British Journal ofOphthalmology, 1982, 66, 71-74

Lacrimal canalicular obstruction following chickenpoxROBERT F. SANKE AND RICHARD A. N. WELHAM

From the Institute of Ophthalmology, Moorfields Eye Hospital, City Road, London ECIV 2PD

SUMMARY Three cases of unilateral epiphora following an attack of chickenpox were studied. Eachpatient was a child who was in good health prior to the onset of the attack. During the illness eachhad ocular symptoms suggesting local infection from the virus. A dacryocystogram revealedobstruction of the common canaliculus in each case caused by a fibrotic scar. All cases responded toappropriate surgical management.

Lacrimal canaliculus obstruction is a known com- the illness vesicles were present on the eyelids, andplication of virus infection.' Although several the eyes were 'red and irritable' with crusting on thedifferent viral diseases have been implicated in this lashes and considerable tearing. The general ocularway, chickenpox has been mentioned only sparingly examination was nonnal, but an obstruction wasin the medical literature as havingsuch a complication.Three cases were recently observed and provided theopportunity to examine this more closely. The resultsare reported here.

Materials and methods

During the past year 3 cases of common canaliculusobstruction following an attack of chickenpoxpresented at the Lacrimal Clinic of Moorfields EyeHospital, City Road, London. All were children whowere in good health and asymptomatic before theonset of the illness.

In addition to the general ocular examination adacryocystogram (DCG) was performed on eachpatient to identify and localise the obstruction. Allpatients have undergone surgery. Either a dacryo-cystorhinostomy (DCR)2 with resection of theobstruction from within the sac or a Barrie Jones typeof canaliculodacryocystorhinostomy (CDCR)3 wasperformed. In all patients the system was leftintubated with polyethylene tubing (no. 10 Portex)for 3 months. A tissue specimen from one of the caseswas sectioned for histological study and examined forevidence of the virus.

CASE REPORTSPatient 1. A 10-year-old boy presented with a 14-month history of epiphora in his right eye followingimmediately after an attack of chickenpox. During

Correspondence to Mr Richard A. N. Welham, FRCS, Moorfields Fig. 1 Dacryocystogram ofpatient I showing obstructionEye Hospital, City Road, London EClV 2PD. at the medial end ofthe right common canaliculus.

71

on Septem

ber 16, 2020 by guest. Protected by copyright.

http://bjo.bmj.com

/B

r J Ophthalm

ol: first published as 10.1136/bjo.66.1.71 on 1 January 1982. Dow

nloaded from

Robert F. Sanke and Richard A. N. Welham

ethylene tubing for 3 months. The symptoms dis-appeared afterwards. There were no complications.

Patient 3. An 11-year-old girl presented with a 2-.year history of epiphora of her right eye that beganimmediately after an attack of chickenpox. The eyeswere described as being 'red and irritable' during the

Fig. 2 Dacryocystogram ofpatient2 showing partialobstruction ofthe common canaliculus at its medial end in theright eye.

found at the medial end of the right common cana-liculus on the DCG (Fig. 1). At surgical operation aplaque of fibrous tissue was found to be occluding theinternal opening of the common canaliculus, and thiswas excised from within the sac. After a conventionalDCR had been completed the canaliculi were lefttemporarily intubated with soft polyethylene tubingfor 3 months. After removal of the tubes the patienthas remained symptom free.

Patient 2. A 10-year-old boy presented with an18-month history of epiphora of the right eye that wasfirst noted immediately following an attack ofchickenpox. The eyes were 'red and irritable' duringthe illness, but no vesicles were noted near them. Theocular examination was unremarkable except forpartial obstruction at the medial end of the rightcommon canaliculus seen on the DCG (Fig. 2). Atsurgery the internal canalicular opening was found tobe stenosed by a fibrous scar which was excised fromwithin the sac. A DCR was completed and thecanaliculi temporarily intubated with the poly-

Fig. 3 Dacryocystogram ofpatient 3 showing obstructionofthe right common canaliculus at its medial end.

72

on Septem

ber 16, 2020 by guest. Protected by copyright.

http://bjo.bmj.com

/B

r J Ophthalm

ol: first published as 10.1136/bjo.66.1.71 on 1 January 1982. Dow

nloaded from

Lacrimal canalicular obstruction following chickenpox

illness, with vesicles on the eyelids and on the bulbarconjunctiva. The general eye examination wasnormal, but an obstruction of the medial end of thecommon canaliculus was seen on the DCG (Fig. 3).Because of the experience in the previous 2 cases thecommon canaliculus was dissected and exposed priorto opening the tear sac. A fibrotic scar, which wasfound again to involve the internal opening of thecommon canaliculus, was resected. A CDCR wasthen completed by anastomosing the divided commoncanaliculus to the nasal mucosa, the lacrimal sac beingused as a bridge. The system was left intubated withthe soft polyethylene tubing for 3 months. There wereno complications.The excised tissue from patient 3 was sent for

histology and virus identification studies. It was foundto be composed of fibrous scar tissue but was other-wise unremarkable. No giant cells or intracellularinclusion bodies were found. Indirect immunofluor-escent staining tests with human antisera werenegative for virus, including the varicella-zoster (V-Z) virus. Antibodies in the patient's blood for V-Zvirus indicated past infection.

