ARTICLE

Year : 1967 | Volume : 15 | Issue : 5 | Page : 159--164

Histological appearance of dacryocystitis

AH Rahi, SL Rahi, OP Ahuja, BR Shukla
Institute of Ophthalmology, Aligarh Muslim University, Aligarh, India

Correspondence Address:
A H Rahi
Institute of Ophthalmology, Aligarh Muslim University, Aligarh
India

How to cite this article:

Rahi A H, Rahi S L, Ahuja O P, Shukla B R. Histological appearance of dacryocystitis.Indian J Ophthalmol 1967;15:159-164

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Rahi A H, Rahi S L, Ahuja O P, Shukla B R. Histological appearance of dacryocystitis. Indian J Ophthalmol [serial online] 1967
[cited 2023 Nov 2 ];15:159-164
Available from: https://journals.lww.com/ijo/pages/default.aspx/text.asp?1967/15/5/159/38800

Full Text
As remarked by DUKE-ELDER (1952) inflammation of lacrimal sac is a common disease and an unpleasant one, partly because of
the trouble�some and conspicuous symptoms it may cause and partly because it has little tendency to resolve itself. Its adequate
treatment also presents problems. His�topathological studies on the inflammed sac have been made by several work�ers
notably-ROLLET AND BUSSEY (1923); POLACK (1930); BOMER (1931); VITTADINI (1933) and FAHMY (1934). Although various
changes have been described no classi�fication of the disease on the basis of histopathology was suggested.

Further, opinions have differed re�garding the appearance of epithelium lining the lacrimal sac. The exact des�cription varied
with different workers as shown in [Table 1].

In the present study we have made an attempt to classify the inflammatory process on the basis of our histopatho�logic findings.
Also, we have presented our view regarding the nature of epi�thelium lining the lacrimal sac.

Present Study

It was based on the examination of 304 lacrimal sacs excised in cases of chronic dacyocystitis. Microsection from each specimen
was examined un�der hematoxylin-eosin, PAS, vanGie�son, Reticulin, Verhoeff and Giemsa stainings. Various changes
observed in these sections are summarised as be�low:-�

(A) Changes in Lumen: Main find�ings were in the form of dilata�tion, division into compartments (multi-locular sac),
obliteration, exudation which may be cellular or acellular.

(B) Changes in Epithelium: Various changes seen in different sections were in the form of necrosis, hyperplasia and stratification, fold
formation and an increase in goblet cells. At places epithelium was seen to be dipping into sub�mucosa giving the impression of
pseudogland formation.

(C) Changes in Sac Wall:-These were in the form of hyperemia diffuse infiltration, degeneration of elastic tissue, increase in
collagen�ous element and follicle forma�tion.

(D) Changes in surrounding Tissues:� Acute or chronic inflammatory reactions were found in the sur�rounding tissue (Peri-
dacryocysti�tis) depending upon the nature and phase of inflammation at the time of surgical removal.

On the basis of observations stated above we suggest the following classi�fication for a better orientation of the present concept of
pathology of the disease process.

Classification of Dacyocystitis :�-

I. SUPPURATIVE :-[Figure 1] :�Characterised by infiltration of lacri�mal sac by acute inflammatory cells. Lumen is filled with
thick exudates containing plenty of neutrophils. Epithelial lining shows necrosis and denudation at places. There is no hyperplasia.

II. NON-SUPPURATIVE :

�(A) Non-granulomatous:�-

(1) Chronic catarrhal type: No evidence of acute inflammation. Goblet cells increase in number [Figure 2]. Lumen is filled with acellar
secretion (mucin). When this process lasts longer and pass�ages are almost blocked it leads to a condition called mucocele.
When infected it may give a pic�ture of suppurative variety, other�wise not.

(2) Hyperplastic type :-The sac wall shows evidences of non-speci�fic inflammation. Most striking changes however are seen in
the epithelium. From pseudestratified, it is converted into true stratified epithelium of 5-10 layers. At times it may be thrown into folds
to form polypoidal growth. At places epidermidalization may also be evident [Figure 3]. In this type of hyperplasia the goblet cells may
take some part but are never predominant.

(3). Dacryocystitis pseudoglanda�laris [Figure 4],[Figure 5]: The mucosa instead of projecting into the lumen may dip into the
sub�mucosa and the wall, to form pouches. These may lose con�tact from the general cavity and may form independent lumen
[Figure 4]. The goblet cells increase in number and may form gland like aggregates [Figure 5]. Similar condition is found in the gall
bladder and is called cholecystitis glandularis (BOYD 1961). As such this histological entity of dacryocystitis can better be
desig�nated as dacryocystitis pseudo�glandularis. Since there is no true gland formation the term ' pseudo�glandularis' is
more suited than "glandularis."

(4) Follicular Types:-In this variety the brunt falls mainly on the wall of the sac. Apart from non-specific changes in the epithelium, the
wall shows a characteris�tic follicle formation [Figure 6]. The lymphocytes aggregate in a lymph�node fashion and are mostly
dis�crete, but in certain cases they may show confluence and necro�sis. These, along with hyperaemia of the wall are
suggestive of trachomatous dacryocystitis.

