DACRYOCYSTITIS

Dacryocystitis is inflammation of the lacrimal sac which typically occurs secondarily to obstruction within the nasolacrimal duct and the resultant blockage and stagnation of tears within the lacrimal sac.

• Presentation differs for acute and chronic dacryocystitis.

• In acute dacryocystitis, the symptoms may occur over several hours to several days and include pain, erythema, and edema over the medial canthus and the area overlying the lacrimal sac at the inferomedial portion of the orbit.

• The redness can extend to involve the bridge of the nose. Purulent material can sometimes be expressed from the puncta and tearing may be present

• In cases of chronic dacryocystitis, excessive tearing and mucus reflux (mucocele) are the most common symptoms. Changes in visual acuity may be present due to altered tear film dynamics.

• Visual inspection: A doctor will look for redness, swelling, and discharge in the inner corner of the eye. 

• Palpation: Gentle pressure on the lacrimal sac area may cause pus-like discharge to come out of the tear duct opening (punctum). 

• Blood tests: These may be used to check for an elevated white blood cell count, which can indicate an infection. 

• Differential diagnosis: A doctor will rule out other conditions with similar symptoms, such as conjunctivitis or blepharitis. 

• Red flag symptoms: Certain symptoms may indicate a more severe issue, such as a firm mass, bloody discharge, or lack of response to antibiotics, and may require an urgent consultation. 

• Females are at greater risk than males, due to their narrower duct diameter

• Older age leads to narrowing of the punctal openings, slowing tear drainage

• Dacryoliths: a collection of shed epithelial cells, lipids, and amorphous debris within the nasolacrimal system 

• Nasal septum deviation, rhinitis, and turbinate hypertrophy

• Damage to the nasolacrimal system due to trauma of the ethmoid or maxillary (midfacial) bones

• Definitive treatment requires addressing the underlying cause of the dacryocystitis. In most adults, this is a dacryocystorhinostomy (DCR) for the underlying involutional acquired NLDO. In children, a more conservative route is typically followed, as congenital NLDO has up to a 90% chance of resolution by 1 year of age.

• First, acute dacryocystitis should be treated with oral antibiotics. Warm compresses and Crigler massages can also be employed in children. If the dacryocystitis is progressing despite oral antibiotic therapy, the patient shows evidence of orbital cellulitis, or the case is otherwise complicated, this may require use of intravenous antibiotics.

• Once the acute inflammation/infection is controlled, the underlying cause can then be addressed. In children, so treatment begins conservatively with Crigler massages (parents are taught how to perform the massage at home), and antibiotics are prescribed for the treatment of acute flares. 

• Patients who fail conservative treatment often undergo lacrimal probing, which is successful in 70% of cases. If the dacryocystitis still persists, additional surgical interventions may be needed such as dacryocystorhinostomy (DCR). DCR can be done percutaneously as an external DCR or endoscopically as an endonasal DCR.