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 Table of Contents  
PHOTO ESSAY
Year : 2021  |  Volume : 1  |  Issue : 4  |  Page : 844-845

Endoscopic features of a giant mucopeptide concretion of the lacrimal sac


1 Department of Ophthalmology, Jozef Strus City Hospital, Poznan, Poland
2 ‘Govindram Seksaria Institute of Dacryology’, L.V. Prasad Eye Institute, Hyderabad, Telangana, India

Date of Submission20-Jan-2021
Date of Acceptance20-Mar-2021
Date of Web Publication09-Oct-2021

Correspondence Address:
Dr. Mohammad Javed Ali
L.V. Prasad Eye Institute, Road No 2, Banjara Hills, Hyderabad - 34, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_171_21

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How to cite this article:
Nowak R, Ali MJ. Endoscopic features of a giant mucopeptide concretion of the lacrimal sac. Indian J Ophthalmol Case Rep 2021;1:844-5

How to cite this URL:
Nowak R, Ali MJ. Endoscopic features of a giant mucopeptide concretion of the lacrimal sac. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Oct 18];1:844-5. Available from: https://www.ijoreports.in/text.asp?2021/1/4/844/327718



The presence of mucopeptide concretions (MPC) or dacryoliths within the lacrimal sac is well known; with recent literature decoding their possible etiopathogenesis.[1],[2],[3],[4] Giant mucopeptide concretions are uncommon in the lacrimal sac, and they usually mold to the shape of the sac beyond a specific size. A 49-year-old female patient presented with a 14-month history of a left-sided epiphora and a soft palpable lacrimal sac swelling. The lacrimal sac irrigation was not patent. The patient was diagnosed with primary acquired nasolacrimal duct obstruction (PANDO) and an evolving mucocele. The patient underwent a left powered endoscopic dacryocystorhinostomy. Following the osteotomy, the sac was found to be bulging and stretched all around [[Figure 1], Panel A]. However, there was no breach of the sac wall (Panel A). The sac was initially marsupialized at the sac duct junction to rule out any mass lesion or tumor growth, which was not present. Subsequently, a full-length marsupialization of the lacrimal sac revealed a large dirty-yellow mucopeptide concretion protruding beyond the sac's dimensions (Panel B). With the help of a fine angulated ball probe and gentle maneuvering, the giant concretion was removed from the sac.
Figure 1: Endoscopic image of the left nasal cavity demonstrating an expanded lacrimal sac (Panel A). A giant mucopeptide concretion was noted following the sac marsupialization (Panel B). The giant concretion teased out of the sac (Panel C) and its measurements (Panel D)

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Further endoscopic evaluation did not reveal any residual or other smaller concretions. The concretion had taken the shape of the lacrimal sac and had both smooth and irregular surfaces (Panels C and D). The rest of the surgery and post-operative course was uneventful. Upon follow up, the ostium was patent, and the patient reported subjective resolution of epiphora. Large mucopeptide concretions are known to take the shape of the lacrimal sac and can occasionally be an accidental finding during a dacryocystorhinostomy. Endoscopy guidance helps in the careful evacuation of the giant concretion and also assess the presence of other smaller ones.


  Discussion Top


Detailed immunohistochemical, electron microscopic and cinematic rendering studies have shown that the core of the MPC is blood-derived network of fibrillary tangles with interspersed blood cells.[1],[2],[3],[4] Around the core is the serial laying of mucopeptides. The currently believed pathogenesis is that in susceptible individuals, the initiating event is a blood leak following chemical or a mechanical trauma to the lacrimal sac epithelium. This leaked blood would act as a nidus, around which the mucopeptides (following their increased upregulation locally and in tears) are progressively deposited to form the mucopeptide concretions.

Financial disclosure

Mohammad Javed Ali receives royalties from Springer for the textbook “Principles and Practice of Lacrimal Surgery', ' Atlas More Details of Lacrimal Drainage Disorders', and 'Video-atlas of lacrimal surgery'.

Financial support and sponsorship

Hyderabad Eye Research Foundation.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mishra K, Hu KY, Kamal S, Andron A, Della Rocca RC, Ali MJ, et al. Dacryolithiasis: A review. Ophthalmic Plast Reconstr Surg 2017;33:83-9.  Back to cited text no. 1
    
2.
Ali MJ, Schicht M, Heichel J, Nadimpalli SK, Paulsen F. Electron microscopic features of the lacrimal sac mucopeptide concretions. Graefes Arch Clin Exp Ophthalmol 2018;256:1313-8.  Back to cited text no. 2
    
3.
Ali MJ, Heichel J, Paulsen F. Immunohistochemical analysis of the lacrimal sac mucopeptide concretions. Ophthalmic Plast Reconstr Surg 2019;35:562-5.  Back to cited text no. 3
    
4.
Ali MJ, Scholz M, Singh S, Heichel J, Paulsen F. Etiopathogenesis of lacrimal sac mucopeptide concretions: Insights from cinematic rendering techniques. Graefes Arch Clin Exp Ophthalmol 2020;258:2299-303.  Back to cited text no. 4
    


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