DACRYOCYSTITIS

Swollen nasolacrimal system in dacryocystitis.

The nasolacrimal apparatus drains the tears and tear constituents from the lacrimal lakes of the eyes into the nose.^1-8 Pain, redness and swelling over the inner aspect of the lower eyelid and epiphora may signify aggravated blepharitis, meibomianitis or canaliculitis. If the problem becomes recurrent, associated with fever and severe erythematous swelling around the nasal aspect of the lower lid involving the lacrimal sac such that a mucopurulent discharge can be expressed from the inferior punctum when pressure is applied, the suspicion of dacryocystitis should be high.^2­6,8

Pathophysiology

The system consists of inferior and superior puncta (which lie in the nasal canthi of both eyes), their attached 10mm canaliculi (each of which possess a 2mm vertical segment), and an 8mm nasal running segment, which courses 10mm through the lacrimal sac to the common 17mm interosseous/intermembraneous nasal lacrimal duct that drains into the nose through the valve of Hasner beneath the inferior turbinate.^4,6

The primary etiology of dacryo-cystitis is nasolacrimal apparatus obstruction secondary to mucocele of the lacrimal sac which is precipitated by chronic blockage of the interosseous or intermembraneous nasolacrimal duct.^4,6 Most cases of nasolacrimal duct obstruction are found in the older population, resulting from chronic mucosal degeneration, ductile stenosis, stagnation of tears and bacterial overgrowth.^3,4,8 Infantile dacryocystitis is uncommon but presents with the same signs and symptoms. A study examining the most frequently recovered anaerobes from dacryo-cystitis reported Pepto-streptococcus spp., Propionibacterium spp., Prevotella spp. and Fusobacterium spp. as the most frequently associated pathogens.⁸

Lacrimal sac obstructions often produce signs and symptoms that are 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 found and expressed from the infected lacrimal sac.

Dacryoliths are caused by the bacteria Actinomyces israelii (Streptothrix), fungi such as Candida, Aspergillus or Fusarium, and viruses such as herpes simplex virus and varicella virus. When present, dacryoliths should be removed with curettage or canaliculotomy, cultured and treated accordingly with both topical and oral antibiotic, antiviral or antifungal preparations.^2-4

Management

Management of the nonfebrile child includes oral amoxicillin/clavulanate (Augmentin, GlaxoSmithKline) 20­40mg/kg/day, po, tid or oral cefaclor 20­40mgs/ kg/day po, tid, along with topical antibiotic drops qid, ointments bid, warm compresses and acetaminophen. Management of the adult nonfebrile patient includes cephalexin (Keflex, Lilly) or Augmentin 500mg po, qid along with topical antibiotic drops, ointments, warm compresses and aspirin or ibuprofen for pain and inflammation, as needed.

Management of the febrile patient must be handled with extreme caution.

Patients who are acutely ill should be hospitalized and placed on IV cefazolin (Ancef, Glaxo-SmithKline) q8h along with the other modalities. CT or MRI should be considered when other etiologies or differentials are in question.

In a recent study, polyurethane stents placed into the cannilicular apparatus were evaluated as a percutaneous management of the persistent epiphora left by canilicular disease.⁷ Minor postoperative complications such as epistaxis, palpebral edema, headache and, ironically, two acute cases of dacryocystitis were recorded. The initial technical success rate of stent placement was 95%. The average time of the procedure was six minutes. Resolution of epiphora was complete in 452 eyes and partial in 18. On follow-up, 340 of 496 stents remained patent. Of the 156 obstructed stents, 114 were withdrawn and 49 of these patients remained asymptomatic for a mean of 27 months. After stent removal, the sac configuration was unchanged in 81.5%, contracted in 9.6%, and widened in 8.8% of cases. The procedure appears to be simple and safe, both in stent insertion and in withdrawal. The success rate was >75% in the short term and >55% in the long term. While not totally without concerns, the technique is attractive for most patients who prefer not to undergo surgery or are unsuitable surgical candidates.⁷

An even more recent study set out to investigate whether acute dacryocystitis complicated by abscess formation could be successfully treated using laser-assisted endonasal dacryocystorhinostomy (DCR).⁶ Resolution of symptoms and signs of acute dacryocystitis occurred in all nine patients treated.⁶ No recurrence of acute dacryocystitis occurred during the median follow-up period of 11 months.⁶ Laser assisted endonasal DCR appears to be an effective tool in the primary treatment of acute dacryocystitis complicated by abscess formation.⁶ In addition, any pre-existing symptoms of epi-phora or recurrent nasolacrimal infections seem to be concurrently relieved following the procedure in the majority of patients.⁶

Clinical Pearls

• Obstruction of the tear drain-age system can occur at any age.
• Punctal stenosis may result from conjunctival diseases such as Stevens-Johnson syndrome (dry eye, dry mouth secondary to reaction to sulfa medicine), ocular cicatricial pemphigoid, mechanical, thermal or chemical injury. In the young, congenital anomalies of the nasolacrimal system include congenital dacryostenosis, congenital dacryocystocele and congenital canalicular fistula.^2­6
• Obstruction in the adult may result from midfacial trauma, sinus surgery, sinus infection or tumor. 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.^2,3,6
• Prompt, decisive, aggressive management is essential.^2­8 Hospital- ization with intravenous antibiotics should be considered in severe, febrile or recalcitrant presentations.
• Punctal dilation and nasolacrimal irrigation is always contra-indicated in the acute stages due to risk of inducing preseptal cellulitis.

Other reports in this section

• Floppy Eyelid Syndrome
• Herpes Simplex Blepharitis
• Dacryocystitis
• Dermatochalasis & Blepharochalasis
• Xanthelasma