Congenital lacrimal fistulas with secondary infection mimicking acute dacryocystitis: a case report and literature review

We reported a rare case of congenital lacrimal fistula with recurrent cellulitis secondary to fistulitis,mimicking acute dacryocystitis. Congenital lacrimal fistula is an anomalous development of the lacrimal drainage system manifested by a patent communicating with skin on one side and the canaliculus, lacrimal sac, or the duct on the other

. Most congenital lacrimal fistulas are asymptomatic,or minimally symptomatic. Some may have symptoms when coughing, blowing the nose, or in the case of hyperlacrimation,such as in windy weather

. However, symptomatic cases typically present with epiphora from the fistula or the eye,especially in patients with nasolacrimal duct obstruction.Rare few patients may, on occasion, demonstrate recurrent inflammatory symptoms, such as dacryocystitis, canaliculitis,blepharitis or fistulitis

. The diverse clinical features may result to high rate of misdiagnosis.

The retrospective study was reviewed and approved by the Ethics Committee of the Second Affiliated Hospital of Zhejiang University, and followed the tenets of the Declaration of Helsinki. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

A 3-year-old female child was referred to our eye center for evaluation of recurrent cellulitis manifested with eyelid redness and swelling at the right lower eyelid and medial canthal (Figure 1A, 1B). Two weeks before our examination,the swelling developed again, and a subcutaneous mass was formed at the right medial canthal region. Her parents reported three previous episodes of presumed right-sided dacryocystitis within 2y but denied having epiphora in remission stage.During the previous episodes of acute inflammation, the punctums at medial canthal region were ignored, and the patient was treated with repeated stab incision and drainage in other medical institutions. Due to poor outcomes and repeated episodes, the patient once was advised to undergo dacryocystorhinostomy (DCR) surgery. Upon our examination,the patient was firstly found to have bilateral pits located at the medial canthal region (Figure 1C, 1D). A skin scar of the right lower eyelid from previous incision and drainage was found.The child did not suffer from epiphora. No discharge was elicited from the puncta or fistulas when pressure was applied to the lacrimal sac. When lacrimal irrigation through the lower puncta was performed, the fluid passed into the nose and no reflux from the puncta or fistulas was found, which implied that the lacrimal drainage system was functioning normally.By probing of the cutaneous opening of the right side, we revealed that the probe could not reach the lacrimal sac, which suggested that the connection between the fistula tract and the lacrimal sac was closed presumably due to the repeated inflammation. There was no history of systemic diseases,trauma, or eyelid surgeries. No other nasal or ocular anomalies were found, and no family member had a lacrimal fistula. The diagnoses of bilateral congenital lacrimal fistula and right-side cellulitis secondary to fistulitis were made.

于是我就開始琢磨，怎樣讓學(xué)生形成一種在有限的時間內(nèi)有效甚至高效的閱讀并準(zhǔn)確簡明答題的意識？畢竟應(yīng)試閱讀是戴著腳鐐在跳舞，這里的腳鐐就是時間限制。我們不可能從頭到尾一點(diǎn)一點(diǎn)慢慢地啃，帶著問題去閱讀，才知道閱讀的重點(diǎn)在哪里，才清楚要落筆的重點(diǎn)在哪里，也許這才是講求效率的做法。當(dāng)然“冰凍三尺非一日之寒”，若離開了平日備考時前后一致的“帶著問題”訓(xùn)練，一切都是空話。

Most patients with congenital lacrimal fistulas are asymptomatic and usually remain undetected, and it is uncommon for asymptomatic congenital fistula to cause epiphora suddenly.It is universally acknowledged that patients who are asymptomatic or have very minor symptoms should merely be kept under observation

. While for symptomatic cases,there are no definite guidelines for treatment. AI-Salem

reported that lacrimal sac massage can lead to resolution of tearing and avoid the need of surgery in four cases with combined ocular and fistula tearing. What’s more, two of the four were found to have spontaneous occlusion of their fistulas when gently probing through the cutaneous opening

. They presumed that diversion of tears from the fistula through the natural duct resulted in drying and occlusion of the tract,which might be similar to spontaneous canalicular occlusion resulting from punctual eversion. The most important reason to keep a fistula open is the outflow of fluids. If the obstruction of lacrimal drainage system was resolved, the fistula might be spontaneously closed. However, the result is limited to small case series, and further researches from larger samples are needed to verify this link.

《水利工程混凝土耐久性技術(shù)規(guī)范》提出的水利工程混凝土設(shè)計(jì)、施工、運(yùn)行管理等階段的耐久性技術(shù)要求，有利于促進(jìn)資源節(jié)約利用，提高水利工程興利減災(zāi)效果，有利于更好地實(shí)現(xiàn)水利工程設(shè)計(jì)使用年限目標(biāo)，適應(yīng)水利現(xiàn)代化的需要。

作為護(hù)理人員,首先要有一顆善解人意的心,對患者要有足夠的同情、關(guān)心和耐心,遇到任何問題都能夠心平氣和的和患者交流,將患者當(dāng)做自己的家人,給他們以無微不至的關(guān)懷,不要讓患者在治療過程中感覺到任何不適的眼光和對待,從而讓患者將醫(yī)院當(dāng)作家,有一個非常舒服的狀態(tài),以一個非常平和的心態(tài)接受治療。其次,護(hù)理人員也應(yīng)該利用工作之余不斷提高自己護(hù)理的專業(yè)水平,與患者交流時,如果有足夠?qū)I(yè)的知識儲備和實(shí)踐經(jīng)驗(yàn),就能夠用非常舒適的技巧跟患者交流,并且用非常平易近人的態(tài)度給患者講解更多關(guān)于治療方案的專業(yè)知識,盡可能平復(fù)患者緊張的情緒,對患者的問題有問必答,治療和護(hù)理時得心應(yīng)手,找到一個最和諧的交流和護(hù)理方式?！?br>