Lacrimal sac compression by an anterior ethmoidal mucocele presenting as a late complication of dacryocystorhinostomy
A 22-year-old lady presented to the Joint Ophthalmology & ENT watery eye clinic with a 12-month history of a painless lump in the medial corner of her left eye, which was not increasing in size. Six months after noticing this painless lump, she developed left-sided intermittent epiphora. At the age of 10, she first had a watery left eye, and following a DCR when she was 15 years old, her symptoms seemed to resolve until this episode. She denied any nasal symptoms.\nShe had a history of depression, for which she was on fluoxetine but was otherwise well. She smoked three cigarettes per day and drank alcohol occasionally.\nClinical examination revealed a small cystic swelling in her left medial canthus (Fig. ). There was no discharge on pressure, mild tenderness was elicited and the swelling was not compressible. The rest of the eye examination was normal with a visual acuity of 6/6 in both eyes.\nAnterior rhinoscopy showed a reasonable nasal airway with healthy mucosal lining. Flexible nasendoscopy revealed no nasal lesions with the septum slightly deviated to the right.\nAn MRI scan of the orbits showed a well-defined, thin-walled 22 × 16 mm cyst medial to the left orbit containing fatty/proteinaceous material, which was lying within and mildly expanding the left ethmoid air cells (Figs –).\nA CT scan of the paranasal sinuses and orbits revealed the cystic expansile 1.6 cm mass at the left medial canthus to be of soft tissue density. The lateral wall of the mass expanded outwards into the orbit (suggesting an anterior ethmoidal mucocele) rather than being pushed medially (which could have been indicative of a dacryocystocele) (Fig. ).\nAll pre-operative blood tests were normal. A joint operating session by the ENT and Ophthalmic surgeons was planned with a view to performing an endoscopic left anterior ethmoidectomy with marsupialisation of the mucocele in combination with an endoscopic DCR.\nThe puncti were probed (Fig. ) and fluorescein dye instilled with no dye outflow to the left inferior meatus. It was not possible to pass the probe through the upper punctum so a mini-monoka DCR stent was inserted and secured (Figs. and ). Chloramphenicol eye drops were instilled.\nThe nasal cavity was prepared with modified Moffet's solution and a Storz 30° endoscope used with visualisation of the nasal cavity on a monitor. An inferiorly based mucosal flap was elevated on the lateral nasal wall (Fig. ) with the incision performed using a small myotome. Removal of part of the lateral nasal wall anterior to uncinate process was performed for access to the lacrimal system (unciformian endonasal DCR)\n30° punch forceps were used to nibble bone sequentially for adequate exposure. Further drilling of the lateral bony wall was undertaken with a small cutting burr. An endoscopic left anterior ethmoidectomy was performed (Fig. ) with marsupialisation of the mucocele (Fig. ) and trimming of the DCR stent (Fig. )\nPost-operatively, she was discharged the next day and advised to administer chloramphenicol eyedrops as well as betnesol nasal drops for a week. The DCR stent remained in situ for 3 months and was removed in the clinic. There was clinical resolution of the medial canthal swelling and epiphora.