Samia Sultana Anny, a 40-year-old housewife, presented with watering and purulent discharge from her left eye for 4 years and 1 year, respectively. Examination revealed matted eyelashes, full lacus lacrimalis, and a positive regurgitation test on the left side, indicating chronic dacryocystitis. Investigations and management with left dacryocystorhinostomy and intubation were planned. Differential diagnoses included acute dacryocystitis and punctum stenosis.

1. Long Case
Presentation
DR.MALIHA NAWAR
RESIDENT,PHASE-A(YEAR-2)
COMMUNITY
OPHTHALMOLOGY
BANGABANDHU SHEIKH
MUJIB MEDICAL UNIVERSITY

2. Particulars of the patient:
Name- Samia Sultana Anny
Age- 40 years
Sex- female
Religion- Islam
Marital status-Married
Occupation- Housewife
 Address- Hatirpul,pukurpar mosjid,Dhaka.
Date of examination- 12/10/2021

3. Chief Complaint:
Watering from left eye for 4 years.
Purulent discharge from left eye for 1 year.

4. History of present illness:
According to the statement of the patient, she was quite well 4 years
back since she developed watering from left eye which was initially
associated with painless swelling of the left eye. She gave no history
of ocular trauma ,nasal pathology, redness or any visual disturbance.
With these problems she visited doctors in her locality and was
prescribed with some eye drops, name of which she could not
mention.

5. History of present illness:
After using those medication her condition improved a bit but again
symptoms aggravated when she stopped medications. Initially
watering was scanty in amount but gradually it increased and
purulent discharge was associated with it for last 1 year. 9/10/2021
she again visited doctor and was advised Moxibac(Moxifloxacin)
eyedrop.

6. History of present illness:
With these complaints she came into BSMMU , Department of
Community Ophthalmology through OPD for better management.
She is non diabetic , normotensive and non asthmatic.

7. History of past illness:
No history of trauma, surgery or any significant systemic illness in
the past.

8. Family History:
None of her family member is suffering from same type of
problem.
She has a daughter.
All of them are healthy.

9. Drug History:
She used some eye drops earlier name of which she could not
mention and from 9/10/2021 she started using
Moxibac(Moxifloxacin) eyedrop.

10. Personal History:
She is non smoker and does not eat betel leaf & nut.
Maintain personal hygiene.

11. Socio-economic History:
The patient belongs to a middle class family.
She lives in concrete house with proper water supply and sanitary
facilities.

12. Immunization History:
She is well immunized according to EPI schedule.

13. General Examination:
Appearance- Normal
Co operation-Co-operative
Body built- Average
Nutrition-Good
Decubitus- On choice
Anaemia- Absent
Jaundice-Absent
Cyanosis- Absent
Oedema-Absent

14. General Examination:
Dehydration: Absent
Clubbing-Absent
Neck vein-Not engorged
Lymph node –Not enlarged
Thyroid gland-Not enlarged
Pulse -76 beats/minute
BP-110/70 mm of Hg
Respiratory rate- 16 breaths/min
Temperature-98.6 degree F

15. Local Examination:
On inspection-
Head position is normal
No facial asymmetry
Eyelids: Normal in both side
Eye lashes: Matted in left side , normal in right side.
Lid margin is normal in both sides.
Punctum : both upper and lower puncta are normal in position both sides

16. Local Examination:
Lacus lacrimalis was full of water in left side.
Nasal cavity-normal in both sides , there is no deviation of septum ,polyps or
tumor . Nasal mucosa is normal.
Oral cavity- normal .

17. Local Examination:
On palpation
Temperature-normal
Tenderness-absent
Regurgitation test-Right eye - Negative
Left eye - positive

18. Regurgitation test

19. Ocular examination:
Ocular Examination Right eye Left eye
Visual acuity-distant vision 6/6, unaided 6/6,unaided
with pinhole 6/6 6/6
near Vision N6 with +1.00D N6 with +1.00D
Pupillary light reflex- Direct
Consensual
Brisk
Present
Brisk
Present
Hirschberg reflex Central Central
RAPD Absent Absent
Ocular motility Full in all gaze Full in all gaze
Color Vision Trichromatic Trichromatic

