
 an acquired dacryocystocele is a diffuse and centrifugal enlargement of the lacrimal sac that forms as a result of obstruction of lacrimal drainage system proximally at the level of the common canaliculus and distally at the level of nasolacrimal duct .
findings associated with dacryocystocele are irreversible fibrotic narrowing in the lacrimal system , osseous changes in the nasolacrimal duct and chronic and low - grade inflammation . adult dacryocystoceles are often observed after dacryocystitis ; however , they may also develop idiopathically or due to autoimmune fibrous diseases , sinusitis and paranasal sinus mucoceles , after trauma or osseous configuration in the dysplastic duct wall and tumors , or secondarily to dacryocystorhinostomy surgeries . in computerized tomography ( ct ) and magnetic resonance imaging ( mri ) ,
a dacryocystocele appears as a fluid collection that is separated from other solid structures by a thin rim .
differential diagnosis includes malformations of the lacrimal sac , diverticulum , dermoid and epidermoid cysts , encephalocele , primary epithelial tumors of the sac , and external tumors . in this study
, we aimed to determine the probable etiology as well as clinical , microbiological , histopathological , and radiological findings of dacryocystoceles in acquired dacryocystocele cases . to our knowledge , this is one of the largest case series published of acquired dacryocystoceles in adult patients .
in the study , the charts of patients who had undergone external dacryocystorhinostomy ( edcr ) surgery in our clinic between 2008 and 2013 were reviewed retrospectively , and 10 eyes of 8 patients who were diagnosed with dacryocystocele were included in the study .
the median follow - up time for those patients was 22 months ( range 13 to 38 months ) .
the study was conducted in accordance with the tenets of the declaration of helsinki by obtaining written consent from all patients , with the approval of the local ethical review board .
complete ophthalmologic examinations , nose examinations , and ct imaging were done preoperatively for all cases .
those patients who had epiphora complaints , who were observed with a palpable mass at the medial chantal region and no pus coming out from the lower and upper punctum when the mass was pressed with a finger , and who showed a soft ending when a lavage cannula was placed into the punctum were diagnosed with dacryocystocele .
culture specimens were collected from the surgically excised lacrimal sac walls and fluid samples were collected perioperatively for microbiological analysis . the material was also smeared onto sterile labeled glass slides for 10% potassium hydroxide
wet mount , gram stain , giemsa stain , ziehl - neelsen acid fast stain , and kinyoun 's acid fast stain .
specimens were inoculated into sheep 's blood agar , chocolate agar , sabouraud 's dextrose agar , brain heart infusion broth , and thioglycollate medium . at the stage of preparation of preoperative lacrimal sac flaps ,
incisional biopsy samples were collected from the lacrimal sac for histopathological assessment to establish a differential diagnosis .
, an obstruction was experienced in the common canaliculus and it was noted that the obstruction was overcome with a click sound while inserting the intubation tube .
routine external dcr operations were completed and control examinations were made on postoperative day 1 , week 1 , and month 1 and month 3 , month 6 , and then yearly .
anatomic success was assessed by diagnostic probing with a hard stop and irrigation through the passage in all adult patients .
the records of 412 patients who underwent external dcr surgery due to acquired nasolacrimal duct obstruction were reviewed retrospectively .
a total of 10 eyes of 8 patients ( 4 females and 4 males , aged 29 to 75 , mean 52  16.1 years ) with dacryocystoceles were included in this study .
the most common initial symptoms and findings were epiphora ( 100% ) and palpable mass ( 100% ) in the medial canthal area ( figures 1(a ) and 1(b ) ) . in the histories of the patients ,
it was observed that there was the history of a mass in the lacrimal sac region unaccompanied by inflammation in 7 eyes ( 70% ) and dacryocystitis history in 3 eyes ( 30% ) which had been treated in accordance with the diagnosis of acute dacryocystitis . in the initial examination
there was no acute dacryocystitis , trauma history , or any local or systemic disorder which could result in damage in the lacrimal system . in nose examinations ,
computerized tomography imaging demonstrated the fluid collection separated from adjacent tissues by a thin rim corresponding to a dacryocystocele in the sac , but no further lesions ( figures 3(a ) and 3(b ) ) . in the histopathological evaluation of the sample collected from the lacrimal sac wall during surgery
, chronic inflammation findings were observed in all eyes ( 100% ) as well as fibrosis in 2 eyes ( 20% ) ( figure 2 ) .
again , in the microbiological examination of the fluid samples collected from within the cyst during surgery , no bacteria growth in 5 eyes ( 50% ) , gram negative bacillus in 3 eyes ( 30% ) , and gram positive cocci in 2 eyes ( 20% ) were observed ( table 1 ) .
all cases were treated with external dcr combined with bicanalicular silicone tube placement , and no complications were observed , at least at annual follow - ups .
an acquired dacryocystocele is a rare , benign , and painless mass located at the side of the lacrimal sac .
dacryocystoceles usually occur congenitally or less frequently as a result of chronic inflammation , surgeries , and tumors which originate from medial canthal region or sinuses , radiation therapy , or as a side effect of chemotherapeutic drugs .
previously published literature about dacryocystoceles is mostly related to the congenital form . in congenital cases
particularly , dacryocystocele occurrence has been explained as the obstruction of the common canaliculi and lacrimal sac junction , by enlargement of the sac fundus which limits the movement of the rosenmuller valve indirectly , and obstruction of the distal duct by the presence of a persistent membrane between the lacrimal duct and nasal mucosal epithelium , which is present in many newborns [ 35 ] . in patients who develop dacryocystitis following nasolacrimal duct obstruction ( nldo ) , infective materials that accumulate in the sac may enlarge the sac in a form similar to congenital dacryocystocele .
