Large dacryops with an ectopic lacrimal ductule following membranous conjunctivitis

The lacrimal ductular cysts (dacryops) arising from the palpebral lobe and Krause’s accessory lacrimal glands are rarely observed together.[^1,2] We describe such a rare association in a case of large dacryops following membranous conjunctivitis. A 36-year-old female complained of incomplete eyelid opening and photophobia with irritation in the right eye following an episode of conjunctivitis [Fig. 1a and b]. She had membranous conjunctivitis in the right eye six weeks earlier and had bleeding from the eye when membranes were peeled off. She had used topical steroids and antibiotics during the episode, which resolved over one week. Six weeks later, she had irritation and a burning sensation in the right eye. Her unanesthetized Schirmer values in the right and left eye were 1mm and 18mm, respectively. Her best corrected visual acuity was 20/30, 20/20 in the right and left eye, respectively. Her ocular examination revealed upper eyelid ptosis with a large cystic lesion occupying the whole of the superior fornix [Fig. 1c]. Inferior fornix showed subtle symblepharon at multiple locations [Fig. 1d]. The right palpebral lobe area showed scarring and cystic dilatation with single visible tear secreting ductule along the lateral canthal area [Fig. 1e, 1f].[³] The right cornea had multiple nummular opacities involving anterior stromal layers and punctate fluorescein staining. The diagnosis of severe dry eye disease and dacryops was made based on the location of the cysts exactly at the palpebral lobe area and along the fornix. The possible differential diagnosis is conjunctival inclusion cyst, but they usually occur secondary to previous surgery or trauma and can be differentiated on histology.[²] The patient did not opt for any surgical correction.

Figure 1: (a), Ocular photograph shows right upper eyelid ptosis with conjunctival congestion. (b), Multiple corneal opacities visible on slit-lamp imaging (marked with an arrow). (c), Everted upper eyelid shows a large cystic lesion occupying the superior fornix, and symblephara in the inferior fornix ((d), marked with an arrow)). The palpebral lobe of the lacrimal gland (borders highlighted) is not visible and has cystic dilatation (e) with one secretory ductule located at the lateral canthus ((f), marked with an arrow)

Discussion

In the current case, complete obliteration of the main and accessory lacrimal gland ductules secondary to conjunctival scarring could have resulted in absolute tear deficiency on the ocular surface. Only one visible ductule in the current case had an atypical location along the inferior aspect of the lateral canthal area, which one should be careful to avoid in case marsupializing the cysts surgically. One should look for symblepharon formation in the lacrimal gland area while managing a case of membranous conjunctivitis for this complication, which can be irreversible.

Financial support and sponsorship

Hyderabad Eye Research Foundation (HERF).

Conflicts of interest

There are no conflicts of interest.