Dacryocystitis

Dacryocystitis is inflammation of the lacrimal sac due to nasolacrimal duct obstruction and the subsequent stasis of tears. The condition can have an acute or chronic onset. Acute dacryocystitis presents within hours or days with redness, swelling, tenderness, and excessive tearing. The chronic type has a gradual course, often manifesting with epiphora. By etiology, dacryocystitis can be congenital or acquired. Nasolacrimal duct obstruction affects 6% of newborns. Acquired cases occur due to trauma, systemic diseases, or tumors. Diagnosis is made clinically. In some cases, laboratory tests and imaging help determine abnormal structures and underlying disease. Initial treatment includes conservative measures such as Crigler massage, warm compresses, and antibiotics, if indicated. If these fail, surgical options are tried.

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Overview

Definition

Dacryocystitis is an inflammation of the lacrimal sac due to nasolacrimal duct (NLD) obstruction and the subsequent stasis of tears.

Anatomy and physiology

  • Lacrimal glands
    • Location: upper lateral aspect of orbit (lacrimal fossa)
    • Function: produce tears that protect and lubricate the outer portion of the eye
  • Tear drainage system
    • Lacrimal canaliculi
    • Valve of Rosenmuller: mucosal fold between the canaliculi and lacrimal sac
    • Lacrimal sac: dilated portion of the NLD
    • NLD: drains into the inferior nasal meatus
    • Valve of Hasner: mucosal fold partially covering the NLD that opens into the nasal meatus
  • Physiology
    • Released tears lubricate the eye → enter the canaliculi lacrimales (through puncta lacrimalis) at the medial eye corner → common canaliculus → lacrimal sac → drains into the NLD
Lacrimal apparatus anatomy

Lacrimal apparatus anatomy

Image by Lecturio.

Epidemiology

  • Bimodal distribution:
    • After birth (congenital cases)
    • In adults > 40 years of age
  • Congenital NLD obstruction: affects 6% of newborns
  • Women > men
  • Caucasians more commonly affected

Types of Dacrycystitis

Based on etiology

Nasolacrimal system obstruction is the main etiology.

  • Congenital NLD obstruction
    • Most common cause: membranous obstruction at the valve of Hasner due to incomplete canalization of the nasolacrimal apparatus 
  • Congenital dacryocystocele
    • Obstruction at both proximal and distal portions of nasolacrimal duct system
    • Proximal: block at the common canaliculus or the valve of Rosenmuller
    • Distal: block usually at the valve of Hasner
  • Acquired
    • Nasal pathology: deviated septum, nasal polyp, hypertrophied inferior turbinate
    • Tumors: primary lacrimal sac tumors and benign papilloma or malignancies
    • Trauma: nasal fracture and surgery
    • Dacryolith: stone within the lacrimal sac
    • Inflammatory disease: sarcoidosis, granulomatosis with polyangiitis
    • Sinusitis: maxillary and ethmoidal
    • Medications: timolol, pilocarpine, dorzolamide, idoxuridine, and trifluridine

Based on onset

  • Acute dacryocystitis
    • Acute inflammation of the lacrimal sac arising from obstruction of the lacrimal system
    • Obstruction leads to stagnation of tears, providing an environment for bacterial growth. 
    • Common organisms in local infection or abscess:
      • Staphylococcus epidermidis and S. aureus
      • Alpha-hemolytic streptococci
      • Pseudomonas aeruginosa
  • Chronic dacryocystitis
    • Insidious onset
    • Chronic obstruction from:
      • Recurrent infections
      • Dacryoliths
      • Systemic diseases 
      • Tumors

Clinical Presentation

  • Acute dacryocystitis: Symptoms present within hours or days.
    • Redness
    • Swelling in the medial canthus and inferomedial area of orbit
    • Tenderness below the medial canthus of the eye
    • Purulent discharge from the punctum
    • Mattering: debris and surface epithelial cells of the eye
    • Epiphora: excessive tearing
  • Chronic dacryocystitis symptoms include:
    • Epiphora: most common symptom
    • Fluctuating visual acuity: Increased tear film refracts light abnormally.
    • Mucocele:
      • Also called dacryocele or dacryocystocele
      • Palpable mass (formed from trapped fluid) at the medial canthus
Dacryocystitis clinical presentation

Images of lacrimal abscess:
a. and b. Localized right lacrimal abscess, with discharge at the medial canthus;
c. a neonate with right lacrimal abscess;
d. Lacrimal abscess with orbital cellulitis

Image: “Dacryocystitis” by Dacryology Service, Ophthalmic Plastics Surgery, L,V, Prasad Eye Institute, Banjara Hills, Hyderabad 500034, India. License: CC BY 2.0

