Veterinary Ophthalmology (2010) 13, 2, 106–109

CASE REPORT

Nasolacrimal obstruction caused by root abscess of the upper canine

in a cat
James M. G. Anthony, Lynne S. Sandmeyer and Amanda R. Laycock
Western College of Veterinary Medicine, 52 Campus Drive, Saskatoon, SK, Canada S7N 5B4

Address communications to: Abstract

J. M. G. Anthony A 10-year-old, castrated male domestic short hair cat was presented to the Small
Tel.: 306-966-8606
Animal Clinic at the Western College of Veterinary Medicine with a presenting
Fax: 306-966-7156 complaint of chronic, ocular discharge from the left eye. Ocular examination
e-mail: james.anthony@usask.ca confirmed epiphora and mucopurulent discharge but there were no apparent reasons
for the ocular discharge, and nasolacrimal obstruction was suspected. The cat had
swelling of the left side of the face, severe periodontal disease and a fractured upper
left canine tooth with pulpal exposure. Dacryocystorhinography revealed narrowing of
the nasolacrimal duct above the root of the fractured upper left canine and dental
radiographs showed a severe periapical lucency at the apex of the upper left canine
tooth. The fractured canine tooth was removed. Subsequently, the ocular discharge
and facial swelling resolved. After 2 years, the epiphora has never reoccurred. This is
a noteworthy case because a suspected root abscess resulted in extralumenal
compression of the nasolacrimal duct, which shows the importance of a thorough oral
examination when nasolacrimal obstruction is evident.
Key Words: cat, dacryocystorhinography, epiphora, nasolacrimal duct, ocular
discharge, tooth root abscess

Kitchener, ON) examinations were completed. Both upper

CASE REPORT
A 10-year-old, neutered male domestic short hair cat, weigh-
ing 6.1 kg, was admitted to the Small Animal Clinic at the
Western College of Veterinary Medicine. The presenting
complaint was a chronic ocular discharge of three weeks’
duration. The cat had been vaccinated only as a kitten and
had not been dewormed regularly. Neuroophthalmic exami-
nation was normal bilaterally. Schirmer tear test I (Schirmer
Tear Test Strips; Alcon Canada, Mississauga, ON) values
were 20 and 30 mm/min in the right and left eye, respec-
tively. Intraocular pressures were estimated using a rebound
tonometer (Tonvet; Tiolat, Helsinki, Finland) and were
15 mmHg bilaterally. Fluorescein sodium dye (Fluorets;
Bausch & Lomb Canada Inc., Markham, ON) was negative
bilaterally. Mild conjunctival hyperemia and moderate mu-
copurulent discharge was present in the left eye (Fig. 1). The
pupils were dilated with tropicamide (Mydriacyl; Alcon
Canada), after which biomicroscopic (Osram 64222; Carl
Zeiss Canada, Don Mills, ON) and indirect ophthalmo-
scopic (Heine Omega 200; Heine Instruments Canada,
and lower puncta were present and normal in position and
size bilaterally. A focal, well demarcated area of tapetal
hyperreflectivity was present in the left superior fundus
consistent with a retinal scar. Fluorescein sodium dye
passage test showed patency into the right nostril within
5 min but not into the left nostril at any time. Based on clini-
cal signs and negative fluorescein dye passage test for the left
side, nasolacrimal obstruction was suspected. Nasolacrimal
irrigation was not attempted at initial evaluation due to
difficulty in applying adequate restraint in the awake cat.
Temperature (37.9 °C), pulse (144 b.p.m) and respiration
(48 b.p.m) were normal. Remarkable findings on general
physical examination included left sided suborbital swelling
and coronal fracture of the upper left canine tooth (tooth
#204) with necrotic pulp exposure. The cat was prescribed
250 mg Amoxicillin suspension (Nu-Amoxi; Nu-Pharm
Inc., Richmond Hill, CA) by mouth twice daily for 10 days
to reduce bacteria that were potentially responsible for the
oral disease and was referred to the dental service at the
Western College of Veterinary Medicine.

