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Disease[edit | edit source]

Dacryocystitis is an inflammation of the lacrimal sac.

Etiology[edit | edit source]

In children: staphylococcus aureus, B-hemolytic streptococcus and pneumococcus and haemophilus influenzae In adults:staphylococcus epidermidis ,staphylococcus aureus ,streptococcus pneumoniae and pseudomonas aeruginosa

Risk Factors[edit | edit source]

• Almost always related to nasolacrimal duct obstruction.
• Nasal pathologies like nasal septum deviation, rhinitis and inferior turbinate hypertrophy on the same side.
• Female is also a known risk factor for the development of this infectious condition due to narrow duct diameter.
• The presence of dacryoliths at various levels of the lacrimal drainage system.
• The occurrence of acute dacryocystitis being more prevalent with increasing age.

Pathophysiology[edit | edit source]

Dacryocystitis usually occurs because of obstruction of the nasolacrimal duct. The obstruction may be an idiopathic inflammatory stenosis (primary acquired nasolacrimal duct obstruction) or maybe secondary to trauma, infection, inflammation, neoplasm, or mechanical obstruction (secondary acquired lacrimal drainage obstruction). Obstruction of the nasolacrimal duct leads to stagnation of tears in a pathologically closed lacrimal drainage system which can result in dacryocystitis

Symptoms and Signs[edit | edit source]

Congenital dacryocystitis is a serious disease associated with significant morbidity and mortality. If it is not treated promptly and aggressively, newborn infants can experience orbital cellulitis (because the orbital septum is formed poorly in infants), brain abscess, meningitis, sepsis, and death.

Acquired dacryocystitis can be acute or chronic. Acute dacryocystitis is heralded by the sudden onset of pain and redness in the medial canthal region.

Acute dacryocystitis
• Sudden onset of pain, redness, and edema overlying the lacrimal sac area.
• It is not uncommon for the sac to rupture and fistulize through the skin. This fistula commonly closes after a few days of drainage.
• Conjunctival injection and preseptal cellulitis often occur in conjunction with acute dacryocystitis.
• More serious sequelae of acute dacryocystitis is the extension into the orbit with formation of an abscess and development of orbital cellulitis.

Chronic Dacryocystitis
• Tearing is the most common presentation
• Mattering:
1. This is caused by the obstruction of drainage of the mucous layer of the tear film with collection of debris and denuded epithelial cells from the surface of the eye.
2. Chronic low grade bacterial infection inside the lacrimal sac.

Diagnostic procedures[edit | edit source]

• The diagnosis is clinical in most cases.
• Blood counts may reveal leucocytosis.
• Antineutrophilic cytoplasmic antibody testing may be useful to rule out Wegener’s granulomatosis.
• Imaging is rarely needed. In most cases it may reveal enlargement of the sac or foreign bodies or masses. Post traumatic cases or cases suspected of harboring an occult malignancy, Computer Tomography (CT) scan may be needed.
• Dacryocystography and dacryoscintigraphy are useful to detect anatomical abnormalities.
• Subtraction DCG with a CT scan is also useful in understanding anatomical features of the lacrimal sac and surrounding structures.
• The fluorescein dye disappearance test is useful in the clinic especially in those who cannot be syringed in the clinic. Prolonged retention of the dye usually more than 5 minutes indicates delayed drainage. The Jones test is useful to differentiate a functional block from an anatomical block.
• Nasal endoscopy is useful to rule out hypertrophy of the inferior turbinate, septal deviation and inferior meatal narrowing

Differential diagnosis[edit | edit source]

• Acute ethmoid sinusitis
• Infected sebaceous cysts
• Cellulitis
• Eyelid ectropion
• Punctual ectropion
• Allergic rhinitis
• Lacrimal sac or sinonasal tumor

Management[edit | edit source]

• Management of acute dacryocystitis :
o Application of heat
o Systemic antibiotics
o Percutaneous abscess drainage
o DCR (dacryocystorhinostomy) few weeks after acute infection resolves.

• Management of chronic dacryocystitis :
o Definitive treatment is a dacryocystorhinostomy, which can be performed as an external or internal endoscopic procedure. Relative contraindications to an internal endoscopic approach would be possible retained foreign body, dacryoliths, suspicion of tumor, or difficult intraoperative nasal visualization.

Complications[edit | edit source]

1. Fistula formation
2. Lacrimal sac abscess
3. Orbital cellulitis
4. Meningitis
5. Cavernous sinus thrombosis

References[edit | edit source]

1. Orbit, Eyelids and Lacrimal System, section 7.Basic and Clinical Science Course, AAO, 2011-2012.

2. Bartley GB. Acquired lacrimal drainage obstruction: an etiologic classification system, case reports, and a review of the literature. Part 1. Ophthal Plast Reconstr Surg 1992; 8: 237–242.

3. Pinar-Sueiro S, Sota M, Lerchundi TX, Gibelalde A, Berasategui B, Vilar B, Hernandez JL Dacryocystitis: Systematic Approach to Diagnosis and Therapy .Curr Infect Dis Rep. 2012

4. Chaudhry IA, Shamsi FA, Al-Rashed W. Bacteriology of chronic dacryocystitis in a tertiary eye care center .Ophthal Plast Reconstr Surg.2005;21:207-10.

5. Mills DM, Bodman MG, Meyer DR, Morton AD. The microbiologic spectrum of dacryocystitis: a national study of acute versus chronic infection. Ophthal Plast Reconstr Surg. 2007;23(4):302-6