Complications

  • Complications involving other ocular structures:
    • Preseptal cellulitis:
      • Infectious inflammation of the structures anterior to the orbital septum (skin and subcutaneous tissue) 
      • Presents with pain, fever, swelling, redness, and discharge
    • Orbital cellulitis: 
      • Infectious inflammation of the structures posterior to the orbital septum (orbital fat, muscles, bone)
      • Presents with pain, fever, redness, discharge, swelling, proptosis, diplopia, and abnormal eye movement
  • Complications beyond the eye:
    • Meningitis: inflammation of the meninges 
    • Sepsis: infection associated with life-threatening organ dysfunction
    • Cavernous sinus thrombosis: embolization of infectious organism(s) causing thrombosis in the cavernous sinus

Diagnosis

  • Clinical: based on signs and symptoms
  • Laboratory tests: 
    • Culture of lacrimal sac discharge: guides antibiotic treatment 
    • Obtained if systemic diseases are considered as etiology
  • Fluorescein dye disappearance test: 
    • Fluorescein dye is placed into the patient’s eye and after 5 minutes, an evaluation is done (with cobalt blue filter of slit lamp).
    • Persistence of dye and asymmetric dye clearance: NLD obstruction confirmed
  • Imaging:
    • Computed tomography (CT) scan:
      • To evaluate structures in cases of trauma/fractures
      • To assess mass or tumor involvement
      • To determine extent of infection/abscess
    • Dacryocystography: 
      • Helps in assessment of anatomical abnormalities of the duct
  • Nasal endoscopy: 
    • Evaluates intranasal pathology such as septal deviation, inferior meatal narrowing, and inferior turbinate hypertrophy

Management

  • Acute dacryocystitis from congenital NLD obstruction
    • NLD probing: contraindicated in acute dacryocystitis
    • Crigler massage:
      • Push index finger down on the lacrimal sac and slide the finger downward against the bony side of the nose.
      • 10 motions performed 3 times a day
      • Done until child is 1 year of age
      • 90% of NLD obstructions resolve by 612 months of age.
    • Warm compresses (10 minutes, 4 times a day) 
  • Acute dacryocystitis with infection
    • Localized infection: 
      • Conservative measures (massage, warm compress)
      • Oral antibiotics (coverage for gram-positive organisms)
    • Complicated cases with spread of infection: IV antibiotics (coverage for gram-positive and gram-negative organisms)
  • Chronic dacryocystitis 
    • NLD probing: 
      • Successful in 70% of cases
      • Done as an outpatient
    • Other options if probing fails: 
      • Nasolacrimal stenting
      • Balloon dacryoplasty 
      • Nasolacrimal intubation 
    • Percutaneous dacryocystorhinostomy (DCR) or endonasal dacryocystorhinostomy (EN-DCR)
      • Done when previous therapeutic measures fail
      • For complete NLD obstruction

Differential Diagnosis

  • Conjunctivitis: inflammation of the conjunctiva, the outer lining of the eye. Etiology can be infectious or non-infectious. Patients present with redness and discharge on 1 or both eyes. Bacterial conjunctivitis often has purulent discharge whereas viral causes have watery discharge.
  • Hordeolum (stye): an abscess affecting the eyelash follicle or eyelid gland. Stye usually presents as a locally painful, erythematous, swollen eyelid margin. Most lesions resolve spontaneously, but gentle warm compresses facilitate drainage. If the abscess does not resolve, incision and drainage by an ophthalmologist are performed.
  • Chalazion: a firm, nontender mass at the eyelid resulting from obstruction of the Zeis or meibomian glands. The condition is usually managed conservatively with warm compresses. Persistence of the lesion requires incision and curettage or glucocorticoid injection by an ophthalmologist.

References

  1. Denniston, A., Murray, P. (2014). Oxford Handbook of Ophthalmology, Third edition. Oxford University Press, Oxford.
  2. Gilliland, G., Law, S., Ing, E. (2019). Dacryocystitis. Medscape. Retrieved 24 Sept 2020, from https://emedicine.medscape.com/article/1210688-overview#a4
  3. Paysse, E., Coats, D., Olitsky, S., Armsby, C. (2019). Congenital nasolacrimal duct obstruction (dacryostenosis) and dacryocystocele. UpToDate. Retrieved 24 Sept 2020, from https://www.uptodate.com/contents/congenital-nasolacrimal-duct-obstruction-dacryostenosis-and-dacryocystocele?search=dacryocystitis&sectionRank=1&usage_type=default&anchor=H772424785&source=machineLearning&selectedTitle=1~12&display_rank=1#H772424785
  4. Revere, K. (2019). Nasolacrimal Duct Obstruction: The Right Way to Teach Parents. Medscape. Retrieved 25 Sept 2020, from https://www.medscape.com/viewarticle/902470
  5. Snell, R. (2012). Clinical anatomy by regions (9th ed.). Lippincott, William and Wilkins, Philadelphia, USA.
  6. Taylor, R., Ashurst, J. (2020). Dacryocystitis. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK470565/

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