Clinicopathological Study of Lacrimal Sac Dacryolith in Patients Treated for Nasolacrimal Duct Obstruction

Seung Woo Choi; Jong Seo Park; A Young Kwon; Helen Lew

doi:10.3341/jkos.2016.57.1.6

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Choi, Park, Kwon, and Lew: Clinicopathological Study of Lacrimal Sac Dacryolith in Patients Treated for Nasolacrimal Duct Obstruction

Original Article

J Korean Ophthalmol Soc 2015;57(1):6-13.

Published online: 29 August 2015

DOI: https://doi.org/10.3341/jkos.2016.57.1.6

Clinicopathological Study of Lacrimal Sac Dacryolith in Patients Treated for Nasolacrimal Duct Obstruction

Seung Woo Choi, M.D¹, Jong Seo Park, M.D¹, A Young Kwon, M.D², Helen Lew, M.D^1,

¹Department of Ophthalmology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea

²Department of Pathology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea

Address reprint requests to Helen Lew, MD Department of Ophthalmology, CHA Bundang Medical Center, #59 Yatap-ro, Bundang-gu, Seongnam 13496, Korea Tel: 82-31-780-5330, Fax: 82-31-780-5333 E-mail: eye@cha.ac.kr

‗ This study was presented as a narration at the 113th Annual Meeting of the Korean Ophthalmological Society 2015.

Received 12 June 201524 August 2015 Accepted 15 October 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To evaluate the correlation between clinical manifestation of patients with nasolacrimal duct obstruction and patho-logical characteristics of lacrimal sac and dacryolith found during endoscopic dacryocystorhinostomy.

Methods

This retrospective study included 158 patients (189 eyes) who received endoscopic dacryocystorhinostomy. We defined lacrimal dacryolith by gross discovery in the lacrimal sac during surgery or findings during pathological examination as dacryolith or calcification, including size and distribution in pathology slides. We correlated the relationship between the patients’ clinical manifestations, surgical results, lacrimal sac's pathological findings including calcification, inflammation and fibrosis, and patho-logical findings of lacrimal sac dacryolith.

Results

Dacryolith was found in 61 eyes (32.3%) and among them, grossly found in 13 eyes (6.9%). Dacryolith's filling defect on dacryocystography was found in 17 eyes (9.0%) and based on grossly found dacryolith, dacryocystography's sensitivity and specif-icity were 58.8% and 1.7%, respectively. The average size of dacryolith was 0.3 ± 0.8 mm² with an average distribution of 20.1 ±17.9%. Distribution of dacryolith and the proportions of inflammatory cells and fibrosis in the lacrimal sac were negatively correlated ( p < 0.05). The size of dacryolith and the proportions of fibrosis in the lacrimal sac were also negatively correlated ( p = 0.008). In cases where the proportion of calcification in pathology slides was over 50%, the duration of symptoms in the calcification-dominant group was shorter than in other groups ( p = 0.006). The success rates of endoscopic dacryocystorhinostomy with dacryolith and without dacryolith were 91.8% and 80.5%, respectively ( p = 0.046).

Conclusions

The patients with lacrimal sac dacryolith in nasolacrimal duct obstruction showed shorter duration of symptoms, lower fibrosis of lacrimal sac, and higher surgical success rates than the other cases. Therefore, additional research may be necessary to determine the mechanism of dacryolith formation and early treatment in nasolacrimal duct obstruction with lacrimal sac dacryolith.

Keywords: Dacryolith, Endoscopic dacryocystorhinostomy, Lacrimal sac, Nasolacrimal duct obstruction, Pathology

References

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Figure 1.

Histopathologic findings of calcification in lacrimal sac dacryolith. (A) Lacrimal sac epithelium. (B) Submucosa layer. (C) Calcification (Hematoxylin & Eosin stain, ×100).

Figure 2.

Measurement of size for lacrimal sac dacryolith. Size (mm²) = longest length (A) × shortest length (B) of da-cryolith (Hematoxylin & Eosin stain, ×100).

Figure 3.

The major pathologic findings of the lacrimal sac. (A) Calcification-dominant lacrimal sac (Hematoxylin & Eosin stain, ×100). (B) Inflammation-dominant lacrimal sac (Hematoxylin & Eosin stain, ×100). (C) Fibrosis-dominant lacrimal sac (Hematoxylin & Eosin stain, ×100).

Figure 4.

Histopathologic analysis of lacrimal sac based on the severity of fibrosis and inflammation. (A) Indicator for measurement of tissue’s occupying ratio (arrow, 150 μ m-sized, HE stain, ×100). (B) Inflammatory portion of lacrimal sac (surrounded by dash-ed-line, HE stain, ×100; Black solid line = 150 μ m). (C) Fibrotic portion of lacrimal sac (surrounded by dashed-line, HE stain, ×100; Black solid line = 150 μ m). HE = Hematoxylin & Eosin.

