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Orbital Spread of Fungal Granuloma Post Dacryocystorhinostomy

Bothra, Nandini, M.D.; Nayak, Arpita, M.D.; Ali, Mohammad Javed, F.R.C.S.

Ophthalmic Plastic & Reconstructive Surgery: May/June 2019 - Volume 35 - Issue 3 - p e87
doi: 10.1097/IOP.0000000000001316
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Govindram Seksaria Institute of Dacryology, L.V.Prasad Eye Institute, Hyderabad, India.

Accepted for publication December 13, 2018.

Dr. Ali received support from the Alexander von Humboldt Foundation for his research and he also receives royalties from Springer for the textbook “Principles and Practice of Lacrimal Surgery” and “Atlas of Lacrimal Drainage Disorders”. The remaining authors have no financial or conflicts of interest to disclose.

Address correspondence and reprint requests to Mohammad Javed Ali, F.R.C.S., Govindram Seksaria Institute of Dacryology, L.V.Prasad Eye Institute, Hyderabad, India. E-mail: drjaved007@gmail.com

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A 32-year-old male presented with a history of swelling in the right lacrimal sac region extending into the medial orbital region (Fig. A) of 18 months duration. He was a known case of fungal sinusitis (Aspergillus) and had undergone functional endoscopic sinus surgery 3 years ago with a suboptimal response. Subsequently, he had undergone a right external dacryocystorhinostomy (DCR) elsewhere 3 years ago. Endoscopic evaluation showed retained discharge with focal whitish lesions within the sinuses suggestive of a severe maxillary and ethmoid sinusitis. Dacryocystorhinostomy ostium was filled with a similar whitish lesion with discharge in the vicinity (Fig. B). CT scan of the orbits showed bilateral sinusitis involving the ethmoid, maxillary, and partly frontal sinuses with isodense mass lesion extending into the medial orbit through the DCR ostium and displacing the globe temporally (Fig. C,D). Biopsy of the sinus lesions, ostium cicatrix, and orbital lesion were similar on histopathology, which showed epitheloid granulomas formed of multinucleated giant cells, epitheloid histiocytes, and lymphoplasmacytic cells (Fig. E). Gomori methanamine stains showed the presence of fungal filaments (Fig. F). Because the orbital lesion was displacing the globe, it was debulked along with a concurrent treatment for fungal sinusitis.

It is a likely possibility that preexisting fungal sinusitis followed by DCR allowed the fungus to spread to the orbit through the bony ostium. Therefore, any preexisting sinusitis especially of fungal origin should be well treated before advising a lacrimal bypass procedure.

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