Gangadhara Sundar
Dr. Sundar graduated from the Madras Medical College. Following his basic ophthalmology training in India, he received his postgraduate ophthalmology residency and Fellowship training in Ophthalmic Plastic & Reconstructive Surgery and Ocular Oncology at the Henry Ford Hospital, Detroit. With an extensive multinational multiethnic multispeciality practice and patient experience, he currently serves as Head, Orbit & Oculofacial Surgery, Ophthalmic Oncology at the National University Hospital, Singapore and is committed to clinical research, education of residents & fellows with national, regional and international outreach. His interests include orbital inflammatory diseases including Thyroid Eye Disease, minimally invasive orbital, lacrimal and oculofacial surgery, orbitofacial trauma and esthetic oculofacial surgery. He is a strong proponent of multidisciplinary approaches to complex orbito-facial disorders.
Introduction and Overview
Dacryocystitis is a common condition of bacterial etiology that ophthalmologists and oculoplastic surgeons face. Although typically seen in the middle aged and elderly [1], it may be seen in any age group. The diagnosis is often missed by the general ophthalmologist when the symptoms are either minimal or chronic. We shall discuss the presentation, diagnosis, and management in the section below.
Definition
Dacryocystitis is an acute, subacute, or chronic suppurative infection of the lacrimal sac and proximal nasolacrimal duct [2], secondary to underlying nasolacrimal duct obstruction. The obstruction may be due to developmental dysgenesis or acquired in origin. Acute fulminant or chronic infections may also involve the lacrimal sac walls and perisaccal tissues, resulting in a lacrimal sac abscess, an overlying facial cellulitis, or even orbital cellulitis [3].
Etiology
Most infections are of bacterial origin secondary to an underlying nasolacrimal duct obstruction. The bacteria may be native to the lacrimal sac and nasolacrimal duct or from the ocular surface. While most acute suppurative infections are caused by gram-positive organisms [4], chronic or partially treated infections are often polymicrobial, gram-positive and gram-negative organisms, sometimes even multidrug resistant [5]. Anaerobic infections, fungal infections, and parasitic infestations are extremely rare.
Nasolacrimal duct obstructions may either be due to developmental dysgenesis from failure of canalization of the nasolacrimal duct [6] (congenital nasolacrimal duct obstruction CNLDO), primary acquired nasolacrimal duct obstruction (PANDO) [7] or secondary acquired nasolacrimal duct obstruction (SANDO) from foreign bodies [8], trauma (midfacial or naso-orbital ethmoidal (NOE) fractures) [9], growths or tumors within the lacrimal sac, nasolacrimal duct or nasal cavity or rarely from disruption of the nasolacrimal duct during endonasal surgeries [10].
Types
Hyperacute: Uncommon, it is typically seen in the elderly and immunocompromised.
Acute: Typically unilateral, it is a more common presentation, seen in middle-aged and elderly females (Fig. 39.1), although it may be seen in all age groups. Affected patients present with pain, redness, and swelling in the region of the medial canthus, with purulent discharge and an injected eye. Less commonly it may be seen in the newborn, young adult males and may be bilateral (Fig. 39.2).
Fig. 39.1
Right acute dacryocystitis in middle-aged female
Fig. 39.2
Bilateral acute dacryocystitis in young adult male
Chronic: The most common presentation, especially in adults and young children (Fig. 39.3) who are known to have an underlying nasolacrimal duct obstruction, with waxing and waning symptoms. Not infrequently these patients would have been managed as chronic conjunctivitis with intermittent topical antibiotic treatment [11].
Fig. 39.3
Chronic dacryocystitis in child from untreated congenital nasolacrimal duct obstruction
Incidental: Typically diagnosed in patients undergoing routine preoperative lacrimal irrigation prior to intraocular surgery, a common practice in some developing nations, when mucoid or mucopurulent regurgitation is observed [12].
Secondary: These may be as a result of intraluminal foreign bodies (migrated punctal/intracanalicular plugs), long-term indwelling migrated lacrimal stents, or secondary infection with lacrimal sac tumors.
Clinical Presentation
Dacryocystitis may be diagnosed in all age groups. Symptoms and signs are dependent upon the age, duration, underlying immune status, and previous treatment if any. Typical symptoms and signs are described below. Occasionally atypical presentations may also occur.
Symptoms: Most patients with acute dacryocystitis present with unilateral severe throbbing pain, redness, and swelling below the medial canthus with ipsilateral tearing and discharge from that eye for months or years. Rarely, they may present with fever, malaise, and loss of appetite, especially when there is overlying facial cellulitis (Fig. 39.4). In the partially treated patient, symptoms may be minimal. These include overlying erythema and induration without tenderness or swelling below the medial canthus alone.
