Sir,
A case of epiphora and dacryocystitis following an attack of chickenpox is presented. The child was well before the onset of the attack. The ocular symptoms during the illness suggest local viral infection.
Case report
A 7-week-old boy was referred by his GP with a 2-day history of a red swelling at the left inner canthus associated with a watery left eye and discharge. One week previously he was noted to have bilateral watery eyes, and was diagnosed by his GP as having conjunctivitis. The right eye settled spontaneously over 3 days. Five weeks previously he had chickenpox. During the illness, vesicles were noted to be present medially on his left lower eyelid margin. This was associated with a mild red eye at the time, that settled spontaneously over a week. He had no other past medical history. On examination he appeared well and was apyrexial. Ocular examination confirmed left dacryocystitis. He was admitted to the paediatric ward, conjunctival swabs were performed and intravenous co-Amoxiclav was commenced. Within 2 days the swelling had improved and antibiotic therapy was continued orally for a week. At 3 weeks he had a persistent non-tender expressible swelling at the medial canthus and normal ocular examination. With gentle massage over the medial canthal area the swelling gradually resolved over 6 weeks. He remained well during this course, with no symptoms of epiphora.
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 Comment
Lacrimal canaliculus obstruction, in the form of a localised dense fibrous common canalicular scar, is a known complication of viral infections such as chickenpox.1 Ocular involvement in systemic chickenpox is rare and has been reported to occur in less than 5% of cases.2 The majority of these cases would be vesicles on the eyelids or conjunctiva. It is not known, however, what proportion cause lacrimal canaliculus obstruction or nasolacrimal duct obstruction.
To the author's knowledge, nasolacrimal duct obstruction and dacryocystitis after chickenpox has never been reported.
In view of the circumstances of this case, there is little doubt that varicella-zoster virus infection caused lacrimal obstruction. There was no epiphora or dacryocoele prior to the onset of the infection. Vesicles were noted to be present on the lower eyelid margin and this was associated with a mild red eye at the time of infection. Tearing was noted after the illness (4 weeks after the initial onset of chickenpox). This is consistent with the findings of Sanke and Welham1 who described three cases, all of whom developed symptoms immediately after an attack of chickenpox. Canalicular obstruction secondary to varicella-zoster virus infection often requires surgery in the form of dacryocystorhinostomy (DCR) or canaliculo-DCR, with intubation. In the event of extensive or proximal canalicular involvement, a Jones' tube procedure is indicated.1,3,4
It has been suggested that in the event of ocular involvement during an attack of chickenpox, local antiviral treatment may help prevent lacrimal complications.1,3 However, due to the rare nature of this condition, the degree of spontaneous resolution of acquired lacrimal obstruction due to chickenpox is not known. This has not been evaluated in any prospective study and to the author's knowledge, no retrospective data exist to support this suggestion either.
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