We describe 2 cases of congenital lacrimal system anomalies that mimicked recurrent acute dacryocystitis. Two patients with painful swelling below the medial canthal tendon who were referred for acute dacryocystitis were evaluated clinically with findings suggestive of lacrimal system anomalies. Both patients presented in adulthood and both had a history of recurrent presumed acute dacryocystitis without epiphora. Both patients had complete absence of the lower puncta on the involved side. Irrigation via the upper system showed lacrimal drainage system patency in both cases. Surgical exploration confirmed the diagnosis of lacrimal system anomalies. The first patient had a lacrimal sac diverticulum; the second patient had a fistula connected to the common canaliculus with an adjacent cyst. Both patients were successfully treated with excision of the outpouchings. Congenital lacrimal drainage system anomalies should be considered in the diagnosis of recurrent dacryocystitis in cases where the lacrimal system appears patent. The infection can involve a fistula or diverticulum.
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