Ó 2010 American College of Veterinary Ophthalmologists

 nasolacrimal obstruction caused by root abscess 107

Figure 1. Clinical photograph of domestic shorthair cat with left

nasolacrimal duct obstruction. Note left sided ocular discharge.

The cat was evaluated by the dental and ophthalmology Figure 2. Feline dacryocystorhinogram. The nasolacrimal duct is
service 2 weeks later and clinical signs remained unchanged. patent, confirmed by dye exiting the nasal passage. There appears to be
Dacryocystorhinography was completed to evaluate patency slight narrowing and elevation of the duct at the base of the left upper
canine tooth root (arrowhead).
of the nasolacrimal duct. Routine complete blood cell count
(CBC), serum biochemistry profile and urinalysis were
completed prior to anesthesia and were unremarkable. The
cat was pre-medicated with Morphine (Morphine, 0.5 mg/
kg; Sandoz Canada Inc., QC) and Acepromazine (Atravet;
Ayerst Veterinary Laboratories, Guelph, ON) at 0.1 mg/kg
by intramuscular (IM) injection, and anesthesia was induced
with Propofol (Propofol Injection; Novopharm Ltd.,
Toronto, ON) 6.0 mg/kg intravenous (IV) injection and
maintained with Isoflurane (IsoFlo; Abbott Laboratories
Ltd., Saint-Laurent, QC) in oxygen via endotracheal intu-
bation. Nasolacrimal irrigation with sterile saline was
attempted but required excessive force to complete on the
left side. The upper and lower canaliculi were catheterized
on the left side with 24 gauge IV catheters. Radiopaque dye
(Omnipaque; GE Healthcare, Mississauga, ON), 1 mL, was
injected to allow radiographic contrast visualization of the
nasolacrimal duct. The left nasolacrimal duct was patent but
had slight narrowing and elevation of the duct at the base of Figure 3. A rostral maxillary bisecting angle view of the feline rostral
the root of the left upper canine tooth (Fig. 2). Complete maxilla. Note the fractured crown with pulpal exposure (arrowhead),
dental series of radiographs were made and showed a severe the widened endodontic system (arrow) and the periapical lucency
periapical lucency of tooth 204. This canine was subse- (dotted line) and root resorption associated with tooth #204.
quently extracted (Fig. 3). A left infraorbital nerve block was
done by infiltrating 0.25 mL of 0.5% Bupivicaine HCl with
1:200 000 epinephrine (Vivicaine; Novocol Pharmaceutical weeks after surgery, the extraction sites had completely
of Canada Inc., Cambridge, ON) to aid in a balanced anal- healed. There was no ocular discharge or facial swelling.
gesia. Hydromorphone (Hydromorphone HP 10; Sandoz Complete ocular examination was repeated and there was no
Canada Inc., QC) at 0.05 mg/kg IV and meloxicam indication of conjunctival hyperemia or epiphora. Epiphora
(Metacam; Boehringer Ingelheim, Burlington, ON) at has not reoccurred for 2 years following surgery as reported
0.2 mg/kg subcutaneously were administered postopera- by the client.
tively for analgesia. The owner was instructed to administer
25 mg Clindamycin (Antirobe Aquadrops; Pharmacia
DISCUSSION
Animal Health, Orangeville, ON) by mouth twice daily
for 10 days and to apply two drops of oral cleansing gel Excessive tearing and ocular discharge may be the result of
(Maxi-Guard Oral gel; Addison Biological Laboratory Inc., several processes including reflex hypersecretion, nasolacri-
Fayette, MO) and two drops of oral rinse (C.E.T. Oral mal pump failure, and epiphora due to nasolacrimal duct
Hygiene Rinse; Virbac Animal Health Inc., Fort Worth, constriction or obstruction.1 Reflex hypersecretion is a
TX) to each side of the mouth twice daily indefinitely. Two response to an ocular irritation usually caused by surface or

Ó 2010 American College of Veterinary Ophthalmologists, Veterinary Ophthalmology, 13, 106–109