reasons such as the limitation of the movement of the valve , damage to the valve epithelium due to an infective environment , and chronic inflammation may lead to irreversible synechia in the common canaliculus . in our study , a history of dacryocystitis was detected in 3 eyes ( 30% ) , whereas there was no history of dacryocystitis in 7 eyes ( 70% ) ; therefore , these cases were assessed as idiopathic dacryocystocele .
then , one comes to the question as to why the common canaliculus does not get blocked after every chronic dacryocystitis , or in other words , why dacryocystocele does not develop in all chronic dacryocystitis cases . taking this question as the starting point
, we strived to understand the histopathological causes for patients who develop dacryocystocele after nldo , by collecting preoperative microbiological samples and perioperative biopsy samples from the lacrimal sac .
histologically evaluated dacryocystoceles and detected chronic inflammation from the cystic wall of the patients ' samples ,   whereas woo and kim , in their series of 4 cases , identified partial necrotic changes in addition to chronic inflammation . in our study , we collected specimens from all patients with dacryocystoceles perioperatively , and only the cultures of 5 eyes reproduced bacteria .
further , as the bacteria strains produced were different from each other , we concluded that the formation of dacryocystoceles is not associated with a specific pathogenic agent .
perry et al . reported that prevotella ( gram (  ) bacillus ) and peptostreptococcus ( an aerobic gram ( + ) coccus ) grew in the microbiological analysis of specimens from the dacryocystomucopyocele fluid , which are members of the normal otolaryngeal flora .
reported two familial cases one of which was determined as bilateral dacryocystoceles and the other as unilateral dacryocystoceles .
woo and kim reported bilateral dacryocystoceles in one out of the four cases which was a congenital case associated with punctual agenesis .
we observed bilateral dacryocystoceles in two cases none of which was associated with punctual or canalicular agenesis .
studied the imaging characteristics of dacryocystoceles that occurred after surgery for sinonasal cancers and reported that ct and mr imaging revealed characteristic findings such as a cystic , fluid filled structure with thin rim enhancement and no solid components . in accordance with these findings , we performed ct imaging in all cases in our study , which demonstrated fluid collection separated from adjacent tissues by a thin rim corresponding to a dacryocystocele in the medial canthal area but no other pathologic lesions .
the treatment of dacryocystoceles includes conservative management and drainage followed by external or endoscopic dcr , combined with or without silicone tube placement or dacryocystectomy [ 710 ] . in the previous literature
, it seems that mostly conservative management was preferred in congenital cases and dacryocystectomy was reserved for patients with dry eyes or those who were poor surgical candidates .
we preferred external dcr with silicone tube placement and found that it is a well tolerated and effective method that yields satisfactory results .
particularly when there is no upper lacrimal system absence , such as punctual or canalicular agenesis , external or endoscopic dcr can be the first choice of surgical technique .
if there is an upper lachrymal system damage , then conjunctival dcr may be the first choice . in conclusion
, dacryocystocele should be taken into consideration in the diagnosis of any painless cystic mass in the lacrimal sac area , and ct imaging can be helpful for diagnosis , whereas surgical interventions combining silicon tube placement may give successful results .
we found that although it is not possible to obtain a definite pathogenic agent in all cases of microbiological analysis of dacryocystocele specimens , dacryocystoceles may occur due to chronic dacryocystitis .
it may also develop idiopathically or due to autoimmune fibrous diseases , sinusitis and sinus mucoceles , trauma or osseous configuration in the dysplastic duct wall , from tumors , and secondarily to dacryocystorhinostomy .
previous studies about adult dacryocystoceles are mostly case reports or case series . to our knowledge , however , this study is one of the largest series ; therefore we think that adult dacryocystoceles are more common than expressed through published literature .
further studies on adult dacryocystoceles with larger sample sizes are required to determine the pathologic mechanism and the gold standard treatment modalities .
 
 purpose . 
 the aim of this study is to investigate the etiology and the clinical , microbiological , histopathological , and radiological findings of acquired dacryocystoceles . methods . in this retrospective study 
 , we reviewed the clinical records of 10 eyes of 8 patients with dacryocystoceles who underwent external dacryocystorhinostomy ( dcr ) surgery . 
 etiology , presenting symptoms and radiological findings as well as microbiological and histopathological assessment results and outcome were analyzed . results . 
 the records of 8 patients with dacryocystoceles were included in this study . in the histopathological evaluations of the samples collected from the lacrimal sac wall , 
 chronic inflammation was found in all biopsied samples and fibrosis was observed in two histopathological evaluations . 
 computerized tomography ( ct ) imaging showed fluid collection separated from adjacent tissues by a thin rim , corresponding to dacryocystoceles in the sac . in the microbiological culture examination of samples collected from the fluid within the cyst , no bacterial growth in 5 eyes , gram - negative bacillus growth in 3 eyes , and gram - positive cocci growth in 2 eyes 
 were found . conclusions . 
 acquired dacryocystoceles were observed extremely rarely and a definite pathogenic agent could not be identified in any of the cases , either microbiologically or histologically , whereas chronic inflammation was detected in all cases in our study . 
1. Introduction
2. Material and Method
3. Results
4. Discussion