Lacrimal Sac Tumors (Tear Sac Tumors)

Where the lacrimal sac is

Tears are made by the lacrimal gland above the outer corner of the eye. They wash across the eye and drain through two tiny openings at the inner corner of the eyelids into the lacrimal sac, which sits in a bony groove beside the nose. From there tears pass down the nasolacrimal duct into the nose.

A tumor in the sac blocks this pathway, so tears overflow onto the cheek. It can also grow out of the sac into the eye socket, sinuses or nose.

Types of lacrimal sac tumors

About 55 to 75% of lacrimal sac tumors are malignant.

Human papillomavirus (HPV) is found in some papillomas and carcinomas of the lacrimal sac.

Symptoms

Early symptoms overlap with a blocked tear duct and dacryocystitis:

• Watery eye (epiphora), usually one side, in an adult
• Sticky discharge and repeated infections of the sac
• A lump at the inner corner of the eye

Features that point to a tumor rather than a simple blockage:

• Bloody tears (hemolacria) or blood when the sac is pressed
• A firm, non-tender mass that does not shrink when pressed
• A mass that extends above the medial canthal tendon (the small tendon at the inner corner). Simple sac swellings from blockage usually stay below it.
• Nosebleeds or nasal blockage on the same side
• Pain, numbness of the cheek, or swollen lymph nodes
• Symptoms that persist or return after dacryocystorhinostomy (tear duct bypass surgery)

How lacrimal sac tumors are diagnosed

1. Eye and eyelid examination, including pressing on the sac and testing whether tears drain.
2. Lacrimal irrigation: flushing saline through the drainage system. Blood or an unusual blockage raises concern.
3. Nasal endoscopy to look for tumor spreading into the nose, or a primary nasal tumor extending upward.
4. CT scan to show bone erosion and spread into the sinuses or orbit. MRI shows soft tissue detail.
5. Dacryocystography (X-ray dye study) occasionally, showing a filling defect inside the sac.
6. Biopsy: confirms the type. Some tumors are only discovered when tissue is sent to the lab during routine tear duct surgery, which is why many surgeons biopsy the sac wall when it looks abnormal.
7. Staging: for cancers, scans of the neck, chest or whole body to look for spread.

Treatment

Benign tumors

Complete surgical removal of the sac (dacryocystectomy) with clear margins. Papillomas need full removal because they tend to recur and can become malignant.

Malignant epithelial tumors

• Surgery: wide removal of the lacrimal sac and nasolacrimal duct, sometimes with part of the surrounding bone, sinuses or eyelid. More extensive tumors may need removal of the eye socket contents (orbital exenteration).
• Radiotherapy after surgery to reduce the risk of recurrence.
• Neck dissection or radiotherapy if lymph nodes are involved.
• Chemotherapy for advanced disease.

Lymphoma

Lymphoma of the lacrimal sac is usually treated with radiotherapy and, if it is more widespread, chemotherapy or immunotherapy such as rituximab, rather than major surgery.

Reconstruction

After the tumor is removed, the tear drainage system may be rebuilt later, often with a small glass tube (Jones tube), once there has been no recurrence for a period.

Outlook

The outlook depends on the type and stage. Benign papillomas have an excellent outlook if completely removed. Malignant epithelial tumors can recur locally or spread to lymph nodes, so long-term follow-up with exams and scans is needed. Lymphomas often respond well to treatment. Melanoma has the poorest outlook.

Frequently asked questions

What are the symptoms of a lacrimal sac tumor?

The most common symptoms are a watery eye and a lump at the inner corner of the eye. Bloody tears, a firm lump that extends above the inner corner, nosebleeds on the same side, and symptoms that keep returning despite treatment are warning signs that suggest a tumor.

How is a lacrimal sac tumor different from a blocked tear duct?

A blocked tear duct causes watering and sometimes a soft swelling that empties with pressure, usually below the inner corner tendon. A tumor tends to be firmer, may extend above that tendon, and can cause bloody tears. Imaging and biopsy confirm the difference.

Are lacrimal sac tumors cancerous?

Many are. Between half and three-quarters are malignant, most often squamous or transitional cell carcinoma or lymphoma. Benign papillomas also occur but can recur or become cancerous if not completely removed. A biopsy is the only way to know the type.

What causes bloody tears?

Bloody tears can come from eye surface injury, conjunctivitis, nosebleeds traveling up the tear duct, bleeding disorders and, rarely, tumors of the conjunctiva or lacrimal sac. Persistent or unexplained bloody tears should be examined by an ophthalmologist.

How rare are lacrimal sac tumors?

They are very rare. Most ophthalmologists see only a few in their careers. Because watery eyes and tear sac swellings are usually caused by simple blockage or infection, tumors are easily missed, which is why atypical signs need careful assessment.