Figure 5.

The results of dacryocystography in patients with dacryolith. (A) Filling defect of lacrimal sac in dacryocystography’s finding. (B) Nasolacrimal duct stenosis without filling defect of the lacrimal sac.

Figure 6.

The results of correlation analysis between pathologic properties of dacryolith and the lacrimal sac.

Table 1.

Demographic characteristics of the patients treated with endoscopic dacryocystorhinostomy

	Dacryolith (+)	Dacryolith (-)	Total	p-value^*
Cases (%)	61 (32.3)	128 (67.7)	189
Sex (male:female)	11:50	26:102	37:152	0.76
Age (years)	58.0 ± 14.2	57.2 ± 13.3	57.6 ± 13.8	0.74
Duration of tearing (months)	72.0 ± 73.4	79.3 ± 94.7	75.9 ± 85.3	0.62

Values are presented as mean ± SD unless otherwise indicated.

^* By student t-test.

Table 2.

Dacryocystographic findings related with lacrimal sac dacryolith grossly found in operation

	DCG filling defect^*
	Presence (%)	Absence (%)
Grossly found dacryolith in operation
Presence (n = 13)	10 (76.9)	3 (23.1)
Absence (n = 176)	7 (4.0)	169 (96.0)
Total (n = 189)	17 (9.0)	172 (91.0)

DCG = dacryocystography.

^* Pearson χ² 78.694 ( p = 0.00).

Table 3.

The distribution of dacryolith according to pathologic findings of the lacrimal sac in the total patients

Pathologic findings of lacrimal sac	Dacryolith
	Presence (%)	Absence (%)
Calcification dominant (n = 9)	9 (100.0)	0 (0.0)
Inflammation dominant (n = 36)	9 (25.0)^*	27 (75.0)^*
Fibrosis dominant (n = 144)	43 (29.9)^*	101 (70.1)^*
Total (n = 189)	61 (32.3)	128 (67.7)

^* Pearson χ² 0.331 ( p = 0.57).

Table 4.

Clinical characteristics according to the major pathologic findings of the lacrimal sac

Major pathologic findings	Duration of tearing (months)	History of eye discharge (number of eyes)	Syringing score^*	LTMH (μ m)^†
Calcification dominant (n = 9)	31.2 ± 39.3^‡	4	1.9 ± 0.9	484.5 ± 255.5
Non-calcification dominant (n = 52)	79.9 ± 76.1^‡	23	2.1 ± 0.8	578.9 ± 420.6
Inflammation dominant (n = 9)	67.7 ± 80.6	5	1.9 ± 0.9	578.5 ± 153.4
Fibrosis dominant (n = 43)	81.9 ± 76.1	18	2.2 ± 0.8	579.0 ± 438.8

Values are presented as mean ± SD unless otherwise indicated.

LTMH = lower tear meniscus height.

^* The results of canaliculus irrigation test. 1 for complete passage, 2 for partial passage and 3 for no passage

^† Lower tear meniscus height meas-ured with anteiror segment optical coherence tomography) (Spectralis optical coherence tomography [OCT], Heidelberg Engineering, Heidelberg, Germany)

^‡ p = 0.006, Mann-Whitney test.

Table 5.

Correlation analysis between pathologic properties of lacrimal sac dacryolith and lacrimal sac and clinical findings (n = 61)

	Lacrimal sac dacryolith	Duration of tearing^*	Syringing score^*†	LTMH^*‡
Size (mm²)	0.3 ± 0.8	0.07 (0.59)	-0.18 (0.17)	-0.17 (0.39)
Distribution (%)	20.1 ± 17.9	-0.01 (0.97)	-0.11 (0.40)	-0.15 (0.44)

Values are presented as mean ± SD unless otherwise indicated.

LTMH = lower tear meniscus height.

^* Pearson coefficient of correlation ( p-value)

^† The results of canaliculus irrigation test. 1 for complete passage, 2 for partial passage and 3 for no passage

^‡ Lower tear meniscus height measured with anteiror segment optical coherence tomography (Spectralis OCT, Heidelberg Engineering, Heidelberg, Germany).

Table 6.

The success rate of endoscopic dacryocystorhinostom according to lacrimal sac dacryolith

Endoscopic dacryocystorhinostomy	Dacryolith
	Presence (%)	Absence (%)
Success (%)^*	56 (91.8)	103 (80.5)
Failure (%)	5 (8.2)	25 (19.5)
Total (n = 189)	61 (100)	128 (100)

^* Pearson χ² 3.98 ( p = 0.046).

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