| Dacryocystitis  SIGNS AND SYMPTOMS
Pain, redness and swelling over the inner aspect of the lower eyelid
and epiphora may signify aggravated blepharitis, meibomianitis or canaliculitis. However,
suspect dacryocystitis if the problem recurs and is associated with fever and severe
erythematous swelling around the nasal aspect of the lower lid; or if it involves the
lacrimal sac such that mucopurulent discharge can be expressed from the inferior punctum.
Older patients are predisposed to the condition as the lacrimal drainage system loses its
elasticity and thins, and tears fail to flush debris through the complex. Patients with
poor hygiene are at greater risk.
PATHOPHYSIOLOGY
The primary etiology of dacryocystitis is nasolacrimal obstruction
secondary to mucocele of the lacrimal sac, which is precipitated by chronic blockage of
the interosseous or intermembranous nasolacrimal duct. Most cases of nasolacrimal duct
obstruction are found in the older population, and result from chronic mucosal
degeneration, ductile stenosis, stagnation of tears, and bacterial overgrowth. Infantile
dacryocystitis is uncommon but presents with the same signs and symptoms.
Lacrimal sac obstructions often produce signs and symptoms similar to
dacryocystitis but not as severe. They are collectively known as canaliculitis. These
infections are differentiated by solid concretions called dacryoliths, which can be
expressed from the infected lacrimal sac. Dacryoliths can result from bacterial, fungal or
viral infections.
MANAGEMENT
Management of an afebrile child with dacryocystitis includes oral
amoxicillin/clavulanate (Augmentin) 20-40mgs/kg/day, PO, TID, or oral cefaclor
20-40mgs/kg/day, PO, TID, along with topical antibiotic drops QID (e.g. Polytrim, Tobrex,
Ocuflox), ointments BID, warm compresses and acetaminophen. Management of an adult
afebrile patient includes cephalexin (Keflex) or Augmentin 500mgs PO, QID along with
topical antibiotic drops, ointments, warm compresses and aspirin or ibuprofen for pain and
inflammation, as needed. Manage febrile patients with extreme caution. Patients who are
acutely ill should be hospitalized and placed on IV cefazolin (Ancef), Q8H along with the
other modalities. Consider neuroimaging (CT or MRI) when the etiology is in question.
Dacryoliths should be removed with curettage or canaliculotomy, cultured
and treated accordingly with both topical and oral antibiotic, antiviral or antifungal
preparations.
CLINICAL PEARLS
- Obstruction of the tear drainage system can occur at any age. Punctal or
canalicular stenosis may develop from a myriad of conditions. Punctal stenosis may result
from conjunctival diseases such as Steven's-Johnson syndrome (dry eye and dry mouth
secondary to reaction to sulfa medicine), ocular cicatricial pemphigoid, and mechanical,
thermal or chemical injury. In the young, congenital anomalies of the nasolacrimal system
include dacryostenosis, dacryocystocele and canalicular fistula
- Bloody tears with a history of medial canthal mass should heighten
suspicion for space occupying lesions. Facial cellulitis and acute ethmoidal or frontal
sinusitis are among the important differential diagnoses.
- Prompt, decisive and aggressive management is essential. Hospitalization
with intravenous antibiotics should be considered in severe, febrile or recalcitrant
presentations. Punctal dilation and nasolacrimal irrigation is always contraindicated in
the acute stages. In fact, following the resolution of the acute infection, most cases
remain with symptomatic epiphora, requiring dacryocystorhinostomy.
Other reports in this section
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