recurrence of the inflammation was found in nine of 10 cases (Table). After a symptom-free period of several months, a low-grade chronic inflammation gradually developed in patient 6, in whom a reocclusion of the junction was found at the end of follow-up. In seven of the 10 cases, epiphora that had been present for a long time in most cases was found to have been cured at the end of the follow-up period. In patient 8b, there was a clear decrease in epiphora compared with that before abscess drainage, but epiphora had not been cleared up completely. Severe epiphora had recurred in patients 4 and 6. At the end of the follow-up period, good patency and normal morphologic characteristics of the lacrimal duct system were seen in five cases. In the other five cases (patients 3, 4, 5, 6, and 8b), including all three cases with extension of the obstruction along the nasolacrimal duct, complete reocclusion of the lacrimal drainage system was seen at the junction level. In patient 3, a mucocele (ie, a dilated lacrimal sac filled with mucus) was found.
Patients tolerated the treatment well with local anesthesia. Occasionally, a patient experienced some pain during balloon inflation. In all cases, there were no complications during the drainage procedure. No signs of spreading of the local infection were observed in the patients included in this study.
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Discussion
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Failure of antibiotic treatment of a lacrimal abscess due to chronic or subacute dacryocystitis is associated with obstruction of the lacrimal drainage system distal to the lacrimal sac, which prevents drainage of pus from the lacrimal sac. The treatment method described herein ensures pus drainage by means of a stent placed in the nasolacrimal duct. Stent placement in the nasolacrimal duct is not a new treatment strategy, and it is used with varying success rates to treat epiphora due to an obstruction of the lacrimal system. Interventional procedures in the lacrimal duct system have not been performed in the presence of an active infection because of the theoretic risk of spreading the inflammation (7,8,12), although, to our knowledge, no mention has been made of this complication in the literature. Our limited patient population included no cases in which the inflammation spread as a result of manipulation of the inflamed lacrimal system. We think that the risk of spreading the inflammation can be reduced by using a flexible, hydrophilic, coated atraumatic guide wire to pass the obstruction instead of a stiff wire or probe that might cause false passage. We believe that manipulation in the lacrimal drainage system is contraindicated in cases of acute dacryocystitis because of the much higher potential risk that the inflammation will spread. Potential complications when the inflammation spreads include extension around the lacrimal sac (pericystitis) or to the orbita (orbital cellulitis). At worst, an orbital abscess might develop that is potentially life threatening. Acute dacryocystitis is treated with antibiotics, possibly supplemented with sac decompression, for instance by means of direct percutaneous puncture of the lacrimal sac.
We decided to perform temporary stent placement in the nasolacrimal duct because the stent was intended to facilitate only drainage of the lacrimal system during treatment and because there are some disadvantages associated with long-term stent placement. One of the disadvantages is that the long-term presence of a foreign body in the lacrimal system will cause chronic inflammation of the lacrimal system in the longer or shorter term (7). Another disadvantage is that long-term stent placement does not guarantee permanent patency of the lacrimal system, because stents can be obstructed by mucus or ingrowing granulation tissue (11), which necessitate stent removal. In the majority of cases, reocclusion will occur rapidly after removal of a stent that has been in place for a long time (11).
Although lacrimal stents are commercially available (10,11), we prefer to use a stent fabricated from a polyurethane enteral feeding tube in the interventional suite during the procedure. These stents are inexpensive, easy to position, and easily visible with fluoroscopy. No dislocation or obstruction of stents was observed in this study.
Temporary stent placement in the nasolacrimal duct to relieve an abscess of the lacrimal sac was supported with use of systemic and topical broad-spectrum antibiotics. The pus that was present in the lacrimal sac was not routinely cultured because the organisms involved in chronic dacryocystitis are usually commensal organisms within the duct, such as staphylococcus and streptococcus (14), that are sensitive to the usual broad-spectrum antibiotic regimen. In our opinion, failure of antibiotic treatment of a chronic lacrimal abscess is not attributable to the choice of antibiotic agent or the sensitivity of the organisms involved but rather to obstruction of the lacrimal duct system distal to the lacrimal sac. This prevents drainage of pus from the abscess during the treatment with antibiotics or causes a reinfection with commensal organisms shortly after the treatment has ended. We think that culturing is indicated in only cases in which the treatment with antibiotics during stent placement is not successful.
Treatment appeared to be successful in our small patient group with respect to curing the infection. Lacrimal abscess had disappeared in all cases. In nine of the 10 cases the lacrimal drainage system showed no sign of infection, and minor signs of chronic infection developed in only one patient in the course of the follow-up period. Patency of the lacrimal system persisted in only five of the 10 cases at the end of follow-up. This is consistent with findings reported by other authors (11), who describe recurrent obstructions after removal of stents that have been in the lacrimal system for a longer period (months or years) to treat epiphora due to obstruction of the lacrimal drainage system. It is also consistent with reports by authors (7,8) who consider an infection of the lacrimal system as a contraindication for dacryocystoplasty with balloon dilation because of the high percentage of reocclusions. If a reobstruction causes epiphora or a mucocele, the obstruction can be treated when the symptoms of infection have disappeared after dacryocystoplasty with balloon dilation or surgical dacryocystorhinostomy. Reobstruction of the lacrimal system after stent removal does not cause recurrence of epiphora in all cases; patients 3 and 5 in our study did not experience recurrence of epiphora. This may be explained by increased tear secretion due to the infection of the lacrimal system. When the infection is cured, the reflex hypersecretion disappears and tear production returns to an age-related normal level. In elderly people, this level can be so low that no epiphora occurs even when the lacrimal system is obstructed (15).
Previous surgical dacryocystorhinostomy is not a contraindication for treatment. Dacryocystorhinostomy for severe epiphora was performed in patients 2 and 5 at 1–2 years before abscess drainage. They developed recurrent epiphora shortly after surgery that was complicated by intermittent infections of the lacrimal duct system. At computed tomographic (CT) dacryocystography (ie, CT of the lacrimal duct system after injection of contrast medium into the lacrimal duct system [13,16]) in both cases, full reclosure of the surgically created opening between the lacrimal sac and the nose was seen. In these patients, the stent was placed in the nasolacrimal duct, not in the reobstructed surgically created opening.
In conclusion, temporary stent placement in the nasolacrimal duct supported with use of local and systemic antibiotics is a suggested treatment for lacrimal abscess due to chronic or subacute dacryocystitis that appears to be promising to treat the infection and attendant epiphora, but long-term patency of the lacrimal duct system is not ensured. Additional treatment with dacryocystoplasty with balloon dilation or surgical dacryocystorhinostomy must be considered if reobstruction of the lacrimal duct system occurs.
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Acknowledgments
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We thank Mereke L. B. Gorsira, BA, for correcting the English in the manuscript for this article and Ad J. Petersen for his help with the images.
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Footnotes
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Author contributions: Guarantors of integrity of entire study, all authors; study concepts, A.G.J., K.M.; study design, A.G.J., K.M., J.J.B.; definition of intellectual content, A.G.J., K.M.; literature research, A.G.J.; clinical studies, A.G.J.; data acquisition, A.G.J.; data analysis, J.J.B.; manuscript preparation and editing, A.G.J.; manuscript review, R.A.M., J.A.C.
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Abstract
Introduction
