Nodular Fasciitis Resulting in a Nasolacrimal Duct Obstruction

A 22-year-old woman was referred for dacrocystitis and epiphora for the past 6 months. The patient had no prior ophthalmic history and no visual complaints. The patient was previously treated with 3 courses of oral amoxicillin/clavulanate and then multiple antibiotic eye drops without improvement of her symptoms. CT scans of the orbits revealed nasolacrimal system distention extending from below the medial canthal tendon along the nose (panel A). The lacrimal sac was tender to palpation. The patient elected to proceed with dacryocystorhinostomy. Intraoperatively, the indurated area that was initially believed to be a distended nasolacrimal sac in the medial canthal region was noted to be separate from the lacrimal sac (panel B). Since this was an unexpected finding, multiple incisional biopsies of the medial canthal mass were obtained. Histopathology revealed a proliferation of spindle cells (hematoxylin and eosin) (panel C) and, under increased magnification (panel D), showed positive reactivity for smooth muscle actin and vimentin (panels E and F, respectively). The findings were consistent with the diagnosis of nodular fasciitis. Postoperatively, the inflammation improved with an oral steroid taper, and the nodule size remained stable. The patient became pregnant a month after the initial surgery and deferred full excision of the lesion until after delivery.FIG