Jacqueline R. Carrasco

BASICS

DESCRIPTION

• 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

RISK FACTORS

• Structural predispositions:

– Brachycephalic head

– Narrow face with flat nose

GENERAL PREVENTION

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.

PATHOPHYSIOLOGY

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.

ETIOLOGY

• 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.

DIAGNOSIS

HISTORY

• Acute, chronic, or congenital forms

• Pain, redness, swelling over medial canthal region

• Epiphora

PHYSICAL EXAM

• 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

Diagnostic Procedures/Other

• 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

DIFFERENTIAL DIAGNOSIS

• Canaliculitis

• Encephalocele

• Lacrimal sac tumor

TREATMENT

ADDITIONAL TREATMENT

General Measures

• Oral antibiotics

• Warm compresses

• Topical antibiotic ophthalmic drops and/or ophthalmic ointment

• IV antibiotics for severe cases, or concern for orbital cellulitis

SURGERY/OTHER PROCEDURES

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].

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

• Ophthalmologist

• Oculoplastic surgeon

Patient Monitoring

See “Follow-up”

PROGNOSIS

Excellent

COMPLICATIONS

• Orbital cellulitis

• If severe infection, may lead to sepsis and rarely death

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