Dacryocystitis

Dacryocystitis is infection of the lacrimal sac, nearly always secondary to nasolacrimal duct obstruction with stagnation of tears. It may be acute or chronic.

• Causes of obstruction: involutional stenosis (older women, the commonest), trauma, previous sinus or nasal surgery, chronic rhinosinusitis, dacryoliths, granulomatous disease (sarcoidosis, granulomatosis with polyangiitis, tuberculosis), tumours of the sac or nose, and congenital obstruction in infants.
• Organisms: Staphylococcus aureus (including MRSA), coagulase negative staphylococci, Streptococcus pneumoniae, Pseudomonas aeruginosa, and, in children, Haemophilus influenzae; polymicrobial infection is common.
• Peak incidence in infants and in women over 40 years.

• Acute: sudden pain, redness, warmth, and swelling over the lacrimal sac inferomedial to the medial canthal tendon (below the tendon, which distinguishes it from ethmoid or frontal disease), epiphora, mucopurulent discharge, fever, and possible abscess with cutaneous fistula; spread to preseptal or orbital cellulitis is possible.
• Chronic: persistent epiphora, mucopurulent discharge, recurrent conjunctivitis, a non-tender mucocele, and reflux of pus on pressure over the sac.
• Neonatal dacryocystocele: bluish swelling below the medial canthus in the first days of life, with a risk of acute infection, respiratory distress from nasal cyst, and fever.

• Clinical, with pressure over the sac showing purulent reflux through the punctum; avoid vigorous palpation in acute infection.
• Culture of discharge or aspirated pus.
• Imaging: CT of the orbit and sinuses with contrast (in suspected abscess, orbital extension, or tumour, atypical or bloody discharge, or trauma), dacryocystography or scintigraphy in selected chronic cases; nasal endoscopy.
• Complete blood count and inflammatory markers in severe infection; blood cultures in febrile children.
• Do not syringe or probe during acute infection.

• Acute dacryocystitis:
  • Warm compresses, analgesia, and systemic antibiotics: cefalexin 500 mg orally every 6 hours for 10 to 14 days or amoxicillin clavulanate 625 mg every 8 hours; for penicillin allergy or MRSA suspicion, clindamycin 300 mg to 450 mg every 6 to 8 hours, or trimethoprim-sulfamethoxazole 160 mg/800 mg twice daily with doxycycline.
  • Intravenous antibiotics for severe infection, fever, systemic illness, orbital extension, or in infants: cefazolin 1 g every 8 hours (child 25 to 50 mg/kg every 8 hours) with vancomycin 15 mg/kg every 8 to 12 hours when MRSA is likely, and add gram negative cover (ceftriaxone 1 to 2 g daily) if Pseudomonas or sepsis is suspected.
  • Topical antibiotic drops (moxifloxacin 0.5 percent or tobramycin 0.3 percent) four times daily are adjuncts but do not reach the sac.
  • Abscess pointing or fluctuant: incision and drainage or needle aspiration with minimal skin incision to avoid a fistula; send culture.
• Definitive treatment is surgical because the obstruction persists: dacryocystorhinostomy (external or endoscopic transnasal, with silicone intubation for 3 to 6 months) after the acute infection has settled (3 to 4 weeks), with a success rate of 90 to 95 percent. Dacryocystectomy is an option in elderly patients with a high surgical risk.
• Chronic dacryocystitis: intermittent topical antibiotics are temporising; surgery should not be delayed because of the risk of corneal infection after any intraocular surgery (dacryocystitis is a contraindication to elective cataract surgery until treated).
• Neonatal dacryocystocele: warm compresses and massage, antibiotics for infection, and early probing with endoscopic marsupialisation if associated with respiratory distress or infection.
• Congenital nasolacrimal duct obstruction without cyst: massage (Crigler) and observation (90 percent resolve by 12 months), probing at 12 months if persistent.
• Follow up after surgery for patency by syringing and symptoms.
• Complications: orbital cellulitis, abscess, cutaneous fistula, sepsis, cavernous sinus thrombosis, meningitis, and corneal ulcer.