(5) Fibrotic type :-The sac epi�thelium as well as the wall is atrophied. Every tissue is replaced by dense fibrosis and only a
skele�ton suggestive of a lumen is left [Figure 7]). This is the ultimate end of the story in long standing cases with minimum of
infection and inflammation.

(B). Granulomatous :-In this variety the sac shows more or less a circums�cribed lesion in which the cells are mostly of histiocytic
origin. The sac epithelium shows epithelioid cells and varied number of giant cells.

Specific varieties of dacryocystis like tubercular, leprotic, syphilitic, fungal, etc. as described by Duke-Elder (1952) can be grouped
under this general heading.

The relative incidence of various types of dacryocystitis as observed in the present study, (according to the suggested classification)
are given be�low [Table 2].

The low incidence of suppurative variety as shown in this table is due to the fact that removal of the sac is usually deferred in acute
stages, sur�gery being done after control of infec�tion only. Hence by that time the histological behaviour changes
consi�derably.

Comments
We have suggested a classification in the belief that the histopathology of chronic dacryocystitis would be under�stood better and
in its right perspec�tive. We are aware of the fact that this classification and description by no means is final. However, this may
provide a lead for further studies by the students of the subject on these lines and a universally accepted des�cription may finally
emerge.

Regarding the nature of epithelium lining the normal lacrimal sac our at�tention was drawn by our micro-studies of the diseased
lacrimal sac. It was observed universally, that the epithe�lium was never ciliated. It may be suggested that the cilia might have
been lost during the phase of prolonged inflammation. On theoretical grounds this may not be absolutely tenable, be�cause cilia
are observed in the epithe�lium of a frontal sinus even after years of inflammation [Figure 8]-RAHI et al 1966. They are nexer lost
completely in this process. Based on these ob�servations, histology of uninflammed lacrimal sacs was performed and in these too,
we failed to observe any cilia. These findings are in agreement with the description of DUKE-ELDER (1961) who has described the
epithe�lium as non-ciliated in adults. He however has suggested that cilia are found in the lacrimal sac epithelium of the foetus.
We have not yet studied this aspect of the problem.

During these studies we also observ�ed that except in cases where hyper�plasia was the predominant feature (hyperplastic
decryocystitis) the sac was mostly lined with a single layer of epithelium. These findings were corro�borated with our studies on
the nor�mal lacrimal sac epithelium. It is always single layered although the types of cells are seen i.e. columnar and flattened.
Bases of columnar cells pass in between the flattened cells to be attached to the same basement membrane. Because of the
difference in height of the two types of cells, it provides an optical illusion in the form of two layered epithelium [Figure 9]. This type of
epithelium is seen also in paro�tid duct, male urethra, and trachea. It is suggested that because of its special nature, lacrimal sac
epithelium should be termed as pseudostratified columnar, the term which has been suggested for similar type of epithelium
elsewhere (MAXIMOW and BLOOM-1954; SMITH and COPENHAVER-1953).

Summary

Over 300 cases of lacrimal sac in�flammations have been studied histo�logically under routine hematoxylin�eosin, and PAS,
Giemsa, V. G. Ver�hoeff and Reticutin differential stain�ings.

The microscopic anatomy in diseased sac is described and a classification of dacryocystitis is proposed on the basis of histological
appearances.

Relative incidence under each head is tabulated.

On the histological finding of two types of cells with different heights resting on the same basement mem�brane, the normal sac
epithelium is considered to be composed of a single layer.

Acknowledgement

The technical assistance extended to us by Mr. A. Y. Khan, technician his�topathology and Mr. U. C. Gupta, phototechnician in
preparation of this manuscript is gratefully acknowledged.[15]

References
1 Ashton, N. (1961), quoted by Duke�Elder in 5.
2 Bomer (1931), quoted by Duke-Elder in 4.
3 Boyd, W. (1961), Text Book of Patho�logy, VII Ed. p. 825.
4 Duke-Elder S. (1952), Text Book of Ophthalmology, Vol. V, p, 6000. Henry Kimpton, London.
5 Duke-Elder S. (1961), System of Oph�thalmology, Henry Kimpton, Vol. 11, p. 577.
6 Fahmy, A. Y. (1934), Bull Ophthal. Soc. Egypt 27, 41.
7 Hogan M. J. and Zimmerman L.E., "Ophthalmic Pathology", W. B. Saunders & Co. II Ed. p. 222, 1962.
8 Last R. J., Wolff's Anatomy of the Eye and Orbit, H. K. Lewis, London, V Ed. p. 208, 1962.
9 Maximow A. A. and Bloom W� A Text Book of Histology, W B Saunders & Co. VI Ed., p. 29, 1954.
10 Polack, (1930). Russ. O. J., 12: 567:
11 Rahi A. H., Rahi, S. L. and Ansari M. W. (1966), The Medicine and Surgery, 12, 14.
12 Rollet and Bussey (1923), quoted by Duke-Elder in 4.
13 Smith, P. E. and Copenhaver, W. H. (1953) Baileys Text Book of Histology, X111 Ed. 1953.
14 Sorsby, A. (1963), Modern Ophthal�mology, Butterworth Lond., Vol. I, p. 208.
15 Vittadini (1933) quoted by Duke-Elder in 4.

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