3D Computed Tomography—Dacryocystography Features and Management of Intrasaccal Granuloma

A 17-year-old girl presented to the dacryology clinic with OS epiphora since birth and medial canthal swelling of 2 years duration. Clinical evaluation showed telecanthus with a diffuse palpable swelling in the inferomedial aspect of the OS, with slight extension beyond the medial canthal tendon. A three-dimensional computed tomography-dacryocystography was performed, which showed the dye filling the grossly dilated sac lumen with anterolateral and superior outpouchings, suggestive of a diverticulum (panel A, red arrow). The extension beyond medial canthal tendon could be correlated to the evolving superior diverticula visualized beyond the fundus (red arrow, panel B), and the lower end of the sac was noted to abruptly end without any evidence of a nasolacrimal duct (panels A and B). A significantly large hypodense area within the lacrimal sac showed partial dye filling, reflecting an incomplete filling defect (red circle, panel A). Focal hyperdense areas were noted within the partial filling defect (panels A and B). An external dacryocystorhinostomy was performed, and the lacrimal sac was evaluated with a high-definition endoscopy before initiating the bony osteotomy. Intraoperatively, a grossly dilated sac with a large intrasaccal granuloma (arrow, panel C) and a blunt, abrupt ending of the sac (circle, panel C) correlated with all the findings noted on computed tomography-dacryocystography. The granuloma was excised, and triamcinolone acetonide (40 mg/ml) 0.2 cc was injected at the base to avoid recurrence (panel D).FIG.