Jacqueline R. Carrasco
• Dacryocystitis is an inflammatory condition of the lacrimal sac, usually infectious in nature
• May occur as sequelae of nasolacrimal duct obstruction (NLDO), and it may lead to recurrent episodes
• May be chronic, acute, or congenital
• Structural predispositions:
– Brachycephalic head
– Narrow face with flat nose
There is no preventive counseling prior to a first episode. Once an episode of dacryocystitis has occurred, undergoing a dacryocystorhinostomy (DCR) procedure in certain cases may help to prevent future recurrences.
The surfaces of the lacrimal passages are normally colonized with bacteria. When blockage occurs for any reason, and tears do not flow normally through the system, dacryocystitis can result.
• Structural midface abnormalities
• Ethmoidal inflammation
• Obstruction, including nasal fractures, impacted punctal plugs, lacrimal sac tumors, or cysts
• Bacterial: Staphylococcus epidermidis, Staphylococcus aureus, Streptococci, and Pneumococci, as well as gram-negative bacteria and anaerobes.
• Acute, chronic, or congenital forms
• Pain, redness, swelling over medial canthal region
• Tenderness to palpation over lacrimal sac region
• Firm nodule inferior to medial canthus
• Purulent discharge from puncta
• May have drainage through dacryocutaneous fistula, which may close spontaneously
• A secondary orbital cellulitis may result in an afferent pupillary defect, limited extraocular movement
DIAGNOSTIC TESTS & INTERPRETATION
• Usually a clinical diagnosis
• If an inflammatory etiology is suspected: ANA, ANCA, ACE, CBC
• If unresponsive to empiric therapy, may obtain cultures of discharge or blood cultures
• CT scan to evaluate for structural abnormalities and other obstructive causes, not always necessary.
• Dacryocystography and dacryoscintigraphy may be used to help define the lacrimal system anatomy.
• Jones dye test (I or II)
• Endoscopy to evaluate anatomy by direct visualization
• Lacrimal sac tumor
• Oral antibiotics
• Warm compresses
• Topical antibiotic ophthalmic drops and/or ophthalmic ointment
• IV antibiotics for severe cases, or concern for orbital cellulitis
Usually a DCR – external or endonasal – must be done to avoid recurrence once the initial infection has resolved with antibiotic therapy. Although endonasal DCR avoids external scars, there are no recent randomized prospective trials with direct comparison of efficacy. A Cochrane Review found mixed data and paucity of randomized controlled trials (1)[B]. A comparison of external DCR with endonasal laser-assisted (endocanalicular) DCR found similar efficacy (92.4 vs. 94.2% respectively) (2)[B]. Routine biopsy of lacrimal sac at time of DCR is controversial. A recent large retrospective review suggests biopsy in atypical or suspicious cases (3)[C].
• Oculoplastic surgeon
• Orbital cellulitis
• If severe infection, may lead to sepsis and rarely death
1. Anijeet D, Dolan L, Macewen CJ. Endonasal versus external dacryocystorhinostomy for nasolacrimal duct obstruction. Cochrane Database Syst Rev 2011;1:CD007097.
2. Ajalloueyan M, Fartookzadeh M, Parhizgar H. Use of laser for dacryocystorhinostomy. Arch Otolaryngol Head Neck Surg 2007;133:340–343.
3. Salour H, Hatami MM, Parvin M, et al. Clinicopathological study of lacrimal sac specimens obtained during DCR. Orbit 2010;29(5):250–253.