Results

There were no unusual systemic symptoms during thechickenpox attack in any of these patients. The eyesin all 3 cases, however, were 'red and irritable,' and in2 of the 3 cases the parents recalled that vesicles werepresent on the eyelids or on the conjunctiva. Apartfrom the epiphora beginning immediately after theattack there were no other complications. The healthof each of the patients has returned to normal.The features common to these 3 patients were: an

ocular inflammation complicating an attack ofchickenpox, unilateral epiphora, and an obstructionof the lacrimal drainage apparatus which was locatedat the level of the common canaliculus. Although thex-ray appearances suggested a mucosal type ofobstruction, which is usually a characteristic ofchronic sac disease, surgical exploration showed thisnot to be present; a localised, dense fibrous scarinvolving the common canalicular opening was foundin all cases.4

Discussion

The circumstances in these 3 cases enable us to con-clude that the common canaliculus obstruction wasthe result of the chickenpox attack. That other virusesare known to act in a similar way supports this.

In its systemic manifestations chickenpox mayinvolve almost any organ of the body,5 though ocularinvolvement is rare. Griffin and Searle reported onlya 4% incidence of lesions in the eye.6 These were

limited to isolated vesicular eruptions of the eyelidmargin and to the conjunctiva and corneosclerallimbus. A report by Edwards7 separated ocularinvolvement into 4 categories: the eyelids, the corneaand conjunctiva, intraocular complications, andneurological complications. However, there was nomention of any effects on the lacrimal system. Werbcommented in passing on 'secondary infections'involving the punctum and canalaculus from chicken-pox but gave no further inforgation about them.8Attempts to identify thepresence ofV-Zvirus in the

fibrous scar excised from patient 3 gave negativeresults, but this does not exclude a cause-effectrelationship. McSorley et al.9 examined new lesionsduring the active, infectious phase of chickenpox butfound only a few which reacted 'weakly positive' toimmunofluorescent testing, while the majority gave anegative reaction as had occurred in our case.There is no doubt that identification of virus

provides strong evidence of the connection betweenthe infection and scar formation. Bouzas has shownthat this relationship can still be deduced from theparticular circumstances of the case."' It was seen inthe present cases that:

(1) there was no epiphora prior to the onset of theinfection with its ocular involvement;

(2) the tearing was noted immediately after theillness had resolved;

(3) formation of fibrous scar tissue is a characteristicresult of inflammation in mucous membranes causedby viruses.

This result has been previously recognised, and areview of cases from the Lacrimal Clinic at MoorfieldsEye Hospital showed that virus diseases were themost common cause of lacrimal canaliculusobstruction. "The ocular symptoms indicate that during the active

phase of the illness the infection also involves the eyesthemselves. The causative agent for chickenpox, thevaricella-zoster (V-Z) virus, is an encapsulated DNAvirus. 2 It acts on host tissue by entering the nucleus ofthe cell and after replicating causes the cell to ruptureand release the newly created particles. These newvirus particles can then infect other cells, perpetuatingthe cycle. 3

This virus is very susceptible to DNA inhibitorssuch as the ophthalmic antiviral agents idoxuridine,cytosine arabinoside, and adenine arabinoside.'2 Inthe event of ocular involvement during an attack ofchickenpox, local treatment with these antivirals mayprevent lacrimal complications and their associatedmorbidity.

We thank Professor S. Darougar and Dr P. Walpita of the VirusLaboratory, Institute of Ophthalmology, London, for their help withthe virus identification studies, and Miss Catherine Elliot for herassistance in preparing the manuscript.

73

on Septem

ber 16, 2020 by guest. Protected by copyright.

http://bjo.bmj.com

/B

r J Ophthalm

ol: first published as 10.1136/bjo.66.1.71 on 1 January 1982. Dow

nloaded from

Robert F. Sanke and Richard A. N. Welham

References

I Duke-Elder S, MacFaul PA. The ocular adnexa. System ofOphthalmology. London: Kimpton, 1974; 13:696.

2 Welham RAN. Surgery of the lacrimal apparatus. In: Miller S.ed. Operative Surgery of the Eye. London: Butterworths, 1976:116-8.

3 Jones BR. The surgical cure of obstruction in the common

lacrimal canaliculus. Trans Ophthalmol Soc UK 1960; 80: 343-53.4 Keast-Butler J, Lloyd GAS, Welham RAN. Analysis of intuba-

tion macrodacryocystography with surgical correlations. TransOphthalmol Soc UK 1973; 93: 593-5.

5 Downie AW. Chickenpox and zoster. Br Med Bull 1959; 15:197-200.

6 Griffin WP, Searle CWA. Ocular manifestations of varicella.Lancet 1953; ii: 168-9.

7 Edwards TS. Ophthalmic complications from varicella. J PediatrOphthalmol 1965; 2: 37-40.

8 Werb A. The surgery of canaliculus obstruction. In: Rycroft PV,ed. Corneo-Plastic Surgery. Proceedings from the Second Inter-national Corneo-Plastic Conference, London, 1967. Oxford:Pergamon Press, 1969: 87-99.

9 McSorley J, Shapiro L, Brownstein MH, Hsu KC. Herpessimplex and varicella-zoster: comparative histopathology of 77cases. IntJ Dermatol 1974; 13: 69-75.

10 Bouzas A. Canalicular inflammation in ophthalmic cases ofherpes zoster and herpes simplex. Am J Ophthalmol 1965; 60:713-6.

11 Coster DJ, Welham RAN. Herpetic canalicular obstruction. BrJOphthalmol 1979; 60: 259-62.

12 Mandell GL, Douglas RG, Bennett JE. Principles and Practice ofInfectious Disease. New York: Wiley, 1979:1295.

13 Rothschild H, Allison F, Howe C, Chapman CF. Human DiseasesCaused bv Viruses. New York: Oxford University Press, 1978:54.

74

on Septem

ber 16, 2020 by guest. Protected by copyright.

http://bjo.bmj.com

/B

r J Ophthalm

ol: first published as 10.1136/bjo.66.1.71 on 1 January 1982. Dow

nloaded from