108 a n t h o n y , s a n d m e y e r a n d l a y c o c k
intraocular disease or by nasal irritation.1,2 A common cause
of lacrimal hypersecretion or ocular discharge in the cat is
primary conjunctivitis which may be caused by infection with
Feline Herpesvirus-1 or Chlamydophila feli or Mycoplasma
sp;3–5 or may be due to lipogranulomatous, and eosinophilic
inflammation.6,7 Corneal and intraocular disease such as uve-
itis and glaucoma may also cause ocular discharge.2,8 In the
cat reported here, the ophthalmic examination revealed no
evidence of concurrent corneal or intraocular disease and
primary conjunctivitis was considered less likely due to the
lack of substantial conjunctival inflammation or blepharo-
spasm.
Nasolacrimal pump failure prevents tears from being
moved into the nasolacrimal duct from the eye. Facial nerve
paralysis, weakness of the orbicularis oculi muscle or ever-
sion of the eyelid can result in nasolacrimal pump failure.1
Epiphora may occur in brachycephalic breeds as a confor-
mational condition related to medial ventral entropion.8
However, the cat reported here had a normal menace
response and palpebral reflexes and did not have eyelid con-
formational abnormalities.
Nasolacrimal obstructions may be intralumenal, intramu-
ral or compressive extralumenal and can be categorized as
congenital or acquired.9 Congenital abnormalities of the
puncta, canaliculi or nasolacrimal duct occur most frequently
in young animals.9,10 A common cause of acquired nasolacri-
mal obstruction in the cat is fibrosis and symblepharon of the
nasolacrimal puncta following severe conjunctivitis.11 Other
causes include dacryocystitis attributable to intralumenal
foreign material, nasolacrimal inflammation or infection,
and trauma to the nasolacrimal system.9,12 Inflammation,
cysts, or neoplasia of adjacent periorbital or nasal tissue may
also cause compressive extralumenal nasolacrimal duct
obstruction.13–17 In this cat partial extralumenal nasolacri-
mal duct compression was suspected to be due to adjacent
maxillary apical periodontitis. Nasolacrimal obstructions
lead to inflammation of the nasolacrimal sac and duct and
result in chronic ocular discharge, epiphora, and secondary
conjunctivitis.10
Ocular disease may occur commonly in association with
dental disease in dogs and cats due to the proximity of the
posterior maxillary teeth and the orbit.15 Ocular manifesta-
tions of dental disease include orbital, periorbital, conjuncti-
val, nasolacrimal, neuro-ophthalmic, and even uveal signs.15
Commonly in cats, pulpal exposure of the maxillary canine
tooth leads to an apical periodontitis and with time may also
cause external compression of the nasolacrimal duct lumen.
Chronic involvement of the maxillary canine tooth in the
cat may be misconstrued clinically as nasolacrimal signs or
disease.15 A cutaneous draining tract was not present in this
case and partial extralumenal nasolacrimal obstruction was
observed via radiographs and extreme resistance to nasolacr-
imal duct irrigation.
Nasolacrimal disease is uncommon in the cat because of
the relatively short nasolacrimal duct that provides less
opportunity for obstruction.8,18 Dacryocystorhinography
Ó 2010 American College of Veterinary Ophthalmologists, Veterinary Ophthalmology, 13, 106–109
revealed extralumenal compression of the nasolacrimal
duct immediately dorsal to the endodontic infected tooth
apex. (204) Dental radiographs showed a periapical lucency
consistent with a periapical abscess. Due to the direct con-
tact of the nasolacrimal duct to the periapical lucency of
204, we feel that the tissue inflammation caused compres-
sion of the adjacent nasolacrimal duct resulting in second-
ary conjunctivitis, and chronic mucopurulent ocular
discharge.
We conclude that the presumptive periapical abscess
of 204 extended to encompass the nasolacrimal duct and,
due to chronic exposure to the abscess, developed com-
pression of the duct. After extraction of the affected
tooth (204), ocular signs resolved without ocular treat-
ment. Development of permanent stricture, therefore, is
unlikely. Nasolacrimal obstruction occurs infrequently in
the cat, and may be overlooked. Thorough oral/dental
examination should always be completed in cats with
chronic ocular discharge.
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