Atypical lacrimal sac mucoceles

To report the clinical features and operative findings of a series of patients with lacrimal sac mucoceles extending above the anatomic level of the medial canthal tendon (MCT).

A retrospective chart review of all patients presenting with lacrimal sac mucocele extending above the anatomic level of the MCT over a period of five years from 2019 and 2023. All patients underwent surgical management. Diagnosis of lacrimal sac mucocele was based on clinical examination, imaging where indicated and intraoperative confirmation.  Data obtained include demographics, clinical presentations, duration, imaging features, type of surgical intervention, intraoperative findings, and outcomes.

A total of 62 patients were analyzed, of whom 67.7% were female. The mean age at presentation was 49.11 years. The mean duration of the lacrimal sac swelling was 18.15 months (SD = 21.94). Epiphora, discharge, and dacryocystitis were frequent associations. Regurgitation on Pressure over the lacrimal sac area (ROPLAS) decompressed the swelling   in 35 (56.5%) patients.In 61.3% of patients, the medial canthus remained in its normal position, while the medial canthal tendon (MCT) exerted pressure on the overextending mucocele to varying degrees, resulting in a dumbbell-shaped appearance in certain cases. In 38.7% of patients, the mucocele caused superior displacement of the medial canthus compared to the contralateral side. The surgical interventions were successful in resolving the mucocele.

Lacrimal sac mucoceles can extend above the level of the MCT. While a lacrimal sac swelling above the MCT should raise suspicion for a mass lesion of neoplastic etiology, it is not a tell-tale sign.