Dacryocystitis

By usmlevideoss

Introduction

Dacryocystitis is an infection or inflammation of the lacrimal sac due to obstruction of the nasolacrimal duct, leading to painful swelling near the inner corner of the eye. It can be acute or chronic and requires appropriate management to prevent complications such as orbital cellulitis.

Etiology

  • Obstruction of the nasolacrimal duct is the primary cause.
  • Common pathogens:
    • Acute dacryocystitis: Staphylococcus aureus, Streptococcus pneumoniae
    • Chronic dacryocystitis: Staphylococcus epidermidis, Pseudomonas aeruginosa, anaerobes

Epidemiology

  • Age: More common in infants (congenital nasolacrimal duct obstruction) and older adults. Nasolacrimal duct obstruction is the most common cause of persistent tearing and ocular discharge in children.In adults, nasolacrimal duct obstruction typically occurs in postmenopausal women. 
  • Sex: Slight female predominance due to narrower nasolacrimal anatomy.
  • Risk factors:
    • Congenital anomalies (infants)
    • Trauma or facial fractures
    • Chronic sinus infections
    • Nasal or lacrimal duct tumors

Pathophysiology

  • Obstruction of the nasolacrimal duct leads to the accumulation of tears and debris in the lacrimal sac.
  • This stagnant fluid serves as a breeding ground for bacteria, resulting in inflammation and infection.
  • In chronic cases, long-standing obstruction and recurrent infections can lead to fibrosis and scarring.

Clinical Manifestations

  • Acute dacryocystitis:
    • Painful, erythematous, and swollen area over the medial canthus
    • Purulent discharge upon pressure over the lacrimal sac
    • Tearing (epiphora)
    • Fever in severe cases
  • Chronic dacryocystitis:
    • Persistent tearing
    • Minimal pain
    • Mucopurulent discharge without significant swelling

Diagnosis

  • Clinical diagnosis based on history and physical examination.
  • Palpation of the lacrimal sac: Expresses purulent material in acute cases.
  • Imaging:
    • CT scan: To rule out orbital cellulitis or abscess.
    • Dacryocystography: To assess duct obstruction in chronic cases.
  • Culture of discharge: To identify the causative organism in recurrent or refractory cases.

Treatment

1.Acute dacryocystitis:

  • Antibiotics:
    • Oral antibiotics: Amoxicillin-clavulanate, cephalexin
    • Severe cases: IV antibiotics (e.g., ceftriaxone)
  • Warm compresses to reduce swelling and pain.
  • Downward lacrimal sac massage (“Crigler” massage) two to three times a day
  • Incision and drainage if abscess formation occurs.

2.Chronic dacryocystitis:

  • Surgical intervention is often required:
    • Dacryocystorhinostomy (DCR): Creation of a new drainage pathway from the lacrimal sac to the nasal cavity.
    • Balloon catheter dilation for infants.

Prognosis

  • Acute dacryocystitis: Usually resolves with appropriate antibiotics.
  • Chronic cases: Surgical correction has a high success rate, especially with DCR.
  • Complications include orbital cellulitis, abscess formation, and rarely, sepsis if left untreated.

Memory Aid or Mnemonic:

“D-A-C-R-Y” is about “L-A-C-R-Y” 

  • L: Lacrimal sac infection 
  • A: Antibiotics for acute cases
  • C: Chronic cases require surgery (Dacryocystorhinostomy (DCR)
  • R: Redness and swelling over the medial canthus
  • Y: Yellow (purulent) discharge

SUPERPoint:

Dacryocystitis is a painful infection of the lacrimal sac due to nasolacrimal duct obstruction, characterized by swelling, redness, and purulent discharge near the inner corner of the eye, and can be managed with antibiotics and surgical interventions in chronic cases.

SUPERFormula:

Nasolacrimal duct obstruction + lacrimal sac infection + pain and redness over medial canthus + purulent discharge = Dacryocystitis

References

Singh M, Whitfield D. Dacryocystitis. In: Knoop KJ, Stack LB, Storrow AB, Thurman R. eds. The Atlas of Emergency Medicine, 5e. McGraw-Hill; 2021.