Dacryolithiasis is a disease characterized by the formation of concretions (dacryolites) in the lacrimal duct. The main clinical symptoms are a feeling of “bursting”, soreness in the inner corner of the eye, impaired tear outflow, conjunctival hyperemia. To make a diagnosis, a physical examination, biomicroscopy, ultrasound of the eye, dacryocystography, Norn and Schirmer samples are performed. With total obstruction, dacryocystorinostomy is indicated. With partial patency, massage, washing or probing of the tear ducts is performed. Invasive interventions are performed under local anesthesia.
Dacryolithiasis is a relatively rare ophthalmopathology. The acquired form of the disease is diagnosed in 7% of middle-aged and elderly patients. Congenital obstruction of the lacrimal canal due to the formation of tear stones is detected in 1-2% of children in the neonatal period. The formation of concretions in about 30% of cases leads to the development of complications, due to their large size and high density. Dacryolithiasis occurs with the same frequency among males and females. There are no epidemiological data on the prevalence of the disease.
The etiology of the disease has not been fully clarified. Researchers are studying the role of metabolic disorders and nervous regulation in its occurrence. Specialists in the field of ophthalmology believe that the risk of formation of concretions is higher in persons working at harmful enterprises (contact with dust, industrial waste) if sanitary and hygienic standards are not observed. The triggering factors of the development of dacryolithiasis are:
- Chronic dacryoadenitis. With inflammation of the tear ducts, the difficulty of separating tears leads to the accumulation of inorganic substances such as sodium chloride, calcium sulfate, sodium carbonate, calcium phosphate.
- Traumatic injuries. Traumatization leads to bleeding, the formation of blood clots and increased secretion of exudate in the lacrimal sac. Secondary infection and mucin secretion under the condition of impaired outflow contribute to the formation of dacryolites.
- Non-compliance with the rules of personal hygiene. If the makeup is removed incorrectly, the remnants of cosmetics become the cause of obturation. This happens when using low-quality decorative cosmetics or using expired products.
- Blockage of amniotic fluid. Causes the development of a congenital form of the disease. Amniotic fluid usually enters the lacrimal tract at birth through the natural birth canal. When the contents are infected, secondary dacryocystitis develops.
Anatomical and physiological features of the structure. In newborns, the occurrence of dacryolithiasis is often due to the preservation of the germ film, which closes the lower part of the nasolacrimal canal in the fetus. Duct obstruction potentiates the accumulation and calcification of the contents of the lacrimal sac.
Chronic inflammation of the lacrimal tract provokes a violation of the outflow of tears. The functions of the lacrimal gland are not impaired. The result of stagnation of the lacrimal fluid is the formation of specific tear stones. Lacrimal tract concretions consist of mucin, lipids and calcium. The appearance of symptoms of dacryolithiasis is facilitated by squamous metaplasia of the epithelium of the lacrimal sac. With inflammation of the nasolacrimal canal, mucin accumulates in large quantities, which is a kind of matrix for the formation of a stone. With the traumatic genesis of pathology, the concretion often contains erythrocyte masses.
With chronic inflammation of the nasolacrimal duct, the disease develops due to excessive accumulation of exudate and deposition of inorganic components of the lacrimal fluid. In the pathogenesis of the disease in women, the leading importance is given to improper eye and eyelid care when removing decorative cosmetics. Less often, the disease occurs when foreign microparticles accumulate in the lacrimal canal during prolonged contact with dust or industrial chemicals. Dacryolithiasis in newborns is caused by the ingress of amniotic fluid into the nasolacrimal canal.
If dacryolites do not block the lumen of the lacrimal duct, and the outflow of tears is not disturbed, the disease is characterized by an asymptomatic course. Less often, patients feel discomfort in the projection area of the lacrimal tract. With light massaging, the symptoms disappear. The formation of large concretions of high density leads to overgrowth of the duct wall and the development of pain syndrome. Patients complain of excessive lacrimation, a feeling of “bursting” in the medial corner of the eye and swelling in the periorbital region. When pressing on the affected area, the pain increases, there is a reflux of tears.
