Lacrimal Sump Syndrome
Lacrimal sump syndrome can be a cause of failed dacryocystorhinostomy surgery (DCR) but is not frequently recognised by the ophthalmologist. 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.
Lacrimal sump syndrome
Lacrimal sump syndrome
Lacrimal sump syndrome is a condition where patients report persistent tearing following DCR when the inferior portion of the lacrimal sac, or the bone adjacent to the inferior 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 DCRs. It is however a diagnosis of exclusion, after rule out prepunctal ethology (lower eyelid laxity, eyelid margin malpositions, etc), punctal and canalicular obstructions.
- Inadequate bony osteotomy and poor exposure especially of the dependent inferior portion of the lacrimal sac and proximal nasolacrimal duct. It is more commonly seen with poorly performed external DCRs especially with small incisions and by novices.
- Incomplete opening of the lacrimal sac and nasolacrimal duct.
- Inadequate securing of proper mucosal flap position, particularly the inferior and superior edges of the flaps.
- Intranasal adhesions.
Tear transit through the lacrimal drainage pathway is stalled as tears collect in the remnant lacrimal sac before overflow and nasal drainage with possible development of recurrent / chronic infections.
- Adequate bony osteotomy including medial wall of bony nasolacrimal duct allowing complete opening of the lacrimal sac down to the proximal nasolacrimal duct.
- Secure placement of mucosal flaps by meticulous apposition by suturing (external DCR) or tension free approximation to nasal mucosa (endoscopic endonasal DCR) to prevent 'sac'reformation.
- Minimize intranasal scarring by avoiding bone exposure, excision of endonasal granuloma and maintaining nasal hygiene and promote primary wound healing with intranasal saline, . corticosteroid spray, etc.
Lacrimal sump syndrome may be suspected in a symptomatic patient post external or endoscopic DCR , with raised tear meniscus with or without discharge, who on endonasal examination has an anatomically patent but high osmium but discharge and residual inferior sac/nasolacrimal duct confirmed dacryocystogram, radiographic imaging..
Patients experience epiphora following DCR but found to be patent on lacrimal irrigation. 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 and infection.
- Irrigation suggests anatomic 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.
- Common canalicular obstruction
- Scarring of osteotomy site
- Incomplete clearance of anterior ethmoidal air cell
- Intranasal adhesion
- Lacrimal pump failure
- Eyelid laxity
- Reflex tearing
If the tearing is sufficient for the patient to request treatment, surgery is required.
Endonasal revision Dacryocystorhinostomy either under local or general anesthesia is the procedure of choice to address the sump syndrome although it can be performed through an external approach. A larger lower osteotomy with marsupialization of the dependent inferior sac/nasolacrimal duct and ensuring mucosal apposition to the nasal mucosa is often therapeutic. Care should be taken to prevent reformation. This may require mucosal excision, or flaps oriented with wide spacing and consideration for additional topical intraoperative Mitomycin C.
Failure to address symptoms and other complications of a DCR; however, expected to be less frequent given the reduced tissue manipulation involved.
Small series have reported very high rates of success with surgery.
- Welham RAN, Wulc AE. Management of unsuccessful lacrimal surgery. Br J Ophthalmol 1987;71:152-157.
- Jordan DR, McDonald H. Failed dacryocystorhinostomy: the sump syndrome. Ophthalmic Surg 1993;24:692-693.
- Migliori ME. Endoscopic evaluation and management of the lacrimal sump syndrome. Ophthal Plast Reconstr Surg 1997;13:281-284.