Fig. 39.4
Right acute on chronic dacryocystitis with facial cellulitis
Signs: Classic signs of acute inflammation are usually present. These include erythema, warmth, swelling with or without induration, pain or tenderness, and regurgitation on pressure over the lacrimal sac below the medial canthal tendon (Fig. 39.5). A patient with chronic infection may present with minimal signs except for mucoid or mucopurulent regurgitation on lacrimal sac irrigation, swelling with induration below the medial canthal tendon (mass lesion), or slightly raised tear meniscus with debris on slit lamp examination.
Fig. 39.5
Chronic dacryocystitis
Based on the above, a subcutaneous inflammatory mass lesion below the medial canthal tendon is a dacryocystitis until proven otherwise. When a mass lesion presents above the medial canthal tendon, other conditions like a lacrimal sac tumor, medial orbital tumor, or intracranial space-occupying lesion with extension should be considered and thus imaging is warranted.
Differential Diagnosis
In most cases, the diagnosis is straightforward and obvious. However there are special situations that one should be aware of and are listed below:
Medial canthal skin tumors (Fig. 39.6). Differentiating features include chronicity, inability to pinch the skin, and complete mobility from the underlying tissues.
Fig. 39.6
Right medial canthal neurofibroma
Subcutaneous extrasaccal medial canthal tumors and infection. These are more difficult to diagnose and usually proven by patency of nasolacrimal duct on irrigation. Rarely an infected diverticulum of the lacrimal sac or canaliculus may present like a dacryocystitis (Fig. 39.7).
Lacrimal sac/drainage system tumors [13] (Fig. 39.8 a, b). Diagnosed based on high degree of clinical suspicion, findings on imaging (CT scan or MRI, dacryocystography), and rarely intraoperatively.
Fig. 39.7
Infected lacrimal anlage (fistula)
Medial orbital tumors. This is suspected based on posterior extension of the lesion, lateral displacement of the globe with or without ocular motility problems.
Nasal tumors.
Fig. 39.8
(a) Carcinoma of right lacrimal sac and nasolacrimal duct. (b) MRI showing infiltration of the right lacrimal drainage apparatus with globe displacement
Intracranial tumors.
In most situations, a good history including the duration of symptoms, previous medical and surgical interventions, clinical examination, and ancillary clinical investigations are sufficient to make a reliable diagnosis.
Examination
All patients should undergo a complete ophthalmic examination of both eyes. Specific attention should be paid to the resting tear meniscus (height, debris, and discharge), laxity of the lower eyelid, position, size and tone of the lacrimal puncta, and microscopic or macroscopic regurgitation on pressure over the lacrimal sac (ROPLAS) [12]. Inspection of the overlying skin of the medial canthus for inflammation, induration, preexisting skin creases (relaxed skin tension line), epicanthal fold, previous scars of abscess drainage or external dacryocystorhinostomy, should be performed. Lacrimal irrigation is contraindicated in all cases of suspected acute dacryocystitis. However it may be performed gently in subacute or chronic cases especially when alternative differential diagnoses are being considered [14]. All patients with lacrimal system infections and obstructions should undergo a nasal endoscopic examination [15] under topical anesthesia and vasoconstrictors (Fig. 39.9). Specific attention should be paid to the inferior meatus under the inferior turbinate for the presence of tumors and adhesions and to the middle meatus (Fig. 39.10), scarring from previous surgery (Fig. 39.11a), or the presence of foreign bodies from previous facial trauma reconstruction (Fig. 39.11b). Any abnormal pathology should be documented and biopsy considered for suspicious lesions. Regional examination for lymphadenopathy (preauricular, submandibular, submental) and general systemic examination of the patient’s overall well-being complemented by detailed medical history, medications taken including antiplatelet agents, fitness for locoregional, or general anesthesia should also be performed.
Fig. 39.9
Office nasal endoscopy
Fig. 39.10
Tumor of nasal cavity on endoscopy
Fig. 39.11
(a) Scar at the site of previous DCR. (b) Nasal endoscopy showing miniplate and screws in the region of lacrimal sac fossa causing obstruction
Investigations
In most cases of suspected dacryocystitis, laboratory investigations may not be necessary to confirm the diagnosis.
A smear of the conjunctival discharge or mucopurulent regurgitant on lacrimal sac pressure may be sent for Gram and Giemsa stains and routine bacterial cultures and antibiotic sensitivity. This may help guide antibiotic coverage in chronic infections not responding to conventional systemic antibiotics. A negative smear in patients who have been treated with antibiotics however may not be reliable.
Systemic investigations including complete blood count (CBC) may be useful in patients with systemic symptoms and hospitalized patients with multiple systemic comorbidities. An erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) may also serve as a surrogate inflammatory marker. Blood cultures for aerobic and anaerobic organisms may also be performed in patients with fulminant infections, systemic symptoms, or immune compromise.
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