Lacrimal sump syndrome

From EyeWiki


The lacrimal sump syndrome can be a cause of failed dacryocystorhinostomy surgery (DCR). It occurs when a remnant pouch of lacrimal sac retains tears and interrupts transit into the nose. When recognized, surgical revision is usually straightforward and successful.

Disease Entity

Lacrimal sump syndrome

Disease

Lacrimal sump syndrome

Etiology

Lacrimal sump syndrome occurs following DCR when the inferior portion of the lacrimal sac is incompletely opened such that dependent fluid continues to collect in the sac, or when mucosal healing leads to re-approximation of cut surfaces. It may be seen following both external and endonasal DCR.

Risk Factors

  • Inadequate bony osteotomy and poor exposure of the dependent inferior portion of the lacrimal sac.
  • Incomplete opening of the lacrimal sac.
  • Inadequate securing of proper mucosal flap position, particularly the inferior and superior edges of the flaps.
  • Intranasal adhesions.

Pathophysiology

Tear transit through the lacrimal system is stalled as tears collect in the remnant lacrimal sac before overflow and nasal drainage.

Primary prevention

  • Adequate bony osteotomy allowing complete opening of the lacrimal sac. Some authors advocate opening the superior portion of the nasolacrimal duct.
  • Secure placement of mucosal flaps to prevent sac reformation.
  • Management of intranasal pathology (ex. corticosteroid spray, partial middle turbinate resection) to limit adhesion.

Diagnosis

Lacrimal sump syndrome may be suspected on clinical grounds and/or confirmed by dacryocystogram, radiographic imaging, or endonasal examination.

Clinical diagnosis

Patients experience epiphora following DCR. Pressure over the medial canthus may expel the collected fluid from the sac and into the nose, which may be felt by the patient. This can lead to transient improvement in tearing.

Diagnostic procedures

  • Irrigation frequently suggests patency.
  • Dye disappearance test may show delayed transit.
  • Dacryocystogram (DCG) will demonstrate contrast entering the nose, but also retained in the lacrimal sac remnant, which is usually dilated.
  • Endoscopic endonasal examination with probing of the upper system can demonstrate the residual sac. Endoscopic examination of dye transit can also be useful when possible.

Differential diagnosis

  • Common canalicular obstruction
  • Scarring of osteotomy site
  • Incomplete clearance of anterior ethmoidal air cell
  • Intranasal adhesion
  • Lacrimal pump failure
  • Reflex tearing

Management

If the tearing is sufficient for the patient to request treatment, surgery is required.

Surgery

Re-operation to address the sump syndrome can be performed through an external or endonasal approach. Cutting into the residual sac will disclose retained mucoid material. Additional bone removal may be required in order to open the sac completely. Care should be taken to prevent reformation. This may require mucosal excision, or flaps oriented with wide spacing.

Complications

Potentially the same as primary DCR; however, expected to be less frequent given the reduced tissue manipulation involved.

Prognosis

Small series have reported very high rates of success with surgery.


References

  1. Welham RAN, Wulc AE. Management of unsuccessful lacrimal surgery. Br J Ophthalmol 1987;71:152-157.
  2. Jordan DR, McDonald H. Failed dacryocystorhinostomy: the sump syndrome. Ophthalmic Surg 1993;24:692-693.
  3. Migliori ME. Endoscopic evaluation and management of the lacrimal sump syndrome. Ophthal Plast Reconstr Surg 1997;13:281-284.