With an asymptomatic course, dacryolites are detected during dacryocystorinostomy. In the anamnesis, patients have frequent exacerbations of dacryoadenitis in the absence of the effect of antibacterial therapy. Over time, there is a feeling of excessive tearfulness. When pressing on the inner corner of the eye, a local increase in temperature is noted, which indicates the development of inflammatory complications. In patients with total obstruction, the medial parts of the ocular region are hyperemic, edematous. Often it is a cosmetic defect that becomes the reason for seeking help from a doctor.
The most common complications of dacryolithiasis are dacryoadenitis, dacryocystitis, abscess. Obturation of the lumen of the nasolacrimal canal contributes to the disruption of the passage of tears. The formation of dacryolites provokes compression of surrounding tissues. In most patients, increased lacrimation entails the development of blepharoconjunctivitis, keratitis. With a severe course of the disease, a tear of the lacrimal duct or sac is possible. Hemorrhage in the periorbital tissue causes the formation of a hematoma. In rare cases, the disease is complicated by phlegmon of the orbit.
The diagnosis by an ophthalmologist is based on a physical examination and instrumental research methods. When palpating the affected area, an enlarged, hard lacrimal sac is determined. As a rule, in patients over 40 years of age, tear stones are an intraoperative finding, and the diagnosis is made retrospectively. Specific methods for the diagnosis of dacryolithiasis include:
- Biomicroscopy of the eye. Conjunctival redness and single erosive defects on the cornea of the eye are visualized. Signs of inflammation of the palpebral conjunctiva are revealed.
- Ultrasound of the eyes. Ultrasound examination is used to determine the density of dacryolites. The size of the concretions varies from small granules up to 7 mm. The tear ducts are dilated. The volume of the lacrimal sac is increased.
- Dacryocystography. Dacryolites are detected, representing filling defects of different shapes and sizes. The study makes it possible to accurately determine the localization of the obstruction zone.
- Schirmer’s sample. The test is assigned to study the production of tear fluid. An anesthetic is used before it is performed. The process of lacrimation is not disturbed. In 5 minutes of the test, all the filter paper becomes moistened with tears.
- A Norn sample. When performing the test, the tear film rupture time is 10 seconds or less, which indicates its instability. Ruptures are more often located in the lower-outer quadrant of the cornea.
- Histological examination. A targeted microscopic examination of the sections allows you to determine the composition of the concretions. Lacrimal stones are represented by an amorphous acellular organic substance, which includes calcium.
The tactics of treatment depends on the degree of overlap of lacrimal pathways with concretions. With complete obstruction of the duct, dacryocystorinostomy is indicated. After surgery, the surgical fistula is washed. In the postoperative period, with the help of ultrasound, its viability is assessed. With preserved patency , the following are shown:
- Massage. The first stage of the procedure is a careful squeezing of the contents of the ducts. Next, instillation of antiseptic solutions at room temperature into the lacrimal canal is carried out. The movements should be jerky, directed to the inner corner of the eye. Pathological masses are removed with a cotton pad.
- Flushing of the lacrimal pathways. The manipulation is reduced to the infusion of room temperature liquid into the lacrimal tubules under moderate pressure. The procedure allows you to assess the patency of the canal and introduce medications.
- Probing of ducts. The use of the technique is advisable with a low density of concretions. Probing at a high density of dacryolites is complicated by damage to the wall.
All invasive interventions for dacryolithiasis are performed under regional anesthesia. To improve patency, proteolytic enzymes and glucocorticosteroids are injected directly into the tear ducts. With concomitant development of dacryoadenitis, a short course of antibacterial therapy (5-7 days) is indicated. The route of administration of antibiotics is instillation.
Prognosis and prevention
With incomplete patency of the nasolacrimal canal, the prognosis for visual functions is favorable. With complete obstruction, lacrimal sac rupture is a frequent outcome of dacryolithiasis. Specific prevention of the disease has not been developed. Non-specific preventive measures are reduced to compliance with the rules of hygiene when caring for the eyes. It is necessary to remove makeup in a timely manner, use moisturizers with the development of signs of xerophthalmia. When working in production, personal protective equipment (glasses, mask) should be used. To prevent the formation of dacryolites in newborns, mothers should massage in the area of the projection of the tear ducts.