What is Dacryocystitis?
Dacryocystitis is inflammation of the lacrimal sac and is commonly caused by the Staphylococcus species, beta-hemolytic streptococci, pneumococci, and Haemophilus influenzae. The nasolacrimal duct blockage may be considered primary or secondary due to trauma, infection, neoplasm, or an intranasal pathology such as deviated nasal septum or rhinitis. The obstruction results in the stasis of secretions in the lacrimal sac leading to infection. Tears are usually backed up or stagnant within the lacrimal sac.
- Dacryocystitis is inflammation of the lacrimal sac due to blockage.
- 90% of all nasolacrimal duct blockages in children resolve by 1 year of age.
- Redness, swelling, and pain in the medial part of the orbit are typical signs of dacryocystitis.
Dacryocystitis can be divided by duration–acute or chronic–and acquired vs congenital. Acute dacryocystitis usually requires systemic antibiotic therapy prior to intervention for the nasolacrimal duct obstruction. Chronic dacryocystitis presents with less inflammatory signs and requires surgical therapy for the primary cause.
The congenital form of dacryocystitis is typically due to obstruction of the valve of Hasner, located in the distal portion of the nasolacrimal duct. If amniotic fluid is not expelled from the nasolacrimal system a few days post-delivery, it can become purulent, leading to neonatal dacryocystitis. Acquired causes of dacryocystitis include aging changes, systemic disorders, surgeries, neoplasms, and certain medications.
Risk Factors for Dacryocystitis
Risk factors for dacryocystitis vary but are related to nasolacrimal duct obstruction. Age is a risk factor for dacryocystitis. Most cases occur after birth (congenital dacryocystitis) or in adults older than 40 years of age (acute dacryocystitis). Older age leads to narrowing of the puncta slowing tear drainage. Females are affected more than males, and Caucasians more than African Americans.
Nasal septum deviation, rhinitis, turbinate hypertrophy, damage to the nasolacrimal system due to trauma, neoplasms of the nasolacrimal system and certain system diseases such as sarcoidosis, and lupus are risk factors for dacryocystitis. In addition, certain medications such as timolol, pilocarpine, idoxuridine, and trifluridine are risk factors.
Presentation may differ between the types of dacryocystitis. Symptoms may occur over hours or days and often include:
- Redness, swelling, and pain in the medial part of the orbit
- Excessive tearing
- Expression of purulent material from the puncta
- Blurry vision
- Eyelid necrosis, orbital cellulitis, orbital abscess, and vision loss in children
- Progression into preseptal cellulitis (swelling around eye, conjunctival injection)
- Progression into orbital cellulitis (Proptosis, pain on eye movement, ophthalmoplegia)
Dacryocystitis is diagnosed clinically from a patient’s history and exam. In acute cases, a Crigler, or tear duct, massage can be performed to express material for culture and gram stain. With patients who appear to be acutely toxic or those with visual changes, imaging and blood work should be performed. In chronic cases, bloodwork may be performed if systemic conditions are suspected.
Imaging is not needed unless suspicion arises. CT scans may be performed in cases of trauma. Dacryocystography or dacrosystogram (DCG) should be performed when anatomic abnormalities are suspected. Nasal endoscopy is useful to rule out hypertrophy of the inferior turbinate, septal deviation, and inferior meatal narrowing.
The fluorescein dye disappearance test (DDT) is used to evaluate adequate lacrimal outflow, especially in patients unable to undergo lacrimal irrigation. In a DDT, sterile fluorescein dye is instilled into the conjunctival fornices of each eye, and the tear film is then examined using a slit lamp. The presence of dye combined with asymmetric clearance of the dye from the tear meniscus after five minutes, indicates an obstruction. This test does not distinguish between an upper (punctal, canalicular, or sac) and lower (nasolacrimal duct) obstruction.
Treatment requires treating the underlying cause of the dacryocystitis. With children, a more conservative route is followed as congenital obstruction has a 90% chance of resolution by 1 year of age. Common treatment includes antibiotics (eg, amoxicillin, ciprofloxacin, clindamycin) and drainage of the abscess. Antibiotic administration route depends on infection severity, with intravenous antibiotics preferred if complications arise. In children, management should be tailored individually for each case. Hospital admission for younger patients is more commonly advised.