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Year : 2022  |  Volume : 2  |  Issue : 3  |  Page : 835-836

Endoscopic features of lacrimal sac and nasolacrimal duct in a child with all four punctal and canalicular agenesis

Department of Otorhinolaryngology, Dr Shroff's Charity Eye Hospital, Daryaganj, New Delhi, India

Date of Submission26-Feb-2022
Date of Acceptance27-May-2022
Date of Web Publication16-Jul-2022

Correspondence Address:
Dr. Nishi Gupta
Dr. Shroff's Charity Eye Hospital, Daryaganj, New Delhi - 110 002
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_539_22

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Keywords: Agenesis, congenital nasolacrimal duct, epiphora, lacrimal puncta, lacrimal sac

How to cite this article:
Gupta N, Ganesh S, Jain S, Gandhi A. Endoscopic features of lacrimal sac and nasolacrimal duct in a child with all four punctal and canalicular agenesis. Indian J Ophthalmol Case Rep 2022;2:835-6

How to cite this URL:
Gupta N, Ganesh S, Jain S, Gandhi A. Endoscopic features of lacrimal sac and nasolacrimal duct in a child with all four punctal and canalicular agenesis. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 19];2:835-6. Available from: https://www.ijoreports.in/text.asp?2022/2/3/835/351200

There have been very few reports of all four punctal agenesis in children presenting with congenital nasolacrimal duct obstruction in the literature, and even fewer with associated lacrimal sac and nasolacrimal duct (NLD) abnormalities.[1],[2]

An 11-year-old boy presented with a large medial canthal swelling on the left side of two years duration [Figure 1]a. He also complained of bilateral epiphora, and upon examination, there were signs of punctal agenesis on both sides [Figure 1]b. On computed tomography, the right NLD seemed normal, but the left NLD exhibited proximal dilatation and a bony obstruction at the bottom that separated it from the inferior meatus [Figure 1]c. The right NLD was normal and patent on nasal endoscopy, but the left NLD opening was missing in the inferior meatus [Figure 1]d, a finding consistent with computed tomography (CT) results. Lacrimal sac mucocele was caused by a blocked NLD on the left.
Figure 1: (a) A clinical image of a child with swelling in the left medial canthus and a high tear film in the right eye; (b) An enlarged endoscopic view of bilateral upper and lower eyelids with agenesis of all four puncta; (c) CT scan of a dilated sac and a dilated and obstructed NLD (yellow arrow) on the left and a normal nasolacrimal system on the right (red arrow); (d) Endoscopic image of the left nasal cavity, the inferior turbinate (IT) (yellow arrow) has been retracted away from the lateral wall (LW) (star) of the nose, and the distal NLD aperture in the inferior meatus (IM) is missing (white arrow)

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The lacrimal sac was observed to be dilated with thin, translucent walls during endoscopic osteotomy [[Figure 2]a, red star]. The lacrimal sac was marsupialized, revealing mucoid fluid and weak membranous sac flaps that made attaining a satisfactory lacrimal sac mucosa to nasal mucosa approximation difficult [[Figure 2]b, star]. The nasolacrimal duct was found to be grossly dilated [[Figure 2]c pointer]. Histopathology revealed an irregular lumen lined by thinned out pseudostratified columnar epithelium with goblet cells [Figure 2]d.
Figure 2: (a) A left endoscopic dacryocystorhinostomy (DCR) was done to reveal a very thin and transparent maldeveloped lacrimal sac (red star). Middle turbinate is visible medial to it (black star); (b) As the lacrimal sac is dissected, mucoid fluid drains and a clear lumen is visible (red star). The common canalicular opening is absent, and membranous sac walls have given way. Flaps cannot be formed since there are no well-defined sac walls; (c) A close endoscopic image of sac lumen reveals sac duct junction (white arrow) and a dilated NLD (pointer); (d) A microphotograph shows columnar epithelium and goblet cells

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  Discussion Top

The membranous lacrimal sac flaps indicate that the lacrimal sac has not fully formed. Thus, in cases of proximal lacrimal agenesis, distal lacrimal dysgenesis may be present, affecting surgical planning.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Yuen SJ, Oley C, Sullivan TJ. Lacrimal outflow dysgenesis. Ophthalmology 2004;111:1782-90.  Back to cited text no. 1
Ali MJ, Singh S, Naik MN. Endoscopic features of a lacrimal sac in a case of punctal and canalicular agenesis. Ophthal Plast Reconstr Surg 2017;33:153-4.  Back to cited text no. 2


  [Figure 1], [Figure 2]


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