Dacryocystitis
An infection of the tear sac located near the inner corner of the eye, causing pain, redness, swelling, and excessive tearing, usually due to a blocked tear duct.
Emergency Management: Development of orbital cellulitis requires emergent hospitalization, IV antibiotics, and urgent ophthalmologic/ENT consultation.
Dacryocystitis is an infection or inflammation of the lacrimal sac, usually secondary to obstruction of the nasolacrimal duct. It presents acutely with pain, erythema, and swelling over the medial canthus, or chronically with persistent tearing and mucopurulent discharge.
Detailed Overview
The lacrimal sac collects tears from the eye surface before they drain via the nasolacrimal duct into the nasal cavity. When this duct is obstructed, tears stagnate in the sac, creating a prime environment for bacterial overgrowth. Acute cases are typically infectious, requiring antibiotics, while chronic cases are primarily obstructive, requiring surgical intervention.
Epidemiology & Demographics
Bimodal age distribution: most common in infants (due to congenital nasolacrimal duct obstruction, affecting up to 20% of newborns) and in adults > 40 years old (mostly females, likely due to narrower duct anatomy).
Etiological Mechanism
Acute dacryocystitis is most commonly caused by Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae (especially in children). Chronic dacryocystitis may involve Pseudomonas aeruginosa, Actinomyces, or Candida.
Primary Causes
Nasolacrimal duct obstruction (NLDO). In infants, it is usually congenital (failure of the valve of Hasner to open). In adults, it can be acquired through age-related stenosis, trauma (nasal/facial fractures), sinonasal disease, or dacryoliths (tear stones).
Obstruction of the nasolacrimal duct leads to stasis of lacrimal fluid within the lacrimal sac. This stagnation alters the local microbiome and provides a nidus for bacterial proliferation. In acute dacryocystitis, rapid bacterial multiplication leads to acute suppurative inflammation, distension of the sac, and perisaccular cellulitis. In chronic cases, low-grade inflammation causes thickening of the sac wall and chronic mucopurulent discharge without overt acute infectious signs.
Diagnostic Criteria & Guidelines
Diagnosis is clinical based on the characteristic location of the swelling (inframedial to the medial canthus) and expression of purulent material from the punctum. Probing and irrigation of the tear ducts are contraindicated during acute infection.
For acute, mild cases: Oral broad-spectrum antibiotics (e.g., Amoxicillin-Clavulanate 875/125 mg PO BID or Cephalexin 500 mg PO QID for 7-10 days) + warm compresses and pain control. For acute, severe cases (or in infants): Admission for IV antibiotics (e.g., IV Cefazolin or IV Vancomycin if MRSA suspected).
Second-Line & Adjunctive Therapy
For acute cases with a fluctuant abscess pointing to the skin: Incision and drainage of the lacrimal sac to decompress the infection. For chronic dacryocystitis: Topical antibiotic drops (e.g., Tobramycin or Moxifloxacin drops QID) to manage discharge temporarily until surgery.
Surgical & Procedural Management
Dacryocystorhinostomy (DCR) is the definitive treatment. It surgically creates a new bypass fistula between the lacrimal sac and the nasal cavity, bypassing the obstructed nasolacrimal duct. Performed after the acute infection has resolved. In infants with congenital NLDO, simple probing of the duct (often successful >90%) is performed if conservative measures fail by 12 months of age.
Patient Counseling & Advice
Educate that antibiotics will cure the immediate infection, but because the plumbing is blocked, the infection will likely return unless the duct is bypassed surgically (DCR).
Follow-Up & Monitoring Schedule
Close follow-up within 24-48 hours for acute cases to ensure infection is not spreading to the orbit. Oculoplastic referral for definitive DCR surgery.
Preventive Strategies
Prompt treatment of chronic rhinitis or sinusitis. Early nasolacrimal probing in infants if symptoms persist beyond 1 year.
Excellent with definitive surgical treatment (DCR has a success rate of >90%). Without surgery, recurrent acute attacks or chronic discharge are the norm.