20. Slit lamp findings:
Right eye Left eye
EYE LIDS Normal Normal
EYE LASHES Normal Matted. Lacus lacrimalis full of water.
Marginal tear stripes height increased
CONJUNCTIVA Not congested Not congested
CORNEA Transparent Transparent
ANTERIOR CHAMBER Normal in depth both in centre and
periphery
Normal in depth both in centre and
periphery
IRIS Normal in color and pattern Normal in color and pattern
PUPIL Round regular and Reacting to light Round regular and Reacting to light
LENS
IOP(by GAT at 12/10/2021 @ 1.06pm)
Transparent
14 mm of Hg
Transparent
14mm of Hg

21. Fundus examination:
Fundus examination (Direct
ophthalmoscopy)
Right eye Left eye
Media Clear Clear
Optic disc-Color Pink Pink
Margin Well defined Well defined
Shape Circular Circular
CD ratio 0.3 0.3
Blood vessels Normal in number and distribution Normal in number and distribution
Background fundus Normal Normal
Macula Healthy, Foveal reflex present Healthy, Foveal reflex present

22. Special ocular examination:
Sac patency test-
On right side- Fluid easily pass into the nose and naso-pharynx
indicates the lacrimal drainage system is patent.
On left side- Cloudy fluid come out through the upper punctum
indicates block into the nasolacrimal duct.

23. Sac patency test:

24. Special ocular examination:
Schirmer ‘s test-1
On right eye : 16 mm within 5 minute
On left eye : 30 mm within 5 minute

25. Watering and discharge from left
eye

26. Matted eyelashes( left eye)

27. Left lower punctum

28. Marginal tear stripes height
increased

29. Marginal tear stripes height
increased

30. Examination of the cardiovascular
system:
Inspection –
Shape of the chest-normal.
Anaemia , cyanosis , clubbing , coldness of extremities , pyrexia , oedema
absent.
Arterial pulse- 76 beats/min
Blood pressure- 110/70 mm of Hg

31. Examination of the cardiovascular
system:
Palpation-
 Apex beat-present in left 5th intercostal space just medial to the mid clavicular
line.There was no thrill.
Percussion-area of superficial cardiac dullness normal.
Auscultation-
 The first and second heart sounds were audible .
There is no added sound.

32. Examination of the Respiratory
System:
Inspection-Nasal cavity-normal
Nasopharynx-NAD
Oral cavity-NAD
Oropharynx-NAD
Respiratory rate-16 breaths/min
Shape of the chest-normal ,bilaterally symmetrical
Palpation-position of the trachea central.
Percussion-resonant
Auscultation-vesicular breath sound

33. Alimentary system:
Inspection : Size and Shape – Normal
 Position of the Umbilicus – central
Palpation : Temperature is normal.
 There is no tenderness, rigidity or swelling.
Percussion : Tympanitic
Auscultation : Bowel sound present.

34. Musculoskeletal system:
Gait: Normal
Arms: Normal
Limbs: Normal
Spine: Normal

35. Examination of the Nervous
System:
Higher cerebral function- intact
Patient is conscious and oriented , gait normal.
All cranial nerves-intact
Motor function-There is no muscle wasting ,bulk and tone of muscle
is normal in both upper and lower limbs .
Reflexes- are intact and normal.
Sensory function-Temperature ,touch , pain and vibration and position sense
intact.
Cerebellar function- intact
Signs of meningeal irritation -absent

36. Salient feature:
Mrs. Samia Sultana Anny 40 years old normotensive and non diabetic housewife
hailing from Hatirpool,Dhaka came into the department of community
ophthalmology,BSMMU on 12.10.2021 with the complaints of watering from left eye
for 4 years and purulent discharge from left eye for 1 year.
On Slit lamp examination left eye reveals that eye lashes were matted, lacus
lacrimalis was full of water, lower tear film meniscus height was increased and
regurgitation test –positive on left side .Sac patency test reveals NLD block of left
side.
Other ocular, general and systemic examination were within normal limit.

37. Provisional diagnosis:
Chronic dacryocystitis of left side

38. Differential diagnosis:
Acute dacryocystitis of left side
Punctum stenosis of left side
Lacrimal pump failure of left side

39. Following Investigations were
advised:
CBC with ESR
RBS
HbsAg
Bleeding time
Clotting time
RT PCR for COVID 19
X ray PNS O/M view

40. Management:
Dacryo-cysto-rhinostomy(DCR) of left side with intubation
under local anaesthesia.